1

K KH H M M B B M M Y Y H H H H P P

MC TIU:
1. Trnh by c cch khai thc bnh s, tin s ca bnh nhn.
2. M t c cc triu chng c nng, thc th v cc du hiu ton thn.
3. Trnh by c cc xt nghim cn lm sng cn thit.
NI DUNG:
1. i cng: Khm lm sng b my h hp l phng php n gin nht nh
gi s hot ng ca h hp. Qua lm sng ta c th pht hin c nhiu trng hp
bnh l, c hng tin hnh cc thm d cn lm sng c chn on v tin lng
c chnh xc. Trn thc t khng th b qua c cch khm lm sng trong iu
tr.
2. Khm ton thn:
2. 1 St: o nhit bit bnh nhn c st hay khng, st bao nhiu . Nu st
cao rm r thng do vim phi cp do vi khun hoc vi rt, cng c th trn dch
mng phi do lao.
2. 2 Tm:Thng thy u chi, nim mc vi mu hi xanh sm, pha ln mu tm
sm. Tm xut hin khi t l Hemoglobin kh trn 5g/100ml trong mu vi qun. Khi
c tm thng chng t suy h hp v tng ln khi gng sc, cng c th tm do lng
khng kh ni thiu oxy, ri lon trao i mu tim (Shunt phi - tri), ri lon tun
hon do bnh tim.
2. 3 Mng tay khum: l trng hp mng tay vng ln nh mt knh ng h,
km theo u ngn tay to ra.
2. 4 Khm tim mch:
- Khm tim: Cn tm cc du hiu ca suy tim, nht l nhng du hiu ca suy tim
phi do bnh phi.
- o huyt p.
3. Khm ng h hp trn:
- Khm mi: quan st ming mi, vch mi.
- Khm hng xem c b vim khng, v nim mc hng phn nh tnh trng ca nim
mc ph qun.
Cn thm khm mi hng v cc bnh tch ny c th l khi u ca nhim khun
ph qun phi hoc cn hen.
4. Khm lng ngc:
4. 1 Nhc li gii phu:
- Hai phi c nm trong mt rt cng l lng ngc, hai phi c bao bc bi
mt l mmg gi l l tng, n bao ph ton b cc thy ca phi (bn phi c 3 thy,
bn tri c 2 thy). L thnh bao ph mt trong ca lng ngc v trung tht.
2
- Vng chiu ca cc tng trong lng ngc.
+ y phi:
Bn tri: i t sn sn 6 xung dc theo b trn xng sn 7 ri ti b di
xng sn 7 trn ng nch gia, xng sn 9 trn ng nch sau, xng sn
11 khi i ti ct sng.
Bn phi: cng tng t nhng v c gan nn ch xung ti xng sn 10 pha
sau.
+ B trong phi:
Bn phi: i t khp c n, i thng gc ti khp sn sn 6 ni tip vi y
phi.
Bn tri: ng i tng t nhng ti xng sn 4 th qut ra ngoi to thnh mt
khong lm trong c tim ri i xung ni tip vi y phi.
+ Mng phi: bc ly phi to thnh cc ti cng.
+ Rnh lin thy:
Bn tri: i t pha sau mc xng sn 3, ct xng sn 4 trn ng nch gia
ri i cho xung phn trc ca xng sn 7.
Bn phi: rnh lin thy trn tch khi rnh di v i ln trn ra pha trc, rnh
ny qua mng lin sn 2 trn ng nch gia.
+ Rn phi: trc chiu ln lin sn 3, sau b xng c pha sau ln
khoang lin b ct sng khoang lin sn 5.
4. 2 Khai thc bnh s, tin s ca bnh nhn:
- L do n khm: thng gp l cc triu chng c nng hoc nhng iu bt thng
khi chp phim lng ngc mt cch h thng, hoc l cc du hiu ton thn nh st,
km n, mt nhc, gy st
- Thi gian khi bnh, din tin ca cc triu chng.
- Tin s gia nh v bn thn:
+ V tin s gia nh ch tnh trng d ng ngi hen hoc tnh cht ly lan
bnh nhn b lao.
+ V bn thn: cc bnh phi, mng phi, kt qu x quang chp trc y nht l
i vi bnh ngh nghip.
- iu kin sng v lm vic ca bn thn: ngh nghip, mi trng x hi v gia
nh, c ht thuc l khng.
4. 3 Cc triu chng c nng, thc th:
4. 3. 1 Triu chng c nng:
4. 3. 1. 1 Ho:
- M t:
+ Thi gian xut hin:
Cp: thng gp trong vim cp tnh phi hoc ng h hp.
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Mn tnh: thng gp trong bnh phi mn tnh.
+ Cht tit:
Ho c m: sau khi ho khc m, c th m long hay c, ln mu m, b u,
s lng t hoc nhiu.
Ho khan: l ho khng c cht tit.
+ Thi gian: cn hi k thi gian no trong nm b ho, bt u ho thy th no c
hng chn on nguyn nhn.
- Gi tr v hng chn on:
+ Ho cp:
Do nhim khun: vim hng, vim thanh qun, vim phi cp, vim phi, trn dch
mng phi.
Do d ng: hen ph qun.
Bnh nh hng n tm ti: ph phi, biu hin v phi do bnh tim.
Ht phi bi hoc cc cht kch thch.
+ Ho ko di c km cht tit: a s cc trng hp vim phi phi mn tnh nht l
bnh nhn ht thuc l, thuc lo.
+ Ho khan ko di cn ch n: bnh ca thanh qun, ung th phi phi, x phi
hoc lao k,
4. 3. 1. 2 Khc m khng c mu:
- M t: + Thi gian khc m, mi khc hoc c t lu.
+ Khc t nhin hay sau khi thay i t th.
+ Gi khc m.
+ S ln khc m, s lng.
+ Tnh cht ca m: m thanh dch, m nhy, m, m m nhy, b u.
- Hng chn on:
+ Khc m cp km c du hiu nhim khun:
Nu chp phi bnh thng: vim phi cp.
Nu chp phi c iu bt thng v nu khc m mu g st: vim phi do vi
khun. Khc m m: p xe phi.
+ Khc m cp + c c a d ng: hen ph qun.
+ Khc m cp + biu hin bnh l tim tri: ph phi.
+ Khc m ko di:
Nhy hoc nhy m, s lng nhiu, ho ko di ln hn 3 thng/1 nm v t nht l
2 nm lin: vim ph qun mn.
Nhy m hoc m thc s, s lng rt nhiu: gin ph qun.
4. 3. 1. 3 Kh th:
- nh ngha: l tnh trng kh khn trong vic th.
- Bnh thng nhp th u, 12 - 16 ln/pht.
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- Bt thng:
+ Ngng th: khng cn h hp.
+ Th chm: nhp th gim.
+ Th nhanh: tn s tng.
- M t:
+ Lc xut hin:
Mn tnh, ko di c th do kh th c t trc.
Cp hoc mi xy ra ln u, rt t ngt.
+ Gi xut hin: kh th khi gng sc, tnh trng nhim khun, ht phi hi c
ha cht gy d ng.
+ Thi k th:
Kh th khi ht vo.
Kh th khi th ra.
+ Tnh cht:
Tn s th: t nht phi theo di trong 30 giy.
Cng : kh th khi gng sc hay khi nm. Chia ra thnh 5 giai on ty theo s
xut hin ca tnh trng kh th;
Giai on 1: Gng sc nhiu.
Giai on 2: i ln gc hoc i bnh thng.
Giai on 3: i trn b mt phng cng vi ngi bnh thng,
cng tui vi bnh nhn.
Giai on 4: i bnh thng trn mt phng.
Giai on 5: Lm vic bnh thng hng ngy.
- Gi tr triu chng v hng chn on:
+ Kh th cp:
Kh th vo: thng do nguyn nhn thanh qun nh vim thanh qun do virus,
ung th thanh qun.
Kh th ra: hen ph qun.
Kh th 2 th: ph phi cp, vim phi cp, tc ng mch phi, xp phi, trn kh
mng phi, trn dch mng phi.
+ Kh th lin tc: suy h hp, suy tim ton b.
4. 3. 1. 4 au ngc: M t
- Thi gian xut hin:
+ Cp mi bt u: bnh nhn c th ni r gi au, v tr au.
+ Mn tnh: au tng ln hoc m .
- Yu t khi pht:
+ Sau gng sc v gim i sau khi ngh ngi: thng nguyn nhn ng mch
vnh.
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+ au tng ln khi ho v ht vo su thng l nguyn nhn mng phi.
- Tnh cht au:
+ au nh tht: suy vnh.
+ au nh dao m: trn kh mng phi.
4. 3. 2 Triu chng thc th:
4. 3. 2. 1 Nhn:
4. 3. 2. 1. 1 Hnh dng lng ngc:
- Bnh thng: lng ngc phi cn i, cc xng sn hi nghing t trn xung
di, t sau ra trc. ngi ln bnh thng t l ng knh trc sau vi ng
knh ngang khong 1/2, tr s sinh l 1.
- Nhng bt thng c th gp:
+ Bin dng:
Lng ngc hnh thng: ng knh trc sau tng ln, gp trong gin ph nang.
Khng i xng do co ko, na lng ngc b lp li, cc xng sn thng xung
hn, khong lin sn hp.
Khng i xng trong mt na lng ngc li phnh ln, to ra, cc xng sn
nm ngang, khong lin sn gin rng.
Bin dng ct sng: vo, g, xng c b nh ra pha trc.
+ Tun hon bng h: cc mch mu lng ngc gin to ra, ngon ngoo, ni r
trn mt da thng km theo gin tnh mch c, chng t c chn p tnh mch ch
trn.
+ Ph:
Ph c 2 bn, t tht lng tr ln gi l ph o khoc.
Ph mt bn nht l ng y lng ngc thng thy trong trn dch mng phi m.
4. 3. 2. 1. 2 Di ng ca th:
- Tn s, nhp th u hay khng u.
- Kiu th: th bng hay th ngc.
- co gin ca lng ngc: c th gin ton b trong gin ph nang hoc hen nng.
- Co ko cc c h hp.
* iu cn nh v hnh dng lng ngc:
- Gin cng ton b:
+ Gin ph nang.
+ Vim ph qun mn tnh.
+ Hen ph qun.
- Bin dng ca xng:
+ Vo g.
+ Lng ngc hnh thng.
+ Gy xng sn.
6
- Khng i xng v phnh:
+ Trn kh mng phi.
+ Trn dch mng phi.
+ Kn hi.
- Khng i xng v co ko:
+ Xp phi.
+ Di chng ca trn dch mng phi.
4. 3. 2. 2 S: B sung cho nhng du hiu ghi nhn c khi nhn v nhp th v
bin , s ch yu bit rung thanh.
- Phng php: p st lng bn tay ln thnh ngc cc v tr i xng v bo bnh
nhn m 1, 2, 3. Cn so snh cc vng i xng ca thnh ngc.
- Kt qu:
+ Bnh thng m pht ra t thanh qun truyn qua thnh ngc, bn tay c hin
tng rung nh.
+ Rung thanh tng l trng hp ng c ca vng phi pha di.
+ Rung thanh gim hoc mt; chng t c dch hoc hi ngn cch gia nhu m
phi v tay ca ngi khm. Thnh ngc dy cng lm rung thanh gim.
+ S cng cn cho bit: cc im au, hch c bit l hch thun n.
+ iu cn nh khi s n rung thanh tng: ng c phi. Rung thanh mt:
trn dch mng phi, trn kh mng phi.
4. 2. 2. 3 G:: Dng ngn tay gia ca bn tay phi p vo ngn tr hay ngn gia
ca bn tay tri p st vo thnh ngc v ngn tay song song vi khoang lin sn.
ng tc ca tay phi p bng khp c tay, phi g u tay v so snh cc vng i
xng.
- Kt qu:
+ Bnh thng: g thy trong.
+ Nghe c khi trong gim, m sc trm, gp trong trn dch mng phi,
vim phi.
+ Nghe thy vang trng l hin tng qu trong gp trong trn kh mng phi,
gin ph nang.
iu cn ghi nh khi g: c: trn dch mng phi; vim phi. Vang trng: trn kh
mng phi; gin ph nang
4. 2. 2. 4 Nghe: bnh nhn th su, th u, th mi. t ng nghe trn ton b
lng ngc 2 bn, phi nghe khi bnh nhn th u bnh thng, lc th ra mnh,
bo bnh nhn ho hoc ni.
Kt qu: Ting th bnh thng: c 2 loi
+ Ting th kh ph qun: nghe th, lin tc, cng ln v nghe c c 2
th. Ting ny do lung kh xoy trong kh qun v ph qun ln.
7
+ R ro ph nang: l nhng ting lin tc, m du, cng thp, ko di sut
thi k ht vo v u thi k th ra. R ro ph nang l do khng kh i vo cc
ph nang.
Nhng ting bt thng: R ro ph nang c th: Mt khi c trn dch mng
phi hoc trn kh mng phi, phi b ng c. Gim khi thnh ngc qu dy,
gin ph nang.
+ Ting kh ph qun: khi bt thng ting ny truyn ra ta nghe c trong
mt s qu trnh bnh l gi l ting thi.
Ting thi mng phi: m, xa xm, nh, r thi k th ra. Nghe c
pha trn ni c trn dch mng phi th trung bnh. Ting thi ng: mnh, th,
m cao, nghe r c hai th, gp trong hi chng ng c, l ting kh ph
qun gim truyn qua mi trng ng c.
Ting thi v: nghe nh ting kim kh, m cao, r thi k th ra. Ting ny
pht sinh do s cng hng ca ting th bnh thng khi qua mt ti hi (trn kh
mng phi khu tr).
Ting thi hang: mnh, m sc rng, m cao, nghe r thi k th vo. Pht
sinh do s truyn ca ting kh ph qun qua mt hang rng trong nhu m phi (hang
lao, p xe phi).
Cc ting ph:
* Ran rt: m cao, nghe nh ting chim ru rt hoc ting gi thi mnh qua khe ca.
* Ran ngy: m trm, nghe nh ting ngy ng, nghe r c hai th.
* C ch: xut hin khi lung khng kh lu thng trong ph qun c mt hoc nhiu
ni hp li. Nguyn nhn: vim ph qun cp, hen ph qun, hp ph qun do u chn
p ph qun.
* Ran n: nghe kh nh, m cao, r thi k th vo v khng thay i khi ho.
Xut hin lc khng kh vo cc ph qun nh v ph nang v bc tch dn vch ph
qun nh v ph nang b lp dch qunh c lm dnh li. Thng gp trong vim
phi, tc ng mch phi gy nhi mu phi, y phi ca ngi nm lu ngy.
* Ran m: nghe lc xc khng u, mnh, r c hai th v thay i khi ho.
* Ting c mng phi: do 2 l ca mng phi c vo nhau. Nghe kh, th rp, nghe r
c hai th. Gp trong giai on u sau khi bt ca trn dch mng phi.
4. 4 Cc xt nghim cn lm sng:
4. 4. 1 Chiu chp x quang lng ngc: ty tng trng hp m yu cu chp x quang
phi t th thng, nghing, chp ph qun, chp mch mu ca phi, chp ct lp theo
t trng.
4. 4. 2 Soi ph qun bng ng soi mm:
Ch nh: + Ung th phi.
+ Ho mu
8
+ Tc ph qun
+ Nhim khun ph qun: ly bnh phm xt nghim.
4. 4. 3 Xt nghim cht tit ph qun v mt t chc hc v vi khun:
- V mt t chc hc: tm bch cu thoi ha, t bo ung th, bch cu a acid, tinh
th Charcot - leyden
- V mt vi khun: tm k sinh vt nh sn l phi, nm phi, trc khun lao, cc vi
khun khc.
4. 4. 4 Thm d mng phi:
- Phng php: bnh nhn ngi, ci ra pha trc chc khong lin sn 8 - 9
ng nch sau. Chc b trn ca xng sn di.
- Tnh cht dch: dch vng chanh, dch mu, dch m, dch dng chp.
4. 4. 5 Thm d chc nng h hp:
o th tch kh lu thng, dung tch sng, VEMS, ch s Tiffeneau.
4. 4. 6 Thm d chc nng trao i kh: o PH, PaC0
2,
Pa0
2,
Sa0
2

TI LI U THAM KHO:
- Triu chng hc ni khoa Tp 1, trang 197 - 230, NXB Y hc H Ni 2000.
- Ni khoa c s tp 1, trang 205 - 269, NXB Y hc H Ni 2003.
- Triu chng hc ni khoa Tp 1, trang 100 - 114, NXB Y hc H Ni 1988.

9
H H I I C CH H N NG G T TR R N N K KH H M M N NG G P PH H I I. .

MC TIU:
1. Nu c nh ngha v cc nguyn nhn gy trn kh mng phi.
2. M t c triu chng c nng v thc th ca trn kh mng phi.
3. Nu c chn on xc nh, chn on mc nng, chn on nguyn nhn
ca trn kh mng phi
NI DUNG:
M u: trn kh mng phi l hi chng thng gp trong cp cu ni ngoi khoa, ti
khoa cp cu hi sc vin lao v bnh phi (1990 - 1994) c 946 bnh nhn trn kh
mng phi chim t l 20, 12% s bnh nhn vo khoa (Hong Minh, 1994). T lu
trn kh mng phi c k n trong cc y vn trong v ngoi nc nh l mt cp
cu phi x tr ngay.
1. nh ngha: Trn kh mng phi l s c kh mt cch bt thng trong khoang
mng phi, gia mng phi thnh v mng phi tng do tn thng nhng l ny gy
xp mt phn hay ton b mt phi.
2. Cc nguyn nhn gy trn kh mng phi: Lao, kn hi, chn thng ngc, t
cu mng phi, hen phi, kh ph thng, tai bin th my.
2. 3 T pht: > 80% trng hp, thng gp ngi tr tui (thanh nin)
3. Triu chng: Chng ti ly hi chng trn kh mng phi ton b lm in hnh.
3. 1 Triu chng c nng:
3. 1. 1 au ngc: t ngt, d di nh dao m vng lng ngc c trn kh, tng ln
th ht vo khi ho.
3. 1. 2 Ho: ho khan, ho tng cn ngn.
3. 1. 3 Kh th: xut hin t ngt v i lin sau du hiu au. Mc kh th ty
mc trn kh v kh nng h hp ca pha phi cn li.
3. 2 Triu chng thc th:
- Nhn: na lng ngc bn trn kh km di ng, cng phng, khong lin sn gin
rng.
- S: rung thanh mt.
- G: g vang trng.
- Nghe: r ro ph nang mt.
Ba triu chng hp thnh tam chng Galliard.
+ Rung thanh mt.
+ R ro ph nang mt.
+ G vang trng
3. 3 Triu chng cn lm sng:
3. 3. 1 X quang phi:
10
- Na lng ngc pha c hi: ph trng qu trong, khng thy cc nhnh ph qun,
mch mu ca phi.
- Na lng ngc cng to, khong lin sn gin rng.
- Nhu m phi b co ko v pha rn phi, trung tht b y.
4. Chn on:
4. 1 Chn on xc nh da vo:
- Du hiu lm sng: au, kh th.
- Du hiu x quang: hnh tng sng vng trn kh, rn phi co li.
4. 2 Chn on mc nng: Ch yu da vo du hiu suy h hp, kh th v tnh
trng ton thn (ngt xu, sc ).
4. 3 Chn on nguyn nhn:
- Lao phi. - Ung th phi.
- Hen phi. - Trn kh do chn thng.
- Trn kh t pht.
4. 4 Chn on phn bit:
- Vi nhng nguyn nhn gy kh th cp: vim phi, ph qun ph vim, ph phi
cp, tc mch phi v nhi mu phi.
- Vi nhng nguyn nhn gy au cp: trn dch mng phi, xp phi.
5. Tm li:
- X quang l du hiu quan trng nht trong chn on trn kh mng phi.
- V lm sng:
+ Nn ch ti triu chng au ngc v ton thn nng mt ngi c bnh
phi nh lao, p xe, v ngay c i vi nhng ngi tr khe mnh.
+ Trn kh ton b c th chn on c trn lm sng da vo triu chng
thc th, trong triu chng g vang trng l mt du hiu quan trng.
TI LI U THAM KHO:
1. Triu chng hc ni khoa Tp 1, trang 254 - 256, NXB Y hc H Ni 2000.
2. Cp cu ho ra mu, trn kh mng phi, trn dch mng phi, trang 56 - 74 NXB Y
hc 1996.
3. Bnh hc lao v bnh phi, trang 446, 456 Tp 2, NXB y hc H Ni 1996.

11
H H I I C CH H N NG G T TR R N N D D C CH H M M N NG G P PH H I I

MC TIU:
1. Nu c nh ngha v 2 nhm nguyn nhn gy trn dch mng phi.
2. M t c triu chng lm sng ca trn dch mng phi.
3. M t c v tr chc d mng phi v hnh nh chp Xquang ca trn dch mng
phi t th thng.
4. Nu c chn on trn dch mng phi.
NI DUNG:
1. M u: Trn dch mng phi l mt cp cu rt hay gp, do nhiu nguyn nhn
gy ra. khoa cp cu hi sc vin lao - bnh phi nm 1994 c 241 trng hp trn
dch mng phi, chim t l 19, 78% s bnh nhn vo cp cu. Tr trng hp trn
dch mng phi do cc bnh c tnh, mi trn dch mng phi u c th iu tr c kt
qu tt nu c pht hin sm v iu tr tch cc, ng cch.
2. nh ngha: Trn dch mng phi l s c mt bt thng ca dch trong khoang
mng phi.
3. Triu chng lm sng:
Trn dch mng phi l mt hi chng do nhiu nguyn nhn nn triu chng lm
sng cng rt phc tp.
3. 1 Triu chng ton thn: Ty theo nguyn nhn gy trn dch.
St: st va trong trn dch thanh t, st cao dao ng trong trn dch m, khng
st trong trn dch mn tnh.
Nhp tim nhanh, mch nhanh, mt mi, th trng suy sp
3. 2 Triu chng c nng:
- au ngc: au nhi hoc m , au bn ngc c trn dch. Thng au giai on
vim, cn khi c trn dch nhiu th au.
- Kh th: t l thun vi s lng dch trong khoang mng phi.
- Ho: thng ho khan, ho tng ln khi thay i t th.
3. 3 Triu chng thc th:
3. 3. 1 Trn dch mng phi th t do:
- Nhn: lng ngc bn c trn dch hi nh ln, khong lin sn rng hn, khi th
di ng ca lng ngc km hn pha khng c trn dch.
- S: rung thanh vng c trn dch gim hoc mt hon ton.
- G: c vng c trn dch
- Nghe: r ro ph nang gim hoc mt. C th nghe thy ting c mng phi trong giai
on u v giai on khi rt nhiu dch. Ba triu chng: g c, rung thanh gim
hoc mt, r ro ph nang gim hoc mt hp thnh hi chng ba gim.
3. 3. 2 Trn dch mng phi th khu tr: Lm sng thng kh pht hin, phi c
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Xquang kt hp vi chc d mi c th xc nh c.
4. X quang phi thng: Ty dch nhiu hoc t s thy din m ln hoc nh.
- Nu trn dch mng phi t: gc sn honh m, t. (Hnh v 4. 1)
- Nu trn dch mng phi trung bnh: m u 2/3 ph trng, c th thy ng cong
Damoiseau m pha lm quay ln trn. (Hnh v 4. 2)
- Nu trn dch mng phi nhiu: m ton b lng ngc bn pha trn dch, khong
lin sn gin rng, tim v trung tht b y v pha i din. (Hnh v 4. 3). (Nu
chiu Xquang th c thm lng ngc bn trn dch km di ng)
- Trn dch mng phi khu tr: hnh m tng ng vi ni trn dch.
5. Siu m: pht hin c dch trong mng phi v mc trn dch.
6. Chc d mng phi: l mt phng php gip cho chn on xc nh, chn on
nguyn nhn gy bnh v iu tr mt s trng hp kh th nhiu do trn dch
lng nhiu.
- Dch chc ra c th: dch vng chanh, dch trong, dch mu hng hoc , dch m,
dch trng c nh sa.
- Dch mng phi ht ra cho vo cc ng nghim a i xt nghim v sinh ha, t
bo, vi khun.
7. Nguyn nhn:
7. 1 Dch thm: C phn ng Rivalta (-), t l Protein < 30g/lt, c t t bo, thng
gp trong cc bnh gy nc trong c th nh:
Suy tim ton b.
X gan.
Hi chng thn h.
7. 2 Dch tit: C phn ng Rivalta (+), t l Protein > 30 g/lt, c nhiu t bo thng
gp trong vim hoc phn ng kch thch mng phi nh:
Trn dch mng phi do lao.
Trn dch mng phi do ung th: ung th ph qun, ung th phi, ung th mng
phi hoc ung th t ni khc di cn vo mng phi.
Vim phi mng phi.
Nhi mu phi.
Vim phi do vi khun.
p xe phi v vo mng phi.
p xe gan v ln phi.
Ngoi ra cn trn dch c cha nhiu cholesterol, dng chp nhng rt him khi
gp.
8. Chn on:
8. 1 Chn on xc nh da vo:
Lm sng: hi chng ba gim.
13
Xquang: c hnh nh trn dch khi chiu, chp phi.
Siu m: c hnh nh trn dch mng phi.
Chc thm d: ht ra c dch.
8. 2 Chn on mc :
8. 2. 1 Trn dch mng phi t:
Triu chng c nng v thc th t, khng r rt.
Xquang phi thng: gc sn honh m, t.
8. 2. 2 Trn dch mng phi trung bnh:
Cc triu chng lm sng biu hin r (kh th, ho, au ngc, hi chng ba gim)
Xquang phi thng: hnh m u 2/3 ph trng, c th thy ng cong
Damoiseau
8. 2. 3 Trn dch mng phi nhiu:
Cc triu chng lm sng biu hin r hn nht l triu chng kh th, hi chng
ba gim rt in hnh.
Xquang phi thng: m ton b lng ngc bn pha trn dch, khong lin sn
gin rng, trung tht v tim b y sang pha i din.
8. 3 Chn on phn bit:
8. 3. 1 Xp phi:trn lm sng cng c hi chng ba gim tuy nhin hnh nh Xquang
ca xp phi l hnh nh co ko cc tng, cc b phn v pha phi xp, khong lin
sn hp li.
8. 3. 2 Vim mng phi dy dnh: cn hi k v tin s, thng trc c trn dch
mng phi do lao hoc vim mng phi m c iu tr khi. Chc d khng c
dch.
8. 3. 3 U phi: lm sng c hi chng ba gim nht l khi u nng. Chn on phn
bit bng cch chiu, chp phi nhiu t th thy hnh nh m m m, trn, b
tng i r. Tuy nhin c trng hp khi u gy trn dch, khi d ch n trn
dch m b st mt khi u nguyn nhn. Thng chc tho ht dch cho chp Xquang
phi mi l ra khi u.
9. Tm li: Trn lm sng c th pht hin c trn dch mng phi qua hi chng
ba gim. Tuy nhin hi chng ba gim cn gp trong: xp phi, u phi, vim mng
phi dy dnh v vy chc d c gi tr chn on quyt nh v gip cho chn on
nguyn nhn. X quang c gi tr chn on quan trng, nht l i vi trng hp trn
dch nh.
TI LI U THAM KHO:
1. Triu chng hc ni khoa Tp 1, trang 253 - 254, NXB Y hc H Ni nm 2000.
2. Cp cu ho ra mu, trn kh mng phi, trn dch mng phi, trang 126 - 136, NXB
Y hc 1996.
3. Ni khoa c s, tp 1, trang 274 - 275, NXB Y hc H ni 2003.
14
4. K thut chm sc ngi bnh - V khoa hc o to. n 03/ SIDA/
INDEVELOP trang 294 - 295.

K KH H M M B B M M Y Y T TU U N N H HO O N N

MC TIU:
1. Khai thc c bnh s v tin s bnh tim mch.
2. Trnh by c cc phng php thm khm h tim mch, v mch mu.
3. xut v nhn nh c kt qu xt nghim.
4. Phn bit c cc ting thi.
5. Trnh by c tnh cht lm sng v c ch pht sinh ca cc ting thi.
6. Phn bit c ting thi thc th vi ting thi c nng v ting c mng tim
vi ting c mng phi.
NI DUNG:
1. i cng: H tun hon gm tim v cc mch mu (ng mch, tnh mch, mao
mch mu v tn mch). N c nhim v quan trng l vn chuyn mu i khp c th
nui cc b phn, v vy nu h tim mch b tm thng th dn ti cc hu qu
nng n, thm ch nh hng ti tnh mng ngi bnh.
Ngy nay, trn th gii cng nh trong nc, t l ngi bnh cht v cc bnh
tim mch vn chim cao nht. Trong my nm gn y theo thng k ca T chc Y
th gii kho st 27 nc, cho thy trung bnh c 1. 000. 000dn th c 327 ngi
cht v bnh tim mch, nhng ngi trn 65 tui th t l cht v bnh tim l 35%.
Vit Nam, theo thng k ca khoa Ni bnh vin Bch Mai, bnh tim mch
chim t l gn 27%, so vi cc bnh ni khoa khc, bnh tim mch ng vo hng
th hai, th ba.
2. Cc phng php thm khm h tim mch.
2. 1. Khm tim: Cc phng php lm sng.
2. 1. 1. Hi bnh: Ngi bnh tim thng biu hin mt s triu chng do ri lon
chc nng tim, cc triu chng l: Kh th, ho ra mu, tm ti, ph, au ngc trc
tim, hi hp, ngt v. v. . .
Trong khi hi bnh, cn phi khai thc cc triu chng trn v lu thm mt s
vn sau:
- Lc nh, ngi bnh c tt bm sinh g khng ?
- Trc kia ngi bnh c b thp khp cp khng ?
- Ngh nghip v iu kin lm vic ca ngi bnh, c cng thng qu khng?
C phi tip xc vi cht c g khng ?
- Tnh trng thn kinh nh th no ? mc ch l xc nh mt s triu chng
tim mch m nguyn do thuc v thn kinh tm thn nh ri lon thn kinh tim, tim
15
kch ng.
- Ngi bnh c dng nhiu ch, ru, c ph, thuc l khng ? (v nhng th
ny nh hng n hot ng tim mch).
- C ri lon g v h ni tit khng? c bit ph n nh trong giai on mn
kinh chng hn.
2. 1. 2. Triu chng lm sng:
2. 1. 2. 1. Nhn: Trc ht xem ngi bnh c kh th khng? C ph khng ?
Tnh trng tinh thn nh th no? C lo lng hong ht khng? Sau :
- Nhn xt mu sc da v nim mc ngi bnh: Mi tm trong cc bnh tim bm
sinh, trong suy tim. Ngn tay v ngn chn di trng gp trong cc bnh tim bm sinh
hoc vim mng trong tim bn cp v mt s bnh phi mn tnh hoc u phi.
- Nhn xt hnh dng lng ngc: Lng ngc d ra trc nhng ngi b bnh
tim t b v lc t ct ha cha hon ton nn lng ngc d bin dng.
- Nhp p ca tim: ngi bnh thngta c th nhn thy mm tim dp di v
trn ng gia xng n vo khong gian sn 4-5 mm tim p mnh trong
trng hp tht tri to hoc tim to ton b, mm tim p yu trong trng hp trn
dch mng ngoi tim hoc nhng ngi bo c thnh ngc dy.
- ngi b ti phnh ng mch ch: ta c th nhn thy mt khi u p
khong gian sn 2 st hai bn xng c, khi u p theo nhp tim.
- Tnh mch c ni trong suy tim phi, ng mch c p mnh trong bnh h
van ng mch ch.
- Cn khm xem tuyn gip trng c to khng ? V c mt s ngi b cng
tuyn gip c bin chng tim.
- Vng thng v v trung v h sn phi: C th thy vng thng v p
theo nhp tim khi tim phi to, khi suy tim phi hoc suy tim ton b: Gan thng to ra,
ta nhn thy vng h sn phi dy hn bn kia.
2. 1. 2. 2. Phng php s:
+ Tm mm tim: S mm tim hai t th (nm nga v nghing sang tri).
Bnh thng mm tim p khong gian sn 4-5 trn ng gia xng n
bn tri. Mun s mm tim ta dng lng bn tay p st vo lng ngc ch mm tim.
Mm tim c th thay i v:
- V tr: Bnh thng khi nm nghing sang tri, mm tim s lch sang tri khong
hai khot ngn tay, t th ny s thy mm tim r nht. Khi nm nghing sang phi,
mm tim lch sang phi rt t. Trong trng hp bnh l tim to ra, mm tim thp
xung hoc ra ngoi ng gia n tri. Trong cc trng hp trn dch v trn kh
nhiu mng phi mt bn, tim b y sang bn kia. Trng hp dy dnh mng phi
v mng tim. Tim s b co ko v pha vim dy dnh, nu ch c cc mng tim dnh
vo nhau v dnh vi phi tip cn th din tim nh li v mm tim khng i v tr d
16
ngi bnh thay i t th. Trng hp c trn dch mng bng nhiu hoc c khi u
to trong bng, c honh b y cao ln v mm tim cng thay i v tr: tim t th
nm ngang.
- Cng : Mm tim p khng r ngi bo qu, trong bnh vim mng
ngoi tim c trn dch hoc dy dnh mng tim. Mm tim p mnh trong trng hp
tim tri to, trong bnh h van ng mch ch hoc trng hp cm ng.
+ S tm cc ting rung miu: Trong cc bnh tim, c th gp: Cc trng hp
dng mu phi xoy mnh qua mt ch hp (v d: Hp van ng mch ch, hp van
2 l. . . ) do tc mu i nhanh, xoy qua ch hp lm rung cc t chc van, thnh
tim, thnh mch ln cho nn khi t tay vo thnh ngc gn ch lung mu qua ch
hp ta d thy mt cm gic rung ging nh khi t tay ln lng mo lc n rn. Cm
gic gi l rung miu. Ty theo rung miu th tim bp hay tim gin m ta gi l
rung miu tm thu hoc rung miu tm trng.
2. 1. 2. 3. Phng php g tim: Mc ch xc nh v tr, kch thc tim v ng
mch ch, c trng hp g ng vai tr rt quan trng chn on bnh, v d trong
bnh trn dch mng ngoi tim, ta cn g xem din tim to ra n u. Din c ca tim
bnh thng chiu ln thnh ngc l mt hnh 4 cnh gn ging hnh thang.
- Tm mm tim: Nu gp trng hp nhn v s vn cha xc nh c th g
cho t di ln trn, t trng sang phi n ch bt u c, l v tr t mm tim.
- Tm b trn gan: t ngn tay gia dc theo k lin sn bt u t di xng
n, g t trn xung di cho n lc va ti vng c ca gan, l b trn gan,
bnh thng gii hn c ca b trn gan mc gian sn 5.
- Tm b phi tim: Tay tri t ngn gia song song vi xng c, u ngn
trong rnh gian sn, dng tay phi g vo ngn gia tri, g t ng nch trc tr
vo theo khoang gian sn cho n khi thy vng c ca b phi tim, c nh th g
t trn xung di ghi ly im gp nhau ca b phi tim v b trn gan. Bnh thng
vng c ca b phi tim khng vt qu b phi xng c, tr ch st b trn gan th
c ra bn phi xng c t 1-1, 5cm. B phi tim ng vi tm nh phi, chiu cao
ca b ny thng khng qu 9cm.
- Tm b di tim: Ni mm tim vo giao im ca b phi tim v b trn gan, ta
c b di tim, b ny ng vi tm tht phi, thng thng b ny khng di qu
12cm.
- Tm b tri tim: Ta g chch t hm di nch tri v pha mi c, g t ngoi
vo trong, t trn xung di, song song theo hng thng thng ca b tim cho n
khi tm c mt ng gii hn din c ca b ti tim. Bnh thng gii hn ny i
t st b tri xng c ch xng sn 2 i xung, ct ngang ng, cnh c ri
phnh ra thnh mt ng cong cho ti gian sn 4-5 pha trong ng gia xng
n t 1 -2 cm. B tri ch yu ng vi tm tht tri.
17
- Tm b trn tim: G t trn xung st hai bn cnh c xc nh b trn tim,
thng b trn ny t c gi tr chn on trong thc t, gii hn c ca b trn
thng t xng sn 2.
Cc gii hn ni trn l gii hn vng c tng i ca tim, tc l khong chiu
ca tim ln lng ngc ni c phi xen gia tim v thnh ngc.
2. 1. 2. 4. Phng php nghe tim.
Cch nghe: Nn nghe u t th, nm nga, nm nghing sang tri, ngi. Cn nghe
c 5 van tim.
+ van hai l: mm tim, vo khong gian sn 4 hc xng sn 5 trn
ng v tri. Khi b bnh, mm tim c th sa xung thp hoc sang tri th phi nghe
v tr mi ca mm tim.
+ van 3 l: trn sn sn 6 bn phi.
+ van ng mch: Mt khong gian sn 2 bn b phi xng c v mt
na lin sn 3 st b tri c gi l Erb-Bottkin.
+ van ng mch phi: khong gian sn 2 bn tri st xng c.
Ting tim: Bnh thng trong mi chu chuyn tim ta nghe c 2 ting.
- Ting th nht nghe trm di gi l T 1.
- Ting th 2 nghe thanh v gn hn, gi l T2
Ting th nht cch ting th hai bi mt khong ngh ngn, ting th hai cch
ting th nht ca chu chuyn sau bng mt khong ngh di. Ting th nht tng
ng vi lc mch p, tc l m u th tm thu. Ting th hai tng ng vi mch
chm, m u th tm trng.
Ting th nht nghe r mm tim, ting th hai nghe r hn y tim. mt s
tr em v thanh nin, c khi ta nghe c mt ting th ba theo sau ting th hai.
Ting th ba ny ch l ting tim sinh l do mu dn mnh t nh xung tht thi k
u tm trng. Cng ting tim ph thuc vo 5 yu t: thnh ngc, mi trng
gia tim v ngc, mu, c tim v van tim.
+ Cng tng: Hai ting tim u mnh hn khi tim b kch thch nh khi b
cm ng, sau khi tp th thao, lao ng mng, khi st, trong bnh cng tuyn gip
ngi gy thnh ngc mmg ting tim nghe r hn nhng khng phi bnh l.
+ Cng gim: C tim yu nn van tim cng p yu, mt khc van tim c
bao ph bi lp mng. Bnh thng mng trong tim nhn nhi, khi b vim, b ph van
th ting van p khng mnh na.
Bnh thng l tng v l thnh ca mng ngoi tim trt st vo nhau, khi c
nc gia hai l th ting tim truyn ra lng ngc b cn li nn nghe ting tim
khng r na, do ta gp hai ting tim nghe nh trong:
Trn dch mng ngoi tim.
Vim c tim, nhi mu c tim.
18
Vim mng trong tim cp.
Cn ch ngi bo, n gii do tuyn v cn tr, ting tim cng nh.
* Thay i cng ting th nht mm tim:
- Ting th nht anh trong bnh hp van hai l, l do v:
Cc van tim b dy, cng do vim, khi ng li cc van p vo nhau gy ra ting
anh.
im na, trong bnh hp van hai l, mu dn v tht tri t nn khi cn. . . . . . sc
co bp ca c cn tt, n khng b gin ra nhiu trong th tm trng nn khi bp s
nhanh tm thu ngn v th ting gn anh.
Ting th nht m trong cc bnh c tim v vim mng trong tim v c tim b vim
nn co bp yu v cc van tim b vim nn ph khp khng kn lm cho ting tim b
m.
* Thay i cng th hai:
ng mch ch:
- Gim: Cng vi ting th nht trong vim mng trong tim cp.
- Tng: Trong bnh tng huyt p v trong trng hp huyt p cao, mu
dn v thnh van mnh lm ting T 2 mnh trong u th tm trng.
ng mch phi:
- Bnh thng ting th hai van ng mch phi vn mnh hn ting th
hai ng mch ch v ng mch phi st thnh ngc hn.
- Trng hp bnh l ting th hai anh trong bnh hp van hai l, v trong
bnh ny mu li nh tri ri li tiu tun hon nn mu ng
mch phi dn mnh v thnh van khi ng gy ra ting anh.
* Thay i v nhp:
Bnh thng nhp tim rt u do h thng thn kinh t ng chi phi. Khi h
thng ny b tn thng nhp tim s nhanh, chm hoc lon nhp.
* Thay i v s lng ting tim:
Nhp ba ting: Cc loi nhp ba ting sau y c to bi:
- Ting th hai phn i sinh l.
- Ting th nht phn i sinh l.
- Ting Clc m van hai l.
- Ting nga phi.
Ting th hai phn i sinh l: Nghe r khong gian sn 2 hoc 3 bn tri vo
cui th th vo, khng nghe thy thng xuyn (ch c chu k).
Cn phn bit ting th hai phn i sinh l vi:
- Ting th hai phn i bnh l (thng c lin tc trong bnh hp van hai l).
- Ting th ba ca tim (ting th ba ca tim bao gi cng nghe sau ting th hai
mt thi gian v v tr nghe ting th ba li mm tim.
19
Ting th nht phn i:
Gm hai ting rt st nhau, nghe r vng mm tim hoc pha trong ng gia
xng n trn gian sn 5 bn tri. Thng nghe c khi ngi bnh ng, cn khi
nm ting nh i hoc khng nghe thy. Ting th nht phn i sinh ra do cc van
nh tht ng khng u. N c th gp mt s ngi tim hay kch ng.
Ting Clc m van 2 l: L mt ting thm vo sau ting th hai nghe ging nh
ting Clc, m sc kh, nghe r khong gian sn 4-5 tri vng trong mm tim,
i khi nghe c vng y tim. Ting ny c gi tr trong bnh hp van hai l, n
pht sinh do van hai l x cng, cc mp van khi m ra tch khi nhau nghe thnh
ting Clc.
Ting nga phi: Nhp ba ting ny do mt ting nh thm vo thi k tm
trng. Ting ny sinh ra trong trng hp tm tht b suy nhiu, d gin ra khi mu t
nh dn xung tm tht v y mm tim chm vo thnh ngc lm ta nghe c thm
mt ting trong thi tm trng.
Ting nga phi nghe r nht vng trong mm tim, hoc mm tim, khi ngi
bnh nm nghing v bn tri s nghe r hn, ting ny thng khu tr mt ni
nht nh khng lan xa. Ta thng gp ting thm vo ny th tin tm thu (gi l
nga phi tin tm thu). Nga phi tin tm thu sinh ra do nh bp y mu xung
lm gin thnh tm tht. Cn loi nga phi u tm trng sinh ra do tm tht
nho qu nn ngay khi cc van nh tht m, lung mu t tm nh xung di vo
thnh tm tht lm gin thnh tm tht ngay. Ngi ta gi l ting nga phi phi
hay tri ty theo tm tht phi hay tm tht tri b suy. Nga phi phi nghe r
cnh mm c, nga phi tri nghe r mm tim.
*Cc ting thi: Gm c ting thi thc th v ting thi chc nng
Ting thi thc th:
- V tr: Ty theo tn thng van no, ting thi s nghe r van (van hai l,
van ba l, van ng mch ch, van ng mch phi). V d ting thi tm thu mm
tim trong bnh h van hai l.
- Thi gian: Ting thi c th chim c hoc chim mt phn th tm thu hoc tm
trng th gi l ting thi lin tc, ting thi ny nghe , nh ting xay la nhng
thng mnh ln trong th tm thu. Cn c vo thi gian c: Ting thi tm thu, ting
thi tm trng (ring ting thi tm trng mm tim c m sc nh ting rung di
trng trn mt trng nn gi l ting rung tm trng) v ting thi lin tc.
- Lan truyn: Trong a s trng hp ting thi thng lan truyn theo hng i ca
dng mu. Ting thi nghe r nht v tr van tn thng, cc ni khc nghe t r hn
l hng lan ca ting thi.
- Cng , m thanh, m sc: Ting thi nghe trm nu dng mu qua mt l tng
i to, m thanh nghe cao nu l nh hn. m sc cao, th, rp khi cc thnh ny cn
20
mn hoc sng ph c tht si, tn thng cn mi hoc ang tin trin.
- C ch pht sinh cc ting thi: Cc ting thi tim pht sinh bi mt nguyn do l
dng mu i t ch rng vo ch hp ri li qua ch rng.
* Trong trng hp h van hai l, ting thi tm thu pht sinh do dng mu
pht t tht tri ln nh tri qua l van hai l khng ng kn.
* Trong bnh hep van ng mch ch v hp van ng mch phi, ting thi
sinh ra do dng mu t tht tri v tht phi i qua l hp ca cc van t chim trong th
tm thu.
* Trong bnh h van ng mch ch c ting thi tm trng v c mt lung
mu t ng mch ch chy v tht tri trong th tm trng do van ng mch ch
ng khng kn.
* Trong bnh h van ng mch phi c ting thi tm trng v c dng mu
t ng mch phi chy li tht phi trong th tm trng do van ng mch phi h.
* Trong bnh thng lin tht, dng mu i t tht tri sang tht phi qua l thng
gy ra ting thi.
* Trong bnh hp van 2 l, ting rung tm trng pht sinh do lung mu i t
nh tri dn qua ch hp ca van v va vo h thng dy chng ct c.
* Trong bnh cn ng ng mch, c ting thi lin tc l v c dng mu xoy
qua ng, ng thi v c s thay i p lc mu t ng mch ch ti ng mch phi
m gy ra ting thi lin tc.
Bng sp xp cc ting thi thc th.

Ting
thi
a im Tnh cht Hng lan Tn bnh
Ting
Thi
Tm
Thu
Mm tim
Chim ht th tm thu
nh ting pht hi
nc c th c rung
miu
Ra nch v sau
lng
H van hai l
Gian sn hai
tri cnh c
C rung miu, chim
ht th tm thu
Xng n tri
Hp van ng
mch phi
Gian sn hai
phi cnh c
C rung miu, chim
ht th tm thu
Xng n
phi
Hp van ng
mch ch
Gian sn 3-4
tri vng
trc
C rung miu, chim
ht th tm thu
Lan theo hnh
cc nan hoa
bnh xe
Thng lin
tht
Thi
tm
Gian sn 2
phi hoc 3 tri
Nh, m nh ht vo
Dc xng c
hoc bt cho
H van ng
mch ch
21
trng cnh xng c xung mm
tim
Rung
tm
trng
Mm tim
Nh ting v nh di
trn mt trng c rung
miu tm trng
t lan
Hp van hai
l
Ting
thi
lin tc
Gian sng 1,
2 tri
Mnh ln cui th
tm thu u tm
trng, c th c rung
miu
Xng n tri
Cn ng ng
mch
Ting thi chc nng:
C khi van tim khng b tn thng nhng v mt l do no lm bung tim
gin to, cc van khng ng kn c na. V th pht sinh ting thi khi tim co bp.
c im ca loi ting thi ny thng m du, t khi lan v hay thay i, khng bao
gi c rung miu c v d: Ting thi chc nng trong nhng trng hp suy tim tri,
trong bung tim b gin to khin cc van khng ng kn c na gy ra h chc
nng ca van hai l v pht sinh ra ting thi. Ting thi chc nng s mt i khi ta
iu tr suy tim lm cho bung tim nh li.
Bng phn bit ting thi thc th v ting thi chc nng.

Ting thi thc th Ting thi chc nng
V tr C c 5 van tim
Hay c ng mch phi sau
n van hai l
Thi gian
Tm thu, tm trng, lin
tc
Ch yu l ting thi tm thu m t
khi chim ht th tm thu, rt t khi
gp ting thi tm trng chc
nng
Cng m
sc
Thng mnh r (tr ting
thi tm trng khng
mnh bng)
Thng nh, m du, rt t khi
mnh, nu c mnh cng khng
c rung miu.
Lan truyn Lan xa theo dng mu t lan
Rung miu
Thng c, nht l trong
cc trng hp hp van
Khng c
Tnh cht
thng xuyn
C thng xuyn, khng
thay i khi thay i t th
ngi bnh
C th thay i, thm ch mt hn
khi ngi bnh ht vo su, i t
th hoc sau kt qu iu tr
2. 1. 2. 5. Ting c mng ngoi tim
C ch: Trong trng hp bnh l, hai l ca mng ngoi tim b vim nhim s mt
22
tnh cht nhn bng thng c v tr nn rp v gia hai l hnh thnh nhng m
gi mc, cho nn khi co bp, cc l ca mng ngoi tim khng th trt trn nhau im
lng nh bnh thng m pht sinh ra ting c.
Tnh cht lm sng: l ting cng thm vo cc ting tim bnh thng, nghe rt
gn bn tai. C th c mt hay hai ting.
V tr: Nghe r vng trc tim, st xng c tri gn mi kim, n khng lan,
nghe thy hai ting i vi hai th ca tim, ting c sinh ra v mt i cng mt ch.
Thi gian: vo sau hai ting tim, nhng thng nu nghe thy hai ting c th ting
tim ch nghe khng r na.
Cng , m sc: ting nghe rp nh hai ting la mi c vo nhau.
Cn phn ting c mng ngoi tim vi ting c mng phi: Ting ny mt i khi
ngi bnh nn th.
Ting c mng ngoi tim thng gp trong trng hp: Vim mng ngoi tim
kh v vim mng ngoi tim c trn dch giai on u lc nc cn t, hoc giai
on sau lc nc rt i.
2. 1. 3. Cn lm sng
2. 1. 3. 1. Xquang tim mch.
Chiu: Dng cch chiu ta c th thay i ngi bnh qua nhiu t th khc nhau.
Khi chiu ta s xem: Hnh th, kch thc v tr tim v cung tim, S co bp v gin
n ca tim, ni cch khc l xem tnh trng tim v ng mch ch p nh th no;
hnh thi cc ng mch phi ra sao, v tnh hnh c ng ca c honh.
Chp X quang tim:
- T th thng: Bn phi: Cung trn tnh mch ch trn v cung nh phi di.
Bn tri: T trn xung di c: cung trn quai ng mch ch, cung
gia thn ng mch phi v cung di l tm tht tri.
T th chch phi trc (nghing 45
0
, vai phi ng trc): Trn phim thy hnh
tim pha phi ct sng, pha trc v sau ct sng cn thy t chc phi:
- B trc: t trn xung l: Phn trn ca ng mch ch, thn ng mch phi
v tm tht tri.
- B sau: Phn xung ca ng mch ch, tm nh tri v tm nh phi.
T th chch tri trc (nghing 45
0
vai tri ra trc):
- B trc: t trn xung di l: Tnh mch ch trn, Phn ln ca ng mch
ch v tm nh phi.
- B sau: Khc xung ca ng mch ch, tm nh tri v tm tht tri.
S thay i hnh th, v tr tim trong mt s trng hp.
V tr tim b y ln hay ko xung:
ngi bo, bng to hoc do c mang hoc do trn dch mng bng y c honh
cao ln lm cho tim nm ngang v mm tim lch sang tri, b tim chuyn sang tri,
23
nhng tim khng b to ra.
ngi gy, cao hoc c honh thp xung, tim c hnh nh nh th vo gia ngc,
sau xng c, c trng hp tim b qu ngi ta gi tim hnh git nc.
Tim lch ch:
Mt s trng hp d dng bm sinh, tim khng nm bn tri m nm bn phi, cc
ph tng khc cng c th o ln bn tri sang bn phi hoc ch ring tim b thay i
v tr thi.
Mt s trng hp trn dch, trn kh nhiu mng phi mt bn s y tim sang
bn kia.
Cc tn thng xng ca mng phi, phi cng c th co ko tim v pha x.
Kch thc:
+ Tht tri to:
- Trn X quang thy cung di tri to.
- t th chch tri trc: Mt vng sng sau tim.
+ Tht phi to:
- Nhn thng: Hnh tim, hnh mi hia, nh hnh ui vt bu v mm tim nghing
ln.
- Nhn nghing b trc tim st vi xng c trn mt on di hn.
+ Nh tri to:
- Nhn nghing: Cho ngi bnh ung Baryte thy Baryte i xung qua mt ch
hp v nh tri vo.
- Nhn thng: Khi nh tri to nhiu vt sang bn phi thnh mt ng cong
chng ln cung nh phi.
+ Nh phi to:
- Nhn thng: Cung nh phi phng to.
- Nhn chch phi: Cung di ph sau to ra.
+ ng mch ch to: Cung trn tri ni to, ni r sang tri.
+ ng mch phi to nhn thng: Cung gia tri to
Hnh nh X-quang trong bnh tim.
+ H van hai l: Cung di tri to v tht tri ph i.
+ Hp van hai l: Nh tri to, tht phi to nn:
Nhn thng: B tim tri 4 cung.
Nhn nghing (ung baryte): Thc qun b do nh tri to.
+ H ng mch ch:
- Cung di tri ln gn st b gian sn do tht tri to.
- ng mch ch p mnh.
- ng mch ch cong nhiu hn, cung ng mch ch rng ra.
+ Trn dch mng ngoi tim.
24
Tim to ton b, hnh nh mt bu nc, c th xa cc b cung ca tim. Bin
tim p rt yu.
Gc tm honh hai bn thnh gc t.
Cung tim b che lp vo hnh tim.
2. 1. 3. 2. in tm .
Dy nh tri. : DII: Sng P > 0, 11 giy, Sng P hnh lng lc . T l gia rng
sng P v PR > 1. 6. ; V
1
: Pt > 0, 04 mm giy, Trc sng P lch tri: - 30
0
- + 45
0
.
Dy nh phi: DII: Sng P 2, 5mm, V
1
: Pi > 0, 06 mm giy (Pi = Pinitial force).
Trc sng P lch phi: > 70
0
(P ph). . .
Dy hai nh. P DII: Rng v cao, PV
1
: Pi > 1, 5mm, Pt > 0, 03 giy.
Dy tht tri: Tiu chun Sokolov Lyon: SV
1
+ R (VS hoc V6) > 35mm, hoc
RV5 hoc V6 > 26 mm.
Dy tht phi: Tiu chun Sokolov Lyon: R V
1
+ S (VS hoc V6) 11mm.
Dy 2 Tht: R cao trn tt c cc chuyn o ngc.
2. 1. 3. 3. Siu m tim (Siu m hai chiu): Cho php kho st cu trc qu tim ang
vn ng, o phn sut tng mu, p lc ng mch phi. . .
2. 1. 4. Khm mch mu.
2. 1. 4. 1. Khm ng mch.
Nhn:
+ ln ca chi: Chi teo nh trong trng hp suy tun hon ngoi vi mn tnh, c
th teo c cng chn, c i cng nh m di da.
+ Mu sc ca chi: Bnh thng mu vng nht v hi nng.
- Trong trng hp gin mch da v nng hn.
- Nu tun hon km lu thng, chi b thiu dng s vo thy lnh, da tm ti v
nht.
Ta c th dng nghim php sau y khm v ri lon dinh dng ca chi:
a mt s chi ln cao trong 30 giy th chi nht mu so vi chi bnh thng, cc
ngi bnh b tc ng mch, ty theo mc tc, cng tc nghim trng th mu sc
da ca chi cng nht mu khi gi cao.
Trong cc trng hp u mch mu hoc phng ng mch, ta thy mt u trn
ng i ca mch, c c im: U mm, p theo nhp p ca ng mch, s c
thy rung miu nu u to v thnh cc huyt qun ln.
Nhn mt s ng mch nng nh ng mch thi dng, ng mch cnh tay,
ng mch quay. . . C trng hp ngon ngoo v ny nhp nhng gi l du git dy
chung gp ngi b x cng ng mch c huyt p cao.
Pht hin ch lot hoc hoi th do tn thng: c th do b thiu mu ti ch lm
cho cc phn xa ca chi (ngn tay, ngn chn, cc mng) khng c dinh dng
ri lot, kh mng, rng mng hoc hoi th tng t ca ngn tay, ngn chn (gp
25
trong trng hp bnh vim tc ng mc, ri lon thn kinh vn mch).
S ngai da: Kho st nhit da: Thng ta s bng mu bn tay: Bnh thng
da ngi c dinh dng s hi nng. Nu da lnh l do tun hon ng mch
km, nh trong bnh Reynaud, bnh vim tc ng mch. Da c th nng nhiu trong
trng hp phnh ng mch.
S ng mch: Dng u cc ngn tay (cc ngn 2, 3, 4) t vo rnh ng mch
quay pha trn c tay s mch. Ngoi ng mch quay c th s cc mch bn,
mch thi dng, mch cnh, mch mu chn. . . nn bt mch 2 bn so snh. Khi
bt mch ta s nhn nh v: Tn s, thay i v nhp, thay i v bin v chc,
nht l khm ng mch thi dng tm du hiu dy thng di tay trong bnh x
va mch.
Nghe ng mch: Bnh thng khi nghe ng mch, ta c th nghe c mt
ting nh th tm thu, ring cc ng mch gn tim nh ng mch ch, ng
mch cnh, ng mch di n ta cn nghe c mt ting th hai l ting lan ca
ting tim th hai.
Phng php o huyt p ng mch: o huyt p cng tay, 1/3 di
cng chn, ng mch khoeo, 1/3 di i. Li ch ca vic o huyt p tng ni
l chn on xem ng mch tc mt phn hay ton phn, chn on v tr tc ca
ng mch quyt nh chn on iu tr.
Khm ng mch bng dng c:
+ Chp ng mch sau khi bm cht cn quang: Dng xc nh xem ng mch c
b tc khng? C t khng ? Nu tc th tc on no? C u mch? C phnh ng
mch hoc u cnh mch p lm cn tr tun hon ng mch.
+ ng mch : Ngi ta phn tch hnh dng, bin ng ca ng mch chn
on mt s bnh.
+ Siu m mch mu tm du hiu x va mch, cht hp, tm nhn calci, phnh
mch...
2. 1. 4. 2. Khm tnh mch:
Nhn:
- Tnh mch ni to v ngon ngo chn trong trng hp gin tnh mch.
- Cng c trng hp tnh mch ni to l biu hin th pht ca mt bnh khc nh:
Tnh mch c ni to trong suy tim, cc trng hp x gan teo, chn p tnh mch ln,
vim tc tnh mch ln bn trong v. v. . . cc tnh mch ngoi nng, ni ln v pht
trin cc nhnh bn bng gi l tun hon bng h. Ngi ta chia ra 3 loi:
a. Tun hon bng h gnh ch: gp trong bnh x gan, mu trong tnh mch
gnh li li i vo cc nhnh ph vo tnh mch ch trn hay ch di. Trong
loi tun hon gnh ch trn, cc nhnh bn xut hin nhiu rn, h sn phi (ni
tnh mch gnh vi tnh mch ch trn). Trong loi tun hon gnh ch di, cc
26
nhnh bn xut hin rn (ni tnh mch gnh vi tnh mch ch di).
b. Tun hon bng h ch di: Gp trong cc trng hp chn p hoc vim tc
tnh mch ch di, cc nhnh bn xut hin bn bn, hai bn bng di i ngc
ln trn (cc nhnh ni t tnh mch ch phn di i ln tnh mch ch phn trn ch
tc).
c. Tun hon bng h ch trn: Gp trong cc hi chng chn p trung tht. Tnh
mch ch trn b , mu vo tim phi qua cc nhnh ph. Ta thy tun hon bng
h xut hin ngc, ch yu bn phi, ng thi c biu hin ph o khoc, tnh mch
ni to.
S: Ta c th c mt bi cc tnh mch gin ra nh trong trng hp gin tnh
mch thng tinh, gin m ri tnh mch khoeo.
Trng hp c l thng gia ng mch v tnh mch, ta s thy rung miu da gn
ch thng.
Nghe: Trng hp c l thng ng - tnh mch th nghe gn ch thng, c th thy
ting thi lin tc.
TI LI U THAM KHO:
- Triu chng hc Ni khoa tp I. Nh xut bn Y hc H Ni 1988
- Ni khoa c s. Nh xut bn Y hc H Ni 1997.
- Tim mch hc Nh xut bn Y Trng i hc Y Dc TP H Ch Minh 2001.

H H I I C CH H N NG G S SU UY Y T TI IM M
MC TIU:
1. Trnh by c nh ngha suy tim.
2. Chn on - nguyn nhn ca suy tim tri, suy tim phi, suy tim ton b.
3. Trnh by c phn loi mc suy tim theo Hi tim mch New York v Hi
ni khoa Vit Nam.
NI DUNG:
1. Mt vi nh ngha.
Suy tim xy ra khi tim khng p ng cung lng duy tr kh nng chuyn ho
ca c th.
Da vo sinh l bnh v s khc bit ca phng php iu tr ngi ta thng
phn ra:
- Suy tim cp
- Suy tim mn
- Suy tim tm thu
- Suy tim tm trng
- Suy tim tri, suy tim phi, suy tim ton b.
Suy tim cp bao gm ph phi cp, sc tim v c th l t mt b cp ca suy
27
tim mn.
Suy tim tm thu xy ra khi kh nng tng mu ca tim gim (phn xut tng mu
gim). Cc triu chng lm sng chnh thng l cc triu chng cung lng tim thp
nh mt mi, cm thy yu, tay chn lnh do gim ti mu ngoi vi, l ln, l ,
lng nc tiu gim, cui cng l sc.
Suy tim tm trng xy ra khi n hi (compliance) ca bung tht gim, do
nhn mu km. Cc triu chng lm sng chnh thng l cc triu chng sung huyt
phi v mch h thng nh:kh th khi gng sc, kh th phi ngi ph phi, dn tnh
mch c, ph chi, trn dch mng phi, mng tim, sung huyt gan.
2. Nguyn nhn.
2. 1. Suy tim tri:
* Tng huyt p ng mch: l nguyn nhn thng gp nht gy ra suy tim tri.
Chnh tng huyt p lm cho cn tr s tng mu ca tht tri tc l lm tng hu
gnh.
* Mt s bnh van tim:
- H hp van ng mch ch n thun hoc phi hp vi nhau.
- H van hai l.
* Cc tn thng c tim:
- Nhi mu c tim.
- Vim c tim do thp tim, nhim c hay nhim khun.
- Cc bnh c tim.
* Mt s ri lon nhp tim: c 3 loi ri lon nhp tim ch yu c th a n bnh
cnh ca suy tim tri.
- Cn nhp nhanh kch pht trn tht, nht l cn rung nh hay cung ng nh.
- Cn nhp nhanh tht.
- Block nh tht hon ton.
* Mt s bnh tim bm sinh:
- Hp eo ng mch ch
- Con ng ng mch
- ng nh tht chung. . .
2. 2 Suy tim phi:
- Cc nguyn nhn v phi v d dng lng ngc, ct sng. Cc nguyn nhn v ct
sng v d dng lng ngc khc.
- Hp van hai l l nguyn nhn thng gp nht Vit Nam.
- Mt s bnh tim bm sinh: hp ng mch phi tam chng Fallow. Mt s bnh tim
khc c lung Shunt tri - phi (thng lin nh, thng lin tht . . . ) n giai on
mun s c bin chng ca tng p ng phi v gy suy tim phi.
- Vim ni tm mc nhim khun gy tn thng nng van 3l.
28
- Mt s nguyn nhn t gp: u nhy nh tri, v ti phnh xoang Valsalva vo cc
bung tim phi. . .
2. 3 Suy tim ton b:
- Thng gp nht l cc trng hp suy tim tri tin trin thnh suy tim ton b
- Cc bnh c tim gin.
- Vim tim ton b do thp tim, vim c tim.
- Cui cng cn phi nhc n mt s nguyn nhn c bit gy suy tim ton b vi
lu lng tng: Cng gip trng, thiu vitamin B
1
, thiu mu nng, r ng - tnh
mch.
3. Cc yu t nguy c: Tui gi, mp ph, tng huyt p, thiu mu c tim cc b,
tiu ng typ II. . .
4. Triu chng lm sng:
4. 1. Triu chng Suy tim tri:
4. 1. 1. Triu chng c nng:
+ Kh th: l triu chng thng gp nht. Lc u ch kh th khi gng sc.
V sau kh th xy ra thng xuyn, bnh nhn nm cng kh th, nn thng phi
ngi dy th.
- Din bin v mc kh th cng rt khc nhau:c khi kh th n mt cch dn
dn, nhng nhiu khi kh th li p n mt cch t ngt, kh th d di nh trong
cn hen tim, ph phi cp.
+ Ho: Hay xy ra vo ban m hoc khi bnh nhn gng sc. Thng l ho khan,
nhng cng c khi ho ra m ln vi mt t mu ti.
4. 1. 2. Triu chng thc th:
+ Khm tim:
- Nhn v s thy mm tim p hi lch sang tri.
- Nghe tim: ngoi triu chng c th gpca mt bnh van tim gy nn suy tim
tri, ta thng thy 3 du hiu:
* Nhp tim nhanh.
* c th nghe thy ting nga phi.
* Cng thng thy c mt ting thi tm thu nh mm, du hiu ca h hai l
c nng v bung tht tri gin to.
+ Khm phi:
- Thng thy c mt s ran m hai y phi. Trong trng hp cn hen tim ta
c th nghe c nhiu ran rt ran m phi, cn trong trng hp ph phi cp ta s
nghe thy rt nhiu ran m to nh ht t hai y phi dng nhanh ln khp hai ph
trng nh thu triu dng
+ Huyt p: Trong a s cc trng hp, huyt p ng mch ti a thng b
gim xung, huyt p ti thiu bnh thng nn s huyt p chnh lch thng b nh
29
li.
4. 1. 3. Cn lm sng:
+ Xquang:
- Tim to ra, nht l cc bung tim bn tri. Trn phim thng:tm tht tri gin,
biu hin bng cung di bn tri hi phng v b ko di ra.
- C hai phi u m, nht l vng rn phi.
i khi c th gp hnh nh ng Kerley (do ph cc t chc k ca h thng bch
huyt phi).
+ in tm :
- Thng ch thy nhng du hiu th hin tng gnh ca cc bung tim tri:
- Trc tri, dy nh tri v dy tht tri.
+ Siu m tim: Thng thy kch thc cc bung tim tri (nh tri v nht l
tht tri) gin to.
Ngoi ra siu m tim cn gip cho chng ta bit c s co bp ca cc vch tim
cng nh nh gi c chnh xc chc nng ca tm tht tri.
Trong nhiu hp, siu m tim cn gip cho ta khng nh c mt s nguyn
nhn gy ra suy tim tri nh: cc tn thng ca van ng mch ch, bnh c tim.
+ Thm d huyt ng: Nu c iu kin thng tim v chp mch - tim s cho php
ta:
- nh gi mc suy tim tri thng qua vic do ch s tim (bnh thng: 3 - 3,
5 l/pht/m
2
), o p lc cui tm trng ca tm tht tri.
- nh gi chnh xc mc nng nh ca mt s bnh van tim.
4. 2. Triu chng suy tim phi:
4. 2. 1 Triu chng c nng:
- Kh th: t hoc nhiu, nhng kh th thng xuyn ngy mt nng dn v khng c
cc cn kch pht nh trong suy tim tri.
- Ngoi ra, bnh nhn hay c cm gic au tc vng h sn phi (do gan to v au)
4. 2. 2 Triu chng thc th: ch yu l nhng du hiu ca mu ngoi bin:
- Gan to u, mt nhn, b t, au mt cch t pht hoc khi s vo gan th thy au
- Lc u, gan nh i khi c iu tr v gan to li trong t suy tim sau, nn cn gi
l gan n xp. V sau, do mu lu, nn gan khng thu nh c na v tr nn
cng.
- Tnh mch c ni to v du hiu phn hi gan - tnh mch c dng tnh.
- p lc tnh mch trung ng v p lc tnh mch ngoi bin u tng cao.
- Tm da v nim mc: Tm l do mu tr ngoi bin, nn lng Hemoglobin kh
tng ln trong mu. Tu theo mc suy tim m tm nhiu hay t. Nu suy tim nh
th ch thy tm t mi v u chi. Cn nu suy tim nng th c th thy tm r ton
thn.
30
- Ph: ph mm, lc u ch khu tr hai chi di, v sau nu suy tim nng th c th
ph ton thn. Thm ch c th c thm trn dch cc mng (trn dch mng phi, c
chng. . . . )
- Bnh nhn thng i t (khong 200 - 500ml/ngy), nc tiu sm mu.
- Khm tim:
+ S: c th thy du hiu Hartzer (tm tht phi p vng mi c) nhng khng
phi bnh nhn no cng c du hiu ny.
+ Nghe: Ngoi cc triu chng ca bnh gy suy tim phi, ta cn c th nghe thy
nhp tim thng nhanh, i khi c th nghe c ting nga phi phi. Cng c khi
nghe thy mt ting thi tm thu nh trong mm vng mi c do h ba l c nng.
Khi ht vo su th ting thi ny thng r hn.
- Huyt p ng mch ti a bnh thng, nhng huyt p ng mch ti thiu thng
tng ln.
4. 2. 3 Cn lm sng:
Tr trng hp suy tim phi do hp ng mch phi, c nhng c im ring, cn
trong a s cc trng hp khc ta thy:
Xquang:
+ Trn phim tim phi thng: Cung di phi (th hin tm nh phi) gin, mm tim
nng cao hn pha trn ca vm honh tri do tm tht phi gin, ng mch phi
cng gin to, phi m nhiu do mu phi.
+ Trn phim nghing tri: tht phi to lm cho khong sng sau xng c b hp li.
in tm : Thng thy cc du hiu ca trc phi: dy nh phi, dy tht phi.
Siu m: Ch yu thy kch thc tht phi gin to. Trong nhiu trng hp c th
thy cc du hiu ca tng p lc ng mch phi.
Thm d huyt ng: p lc cui tm trng ca tm tht phi tng (>12mmHg ) p
lc ng phi cng tng.
4. 3. Triu chng Suy tim ton b:
Thng l bnh cnh ca suy tim phi mc nng:
- Bnh nhn kh th thng xuyn, ph ton thn.
- Tnh mch c ni to.
- p lc tnh mch tng rt cao.
- Gan to nhiu.
- Thng c thm trn dch mng phi, mng tim hay c chng.
- Huyt p ti a h, huyt p ti thiu tng, lm cho huyt p tr nn b kt.
+ Xquang: tim to ton b.
+ in tm : c th c biu hin ca dy hai tht.
5. nh gi mc suy tim.
5. 1 Phn loi mc suy tim theo hi tim mch New York (NYHA):
31
Mc suy tim Biu hin
I

II

III

IV
- Bnh nhn c bnh tim nhng khng c triu chng c nng
no c.
- Cc triu chng c nng ch xut hin khi gng sc nhiu.
Bnh nhn c b gim nh cc hot ng v th lc.
- Cc triu c nng xut hin k c gng sc rt t, lm hn ch
nhiu cc hot ng th lc.
- Cc triu chng c nng tn ti mt cch thng xuyn, k
c lc bnh nhn ngh ngi khng lm g c.
5. 2 Phn loi mc suy tim trn lm sng.

Mc suy tim Biu hin
I
- Bnh nhn c kh th nh nhng gan cha s thy trn lm
sng.
II
- Bnh nhn kh th va, gan to di b sn vi centimet.
III
- Bnh nhn kh th nhiu, gan to gn st rn nhng khi c
iu tr gan c th nh li.
IV
- Bnh nhn kh th thng xuyn, gan lun to nhiu mc d
c iu tr.

TI LI U THAM KHO:
1. Triu chng hc ni khoa - TH Y-Khoa H- Ni (cc b mn ni), Trang 83- 86.
NXB Y Hc - H Ni 1997.
2. Bnh hc ni khoa- TH Y Khoa - H-Ni (cc b mn ni), Trang 44 - 54,
NXB Y-Hc - H Ni 1991
3. Tim mch hc TH Y Dc Tp HCM (GS, TS, BS Nguyn Huy Dung)
Trang 173 - 185. NXB Y-Hc - chi nhnh TP. HCM 2001.
4. Bi ging chn lc ni khoa tim mch (GS, BS Nguyn Huy Dung), Trang 89- 96,
NXB Y - Hc H - Ni 2000.
5. Bnh l tim mch, Tp II- PTS, BS Phm Nguyn Vinh, Trang 125- 147,
NXB Y- Hc Chi nhnh Tp HCM 1999.

32
K KH H M M B B M M Y Y T TI I U U H H A A
MC TIU:
1. Trnh by c cc cu hi khai thc triu chng c nng, bnh s v tin s
ca cc bnh nhn b bnh l ti h tiu ho.
2. M t c cc triu chng chc nng thng gp trong bnh l h tiu ha.
3. Trnh by c phn khu vng bng v hnh chiu ca cc tng tng ng.
4. Trnh by c cc im au ca rut tha, ui ty, thn ty, thn, niu qun, d
dy, ng mt, ti mt.
5. Trnh by c cch khm gan, lch, thn.
6. Trnh by c cch thm khm bng: nhn, s, g, nghe.
7. Trnh by c cch thm khm hu mn, trc trng.
8. M t c cch khm phn.
9. Trnh by c cc cn lm sng thng thng trong thm khm h tiu ho.
NI DUNG:
1. Hi bnh:
Tm cc ri lon c nng ca b my tiu ha. Hi bnh l bc rt quan trng v
l bc u tin trong qu trnh thm khm bnh; gip thy thuc khu tr v tr tn
thng. Hi bnh nhm xc nh thi gian bt u ca bnh, khai thc cc triu chng
c nng, v s lin quan lgich gia cc triu chng vi nhau, din bin v tin trin
ca n, s lin quan ca qu trnh bnh l hin ti vi qu kh. Cc triu chng c
nng ca b my tiu ha thng gp:
1. 1. au: L triu chng ch im cho mt tn thng thc th. Cn hi k v:
1. 1. 1. V tr au
1. 1. 2. Cng ca triu chng au: v d au m hoc au d di qung qui.
1. 1. 3. Thi gian au: au lin tc hoc au tng cn.
1. 1. 4. Thi im au, chu k ca cn au: v d au sau khi n, i th gim au.
1. 1. 5. Hng lan ca cn au
1. 2 Ri lon v nut: nut kh, nut au
1. 3 Nn, bun nn: thng l do nguyn nhn ca b my tiu ha nhng cng c
th do nguyn nhn nm ngoI b my tiu ha.
1. 3. : L tnh trng cht cha trong d dy thc qun k c hi i ngc ln ming.
Do ri lon chc nng vn ng ca ng tiu ha trn, c th c hi, chua, thc
n, nc ng.
1. 4. Ri lon v phn: ri lon vn ng, tiu ha hoc ri lon hp thu th hin qua
khi lng phn, s ln i cu, cht lng phn.
1. 5. Ri lon v i tin: Kh i tin, au hu mn khi i tin, mt rn.
1. 6. Ri lon v s thm n: khng c cm gic thm n, y bng kh tiu, n
khng bit ngon, ng ming.
33
1. 7. Hin tng sinh hi trong ng tiu ha: Trung tin nhiu, si bng, y bng.
1. 8. Hin tng chy mu tiu ha: Nn ra mu: cht nn c ln thc n v mu, i
cu ra mu: phn c mu ti, mu en lng sn st nh nha ng, mu c th
trn u trong phn hay nm ring.
2. Khm lm sng:
2. 1. Khm ming: khm mi, h ming, li, khm li v rng, khm hng, khm
tuyn nc bt: tuyn mang tai, tuyn di hm v tuyn di li.
2. 2. Khm lm sng bng:
2. 2. 1. Phn khu vng bng:
2.2.1.1. K 2 ng ngang: ng trn qua Im thp nht ca 2 xng sn; ng
di qua 2 gai chu trc trn.
2.2.1.2. K 2 ng dc bng: Qua gia b sn v cung i (mi bn mt ng).
Bn ng k ny chia bng thnh 9 vng: Vng thng v, vng h sn phi,
vng h sn tri, vng rn, vng mng m phi, vng mng m tri, vng h v,
vng h chu phi, vng h chu tri.
2.2.1.3. Hnh chiu ca cc c quan trong bng ln tng vng:
. Vng thng v: thu gan tri, phn ln d dy k c tm v v mn v, mc ni
gan-d dy trong c mch mu v ng mt, t trng, ty tng, m ri thi
dng, ng mch ch bng, ng mch thn tng. Tnh mch ch bng, h
thng hch bch huyt.
. Vng h sn phi: Thy gan phi, ti mt, gc i trng phi, tuyn thng
thn phi, cc trn thn phi.
. Vng h sn tri: Lch, mt phn d dy, gc i trng tri, ui ty, tuyn
thng thn tri, cc trn thn tri.
. Vng rn: mc ni ln (khng ch vng ny m lan to nhiu vng trong
bng), i trng ngang, rut non, mc treo rut (trong c mch mu ca rut), h
thng hch mc treo v cc hch ngoi mc treo, ng mch ch bng, ngmch thn
hai bn, tnh mch ch bng.
. Vng mng m phi: i trng ln, thn phi, rut non.
. Vng mng m tri: i trng xung, thn tri, rut non.
. Vng h v: Rut non, trc trng v i trng sigma, bng quang, on cui ca
niu qun; ph n c thm t cung, 2 vi trng, day chng rng, dy chng trn,
ng tnh mch t cung.
. Vng h chu phi: Manh trng, rut non ch yu l on rut cui, rut tha,
bung trng phi, ng mch chu gc phi, h thng hch bch huyt, mt phn
c y chu.
. Vng h chu tri: i trng sigma, rut non (on c ti tha Meckel), bung
trng tri, ng mch chu gc tri, tnh mch chu gc tri. H thng hch bch
34
huyt, mt phn c y chu.
S phn khu trn y ch l tng i v v tr mt s ni tng c th thay i bm
sinh hoc mc phi.
2.2.2. Cch khm bng:
2.2.2.1. Nguyn tc chung:
. T th ngi bnh: nm trn ging, hai tay dui thng hai bn ngi, hai
chn hi co lm cho mm thnh bng. Phi nm cn i ngay ngn, khng
nn gi u cao qu.
. T th thy thuc: ngi hoc ng bn phi ngi bnh.
2.2.2.2. Phng khm: nh sng, kn o, m, dng c khm k c gng tay
cao su.
2.2.2.3. Cch khm: Phi bc l ht vng bng; phi khm nhn, s, g, nghe. v
cui cng l thm trc trng nu cn thit.
. Nhn: bnh thng thnh bng ngang xng c, c ng nhp nhng theo nhp
th, rn lm. Ngi bo hoc ph n nhiu bng b ra 2 bn, trn da c
vt rn nu .
Quan st bng tm nhng thay i v hnh thi: bng lm lng thuyn, bng trng,
rn li.
Quan st tm nhng thay i v c ng thnh bng: thnh bng co cng
khng c ng theo nhp th gp trong vim phc mc, hoc do au qu.
thnh bng khi chng cng qu cng khng c ng theo nhp th c
Quan st tm du hiu rn b: c th thy ton bng hay ch mt vng,
gp trong hp mn v, tc i trng, tc rut non.
Quan st tun hon bng h: cn phn bit tun hon bng h vi trng hp ngi
gy, c th thy mt s mch mu l r hn v mt lp m da bng.
. S nn: y l ng tc quan trng nht: s nn phi nh nhng, bt u t
vng khng au trc; phi t st c lng bn tay vo thnh bng, khng ch dng 5
u ngn tay. Bo bnh nhn th u, s nhp nhng theo ng tc th ca bnh nhn.
C th dng mt bn tay hoc dng c 2 bn tay p ln thnh bng hoc 2 bn tay
chng ln nhau n su xung bng. S t th nm nga l chnh, nu cn phi
s t th nm nghin nh cch khm gan, lch bng phng php mc; i khi s
t th ngi hoc ng.
S c th nh gi b dy bt thng ca lp da bng nh trong bnh x cng b;
Pht hin thnh bng ph n: dng 2 ngn tay ci v tr vo vo da bng,
nu c ph n s li vt lm; pht hin thnh bng cng hoc co cng; tng
cm gic au khi s l du hiu ca vim phc mc, vim rut tha, vim ti
mt; S pht hin c khi u trong bng: phi m t v tr, hnh dng,
kch thc, mt ca khi u, b mt nhn hay g gh, di ng hay khng;
35
Phng php s cn dng khm tm b di ca gan hoc lch khi cc c
quan ny ln. Dng 1 hoc 2 u ngn tay n vo vng nghi ng tm im
au mt cch chnh xc. Cc im au c bit:
im au ti mt: im gp nhau ca b ngoi c thng to v b sn phi,
tm im au ti mt ta phi lm nghim php Murphy: n nh v t t u ngn tay
vo vng ti mt t nng n su, trong khi bo bnh nhn ht vo su mt cch t
t. Nu nghim php dng tnh: bnh nhn s ngng ht vo v au: gp trong vim
ti mt.
im rut tha = im Mac Burney: im chia 1/3 ngoi v 2/3 trong ca ng
ni gia rn v gai chu trc trn bn phi. im ny au trong vim rut tha.
im mi c: ngay di mi c trn ng trng gia, thng gp trong cc
bnh d dy (lot, ung th. . . ), bnh si mt, giun chui ng mt hoc vim ti mt.
Vng u ty v ng mt ch: trong mt gc 45
0


m mt cnh l ng trng
gia bng, cnh kia pha bn phi i t rn ln h sn phi. Vng ny au gp
trong bnh vim ty, si ng mt ch.
im sn lng: nm trong gc gia xng sn th 12 v khi c chung tht
lng. im ny au gp trong vim ty cp, vim quanh thn.
Cc im niu qun: im niu qun trn, im niu qun gia v im niu
qun di.
. G bng: C nhiu cch g bng; g theo ng ngang ln lt t trn xung di,
g theo ng dc t mn sn bn ny sang mn sn bn kia, c th g t rn g
ra theo hnh nan hoa.
Bnh thng vng trc gan g c. Cn dng phng php g tm gii hn
trn ca gan, gii hn di ca gan, chiu cao ca gan bnh thng l 10 -12 cm, gii
hn trn v di ca lch. Vng c trc gan mt gp trong thng tng rng. G
vang ton bng gp trong bng chng hi; g c vng thp khi c nc trong
bng. Du hiu sng v gp trong trn dch mng bng lng nhiu, du hiu chm
cc gip pht hin khi u trong bng hoc gan, lch ln bnh nhn c nc
trong bng.
. Nghe bng: C th nghe bng tai thng hoc nghe bng ng nghe:
Nghe ting si bng khi c nhiu hi v dch trong ng tiu ha: gp trong
bn tc rut.
Nghe ting c ch trong d dy khi i: chng t c hp mn v.
Nghe bng ng nghe dc ng mch ch, ng mch thn tm tingthi tm thu
trong hp ng mach ch, hp ng mch thn; ting thi lin tc trong phnh mch.
Ngoi ra c th nghe ting thi tm thu cc khi u c nhiu mch mu tng sinh.
2. 2. 3. Khm hu mn trc trng:
2. 2. 3. 1. Khm hu mn: T th bnh nhn: Bnh nhn nm ph phc, hai chn qy
36
hi dng, mng cao, vai thp. Thy thuc ng i din vi hu mn bnh
nhn, dng 2 tay ko gin v banh cc np nhn hu mn ra, ng thi bo bnh
nhn rn nh rn a lm gin hn na cc np nhn hu mn. Bnh
thng da ca hu mn nhn, cc np nhn mm mi u n, l hu mn
khp kn, kh ro, cc np nhn tp trung u n vo l hu mn. Cc bnh
l c th gp: l r hu mn, tr hu mn, vim hu mn, vt nt hu mn,
sa trc trng.
2.2.3.2. Thm trc trng: l mt ng tc rt cn thit v bt buc trong qa trnh
thm khm h tiu ha pht hin cc bnh ca trc trng v cn pht
hin cc bnh ngoi trc trng nh cha ngoi d con b v, vim rut tha.
T th bnh nhn v thy thuc: Bnh nhn nm ph phc nh khi khm
hu mn hoc bnh nhn nm nga 2 chn co v dang rng, thy thuc dng bn phi
ngi bnh hoc bnh nhn nm nghing, chn di dui chn trn co, thy thuc
ng sau lng thp hn mng bnh nhn.
Cch khm: thy thuc mang gant tay cao su, bi du parafin. a ngn tay tr t
t nh nhng vo hu mn, phi xoay ngn tay sao cho c th thm khm c ton
b chu vi ca bng trc trng.
Bnh thng: trc trng rng, khng au. Khi n vo ti cng mng bng (ti
cng Dougla), nim mc mm mi, nhn, rt tay ra khng c mu hoc mi nhy.
Thm trc trng c th pht hin nhng tn thng sau y: Tr ni, polyp
trc trng, ung th trc trng, n khi thm trc trng phi hp vi tay trn
bng c th s thy t cung, bung trng, nam khi thm trc trng c th s thy
tin lit tuyn nm vng c bng quang; thm trc trng cn c th pht hin cc
khi u trong bng cnh trc trng, vim phc mc, cha ngoi d con v gy chy
mu trong bng, vim rut tha: n thnh trc trng bn phi au.
2.2.4. Khm phn: Trong trng hp bt thng ngi thy thuc phi xem phn trc
tip, khng nn ch nghe ngi bnh khai: nh gi cng mm, khi lng, khun
phn: nh, dt, c rnh thng do u trc trng hay ng hu mn; mu sc phn, c ln
nhy mu khng; cht lng phn: phn sng, c vng m, cn thc n cha tiu gp
trong tiu ha km, suy ty, vim i trng; mi.
3. Khm cn lm sng b my tiu ha:
3.1. Thm d hnh thi
3.1.1. X quang:
- Chiu chp x quang bng khng dng thuc cn quang: tm lim hi trong thng
tng rng hoc nhn to. mc hi nc trong rut gp trong tc rut, tm si mt, si
ty, si thn, tm mc c honh.
- Chp ng tiu ha c ung hoc tht thuc cn quang: thm st thc qun, d dy,
rut non; rut gi v rut cui
37
- Chp ng stenon c bm thuc cn quang.
- Chp ng mt bng ung hoc tim thuc cn quang vo mch mu hoc chp
ng mt qua da; hoc chp ng mt v ty ngc dng.
3. 1. 2. Soi ni tng: gip chn on v iu tr cc bnh h thuc tiu ha nhanh v
chnh xc cao:
- Soi bng; gip chn on v sinh thit cc b phn bnh l nm trong bng, ngy
nay qua ni soi bng ngi ta m ni soi.
- Ni soi thc qun, d dy v t trng: phc v trong chn on bnh l d dy t
trng, ng mt; ngoi ra ni soi d dy cn gip cm chy mu ng tiu ha rt
hiu qu, ly si mt, ct polyp.
3.1.3. Siu m: Siu m thm d c cc c quan c nh gan, lch, cc khi u
trong bng, cc hch mc treo, ng mch ch bng, ng mach thn. Siu
m cho bit kch thc, hnh dng, mt lng hay c ca cc tn thng c ng
knh > 1cm ca cc c quan. Ngoi ra siu m cn c th hng dn cho bc s lm
sng chc ht cc tn thng mt cch chnh xc.
3.1.4. Chp ct lp qut theo t trng: Chp hnh cc tng c thnh nhiu lp lin
tip nhau; ty theo t trng (c, lng, m) ca c quan din ct m n c th c
nhng hnh nh khc nhau. Thng c ch nh tm cc tn thng ca cc tng
c, v pht hin cc khi u bng khng r ngun xut pht.
3.1.5. Ghi hnh bng vang t trng ht nhn: Phng php ny t c p dng trong
lnh vc tiu ha. i vi u mch mu ca gan th phng php ny mang li hnh nh
c bit r hn cc phng php khc v trnh khng phi chp ng mch.
3.1.6. Siu m ni soi: p dng cho thc qun, d dy v trc trng.
3.1.7. Ni soi mm c gn b pht siu m c th va tin hnh ni soi va lm siu
m. Phng php ny cho hnh nh ng tiu ha rt r, c kh nng chn on sm
ung th tiu ha, cho bit tnh trng ca cc bch huyt ln cn bit ung th di
cn cha.
3. 2 Thm d m bnh hc:
3.2.1. Phng php sinh thit: Dng kim sinh thit ly 1 mnh t chc, ct lt, nhum
v soi bng knh hin vi thng, knh hin vi in t hoc xt nghim ho hc t bo.
Qua ni soi d dy c th sinh thit thc qun, d dy, rut non hc cc khi u ca
ng tiu ha. Qua ni soi i trng c th sinh thit trc trng, i trng, cc khi u
ca trc, i trng. Sinh thit gan, sinh thit khi u bng: c th sinh thit di s
hng dn ca ni soi bng, ca siu m; trong x gan thng sinh thit m. Sinh
thit hch chn on bnh l ca hch hoc tm ung th di cn.
3.2.2. Phng php t bo hc: Trong thm d gan, khi u hoc hch: dng ng bm
tim ht t bo ca t chc , xt ln lame knh v nhm soi t bo. Xt nghim t
bo hc ca thc qun, d dy, trc trng: qua n ni soi, dng bn chI qut ln ch
38
tn thng lm bong t bo ra, hoc dng kim ht cht dch trn b mt tn thng
ri pht ln phin knh.
3. 3. Xt nghim tm vi khun, k sinh trng: Xt nghim tm vi khun helicobacter
pylori trong nim mc d dy, Tm vi khun hoc amibe trong m ca p xe gan; tm
vi khun, trng giun, nm, amibe trong phn
3. 4. Cc xt nghim thm d chc nng:
3.4.1. Xt nghim phn: phn l kt qu cui cng ca cc hin tng tiu ha v hp
thu cho nn n phn nh tnh trng ca ton b c quan tiu ha.
3.4.1.1. Xt nghim nh tnh: nhum ht amidon bng lugol nh gi hin tng
tiu ha tinh bt; kim tra ht m, tm si c, cellulose
3.4.1.2. Xt nghim nh lng: nh lng lipid trong phn, bnh thng lipid cn li
trong phn khng qu 5% s lng n vo.
3. 4. 1. 3. Thm d chc nng tng b phn: gan, ty, d dy. . .
TI LIU THAM KHO:
- Ni khoa c s tp 2, "Triu chng hc tiu ha Nguyn Khnh Trch Trng i
hc Y H Ni NXBYH, H Ni, 1997. Trang 171.
- Bnh hc ni khoa tp 2, Chng tiu ho Nguyn Khnh Trch, Phm th Thu
H, Trng i hc Y H Ni- NXBYH, H Ni, 2002. Trang 112.

K KH H M M C CH H N N O O N N G GA AN N T TO O

MC TIU:
1. Trnh by c cch khm lm sng gan to.
2. K c cc nguyn nhn gy gan to.
3. Trnh by c chn on y gan to.
4. Nu c mc tiu thm khm bnh nhn gan to.
NI DUNG:
1. Phng php khm gan:
1. 1 T th bnh nhn v thy thuc:
- Bnh nhn: Nm nga hoc nghing bn tri, hai chn co, u gi bnh thng.
- Thy thuc:
+ Khm thng thng: ng hoc ngi bn phi bnh nhn.
+ Khm mc gan: Bnh nhn nm nghin bn tri, thy thuc ng pha sau lng bnh
nhn.
1. 2 Thao tc k thut:
1.2.1. Nhn: Khi gan to nhiu, c th nhn thy mt vm ni ln di b sn phi.
1.2.2. S: Bo bnh nhn th chm, su, u ng thi th lng c bng
Trng hp gan to va: Thy thuc ngi bn phi bnh nhn, t bn lng tay
39
phi vo vng bng bnh nhn di h sn phi gia ng nch trc v trung
n phi. Bo bnh nhn ht tht su, b di ca gan h thp, trt ln u ngn tay
gip ta xc nh b di ca gan. Khi bnh nhn th ra, th vo, tay thy thuc s c
cm gic gip nhn nh v b gan sc hay t, , b mt ca gan nhn hay g g, mt
ca gan cng, chc hay mm. n vng gan xem gan c au khng? Gan to tan th hay
to khu tr.
Du hiu rung gan: t bn tay tri ca thy thuc ln vng gan, dng b pha
ngn t ca bn tay phi, cht nh vo bn tay tri, xem bnh nhn c au khng? Nu
bnh nhn au ku au th gi l nghim php rung gan dng tnh, thng ch im
cho p xe gan. Khi n vo gan dc khoang lin sn vng gan tm v tr au nht
trong p xe gan.
Trng hp gan to t: Cho bnh nhn nm nghing hn sang tri. Thy thuc
ng sau lng bnh nhn, dng phng php mc gan: Dng cc u ngn tay lm
mc v mc nh vo b di sn phi. Bo bnh nhn ht tht su vo th u cc
ngn tayc th chm vo b di ca gan.
1.2.3. G: Cho bnh nhn nm nga, Thy thuc ngi bn phi bnh nhn.
G xc nh b trn ca gan: l ranh gii gia ting trong ca phi v ting c
ca gan: t ngn tay gia bn tay tri ca thy thuc dc theo cc khoang lin sn,
ngn tr tay phi ca thy thuc g vo ngn tr tay tri, tm ranh gii m trong v
c. ngi bnh thng b trn ca gan lin sn 5 trn ng cnh c phi, lin
sn 6 theo ng gia xng n, v lin sn 7 trn ng nch trc.
Ngai ra g cn h tr thm vic xc nh b di ca gan: ngn tay tri t song
song vi b sn phi ca bnh nhn, G t rn ln, khi nghe ting trong, tay tri di
chuyn dn ln pha h sn phi, khi ting g chuyn t trong sang c, l v tr
b di ca gan. Bnh thng ranh gii pha di ca gan vng theo cung ca b sn
phi, khng vt qu b sn, di mi c cnh ng c phi 2 cm, khng vt
qu ng cnh c tri. G gip xc nh chiu cao ca gan: Bnh thng din c
ca gan theo ng nch trc phi t 10 12 cm, theo ng gia xng n phi t
9- 11 cm, theo ng cnh c phi t 8-11 cm.
Nu bnh nhn b c chng, kh pht hin b di ca gan, c th khm b di
trong t th bnh nhn ngi hoc c th khm gan sau khi chc bt dch c chng.
1. 2. 4. Nghe gan: C th nghe ting thi tm thu hoc thi lin tc trong ung th gan
do mch mu tng sinh
2. Cc cn lm sng:
2. 1. Thm d hnh thi ca gan:
2.1.1. X quang: Chp mt qua da gip nh gi tc mt trong gan hoc sau gan.
2.1.2. Siu m gan: rt c gi tr, gip nh gi v hnh thi gan to hay nh, chiu cao
gan mt cch chnh xc, ngai ra siu m gan rt c gi tr trong vic chn an p xe
40
gan, k gan giai an sm. Ngai ra siu m cn gi tnh trng gan nhim m hoc
x gan, tng p lc tnh mch ca. tnh trng dn hoc tc ng mt.
2.1.3. X hnh gan: Chp nhp nhnh phng x gan, nh gi s phn b phng x
trn gan u hay khng u.
2. 2. Thm d v min dch:
2.2.1. Alpha Feutoprotein: tng trong ung th gan nguyn pht.
2.2.2. Cc khng th: X gan mt nguyn pht c c ch t min. Do c th lm
cc xt nghim tm khng th khng ty lp th, khng th khng c trn, khng nguyn
HBc, Hbe, nh lng globulin min dch IgG, IgM, IgA trong bnh vim gan mn.
2. 3. Thm d chc nng gan:
2. 3. 1. in di protein mu, tm t l A/ G.
2. 3. 2. nh lng nng Albumin trong mu.
2. 3. 3. nh lng prothrombin, thi gian quick.
2. 3. 4. Thm d chc nng chng c v gi cht mu: nghim php BSP
2. 4. Thm d s hy hai t bo gan:
2. 4. 1. nh lng men ornithin carbamyl transferase: l men tham gia chuyn
amoniac thnh ure trong chu trnh Krebs. Men ny c ch yu trong gan, c t trong
tim, thn v d dy.
2. 4. 2. nh lng men SGOT, SGPT: tng do t bo gan b hy hai, phng thch
men ny vo mu. Trong vim gan cp do virut hoc do nhim c SGPT tng rt cao,
c th gp trm ln, SGOT tng va phi. Nhng SGOT cng tng trong nhi mu c
tim.
3. Chn an gan to:
3. 1. Chn an xc nh: Thng rt d, ch cn khm lm sng i khi ta xc
nh c gan to, cn c vo:
3. 1. 1. B di gan vt qu b h sn phi.
3. 2. 2. Chiu cao gan > 13 cm.
3. 2. Chn an nguyn nhn gan to:
3. 1. Suy tim: Mc gan to tan th, mc to ty thuc vo mc suy tim, mt
mm, mt nhn, n gan c cm gic tc hoc au nh, gan n xp: gan nh
li khi iu tr lnh suy tim v gan to dn tr li khi bnh nhn b suy tim ti pht,
nu suy tim giai an cui: suy tim 4 rt kh iu tr, gan to lu ngy tr nn x
cng gi l x gan tim.
3. 2. p xe gan: gan to nhanh, to khu tr, km hi chng nhim trng, rung gan
dng tnh, n k sn c v tr au chi tng ng vi v tr p xe gan, b t.
3. 3. Nang gan: gan to nhiu hay t ty theo kch thc ca nang, c th l sn l gan,
thng au t hoc khng au, khng c hi chng nhim trng.
3. 4. Gan to do tc mt: thng gp trong si ng mt ch, si ng gan hoc u u
41
ty, km theo triu chng vng da tc mt, gan to mt thy hay to tan th ty v tr
tc mt, au va.
3. 5. K gan: gan to khu tr mt thy, b t, mt chc hoc cng, giai an mun c
triu chng au, km du hiu suy gan v c th suy kit.
3. 6. Vim gan cp hoc vim gan mn: gan thng ch hi ln, di b sn
khang 1- 2cm, n tc nh, c cm gic tc nh vng gan. Km cc triu chng
nhim siu vi gan cp hoc mn.
4. Chn an phn bit:
4. 1. Gan sa: B di gan xung di h sn phi 1 2 cm, nhng b trn cng
xung thp khang gian sn 6, gian sn 7 trn ng trung n v chiu cao
gan gii hn bnh thng: khang 9 12 cm.
4. 2. Thn phi to: Ranh gii khng r, c du hiu chm tht lng, g di h sn
phi nghe trong.
4. 3. Khi u d dy: d nhm vi gan to thy tri, khng di ng theo nhp th, g
trong, c triu chng ca bnh l d dy.
4. 4. Vim c thnh bng h sn phi: V tr khi u nng, chy dc theo c thng
bng.
4. 5. Khi u gc i trng phi: Ch nhm vi gan to khi khi u dnh vi gan nn di
ng theo nhp th, thng c du hiu bn tc rut.
TI LIU THAM KHO:
- Ni khoa c s tp II, Triu chng hc gan mt, thm khm lm sng gan mt,
Vng da Nguyn Khnh Trch, Phm th Thu H, Trng Y H ni, NXBYH, H
Ni, 1997. Trang 274, 288 v 297.
- Bi ging bnh hc ni khoa tp II, Chn on hong m, Hong m mt,
Nguyn Khnh Trch v phm th Thu H, Trng Y H Ni, NXBYH, H Ni, 2002.
Trang 116, 126.

C C C CH H N NG G

MC TIU:
1. Trnh by c cch pht hin c chng
2. Nu c cch nhn nh nc c chng
3. Trnh by c cc nguyn nhn gy c chng
NI DUNG:
1. nh ngha: Bnh thng trong bng khng c nc. Khi c nc trong bng
gi l c chng
2. Triu chng Lm sng
2. 1. C nng: Trc khi xut hin dch, bnh nhn thng thy mt mi, chn n,
42
ngi gy st, y bng. Tu theo nguyn nhn m c th st nh hay au m vng
bng
2. 2. Thc th:
2. 2. 1. i vi c chng th t do loi nhiu nc v trung bnh
Nhn: Da bng cng bng, rn li. Tu theo nguyn nhn m c th thy tun hon
bng h ca - ch. Khi bnh nhn nm bng b ra 2 bn, bng s ra pha trc v
xung di khi ng hay ngi
S: S c cm gic cng v c du hiu sng v nu l c chng t do, nu c
gan lch to th s c du hiu chm cc
G: i vi c chng t do s thy g c vng thp v hai bn gii hn trn ca
vng c l 1 ng cong lm. Thay i t th vng c, vng trong s thay i theo
2. 2. 2. Trong trng hp dch t c th thay i t th bnh nhn hay thm trc trng
hoc m o thy c ti cng cng, n tay trn bng s c nc chm vo u cc
ngn tay, choc d c chng ht ra nc
2. 3. i vi c chng th khu tr: G s c ch c ch trong xen k. Chc d
nhng vng nghi c nc s ht ra nc
2. Cn lm sng: Chc d dch c chng; dch c th trong, vng chanh, vng rm,
c mu hay c nh sa
C 2 loi dch
Dch thm: Nc trongvng chanh, vng rm
Lmg Protein < 30g/ l
Phn ng Rivalta m tnh
t t bo
Dch tit: Vng sm, mu, c hay c nh sa
Lng Protein > 30g/ l
Phn ng Rivalta dng tnh
Nhiu t bo
Ngoi ra cn c dch ton mu khng ng nhiu hng cu v bch cu, v c th
c t bo l gp trong ung th
3. Chn on:
3. 1. Chn on xc nh: D, tr trng hp dch t phi g nhiu t th, chc chn
nht l chc d c dch
3. 2. Chn on phn bit:
3. 2. 1. Bng bo nhiu m: Bng chc, da bng dy, rn li, g trong v khng c du
hiu sng v
3. 2. 2. Bng chng hi: G trong ton bng
3. 2. 3. Bng quang cng trong b tiu: Bnh nhn c cm gic tc tiu nhng khng
tiu c, g vng c h v, gii hn trn ca vng c l 1 ng cong li ln
43
trn, xng tiu s ht
3. 2. 4. U nang, nht l u nang nc ca bung trng: G s thy vng c gia,
xung quanh thy trong, gii han gia vng c v vng trong l 1 ng cong li
ln trn. trong trng hp kh chn on c th nh siu m xc nh
4. Nguyn nhn:
4. 1. C chng dch thm
4. 1. 1. X gan: Trong x gan chng ta gp c chng t do, trn da bng c tun hon
bng h, km du hiu suy chc nng gan nh km n, s m, vng da, nt nhn
. . .
4. 1. 2. Suy tim: Gp trong cc bnh suy tim ton b, suy tim phi hay hi chng Pick
(vim mng ngoi tim co tht). Dch mu vng chanh hay vng rm
4. 1. 3. Bnh thn: Thng gp trong hi chng thn h, vim cu thn bn cp. . .
Ngoi c chng cn c du hiu ph ton thn, triu chng khc v bnh thn.
Dch thng trong
4. 1. 4. Suy dinh dng: Bnh nhn ph ton thn v c c chng. Dch rt trong v
lng Protein rt thp, Protein mu gim
4. 2. Dch tit:
4. 2. 1. K gan: C chng t do, pht trin rt nhanh, dch thng c mu, c th c t
bo l km theo gan to cng v suy sp ton thn
4. 2. 2. Lao mng bng: C 2 loi c chng
C chng t do: Dch thng t hay trung bnh km theo n au khp bng IDR
dng tnh km theo c du nhim lao cc b phn khc nh lao phi
C chng khu tr: Bnh nhn au m h khp bng, mng bng b vim dnh,
nc xut hin tng vng, n ch mm ch rn, g ch c ch trong Ngoi ra c du
hiu bn tc rut v du nhim lao.
Dch c chng trong lao mng bng c c 2 th thng l vng chanh, cng c
th c mu, xt nghim c nhiu bch cu Lympho.
4. 2. 3. K cc hch trong bng: V d K hch mc treo hay Lymphosarcoma. Dch c
mu, c khi tm thy t bo l
4. 2. 4. Vim mng bng: Gp trong thng d dy, vim rut tha v m, abces gan v
Ngoi ra c 1 s c chng khc him gp trn lm sng nh:
C chng dng chp: Dch mng bng ton dng chp, c nh sa. Thng
gp do giun ch hay K cc ni di cn vo mch bch huyt lm v mch bch huyt
5. iu tr: y l triu chng ca rt nhiu nguyn nhn, cn phi tm ng nguyn
nhn iu tr, c khi rt kh khn.
44

K KH H M M V V C CH H N N O O N N V V N NG G D DA A
MC TIU:
1. Trnh by c triu chng lm sng v cn lm sng ca vng da.
2. Trnh by c phn loi vng da.
3. Trnh by cch chn on c hi chng vng da.
4. Trnh by c cc nguyn nhn ca vng da.
NI DUNG:
1. i cng v nh ngha:
Mu vng ca da v nim mc l do bilirubin trong mu tng ln, thng l triu
chng ch Im cho bnh l h thng gan mt. Chn on vng da khng kh nhng
quan trng hn l chn on nguyn nhn gy vng da, gip thy thuc quyt nh
hng iu tr.
2. Nhc li qu trnh chuyn ha ca bilirubin mu:
Hng cu v gii phng hemoglobin. Hemoglobin c chuyn thnh bilirubin
gin tip. Bilirubin ny s gn vo mt protein ca huyt tng v chuyn ch n t
bo gan, y protein nh bilirubin gin tip ra v c hp th vo trong t bo gan
nh mt protein c bit trong t bo gan l protein Z v Y. Trong t bo gan, bilirubin
gin tip c chuyn thnh bilirubin trc tip nh hai qu trnh lin hp: glycuronic
v sunfonic; qu trnh lin hp ny c thc hin nh men glycuronyl tranferaza c
sn trong t bo gan. Bilirubin trc tip c t bo gan bi tit vo ng mt qua mng
t bo. Trong ng mt, bilirubin c chuyn xung rut. rut bilirubin c oxy
ho v chuyn thnh urobilinogen. Mt phn urobilinogen c chuyn thnh
stercobilinogen ri thnh stercobilin, phn cn li c ti hp thu vo mu, y mt
phn ln li tip tc chu trnh chuyn ha bilirubin, mt phn nh c o thi qua
nc tiu, trong nc tiu urobilinogen b oxy ha thnh urobilin.
ngi bnh thng bilirubin tan phn trong mu l 12mg/lt trong 2/3 l
bilirubin gin tip, 1/3 l bilirubin trc tip, phn c mu vng va phi vi m
stercobilin l 100mg/100g, nc tiu trong khng mu c t urobilin. Trong trng
hp tan mu nhiu, trong mu bilirubin gin tip tng ln, trong phn stercobilin cng
tng, phn c mu vng m nhng nc tiu vn trong (v bilirubin gin tip khng
bi tit qua nc tiu c) c nhiu urobilinogen v urobilin. Ngc li trong trng
hp tc mt, bilirubin trc tip tng cao trong mu. stercobilin trong phn gim, phn
nht mu, c khi thnh mu trng nh vi, nc tiu sm mu v c bilirubin, ng
thi xut hin mui mt trong nc tiu nhng khng c urobilinogen v urobilin.
3. Triu chng lm sng ca hi chng vng da:
3. 2. Da vng nhiu hay t: nn quan st vng da c che kn nh da lng, bng,
ngc th chnh xc hn mu da tay, chn, mt.
45
3. 3. C th quan st mu vng kt mc mt, nim mc di li.
3. 4. Mu sc nc tiu: nc tiu c mu vng sm do tng c sc t mt, mui mt.
3. 5. Mu sc ca phn: Trc bnh nhn b vng da, ta lun lun phI hi mu sc
ca phn: nu tc mt hon ton th phn s bc mu do khng c stercobilin.
3. 6. Cc triu chng lm sng i km theo vng da: Trc bnh nhn b vng da ta
phi thm khm thm cc triu chng i km nh khm gan, lch, ti mt, nga,
du hiu xut huyt da nim, hi chng nhim trng.
4. Triu Chng cn lm sng: ngi b vng da cn lm cc xt nghim chn
on xc nh hi chng vng da, v cc cn lm sng gip tm nguyn nhn ca
vng da:
4. 1. Triu chng cn lm sng gup chn on xc nh hi chng vng da:
4. 1. 1. Nc tiu: Tm sc t mt, mui mt.
4. 1. 2. Xt nghim huyt hc: nh lng Bulirubin ton phn, trc tip v bilirubin
gin tip trong mu.
4. 2. Cn lm sng gip tm nguyn nhn ca vng da:
4. 2. 1. Xt nghim mu: cng thc mu, HBsAg, In di Hemoglobon mu, nh
lng men glycuronyl transferaza, Sc bn hng cu, kch thc v hnh dng hng
cu nh lng men transaminaza G
6
PD, st huyt thanh tm nguyn nhn vng da
ti gan hoc nguyn nhn vng da trc gan.
4. 2. 2. Siu m: h thng gan mt, ty, bng tm cc khi u, cc nguyn nhn lm
nghn ng mt.
4. 2. 3. Chp ng mt qua da, chp ng mt ngc dng tm nguyn nhn
gy tc mt, nguyn nhn cht hp ng mt v d si mt.
4. 2. 4. Xt nghim min dch hc: ch nh trong cc bnh gan c phn ng min dch
nh vim gan mn tin trin t min, x gan mt tin pht nh khng th khng
nhn. . . nh lng IgM, IgG v IgA. . .
4. 2. 5. Cc xt nghim thng thng v c bit ty nguyn nhn: v d vim gan cp
do xon khun leptospirose th tm khng th leptose nh phn ng Martin petit
5. Phn loi vng da:
5. 1. Phn loi theo nguyn nhn.
5. 1. 1. Vng da do tan mu: cn gi l vng da trc gan, do s ph hu qu mc
hng cu t chc lin vng ni m gy tng bilirubin t do trong mu, gi l
vng da trc gan.
5. 1. 1. 1. Bm sinh: bnh huyt sc t nh bnh Thalasemie, bnh Minkowski
chauffard.
5. 1. 1. 2. Mc phi: bt ng nhm mu do truyn mu; tan mu do st rt I huyt
st t
5. 1. 2. Vng da do mt.
46
5. 1. 2. 1. mt trong gan nh vim gan siu vi, vim gan mn, vim gan nhim c
do thuc, x gan mt tin pht, vim x ng mt nh.
5. 1. 2. 2. mt ngoi gan: nh k gan, si ng mt ch, u ty, vim c oddi.
6. Chn on vng da:
Chn on hi chng vng da rt d nhng chn on nguyn nhn vng da I
khi d, ta c th khm v chn on c nguyn nhn ngay ti cng ng, ti tuyn y
t c s nu triu chng lm sng v cn lm sng In hnh; nhng nhiu lc chn
on nguyn nhn rt kh, ta phI chuyn bnh nhn ln Y t tuyn huyn hoc tuyn
trung ng mi c phng tin chn on nguyn nhn vng da. Iu quan trng
nht l phI I tng bc.
6. 1. Bc mt: Tr li cu hi: c phi vng da trc gan hay khng ?
L vng da do huyt tn, st rt, nhim khun mu. Hi v khm bnh mt
cch t m v hon cnh xut hin triu chng vng da, t t hay t ngt, lin tc hay
ti pht tng cn; tin s ca vng da; mu sc phn v nc tiu; yu t dch t hc;
hi chng nhim trng; hi chng thiu mu; khm h thng gan mt, tun hon bng
h. C khi ch bng khm lm sng cn thn chng ta tr li c cu hi ny, V
d vng da tan mu sau truyn mu hoc vng da tr s sinh hoc vng da do st rt
i huyt st t.
Cc cn lm sng gip tr li cu hi ny t n gin n phc tp l: Cng
thc mu s lng hng cu, bch cu, cng thc bch cu, k sinh trng st rt;
Bilirubin trc tip, gin tip v bilirubin mu ton phn; HbsAg; SGOT, SGPT; Siu
m gan mt; Comb test.
Kt qu cc xt nghim trn gip ta tr li cu hi ca bc mt chnh xc.
6. 2. Bc hai: Sau khi loi tr nguyn nhn trc gan, ta hng chn on vo
nguyn nhn ti gan, v ta phi tr li cu hi: C suy t bo gan khng? C hi
chng mt khng ?
C 4 tnh hung xy ra:
6. 2. 1. Hi chng suy t bo gan (+), hi chng mt (-): ngh n nguyn nhn
vim gan cc loi hoc x gan.
6. 2. 2. Hi chng suy t bo gan (-), hi chng mt (+): ngh n nguyn nhn
mt do tn thng ng mt.
6. 2. 3. Hi chng suy t bo gan (-), hi chng mt (-): ngh n cc bnh bm
sinh Gilbert (thiu glycuronyl transferaza), Dubin Johnson(ri lon qu trnh vn
chuyn bilirubin vo ng mt), hoc do dng thuc gy ra.
6. 2. 4. Hi chng suy t bo gan (+), hi chng mt (+): c th do mt lu ngy
dn n suy t bo gan hoc do vim gan th mt.
6. 3. Bc ba: Nu c hi chng mt, phi tr li cu hi: mt trong gan hay
mt ngoi gan, ngha l mt ni khoa hay mt ngoi khoa. Trn lm sng nu
47
c ti mt to hoc phn bc mu th chc chn l mt ngoi gan.
tr li chc chn cu hi ny, cn phi da vo siu m, chp ng mt.
6. 4. Bc bn: Chn on cn bnh c th: Tng hp tt c hi chng, bnh s, tin
s, cc cn lm sng c chn on cui cng, v d vim gan siu vi B; nhim
trng ng mt do si ng mt ch.
6. 5. Chn on v iu tr ph hp vi cc tuyn Y t:
6. 5. 1. Tuyn Y t c s: Cn c vo bnh s, tin s, khm lm sng gan mt c th
chn on s b vim gan siu vi, si ng mt, vim ti mt, k ty. . . Nhng
nu tuyn y t c s khng c cn lm sng nh siu m, HBsAg. . . Ta cn chuyn
bnh nhn n trung tm y t c cc xt nghim tng ng c chn on xc
nh.
6. 5. 2. Tuyn Y t Huyn: i vi cc huyn c y cc xt nghim th c kh
nng chn on v iu tr c cc bnh thng thng gy vng da ti gan, trc
gan v sau gan.
6. 5. 3. Tuyn Y t Tnh hoc tuyn trung ng: Tuyn Tnh v trung ng c kh
nng chn on v iu tr nhng bnh nh tan mu do thalassemie, vim gan do
thuc, x gan mt tin pht. . . do vy trc nhng bnh vng mt, vng da khng r
nguyn nhn th phi chuyn ln bnh vin tnh hoc bnh vin trung ng mi c
nhng xt nghim mu cao cp v sinh thit gan, ngoi ra c nhng khi u gan, u ty. .
tuy tuyn y t huyn c th chn on c nhng phi gi ln tuyn tnh hoc tuyn
trung ng iu tr.
6. 6. Cc bnh gy vng da thng gp:
6. 6. 1. Vim gan: Vim gan cp do virut: y l nguyn nhn hay gp nht, nht l
tr em. Bnh thng thnh dch, bt u bng st nh, mt mi, chn n, ri sau
mi xut hin vng da. Bnh thng i khm l do vng da hoc chn n va mt mi.
Xt nghim c HbsAg(+); SGOT v SGPT tng.
6. 6. 2. Vim gan mn tnh tin trin, x gan: bnh tin trin nhiu t bng cc triu
chng st ri vng da, cui cng dn n x gan. Xt nghim c t l A/G ca protein
mu b o ngc, t l prothrombin gim, transaminaza tng, khng th khng nhn
(+)
6. 6. 3. Si ng mt: Triu chng In hnh l tam chng charcot: au, st v vng
da. Siu m gip ch rt nhiu cho chn on. Nu cha r i khi cn phi gi ln
tuyn trn chp ng mt hoc chp ct lp.
6. 6. 4. Ung th u ty: Triu chng vng da ngy cng tng, nga, phn bc mu,
Siu m ty v gan mt cng gip ch rt nhiu cho chn on.
6. 6. 5. Nhim khun cp hoc st rt: Bnh s ca nhim trng cp hoc triu chng
st cn c chu k ca st rt cng gi chn on ny. Xt nghim cng thc mu v
k sinh trng st rt gip chn on xc nh. Leptospirose cng l mt nguyn nhn
48
gy vng da, hi chng nhim trng v hi chng gan thn kt hp vi hi chng
mng no gi chn on bnh ny.
6. 6. 6. Huyt tn: Tuy hi chng ny t gp nhng do nhiu nguyn nhn gy huyt
tn: Bnh bm sinh ti hng cu: Minkausky Chauffard, bnh huyt sc t F, thiu
men gluco 6 photphataza, bnh t min. Mun chn on cn phI lm cc xt nghim
v huyt hc nh sc bn hng cu, st huyt thanh tng, bilirubin t do tng, nghim
php comb (+).
7. T vn v chn on, iu tr v d phng vng da ti cng ng:
7. 1. T vn v chn on v iu tr:
Ti cng ng chng ta khm v hi bnh s, tin s tht cn thn v chi tit c
th c c 60 % gi chn on s b, ch nh cc cn lm sng n gin sn c ti
cng ng hoc y t huyn c chn on xc nh nh test th giy nhng tm
HBsAg, HBsAb, siu m h gan mt, siu m bng, xt nghim bilirubin mu, nc
tiu. Nu l bnh n gin nh vim gan siu vi th nh, nhim trng ng mt do
si. . . ta c th iu tr v theo di; Nu bnh kh hoc khng in hnh th ta t vn
v tuyn hoc n v y t thch hp bnh nhn b vng da n khm. Sau khi bnh
nhn iu tr cc tuyn cao tr v chng ta phi theo di, hng dn bnh nhn bnh
nhn phng ti pht hoc phng bin chng v d i vi bnh nhn b giun chui
ng mt phi ung thuc x giun nh k. Bnh nhn b vim gan siu vi cp, phi
hng dn ch n king m, ch lao ng nh, c 6 thng 1 ln kim tra
HBsAg, HBsAb, HbeAg hng dn Iu tr d phng cp II hoc chuyn tuyn
trn thch hp. . .
7. 2. T vn d phng bnh nhn b vng da:
7. 2. 1. Lin kt vi y ban nhn dn, cc trng mu gio, Vn ng v t chc
tim chng phng nga vim gan siu vi nht l tr nh trong cng ng.
Thng qua cc t chc on th trong cng ng iu tra, Xt nghim phn
trong cng ng c bin php x giun tp th nh k phng nga giun chui ng
mt, si mt.
7. 2. 2. T vn v phng nga nhim trng ng mt do si mt ti pht: dng
thuc tan si acide chenodique, x giun nh k.
TI LIU THAM KHO:
Ni khoa c s tp II, Triu chng hc gan mt, thm khm lm sng gan mt,
Vng daNguyn Khnh Trch, Phm th Thu H, Trng Y H ni, NXBYH, H
Ni, 1997. Trang 274, 288 v 297.
Bi ging bnh hc ni khoa tp II, Chn on hong m, Hong m mt
Nguyn Khnh Trch v phm th Thu H, Trng Y H Ni, NXBYH, H Ni, 2002.
Trang 116, 126.
K yu cc cng trnh nghin cu khoa hc, Nhn xt kt qu bc u t stent
49
ng mt qua ni soi trong iu tr hi chng vng da tc mt BS Phm th Bnh,
Hi khoa hc tiu ha thng nin ln th 9, Nng, 2003. Trang 87.

C CH H N N O O N N A AU U B B N NG G
MC TIU:
1. Phn loi c au bng
2. Thm khm c mt bnh nhn au bng
3. Nu c mt s nguyn nhn chnh gy nn au bng vi nhng du hiu ch
yu.
NI DUNG HC TP:
1. i cng: au bng l mt trong nhng triu chng thng gp, nht l trong
khoa tiu ho. Triu chng ny c th gip ta mt phn hng n c quan b tn
thng, mc v giai on ca tn thng. Nhng y l mt triu chng mang
tnh ch quan, c th ph thuc vo nhiu yu t v khng phn nh hon ton tnh
trng ca bnh, c ngha l khng th ch da vo tnh trng au nhiu hay t
nh gi mc bnh nng hay nh. Do triu chng au ch c tnh cht gi
u tin cho ngi thy thuc da vo tin hnh hi bnh v thm khm
chn on ng bnh
2. Phn loi au bng:
2. 1. au bng cp: y l cn au bng xy ra t ngt, d di, din tin nhanh, c
lc cn iu tr cp cu nikhoa (khng dng n phu thut) hay ngoi khoa (phi
dng n phu thut mi gii quyt c bnh):v d nh vim rut tha, tc rut. .
. Cn au ny thng din tin nhanh trong vi gi hay vi ngy. Nu iu tr ng
v kp thi thng c th gii quyt c bnh.
2. 2. au bng mn tnh: Cn au ny thng xy ra t t, m hay l din tin v
sau ca cn au bng cp. Cn au ny thng ko di hng thng, hng nm (trn
6 tun), thng km theo cc biu hin hay nh hng n ton thn nh suy mn,
thiu mu. . .
i tr cn di hn, p ng chm. Hay ti pht v c khi khng lnh hn
3. Thm khm mt ngi bnh b au bng: ng trc mt ngi bnh b au
bng, ta cn phi tin hnh cc bc sau:
3. 1. Hi bnh:
3. 1. 1. Cn au:
3. 1. 1. 1Yu t khi pht ca cn au: V d khi pht au sau mt ba n nhiu du
m trong cn au qun gan, sau vn ng nhiu trong cn au qun thn.
3. 1. 1. 2Tnh cht khi pht: Khi pht t ngt trong cn au bng cp do vim tu
cp, giun chui ng mt. . hay t t trong cn au ca lot d dy. .
3. 1. 1. 3. V tr u tin ca cn au: Nhiu khi c gi tr quan trng trong chn on.
50
V d nh: au vng thng v: Vim d dy, lot d dy
3. 1. 1. 4. Hng lan: Lan ln vai phi trong cn au qun gan, lan xung i, b phn
sinh dc trong cn au qun thn.
3. 1. 1. 5. Tnh cht ca au: au tc trong trng hp cng do c hc nh si mt
hay giun chui ng mt. au nng rt trong vim d dy. au i trong lot hnh t
trng. au nh dao m trong thng d dy
3. 1. 1. 6. Yu t lm du hay lm tng au: Nh do vn ng, n ung, thuc men
3. 1. 1. 7. Din tin ca cn cn au: au tng cn trong nguyn nhn do si hay giun
chui ng mt, au lin tc trong cc trng hp do vim nh vim tu cp, vim d
dy cp. au c tnh cht chu k, theo nhp trong ngy, trong nm nh trong lot
d dy hay t trng.
3. 1. 2. Hi v cc biu hin km theo: Ch n cc biu hin
3. 1. 2. 1. Du ti ch (Du lin quan n b phn c bnh): Nn ma, ri lon i
tin, i mu.
3. 1. 2. 2. Cc biu hin ton thn nh st, ngt.
3. 2. Hi v tin s:
3. 2. 1. Ch n tnh cht ti pht nhiu ln ca cc cn au ging nhau nh trong
lot d dy. . , si mt.
3. 2. 2. Ngh nghip: C th c lin quan, v d cn au bng ch do ng c ch
nhng ngi hay tip xc vi cht ny
3. 2. 3. Cc thi quen c th c hi nh ung ru nhiu
3. 2. Khm bnh:
3. 2. 1. Khm ton thn: Theo di mch, huyt p, nhit , nhp th, Khm cc b
phn c tnh cht h thng.
c bit ch n mt s tnh trng ton thn nh:
3. 2. 1. 1. Nhim trng: Trong vim ng mt, vim rut tha. .
3. 2. 1. 2. Vng da, vng mt: Trong si ng mt. . .
3. 2. 1. 3. Ri lon tun hon: Biu hin tnh trng chong nh trong a chy, mt
nc, vim tu cp th hoi t, chy mu lot d dy. . ,
3. 2. 1. 4. Suy mn: Trong cc bnh nng giai on cui nh lao mng bng, ung th
gan. . .
3. 2. 2. Khm bng: Kt hp nhn, s, g, nghe v thm trc trng hay m o
3. 2. 2. 1. c bit ch n mt s Im au nh Im rut tha, Im ti mt v
nghim php Murphy, cc Im au niu qun. . .
3. 2. 2. 2. Mt s tnh trng cp cu bng nh:
Thnh bng khng di ng theo nhp th, cng nh g, cc c thnh bng ni
r, mt vng c trc gan trong thng tng rng nh d dy, rut.
Du hiu rn b, du Bouveret, du Koenig i trng
51
Thm trc trng v m o: L ng tc rt cn thit v quan trng v c th
pht hin mt s tnh trng cp cu nh cha ngoi t cung b v c ti cng
Douglas phng v rt au khi thm khm
Xem phn, cc cht nn v nc tiu: Cng gp mt phn quan trng trong
chn on bnh. V d phn c nhiu nhyv mu trong l trc trng, cht nn c
giun trong giun chui ng mt
3. 3. Xt nghim cn lm sng: Sau khi hi bnh v thm khm, tu theo nguyn
nhn ta lm mt s xt nghim khc nhau h tr cho chn on. V d nh
chp phim bng thng ng nu nghi c thng tng rng, ni soi nu nghi vim
hay lot d dy hay hnh t trng Khng nn lm dng cn lm sng.
4. Nguyn nhn: D y ch gi thi mt s nguyn nhn chnh gy nn au
bng vi nhng du hiu ch yu c mt s khi nim rt chung v 1 s
bnh thng thng thng gp
4. 1. Nhng nguyn nhn gy nn au bng cp:
4. 1. 1. au vng thng v v phn bng trn:
4. 1. 1. 1. Ni khoa:
Vim d dy cp: Cn au xy ra mt cch rt t ngt, c th c yu t lm d
nh do thc n. au vng thng v, lan ln ngc hay sau xng c. Nn ma
nhiu, n vo au thm, au kiu nng rt, Khm ti ch c n au vng thng v.
Vim tu cp: Bnh khi pht mt cch rt t ngt. c yu t lm d l sau
mt ba n nhiu ru tht. au vng thng v, lan ra sau lng. Tinh cht au d
di, lm bnh nhn phi ln ln, vt v, nn ma nhiu, c th km theo chong,
C hi chng nhim trng, Khm bng c cc Im au tu dng tnh, Xt
nghim c lng Amylase trong mu tng cao
Giun chui ng mt:Xy ra rt t ngt ngi tr tui, nht l tr em c tin s
nhim giun, au vng thng v hay h sn phi, au d di lm bnh nhn phi
ln ln, vt v, c t th gim au l t th gi ngc, Nn ma nhiu, c th nn ra
giun. Khm: n Im cnh c phi hay Im ti mt au
Vim hay lot d dy hay hnh t trng: au nhiu vng thng v, c th km
theo nn hay chua, hi Trong tin s thng c nhng cn au theo chu k, xut
hin vo nhng gi nht nh, lin quan n cc ba n trong ngy v vo nhng ma
nht nh trong nm
4. 1. 1. 2. Ngoi khoa:
Thng d dy: Thng c tin s lot, ang nm trong cn au lot, cn au t
ngt d di nh dao m. Khm bng c du hiu bng ngoi khoa, G vng c
trc gan mt, Thnh bng cng nh g, Ri hoc chp c honh c lim hi.
Vim tu cp th hoi t: C cc biu hin ca vim tu cp km theo tnh trng
chong v mt mu. Khm ti ch c biu hin bng ngoi khoa.
52
Abces gan: au vng h sn phi lan ln vai phI. au lin tc, km theo nhim
trng. Gan ln, mm, rt au, Khi abces tin trin v vo bng, s gy nn tnh trng
vim mng bng cp.
4. 1. 2. Cn au bng cp vng h v v 2 h chu (di rn)
4. 1. 2. 1. Ni khoa:
Vim i trng cp do amip: Thng au h chu phi v tri (vng hi manh
trng v i trng sich- ma). C hi chng l
au bng kinh (c thng kinh): Thng xy ra ph n tr, cn kinh nguyt. cn
au c lin h n chu k kinh, au 2 bn h chu
Vim phn ph: Thng au 2 bn, yu t lm d l nhim trng ngc dng t
di ln km theo nhim trng ra kh h (huyt trng)
4. 1. 2. 2. Ngoi khoa
Vim rut tha: Khi pht t ngt, au m h chu phi km theo nn hoc b
trung i tin, Hi chng nhim trng. Khm ti ch: n vo Im rut tha rt
auau, c phn ng thnh bng vng h chu phi, Thm trc trng hay m o c
au ti cng bn phi
U nang bung trng xon: Xy ra ph n tr ri lon kinh nguyt, rong kinh, c
khi u trn di ng h chu, au d di km du hiu bng ngoi khoa.
Thai ngoi t cung v: C du hiu mang thai, C ra huyt m o nht l 3 thng
u, Chong mt mu, Khm c du hiu bng ngoi khoa
4. 1. 3. Cn au v tr khng in hnh:
4. 1. 3. 1. Ni khoa:
Vim rut: Yu t lm d l nhim trng, nhim c thc n, au quanh rn. C
du nhim trng nhim c, i chy nhiu ln trong ngy, m rut gia tng, n au
ton bng.
4. 1. 3. 2. Ngoi khoa:
Tc rut, lng rut, xon rut: au bng tng cn, nn ma nhiu, b trung
i tin, Lc u tng nhu ng rut v sau gim v mt, km theo chong v
nhim c, Chp phim c mc hi, nc cc quai rut
4. 2. Nhng nguyn nhn gy nn au bng mn:
Lao rut: au m vng hi manh trng. C hi chng bn tc rut v ri lon
i tin. Km theo du hiu nhim lao cc b phn khc.
Vim i trng mn tnh: au qun bng tng cn dc i trng, ri lon i tin.
Vim mng bng do lao: au bng m , ri lon tiu ho, khm bng thy
mng bng dnh nhiu ni, g ch c ch trong.
Tm li: au bng l mt triu chng chung, do rt nhiu nguyn nhn khc
nhau gy nn. Ngi thy thuc cn phi thm khm tht k lng
chn on chnh xc, nht l khng b st nhng trng hp bng ngoi
53
khoa c thi x tr ng, khng lm nh hng n sc kho ca
bnh nhn.
TI LIU THAM KHO:
-Triu chng hc ni khoa, tp I, trng i hc Y H ni, 1996
- Bi ging Bnh hc ni khoa, tp II, NXB Yhc, 1996

K KH H M M B B N NH H N NH H N N H H N N M M

MC TIU:
1. Trnh by c nh ngha v nguyn nhn hn m.
2. Trnh by c cch khm bnh nhn hn m.
3. Trnh by c cch phn loi hn m.
NI DUNG HC TP:
1. nh ngha:
Hn m l tnh trng mt thc (mt s nhn bit v bn thn v th gii bn
ngoi nh mt ton vn v nhn cch, mt nh hng, mt tr nh, mt t duy lo gic)
v mt s thc tnh (mt tnh to, phn ng vi cc kch thch nh ting ng, nh
sng).
Ch :
C Mt thc tnh trong hn m l tin pht, mt thc ch l hu qu ca mt s thc
tnh
C Hn m ni ln tnh cht nguy kch ca mt bnh thn kinh hay bin chng no ca
mt bnh ton th.
C Nguy c ca hn m:
Ngt h hp.
Suy tun hon.
Thiu mu no.
C Cn phn bit:
Gic ng c hi phc hoc ri lon gic ng (ng thong qua, ng do tng trng
lc c, ng g).
Ri lon v ngn ng (khng ni c, tnh trng do tng trng lc c).
Ngt (thong mt nhn bit):
- S suy sp t ngt c hi phc cc chc nng ca cuc sng (vn ng, cm
gic, thc) cht trong mt thi gian ngn, phi ngng th, tim ngng p
(ngt thng ko di 15 sau tnh li hoc cht hn).
- Ngt l s u m v nhn thc c th dn n mt thc ton b, km theo cc
triu chng xanh xm, bun nn, tai, chut rt v ng, mt ting tim v suy
sp huyt p ng mch.
54
Cn Hysteria: Bnh cnh ging hn m nhng c mt vi yu t gip phn bit:
- Ti pht nhiu ln trong tin s.
- Dng bnh nhn dy ri b t ngt bnh nhn xung ging th bnh nhn vn
ng nhng bao gi cng c phn ng t v (ng t t, trnh au v trnh
thng tch cho bnh nhn).
2. Nguyn nhn: Mt qu trnh bnh l c th gy hn m nu qu trnh xm phm
ti c hai bn cu no hoc/v cu to li ca thn no.
2. 1 Nguyn nhn do tun hon no b nh hng:
2. 1. 1 Tt huyt p nng.
2. 1. 2 Ngt
2. 1. 3 Ri lon nhp tim: nhp tim qu chm <30 hoc qu nhanh >160 chu ky/pht.
2. 1. 4 Tai bin mch mu no: xut huyt no c trn no tht hoc xut huyt no do
tng huyt p v c nh hng n vng h no; nhi mu no vng cu no v trn
cung no; chn thng s no.
2. 2 Nguyn nhn do nh hng n chuyn ha no:
2. 2. 1 Bnh chuyn ha v ni tit: i tho ng, h ng huyt, suy hoc cng
gip, u tuyn ty.
2. 2. 2 Ri lon nc v in gii: Tng hoc gim Na
+
, tng Ca
++
mu
2. 2. 3 Nhim c ni sinh: Suy gan, suy thn.
2. 2. 4 Suy h hp nng.
2. 2. 5 Ph no: Tng p lc ni s, u no, vim hoc Abcess no-mng no, st rt c
tnh, chn thng s no.
2. 2. 6 Ng c: Thuc ng, ru, ma ty, phospho hu c
2. 3 Nguyn nhn do ri lon in no:
2. 3. 1 Chn thng s no.
2. 3. 2 ng kinh.
4. Thm khm bnh nhn hn m:
Ngy nay, hn m khng phi l mt tnh trng m l mt qa trnh tin trin.
su ca hn m l mt biu hin phc tp ca cc khi nim v mc , nh khu,
nng, tnh cht iu tr khn trng. Mt khc hn m c nhiu nguyn nhn nn vic
thm khm mt cch h thng theo mt trnh t nht nh tranmhs b st v ngc
li trnh lm qu nhiu ng tc v xt nghim tha.
4. 1 Hi bnh:
4. 1. 1 Hi bnh nhn: Gip chn on xc nh v mc hn m.
4. 1. 2 Hi ngi nh hoc ngi xung quanh: Xc nh tnh cht hn m.
Hon cnh xut hin hn m:
- Sau chn thng du: Chn thng s no.
- Sau mt thi gian st: Vim hoc abcess h thn kinh, st rt c tnh.
55
- Khi i hoc xa ba n: H ng huyt hoc u ty.
- Sau dng mt s thuc c th gy hn m (thuc ng, thuc phin, thuc h
ng huyt) hoc ha cht (phospho hu c).
- C a bnh nhn c bnh thun li gy hn m: i tho ng, x gan, suy
thn
Cch xut hin:
- T t: Vim mng no, st rt c tnh, bnh chuyn ha
- t ngt: Tai bin mch mu no, chn thng s no
Ln u hay ti pht nhiu ln: Hn m ti pht nhiu ln gp trong ng kinh, h
ng huyt bi u ty
Thi gian bt u hn m v khong tnh:
- Cn co git gy hn m t khi ko di >15 pht, sau bnh nhn tnh dn tuy vn
cn ln ln hng gi.
- Chy mu di mng cng hoc ngoi mng cng hay c khong tnh.
Mc hn m: Nh, va, su v rt su.
4. 2 Khm ton th: Rt quan trng gip chn on nguyn nhn hn m v pht hin
bin chng ca hn m.
4. 2. 1 Cc du hiu ton thn:
Da nim:
- Nht nht: Shock, mt mu, ngt.
- Xanh tm: Thiu oxy t chc.
- Vng: Hn m gan.
- Xut huyt: Chm xut huyt (nhim khun no m cu), ban xut huyt (c a
d chy mu), xut huyt mng tip hp (cn ng kinh ln, tng huyt p).
Nhit :
- St:
+ Nguyn nhn hn m: Vim hoc abcess no-mng no, st rt c tnh, say
nng, mt nc, tn thng h no, chn thng s no
+ Tin lng hn m: Tin lng xu khi st trong hn m do xut huyt no
hoc ng c thuc ng.
- H thn nhit: Nhim c (ru, thuc ng), nhim lnh, suy gan
Hi th v nhp th: Ri lon v nhp th c th l nguyn nhn ca hn m va l
triu chng biu hin tn thng no trong hn m.
- Hi th:
+ Hn m nhim ceton: Mi aceton (qu chn).
+ Hn m gan: Mi chua chua.
- Nhp th:
+ Cheyne-Stokes: Bnh chuyn ha, tng p lc ni s, chn thng s no, tt
56
no vng trn lu tiu no
+ Kussmaul: Nhim toan mu nng do suy h hp, i tho ng
+ Tng thng kh: Toan chuyn ha, suy h hp, tn thng thn no cao
+ Ri lon nhp th vi cn ngng th.
- Tn s:
+ Nhanh: Nhim khun h thn kinh.
+ Chm: Tng p lc ni s, ng c thuc ng hoc thuc phin
Mch v huyt p:
- Mch:
+ Nhanh: Lon nhp tim qu nhanh, nhim khun, shock hoc do tn thng
vng h no hoc nn no
+ Chm: Tng p lc ni s, Block nh tht, ri lon nhp chm
- Huyt p: Tng hoc tt huyt p.
4. 2. 2 Khm cc b phn c th l nguyn nhn gy hn m: Khm k v la chn
thch hp.
Khm du hiu ca chn thng s no: T mu sau tai hoc quanh hc mt l du
hiu ca v h s gia v hc mt.
Khm tim mch: Ri lon nhp tim, tng huyt p.
Khm cc bnh nhim khun h thn kinh.
Khm cc bnh no chuyn ha.
4. 2. 3 Khm cc du hiu ca bin chng thn kinh:
Tng tit m gii trong ng h hp.
Bi nhim phi (bnh nhn hn m qu lu).
Lot: Hay gp lot nhng ni m c u xng t nhiu xung ging (mng,
gt chn)
4. 3 Khm thn kinh:
4. 3. 1 Khm thc:
nh gi xem bnh nhn c tip xc hoc hp tc c vi thy thuc khng? (nh
hng khng gian, thi gian v bn thn).
nh gi xem s p ng ca bnh nhn i vi cc kch thch nh gi tn, ht to,
lc lay, gy au
Tip xc vi bnh nhn tm cc ri lon v hot ng thc:
- Ni chuyn: Bnh thng, bi ri, lp bp hoc ri rc
- Thc hin cc lnh t n gin n phc tp.
Nu khng p ng vi cc yu cu bng li ni th chc nng v no b ri
lon. Kim tra s nhn v nhm mt khi e da xc nh hot ng ca vng th
gic (vng chm, v no).
Xc nh phn ng tnh: M mt t nhin, m mt sau khi kch thch (gi tn, ting
57
ng, gy au)
Ri lon thc trong hn m c th l ri lon hn m bt ng hoc hn m
kch thch vt v
4. 3. 2 Khm mt: Rt quan trng, l c bn trong khm hn m.
C V tr nhn cu:
Hai nhn cu a ra pha ngoi: Hn m tng i su v trng lc c ging nhn
cu mnh hn c khp nhn cu.
Hin tng mt lc: Hai mt khng hp ng.
- Dy III: Nhn cu ra ngoi v xung di.
- Dy IV: Nhn cu a vo trong.
Hai nhn cu nhn ngc chiu vi bn lit: Bnh nhn nhn tn thng ca mnh
bn cu no tn thng trn cu no.
C Kch thc ng t v phn x ng t vi nh sng: L mt ng tc bt buc
trong khm thn kinh bnh nhn hn m v l mt thng tin quan trng gip chn
on nguyn nhn v theo di hn m.
Bnh thng: ng t c kch thc 3-4 mm, cn i hai bn v co nhanh vo khi
p ng vi kch thch nh sng.
Bt thng:
- ng t co nh <2mm hai bn nhng cn phn x vi nh sng tt: Bnh no
chuyn ha; ng c thuc ng, morphin, phospho hu c; tn thng h no
hoc cu no.
- ng t trung bnh v c nh hai bn: Tn thng no gia, tt no trung gian.
- ng t gin v c nh hai bn: Bnh no do thiu O
2
nng v ko di, ng c
thuc gin ng t (Atropin, Scopolamin).
- ng t gin v lit c vn nhn (III, IV, VI): Tn thng thn no. ng t gin
v c nh mt bn, khng cn p ng vi phn x nh sng: Lt thy thi
dng v c khi u chn p.
- Phn x nh sng mt mt bn (tn thng dy III), mt hai bn (tn thng no
gia).
C Mt nhm v chp mt:
Mt khng nhm c: Tn thng dy VII hoc do gim trng lc c trong hn
m su.
Mt chp: C th mt chp t nhin trong hn m nu vng cung no v no trung
gian vn cn nguyn vn; c khi mt chp nhiu hn bnh thng km theo theo
cc du hiu tng phn x mt.
C nhiu th thut cho php tm tm chp mt do kch thch:
- Phn x mi-mi: G vo vng sng mi.
- Phn x tai-mi: p ng vi ting ng.
58
- Phn x nh ng-mi: Chiu mt lung nh sng mnh qua mi, mt nhm li.
- Phn x gic mc: Bn cnh chp mt (dy VII) v nhn cu a ln trn (dy
III), phn x gic mc cho php bit c p ng khi c lit mt. Mt phn x
gic mc c ngha l hn m tng i su hoc tn thng cu no.
C Vn ng nhn cu: Vn ng ca nhn cu c thc hin di s ch huy ca v
no, chu nh hng ca cc phn x.
Hot ng nhn cu: Quan st lu mi pht hin c.
- Nhn cu qu lc, nhn cu th thn (a i a li khng nhp nhng): Tn
thng thn no. Nhn cu ci cho (a mnh xung di ri ln t t): Tn
thng cu no.
- Rung git nhn cu: Rung git n thun (mt o lung tung khp pha) hoc rung
git kiu ng kinh.
Chuyn ng ng b hai mt: Du hiu lin hp hai mt hay phn x vn ng
nhn cu.
- Phn x mt-u (phn x mt bp b): Ch thc hin phn x ny khi khng c
tn thng ct sng c hoc tng p lc ni s.
Quay nhanh u sang tri, sang phi, ln trn v xung di. Nu thn na
khng b tn thng th hai mt s chuyn ng ng b v hng ngc li theo
hng quay u.
+ Quay u sang phi: Hai mt nhn sang bn tri.
+ Quay u sang tri: Hai mt nhn sang bn phi.
+ Nga u ra sau: Hai mt nhn xung di.
+ Gp u ra trc: Hai mt nhn ln trn.
- Phn x mt-tai (phn x nng lnh): Ch thc hin khi c chng ch nh phn x
mt-u v khi khng c tn thng tai ngoi, mng nh v tai trong. Nng cao
u 30
0
trn mt phng ngang, dng bm tim bm khong 10-50 ml nc lnh
hoc m vo ng tai ngoi 1 hoc 2 bn.
+ Bnh thng: Nu bm vo 1 tai th hai nhn cu s rung git nhanh v a
nhanh v bn i din vi tai c bm nc (phn ng t v no); nu bm
vo hai tai th hai nhn cu nhn ln trn.
+ Bt thng: Trong hn m nu cc ng dn truyn trong cu no, cung
no khng b tn thng th hai nhn cu s cng chuyn v pha tai c
bm nc.
Khi tn thng b dc gia: Quay u sang phi hoc tri th mt phi hoc
tri khng a sang bn i din c v dng ngay v tr gia. Khi tn thng
no thp: Mt vn v tr gia, khng thay i khi quay u, gp nga u v
khi bm nc vo tai.
4. 3. 3 Khm cc ni dung khc trong thn kinh:
59
C Cc dy thn kinh s no khc:
Dy VII:
- Nhn trung lch.
- M bn lt php phng theo nhp th.
- Lm nghim php Marie-Foix (n hai tay vo gc hm hoc sau tai) th bnh nhn
nhn mt s mt cn i hai bn.
Dy VIII: Bnh thng khi c mt ting ng mnh bn tai th bnh nhn nhm mt
li. Tn thng ly mt v mt hng l tn thng nhn tin nh; ly mt v cc
hng bnh nhn l m v l ln ngh n nguyn nhn hn m do thuc ng.
Dy IX, X:
- Phn x nut: Cho mt t nc vo ming, xem bnh nhn c nut c khng?
Bnh nhn khng nut c khi bnh nhn hn m su, tn thng phn trn thn
no hoc tn thng c hai bn cu i no.
- Phn x nn: Kch thch vo thnh bn ca hng.
C Du hiu mng no:
Du hiu cng gy.
Du hiu Kernig.
C Khm vn ng:
Vn ng t ch v c lc:
- Quan st vn ng t nhin, c thc hoc t ng.
- Quan st bn chn bn lit s ra ngoi xung mt ging.
- Phn ng kch thch au bnh nhn hn m nh v va:
+ Du hiu Marie-Foix, day tay vo xng c bnh nhn th bnh nhn ly tay
bn lnh gc tay thy thuc ra, tay bn lit khng c ng.
+ p ng vn ng: nh gi ch yu l da vo chi trn. Bao gm: p ng
tt; rt chi di li, nga chi trn ra; p ng cng mt kiu i vi mi kch
thch (chi di thng dui cng, chi trn co v khp vo trong mt v; chi
trn dui khp v p sp trong mt no); khng cn phn ng vn ng.
- Quan st c ng bt thng: Cn co git, git th c, run tay, du hiu v cnh.
- Du hiu Raimist: Nhc hai tay bnh nhn ra khi ging v a ln trc ngc
bnh nhn ri th xung ging th tay bn lit ri nhanh v nng n hn.
Trng lc c: Khi c ri lon v thc tnh th lun c ri lon trng lc c
Quan st v khm ve vy cc chi.
- Gim trng lc c (c nho): Chi khng khng c v t th khng thch hp.
- Tng trng lc c (co hoc dui): Co chi trn, dui chi di (mt v); dui chi
trn v chi di (mt no).
Khm phn x:
Phn x thuc thn no:
60
- Phn x thuc cung no:
+ Phn x nh sng: Chiu mt ngun sng vo mt bn no th ng t bn
co li.
+ Phn x mt bp b dc.
- Phn x thuc cu no:
+ Phn x mi mi: Bng mnh vo gia hai chn my th hai mt bnh nhn
nhm li (t chnh xc).
+ Phn xgic mc: Dng bng kch thch vo gic mc th mt s nhm li.
+ Phn x mt bp b ngang.
+ Phn x mt tin nh.
- Phn x thuc hnh no:
+ Phn x nut, ho.
+ Thn kinh thc vt: Mch, nhit , huyt p, nhp th dao ng.
Phn x gn xng: Thng l phn x gn xng p ng yu do trng lc
c gim v do mc hn m. Phn x gn xng tng c th gp trong hn
m su.
Phn x da: Bn lit gim so vi bn lnh hoc = 0.
Phn x bnh l: Khi hn m qu su th c th nm bt ng, gim trng lc
c v thng mt lun phn x Babinski (hay gp dui ngn c hai bn); thng
thng hay c Babinski bn lit.
C Khm cm gic:
Hn m nh: p ng li bng kch thch au bng cch ly tay gc ra.
Hn m va v su: Khng th khm c.
C Khm ri lon dinh dng v c trn:
Lot (mng, gt chn) do nm qu lu.
i tin khng t ch hoc to bn, tiu tin khng t ch hoc b tiu.
Ri lon thn kinh thc vt:
- H hp: Nhp th tng, gim, hoc ri lon, dao ng. Nhp th Cheyne-Stokes
trong tn thng no trung gian v phn trn thn no, nhp th khng u trong
tn thng cu no v hnh no.
- Tim mch: Co mch, huyt p khng n nh, nhp tim chm trong tn thng
thn no.
5. Khm chuyn khoa v cn lm sng:
5. 1 Soi y mt: Bt buc trong bt k bnh nhn hn m no nhng nu bnh nhn
c co ng t th phi cn nhc v nh thuc gin ng t s lm nh hng n vic
theo di tin trin ca hn m.
Du hiu quan trng nht trong soi y mt l: Ph gai, xut huyt hoc xut tit
vng mc, phng cc ng mch nh trong hn m i tho ng.
61
Ph gai gp trong tng p lc ni s (u no, khi chon ch), ph no, tng thng
kh, ri lon in gii (nht l Na
+
v Ca
++
), nhim khun h thn kinh (vim mng
no, vim tc tnh mch no).
5. 2 Chp s, chp CT Scanner, chp MRI: Gip chn on cc khi u, khi mu t
trong no.
5. 3 Chp ng mch no: Gi tr trong chn on xut huyt no do d dng hoc u
mch mu no.
5. 4 in no: Gi tr trong chn on hn m do ng kinh hay ng c Barbituric,
hn m qu giai on hoc gip phn bit bnh no chuyn ha vi cc trng hp
tn thng thn kinh kh tr.
5. 5 Chc d nc no ty: Ch nh trong nhim khun thn kinh trung ng, cn
nhc trong hn m cha r nguyn nhn. Chng ch nh trong hn m c ph gai
th hoc mi xut huyt no.
5. 6 in tm : Gi tr trong chn on hn m do bnh l ti tim.
5. 7 Xt nghim sinh ha v huyt hc: Rt quan trng trong vic tm nguyn nhn
nht l khi hn m khng c du hiu thn kinh ch im kh tr: Glucose, NH
3,
ure
v creatinin mu, Na
+
, Ca
++
cht c trong dch d dy hoc trong mu.
6. Phn loi hn m:
6. 1 Phn loi hn m theo nguyn nhn:
6. 1. 1 Hn m c triu chng thn kinh ch im:
C Lit na ngi:
Xut huyt no.
Nhi mu no.
Abcess no hoc u no ln.
C Hi chng mng no:
Vim mng no.
Xut huyt mng no.
C Co git:
C st: Vim no, vim mng no, tc tnh mch no, st rt c tnh.
Khng st: ng kinh, h ng huyt, sn git, ph no, ure mu cao, tng p
lc ni s
6. 1. 2 Hn m khng c triu chng thn kinh ch im nhng c st:
St rt c tnh.
Ure mu cao do suy thn m nguyn nhn vim cu thn cp, vim ng thn cp.
Suy gan do vim gan cp.
6. 1. 3 Hn m khng c triu chng thn kinh ch im v khng c st:
i tho ng. Suy h hp.
Suy gan. Tt huyt p nng.
62
Ure mu cao. Ri lon nc v in gii.
Ng c. Suy gip, suy tuyn thng thn.
6. 2 Phn loi hn m theo mc hn m:
6. 2. 1 Phn loi theo lm sng:
C Kinh in:
Giai on I: Bnh nhn l m; p ng chm (tr li chm, khi ng khi sai); cn
p ng tt vi kch thch au (gc ng ch), cc phn x cn tt.
Giai on II: Khng c phn ng thc tnh (gi hi khng p ng), phn ng vn
ng ph hp (kch thch au c gc tay nhng khng ng ch); ri lon phn x
(mt phn x trn mi v th mi; cn phn x gic mc v nut).
Giai on III: Hn m su vi khng p ng vi kch thch au; mt ht cc phn
x nhng cha c ri lon thn kinh thc vt.
Giai on IV: Hn m qu giai on hi phc vi cc triu chng ging giai on
III nhng km theo ri lon thn kinh thc vt (ri lon nhp tim, nhp th, nhit
v h huyt p).
C Thang im Glassgow: nh gi mc hn m cng nh tin trin hn m tt
hn phn loi kinh in.

NI DUNG IM
A. M MT:
- M mt t nhin. 4
- M mt khi gi to. 3
- M mt khi kch thch au. 2
- Lm g cng khng m mt. 1
B. LI NI:
- ng cu hi. 5
- Lc ng lc sai. 4
- Tr li khng ph hp. 3
- Tr li bng m thanh v ngha. 2
- Khng tr li g c. 1
C. VN NG:
- ng theo y lnh. 6
- nh khu khi gy au. 5
- Co chi li khi gy au. 4
- Gp chi bt thng (mt v). 3
- Dui chi bt thng (mt no). 2
- Mm nhn (khng p ng g c). 1
63
Tng im:
15 im : Tnh to hon ton.
11-14 im : Hn m nh.
6-10 im : Hn m va.
4-5 im : Hn m su.
3 im : Hn m qu su.
6. 2. 2 Phn loi theo in no:
Giai on I: Sng alpha chm, c nhiu sng theta v delta mt hnh dng, tng
t; phn ng vi kch thch thng tng.
Giai on II: Sng delta thay sng alpha; cn phn ng vi kch thch mnh.
Giai on III: Sng delta lan ta; khng c phn ng (gi l cht lm sng).
Giai on IV: in no l mt ng thng (cn c vo in no ny ni rng
bnh nhn cht, c th quyt nh ngng cp cu).
TI LIU THAM KHO:
1. i hc Y H Ni (2003), "Triu chng hc hn m", Ni khoa c s, tp I, NXB Y
hc.
2. i hc Y Dc TPHCM (2003), Thn kinh hc, NXB Y hc.

K KH H M M H H T TI I T T N NI I U U
MC TIU:
1. Nu c cch hi v khm thn, niu qun, bng quang, niu o.
2. Trnh by c chn on thn to.
3. Nhng triu chng lm sng chnh ca bnh thn, tit niu.
4. Trnh by c chn on i ra protein.
5. Nu c nh ngha v chn on i ra m.
6. Trnh by c nguyn nhn i ra m.
NI DUNG:
Mi ngi c hai qu thn, nm dc hai bn ct sng, sau phc mc, nm trong
h thn, cc trn ngang L
11
- L
12
cc di ngang t sng tht lng 2 - 3, thn P thp
hn thn. Kch thc thn: nam 11x 6 x 3cm, n 10 x 6 x 3cm. Ni vi hai thn l hai
niu qun dn nc tiu xung bng quang v niu o.
Thn l c quan m nhim rt nhiu chc nng ni tit, ngoi tit, trong c 4 chc
nng chnh:
- Lc ca cu thn.
- Ti hp thu v bi tit ca ng thn.
- i ho thng bng kim - toan, mui - nc.
- Chc nng chuyn ho.
Cho nn khi thn b tn thng th biu hin lm sng v cn lm sng rt a
64
dng. Mt khc h thng thn tit niu l tng th nn khi c mt tn thng d ch la
bng quang hay niu o hoc mt b phn c lin quan nh tin lit tuyn th
thn cng c th b tn thng theo c ch ngc dng hoc ton thn.
V th pht hin bnh thn cn thm khm mt cch c h thng
1. Khm lm sng:
1. 1. Hi bnh: Rt quan trng v n nh hng cho thm khm v xt nghim cn
lm sng tip theo.
1. 1. 1 L do n khm: iu m bnh nhn thy kh chu nht, lo lng nht, quan tm
nht n vi thy thuc.
+ Ton thn: St, mt mi, chn n, bun nn, da xanh, gy st. . .
+ C nng: au lng, au bng, nhc u, m mt, kh th, ph, i but, i
nhiu ln. . .
1. 1. 2 Bnh s:
* Khi pht:
+ Khi pht: ngy, thng, nm.
+ Hon cnh khi pht: Khi ngh ngi, sau khi lm vic nng, sau khi i b xa,
thy nng mi mt sau khi ng dy.
+ Nhng du hiu khc km theo.
* Din bin:
+ T khi pht cho n khi khm bnh: Cc triu chng tng hay gim, lin tc
hay tng lc, c biu hin g thm.
+ Hin ti c nhng du hiu g c th.
1. 1. 3 Tin s:
+ C nhn: C lin quan n bnh ny nh ph, tng huyt p, au hng, i dt. .
. , Bnh nhn lm ngh g.
+ Gi nh: C ai mc bnh nh bnh nhn. . .
1. 2 Khm thc th:
1. 2. 1. Khm ton thn: Cn ch :
- St: St cao, rt run thng gp trong VTBTC
St nhiu ngy thng gp trong thn m.
St ko di nhiu t thng gp trong vim thn do lupus. . .
- Thiu mu: Thng gp trong suy thn mn, VCTM.
- Ph: c im ca ph thn l ph mm, trng, n lm, ph mt trc ri
mi n chi v ton thn, c th kt hp vi trn dch cc mng.
- Tng huyt p: Trn 80% ngi b bnh cu thn c tng huyt p.
- Suy tim v vim mng ngoi tim c th l hu qu ca bnh thn mn tnh.
1. 2. 2. Khm thn:
1. 2. 2. 1. Khm thn: Kt hp nhn, s, g, nghe.
65
- Nhn: T th bnh nhn ngi cn i, thy thuc quan st 2 bn h lng
xem bn no dy hn. T th bnh nhn nm nga, thy thuc quan st vng h sn
phi, vng hng pht hin khi u. . .
- S: C 3 phng php thng dng:
Phng php Guyon: thng thng nht, Bnh nhn nm nga, hai chn co, th
u, thy thuc ngi bn thn nh khm bn tay cng bn t ln vng hng pha
trc (Di b sn, trn rn) cc u ngn tay hng vo khi c thng bng n
xung, bn tay kia t di h lng.
+ Tm du hiu chm tht lng : Bn tay di yn, bn tay pha trn bng
n xung theo nhp th bn tay t di h lng c th c cm gic chm vo mt
khi c Kt lun: Du hiu chm tht lng (+).
+ Tm du hiu bp bnh thn : Bn tay thy thuc t trn bng vng hng n
xung nh ri yn. Dng cc ngn tay ca bn tay pha di n y ht mnh ln v
lm ngc li. ng tc n y cn dt khot, lm nhiu ln. Khi c thn to hai bn
tay c cm gic chm vo mt khi chc bp bnh Kt lun: Du hiu bp bnh
thn (+)
Phng php Israel: Bnh nhn nm nghing bn i din v khm nh phng
php Guyon.
Phng php Glenard: Dng bn tay i din vi thn nh khm, ngn tay ci
trn bng, bn ngn kia pha sau v bp cht vng tht lng Nu thn to th
khi th thy cm gic thn di ng trong lng bn tay.
- G: Thn to khi g nghe ting trong do c i trng che ph (phn bit vi gan,
lch).
- Nghe: Ting thi tm thu trn rn bn tri hoc bn phi ca hp ng mch thn.
1. 2. 3. im au niu qun - thn:
1. 2. 3. 1. im au niu qun trn (im cnh rn): k mt ng ngang rn, gp b
ngoi c thng to hoc cch rn 3 khot ngn tay (tng ng L2 l im ni b thn v
niu qun). Khi khm thy thuc ngi bn phi bnh nhn, dng tay tri hng lng,
dng 3 ngn ca bn tay phi (ngn 2, 3, 4) n nh t trc bng ra sau lng, cc ngn
tay t song song vi b ngoi c thng to va n va quan st nt mt ca ngi bnh
pht hin triu chng au.
1. 2. 3. 2. im niu qun gia: k ng ngang qua hai gai chu trc trn, chia 3
phn, hai im u ca on 1/3 gia l hai im niu qun gia (tng ng L4 - L5).
Cch khm tng t nh cch khm im niu qun trn.
1. 2. 3. 3. im au h sn (im sn lng):
Ch gp nhau ca b di xng sn XII v b ngoi khi c lng. T th bnh
nhn ging nh khm thn. Dng 3 ngn tay ca bn tay n vo h sn lng, bn tay
trn kt hp n xung, nu c au l (+), thng gp trong mt s trng hp c si
66
thn, thn m, vim ty quanh thn, vim thn b thn cp. . . (Ch phn bit vi
vim tu cp)
1. 2. 3. 4 Tm du hiu v h lng hay v thn:
bnh nhn ngi cn i, hi ci ra trc, lng quay v pha ngi khm, bc l
r phn h lng. Thy thuc dng hai mu ca gan bn tay v nh vo 2 h lng 1 n
2 ln, quan st bnh nhn, nu c cm gic au nht l ch au mt bn th chc thn
c tn thng.
1. 2. 4. Khm bng quang:
Bnh thng khi bng quang rng hoc cha t nc tiu khng khm c cu
bng quang. Khi bng quang cng y nc tiu:
1. 2. 4. 1 Nhn: Vng h v ni ln mt khi u trn nh qu cam hoc to ti rn gi l
cu bng quang.
1. 2. 4. 2 S: Khi u trn nhn, s n c cm gic cng mm khng di ng v gy
bun i cho nhn ( u t cung, u nang bung trng n)
1. 2. 4. 3 G: c vng bng quang.
Thng tiu: Nc tiu ra nhiu, khi u xp xung.
1. 2. 4. 3 Khm niu o: Tn thng khi khm thy l niu o vim ty hoc c
dch m chy ra. Mt s trng hp nam c th s nn thy si niu o.
1. 2. 6 Khm tuyn tin lit: Thng thm trc trng khm tin lit tuyn.
Trc khi khm cho bnh nhn i cu ht, nm trn bn khm chn chng i
ging. Ngi khm dng tay phi c i gng cho 1 ngn tay bi du paraphin vo
hu mn bn tay tri t vng h v trn xng mu n mnh ra sau. Dng ngn tay
phi s mt trn trc trng c th xc nh c rnh gia ca tin lit tuyn.
- Bnh thng: Tin lit tuyn l mt khi nh, khng s thy hoc ch hi li ln,
mm, c hai thu, gia c mt rnh, v tr nm gn c bng quang.
- Tin kit tuyn to c th do ung th, u x, vim.
1. 3 Chn on thn to:
1. 3. 1 Chn on xc nh thn to:
1. 3. 1. 2 Lm sng: Da vo v tr, tnh cht ca thn.
Khm tm du hiu chm tht lng, "bp bnh thn l hai du hiu quan trng
chn on thn to.
1. 3. 1. 3 Cn lm sng:
- Chp Xquang:
Chp thn khng cht cn quang: C th thy hnh thn
Chp bm hi sau mng bng: Thy hnh dng bn ngoi ca thn, c bit l
phn bit c thn to hoc khi u tuyn thng thn.
Chp thn c thuc cn quang qua ng tnh mch: Thy dc i b thn gip
chn on nguyn nhn v chn on phn bit vi nhng khi u khc.
67
Chp thn ngc dng: Khi nghi ng c nc b thn.
Chp ng mch thn: Nghi thn to do ung th.
- Siu m: o c kch thc thn, thy r c i b thn.
- Xt nghim: Gip chn on nguyn nhn
Nc tiu: nh lng protein, HC, BC, cy nc tiu tm vi khun
Mu: Ure- creatinin.
1. 3. 2 Chn on phn bit:
1. 3. 2. 1 Thn phi to:
- Khi u ca gan:
Di ng theo chiu ln xung, di ng theo nhp th.
Lin vi b sn.
- Ti mt to:
Khi u mm nhn, trn, cng.
Rt au, du hiu Murphy(+)
C th vng da, vng mt, st.
Di ng ln xung theo nhp th,
- Khi u i trng ln:
St pha b sn
C hi chng bn tc rut.
Chp khung i trng s c hnh khuyt ca khi u.
- Khi u hi manh trng(do lao, k, amp, m qunh rut tha).
thp vng h chu phi.
C hi chng bn tc rut.
t di ng, c tnh cht dnh.
- Khi u u tu:
vng thng v v nm pha sau.
Khng di ng.
C triu chng tc mt, vng da, ti mt to.
1. 3. 2. 2 Thn tri to: phn bit vi
- Lch to:
Lin vi b sn.
Di ng theo nhip th.
C b rng ca.
i khi phn bit bng nghim php co lch: Tim 1ml adrenalin di da, nu
lch to sau 30 pht lch co li.
- Khi u i trng tri:
st pha ngoi b sn tri.
C hi chng i trng v bn tc rut.
68
- Khi u ui tu:
Su pha sau
Khng di dng
Rt to.
1. 3. 2. 2 Chung cho c hai thn:
- Hch mc treo.
Khng di ng.
Nhiu hch dnh vi nhau.
- U tuyn thng thn
Rt kh phn bit bng thm khm lm sng, cn phn bit bng siu m, tt
nht l bng bm hi sau mng bng
- U nang bung trng phi v tri:
Khi u trn nhn
Nm hai bn h chu,
Rt di ng.
- Khi u phn ph:
Khi u nm thp
Thm m o thy c khi u
Rt di ng v mm
- Khi u t cung (ux, k)
Nm vng h v.
Thm m o trc trng thy u lin vi t cung.
- Thn xa.
1. 3. 3 Nguyn nhn thn to:
1. 3. 3. 1 nc, m b thn:
- Si thn, si niu qun.
- Thai, kh u trong bng vo niu qun.
- Lao b thn, niu qun lm hp lng niu qun.
- B i lu ngy do u tin liti tuyn.
1. 3. 3. 2 Ung th thn:
- Nguyn pht:
Thn to, cng, mt ln nhn.
i ra mu t nhin hay i ra mu vi th.
Xquang - Siu m thn: To mt bn, i thn b ko di, ct ct, lch hng.
- Th pht: Sau K t cung, K rau.
1. 3. 3. 3 Thn a nang:
- Thn to mt bn hoc hai bn.
- i khi c cn au qun thn
69
- Khi c bi nhim: i c, cy nc tiu c vi khun
- Ure mu cao mn tnh.
- XQ, SA c nang thn.
1. 3. 3. 4 Thn to b.
- Ch c mt thn
- Nc tiu bnh thng.
2. Nhng triu chng lm sng chnh:
2. 1 au:
Tng p lc trong ng dn niu trn do tc nghn hoc do nc tiu pht ngc
bng quang niu qun. Vim ty quanh thn, p xe thn, thn m. Tn thng
bng quang, niu o, tin lit tuyn.
2. 1. 1 Cn au qun thn: L biu hin ca tng p lc cp tnh ng dn niu, trn
ch tc nghn.
- Khi pht t ngt.
-V tr: hng lng, h sn, h chu.
- ng lan: xung di, dc ng I ca niu qun lan n b phn sinh dc,
mt trong i.
- Cng : tng dn, c khi rt d di. Bnh nhn b kch thch vt v.
- Thi gian ko di 5-10 pht nhng cng c th ko di 1 gi c khi n 4 - 5 gi.
- Triu chng km theo:
i but.
i dt,
au vng h v.
i mu.
Chng bng, bun nn, nn.
St cao km theo au h lng (Vim thn b thn cp)
V niu c th l biu hin ca suy thn cp do si.
- Chn on phn bit:
Vim i trng mn: au tng cn r vng h vi v h chu tri, mt i tin.
Cn au si mt: Thng khi pht h sn phI, km st. vng da. n dim
Murphy (+)
Cn au giun chui ng mt: au d di vng h sn phi, vi t th ngi gp
ngi v pha trc, dng u gi p vo bng cho au.
2. 1. 2 au h lng:
au vng h sn lng hoc vng hng lng.
au d di, cp tnh do i b thn gin
au m , cm gic tc nng lin tc, v h lng au tc l biu hin ca thn
nc, m lu ngy, si i b thn
70
au h lng c th lan xung di hoc khng lan.
au c km theo st cao, bch cu tng trong mu, c protein niu l biu hin
ca vim thn b thn cp.
Vim ty quanh thn.
au c cm gic ngc chiu t bng quang ln hng lng ngay sau khi i l biu
hin ca pht ngc bng quang - niu qun.
2. 1. 3 au bng quang: L thng gp v km i but, i dt biu hin ca vim
bng quang, kch thch bng quang do si, do vt l.
au rt vng h v trn xng mu, lan xung niu o.
au d di km theo i but, i dt do nhim khun cp tnh hoc si bng
quang - niu o.
au m , cm gic tc nng vng h v, au ko di lan xung b phn sinh dc
km i but, i dt ko di thng biu hin ca vim bng quang mn, ti pht
nhiu ln.
2. 2 Ph: L c trng ca bnh cu thn.
c im ca ph thn l trng, mm, n lm. Thng xut hin mi mt, mt
ri mi n chi v ton thn. Ph c th km theo trn dch mng bng, mng phi
Nguyn nhn gy ph trong bnh thn:
Hi chng cu thn cp.
Hi chng cu thn mn.
Hi chng thn h.
Hi chng suy thn cp.
Vim thn b thn mn c suy dinh dng.
Bnh thn c suy tim.
3. Ri lon thnh phn nc tiu:
3. 1 i ra protein:
Protein niu l mt du hiu ch im ca tn thng thn. Nc tiu ngi
bnh thng khng c hoc c rt t protein (150 - 200mg/24h). Tuy nhin hin nay
vi k thut xt nghim min dch phng x nhn thy rng protein niu ngi bnh
thng: 20mg/24h (Bao gm Alb: 9mg, IgG: 3mg, IgA: 2mg, chui nh t do: 3,
3mg).
Do vic pht hin protein niu l rt quan trng v gip cho chn on bnh l
thn chnh xc.
Vi test acid sulfosalicylic 3% c th pht hin protein niu trong nc tiu 24h
c cha 60mg protein.
3. 1. 1 Chn on i protein niu:
3. 1. 1. 1 Chn on xc nh:
- Cch ly nc tiu:
71
Ly nc tiu nhiu ln th.
Ly nc tiu gia dng, hoc nc tiu 24.
C th ly nc tiu qua thng tiu xt nghim trong trng hp cn thit.
- Cch th protein:
+ nh tnh:
Dng que nhng dipstic: Cn c vo s i mu ca Bromophenol (Vng nht
xanh l cy, xanh da tri) (+)
Dng nhit v acid axetic kt ta protein.
Dng acid nitric, acid sunfua salicylic ta protein.
Phn bit protein tht (do cu thn) vi protein gi (Do c mu, t bo hu
hoi) v protein nhit tn.
Protein gi: Dng acid nitric v acid xitric, nu cho acid nitric vo c kt
ta, acid xitric khng ta.
Protein tht: Ngc li vi protein gi.
Protein nhit tn: Bence Jones: Kt ta nhit 40 - 60 C, tan 100
C v ta tr li khi nhit h xung.
+ nh lng:
Kt ta protein trong nc tiu bng acid sunfosalicylic, acid triclo axetic ri so
vi mu c sn.
3. 1. 1. 2 Nguyn nhn i ra protein:
- Protein niu theo c a: Protein niu t th: Gp tui thanh, thiu nin, c th
ht sau tui 20, l protein niu lnh tnh, khng dn n suy thn, nhng phi theo
di cht ch HA v hng cu niu.
- Protein niu Bence Jones (Paraprotein): Thng gp bnh nhn b a u tu
xng. Ngi trn 60 tui m protein niu nhiu khng phi l hi chng thn h th
phi tm Protein niu Bence Jonces.
- Protein niu ngi c thai: 3 thng cui ca thai k xut hin protein niu,
ph, tng huyt p c kh nng b nhim c thai nghn, phi iu tr d phng sn
git.
- Protein niu thng xuyn: Chng t bnh l thc s ti thn
Protein niu cao: 3, 5g/24h gp trong hi chng thn h.
Protein niu trung bnh: 2 - 3g/24h: Vim cu thn tin pht hoc th pht.
Protein niu t: (< 1g/24h): L biu hin ca vim thn b thn cp, mn, thn
a nang. . .
3. 2 i ra m:
3. 2. 1. nh ngha: i ra m l hin tng c nhiu t bo m (BCNTT) trong
nc tiu. (BC 5000BC/ pht hoc 5 BC/ quang trng x 40).
Bnh thng BC niu 2000/ pht hoc 3 bch cu/ quang trng x 40.
72
Tiu ra bch cu hay tiu m phn nh mt tnh trng vim cp hoc vim mn ti
thn, ng dn niu m nguyn nhn c th do vi trng hoc khng do vi trng.
3. 2. 2. Chn on xc nh i ra m:
- Que nhng Dipstic:
+ Nguyn tc: Pht hin leucocyt esterase ca bch cu.
Kt qu (+) nu nc tiu c 5 bc/quang trng x40).
+ Gi tr chn on:
C gi tr nh tnh, bn nh lng, tin dng v r tin.
C th pht hin c BC d BC b ly gii.
nhy ca XN t t 44% - 100% tng ng vi s BC c trong nc tiu
(44%: 6-12BC, 90%: 21 - 50BC, 100%:> 50BC/ quang trng x 40)
- Xt nghim cn lng nc tiu:
+ Nguyn tc: Pht hin BC qua soi knh hin vi.
+ Gi tr chn on: Kho st c BC, tr BC trong nc tiu chnh xc
3. 2. 3. Chn on phn bit:
- i ra dng chp: Nc tiu c nh nc vo go, soi knh hin vi it BC, xt
nghim c nhiu dng chp.
- i ra nhiu cn Phosphat hoc urat: Nc tiu trng nh nc vo go, c lng
cn di, un nng s kt ta, nh acid axetic ta tan, nc tiu trong ( i ra
protein).
- i ra nhiu tinh dch.
- Nc tiu c nhiu vi khun: c, khng m, c mi NH3, BC niu t.
3. 2. 4 Nguyn nhn:
- Ti thn:
Vim thn b thn cp: st, lnh run, au lng, cy nc tiu (+), BC niu nhiu.
Vim thn k do thuc: bnh nhn pht ban, tiu mu, tiu BC i toan.
Vim thn k mn: vim i b thn mn, lao thn, . . . thn m
- Ti ng dn niu:
+ Vim bng quang: Thng c i but, i dt km i m.
Do vi khun lao hoc vi khun thng.
Soi bng quang c th thy vim lot, cn m.
+ Vim niu o: i m thng thng l do lu cu, nhng cng c th vim
m niu o khng do lu. i ra m u bi C km i but hoc khng. C th
quan st ti ch hoc soi knh hin vi dch niu o.
- Vim tin lit tuyn hoc tin lit tuyn - niu o:
i but, i dt hoc au vng quanh hu mn.
St, thm trc trng, tuyn tin lit sng to, au p xe tin lit tuyn.
C i kh, i ngt qung hoc b i, c th i m Ux hoc ung th TLT.
73
TI LIU THAM KHO:
- Chng IX: Thn v tit niu trang 325 - 370, Ni khoa c s Tp II, trng i hc
Y H Ni - Nh xut bn Y hc 2003.
- Bnh hc ni khoa Tp I, trng i hc Y H Ni - 1998.
- iu tr hc Ni khoa tp II, cc b mn Ni, trng i hc Y H Ni 2003.

K KH H M M V V C CH H N N O O N N I I M M U U

MC TIU:
- Nu c nh ngha i mu.
- Trnh by c chn on i mu
- K c nguyn nhn i mu thng gp.
NI DUNG:
1. nh ngha: i mu l s xut hin hng cu vi s lng bt thng trong nc
tiu: HC >5000/1 pht, hoc 5 HC/1 vi trng 40
Bnh thng trong nc tiu khng c HC hoc c khng ng k, thn bi xut
khng qu 1000 HC/1pht (Cn Addis), hoc khng qu 1000 HC/1ml (Nc tiu trung
bnh 1ml/1pht). Nu xem qua knh hin vi (40x) th t 0 - 1 HC/1 vi trng.
2. Chn on:
- i mu i th: Nc tiu c mu hng, c hay mu coca, c lng cn hng
cu (C th s lng hng cu >300. 000/ml)
- i mu vi th: Mu sc nc tiu khng thay i (Hng cu niu > 5000/1 pht
hoc 5 HC/1 vi trng 40) ch pht hin c nh xt nghim nc tiu.
2. 1. Chn on xc nh: Xc nh c i mu.
2. 1. 1. Bng que nhng Dipstick:
- Nguyn tc: Pht hin hot tnh Peroxidase ca Hem trong hng cu, trong Hb t do
hoc trong Myoglobin
- Cho kt qu (+) khi trong nc tiu > 3HC/1 vi trng 40, cht ch th mu chuyn
qua mu xanh l cy, xanh da tri.
+ Gi tr chn on: Nhanh chng, nh tnh, r tin.
+ Hn ch:
(+) gi: Tiu Hemoglobin, Myoglobin, nc tiu c cha cht oxy ho.
(-) gi: Nc tiu c nhiu vitamin C.
2. 1. 2. Cn lng nc tiu:
- Nguyn tc: Pht hin hng cu qua:
Soi knh hin vi thng.
Soi knh hin vi quang hc.
74
- Gi tr chn on:
+ nh lng cho kt qu chnh xc, xt nghim kim chng cc trng hp i
mu i th, hoc que nhng c kt qu (+)
+Tm c tr hng cu.
+ Hnh dng hng cu di knh hin vi quang hc c phng i ln.
2. 1. 3. Cn Addis:
- Mc ch: m s HC, BC, tr hnh trong 1 pht.
- Phng php: C th ly nc tiu 3h, 6h, 9h, 12h.
Nu ly nc tiu 3h (Thng ly nc tiu 3h)
+ 6h sng bnh nhn i tiu ht, ghi gi, pht sau khi tiu ht.
+ Ung 200ml nc si ngui, nm ngh.
+ 9h tiu ht vo cc thu tinh c vch sn, ghi gi.
+ o th tch nc tiu (Ghi r V ml)
+ Tnh s pht v tnh th tch nc tiu trong 1 pht (Vml/pht). Lc u nc tiu
trong cc, ly 10ml quay li tm, ht b 9 ml phn trn, cn 1ml cn lc u, em
ln bung m, m nh m mu.
Kt qu m c /10 Vml nc tiu/1 pht = S HC, BC, tr/1pht.
Bnh thng: - HC: 1000/ 1 pht, BC: 2000/ lpht. 1-3 tr hnh/1 pht.
2. 2. Chn on phn bit:
i mu i th: Cn phn bit vi
- Nc tiu c mu sc ging mu do thc n, nc ung (C ci , phm nhum
thc phm. . ), thuc vitamin B12 liu cao, Rifampicin, Metronidazol, Phenolphtalein. . .
XN nc tiu: HC(-)
- a ra Hemoglobin t do: Nc tiu c mu hoc xm mu, lu khng lng
cn hng cu, xt nghim nc tiu c Hb(Tn huyt do st rt, tai bin truyn mu. . .
)
- i ra Myoglobin: Nc tiu c mu , khng lng cn hng cu (Ly gii c do
chn thng gip nt, co git nng), xt nghim HC(-), Hb (-)
- Nc tiu ca ngi b bnh gan, XN: HC (-), STM (+)
- Chy mu t m o, t cung, mu ln vo nc tiu do:
+ XN nc tiu lc hnh kinh.
+ Bnh ph khoa c gy chy mu(Vim, ung th)
2. 3. Xc nh nguyn nhn i mu:
2. 3. 1. Hi bnh:
- i mu t nhin hay sau lao ng nng.
- i mu nhiu hay it.
- i mu c km theo i but, i rt, cn au qun thn, ph, thiu mu. . .
- Tin s:
75
Cn au qun thn, i kh, i but, i rt, i mu, i c.
i ra si, hoc iu tr si niu.
Vim hng gn y.
Bnh cu thn.
X tr vng chu(K c t cung, K trc trng, K tin lit tuyn)
Tiu ng, cao huyt p.
Cc bnh v ma, dng thuc chng ng.
Gia nh v bnh thn tit niu
- Xc nh yu t dch t: Lao
2. 3. 2. Khm lm sng
- Khm ton thn: Theo di mch, huyt p, nhit , nhp th. . .
- Khm cc b phn mt cch h thng. (Ch Tai mi hng)
- c bit ch n mt s tnh trng ton thn nh:
Nhim trng: Vim i b thn cp. . .
Ph: Bnh l cu thn, suy thn.
Thiu mu: Suy thn mn, Vim cu thn cp, mn.
- Khm b phn tit niu - sinh dc:
Tm du hiu chm thn, bp bnh thn.
Khm im sn lng,
Khm cc im niu qun.
Khm bng quang, niu o.
Khm tin lit tuyn (nam gii)
Khm phn ph (N)
2. 3. 3. Cn lm sng: Sau khi hi bnh v thm khm, tu nguyn nhn m ch nh
mt s cn lm sng h tr cho chn on:
- Nc tiu:
Protein niu/ 24h.
Hng cu niu
Bch cu niu, vi khun niu.
Cn lng - t bo hc nc tiu 3 ln nu nghi lao
Ure- Creatinin niu.
- Mu:
Cng thc mu.
Ure - Creatiin mu.
ng mu lc i.
Trng hp di mu nhiu phi lm cc XN v ng mu.
- Xquang:
Chp h niu khng chun b: Pht hin c si cn quang
76
Chp UIV: S bi tit ca thn, i b thn bin dng, ct ct, lch hng nh
trong K thn, lao thn. i b thn gin do thn nc. . .
- Siu m:
V tr kch thc v gii hn ngoi ca thn:
Thn to: U thn, thn nc, thn a nang. . .
Thn teo trong vim cu thn mn, suy thn mn.
Pht hin c si thn, si bng quang. . .
i b thn gin do nc, i b thn bin dng. . .
- Ni soi bng quang.
- CT-Scanner.
2. 4. Chn on v tr i mu:
2. 4. 1. Lm nghim php 3 cc:
(Phng php c in chn on v tr i mu)
- Ly ba cc bng nhau, cho bnh nhn i ln lt vo 3 cc v quan st bng mt
thng xem cc no nhiu mu nht ( nht).
+ Cc 1: nht - i mu u bi: Chy mu niu o, TLT.
+ Cc 3: nht - i mu cui bi: Chy mu bng quang.
+ C 3 cc nh nhau: i mu ton bi: Chy mu t thn, niu qun
- Ch : Trong trng hp i ra mu nhiu th thng thng thy c mu c 3 cc:
V d nh do khi u c tnh bng quang ; Nghim php 3 cc ch c gi tr tng i
trong chn on v tr i mu.
2. 4. 2. Soi bng quang, niu o: Lc ang chy mu l cn thit v c th thy c
mu ang chy ra t niu o, bng quang (K bng quang, vim bng quang chy mu),
hoc chy mu t thn phi hay thn tri.
2. 4. 3. Mt s gi :
- i ra mu vi th: C hng cu niu, bin dng, mo m, rn rm th nhiu kh
nng tn thng ti cu thn.
- i ra mu vi th, hng cu khng bin dng thng tn thng biu m ng
niu.
- i ra mu vi th km tr hng cu, chc chn ngun gc tn thng ti cu thn.
- i ra mu vi th km Protein niu 2g/ 24h tr ln kh nng tn thng cu thn.
2. 5. Chn on nguyn nhn i mu thng gp:
2. 5. 1 Phn loi nguyn nhn i mu: Trong thc hnh, chn on nguyn nhn i
mu, chia i mu thnh hai nhm: i mu t cu thn do tn thng cu thn v i
mu khng t cu thn.
- i mu t cu thn:
+ c tnh:
Thng gp tiu mu vi th hn i th v khng c mu cc trong nc tiu.
77
Hng cu b bin dng.
C th c tr hng cu.
Thng km tiu m > 2g/ 24h.
+ Nguyn nhn: Bnh cu thn nguyn pht hoc th pht
Vim cu thn cp:
Tng huyt p.
Ph, tiu t.
i mu t ngt vi th hoc i th.
Protein niu, HC niu bin dng, c th c tr HC.
Siu m: Kch thc hai thn bnh thng.
Tin s: Khng c bnh cu thn.
Vim cu thn mn:
Ph, tiu t.
Tng huyt p.
Protein niu, HC niu c th bin dng bin dng
Ure - Creatinin mu c th tng.
Siu m: Kch thc hai thn c th nh hn bnh thng.
Tin s: Bnh thn (Ph, tng huyt p, i mu)
- i mu khng t cu thn:
+ c tnh:
C th c cc mu ng trong nc tiu.
Hng cu khng bin dng.
Khng c tr hng cu.
Thng khng c tiu m, nu c ch mc nh
+ Nguyn nhn:
* Trc thn: Cc bnh v mu hoc do iu tr thuc khng ng qu liu ng
k (Warfarin)
* Ti thn:
Si thn:
Cn au qun thn.
i but, i dt.
Nc tiu .
Tin s: C th c cn au qun thn, i ra mu, i ra si
XN nc tiu c th c hng cu, bch cu, vi khun.
XQ, siu m: Pht hin si
. K thn: Nguyn pht hoc th pht.
Thn to, cng, mt ln nhn.
78
i ra mu t nhin.
Th nc tiu c nhiu hng cu.
Chp UIV: Thn to 1 bn, i b thn bin dng, ct ct
Siu m: Thn to 1 bn, i b thn b ko di, ct ct lch hng.
. Vim thn b thn:
Hi chng nhim trng.
au: au vng h lng 1 bn hoc 2 bn, c th c cn au qun thn.
Hi chng bng quang.
Khm thn- niu qun: C th c du hiu chm thn (+).
im au niu qun c th (+).
XN nc tiu: C HC, BC, vi khun.
Siu m: C th c si ng niu, i b thn gin.
. Lao thn:
Hi chng bng quang (Thng gp).
Tam chng: i nhiu ln, i kh, i mu.
au h lng 1 bn hoc 2 bn.
Khm c th thy thn to v au.
Tnh trng bnh nhn suy sp.
XN nc tiu:
Soi trc tip sau khi nhum Ziehl - Nelsen: TK lao (+)
Nui cy mi trng Loewenstein: TK lao.
XQ phi, h tit niu:
Xquang khng chun b: Bng thn to.
Chp UIV: i thn nham nh, ct ct hoc gin to do tc nghn.
. Thn a nang: Bnh di truyn th tri khng lin quan n gii tnh. C th khng c
triu chng hoc c mt s triu chng sau:
au ngang tht lng.
Tng huyt p.
Nhim khun tit niu.
i ra mu (Nguyn nhn n khm) do v nang thn, si thn. Thn
a nang hay + si Uric (12%)
Tin s gia nh: C nhiu ngi b thn a nang.
. Chn thng thn:
i mu l triu chng quan trng gp 80% trng hp
Tin s: C chn thng.
* Sau thn:
Si niu qun:
C cn au qun thn.
79
C th c hi chng bng quang
i mu i th hoc i mu vi th.
Khm c th c thn to do nc, m b thn.
XN nc tiu: Nhiu hng cu.
XQ, siu m: Si niu qun
Si bng quang:
Hi chng bng quang.
i mu cui bi.
Siu m, Xquang: C si
K, vim, chn thng bng quang
Niu o, TLT: Si, K, vim, chn thng, ph i TLT
i kh, i rt, b i (Si, U TLT), i mu (u bi).
Tm li:
i mu rt thng gp trn lm sng, nht l trong bnh l h thng thn - tit niu.
+ i mu khng kh, nhng lu c im i mu, s b nh hng v tr tn
thng v nguyn nhn nhm tin hnh cn lm sng hp l xc nh v tr tn thng
v nguyn nhn i mu
TI LIU THAM KHO:
- Nguyn Thy Anh, Tiu mu - Bnh hc ni khoa (1998), Trng i YDc-TP H
Ch Minh, Nh xut bn Y hc.
- Nguyn Bu Triu - Nguyn M, Si thn- si niu qun - si bng quang - si
niu o - bnh hc tit niu, Nh xut bn Y hc 2003.
- GS. PTS Nguyn vn Xang, i mu - Ni khoa c s tp 2 (2000) - Nh xut bn Y
hc.

H H I I C CH H N NG G P PH H
MC TIU:
- Nu c nh ngha ph
- Trnh by c cc bc thm khm bnh nhn ph.
- Trnh by c chn on ph.
- Nu c cc cn lm sng cn thit chn on nguyn nhn ph
- Nu c iu tr ph theo mt s nguyn nhn thng gp.
NI DUNG:
1. nh ngha: Ph l hin tng nc trong cc t chc di da hoc ph tng.
S nc c th gy nn bi nhiu c ch, cho nn ph l triu chng ca rt
nhiu bnh. Ph ton thn: ngha l ph c mt, thn, chn tay v thng km theo
trn dch mng phi (TDMP)- trn dch mng bng (TDMB). . .
Tu thuc vo cn nguyn v c ch ca n, ph c th khu tr hoc ph ton thn.
80
Chn on ph rt d trong nhng trng hp r, nhng cng c khi rt kh.
2. Bnh sinh: Trong phm vi bi ny chng ti khng ni n ph ph tng (ph
no, ph phi) c nhng tnh cht ring bit v lm sng m ch ni n ph di da.
Mun a ra gi thuyt v sinh l bnh hc ca mt trng thi ph th iu quan
trng l phi phn bit c nguyn nhn gy ph nh tc tnh mch hoc bch mch,
gim cung lng tim, gim anbumin mu, dch trong cc khoang, tng tnh thm
mao qun vi cc hu qu th pht c th d on c gm mui v nc ca thn.
Gim cung lng tim bt k do nguyn nhn g u c km gim th tch mu
ng mch hiu dng, cng nh gim lu lng mu thn.
Trong suy tim nng, lu lng mu ti t v ngoi ca thn c bit gim nhng
gim t hn ti cc vng trung tm ca thn v c tnh trng gim mc lc cu thn.
Hin tng co cc mch ny ca v thn ng mt vai tr quan trng trong nc v
trong s hnh thnh ph ca suy tim. cc giai on khc nhau ca suy tim s hot
ho h thn kinh giao cm hoc ca h Renin - Angiotensin c trch nhim lm co
mch thn.
Tng ti hp thu dch lc cu thn ti ng thn ng mt vai tr quan trng trong
c ch mui v nc trong suy tim. Suy tim lm tng co tht tiu ng mchthn
s lm tng p lc thu tnh v p lc thm thu quanh cc mao qun trong ng thn
do vy lm tng ti hp thu mui v nc trong ng ln gn.
Ngoi ra, lu lng mu ti thn gim lm cho cc t bo cu thn tng gii
phng Renin, Angiotensin c gan tng hp gii phng Angiotansin I v c
hot ho thnh Angiotensin II gp phn co mch thn v gi mui, nc.
Trong suy tim, Angiotensin II tng trong mu kch thch sn xut Aldosterron c
tc dng gi mui gy ph.
Tc tnh mch v dn lu bch mch ca mt chi: p lc thu tnh ni tc tng ln,
lm dch t lng mch chuyn sang khoang k lm tng m k ca chi, nh hng n
th tch tun hon lm gim th tch mu ng mch hu dng v cui cng cng dn
n hu qu ph.
Hi chng thn h v cc trng thi gim Albumin huyt tng khc nh suy dinh
dng nng, bnh rut non lm gim Albuminmu, bnh x gan nng. . . Trong cc
trng hp ny gim anbumin mu lm gim p lc keo mu, nc thot ra m k lm
gim th tch mu dn n gim th tch mu ng mch hiu dng v din bin nh
m t trn gy ph.
Ph cn do tn thng ni m mao qun, n lm tng dch thm v cho dch
cha nhiu protein hn bnh thng di chuyn sang m k gy ph do vim l ph n
khng lm, thng cc b v km theo cc du hiu vim khc nh , nng, au.
3. Thm khm mt bnh nhn ph:
3. 1 Pht hin ph:
81
3. 1. 1 Trong trng hp ph r: Vic pht hin ph thng d, s nc trong t
chc di da thng lm cho: Ngi ph c cm gic nng n. Nhng vng b ph
sng to, cng mng lm che lp nhng ch li lm bnh thng (mt c, np nhn, u
xng).
Mu da vng b ph nht i. Tm "du n ngn tay"
3. 1. 2 Trng hp ph kn o: S nc cha nhiu biu hin thnh nhng triu
chng lm sng r rt, nhng thng lm thay i cn nng ngi bnh mt
cch nhanh chng. V vy cn phi cn bnh nhn hng ngy: Tng ln t 1 - 2 kg tr
ln trong vi ngy ch c th c gii thch bng hin tng ph.
3. 2 Nhn nh tnh cht ca ph:
- Mc ph nhiu hay t v tin trin nhanh hay chm, tt nht nn theo di cn
nng hng ngy xc nh chnh xc v c th.
- V tr ph: Ph ton thn hay ph khu tr mt vng v xut hin u u tin?
- n lm hay khng ?
- S lin quan n thi gian (bui sng khi mi ng dy hay v chiu):
Ph xut hin bui sng thng gp trong ph thn.
Ph ch xut hin v chiu thng gp trong ph do suy tim thi k u.
Ph xut hin sau khi ng lu: Ph tim trong thi k u, ph tnh mch
-Tc dng ca ch n nht: Thng kh r rt trong ph do suy tim, x gan v
nht l ph do vim cu thn cp.
3. 3 Pht hin cc triu chng km theo:
3. 3. 1 Phn nh mc nc:
- Tnh trng mng phi, mng bng: Thng c trn dch trong cc trng hp ph
to, mu sc dch c th trong hoc hi vng nhng bao gi cng ch co t protein v
Rivalta (-) v l dch thm.
- S lng nc tiu thi tit trong 24h: Ni chung tt c cc trng hp ph (Tr
ph do vim tc tnh mch v bch mch) u lm cho ngi bnh i t. Mc gim
s lng nc tiu thng t l vi tnh trng ph: Ph cng nhiu ngi bnh i tiu
cng t.
3. 3. 2 Ch im cho mt cn tr c gii trn h tun hon:
- Tun hon bng h:
+ ngc: ch im cho mt cc tr c gii h tnh mch ch trn, thng
c trong hi chng trung tht.
+ h sn phi v thng v ch im cho mt cc tr c gii trn h thng
ca ch thng c trong ph x gan.
+ bn v h v ch im cho mt cn tr c gii h tnh mch ch di
thng gp trong cc trng hp tc hoc chn p tnh mch ch di.
- Xanh tm: mi, mt, ch im cho mt cn tr c gii tnh mch ch trn
82
hoc tun hon ln, hoc cc chi tng ng vi tnh mch c bnh.
- Gan to, mm, tnh mch c ni, phn hi gan tnh mch c dng tnh ch im
cho ph do suy tim.
- Kh th: Nhiu hoc t, thng c ph trong suy tim.
3. 3. 3 Ch im cho mt vim nhim a phng:
- Tnh trng nng, , au vng .
- Cc hch bch huyt tng ng vi vng sng v au.
- Thng st nhiu hoc t.
4. Cn lm sng: Tu theo nguyn nhn gy ph, c th chn cc xt nghim:
- Mu:
+ Cng thc mu, VS.
+ nh lng Protein, in di protein mu.
+ Cholesterol, ng mu, in gii , ure, creatinin mu.
- Nc tiu:
+ Th tch nc tiu.
+ nh lng Protein niu, soi cn tm HC, BC, vi khun, cc tr niu. . .
+ Ure niu. . .
- Siu m.
- Xquang.
- in gii .
- o p lc tnh mch trung tm.
5. Chn on:
5. 1 Chn on xc nh: Thng khng kh trong trng hp r v c nhng
trng hp kn o cn c vo cc du hiu v cc bin php nu trn. Nhng vn
quan trng trong chn on ph l tm ra nguyn nhn.
5. 2 Chn on nguyn nhn:
5. 2. 1 Ph ton thn:
- Cc bnh thn: Ph c c im chung ca ph thn:
+ Bao gi cng xut hin u tin m mt, mt, ri mi n cc ni khc
+ Khng lin quan n thi gian trong ngy hoc t th ngi bnh (tr mt s
trng hp ngi bnh phi nm lu).
+ Ph trng, mm, n lm.
+ Bao gi nc tiu cng c Protein nhiu hoc t tu theo bnh thn.
Ngoi nhng c im chung trn, tu theo mi bnh thn s c nhng c
im khc nhau:
* Vim cu thn cp, mn:
Ph nhiu hoc it.
n nht gim ph r rt.
83
Huyt p thng tng
Nc tiu: Protein nhiu hoc t (Nhng khng qu 3, 5g/24h).
Hng cu: i mu i th hoc vi th gn 100% trng hp.
Tr niu: Thng c tr niu v khng c tr trong.
Mu: Ure, Creatinin, Cholesteron, Protein. . . bnh thng.
Thm d chc nng thn: b ri lon.
* Hi chng thn h:
Ph nhiu, ph nhanh, ph to c th km thao trn dch cc mng, n nht
khng gim ph.
Huyt p bnh thng.
Nc tiu: Protein rt nhiu(> 3, 5g/24h), Hng cu niu c hoc khng, Tr
niu: thng c nhiu tr trong.
Mu: Protein gim v gim ch yu l anbumin, mt s trng hp c tng
Cholesterol mu.
Thm d chc nng thn: bnh thng.
* Suy dinh dng: (Mt ch n khng y trong thi gian di)
Ch yu l ph hai chi di nhng cng c khi ph ton thn.
Khng lin quan n thi gian trong ngy v t th ca ngi bnh.
Ph trng, mm, n lm.
Khng bao gi c Protein trong nc tiu.
* Ph ni tit: Ph c th hai chi di nhng cng c th ph ton thn nhng r
kn o: Ngi bnh cm thy mt hi nng, chn hi nng v n hi lm (Phi theo
di cn nng mi bit l ph). Thng xy ra ph n v c lin quan n chu k
kinh nguyt.
5. 2. 2 Ph khu tr: Ph ngc ph o khoc, ph hai chi di, ph mt chi:
- Ph ngc ph o khoc.
- Ph hai chi di:
+ Ph do suy tim phi: Ph lc u t v kn o, ch c mt c chn, xut hin
v chiu v sau ph s thng xuyn v rt. Ch ngh ngi v ch n nht gim
ph. Ph mm, n lm. Bao gi cng km theo gan to, mm, n tc, tnh mch c ni,
tm mi v cc u chi, kh th, tim to, nhp tim nhanh. o p lc tnh mch rt cao.
+ Ph trong x gan:Mc nhiu hoc t, n lm, n nht c th gim ph c th
km theo c trng thm thu, tun hon bng h ca, ch, Anbumin mu gim.
Chc nng gan b ri lon, nn soi bng v sinh thit gan nu nghi ng.
+ Ph do suy dinh dng: ( ni trn).
+ Ph beriberi:
Ph ch yu bp chn, lm bp chn ngi bnh cng to.
C th n lm.
84
Khng lin quan n t th ngi bnh v thi gian trong ngy.
Bao gi cng km theo ri lon cm gic ch quan (t b, kin b, chut rt) v
mt phn x gn gi.
+ Ph thai nghn: nhng sn ph trong nhng thng cui ca thai k.
- Ph mt chi: Thng thng nht l mt chi. Cn ch n hai trng hp:
+Vim tc tnh mch: Ph mm, n khng lm, trng nhng rt au, au t pht
lm ngi bnh khng dm c ng chn, au tng ln khi s nn chi, nht l on
chi gn ch vim tc. Nm ngh v nht l gc chn ln cao, s lm gim bt ph.
Thng km theo st v mch nhanh nhng khng tng xng vi st.
+ Vim mch bch huyt: Lc u cng ph ging nh trong ph tnh mch:
Ph mm, n khng lm, trng v cng rt au, dai dng, hn ch lu thng bch
mch, lm tng nng Protein trong dch m k. Cc hch bch huyt tng ng vi
cc bch huyt sng to v au. V sau cc tn thng n nh, cc t chc di
da v da dy v cng, y l Ph chn voi di chng ca vim bch mch, nguyn
nhn nc ta l do giun ch
- Ph do d ng: Thng xut hin t ngt xung quanh mt, ming v thng
mt i rt nhanh sau khi iu tr.
6. iu tr:
6. 1. iu tr ph:
Trong phm vi bi ny ch cp n iu tr ph do 3 c ch:
- C ch gi natri v nc trong bnh cu thn, trong suy tim. . .
- Gim p lc keo ca mu do gim nng albumin mu trong hi chng thn h,
suy dinh dng, x gan c trng. . .
- a vo qu nhiu natri v nc trong khi lng thi ra t do bnh l gy nn
Nh vy iu tr ph cn phi theo nguyn tc:
To c mt cn bng v nc v natri ngha l lng thi ra nhiu hn lng
a vo c th.
Nng c Protein mu, anbumin mu ngha l nng c p lc keo ca mu.
Mun t c yu cu trn, cn s dng 2 bin php c bn quan trng:
Ch n t natri, t nc, nhu cu m cn thit.
S dng thuc li tiu.
6. 1. 1. Ch n:
- Mui: Ch n nht hon ton: khng mui, mm, bt ngt, bt canh trong ch
bin thc n. Ch n nht va: 2- 3g/ngy.
- m: Tng m trong ch n hng ngy trong mt s trng hp ph do hi
chng thn h, suy dinh dng, x gan. . .
6. 1. 2. Ch ung nc: Lng nc a vo c th t hn hoc bng lng nc
tiu.
85
Ch : Lng nc sinh ra do chuyn ho l 300ml/24h.
Lng nc mt i do m hi, hi th 600ml/24h.
6. 1. 3. S dng li tiu trong iu tr ph:
- Cc li tiu thng dng trong iu tr hin nay:
+ Li tiu Thiazid, tc dng hn ch ti hp thu ng ln gn v ng ln xa:
Hydroclothiazid, hypothiazid (c cho thn, suy thn khng dng)
+ Li tiu quai, tc dng hn ch hp thu natri phn cui nhnh ln quai Henle:
Furosemid (Lasix) khng c cho thn.
- Li tiu gi kali, tc dng hn ch ti hp thu natri v tng hp thu kali cui
ng ln xa v cui ng gp:
Li tiu khng Aldosteron: Spironolacton v Aldacton.
Li tiu khng khng Aldosteron: Amilorid, triamteren.
- S dng li tiu trong hi chng thn h khng c suy thn: cn kt hp n nht
tng i v protein: Lasix 40mg x 1 - 2 vin/ 24h (Tu theo tnh trng ph); -
Trong HC vim cu thn cp: n nht tuyt i, li tiu
- Trong suy thn mn: n nht, hn ch n m. li tiu
- Trong suy tim:
Ph nh: n nht, km li tiu thiazid 25mg x 1- 2 vin/ngy.
Ph nhiu, c gan to: Lasix vin 40mg x 1 - 2 vin/ ngy.
Trng hp ph ko di c th thm: Spironolacton vin 75mg/ 24h
- Trong x gan c trng c ph: Tt nht l dng li tiu khng Aldosteron:
Spironolacton, Aldosteron vin 25mg, 50 mg. Liu khi u 50 - 100mg/24h
- Trong tiu ng c ph thn: Indapamid (Fludex) 2, 5 mg x 2 vin/ ngy chia 2
ln (tcdng li tiu, h p, gim protein niu), Natrilix vin 1, 5mg, phi dng di
ngy mi c kt qu, Lasix vin 40 mg x 1 - 4 vin/ 24h chia 2 ln (nu c suy thn,
ph nhiu)
6. 2. iu tr nguyn nhn ph: Bnh thn, Bnh suy dinh dng, Bnh ni tit,
Bnh suy tim, Bnh x gan.
TI LIU THAM KHO:
Cc nguyn l y hc ni khoa tp I, nh xut bn y hc 1995. Trang 264 - 270.
Triu chng hc ni khoa, nh xut bn y hc nm 1989- 2002. Khm v chn on
ph, Trang 209 - 212.
Bnh hc ni khoa tp II, nh xut bn y hc 2002, trang
iu tr hc ni khoa, nh xut bn y hc 2002, trang 218 - 220

86
K KH H M M B B N NH H N NH H N N M M C C B B N NH H V V M M U U

MC TIU:
1. Nu c cc ni dung cn thm khm bnh nhn mc bnh v mu.
2. Nu c ngha v gi tr bnh thng ca mt s cn lm sng bnh nhn
mc bnh v mu.
NI DUNG:
1. Lm sng:
1. 1 Hi bnh:
1. 1. 1 Triu chng c nng:
C Thiu mu: Hoa mt, chng mt, tai, kh th, mt. . .
C Nhim trng: St, mi kh, mt mi. . .
C Xut huyt: chy mu cam, chy mu chn rng, xut huyt di da, i mu, a
mu. . .
1. 1. 2 Ngh nghip:
C Ngh nng: nht l nhng ngh thng xuyn tip xc vi t hoc phn ti
d mc bnh thiu mu do giun mc.
C Ngh tip xc vi ha cht, phng x: D mc bnh suy ty, Leucemie. . .
1. 1. 3 Cc thuc dng:
C Chloramphenicol, sulfamide: Suy ty
C Aldomet, Penicilline: Tan mu
C Sulfamide, Methotrexate: Gim bch cu.
1. 1. 4 Tin s:
C Bn thn:
Tin s chy mu t nhin (chy mu cam, chy mu rng li) hoc chy mu
lu cm, hoc t mu sau sang chn nh (va chm nh, tim chch, nh rng).
Ph n: Rong kinh, rong huyt mi k kinh hoc khi sinh .
C Gia nh: Mt s bnh c tnh cht gia nh nh Leucemie, Hemophillie. . .
1. 2 Khm thc th:
1. 2. 1 Ton thn:
C Tng trng: Hay gp tng trng gy trong cc bnh l mn tnh hay c tnh.
C Da nim: Da nim nht nht trong thiu mu, xanh vng trong tan mu huyt tn,
xm en trong bnh mu c st. . .
C Ph: Thiu mu do suy dinh dng, nguyn nhn thn hoc thiu mu c bin
chng suy tim. . .
C Xut huyt: Xut huyt do nguyn nhn thnh mch, tiu cu hoc huyt tng
cn m t tnh cht xut huyt.
C Hch ngoi vi: Hch to do nhiu nguyn nhn cn m t tnh cht hch to.
87
Du hiu sinh tn:
- Mch: Mch nhanh trong thiu mu, nhim trng. . .
- HA: Huyt p tt trong chy mu cp, tan mu cp. . .
- Nhit : Nhit tng trong nhim trng, bnh h thng. .
- Nhp th: Nhp th tng trong thiu mu. . .
C Du hiu khc:
- Mng tay khum, mt bng: Thiu mu mn.
- Lng tc kh, d gy v d rng: Thiu mu mn hoc ang iu tr ha cht ung
th. . .
- Nga, ban , ri lon sc t, cc u v ht ni di da.
1. 2. 2 B phn:
C Thm khm cc c quan to mu hoc gn ging c quan to mu:
- Thm khm gan.
- Thm khm lch (hch).
- Thm khm Amian.
C Thm khm cc bnh nguyn nhn gy ra thiu mu: V d.
- Bnh siu vi.
- Bnh h thng.
- Bnh ung th ni khc di cn ty xng.
C Thm khm cc c quan t chc m c th l bin chng ca bnh mu:
- Tim: Suy tim do thiu mu.
- Thn: Suy thn do thiu mu cp hoc tan mu cp.
- Thn kinh, khp: Xut huyt do bnh mu.
2 Cn lm sng: ng vai tr quan trng, nhiu khi mang tnh cht quyt nh v n
mang tnh cht khch quan hn v kho st c s thay i v nhng tn thng
ca t bo mu v c quan to mu m trn lm sng kh hoc khng pht hin
c.
2. 1 Mu ngoi bin:
2. 1. 1 Cng thc mu:
C Dng hng cu:
S lng hng cu:
- Bnh thng: 3.800.000 - 4.500.000/mm
3
.
- Tng: S sinh, mt huyt tng, sau ct lch, bnh Vaquez, tng hng cu
nguyn pht (tm ph mn, bnh tim mch, ng c CO. . . )
- Gim: Ngi gi, ph n c thai, thiu mu. . .
Hematocrit: l t l phn trm ca th tch t bo mu (ch yu l hng cu) so
vi th tch mu ton phn.
- Bnh thng: 38-45%.
88
- Tng: Mt huyt tng hoc thot huyt tng ra khi thnh mch, bnh a hng
cu hoc hng cu to.
- Gim: Truyn dch nhiu, thiu mu. . .
Hemoglobin: L thnh phn c bn ca hng cu ngy nay chn on thiu
mu da duy nht vo Hemoglobin (khng cn da vo hng cu v hematocrit
na).
- Bnh thng: 12-18 g%.
- Tng: a hng cu nguyn pht hoc th pht.
- Gim: Thiu mu.
Th tch trung bnh hng cu (MCV): nh gi hng cu to, nh hoc ng bo.
- Bnh thng: 80-100 Fl.
- Tng (>100 Fl): Hng cu to.
- Gim (< 80 Fl): Hng cu nh.
Lng Hemoglobin trung bnh hng cu (MCH): nh gi hng cu nhc sc
hay ng sc.
- Bnh thng: 27-32 pg.
- Tng hoc bnh thng: Hng cu ng sc.
- Gim: Hng cu nhc sc.
Nng Hemoglobin trung bnh hng cu (MCHC): nh gi hng cu nhc
sc hay ng sc.
- Bnh thng: 32-36 g%.
- Tng hoc bnh thng: Hng cu ng sc.
- Gim: Hng cu nhc sc.
C Dng bch cu:
S lng bch cu:
- Bnh thng: 4. 000-9. 000/mm
3
.
- Tng:
+ Sinh l: Sau n, sau vn ng, c thai.
+ Bnh l: Nhim trng, ung th lot ha, Leucemie, Vaquez, Hodgkin, mt mu
nhiu, Ur mu tng, iu tr Corticoides. . .
- Gim:
+ St rt, thng hn, nhim virus (cm, si, thy u. . . ).
+ Suy ty, gim sn hoc cng lch.
+ Thiu mu do nhim c Asen.
Thnh phn bch cu: Thay i tng thnh phn ca bch cu:
Bch cu a nhn trung tnh: Neutrophil (N)
- Bnh thng: 55-75% (3. 000-6000/mm
3
)
- Tng:
89
+ Sau n, gng sc, mang thai.
+ Nhim trng cp hoc t cp ca nhim trng mn (Lao, ung th), bnh vim
(thp khp cp, VKDT), chn thng, d ng, NMCT cp, xut huyt cp, tng
Ur mu, hn m gan. . .
- Gim: St rt, thng hn, lao, suy ty, ng c ha cht, shock, phn v, nhim
trng ti cp hoc nhim virus giai on ton pht, cng lch, ung th
(Leucemie, Hodgkin).
Bch cu Lym pho: Lymphocyte (L)
- Bnh thng: 20-40% (1. 000-3000/mm
3
)
- Tng: Nhim trng mn, Leucemie dng Lympho, nhim Virus (si, ho g),
vim gan siu vi, thi k lui bnh ca mt s bnh nhim trng cp.
- Gim: Nhim khun cp, shock, Leucemie, Hodgkin, bnh Collagen, sau iu tr
x tr hoc thuc chng ung th.
Bch cu a nhn i toan: Eosophil (E):
- Bnh thng: 2-6% (50-300/mm
3
)
- Tng: Nhim k sinh trng, d ng, Leucemie, Hodgkin, bnh Collagen, sau ct
lch hoc x tr, ng c (benzol, mui ng)
- Gim: Nhim trng cp, hi chng Cushing, shock, thp khp cp, iu tr
Corticoides.
Bch cu a nhn i kim: Basephil (B)
- Bnh thng: 0-2%
- Tng: Thiu mu tan mu, Leucemie kinh dng ht, Vaquez, ng c Anilin.
- Gim: Suy ty, d ng.
Bch cu n nhn Mono: Monocyte (M)
- Bnh thng: 0-1% (0-20/mm
3
)
- Tng: Bnh virus (cm, quai b, vim gan siu vi. . . ), st rt, vim i trng c
lot, bnh tng bch cu n nhn nhim trng, chng mt bch cu ht do nhim
c-d ng, Osler, Amoeba, thi k lui bnh ca nhim trng cp, bnh c tnh
(ung th ng tiu ha, Hodgkin, u ty, Leucemie dng lympho).
C Dng tiu cu:
S lng tiu cu:
- Bnh thng: 150. 000-350. 000/mm
3
.
- Tng: Mt mu nng v t ngt, nhim trng, ct lch, thiu mu nhc sc,
Vaquez, Leucemie kinh, Hodgkin.
- Gim: Gim nguyn pht hay th pht, thiu B12 v Folic, nhim trng cp,
DIC.
tp trung tiu cu: Tp trung tt hay ri rc.
2. 1. 2 Huyt : Ly mu ra khi ty xng kho st c im ca cc dng t
90
bo mu ngoi bin (ch yu l cc t bo mu trng thnh).
C Kho st c im v s lng v hnh dng mu sc ca tng dng t bo mu
(hng cu, bch cu, tiu cu).
C Hng cu li: Bnh thng HCL= 0, 5-2% nh gi ty hi phc hay khng
hi phc (thiu mu trung ng hay ngoi bin).
2. 1. 3 Cc xt nghim khc:
C Lacet, mu chy (TS), mu ng (TC) hoc cc xt nghim ng cm mu khc
(Thi gian Quick, Howell, Cephalin-Kaolin, Thrombin, co cc mu. . . ).
C nh lng cc yu t to mu (St, B12, Folic, Protein).
C nh lng cc yu t ng mu (yu t I - XII).
C in di huyt sc t (chn on bnh Thalassemie).
2. 2 Cn lm sng v c quan to mu:
2. 2. 1 Ty xng:
C Ty : Chc d ly mu trong ty xng kho st c im ca cc t bo
mu trong ty xng (ch yu l cc t bo mu cha trng thnh trong ty
xng)
V tr chc ht ty xng:
- Ngi ln: Xng c (ngang vi gian sn 2 hoc 3, ngay ng chnh gia) hoc
gai chu sau - trn (trn hay ngay trn v tr)
- Tr em: Xng chy (khong 1/3 trn mt trc - trong).
Mc ch:
- Kho st s lng t bo ty xng nh gi ty giu hoc ngho t bo.
- Hnh thi cc dng t bo, t l cc thnh phn ca mt dng hoc t l gia cc
dng t bo mu.
- Kho st s xut hin ca cc t bo bt thng Gi chn on cc bnh l.
Bnh thng:
S lng t bo ty: 30. 000 - 150. 000/mm
3
.
Cng thc t bo ty: Rt c gi tr trong chn on bnh l.
Mt cng thc ty xng c coi l bnh thng, phi t c 4 yu cu sau:
- Giu t bo, nht l t bo c nhn.
- C y cc thnh phn t bo: t bo gc, t bo cc dng hng cu, dng
bch cu ht, dng tiu cu. . .
- Cn i theo t l qui nh.
- Loi t bo trng thnh nhiu hn t bo non (nguyn bo).
Lavergne ngh cng thc n gin, d nh v tin p dng trn lm sng:
- T bo ty xng : 84%
+ Dng bch cu ht:
. Nguyn ty bo : 2%
91
. Tin ty bo : 2%
. Ty bo : 16%
. Hu ty bo : 16%
. a nhn : 32%
+ Dng hng cu (hng cu non) : 16%
- T bo ngoi ty xng : 16%
. Dng Lympho (Lymphocyte) : 14%
. Dng Mono (Monocyte) : 2%
Tng : 100%
(Cng thc trn l cha kha l con s 16. V cng thc ty xng ch c gi tr
bnh l khi c nhng thay i v t l quan trng nn trong thc t th cng thc
ny d nh).
Ngoi ra cn xc nh 2 t s:
- Bch cu ht / Hng cu non # 4 (t s ny tng Leucemie dng ty cp hoc
kinh; gim nh trong thiu mu c hi phc v trong bnh Vaquez; o ngc
trong bnh tng nguyn hng cu).
- Bch cu ht / (Lymphocyt + Monocyt) # 4 (t s ny tng nhiu trong Leucemie
dng ty cp hoc kinh; gim nhiu trong Leucemie dng Lympho hoc Mono
cp hoc kinh).
Khng c t bo l xut hin.
Thay i: Cng thc ty xng ch c gi tr bnh l nu c s thay i tht r rt
v v tht quan trng.
Tng hng cu non (>40%):
- Bnh thiu mu ko di, nht l thiu mu tan mu v thiu mu th Biermer.
- Vaquez.
- Tng sinh phn ng: Hay gp trong thiu mu cp do tng sinh dng hng cu (
tr em c th tng sinh c dng bch cu).
Tng bch cu:
- Tng bch cu a nhn: Tng bch cu a nhn trung tnh trong Leucemie kinh
dng ht, tng bch cu a nhn i toan trong bnh hen v d ng cc loi; tng sinh
c hai loi trn trong bnh Hodgkin. Tng sinh dng ty m khng c km theo s
bt thng v cu trc v nguyn sinh cht trong bnh nhim trng.
- Tng cc nguyn bo (nguyn ty bo, nguyn bo Lympho, nguyn bo Mono):
Leucemie cp khong trng bch cu.
- Tng ty bo v hu ty bo: Leucemie kinh dng ty.
- Tng Monocyte: Leucemie kinh dng Mono.
Tng dng mu tiu cu: Phn ng ca ty khi thiu tiu cu ngoi bin, Leucemie
kinh dng ty, chy mu nhiu.
92
Gim hoc mt hn cc t bo ty xng:
- Gim 1 hay vi dng t bo mu do tng sinh bt thng mt dng bt thng ca
mt dng khc ln t. V d trong Leucemiekinh dng ty th dng bch cu ht
tng mnh ln t trong khi dng lympho v mono gim nhiu, dng hng cu gim
tng i.
- Gim nng hoc mt hn 1 hay c 3 dng do ty xng sinh ra: suy ty, x ha
ty.
Xut hin bt thng cc t bo l: Dng hng cu khng l (thiu mu Biermer)
hoc cc t bo ung th di cn ty xng.
C Sinh thit ty: Ly mt mu ty xng kho st cu trc ca ty xng (khng
kho st tnh cht t bo mu m kho st cu trc c quan to ra t bo mu)
hay p dng trong chn on suy ty.
2. 2. 2 Lch:
C Siu m lch.
C Nghim php co lch.
C Lch : t thc hin, chi lm khi cc phng tin xt nghim khc m khng tm
c nguyn nhn lch to (trc khi chc cn phi lm k cc xt nghim ng cm
mu trnh bin chng chy mu sau chc lch v ch c chc vo nhng lch
to s thy r rng)
Cht dch ht ra d ln vi mu trong cc mch mu nn cng thc t bo trong
lch thng hay b thay i nn nhiu tc gi a ra nhiu cng thc khc nhau.
Ni chung mt lch bnh thng c th c ti:
* 60% t bo dng Lympho (nguyn bo lympho, Lymphocyt v cc nhuyn huyt
bo bt u bit ha sang dng ny).
* 30% t bo dng mono (monocyt, t chc bo).
* 10% t bo dng bch cu ht.
C tc gi ngh cng thc lch n gin (c cha kha l con s 14) nh sau:
Lymphocyt : 56%
Monocyt : 28%
Bch cu a nhn trung tnh : 14%
Bch cu a nhn i toan : 1%
Tng bo v nguyn hng cu : 1%
Tng : 100%
Lch bnh l: Ch yu kho st c hoc khng c cc tnh trng sau:
* Di sn t bo:
- Dng hng cu: Vaquez
- Dng bch cu ht: Leucemie.
- Dng Lympho: Leucemie kinh dng Lympho.
93
* Xut hin cc t bo bt thng:
- T bo Sternberg: Hodgkin.
- T bo ung th: Sarcoma lch.
* Xut hin mt s vi khun v k sinh trng.
- Vi khun lao.
- Tp khun.
- KST st rt.
C Sinh thit lch.
2. 2. 3 Hch:
C Siu m hch:
C Hch : L mt xt nghim n gin, nhanh gn m a li kt qu kh chnh xc,
nht l cc bnh nhn c nhiu hch cc v tr. Ngi ta thng lm hch hn
sinh thit hch v n gin, khng gy au n cho bnh nhn v c th lm bnh
phng d dng.
Hch bnh thng:
* Phin rt giu t bo nhng t l hng cu rt thp.
* Cng thc t bo: Ty theo v tr hch m t l t bo khc nhau. Ni chung bnh
thng l:
- T bo dng lympho rt nhiu (nguyn huyt bo bt u bit ha sang dng
ny).
- T bo dng t chc bo (nguyn t chc bo, t chc bo, tng bo, monocyt,
rt him mastocyt).
- Hng cu (t).
Hch bnh l:
* Xut hin nhiu loi t bo bt thng:
- Bch cu b ph hy ln m: Nhim khun.
- Bch cu non: Leucemie ty.
- T bo ung th: Ung th di cn.
- T bo Sternberg: Hodgkin.
* Ri lon nhiu v cng thc t bo: Tng sn dng lympho trong Leucemie dng
lympho, u lympho c tnh khng Hodgkin. . .
C Sinh thit hch: nh gi cu trc hch v cc t bo trong hch Ch sinh thit
hch khi cn bit r cu trc ca hch v trong trng hp b x ha, ngho t bo.
TI LI U THAM KHO:
1. Nguyn Th Minh An (2003), Mu v c quan to mu, Ni c s, tp II, Trng
i hc Y H Ni, Nh xut bn Y hc.
2. Phm T Dng-Nguyn Th Khnh (2003), Mu, Xt nghim s dng trong
lm ssng, Nh xut bn Y hc.
94
K KH H M M B B N NH H N NH H N N T TH HI I U U M M U U

MC TIU:
1. Nu c nh ngha v thiu mu.
2. Nu c cc nguyn nhn ca thiu mu.
3. M t c triu chng lm sng v cn lm sng ca hi chng thiu mu.
4. Trnh by c phn loi thiu mu.
NI DUNG:
1. nh ngha: Thiu mu l s gim st ca lng huyt sc t (Hb) lu hnh trong
tun hon dn n mu thiu Oxy cung cp cho cc m t bo trong c th.
Theo t chc Y t th gii (OMS): Thiu mu xy ra khi mc huyt sc t (Hb)
lu hnh ca mt ngi no thp hn mc ca ngi khe mnh cng gii, cng
tui v cng mt mi trng sng.
Gii hn bnh thng ca Hb nh sau:
+ Tr s sinh : 136g/l.
+ Tr 3 thng : 95g/l.
+ Tr 1 tui : 110g/l.
+ Tr 10 - 12 tui : 120g/l.
+ N gii khng mang thai : 120g/l.
+ N gii mang thai : 130g/l.
+ Nam gii : 130g/l.
Chng ta c th coi mt ngi thiu mu khi t l huyt sc t (Hb) ca ngi
ny thp hn 130g/l nam v 120g/l n bnh thng. Mi y OMS xc nh chn
on thiu mu ngy ny ch da vo Hb mu: Thiu mu khi Hb <12 g% i vi
ngi 10 tui hoc Hb < 11 g% i vi ngi < 10 tui.
Ch :
C Ch c nh ngha trn mi c gi tr v tt c hu qu ca thiu mu u lin
quan n t l Hb ch khng phi s lng hng cu (HC) v Hematocrite (Hct)
nh cc nh ngha trc y. S lng hng cu ch l mt phn nh khng
trung thnh ca thiu mu v nng Hb trung bnh ca mi hng cu v th
tch trung bnh ca mi hng cu khc nhau ty theo hi chng thiu mu, v
vy lng Hb cng khc nhau i vi cng mt s lng hng cu. Hct ph
thuc vo th tch trung bnh hng cu v cn ph thuc vo bch cu v tiu
cu na.
C Cc trng hp cn xem xt, phn bit vi thiu mu:
+ Hin tng pha long mu: Khi tng th tch huyt tng lm cho HC gim,
Hct gim, v t l Hb gim, nhng vn khng c thiu mu v khi lng ton
b Hb lu hnh vn gii hn bnh thng.
95
+ Hin tng mu b c c: Th tch khi dch tun hon gim lm cho HC v
Hct tng gi to.
+ Tr s sinh: HC, Hct v nng Hb tng hn ngi trng thnh.
+ Gii tnh: HC, Hct v nng Hb ca nam gii cao hn n gii.
2. Nguyn nhn thiu mu:
2. 1 Thiu mu do gim sinh:
2. 1. 1 Thiu yu t to mu:
C Thiu st.
C Thiu acid folic.
C Thiu vitamin B12.
C Thiu protein.
2. 1. 2 Gim sn hoc bt sn ty:
C Suy ty.
C Thm nhim ty: Leucemie, ung th di cn vo.
C Bnh khc: Suy thn mn, nhim khun mn, bnh h thng.
2. 2 Thiu mu do tan mu:
2. 2. 1 Tan mu cp:
C St rt.
C Ng c: Thuc (St rt, Nitrates), nc rn v cn trng.
C Nhim trng huyt hoc bng.
C Bt ng nhm mu ABO do truyn nhm nhm mu.
2. 2. 2 Tan mu mn:
C Min dch.
C Thalassemie.
C Cng lch.
C Thiu men G
6
PD.
2. 3 Thiu mu do chy mu:
2. 3. 1 Chy mu cp:
C Chn thng.
C Xut huyt ni.
C Chy mu cam.
2. 3. 2 Chy mu mn:
C Giun mc.
C Chy mu do vim let d dy, t trng, ng mt, tr. . .
C Ri lon cm mu: Gim tiu cu, Hemophilie. . .
3. Triu chng thiu mu.
3. 1 Lm sng: Cc triu chng lm sng ph thuc rt nhiu tnh trng thiu mu v
kh nng thch nghi ca c th.
96
3. 1. 1 Thiu mu cp: Xy ra nhanh chng sau tan mu nhiu hoc xut huyt nng.
- Da nim nht nht, lng bn tay trng bch.
- Thn kinh: Hoa mt, chng mt, tai, ngt, l m hoc hn m.
- Tim mch: Nhp tim nhanh, huyt p c th tt hoc kt v c th c ting thi tm
thu thiu mu.
- H hp: Kh th, nhp th nhanh.
- C v khp: Mi cc c, i li kh khn.
3. 1. 2 Thiu mu mn: Xut hin t t.
- Da xanh, nim mc nht nht.
- Thn kinh: Hoa mt, chng mt, tai.
- Tim mch: Nhp tim nhanh, huyt p bnh thng, c ting thi tm thu thiu mu.
- H hp: Kh th khi gng sc, nhp th nhanh.
- Cc c quan khc:
+ C xng khp: Mt mi khi i li v lm vic.
+ Tiu ha: n km, a lng hoc to bn, gy st cn.
+ Lng, tc, mng: Mng tay kh, mt bng, c kha, d gy; lng tc tha v d
rng.
+ Sinh dc: Nam th kh nng sinh l gim hoc mt, n th ri lon kinh nguyt
(chm hoc ko di kinh nguyt).
3. 2 Cn lm sng:
3. 2. 1 Xt nghim gip chn on (+) v chn on mc thiu mu.
C HC gim (trung bnh = 3, 8 - 4, 2 triu/mm
3
).
C Hct gim (trung bnh = 37 - 45%).
C Hb gim (trung bnh: Nam = 13 - 18g%, N: 12 - 16g%).
Xt nghim gip nh gi v hng cu.
a) Cng thc mu ngoi bin:
C Th tch trung bnh hng cu (MCV): MCV =


Bnh thng: MCV = 80 - 100 Fl.

C Lng Hemoglobin trung bnh hng cu (MCH): MCH =



Bnh thng: MCH = 27- 32 pg.

C Nng Hemoglobin trung bnh hng cu (MCHC): MCHC =

Bnh thng: MCHC = 32 - 36g%.
b) Huyt : Kho st c im hnh dng, mu sc hng cu ngoi bin.
HC (triu)

x 10


Hct (%)
Hct (%)
Hb (g%)
x 100
Hb (g%)
HC (triu)

x 10


97
3. 2. 3 Xt nghim gip nh gi kh nng hi phc thiu mu.
C Hng cu li: Bnh thng = 0, 5 - 2%.
+ HCL tng: Thiu mu c hi phc (thiu mu ngoi bin).
+ HCL gim: Thiu mu khng hi phc (thiu mu trung ng).
C Ty : Tu giu hoc ngho t bo; c im dng t bo mu trong ty xng.
3. 2. 4 Cn lm sng gip chn on nguyn nhn thiu mu.
C Thiu mu gim sinh: nh lng cc yu t to mu, ty , sinh thit ty. . .
C Thiu mu tan mu: Bilirubine mu, KST St rt, test Coombs. . .
C Thiu mu chy mu: Fe huyt thanh, KST ng rut, ni soi d dy t trng.
3. 2. 5 Cn lm sng gip chn on nguyn nhn thiu mu.
C Suy tim.
C Thiu mu c tim.
C Suy thn cp.
4. Phn loi thiu mu:
4. 1 Phn loi theo nguyn nhn:
4. 1. 1 Thiu mu do gim sinh.
4. 1. 2 Thiu mu do tan mu.
4. 1. 3Thiu mu do chy mu.
4. 2 Phn loi theo huyt hc:
4. 2. 1 Thiu mu hng cu bnh thng, ng sc (thiu mu ng sc, ng bo):
(MCV bnh thng, MCH bnh thng, MCHC bnh thng; huyt kt lun
hng cu ng bo, ng sc)
+ Suy ty, Leucemie, bnh gan, bnh thn, bnh ni tit.
+ Tan mu cp.
+ Chy mu cp.
4. 2. 2 Thiu mu hng cu nh, nhc sc:
(MCV 80Fl, MCH 27pg, MCHC 30g%, huyt kt lun hng cu nh,
nhc sc)
C Fe huyt thanh gim hay gp nht (90%).
+ Chy mu mn: Hay gp nht.
+ Thiu cung cp st (ch n, c a cn nhiu st, hi chng km hp thu)
+ Ri lon phn b st (vim nhim, bnh l c tnh. . . )
+ Thiu toan d dy.
+ Chng xanh mt nguyn pht.
C Fe huyt thanh tng: Gp t hn (10%).
+ Thalassemie.
+ Sideroblastic (ng c ru, INH; ri lon chuyn ha B6. . ).
4. 2. 3 Thiu mu hng cu to:
98
(MCV > 100Fl; huyt kt lun hng cu to).
C Khng c nguyn HC khng l trong ty xng: 100 Fl < MCV< 110Fl.
+ Bnh v mu: Tan mu, mt mu, s sinh, lon sn ty, tin Leucemie. . .
+ Ngoi bnh mu: Thiu nng gip, thiu nng tuyn yn, bnh phi mn tnh tc
nghn. . . .
C C nguyn hng cu khng l trong ty xng: MCV 110Fl.
+ Thiu B12, Folic.
+ Thuc, ri lon sinh ty, ri lon chuyn ha bm sinh.
4. 3. Phn loi theo nng Hb:
C Thiu mu nh : Hb < 12g% ( 10 tui) v < 11g% (<10 tui).
C Thiu mu va : Hb = 6 - 9g%.
C Thiu mu nng : Hb < 6g%.
TI LIU THAM KHO:
1. Nguyn Th Minh An (2003), Chn on - phn loi thiu mu, Ni khoa c s
tp II, Nh xut bn Y hc.
2. Trn Vn B (1998), Tng qut v thiu mu, Huyt hc lm sng, Nh xut bn
Y hc.
3. Thi Qu (2002), Thiu mu, Mu - truyn mu, cc bnh mu thng gp, Nh
xut bn Y hc.
4. Bch Quc Tuyn (1998), i cng v thiu mu, Bch khoa th bnh hc tp
I, Nh xut bn Trung tm Quc Gia bin son t in Bch khoa Vit Nam.


K KH H M M V V C CH H N N O O N N
H H I I C CH H N NG G X XU U T T H HU UY Y T T

MC TIU:
1. Nu c nh ngha v dch t hc ca hi chng xut huyt.
2. Trnh by c phn loi hi chng xut huyt theo nguyn nhn v sinh l bnh.
3. M t c triu chng lm sng v cn lm sng ca hi chng xut huyt.
4. Trnh by c tiu chun, du hiu chn on y hi chng xut huyt.
5. Nu c 3 mc tiu cn thm khm bnh nhn xut huyt.
NI DUNG:
1. nh ngha v dch t hc:
1. 1 nh ngha: Xut huyt l tnh trng mu thot ra khi thnh mch do v mch
hay khng do v mch.
1. 2 Dch t hc:
- Xut huyt l hi chng rt hay gp v gp mi chuyn khoa (Cp cu, Ni, nhi,
99
nhim, sn, ngoi, huyt hc. . . ). Theo Phan Thnh Trinh, trong hai nm 2001-2002
th xut huyt nng chim 7. 87% cc bnh l cp cu nhi iu tr ti Bnh vin tnh
DakLak.
- Hi chng xut huyt bao gm rt nhiu nguyn nhn.
2. Phn loi hi chng xut huyt: Theo nguyn nhn v sinh l bnh, phn loi hi
chng xut huyt theo 3 nhm nguyn nhn sau:
2. 1 Nguyn nhn do thnh mch: t gp
2. 1. 1 Nhim khun: Nhim khun huyt do no m cu, thng hn, bch hu, si,
t cu, ph cu, st xut huyt, lao cp tnh. .
2. 1. 2 Nhim c:
- Thuc.
- Ure mu cao.
2. 1. 3 D ng:
- Mt s thc n.
- Vim mao mch d ng (Schonlein-Henoch).
2. 1. 4 Thnh mch d v:
- Ngi gi, Tng huyt p, i ng, x gan, lao mn tnh. .
- Thiu Vitamines: Vit C, Vit PP.
2. 2 Nguyn nhn do tiu cu: Hay gp nht.
2. 2. 1 Gim s lng tiu cu.
- Nhim khun: St xut huyt, nhim khun huyt, thng hn, Osler. .
- Suy tu, Leucemie.
- Xut huyt gim tiu cu t min (Bnh Werlhoff).
- Cng lch.
- Lupus ban ri rc.
- Ng c v d ng:
+ Thuc v ho cht: Quini, Quinidin, Phenobarbital. .
+ Tia x: Tia X, cc cht ng v phng x.
+ Nc rn, nc cn trng. .
- Bng rng.
- Tr s sinh.
2. 2. 2 Ri lon cht lng tiu cu:
- Suy nhc tiu cu: Bnh Glanzman.
- Lon dng tiu cu: Bnh Tean-Bernard-Solier.
2. 3 Nguyn nhn do huyt tng: Him gp
2. 3. 1 Ri lon sinh Thromboplastin Thiu Thromboplastin:
Bnh a chy mu (Hemophilie): Hemophilie A (Thiu yu t VIII), Hemophilie B
(Thiu yu t IX), Hemophilie C (Thiu yu t XI), Hemophilie D (Thiu yu t XII).
100
2. 3. 2 Ri lon sinh Prothrombin Thiu Prothrombin:
- Bm sinh: Thiu yu t V, VII, X.
- Mc phi: Suy gan, tc mt, thiu vitamin K.
2. 3. 3 Ri lon sinh Fibrinogen Thiu Fibrin:
- Bt thng h thng tng hp:
+ Suy gan nng.
+ Bm sinh khng c Fibrinogen.
- Fibrinogen b ph hu nhiu:
+ Hi chng ng mu ni mch ri rc (DIC).
+ Chn thng, bng nng.
- Nguyn nhn khc: Tai bin truyn mu, Bnh Vaquez, Nhim khun Gram(-),
Ung th ng tiu ho di cn, Leucemie cp th L3, Tai bin iu tr tc mch, rn
cn. . .
2. 3. 4 C cht khng ng lu hnh:
- Sau khi tim nhiu Heparin.
- C th to ra nhiu Heparin sau khi shock hoc sau khi chiu cc tia x. . .
3. Triu chng ca hi chng xut huyt:
3. 1 Lm sng: Cc hnh thi xut huyt:
3. 1. 1 Xut huyt di da:
C Cch xut hin: + T nhin hay th pht sau sang chn?
+ Tin s c xut huyt lp i lp li trc ?
C V tr xut huyt: + Xut huyt ni no?
+ i xng khng?
C Hnh thi xut huyt: Nhiu hnh thi:
+ Chm xut huyt : Bng u tm.
+ Nt xut huyt : Kch thc 1-10mm.
+ Mng xut huyt : Kch thc 1-10cm.
+ Khi mu t : To, ni cc di da.
+ m xut huyt : Tp trung nhiu chm, nt, mng hp li to ra mu sc
khc nhau.
C S lng xut huyt: t hay nhiu.
3. 1. 2 Xut huyt nim mc:
C Nim mc ming li: Chm, nt, mng hay khi mu t nh xut huyt di da.
C Nim mc li, chn rng: T nhin hay sau khi xa rng.
C Nim mc mi: Chy mu cam.
C Nim mc mt: C nhng chm hoc nt xut huyt.
3. 1. 3 Xut huyt cc tng:
C ng tiu ho: Nn ra mu hay i cu ra mu.
101
C T cung: Rong kinh hay rong huyt.
C Xng khp: Nht l xut huyt vo khp gi.
C Cc tng khc: Thn, bng quang, lch, cc mng, no. . .
3. 2 Cn lm sng:
3.2. 1 Cn lm sng gip chn on xc nh xut huyt: C khi cn xt nghim tm
hng cu trong cc dch, ni soi ng tiu ho, . . .
3. 2. 2 Cn lm sng gip nh hng nhm nguyn nhn xut huyt v tm nguyn
nhn xut huyt
C Cn lm sng nh hng nhm nguyn nhn xut huyt:
- Thnh mch: Du hiu Lacet.
- Tiu cu: Du hiu Lacet, s lng v cht lng tiu cu, thi gian mu chy, thi
gian co cc mu.
- Huyt tng: Thi gian mu ng, thi gian Howell, thi gian Quick, thi gian
Cephalin-Kaolin, nh lng fibrinogen. .
3. 2. 3 Cn lm sng gip chn on nguyn nhn xut huyt: Tu theo nguyn nhn
khc nhau m c cn lm sng thch hp.
c) Cn lm sng xc nh hu qu ca hi chng xut huyt gy ra:
- Hi chng thiu mu: HC, Hct, Hb
- Xut huyt cc tng.
4. Chn on hi chng xut huyt:
4. 1 Chn on xc nh:
4. 1. 1 Xut huyt di da:
C Chm, nt, mng hay khi mu t.
C Tm nhun (ly ngn tay cng da hoc dng phm knh vo th khng mt).
C Thay i theo thi gian (mu mu xanh tm mu vng mt).
4. 1. 2 Xut huyt nim hoc cc tng:
C C th c c im nh xut huyt di da.
C Mu chy trc tip hay gin tip (nn ra mu, i cu ra mu, i ra mu. . . ).
C Cn lm sng: Xt nghim tm hng cu trong cc dch, ni soi, . . .
4. 2 Chn on phn bit:
4. 2. 1 Nt mi hay cn trng cn:
- Hay gp nhng ch h (mt, tay, chn).
- Hi ni trn mt da, khng tm nhun.
4. 2. 2 Bt hay nt rui son:
- Hay c t nh
- Khng tm nhun v khng thay i theo thi gian
4. 2. 3 Pht ban trong mt s bnh nh si, d ng
- Khng tm nhun
102
- Trong cng mt vng th cc mu sc thng khng u.
4. 2. 4 Ung thuc hoc thc n m i cu phn en hoc tiu mu .
4. 3 Chn on mc :
4. 3. 1 Mc nh
- Ch yu l xut huyt da.
- Khng thiu mu hoc thiu mu nh.
4. 3. 2 Mc va
- Xut huyt da v nim mc.
- Thiu mc nh hoc thiu mu va.
4. 3. 3 Mc nng
- Xut huyt da nim, xut huyt cc tng hoc nguy c xut huyt ni s.
- Thiu mu va hoc nng
4. 4 Chn on nguyn nhn: Da vo hai du hiu sau:
4. 4. 1 Xut huyt thuc nhm nguyn nhn xut huyt no?
- Thnh mch.
- Tiu cu.
- Huyt tng.
Du hiu Thnh mch Tiu cu Huyt tng
Lm
sng
Cch xut hin
T nhin
hoc th pht
T nhin
hoc th pht
Th pht
V tr XH Da Da, nim, tng Da, c, khp
Hnh thi XH Chm, nt Chm, nt, mng
Mng,
khi mu t
i xng - -
Cn
lm sng
Lacet -
Mu chy
Mu ng
Tiu cu
Ri lon (s lng
hoc cht lng)

4. 4. 2 Triu chng ca bnh nguyn nhn km theo:
C Nhm thnh mch:
- Nhim trng: C hi chng nhim trng, nht l khi c nhim trng huyt.
- Schonlein-Henoch: Tr tui v n vi au khp, au bng, bch cu E tng. . .
C Nhm tiu cu:
103
- Suy tu: Hi chng nhim trng, hi chng thiu mu, tuy ngho t bo v x
ho.
- Cng lch: Lch to m khi tim Adrenalin lm tng t bo ngoi bin r rt.
- Bnh Werlhoff: Khng th khng tiu cu (+) m khng tm ra nguyn nhn no
khc gy gim tiu cu.
C Nhm huyt tng:
- Hemophilie: Gim yu t VIII, IX, XI; c tnh cht di truyn nam gii.
- Suy gan: Chn n, s m; ph hai chi di, vng da, thiu mu, yu t II gim,
Cholesterol etes ho gim, t l A/G mu gim.
4. 5 Chn on bin chng:
4. 5. 1 Thiu mu.
4. 5. 2 Xut huyt tng nng (no, tim, phi, thn): c th gy t vong hoc gy tn
ph (nht l khi xut huyt nhiu ln vo khp).
5. Mc tiu thm khm bnh nhn xut huyt:
5. 1 Thm khm xc nh xut huyt v mc ca n.
- Lm sng.
- Cn lm sng.
5. 2 Thm khm nh hng nhm nguyn nhn v tm nguyn nhn xut
huyt.
- Lm sng.
- Cn lm sng.
5. 3 Thm khm xc nh bin chng ca hi chng xut huyt (nu c).
- Lm sng.
- Cn lm sng.
TI LIU THAM KHO:
1. Nguyn Th Minh An (2003), Chn on hi chng xut huyt, Ni khoa c s tp
I, nh xut bn y hc2.
2. Trn Vn B (1998), Hi chng xut huyt, Huyt hc lm sng, nh xut bn y
hc.

104
C CH H N N O O N N L L C CH H T TO O
MC TIU:
1. Trnh by c cch khm lm sng lch to.
2. K c cc nguyn nhn gy lch to.
3. Trnh by c chn on y lch to.
4. Nu c mc tiu thm khm bnh nhn lch to.
NI DUNG:
1. K thut khm lm sng lch:
1. 1 T th bnh nhn v thy thuc:
1. 1. 1 Bnh nhn: Nm nga v hi nghing bn phi, cnh tay tri c th gi cao ln
trn, hai chn co, u v ngc hi cao.
1. 1. 2 Thy thuc:
- Khm thng thng: ng hoc ngi bn phi bnh nhn.
- Khm mc lch: ng hoc ngi bn tri bnh nhn.
1. 2 Thao tc k thut:
1. 2. 1 Nhn: Khi lch to nhiu, c th nhn thy mt vm ni ln di b sn tri.
1. 2. 2 S: Bo bnh nhn th chm, su, u ng thi th lng c bng
- Trng hp lch to va: Thy thuc ngi bn phi bnh nhn, t bn lng
tay phi vo vng bng bnh nhn di h sn tri gia ng nch trc
v trung n tri. Bo bnh nhn ht tht su v mnh vo, bn tay phi n
xung s ng thy lch (v lch di ng theo nhp th).
- Trng hp lch to t: Cho bnh nhn nm nghing hn sang phi. Thy thuc
ngi bn tri bnh nhn v dng phng php mc lch: Dng cc u ngn
tay lm mc v mc nh vo b di sn vng lch. Bo bnh nhn ht tht
su vo th c th chm vo cc di ca lch.
- Trng hp lch to nhiu xung pha di: Cho bnh nhn nm nga, thy
thuc dng hai bn tay khm: mt bn tay trn bng, mt bn tay
di lng bnh nhn gii hn v tr ca lch v nhn thy r ch eo vo
ca lch.
B trong ca lch nhiu khi gii hn khng r rng c th s c b rng
ca. l rn lch, mt c im rt quan trng trn lm sng chn on
lch to.
1. 2. 3 G: Cho bnh nhn nm nghing thng v bn phi, cnh tay tri gi cao ln
u. Thy thuc ngi mt bn:
- G xc nh b trn ca lch: G t trn xung di theo 3 ng nch trc,
nch gia, nch sau tm vng c ca lch pha trong lng ngc. Ranh
gii gia vng trong ca phi v vng c ca lch l cc trn ca lch.
- G t di bng ln trn tm b di ca lch to.
105
2. Nguyn nhn lch to:
2. 1 Lch to cp tnh: t gp trong cc nguyn nhn ny, lch to ch l mt du
hiu nht thi v ph; thng d chn on nguyn nhn ca lch to.
C Nhim khun huyt do vi khun sinh m.
C Vim ni tm mc cp, bn cp.
C Thng hn.
C Leucemie cp.
C Bnh tng bch cu n nguyn nhn nhim khun.
Lao k.
C Rickettsia.
2. 2 Lch to mn tnh: Hay gp thng kh chn on nguyn nhn hn.
2. 2. 1 Bnh v mu:
C Lch to v hch to:
- Leucemie kinh th tn.
- Hodgkin.
- Sarcoma lan rng.
C Lch to v tng tu bo: Leucemie kinh dng tu.
C Lch to + tng hng cu:
- Bnh Vaquez
- Lao lch
C Lch to + gim 3 dng mu ngoi bin: Cng lch
C Lch to + thiu mu do tng mu: Thiu mu huyt tn
2. 2. 2 Bnh l gan- tnh mch ca:
C X gan.
C Tc hoc hp tnh mch ca.
C Tc tnh mch trn gan (hi chng Budd-Chiari).
C Bnh Hanot.
C Bnh Banti.
2. 2. 3 Bnh l khc:
C Nhim khun: St rt nhiu ln, sn mng.
C U lch: U nang, u lnh, u c.
C Ri lon chuyn ho m.
3. Chn on lch to:
3. 1 Chn on xc nh:
3. 1. 1 Khm ln sng: thy c lch to.
3. 1. 2 Siu m: thy lch to (kh chnh xc).
3. 1. 3 Nghim php co lch: Gip chn on xc nh lch to v gip cho bit tnh
trng x ho ca lch
106
- Tim Adrenaline 1mg, tim di da.
- Sau 15 pht th th tch lch co li v s lng mu ngoi vi tng tng 5 pht
mt.
- Thng thng s lng hng cu tng nhiu nht sau 20 pht, s lng tiu
cu cng tng nhanh, s lng bch cu tng chm hn.
3. 1. 4 Chc d lch v lm lch : Rt t lm v d chy mu, ch lm khi 3
phng php trn m cha (+) v nguyn nhn lch to
Chng ch nh: C a d chy mu, c a d xc cm, c a d nhim
khun, lch to v au
3. 2 Chn on phn bit: Cn phn bit vi cc trng hp sau:
3. 2. 1 Thu tri gan to:
- Thng thng khng th chim ht h sn tri nh lch.
- G khng thy ng ranh gii ngn cch.
- Khng thy b rng ca ca lch.
- Siu m thy gan to.
3. 2. 2 Thn tri to:
- Khi u trn, su hn v b trong khng c hnh rng ca, pha trc th g
trong; chm thn v bp bnh thn().
- Siu m, chp UIV thy thn to.
3. 2. 3 Ung th d dy:
- Khi u su, kh gii hn ri lon tiu ho.
- Chp XQ d dy- t trng c cn quang.
3. 2. 4 U ui tu:
- U su, khng di ng theo nhp th, g k s thy vng trong gii hn gia
khi u v b sn tri.
- Siu m.
3. 2. 5 Khi u i trng ngang gc lch:
- Khi u trn, gii hn r, di ng d ri lon tiu ho (c bit l hi chng
Koenig).
- Chp khung i trng c cn quang.
3. 2. 6 Lao hch mng bng pha tri:
- Khi u to t gii hn khng r rt.
- Siu m, ln nghim php co lch phn bit.
3. 2. 7 Triu chng khc:
- Khi u thng thn.
- Khi u mc treo.
- Vim c hoc u m vng h sn tri.
3. 3 Chn on mc : Da theo phn lch:
107
3. 3. 1 Lch to I : Di h sn tri 2 cm.
3. 3. 2 Lch to II : Di h sn tri 4 cm.
3. 3. 3 Lch to III : n rn.
3. 3. 4 Lch to IV : Qu rn n mo chu.
Ch : Lch c th to theo hai chiu: Hoc
- Chiu thng ng i xung h chu (lch ng).
- Chiu nm ngang i ra gia bng (lch nm).
3. 4 Chn on nguyn nhn: Quan trng nht Ch yu da vo 2 yu t:
3. 4. 1c im lch to:
- Cp hay mn.
- Mc ln.
- B mt, b.
- Mt .
- n au.
3. 4. 2 Triu chng bnh nguyn nhn gy lch to km theo:
- St rt: St rt run tng cn, thiu mu, dch t, k sinh trng st rt (+).
- Nhim khun huyt: St lnh run km ni vn tm da, bch cu N , vi khun
mu (+).
- Leucemie cp: Hi chng suy tu, hi chng tng sinh c tnh, khong trng
bch cu (+), hay gp ngi tr tui.
- Cng lch: Gim cc dng mu ngoi bin m sau khi ct lch th tr li bnh
thng.
- Thiu mu huyt tn: Hi chng thiu mu, du hiu huyt tn.
- X gan: Hi chng tng p lc tnh mch ca, hi chng suy t bo gan, sinh
thit gan.
3. 5 Chn on bin chng:
3. 5. 1 V lch.
3. 5. 2 Chn p cc c quan ln cn.
4. Mc tiu thm khm bnh nhn lch to:
4. 1 Thm khm xc nh lch to v c im ca n:
- Lm sng.
- Cn lm sng.
4. 2 Thm khm xc nh nguyn nhn lch to:
- Lm sng.
- Cn lm sng.
4. 3 Thm khm xc nh bin chng ca lch to:
- Lm sng.
- Cn lm sng.
108
TI LIU THAM KHO:
1. Nguyn Th Minh An (2003), Chn on lch to, ni khoa c s tp 1, nh xut
bn y hc.
2. Trn Vn B (1998), nh bnh hch to- lch to, huyt hc lm sng, nh xut
bn y hc.

C CH H N N O O N N H H C CH H T TO O
MC TIU:
1. Trnh by c cch khm v m t hch to.
2. K c cc nguyn nhn gy hch to.
3. Trnh by c chn on y hch to.
4. Nu c mc tiu thm khm bnh nhn hch to.
NI DUNG:
1 Thm khm hch to:
1. 1 Hch nng (hch ngoi vi): Hch chm, sau mang tai v xng chm, hch
di hm, hch hai bn c (dc theo ng mch cnh v dc theo c c n chm),
hch h thng n, hch nch, hch b trong c nh u cnh tay (hch khuu),
hch bn, hch kheo chn.
1. 1. 1 V tr hch:
- Hch di hm: Vim hng. . .
- Hch bn: Hch vim, hch hoa liu, ung th hch. . .
- Hch na ngi: Lao hch, ung th hch, Hodgkin. . .
1. 1. 2 Tnh cht i xng:
- i xng, u hai bn: Bch cu cp, bnh h thng. . .
- Khng i xng: Ung th hch, hch vim kh tr. . . .
1. 1. 3 Hnh dng v kch thc:
- Hnh trn, u, nhn: Leucemie
- Hnh trn, tng m dnh vo nhau: Lao hch
1. 1. 4 Gii hn:
- R rt: Leucemie, hch vim nhim. . .
- Khng r rt: Lao hch, ung th hch di cn. . .
1. 1. 5 Mt :
- Mm: Hch vim, hch lao giai on u. . .
- Chc: Leucemie
- Cng: Ung th hch, Hodgkin. . .
1. 1. 6 n au v nng:
- Nng, , au: Hch vim
- Khng au: Ung th hch, lao hch, Leucemie (giai on sau c th chn vo dy
109
thn kinh bn cnh gy au).
1. 1. 7 Di ng:
- D dng: Leucemie, hch ung th do di cn. . .
- Kh hoc khng: Ung th hch, Lao hch. . .
1. 1. 8 Tin trin:
- Hodgkin: Hch xut hin tng t.
- Lao: Hch tin trin chm hn hch ung th, c th c l d hoc vt so c nhn
nhm bn cnh hch.
4. 2 Hch su: Hch trung tht, hch mng bng. . .
Hch su khng th khm bng lm sng c m phi da vo cc cn lm sng:
Siu m, chp XQ, chp h bch huyt, ni soi, CT scanner. .
2. Nguyn nhn hch to:
2. 1 Hch vim:
2. 1. 1 Hch vim cp tnh:
- Vim nhim gy sng ty mt vng.
- Bnh truyn nhim: Rickettsia, st pht ban.
- Bnh nhim khun c tng bch cu n nhn.
2. 2. 2 Hch vim mn tnh:
- Hch do c a.
- Bnh hoa liu: Giang mai (giai on 1, 2), bnh Nicolas-Favre. . .
- Lao hch.
- Bnh da mn tnh.
2. 2 Hch ung th:
- Ung th hch.
- Ung th di cn hch (nht l ung th v, sinh dc, d dy, phi).
2. 3 Hch to trong cc bnh v mu:
- Leucemie.
- Bnh Hodgkin.
2. 4 Nguyn nhn khc:
- Bnh t min: Lupus ban , vim khp dng thp. . .
- Bnh Sarcoidose.
3. Chn on hch to:
3. 1 Chn on xc nh:
3. 1. 1 Khm lm sng: thy hch to (hch nng).
3. 1. 2 Cn lm sng: Siu m, ni soi, X quang, chp h bch huyt, hch , sinh
thit hch (nht l i vi hch su).
3. 2 Chn on phn bit:
3. 2. 1 U nang, u m di da
110
- C th khng cc vng hch bch huyt.
- Mt mm hn.
3. 2. 2 U nang v nhn gip trng
- Di ng theo nhp nut.
- Mt mm hn nu l u nang.
3. 2. 3 Vim hoc Abcess c
- Nm vng c.
- Siu m.
3. 2. 4 Thot v bn
- C th y ln c.
- C du hiu tc hoc bn tc rut.
3. 2. 5 U trung tht, u mc treo: Cn da vo cn lm sng hoc m thm d
3. 3 Chn on nguyn nhn hch to: Quan trng nht. Cn da vo hai yu t sau:
3. 3. 1 c im hch to (da vo 8 tnh cht hch to):
- Vim nhim gy sng ty mt vng: Hch to tng ng vi vng b vim nhim
(vim hng c hch di hm, nht i c hch di bn, zona ngc c hch
nch) vi c im: au, nng, , mt chc, xung quanh c hin tng vim
nhim, s lng 1-2 hch, di ng c, khng dnh vo nhau, tin trin c th gy
m.
- Hch do c a: Hch bn, hch di hm, kch thc nh, khng au, di ng d
dng, chc v hch mt khi sc kho ton thn tt hn (hay gp ngi gy st).
- Hch trong bnh da liu:
+ Giang mai giai on I, II: Lc u hay gp hch bn thng c 4-5 hch nh,
hi rn, khng au, di ng d dng sau hch gp nhiu ni khc v c th to
hn.
+ Bnh Nicolas-Favre: Hch to bn (qu xoi) thng nhiu hch dnh vo nhau
to thnh mt khi lm m trong tng im nh v khi r m th c nhiu l
trng nh trn mt mt ci hng sen.
- Lao hch: Lc u hch thng hai bn c (trc vo sau c c n chm) sau
mi lan ln gy, h thng n m t khi gp hch to nch v bn. Hch ni thnh
chui hoc c khi hch ni to mt bn c. Xut hin v tin trin t t, lc u th
chc, nhn, khng au, d di ng v sau th dnh vo nhau v dnh vo da pha
trn lm cho hch kh di ng c th d ra ngoi vi dch mu xanh, ln nhm trng
nh b u li so nhn nhm rt xu, c hch sau khi d m li th ng vi lm
cho hch rn. Quan trng nht trn cng mt m hch ta thy nhng hch c mt
khc nhau tu theo thi gian xut hin ca mi hch (mm, chc, rn).
- Ung th hch: Hch thng to, mt rn, t di ng v dnh vo t chc su.
- Leucemie kinh dng lympho: Hch to v nhiu ni (c, bn, nch) b mt u,
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nhn, mt chc, gii hn r, di ng d dng.
- Leucemie cp: Hch t v nh hn, hay gp vng c v di hm, mt chc, di
ng d dng.
- Bnh Hodgkin: Hch thng ni u tin h thng n tri, kch thc t nh
nh ht n to nh qu cam. Lc u c hch mc ring l nn d nn, gii hn
r rt; v sau cc hch dnh vo nhau thnh m kh di ng. Hch khng au, hi
rn v t khi lot hoi t v d ra ngoi.
3. 3. 2 Du hiu bnh nguyn nhn km theo:
- Hch to do vim ty 1 vng: nhim trng tng ng, hi chng nhim trng,
bch cu tng.
- Hch to do lao: Ngi tr, c sc kho ton thn khng suy sp lm, bnh tin
trin lin tc, xt nghim c VS mu tng, phn ng IDR(+), sinh thit hch c
nang lao.
- Hch to do ung th hch: Hay gp ngi ln tui, sc kho ton thn suy sp
nhanh, bnh tin trin lin tc, sinh thit hch c t bo ung th.
- Hch to do bnh Leucemie: Hi chng thiu mu, nhim trng, xut huyt; gan
lch to; bch cu tng v c bch cu non, tu giu t bo v c th c khong
trng bch cu (trong Leucemie cp).
- Hch to do bnh Hodgkin: Hay gp ngi ln tui, bnh tin trin tng t, st
nga, tnh trng ton thn suy sp dn, c th c hch trung tht, bng v ni
tng. Sinh thit hch c t bo Sternberg.
3. 4 Chn on bin chng hch to: Bin chng chn p cc vng ln cn vi hch to
(mch mu, thn kinh. . ).
4. Mc tiu thm khm bnh nhn hch to:
4. 1 Thm khm xc nh hch to v c im ca n:
- Lm sng
- Cn lm sng
4. 2 Thm khm xc nh nguyn nhn hch to:
- Lm sng
- Cn lm sng
4. 3 Thm khm xc nh bin chng chn p ca hch to:
- Lm sng
- Cn lm sng
TI LIU THAM KHO:
1. Nguyn Th Minh An (2003), Chn on hch to, Ni khoa c s tp 1, nh
xut bn y hc
2. Trn Vn B (1998), nh bnh hch to- lch to, Huyt hc lm sng, nh xut
bn y hc
112
K KH H M M B B N NH H N NH H N N T TH H N N K KI IN NH H

MC TIU:
1. Trnh by c c im chung cch khm ca bnh nhn thn kinh.
2. Trnh by c cch khm vn ng: cc phng php khm, nh gi kt qu, xc
nh a im.
3. Trnh by c cch khm phn x: cc phng php khm, nh gi kt qu, xc
nh a im.
4. Trnh by c cch khm cm gic: cc phng php khm, xc nh v tr, nh
gi kt qu.
5. Trnh by c cch khm dinh dng v ri lon c trn: cc phng php khm,
nh gi kt qu.
NI DUNG:
i cng: Khm bnh thn kinh i hi ngi khm kin nhn, khm trnh t
trnh b st nhng du hiu tn thng. Cn khm y gip bc s lm sng c
hng chn on ban u. Khm bnh thn kinh cng cn nhng bc nh khm cc
bnh khc v nht l cc dng c cn thit ti thiu cho mi ln khm; ba phn x,
kim khm cm gic trn da, bng gn khm cm gic xc gic, m thoa khm
cm gic su dn truyn qua xng v thnh lc, v n pin, n soi y mt khm
phn x nh sng v soi y mt. Ngi thy thuc cng phi hi bnh t m cc qu
trnh bnh v tin s bnh nhn.
Sau y chng ta ln lt im qua cc nguyn tc c bn trong khm bnh thn kinh.
Khm vn ng
Khm vn ng t ch
Mt s cch khm: ngi bnh nhiu t th nh ngi ng nm y
thng khm t th nm.
Hng dn bnh nhn lm mt s ng tc thng thng c hai bn so
snh.
Cc ng tc c chi trn v chi di. Khm c lc ngn chi v gc chi, so snh
2 bn cc c tng ng.
nh gi c lc bng cch to ra cc lc i khng trc tip vi tnh nng tc
dng ca tng nhm c mt, v bng cch xem bnh nhn c thc hin cc
ng tc thng thng chng li nh hng ca trng lc.
C lc ngn chi
Chi trn: bnh nhn nm cht hai ngn tay ca ta trong lng bn tay ca
h, ri rt mnh hai ngn tay ta ra nh gi c lc cc ngn tay ca bnh
nhn.
Nghim php gng km: khi bnh nhn dng ngn ci ln lt to thnh gng
113
km vi cc ngn tay khc, trong khi ta dng cc ngn tay tng ng t trong
gng km c m bung gng km ra. Nu c lc bnh nhn bnh thng th
gng km bnh nhn kh b bung ra.
Chi di: Bnh nhn c gp cc ngn chn vo lng bn chn, trong lc ta
ko chng v pha ngc li.
Bnh nhn c gp c chn bn chn v pha lng bn chn (hoc gp v
pha mt lng bn chn), ta y (ko) bn chn v hng ngc li.
Nu c lc bnh nhn bnh thng ta s kh lm cc ng tc i khng trn,
v ngc li s d dng khi lm cc ng tc i khng vi bnh nhn
C lc gc chi
- Chi trn: bnh nhn gp khuu tay (hoc dui khy tay), trong khi ta lm ng tc
i khng li.
Nghim php Barr:
Ngi bnh nm nga, hai tay a thng to vi mt ging mt gc 60

, bn
no yu (lit) s ri xung trc.
Chi di: bnh nhn nm sp gi hai cng chn v pha i, ta ko ngc li
cng chn thng ra (c gp). Hoc bnh nhn nm sp dui c hai chn st mt
ging, trong khi ta c y cng chn h p vo i
Nghim php Barr chn: ngi bnh nm sp, cng chn ngi bnh 45

vi mt ging. Bn no yu lit s ri xung trc.
Nghim php Mingazzini: ngi bnh nm nga, hai chn a ln, cng chn
thng gc vi i, i thng gc vi mt ging. Bn no y lit s ri xung
trc.
nh gi kt qu: Vic thm khm vn ng v c lc ca tng on cho
php pht hin tnh trng lit, khng nhng v cng lit m cn v a
im lit.
1. 1. 2. 1 Cng : C th lit hon ton, hay ch lit nh. Hy so snh hai
bn pht hin v cn loi tr ng tc yu do teo c hoc bnh khp lm
hn ch c ng.
1. 1. 2. 2 Xc nh a im lit: Ty theo tn thng thn kinh u m lit
c th khu tr hay lan ta. Do xc nh a dim lit l c th xc nh v tr
tn thng thn kinh. V d:
Thn thn kinh: khi lit vn ng mt nhm c chi phi bi mt dy thn
kinh s no hay thn kinh ty, ta c th cho l tn thng thn kinh ngoi
bin. Nh trng hp lit mt ngoi bin, lit thn kinh quay
R thn kinh: khi lit vn ng mt nhm c vng chi phi bi mt hay
nhiu r ty trc, y c th l tn thng hoc r hoc thn kinh ty, hoc
sng trc ty sng. Th d chi trn khi b tn thng C
5
-C
6
cc c en ta,
114
nh u, c cnh tay trc v sp di s khng vn ng c.
Lit mt chi: thng do tn thng r ty, sng trc ty sng, t khi tn
thng vng gii hn v no.
Lit na thn: do tn thng v no i din vi bn lit.
Lit hai chi di: thng do tn thng ty, hoc thng do tn thng
hai bn r ty hay do tn thng thn kinh ngoi bin, rt t khi do tn thng
c hai bn bn cu no.
Lit ngn chi tn thng b thp hoc dy thn kinh ngoi bin.
Lit gc chi: tn thng r hoc bnh ca c.
Trong cc trng hp lit cn xc nh nguyn nhn l tn thng trung
ng hay a phng.
Trong trng hp lit na thn chc chn do tn thng thn kinh trung
ng, cn lit do tn thng thn hay r thn kinh l do tn thng ngoi bin.
Lit ngoi bin thng l lit mn, phn x gn xng gim, c teo c v phn
ng thoi ha in.
Lit trung ng c th c lit mn nhng v sau thng chuyn sang lit cng,
phn x gn xng tng v thng km theo du Babinsky.
Khm trng lc c:
Theo thuyt c in ngi ta cho rng hai chc nng vn ng v trng lc
c khc nhau, vn ng l thc hin cc ng tc cn trng lc l tham gia
duy tr t th v dng b. Theo quan im hin nay hai chc nng ny khng
th tch ri nhau, v hai chc nng ny u c thc hin c vn
Mt s cch khm
Thng khm cc chi, ngi bnh cc chi t th th ng khng ln
gn, hoc bo bnh nhn lm cc ng tc ch ng nh gi
Chi trn: ngi bnh vng tay qua c, t lng bn tay vo vng xng b
vai cng bn.
Thy thuc cm c tay, c chn ngi bnh lc mnh tm ve vy ca
bn chn, hoc bn tay ngi bnh. Hoc lc c thn ngi bnh v phi ri v
tri xem bin vung tay ca bnh nhn.
Chi di: gt chn t vo mng cng bn.
nh gi kt qu. Ngi bnh thng c mt s khng nh khi lm
nhng ng tc th ng trn.
Khi khng tng: cc ng tc trn b hn ch, ta gi tng trng lc c.
Lc cc c thng rn hn bnh thng, mc d ang nh ngi.
Khi khng gim: lc cc c thng nho. Bn tay c th vi ti vng
xng b vai cng bn, hoc gt chn chm mng cng bn.
1. 2. 2. 1 Trng lc c tng: c km theo lit hoc khng km theo lit.
115
Trng lc c tng c km theo lit: l lit cng l du hiu ca lit do tn
thng thn kinh trung ng, c tn thng b thp. Trng hp ny gi l co
cng thp, in hnh nht l lit cng na ngi. Loi tng trng lc c ny
gi l tng trng lc c do thp:
Trng lc c tng thm khi lm ng tc c .
Tng r cc c gp chi trn v nhm c dui chi di.
Tng kiu n hi, chi ang t th gp ko dui ra, thi ko on chi s
gp li v tr c
Trng lc c tng khng km theo lit: l triu chng ca tn thng ngoi
thp, l co cng ngoi thp m tiu biu l bnh Parkinson. y l tng
trng lc c ngoi thp:
Tng r cc c m trch cc ng tc t ng: nt mt, c gi t th i,
ng.
Gc chi tng hn ngn chi.
Tng trng lc to hnh: gi nguyn trng thi v tr t th mi khi ta lm
ng tc on chi .
Khi gp hoc dui cc khc chi ta c hin tng bnh xe rng ca
1. 2. 2. 2 Trng lc c gim cng c hai loi.
Trng lc c gim km theo lit: gi l lit mn. l tt c cc trng
hp lit ngoi bin, v mt s trng hp lit trung ng giai on u.
Trng lc c gim khng km theo lit. c bit trong cc trng hp tn
thng cc ng cm gic su: tn thng thn kinh cm gic, cc r sau,
cc sng sau ty sng (tabes). Cng gp trong cc hi chng tiu no. Tn
thng tin nh ngoi bin.
Khm phi hp cc ng tc v thng bng
Bnh thng d ng tc n gin cng phi c qu trnh phn tch v tng
hp cc ng tc nh v yu t tm tr c s phi hp v gi thng bng.
S mt thng bng v phi hp ng tc gi l lon chong (ataxie) c bit
thng gp trong nhng ri lon cm gic su bnh tabes, hi chng tiu no,
hi chng tin nh.
Nhng nghim php pht hin long chong:
Ngn tay ch mi: bo bnh nhn dang tay ngang ra, dng ngn tr ch ng
vo mi C th c ba kh nng:
Ngi bnh ch ng, khng run: bnh thng.
Ch qu mc: qu tm, gp trong tn thng tiu no.
Ch khng ng ch: ngay lc lm ng tc, ngn tay run ry, hng ch
khng ng: ri tm, gp trong tn thng cm gic su v trong bnh tabs.
Gt chn u gi: bnh nhn nm, hai chn dui a gt chn mt bn ln
116
cao ri t ng vo xng bnh ch, sau a dc gt chn theo xng
chy. Trong tn thng tiu no, bnh nhn c th c ng hng nhng khi
a gt chn dc xng chy th bc l r tht iu, gt chn trt ra ngoi hai
bn cng chn (khi nhm mt lm nghim php trn, ri lon khng tng
thm). Trong tht iu do ri lon cm gic su ca bnh tabs, bnh nhn a
gt chn qu mc cn thit ri mi t chn xung xng bnh ch, a dc
xng chy s chch hng (nhm mt khi lm nghim php cc ng tc s
bc l ri lon hn)
Lt p bn tay lin tip: bnh thng nhp nhng, nhanh nhn. Khi thc hin
ng tc kh khn, ngng nghu th gi l mt lin ng, thng gp trong
hi chng tiu no (triu chng ch c gi tr khi khng c lit v khng c
tng trng lc c).
Du hiu Romberg: ngi bnh ng chm chn, mt nhm, hai tay a ra
pha trc. Romberg (+) ngi bnh s nghin ng, lo o, ri ng.
Tabs: ng bt c hng no.
Hi chng tin nh: lun ng v mt hng, hng ny ph thuc vo t
th u ngi bnh.
Vn ng bt thng
C nhiu loi vn ng bt thng khng t ch.
1. 4. 1 Nguyn tc khm:
Quan st bnh nhn lc ngh, hoc kch thch bnh nhn bng ba phn x
hay kim chm, nht l nhng loi vn ng c bin thp.
Ghi nhn tnh cht vn ng bt thng: a im, nhp iu, cng , thi
gian xut hin v nh hng ca bn ngoi.
Cc ng tc bt thng ch yu:
Run: l nhng c ng bt thng c bin u, u chi. Nhiu kiu run
nh bnh Parkinson, bnh tiu no, Basedow, ung ru, tui gi.
Co git: hin tng git c khu tr hay ton th, bin ln, tn s ln, tn
s thp. Thng gp trong bnh ng kinh, un vn, ur mu cao, sn git, st
cao tr em.
Ma nhanh: l nhng c ng hn n, v ngha. Bin ln, nhanh. in
hnh l cn ma nhanh Sydenham.
Ma vn: c ng chm, un ln, thng khu tr ngn chi trn.
Nghin cu mt vi dng i.
Dng i vng king (kiu pht c): Ngi bnh khng gp i li c (v
lit cng t th dui) nn i vt thnh na vng nh pht c. Trong trng
hp lit na thn v lit cng, nu co cng trung bnh th dng i kiu qut
t.
117
Trong lit cng hai chi di. Ngi bnh i c v hai i st vo nhau,
u gi va vo nhau, bn chn kh nht ln. Trong trng hp co cng qu
phi dng nng, hai chn lng lng nh qu lc ng h.
Dng i chm, hai tay dn st vo thn, khng c vung vy tay trong
bnh Parkinson.
Khm phn x.
Hot ng c bn ca thn kinh l hot ng phn x, l s p ng ca b
my thn kinh i vi nhng kch thch bn ngoi hoc bn trong thng qua
thn kinh trung ng. C nhiu loi phn x. Phn x qua ty nh phn x gn
xng, da, nim mc. Phn x c iu kin i qua no nh phn x Paplop.
y chng ta ch nghin cu phn x qua ty, cch khm v nh gi triu
chng lm sng.
2. 1 Mc ch v ngha ca khm phn x.
Khm phn x c ngha quan trng trong vic khm thn kinh v:
C ri lon phn x, chc chn l c tn thng thc th b my thn kinh.
i chiu cc khoanh phn x vi v tr khu tr ca phn x b ri lon, ta c
th bit c a im ca tn thng.
Ni ngi bnh thng:
Mi phn x u c mt a im gy phn x c nh v hu ht i xng
hai bn.
i vi mi phn x hai bn s tr li u nhau, khi cng kch thch
bng nhau.
Mi phn x tng ng vi 3 khoanh ty. Theo quy c ta ch dng khoanh
gia ch khoanh ty . Th d phn x bnh ch tng ng ty lng L
3,
thuc

khoanh ty L
2
L
3
L
4
.
Cc loi phn x thng thng
2. 2. 1. Phn x gn xng
Nguyn tc chung:
Ngi bnh t th thoi mi. Dng ba phn x c trong lng quy nh g
ng vo gn c v mng xng, khng g vo thn c.
Khm hai bn so snh, t trn xung di theo tnh t nht nh.
Ngi bnh mt phn x, phi chc chn ngi khng ln gn tc l khng
co c ch ng th triu chng mi c gi tr.
Trong trng hp ny ni chuyn vi ngi bnh.
Hoc lm nghim php Jendrassk (mc hai tay ko mnh trong lc thy thuc
g phn x bnh ch).
Khm mt s phn x chnh: khm t th nm hoc ngi.
Phn x gn xng chi trn
118
Phn x gn xng quay: a im g mm trm quay. Phn x xut hin
gp cng tay do co c nga di.
Phn x tam u: g gn c tam u, dui cng tay.
Phn x gn c nh u: gn c nh u, co cng tay.
Phn x gn xng chi di:
Phn x gn bnh ch: g gn t u i, ht cng chn ra trc.
Phn x gt: g gn gt, git c tam u cng chn.
Nhng thay i bnh l:
Tng phn x:
Co git on chi t ngt, mnh, bin rng. Mc cao hn l lan truyn,
v a ng.
Gi tr triu chng ca tng phn x: c tn thng b thp th n kinh trung
ng.
Thng tng phn x i i vi tng trng lc c, nhng trong trng hp
lit mm chuyn sang lit cng phn x tng nhng trng lc c gim.
Gim hoc mt phn x:
C khng git t no, hoc c git yu.
Gim hoc mt phn x gn xng, chng t c tn thng cung phn x.
C th gp tn thng b thp t ngt hay t ngang ty.
Phn x o ngc: g ng quy nh nhng chi git ngc

Phn x Ni kch thch Ni p ng Tng ty lin h Ghi ch
Tr trm St mu trm
xng tr
C tay
chuyn
trong
C8 Cnh tay na
gp, nga nh
Trm quay Trn mu trm
quay
C nga.
C nh u
cnh tay
lm cng
tay gp v
xoay nga
C5-C7 B xng
quay hng
ln trn
C tam u Gn c tam
u pha trn
khuu tay
C tam u
lm khuu
tay dui
C6-C8 Cnh tay, bn
tay a ra
ngoi
C nh u Gn c nh
u np cng
tay
C nh u
tay.
C cnh tay
C5- C6 Ngn ci t
gn c nh u
119
trc lm
khuu tay
gp
Gi Gn c t u C t u
i lm
dui gi
L3-L4-L5 Ngi thng
chn hoc
ngi bt cho
chn
Gt Gn Achille C tam u
i lm gp
lng bn
chn
S1-S2 Bnh nhn
qu gi, nu
nm sp hai
cng chn a
thng gc vi
ging
2. 2. 2. Phn x da, nim mc.
Phn x da.
Phn x da bng: dng vt nhn nhng khng qu st kch thch. C ba
trung tm khc nhau, da bng trn: kch thch trn rn, da bng gia: kich gia
rn, da bng di: kch thch di rn. p ng phn x c bng co git, rn
nh rm (co nhm) li.
Phn x da bu: Kch thch 1/3 trn mt trong i. Da bu co rm li, tinh
hon i ln trn. Gim hoc mt tc bnh l, c tn thng thn kinh.
Du Babinski (phn x da lng bn chn)
Kch thch dc b ngoi bn chn vng n cc np gp ngn chn. Phn x
xut hin l ngn ci v cc ngn khc cp xung trong trng hp bnh
thng. Bnh l l cc ngn ci dui ra, cc ngn khc xe ra nh nang qut,
du babinski (+) c gi tr tuyt i trn lm sng, chng t c tn thng thc
th b thp, nn thn trng khm I khm li nhiu ln. C nhng bin php
khc nhau pht hin tn thng b thp c gi tr nh Babinski, nh
Oppeheim, Gordon, Schaeffer, hoc chi trn c du Hoffman.
2. 2. 3. Phn x chng .
Phn x ny ch xut hin khi bnh l. Khi kch thch s xut hin thng
gp l du hiu ba co, gi l phn thu ngn, bn chn co vo cng chn, cng
chn co v i, i co vo mnh. y l hin tng t ng ty, do tn
thng t bo thn kinh trung ng, gp trong lit cng do p ty. C gi tr
chn on quyt nh v v tr tn thng, nu kch thch t di ln, ch no
khng xut hin du hiu ba co tc l gii hn gia ty b p v ch lnh.
Khm cm gic.
Cm gic c nhiu loi: cm gic ch quan v cm gic khch quan. Cm
120
gic khch quan gm cm gic nng v cm gic su:
Cm gic nng gm: s, au, nng, lnh do b Djerimi ph trch.
Cm gic su gm c cm gic t th, v tr, cm gic rung xng, nhn thc
vt, do b Goll v Burdach, cc b tiu no thng, cho ph trch.
3. 1. Pht hin ri lon cm gic.
Nguyn tc v k thut khm: phi lm ngi bnh an tm, v gii thch
trc khi khm.
Cn nm vng cc s vng cm gic, D
5

ngang v, D
10
ngang rn.
K thut khm:
Cm gic nng: cm gic s, dng bt lng qut vo trong vng da ngi
bnh. Cm gic au dng u kim chm vo da. Cm gic nng lnh dng ng
nghim ng nc ang tan v ng khc ng nc nng p vo da bnh
nhn.
Cm gic su: cm gic rung, khm bng cch dng m thoa, cm gic t
th, v tr, phn xc nh s cp (s), phn xc nh cao cp (nhn bit vt).
3. 2. Gi tr triu chng:
Cm gic nng: cn xc nh khu tr vng mt cm gic, thng th bnh
nhn b mt ba cm gic l s, au, nng lnh, nhng c trng hp cm gic
s vn cn, ch mt cm gic au v nng lnh, trng hp ny gi l phn ly
cm gic gp trong ng so ty (rng ng ty sng).
Cm gic su:
Cm gic t th, v tr: mt cm gic t th v tr thng gp trong bnh tabet
v cc tn thng khc sng sau ty sng, hi chng i th.
Nhn bit vt: ngi bnh khng nhn bit nng nh ca vt: tn thng
v no vng thi dong bn i din. Nu khng nhn bit c vt g tn
thng v no hay th trai.
Khm ri lon dinh dng v ri lon c trn.
4. 1. Ri lon dinh dng:
Cc bnh thn kinh c th gy ri lon dinh dng khc nhau: da, xng
khp, c. cc triu chng c th xut hin sm v c khi l triu chng quyt
nh trong chn on.
4. 1. 1 Ri lon dinh dng c: teo c
Cch khm: ri lon dinh dng c hay gp v kh tm nguyn nhn, nn
ch khi khm: cch xut hin, tin trin nhanh hay chm, mc teo, v tr
teo c, tnh cht i xng, v c co git si c hay khng, cui cng khm
thn kinh ton b, c bit ch : phn x gn xng, phn x c, cm gic.
Nu c iu kin tm phn ng thoI ha in. Khm xt cho ta nhn nh teo
c do thn kinh hay do bnh c.
121
Gi tr triu chng ca teo c do thn kinh: teo c do thn kinh c triu
chng teo ngn chi, rt hay gp c th c co git, c ri lon phn x gn
xng, thng c ri lon cm gic theo khu vc cm gic ca r hoc dy
thn kinh hoc khu tr ngn chi nhiu hn gc chi, c phn ng thoi ha
in. Gp trong bnh thn kinh do tn thng t bo thn kinh ngoi bin:
Teo c do ty tn thng sng trc.
Teo c do r v dy thn kinh.
Teo c do ty:
Tin trin nhanh, gp trong bi lit tr em, vim no khu tr thp, chy
mu trong ty.
Tin trin chm: teo c n thun in hnh c hi chng Aren Duchenne
teo c bn tay ri teo c cng tay, co gn bn tay ging bn tay kh. Teo c
phi hp vi hi chng thp gp trong bnh x cng ct bn teo c ca
Chacot; hoc bnh x cng tong m. toe c phi hp vi hi chng tiu no
gp trong bnh ng so ty (syringomyelie) vi phn ly cm gic. Khu vc teo
c phn x gn xng mt.
Teo c do r v dy thn kinh: teo c i xng, ngn chi, mt phn x gn
xng, ri lon cm gic khch quan v ch quan, khng bao gi c th c
git. Phn bit gia teo c do r hoc dy thn kinh nhiu khi kh, phi chc
d ty sng nu c thay i nc no ty chc chn c tn thng r thn
kinh.
4. 1. 2. Ri lon dinh dng da:
Ta ch nu mt s ri lon c gi tr chn on hoc tin lng:
Ri lon c gi tr chn on: nh bnh lot g bn chn hoc bn tay. u
ngn tay hoc ngn chn b ct, gp trong bnh hi v ng so ty.
Ri lon c gi tr tin lng: trong lit na ngi gy lot xng cng ct.
4. 2. Ri lon c trn
Rt hay gp ri lon c trn trong bnh thn kinh giai on cui. N thng
gy bin chng nhim khun, nhim c, nn n c yu t tin lng bnh.
4. 2. 1. Ri lon c trn bn quan v hu mn:
Nhng ri lon kn o nh i kh, i rt hoc khng nhn i c.
Nhng ri lon r rt nh b i, i vi, i t ng.
Ri lon i tin: b i tin hoc i tin vi.
Gi tr triu chng:
Bnh thng tr em hot ng c trn bng quang v hu mn c tnh cht
t ng theo c ch phn x. trn 2 -3 tui ngi ta c th iu khin c i
tin nh v no. Cung phn x ca tiu tin v i tin l: S
3
S
4
.
Ri lon c trn bng quang, hu mn hay gp trong cc bnh:
122
Tn thng no do hn m cc loi, x cng ng mch no, cc u no tiu
thy k gia, thy trn trc, no tht bn.
Tn thng ty: tn thng cc trung tm phn x lng cng, c bit cc
tn thng vng phnh tht lng v vng nn tn. Thy trong bnh t ngang
ty, vim ty ct ngang cp v mn tnh, p ty cp do u c, p ty tin trin
chm. Trong trng hp c bit nh lit hai chi di nu c ri lon c trn
thi chc chn do tn thng trung ng, nhng trong hi chng uI nga l
lit ngoi bin, ngi bnh c b i, b a.
Trong tabet v trong lon thn kinh nh hysteria cng nh ri lon c trn.
4. 3. Ri lon sinh dc
Lit dng
Lnh kh
Gp trong tn thng xm phm n trung tm cng dng ty cng hay cc
trng hp lit khc. V cn gp trong cc bnh lon thn kinh.
TI LIU THAM KHO:
- Ni khoa c s, tp I, Nh xut bn Y hc H Ni, 2001, tr 283-372.
- L Vn Thnh (1992), Triu chng hc, Bnh hc thn kinh, Nh xut bn Y hc
chi nhnh TP H Ch Minh, tr 9-103.
- Barrity M., Bonniot R. (1960). Examen neurologique, neurologie, huitime partie ,
smiologie cours de clinique mdicale, pg 272-287.
- Hauser L. Stephen & Beal M. Flint. (2006). Neurologic disorder, Part XV,
Principales of endocrinology, Harrisons Prniciples of Internal medicine, Mc Graw
Hill 16
th
edition, pg 2339-2349.

123
K KH H M M B B N NH H N NH H N N N N I I T TI I T T

MC TIU:
1. Tnh by c c im khi khm bnh ni tit
2. Trnh by c cch khm lm sng ton thn: hnh dng, cn nng, chiu cao,
da lng tc.
3. Trnh by c cch khm cc b phn: tuyn gip, tiu ha, tm tinh thn kinh,
tun hon, vn ng, sinh dc. . .
4. Trnh by c cc phng php thm d hnh thi tuyn ni tit.
5. Trnh by c cc phng php thm d chc nng tuyn ni tit: cc thm d
tnh v thm d ng.
NI DUNG:
1. i cng
Tuyn ni tit bao gm nhng tuyn tit ra cc hormon, mi hormon mang tnh
cht ho hc c hiu cho mi tuyn, vi mt liu lng rt nh, cc cht ny vo
mch mu v cc tn mch, hoc khong gian bo, kch thch cc m (t chc)
trong c th.
Ngoi cc tuyn ni tit kinh in, cn c h thn kinh ni tit, l vng di
i v cc nhn trn th.
Hin nay cn c h thng ni tit lan to, gp ng tiu ho ng mt, tu.
ng h hp, b my sinh dc, tuyn v. . , chng va c vai tr ni tit va cn tit
(paracrine: tit ra t m m m n to thnh), cc cht ny cn cha r v chc
nng, tnh c hiu, v c mt phn nh thuc h thng ni tit lan to c gi l
APUD (Amine Precursor Uptake and Decarboxylation), cc hormon ny c sinh ra
t cc apudoma, l cc t bo t u ca tuyn tu, tuyn thng thn, tuyn gip, cc
u t bo hc t, u t bo m thn kinh, u nguyn bo thn kinh.
Bnh ni tit c th do ri lon ca 1 hay nhiu tuyn. Cc ri lon ni tit
thng biu hin trn lm sng l tnh trng cng hoc suy ca tuyn, v vy c s
thay i tuyn v hnh th, kch thc v mt , ng thi bao gi cng c thay i
v hnh dng, ton trng ca bnh nhn.
Cc tuyn ni tit thng nm su trong c th v thng nh (tr tuyn sinh
dc, tuyn gip) nn kh khm trc tip, v li nhng thay i sm chc nng tuyn
ni tit l nhng bin i v th dch v sinh ho.
Do khi khm tuyn ni tit phi t m, ton din, kt hp vi cc phng
php thm d tuyn. Ngy nay nh cc phng php thm d hin i nh: X quang
chp ct lp t trng, sinh ho, cc nghim php thm d tuyn, phng php min
dch phng x, chng ta c th kt hp cc phng tin trn chn on cc ri lon
tuyn ni tit mt cch y .
124
2. Khm lm sng
2. 1. Quan st hnh dng ngi bnh.
a s cc bnh ni tit u c nh hng n hnh dng chung ngi bnh. Cn
ch cc im sau.
Nhn chung bit
T th lc ngh ngi, lc i li.
Hnh dng mt, thn, cc chi.
Mu sc v tnh cht ca da.
Nhiu khi nhn gip ta ngh n bnh no ca tuyn ni tit nh thay i
mt (nt mt c bit ca bnh to cc vin cc, trn v, da kho ming dy v xp np,
mt to ra, cm bnh. . ), mt li trong bnh Basedow
Chiu cao
o chiu cao ngi bnh, so snh tng ng vi tui, c gi tr tr em v
ngi tui tr. ng thi phi o cc xng di, o vng u, o vng ngc. . , nh
gi s cn i gia cc b phn.
Cn nng
Thay i cn nng xy ra cc giai on bnh, thi gian xut hin v cc iu
kin xut hin ca gy v bo.
Gy: khc vi gy t nhin lp m v c pht trin cn i, gy do bnh l lp m v
c pht trin rt km. Trong bnh Simmonds, ngi bnh gy ton thn da bc xng.
Bnh thng gp nh Basedow, i tho ng tp 1.
Bo: c th bo ton thn hay ch mt s b phn c bit l mng, i, mt, bng v
ngc. Nh bo mt v thn trong ph sinh dc. Trong h/c Cushing bo tp trung mt,
thn cn t chi li teo (tr gc chi).
Da, lng, tc, mng
Da: xem thay i mu sc, s xut hin cc mng sc t cc ni ci tay, cc np gp
c nch bn, cc ng nt lng bn tay.
Nhit da nh nng, ra m hi nhiu trong Basedow v ngc li trong suy
gip trng da lc no cng kh, r nht bn tay, bn chn.
Xem nim mc mi, m, li: sm nim mc cng sm da thng gp trong bnh
Addison.
Lng tc mng:
Tc, lng mi, lng my d rng trong suy gip trng, tha trong suy sinh dc,
rng nhiu trong simmonds. Cc triu chng trn kt hp vi da xanh thiu mu gp
trong hi chng Sheehan. C khi rm lng nhiu, ng thi mc nhiu mn trng c
hay gp trong hi chng Apert Gallais.
Ru mc n trong bnh Cushing, nam khng c ru trong suy sinh dc.
Mng d gy trong suy gip. Rng mc km hay su trong suy cn gip, d
125
rng, c vim li trong i tho ng, rng tha trong bnh to vin cc
(Acromegalie).
2. 2. Khm cc b phn
B my sinh dc
Chc nng: phi hi k v kinh nguyt. Ngy bt u c kinh, vng kinh, tnh trng
kinh. Hi k v s ln sinh, sy thai, cn nng ca con.
Khm b phn sinh dc: n b xem kch thc v tr l m o, mi to, mi b, m
vt, tnh trng m o t cung v. Trong h/c thng thn sinh dc th m vt to ra. n
ng xem kch thc dng vt, v tr ln, s lng tinh hon, hi tnh trng tnh dc
c ri lon khng. Teo sinh dc thng thy trong h/c Klinefelter v h/c Turner.
Khm tuyn gip
Nhn: Thy to v di ng theo nhp nut, to ton b hay tng phn.
S v o tuyn gip: bnh nhn ngi t th thoi mi, ni nhiu nh sng, u hi
nghing ra trc, cm hi nga. Ngn ci v ngn tr vo thanh qun v c c n
chm, sau bo ngi bnh nut s thy di ng theo nhp nut. Xc nh th tch,
gii hn ca tuyn. Mt tuyn nhn hay g gh. Mt chc cng hay mn. Tuyn to
ton b hay c nhiu nhn. Nu l bu mch c th s c rung miu tm thu hay
lin tc.
Ngi ta thng o tuyn gip bng dy vng qua ch to nht ca tuyn.
Nghe: ch nghe trong trng hp bu mch, c ting thi tm thu hay lin tc, nm
nghe r hn ngi.
B my tun hon
Cn ch n cc triu chng:
Huyt p: o cao hay thp. Tng huyt p c th thy trong bnh cng tu v v
thng thn, bnh Basedow. H huyt thy trong bnh Addison, suy gip trng.
Tim: thng b nh hng n c tim v ng mch vnh
Basedow c triu chng nhp tim nhanh, khi c bin chng c ri lon nhp tim, suy
tim.
Suy gip, suy tuyn yn: nhp tim chm.
Bnh ph nim (myxoedem), tim to hay trn dch mng ngoi tim.
ng mch vnh x ho trong i ng.
B my tiu ho
Khu v: chn n trong bnh Simmonds, Sheehan. An nhiu trong bnh a ng,
Basedow.
Cc ri lon thn kinh thc vt rut v d dy: To bn trong suy gip, a chy
trong Basedow.
B my vn ng
Long xng: trong Cushing lm xng d gy t pht.
126
Mt calci: trong cng cn gip.
Thoi khp: trong i ng.
S pht trin ca xng: chu nh hng khng nhng ca cn gip trng, m cn c
oestrogen, androgen, corticoid.
Tnh trng th lc v tinh thn
Th lc: li hot ng trong suy gip trng. C lc gim dn trong Addison.
Tinh thn:
Tr nh, tr thng minh km pht trin lm bnh nhn chm chp, li suy ngh, khng
tp trung t tng trong suy gip. D xc ng, hay lo s, ni nhiu trong Basedow.
Cc biu hin lm sng nu trn ch gip ta nhiu trong hng chn on
bnh, nhng chn on chnh xc, chng ta phi lm cc xt nghim thm d v
hnh thi v chc nng ca tuyn ni tit.
3. Cc phng php thm d tuyn ni tit
3. 1. Thm d hnh thi
Tu hng chn on ban u m t ta p dng cc phng php khc nhau
nh gi hnh th ca tuyn ni tit b bnh, c khi pht hin c tn thng di cn
m lm sng khng pht hin c.
Cc phng php thm d hnh thi gm: Xquang, chp ct lp t trong, siu
m, chp x k (hnh) bng phng x.
Chp X quang thng:
Chp nghing s xem h yn rng ra trong u tuyn yn (bt din tch # 100-120mm
2
,
di #12mm, rng # 8-10mm).
Chp vng thng thn pht hin nt vi ho Addison.
Chp ct lp c bm hi sau phc mc pht hin u thng thn.
Chp UIV xem i b thn b di lch trong U thng thn.
Chp t cung vi cn quang bit hnh thi t cung, vi trng thng khng.
Chp u xng xem im ct ha, xut hin sm trong bnh Basedow tr em,
xut hin mun trong suy gip.
Chp ct sng v h thng xng xc nh long xng v xp ct sng trong
cng v thng thn, bnh Hand-Schuller-Christian.
Chp ct lp t trng
Ngy nay phng php thm d ny gi mt v tr quan trng trong vic pht
hin bnh tuyn ni tit, trn 90% ca bnh c pht hin v nhng bin i hnh thi.
Chp k x
Chp k x tuyn gip nh gi s tp trung ca I
131
ti tuyn.
Chp thng thn bng radio cholesterol hoc bng I
131
19 iodo cholesterol
pht hin u thng thn.
Siu m
127
Siu m c th gip nh gi hnh thi, khi lng mt s tuyn ni tit nh
tuyn gip, tuyn thng thn.
Chp ng mch
Trong u v thng thn c th chp ng mch ch bng hoc ng mch
thng thn thy hnh thi tuyn.
i vi u tu thng thn, c th thy tn thng tn to, nm vng thng
thn hoc ngoi thng thn, phng php ny c th gy c cao huyt p hoc sc.
Chp tnh mch.
Chp tnh mch thng dng thm d tuyn thng thn, nh hnh nh cn
quang thy trc tip c tuyn, phng php ny cn gip ly mu nh lng ni
tit t t tuyn, c gi tr cao hn nh lng ni tit t mu ngoi bin.
3. 2. Thm d chc nng tuyn
Cc xt nghim thm d chc nng tuyn ni tit gi vai tr quan trng. Trong
hu ht cc bnh ni tit khi mi pht bnh, ch c ri lon th dch l xut hin, nn
phi nh lng cc ni tit t.
Thm d tnh
C 3 cch nh gi chc nng tuyn ni tit.
nh lng cc ni tit t
nh lng nng cc ni tit t thng xy ra hai tnh hung: nng tng
trong cng tuyn v ngc li gim trong suy tuyn.
Cortisol mu tng trong bnh Cushing, gim trong Addison.
T3, T4 tng trong Basedow, gim trong suy gip trng.
TSH, ACTH tng trong u lnh hoc ph i tuyn yn, gim trong suy tuyn
yn.
nh lng ni tit t i hi cc k thut cao, ho cht c tin, nht l trong
cc bnh tuyn yn.
nh lng cc dn xut ca chuyn ho ni tit ra nc tiu
nh lng 17 OH Cetosteroid trong nc tiu l cht chuyn ho ca cortison.
Cht ny tng trong Cushing, cng v thng thn sinh dc. Gim trong Addison.
nh lng VMA (Vanyl Mandelic Acid) chuyn ho t catecholamin, n tng
trong u tu thng thn.
nh gi cc tc dng sinh hc ca ni tit t:
Mi ni tit t u c tc dng c hiu cho mi cht trn t bo ch.
o chuyn ho c bn (CHCB) tng trong Basedow gim trong suy gip trng.
ng huyt tng trong i ng gim trong u lnh ui tu.
nh lngNa, Cl, K nh gi chc nng hot ng ca aldosteron. Na, Cl
tng v K h trong h/c Conn (cng aldosteron), ngc li Na, Cl h v K tng trong
Addison.
128
Cc thm d ny t gi tr, ch gi , v vy cn kt hp vi cc thm d ca
chnh ni tit t .
Thm d ng
Nh s hiu bit v c ch Feed-back (iu khin ngc) vic thm d hot
ng ca tuyn ni tit gip nh gi tnh trng bnh l r rng hn.
C hai loi nghim php i lp nhau: Nghim php c ch v nghim php
kch thch
Nghim php c ch
Nghim php Liddle, trong chn on bnh Cushing, dng dexamethason c kh nng
km hm (c ch) vng di i khng cho tit ACTH (adreno corticotrophin hormon)
n kch thch v thng thn tit cc ni tit:
nh lng 17- OH corticoid v 17- Cetosteroid trong nc tiu.
Hai ngy u ung 0, 5mg mi ln, 4 ln trong 24gi. Hai ngy tip theo
2mg/ln, 4 ln ngy.
nh lng 17- OH corticoid trong nc tiu v 17- Cetosteroid ngy th 3 v
th 5.
Nu vi 2mg/ ngy c hin tng km hm (lng 17- OH corticoid v 17-
Cetosteroid trong nc tiu gim nhiu) khng phi cng v thng thn kiu
Cushing.
Nu vi 8mg/ ngy mi c hin tng km hm, ngh n h/c Cushing do qu
sn v thng thn.
Nu khng c hin tng km hm, ngh n kh nng u v thng thn, hoc
thiu nng vng di i yn.
Nghim php dng metopyron, thm d s tit ACTH ca tuyn yn. Metopyron
cn tr s tng hp cortisol giai on hp S.
Xt nghim nc tiu 17-cetosteroid v 17 OH corticoid 3 ngy trc, sau :
Cho bnh nhn ung 2 ngy metopyron, mi ngy 4, 5g (750mg/ln, 4 gi 1 ln).
Xt nghim nc tiu 17-cetosteroid v 17 OH corticoid 2 ngy sau khi ung
thuc.
Bnh thng 17-cetosteroid tng 100-150% v 17 OH corticoid tng 100-200%
so vi trc khi ung metopyron.
Ni ngi suy tuyn yn khng thy thay i g hoc ch tng nh khi suy tuyn
yn nh.
Nghim php kch thch
Nghim php vi corticotropin (Synacten).
nh lng cortisol trc v sau khi tim bp 25mg Synacten 30 pht.
Bnh thng cortisol tng 50-100% so vi ban u. Trong bnh Addison do suy
tuyn thng thn, nn synacten khng kch thch lm tng cortisol so vi ban u.
129
Nghim php Querido kch thch tuyn gip bng TSH.
Chp k x ln 1 ta c tp trung I
131
cao mt nhn nng tuyn gip, cn
vng tuyn gip chung quanh tha tht do b c ch.
Chp k x ln th hai sau khi tim TSH 300 n v trong 3 ngy.
Kt qu nu vng tuyn b c ch ln trc nay nh kch thch bng TSH li tp
trung gn nh nhn nng, ta ni nghim php Querido dng tnh v kt lun l u
c tuyn gip.
nh lng cc khng th tuyn ni tit
nh lng khng th khng gip trng: LATS (Long Acting Thyroid Stimulator) y
l globulin. Ngy nay LATS l hai cht TSI (Thyroid Stimulating Immunoglobuline)
v TGI (Thyroid Growth Immunoglobuline).
nh lng khng th khng t bo Langerhans: xut hin phn ln bnh nhn i
ng tp 1, do nguyn nhn t min.
Thm d v di truyn
Yu t di truyn ng vai tr c ngha trong bnh sinh ca nhiu bnh ni tit
v chuyn ho.
Xc nh nhim sc th s lng, hnh th trong mt s bnh ni tit: Dng cht bt
mu gii tnh xc nh tiu th Barr trong nim mc ming. Trong h/c Turner, khi
bt mu tiu th Barr nhn t bo nim mc ming m tnh trong 80% cc trng
hp ( ngi bnh thng khi bt mu dng tnh n v m tnh nam). Trong hi
chng ny nhim sc th gii tnh loi XO.
Trong hi chng Klinefelter, cht bt mu gi tnh thuc XXY.
Nhm bch cu: ngy nay ngi ta cho rng nhm bch cu th hin tnh mn cm vi
trong mt s bnh: Nh i ng tp 1, lin quan vi HLADR
3
, DR
4
,

DR
8
.
Xc nh t bo
Xc nh t chc t bo gip chn on xc nh trong cc bnh.
Hashimoto, thy thm nhim t chc lympho tuyn gip.
Trong vim tuyn gip Riedel thy t chc x pht trin rng tuyn v st
tuyn.
Trong mt s u tuyn nh thng thn, bung trng, gip trng xc nh u
lnh hay c. /.
TI LIU THAM KHO:
- Ni khoa c s tp II. Nh Xut bn Y hc H Ni, 2001.
- Nguyn Thy Khu, (2003) Ni tit hc i cng NXBYH, . Trang 335.
- Thi Hng Quang, (2001) Bnh ni tit. NXB Y hc, H Ni.
- Fitzgerald A. Paul, (2004), Endocrinology, Current medical diagnosis & treatment. -
Forty-third edition by Lange Medical Books/McGraw-Hill, page 1063-1143.
130
- Jameson J. Larry, (2005), Principales of endocrinology, Harrisons Prniciples of
Internal medicine, Mc Graw Hill 16
th
edition, pg 2067-2075.

K KH H M M H H V V N N N NG G ( (K KH H M M K KH H P P) )
MC TIU:
1. Trnh by c cc triu chng lm sng mt bnh nhn b bnh khp
2. Trnh by c cch pht hin mt khp b vim
3. Trnh by c cch pht hin mt trn dch khp gi
4. Trnh by c cc bin chng thng gp mt bnh vim khp: cng khp,
bin dng khp, lch trc.
5. Trnh by c cc cn lm sng thng thng mt bnh khp: xt nghim
mu, dch khp, x quang thng.
6. Trnh by c cch khm cc khp thng gp au khp trn lm sng.
NI DUNG:
1. i cng: Cc bnh ca b my vn ng nht l khp v xng gp mi la
tui nht l tr em v ngi ln tui, bnh l h c xng khp chim n 12%
trong nhn dn; v trn 50% nhng ngi trn 60 tui, thng do h khp gp c
nam v n, y l nguyn nhn ph bin gy au nhc khp v lm gim vn ng
ngi gi, do vy khm nh k cho ngi gi, hng dn ch n ung v cc t
th trong sinh hot v lao ng l cn thit lm gim t l bnh thuc h vn ng
ngi gi. Nhiu bnh khp v bnh ct sng c lin quan n gii, tui, c a v
tnh cht di truyn th d vim khp dng thp thng gp ph n tui trung nin,
bnh gt ch gp nam gii trn 30 tui do lin quan n li sng ca nam gii hay n
nhu qu nhiu, bnh vim ct sng dnh khp gp nam gii c tnh cht di truyn.
Qua nghin cu nh gi thc trng v sc kho sinh sn ca ph n mn kinh
tnh Daklak nm 2002 ca TS. Nguyn Xun Thao cho thy gn 50% ph n
mn kinh b au khp (40, 4%) v c 35, 2% c triu chng thoi ho khp.
2. Triu chng lm sng:
2. 1. Triu chng chc nng:
2. 1. 1. au khp:
L du hiu hay gp nht, phi xc nh v tr v ngi bnh c th khng phn
bit c au ngay ti khp hay cc phn cnh khp nh c, xng, dy
chng: v tr au phi ng v tr ca khp. Cn phn bit triu chng au khp
vi cm gic mi c v khp l du hiu thng thy cc bnh ton thn nh
cm, st rt, thiu mu. . .
2. 1. 1. 1. au do vim:
C tnh cht: au lin tc, c xu hng tng nhiu v m, km theo cc triu
chng khc ca vim nh nng, v sng khp. Gp trong vim khp.
131
2. 1. 1. 2. au khng do vim:
au tng khi vn ng, gim v ht khi ngh ngi. Gp trong thoi ho khp.
2. 1. 2. Hn ch vn ng:
Bnh nhn t cm thy khng lm c mt s ng tc ca khp nh khng
nm c bn tay, khng co c cng tay, khng gi tay ln cao, khng ngi
xm c, khng ci xung, quay c c. . nhng hn ch ng tc c nhiu
nguyn nhn gy nn nh au do vim khp, do dnh khp, do cc tn thng
thn kinh, c, xng. . Cn thm khm k tm nguyn nhn gy hn ch vn
ng.
2. 1. 3. Du hiu cng khp bui sng:
L mt du hiu c bit, khi mi ng dy ngi bnh thy khp cng , kh
vn ng, ch sau mt thi gian mi thy khp mn tr li, d vn ng hn. Hay
gp du hiu ny 2 bn tay v khp gi. Cng khp bui sng ch c gi tr khi
ko di trn mt gi. y l mt trong nhng du hiu c hiu ca bnh vim
khp dng thp.
2. 1. 4. Du hiu ph g khp:
Khc vi cng khp bui sng, du hiu ph g khp hay gp trong thoI khp.
Lc mi ng dy hoc mi khi ng sau mt thi gian ngh ngI dI, thy khp
vng v kh vn ng, nhng ch sau vI ng tc khi ng th du hiu ny
mt I ; ngi ta v nh khp b g v cc ng tc khi ng ph nhng cn
g ca khp.
2. 1. 5. Cc du hiu khc:
Mt s du hiu c th gp khi thm khm:
2. 1. 5. 1. Du lc rc (lo xo):
Khi vn ng khp ku lc rc, thng khng c ngha v tn thng ca
khp, c th thy trong thoI ho khp gi.
2. 1. 5. 2. Du hiu bt l xo:
Gp mt s ngn tay, khi gp hoc dui ngn thy kh v cng, ch sau khi c
th bt c ra mt cch t ngt v nhanh, du hiu bt l xo gp trong vim
bao gn gp ngn tay.
2. 2. Triu chng thc th:
Khi khm phi ci b qun o, bc l ton b cc khp cn khm. Cn so snh
2 bn, so snh tng phn v so snh vi ngi lnh.
2. 2. 1. Sng khp:
L hin tng khp to hn bnh thng, sng khp c th do nhng thay i ca
u xng, sn khp hoc do nhng tn thng ca phn mm quanh khp (bao
khp, mng hot dch, gn, dy chng. . ); Tr khp hng su kh quan st,
phn ln cc khp khi sng u c th khm thy.
132
Ta chia hai loi sng khp ty theo c biu hin vim hay khng:
2. 2. 1. 1. Sng khp do vim hay vim khp:
Khp b vim c sng, nng, , au, c th c nc trong khp.
2. 2. 1. 1. 1. Vim cp:
Du hiu sng nng au nhiu, nht l vim do vi khun sinh m, vim do
tinh th (bnh gt, vI ha sn khp), thp khp cp. V sng au nhiu nn hn
ch vn ng mi ng tc.
2. 2. 1. 1. 2. Vim mn tnh:
Mc sng au va phi, du hiu nng kn o, gp trong hu ht cc bnh
mn tnh (vim khp dng thp, vim ct sng dnh khp, gt mn tnh, lao
khp)
2. 2. 1. 2. Sng khp khng do vim:
Khp sng do nhng thay i ca u xng, sn khp, bao khp, phn mn
quanh khp. . m khng c phn ng vim.
Nhng thay i y l kt qu ca hin tng mc thm xng trong
thoi khp, nhng tn thng lon sn xng, sn, nhng di chng chn thng,
nhng bnh ri lon chuyn ha (gt, bnh alcapton niu. . ). Khp sng to, c
th li lm, khng u, khng cn xng, khng nng, khng v t au.
2. 2. 1. 3. V tr khp sng:
Rt quan trng, v tr khp b vim gi cn bnh v d:
Vim cc khp bn ngn chn ci, c chn: ngh nhiu n bnh gt.
Cc khp nh c tay, bn ngn tay, khp ngn gn y l v tr c bit ca
bnh vim khp dng thp.
Vim cc ct sng lng, khp hng 2 bn: ngh nhiu n vim cng ct sng
2. 2. 1. 4. S lng khp b vim:
Cng rt quan trng, gi cn bnh, ngi ta chia ra 3 loi:
2. 2. 1. 4. 1. Vim a khp: Khi vim t 4 khp tr ln, gp trong cc bnh vim khp
dng thp, bnh gt mn tnh, luput ban . .
2. 2. 1. 4. 2. Vim mt khp: thng l vim khp nhim khun.
2. 2. 1. 4. 3. Vim vi khp: t 2 n 3 khp, gp trong bnh vim khp phn ng, thp
khp cp.
2. 2. 1. 5. Tnh i xng ca khp vim:
Tnh i xng ca khp vim cng l mt tnh cht gi chn on cn bnh v
d: vim khp dng thp c tnh i xng, cc khp vim ca bnh vim khp
phn ng khng c tnh i xng.
2. 2. 1. 6. Din bin ca vim khp:
2. 2. 1. 6. 1. Vim khp di chuyn:
Tnh trng vim t khp ny chuyn sang khp khc, th khp c khi, l din
133
bin in hnh ca thp khp cp.
2. 2. 1. 6. 2. Vim khp tin trin:
Vim nng dn ln mt khp ri pht trin sang cc khp khc, l kiu din
bin ca vim khp dng thp.
2. 2. 1. 6. 3. Vim ti pht tng t:
Vim khp tin trin mt thi gian ngn ri ht hn vim, mt thi gian sau li
tI pht vn v tr khp b vim c, y l cch din bin ca bnh gt cp tnh,
thp khp cp.
2. 2. 1. 6. 4. Vim c nh mt v tr:
Thng l vim do vi khun
2. 2. 2. D dng v bin dng khp:
Nhng d dng l kt qu ca cc bnh bm sinh v d trt khp hng bm sinh.
Nhng bin dng l kt qu ca nhng bnh mc phi nh chn thng, vim
khp. . n lm thay i trc khp
2. 2. 3. Nhng thay i v ng tc:
Khm cc ng tc phI so snh hai bn hoc so snh vi ngi bnh thng.
Khi khm ng tc ca mt khp, phi ch n tt c kh nng vn ng ca
khp nh gp, dui, khp, dng, xoay. . v nn dng mt thc o gc
nh gi kh nng vn ng.
2. 2. 3. 1. Hn ch ng tc:
Mc nng nht l hn ch hon ton, ch c nh t th nht nh, thng l
hu qa ca dnh khp hon ton: hn ch c ng tc ch ng ln th ng.
Hn ch vn ng mt phn hoc hn ch mt s ng tc c th do tn thng
khp, hoc cc phn mm quanh khp hoc do thn kinh: ch hn ch ng tc
ch ng nhng hot ng th ng vn bnh thng
2. 2. 3. 2. Khp lng lo:
Cc khp c ng tc vi bin ln hn bnh thng, c th ch l tnh trng
sinh l do luyn tp, gim trng lc c trong bnh l thn kinh, do bnh khp
mn tnh lm gin cc dy chng v bao khp (vim khp dng thp)
2. 2. 4. Tm im au:
Khi thm khm khp, cn tm cc im au ca khp, mi khp c mt s Im
au c trng v d khp vai c im n qu, im rnh c nh u. Cn phn
bit cc im au ca khp vi vi im au ca cc u gn, li cu nm ngoi
khp.
2. 2. 5. Cc phng php lng gi du hiu au khp:
2. 2. 5. 1. nh gi bng thang nhn:
Trn mt thc vch 10 , bnh nhn t xc nh au no: ( l khng
au, 10 l au ti a khng chu ni)
134
2. 2. 5. 2. Ch s Ritchie:
nh gi bng dng c t nn vo khp: dng mt que cng c u trn, n vo
khp vi mt p lc nht nh, nu au nhiu: 3 im, au va: 2 im, au t: 1
im, khng au: 0 im.
2. 2. 5. 3. Ch s Lee:
nh gi bng cc kh nng lm cc ng tc sinh hot hng ngy: cm, nm, I
li. . v cho im. Nu au nhiu th khng lm c cc ng tc
2. 2. 5. 4. nh gi mc au bng s ln thc gic trong m, bng sc bp ca bn
tay, bng s thuc gim au dng trong ngy.
2. 2. 6. Cc du hiu khc:
2. 2. 6. 1. Cc u quanh khp: cc t phy, ht Meyne, ht di da.
2. 2. 6. 2. Cc nang kn ni to khp do phnh bao hot dch
2. 3. Triu chng ton thn:
2. 3. 1. Nhit , huyt p, cn nng, hnh dng.
C nhiu bnh khp c biu hin ton thn nh st, gy st, thay i hnh dng.
Trong qu trnh khm bn nhn b khp phi ch khai thc.
2. 4. Khm cc b phn lin quan:
Rt nhiu bnh ni khoa c biu hin khp v cng c nhiu bnh khp c du
hiu cc b phn khc, do vy vic thm khm cc b phn khc l cn thit
khi chn on mt bnh c du hiu khp.
2. 4. 1. Khm c:
Phn ln cc bnh khp mn tnh u c teo c vng tng ng.
2. 4. 2. Da v nim mc:
Ch tm cc tn thng da v nim mc nh vy nn trong bnh vim khp
vy nn, ban hnh cnh bm mt trong bnh luput, da dy trong bnh x
cng b. .
2. 4. 3. Cc ht ni di da quanh khp:
Ht Meynet trong thp khp cp, ht tophi trong bnh gt, ht di da trong bnh
vim khp dng thp.
2. 4. 4. Mt:
Nhiu bnh khp c tn thng mt, vim kt mc trong hi chng Reiter, vim
mng mt th mi trong bnh vim khp mn tnh thiu nin. . .
2. 4. 5. Thn kinh, thn, tim mch:
Cc bnh thn kinh gy mt cm gic su u gy nn tn thng khp, nhiu
bnh khp gy tn thng thn nh bnh gt, luput ban , tn thng tim trong
bnh thp khp cp.
3. Triu chng cn lm sng:
Trong nhng nm gn y nhng tin b v cc phng php xt nghim v
135
thm d nh chp ct lp vi tnh, chp cng hng t ht nhn, ni soi khp, . .
gip cho vic chn on sm nhiu bnh khp.
3. 1. X quang:
Nhiu ngi coi X quang c mt vai tr rt quan trng trong chn on bnh
khp v ct sng, nhng tht ra phng php x quang c nhiu hn ch v khp
c cu to bi 2 phn: phn u xng (cn quang) v phn mm k c sn
khp (khng cn quang); do ch c nhng thay i ca phn u xng mi
thy c trn hnh nh x quang.
Hin nay c nhiu phng php chp X quang: chp thng, ct lp, chp sau
bm thuc cn quang vo khp, MRI
Nhng tn thng c bn v X quang ca khp v ct sng gm:
3. 1. 1. Nhng thay i v xng:
Bin dng ca u xng, ca thn ct sng; mt cht vI hay long xng, c
xng hay x xng di sn; Mc gai xng, cu xng; Hnh khuyt, hc,
nham nh bo mn; Ln xng, ln ct sng, xp ct sng; Hnh nh di lch,
lch trc.
3. 1. 2. Nhng thay i ca khe khp.
Khe khp l khong thu quang gia 2 u xng, thc t y l phn sn khp,
(hay da m) v khng cn quang nn khng nhn thy cu trc trn phim.
3. 1. 2. 1. Khe khp hp:
Do sn khp b tn thng. Cc bnh vim khp v thoI ha khp ko dI u
gy tn thng sn v lm hp khe khp.
3. 1. 2. 2. Khe khp gin rng:
Trn dch khp, hay gp khp gi.
3. 1. 2. 3. Dnh khp: Khi sn khp b ph hy hon ton, phn u xng di sn
tip xc trc tip vi nhau v dnh lin, c th c cc di x ni lin 2 phn
xng. Thoi khp khng bao gi dn n dnh khp.
3. 1. 3. Nhng thay i ca din khp:
Din khp l phn xng di sn khp ; ct sng l mt trn v di ca
thn t sng. Din khp thng thay i mun sau nhng tn thng ca sn
khp. Tn thng din khp t nh n nng l: hnh nh din khp m, khng
r nt; nham nh, hc v khuyt u xng, phn di thy hin tng c hay
x xng, khi b dnh khp th khng cn thy din khp 2 pha na.
3. 1. 4. Nhng thay i phn mm quanh khp:
Trong lao khp v lao ct sng c th thy hnh nh p xe lnh quanh vng tn
thng. Mt s bnh khp c th thy hnh nh vI ha bao khp, dy chng
(bnh vim ct sng dnh khp).
3. 2. Ni soi v sinh thit khp:
136
3. 2. 1. Ni soi l phng php a ng soi vo khp nhm chn on v iu tr:
Quan st cu to, mu sc ca mng hot dch v sn khp, hng dn kim sinh thit
ly phn m bnh l chn on m hc.
Ra khp Iu tr.
Ct b nhng dy chng x dnh, ly d vt.
3. 2. 2. Sinh thit:
Dng kim sinh thit chc vo khp ly mt mnh mng hot dch khp chn
on v m hc.
3. 3. Xt nghim dch khp:
Hu ht cc khp u c bao bc bi mt mng hot dch, bn trong cha mt
cht dch nhy gi l dch khp; dch khp c tit ra t mng hot dch c
nhim v lm trn khp khi vn ng v nuI dng sn khp. S lng dch
khp ty thuc vo tng khp t 0, 5 n 4ml. Tnh cht vt l v thnh phn cu
to ca dch khp thay i trong phn ln cc bnh khp, do bng cch chc
v xt nghim dch khp c th gip chn on xc nh bnh.
3. 3. 1. Dch khp bnh thng:
3. 3. 1. 1. Tnh cht vt l: Trong, khng mu hoc hI vng, nht nh lng trng
trng, PH=7, 4.
3. 3. 1. 2. T bo: C t 300 n 500 t bo / 1mm3, ch yu l bch cu a nhn
trung tnh v t bo mng hot dch.
3. 3. 1. 3. Thnh phn ha hc: Protein: 2gr%, lng mucin (a. hyaluronic): 300mg%,
lng glucose gn bng mu.
Nghim php ng mucin (mucin test): dng 1ml dch khp trn 4ml nc ct,
nh vo 0, 13ml dung dch acid acetic 7N. Bnh thng thy mucin ng vn x
x trong nn nc trong, lc khng tan, ngi ta gi phn ng ng vn tt l
bnh thng.
3. 3. 2. Dch khp bnh l:
3. 3. 2. 1. Chy mu khp:
Gp trong chn thng hoc cc bnh v mu: dch khp c mu .
3. 3. 2. 2. Vim khp m:
Dch khp nhiu, c m mu vng hoc trng c, nht gim, mucin test
khng kt vn, T bo > 10. 000/ml a s l bch cu thoI ho, c s hin din
ca vi khun gy bnh.
3. 3. 2. 3. Vim khp do lao:
Dch khp nhiu mu vng nht, nht gim, mucin test khng kt vn, s
lng t bo > 5000/ml c nhiu t bo lympho, t bo khng l, cht b u, vi
khun lao BK.
3. 3. 2. 4. Vim khp dng thp:
137
Dch mu vng nht, nht gim, ng vn gim, t bo > 1000/ml, c t bo
hnh nho trn 10% l nhng bch cu a nhn trong bo tng c cc ht nh,
trng nh mt qu nho c nhiu ht, nhng ht nh l cc phc hp khng
nguyn- khng th m bch cu thc bo, phn ng Waaler Rose (+). B th
gim.
3. 3. 2. 5. Thoi khp:
Dch khp t, gn nh bnh thng mu vng nht, Mucin test ng vn gim, s
lng t bo khng tng 500/ml, c th thy cc tinh th calci, cc mnh v ca
sn trong dch khp.
3. 3. 2. 6. Bnh gt:
Dch khp mu vng chanh, ng vn gim, s lng t bo>1000/ml, dch khp
c tinh th urat l nhng tinh th hnh kim, hai u nhn.
3. 3. 2. 7. Hi chng Reiter:
Dch mu vng chanh, mucin test c gim ng vn, T bo >1000/ml c nhiu
t bo ht vi l hnh nh virut b thc bo bi bch cu
3. 4. Cc xt nghim nh gi hin tng vim trong khp:
Nhng xt nghim ny nhm pht hin c phn ng vim hay khng, mc
vim v theo di din bin ca qu trnh vim.
3. 4. 1. Cng thc mu: Thay i ty nguyn nhn ca vim khp
3. 4. 2. Tc lng mu: tng trong hu ht cc bnh vim khp
3. 4. 3. Si huyt: bnh thng 300- 350mg%, tng trong hu ht cc bnh vim khp.
Tng trong hu ht cc bnh vim khp
3. 5. Cc xt nghim c bit:
3. 5. 1. Cc khng th khng lin cu:
Tng trong bnh thp khp cp: Khng Streptolysin O: ASLO, bnh thng c
150 n v % mu, tng khi >200 n v /100ml mu.
3. 5. 2. Yu t dng thp:
Trong mu bnh nhn vim khp dng thp, c globulin min dch c kh nng
ngng kt vi gama globulin v c t tn l yu t dng thp, bn cht n l
mt IgM, C 2 phng php xt nghim. Phn ng dng tnh xut hin mun
khi bnh gn 1 nm, mc dng tnh khng tng ng vi mc nng
nh ca bnh.
3. 5. 2. 1. Waaler Rose: Dng hng cu ngi c nhm mu 0, Rh(-), gn gama
globulin th mn cm vi hng cu ngi cho vi huyt thanh bnh nhn,
nu c yu t dng thp th thy ngng kt hng cu. Phn ng coi l dng tnh
khi ngng kt pha long huyt thanh < 1/ 16.
3. 5. 2. 2. Gama latex:
Dng cc ht nha latex c gn gama globulin vi huyt thanh bnh nhn <
138
1/32.
3. 5. 3. T bo Hargraves v khng th khng nhn.
3. 5. 3. 1. T bo Hargraves hay t bo L. E:
c tm thy trong mu v ty ca bnh lupus ban h thng. l nhng
bch cu a nhn c ht vi i kim kh ln trong nguyn sinh cht, y nhn ra
ngai bin, bn thn ht vi ny l mt nhn ca t bo b thoI ho.
3. 5. 3. 2. Cc xt nghim khng th- khng nhn, khng th RANA. . . v cc xt
nghim min dch khc
Cc phng php xt nghim min dch ny gp phn chng minh sinh bnh hc
ca cc bnh khp v a ra cc yu t chn on v phn loi bnh.
3. 5. 4. Nhng xt nghim tm nguyn nhn:
3. 5. 4. 1. Ngoy hng tm lin cu trong thp khp cp.
3. 5. 4. 2. nh lng acid uric trong mu v trong nc tiu chn on bnh gt,
bnh thng a. uric niu t 300n 500mg/ 24 gi, acid uric mu < 6mg%.
3. 5. 4. 3. Phn ng tuberculin dng tnh mnh trong lao khp.
3. 5. 5. H HLA v cc bnh khp:
S lin quan gia H thng khng nguyn bch cu ngi ny vi cc bnh khp
c tnh di truyn l mt trong nhng tiu chn gip chn on bnh. v d cc
bnh nhn b vim ct sng dnh khp thng c HLAB27, vim khp dng thp
c HLADR60. . .
4. Phng php thm khm lm sng mt s khp v khm ct sng
4. 1. Thm khm khp hng:
Bnh l khp hng rt phong ph, gp mi la tui do nhiu nguyn nhn khc
nhau nh chn thng, thoi ha, lon sn, vim. .
4. 1. 1. Hi v cc du hiu c nng v tin s:
4. 1. 1. 1. au: thng vng bn, c th vng mng, mu chuyn ln. au lan
xung mt trc i, c th xung mt sau v ngoI i.
4. 1. 1. 2. Hn ch vn ng: Bnh nhn thy kh ng lu, ngi xm b hn ch, bc
ln bc cao gy au.
4. 1. 1. 3. i khp khnh: Xut hin sm, Lc u xut hin khi i mt on xa.
4. 1. 1. 4. Hi v tin s: Ch cc tin s v chn thng, nhim khun, cc d tt
bm sinh trong gia nh.
4. 1. 2. Thm khm lm sng:
4. 1. 2. 1. Quan st:
4. 1. 2. 1. 1. T th ng thng: nu tn thng khp hng nng, s thy bnh nhn
nghing v bn lnh, cc c bn bnh c th teo, nho.
4. 1. 2. 1. 2. ng mt chn (nghim php Trendelenburg): v au bnh nhn khng
ng c chn bn bnh, nu ng chn bn bnh th khung chu s lch
139
nghing v pha bn lnh.
4. 1. 2. 1. 3. Ngi xm: chn bn bnh thng khng co st vo bng c, nu bnh
nng, bnh nhn khng th ngi xm c.
4. 1. 2. 1. 4. Dng i khp khnh ca tn thng khp hng, khi bc ln bc thang
chn bn bnh nhc ln chm v kh.
4. 1. 2. 2. S nn tm cc im au, tm hch to v khm cc c quanh khp
4. 1. 2. 3. Khm cc ng tc l khu quan trng nht, khm cc t th ng, nm
nga v nm sp, c th x dng thc o gc nh gi kh nng vn ng c
th
4. 1. 2. 3. 1. Yu cu bnh nhn thc hin mt s ng tc c tnh cht tng hp
nh gi s b: ci ngi ra trc, ging 2 chn, ngi xm
4. 1. 2. 3. 2. Ln lt khm cc ng tc:gp, dui, khp, ging v quay. Thng
khm vi t th bnh nhn nm nga. Cc gc hot ng ca khp hng bnh
thng: Gp chn dui: 90 , gp chn gp: 120 , Dui c: 30 , Khp: 35
, Ging vi chn dui thng: 45 , Ging vi chn gp: 90 , Quay ra: 40 ,
quay vo: 45
4. 2. Khm khp gi:
Bnh l khp gi rt phong ph, a dng v thng gp trong lm sng.
4. 2. 1. Hi bnh:
4. 2. 1. 1. au: ch khai thc v tr v tnh cht ca au.
au do vim th lin tc v tng v m.
au c gii (thoi ha) tng khi vn ng, khi ln hoc xung cu thang v
gim au khi ngh ngi, Cn phn bit au xng chy hoc au xng i vi
au khp gi
4. 2. 1. 2. Hn ch vn ng: th hin bng cc ng tc i, ng, ngi xung v ng
ln, mt s trng hp c du hiu ph g khp.
4. 2. 1. 3. Ting lo xo khi vn ng: t gi tr trong chn on
4. 2. 1. 4. Ch khai thc tin s bnh: chn thng, bnh v mu, bnh khp trc
y.
4. 2. 2. Quan st:
Quan st nhng thay i v da, phn mm v hnh thi khp gi: sng ty
trong vim khp m, thp khp cp; sng to cng trong trn dch khp gi; ni u
phnh to trc xng bnh ch, vng kheo do cc kn hot dch thot ra ;
mc cc u cc quanh khp trong bnh gt, mc gai xng trong thoI ho.
Quan st hin tng teo c quanh khp.
T th bnh nhn ng thng: pht hin cc d dng khp gi v xng. Tt
khp gi lch vo trong, ra ngoi; xng chy bin dng trong bnh ci xng.
4. 2. 3. S nn:
140
*Tm cc im au: li cu ca xng chy v xng i
*Di ng xng bnh ch: bnh nhn nm nga, chn dui thng, dng cc ngn
tay nm xng bnh ch t 3 pha, ri di ng sang hai bn v di ng dc theo
trc chn, nu c thoi ho khp gi bnh nhn s thy au v cm gic lo xo
khi di ng (du hiu bo g)
*Bp bnh xng bnh ch v du ba ng: Khi khp gi c nhiu dch s c hai
du hiu ny. Bnh nhn nm nga, chn dui thng, thy thuc dng 5 ngn tay
t ln xng bnh ch, ngn tay tr ngay trn mt xng, ngn ci v ngn 3
hai bn b ngoi v b trong xng bnh ch, khi ngn tr n nh xung, ta c
cm gic xng bnh ch chm nh vo xng pha di v nc dn ra xung
quanh (du hiu bp bnh xng bnh ch hay chm xng bnh ch) nu lng
nc nhiu, ta g nh ngn tay 3 s thy c cm gic nc di vongn cI (du
hiu ba ng).
*Du hiu rt ngn ko: Bnh nhn ngi, cng chn vung gc vi i chn. Tay
tri thy thuc c nh pha di i chn, tay phI thy thuc nm chnbnh
nhn ngay phn trn cng chn, ko cng chn bnh nhn v pha thy thuc.
Bnh thng cc dy chng gi c khp gi tt nn ta khng ko ra c, nu
ko ra c cht t gi l khp lng lo.
4. 2. 4. Khm cc ng tc: yu cu bnh nhn lm cc ng tc gp, dui khp gi
ch ng v th ng. Khi khp gi tn thng, hot ng gp dui s hn ch.
Ngc li khi c hin tng dn dy chng s c du hiu khp lng lo c th
hin bng du rt ngn ko v lc lc cng chn
4. 3. Khm khp vai:
Khp vai c kh nng lm nhiu ng tc nht trong c th. Khp vai c mt bao
khp rt rng v lng lo. S vn ng khp vai c s tham gia ca 3 khp
xng v 2 khp xng c: khp cnh tay- b; khp b- lng ngc; khp n-
b; khp c delta- cnh tay v khp c n. Khp vai c tng cng bi nhiu
gn, dy chng v c nhiu mi lin quan n m ri thn kinh cnh tay, chui
hch giao cm c, nh phi, ct sng c.
Bnh l ca khp vai phn ln do nhng tn thng ca phn mm quanh khp;
nhng thng tn thc s ca khp vai rt t gp.
4. 3. 1. Hi bnh:
4. 3. 1. 1. au:
Khp vai c biu hin au nhiu v tr: mm vai, vng xng b, khp c n,
Hng lan ca au c th i xung cnh tay, ln gy v vng chm, au nhiu v
m.
4. 3. 1. 2. Hn ch vn ng khp vai: bnh nhn kh lm mt s ng tc nh chi
u, gi lng, gi tay.
141
4. 3. 1. 3. Hi tin s.
4. 3. 2. S nn: tm triu chng nng ca du hiu vim khp, vim c vng vai.
4. 3. 3. Khm cc ng tc ca khp vai: khm cc ng tc ch ng v th ng ca
khp vai gm:
*Gi tay ra trc, ra sau, ln trn
*Khp tay vo, ging tay ra, ln trn
*Nhn vai ln, h vai xung, a ra trc v ra sau.
*Quay vng trn.
4. 3. 4. Khm cc b phn lin quan
*Teo c vng b vai v cnh tay gp trong vim khp vai ko di.
*Ri lon vn mch bn tay: ph n, teo t, co. . trong hi chng vai gy.
*Cc tn thng ct sng c, cc ni tng trong lng ngc c th c lin quan
n khp vai (hi chng au vai do h ct sng c, do ung th ph qun, nhi
mu c tim)
4. 4. Khm ct sng
Ct sng l ct tr nng v lin kt cc phn ca c th ; ct sng c mi lin
quan mt thit vi ty sng v cc r thn kinh t ty I ra do nhng bnh l
ca ct sng va gy ra du hiu ti ch va c hi chng r thn kinh.
4. 4. 1. Khai thc triu chng c nng, bnh s, tin s:
4. 4. 1. 1. au:
*V tr: au mt Im hay lan to; au ngay ct sng hay hai bn ct sng.
*Hng lan ca au.
*Din bin ca triu chng au, ch du hiu p hay kch thch r thn kinh:
au tng tri ln v lan theo cc r thn kinh khi ho, ht hI, rn mnh (lm tng
p lc ng sng.
4. 4. 1. 2. Hn ch ng tc:
C th hn ch hon ton lm cho mt on ct sng thng khng th lm
c bt k ng tc no; hoc hn ch mt phn: kh ci nht mt vt thp, kh
quay u. . Hn ch ng tc c th do tn thng ca ct sng, nhng cng c
th do tn thng cc phn quanh ct sng gy nn (c, dy chng. . )
Nhng du hiu km theo:
*Hi chng p r, chn p ty: au v lit vng cnh tay: au v lit vng cnh
tay, ri lon c trn, lit 2 chn
*Ch khai thc cc du hiu ton thn nh st, gy st.
4. 4. 2. Quan st v cu to v hnh thi ct sng.
4. 4. 2. 1. Da, t chc di da v khi c cnh ct sng. .
4. 4. 2. 2. Quan st hnh thi ct sng:
*Mt ng cong sinh l: 2 on cong ct sng c v on tht lng li ra trc
142
c th b thay i gp trong vim ct sng hoc do phn ng co cng c cnh ct
sng.
*G: lng cong nh hnh cnh cung gp trong bnh lon sn ct sng lng, long
xng ; G nhn c mt nh nh cao l di chng ca chn thng hoc vim ct
sng nhim khun.
*Vo: nhn t pha sau thy ct sng cong sang mt bn. Vo thng l hu qu
ca tn thng mt bn ct sng, hoc l mt d dng bm sinh.
4. 4. 3. S nn:
4. 4. 3. 1. Tm cc im au ct sng kt hp vi g vo cc gai sau ca t sng
4. 4. 3. 2. Tm cc du hiu li t sng ra pha sau: dng ngn tay cI vut nh t
di ln dc theo cc gai sau ct sng. Bnh thng ngn tay i t di ln
khng b vng, khi c mt t sng li ra pha sau, ngn tay s vp vo phn gai
sau li ra, c th gp trong lao ct sng.
4. 4. 3. 3. S nn khi c chung cnh ct sng tm cc tn thng vim hoc u.
4. 4. 4. Khm cc ng tc ca ct sng.
4. 4. 4. 1. Ct sng c:
*Khm cc ng tc: t th ngi ngi bnh lm cc ng tc ch ng v nu
cn thy thuc lm cc ng tc th ng: ci, nga, nghing 2 bn v quay 2
bn.
*Khong cch chm tng: ngi bnh ng p lng vo tng, chn thng,
bnh thng khong ny = 0. Khi c tn thng ct sng c hay lng th chm
khng st c vi tng. o khong cch ny c th nh gi mc ca bnh.
4. 4. 4. 2. Ct sng lng:
o gin lng ngc: dng thc dy o vng ngc lin sn 4, so snh 2
mc lc th ra c v lc ht vo c. Bnh thng lng ngc gin c t 4 n
6cm. Khi c tn thng vng ct sng lng, gin lng ngc s gim.
4. 4. 4. 3. Ct sng tht lng:
*Khm cc ng tc ci, nga, nghing v quay.
*Nghimphp tay t: Bnh nhn ng thng t t ci xung pha trc, khp
gi gi thng, bnh thng bn tay chm t. Khong cch gia bn tay v mt
t s nh gi mc nng nh ca tn thng.
*o gin tht lng: Bnh nhn ng thng, ngi ta vch mt ng ngang
qua t sng tht lng 5 (ngang 2 mo chu), o ngc ln 10cm ri vch ng
ngang th hai; cho bnh nhn ci xung, chn vn gi thng. Khi ci n mc
ti a, ta o li khong cch gin ra thnh 14-15cm. Khi c tn thng vng tht
lng th gin tht lng gim.
TI LIU THAM KHO:
- Ni khoa c s Trng i hc Y H Ni- NXBYH, 1997. Trang 377-404.
143
- au lng mn tnh, Nguyn th Thn- NXBYH, 1999.
- Bnh hc Ni Khoa, H Khp Trng i hc Y H Ni, NXBYH, H Ni, 2002.
Trang 282, 290.

K KH H M M V V C CH H N N O O N N S S T T

MC TIU:
1. Trnh by c c ch bnh sinh iu ho thn nhit v hin tng st
2. Trnh by c cch khm, pht hin v theo di bnh nhn b st
3. Trnh by c chn on st v cc dng st
4. Trnh by c cch tm nguyn nhn ca st. Cc kiu din bin ca st.
NI DUNG:
Thn nhit c iu chnh mt cch cht ch gi cho chc nng t bo ca
cc c quan hot ng bnh thng, c bit l no. Tng hoc gim nhit trn 4

C
so vi bnh thng c th e do s sng ca t bo. S iu chnh thn nhit c
kim sot bi vng di i duy tr cho c th c mt khong thn nhit nht nh.
H thng thn kinh t ng ng vai tr kho trong qu trnh gi thn nhit bi s
iu ho lu lng mu khi c th tip xc vi s gia tng nhit bn ngoi lm tng
tit tuyn m hi. S gia tng tun hon v gin cc mao mch s lm tng s to nhit
ra bn ngoi, v do lm tng s bc hi ca m hi nn lm gim thn nhit. S
thch nghi ny cng quan trng, trong mi trng nng bc c th tr nn t hot ng
tm bng rm hoc ch im mt hn. Khi thn nhit gim c th chng li bng cch
tng nhit lng c th nh hot ng ca c khi run v tm cch mt m v tm n
ni m p hn.
Nhit bnh thng c th: hng ngy thn nhit thay i, thn nhit gim thp
nht khong t 3-4h sng, tng chm dn ln ti a lc khong 8-10h m, iu ny
cn thit gi thn nhit sut m. Tnh trng thay i nhit ny tip din tng
ngy theo nhu cu ca c th.
Trong cng mt lc, nhit c th khc nhau nhng vng khc nhau: nhit
lng c to ra do cc phn ng ho hc ca chuyn ho t bo, v vy nhit
chch lch t cao nht gan v thp nht da. Thng thng nhit c o hu
mn, ming, hm nch, tai, bn v hng. Gia nhng v tr ny nhit hu mn cao
hn ming v bn khong 0, 3

C, nch thp hn ming 0, 5

C.
Nhit c th duy tr khong t 36 n 37, 5 thay i khong 0, 6. St khi
nhit ly ming trn 37, 5, ly hu mn trn 38. Nhit h kh xc nh,
nu ly ming khi ng di 35.
1. C ch bnh sinh
1. 1. C ch iu ho thn nhit
144
- Sinh nhit: sinh sn nhit lng do phn ng oxy ho t chy cc protein, cht bo,
cc hydrate carbon, cc phn ng ny chu chi phi ca tuyn gip trng, gng sc,
hay run.
-Gim nhit: nh i lu, pht x v bc hi.
-Cc qu trnh ho sinh hoc l sinh trong sn nhit v gim nhit t di s kim
sot ca trung tm iu ho thn nhit no, vng di i.
1. 1. 1. Tng nhit do ri lon iu ho thn nhit
- Cc bnh ca h thn kinh trung ng: tn thng ca cc trung tm Iu ho thn
nhit thng km theo tng nhit (khi u, tai bin mch mu no, vim no), trong
iu kin ny c mt giao ng nhit trong ngy nhng vn trong trng thi sinh l,
khng thot m hi nn cho thuc h nhit khng kt qu.
-Tng sn nhit lng: trong bnh cng gip do tng chuyn ho c bn thng km
theo tng thn nhit 1-2C.
- Gim kh nng tiu nhit lng: c hin tng thn nhit tng khi nhit bn ngoi
cao hn thn nhit, gp trong suy tim, mt s bnh ngoi da, bng rng, dng mt s
thuc khng tit cholin, cc cht phenothiazin.
- Say nng: khi nhit ngoi cao qu v khng kh li m cc trung tm Iu ho
thn nhit tr nn bt lc v thn nhit c th qu 41 nht l khi gng sc c bp
nhiu.
- Tng thn nhit c tnh: gp trong cc trng hp sau gy m ton thn ngi c
c a di truyn.
1. 1. 2. Hin tng st
Nhit tng ln do nhiu yu t lin quan n sc khng min dch, tc ng
mt phn cc trung tm iu ho thn nhit vng di i v mt phn ln cc t
chc ngoi bin. Cc cht sinh nhit l cc vi sinh vt, ni c t, phc hp khng
nguyn khng th, cc cht ny kch thch tn bo -i thc bo, cc t bo ny phng
thch cc cht cytokine gy st, cc cytokine gm IL-1 (interleukin-1), yu t hoi t
m (TNF), INF (interferon gamma), IL-6 (interleukin-6). Cc cht gy st ny tc
ng ln cc th th c hiu ca cc nron vng di i gii phng ra cc
prostaglandin v l ngun gc ca cc tn hiu dn n co mch, tng sinh nhit lng,
cui cng gy st.
1. 1. 3. Tc ng ca cc cht h st
Thuc c tc ng ln vng di i gy c ch tit prostaglandin v to iu
kin cho c th tang tiu nhit bng gin mch v tng tit m hi.
2. Khm bnh nhn b st
2. 1. Pht hin st
Bng nhit k, khng nn da vo cm gic ca ngi bnh hoc s da, s trn. Sau
khi xc nh c st, tip tc tm:
145
- Cch khi pht: t ngt, ang kho mnh t nhin st, nh st rt, st do cm cm,
vim phi. Hoc st xut hin dn dn sau mt thi gian mt mi, kh chu, thng
gp trong bnh lao, thp khp cp, thng hn.
- Tnh cht ca st: St c th triu chng n c, hoc c th km theo rt run, rt
run t trong vim phi, cm, nhng c th rt run tng ln lm bnh nhn phI p
chn trong cn st rt, nhim khun mu.
- Din bin ca st:
Lin tc: ng biu din trn bng nhit thnh hnh cao nguyn, nhit chnh
lch trong ngy khng qu 1, thng gp trong thng hn, vim phi.
Dao ng: y ng biu din thnh nhiu hnh thp trong qu trnh st gm
nhiu cn, gia cc cn nhit khng xung n mc bnh thng hoc xung n
mc bnh thng. Trong dng nhit khng xung n mc bnh thng, st vn
khong trn 37C, l loi st khng dt cn, gp trong nhim khun mu, vim
ng mt, vim b thn, cc nung m su. Trong dng nhit xung n bnh
thng, thy trn bng nhit xut hin tng cn r rt, in hnh loi st ny l st
rt cn.
Hi quy: C tng t st ko di vi ngy k tip nhau, gia cc t , nhit
bnh thng. in hnh ca dng ny l bnh st hi quy do xon khun.
2. 2. Pht hin cc ri lon chc nng km theo st
- Tnh trng tinh thn
Bnh nhn thng c nhng biu hin nh km theo, t c gi tr chn on nh
nhc u, hoa mt, chng mt, mt ng.
Nhng cng c nhng biu hin tinh thn kinh quan trng, cn tm hiu k v c
th gi chn on bnh nh m sng, hn m c cc ng tc bt thng nh tay bt
chun chun, cc cn co git. Cn co git thng xy ra tr em b st cao thuc
nhiu nguyn nhn khc nhau.
- Tnh trng tim mch
St c km theo nhp tim nhanh. Nhit tng 1C th nhp tim tng t 10-15
nhp mi pht. Tuy nhin bnh nhn thng hn, hay c hin tng nhit cao m
mch chm (phn ly nhit mch).
Trong st cn theo di cc triu chng v tim mch v hay c bin chng. V d
trong st xut huyt c th c sc, huyt p tt, rt nguy him. Hoc st v nguyn
nhn nhim khun nh thng hn, nhng li c bin chng xut huyt ni tng hay
thng tng rng nn c th mch tng nhanh, thay v mch chm.
St do thp tim c th km theo nga phi hoc ting thi ca bnh van tim, ting
c mng ngoi tim.
- Tnh trng h hp
St hay km theo tng nhp th, thn nhit tng 1C th nhp th tng 2-3 ln mi
146
pht. Trong ma ng nu c st v ho cn khm hng, ph qun, phi, nht l tr
em v ngi gi. Tr em cn quan st cnh mi php phng, mi tm c nguy c vim
nhim gy suy h hp. St bui chiu dai dng cn lu n lao phi, nn xt nghim
m tm BK, chp X quang phi.
- Tnh trng tiu ho
Nu st km theo biu hin ri lon tiu ho, cn xc nh chn on cc bnh
ng tiu ho nh l trc trng, hoc au vng gan cn cnh gic bnh p xe gan.
Nu ang st nhit t ngt tt xung v km a mu hay lng cn lu n bin
chng tiu ho ca bnh nhim khun. Nu s au u km nn khan, to bn nn tm
triu chng ca vim mng no.
- Cc biu hin khc
Trong khi st ngi bnh thng i t, nc tiu xm mu v khai. Sau khi sp
ht st, hi phc bnh nhn i nhiu hn. Hin tng i c nhiu thng l du
hiu tt chuyn sang giai on thuyn gim.
Cn xem bnh nhn c cc triu chng nh chy mu di da, nim mc, hoc
cc ph tng nh nn ra mu, a mu, i mu, chy mu cam, ho ra mu
2. 3. Pht hin cc du hiu thc th
Nn khm ton th pht hin cc triu chng nh ton thn, cc c quan b
phn, khng b st b phn no, khm cc cht thi tit v mt s dch th khc.
Mi triu chng ca mi c quan s l nhng du hiu gi c th nh hng
cho nhng xt nghim cn thit gip chn on xc nh bnh. Tuy nhin c khi du
hiu thc th khng c hoc khng r, lc ny xt nghim li ng vai tr rt quan
trng c th gip cho chng ta chn on.
2. 4. Xt nghim: Trong hu ht trng hp phi lm cc xt nghim sau y c
hng s b.
- Cng thc mu, tc lng mu: trong h/c nhim khun bch cu tng vi cng
thc bch cu c a nhn trung tnh tng v tc mu lng tng.
- Tm k sinh vt st rt: nht l cc ni c yu t dch t.
- Cy mu tm vi khun c bit bnh nhn st dai dng, tt nht l lc ang st v
cha dng khng sinh.
- Xt nghim huyt thanh chn on d pht hin mt s bnh truyn nhim, thng
hn, Martin petit, Weil Felix, Widalcc xt nghim ny ch dng tnh khi bnh
tin trin mt thi gian.
- Chiu chp phi tt nht l nhiu t th pht hin nhng tn thng nh.
- Cc xt nghim nc tiu nht l tm protein, t bo c khi gip pht hin mt bnh
thn v ng tit niu.
Khi lm sng c nghi mt bnh no m cc xt nghim trn cha gip chn
on, th phi lm cc xt nghim chuyn khoa su hn.
147
3. Tm nguyn nhn st
3. 1. Mi b st
Thng thng do cc nguyn nhn sau y:
- Nhim khun hng: vim hng, vim amydan. Bnh nhn au hng, nut kh v au.
Khm hng thy hng hoc amidan sng to c khi c m. Nu c nhng gi
mc trng, phi cnh gic vi bnh bch hu.
- Nhim khun ng h hp: vim kh qun, vim ph qun cp, vim phi, p xe
phi, lao phi, vim mng phi. Bnh nhn thng ho, au ngc, khc m, khc m,
khc mu, hoc m ln mu. Nghe phi s pht hin nhng du hiu c trng ca mt
s bnh v d cc ran phi hay ting c mng phi.
- Nhim khun gan nh p xe gan, vim mt qun, vim gan siu vi. C cc triu
chng au tc vng gan, c im au r rt gan to au, hong m.
- Nhim khun ng tit niu: vim b thn, vim thn bb thn cp, nung m thn,
p xe thn, vim bng quan. Thng km theo i but, i rt, ph, i t. Khm c
th thy du hiu chm thn, pht hin cc im au thn hay niu qun.
- Nhim khun no mng no do p xe no, vim mng no. Thng km theo nhc
u nn ma, i khi c cng, lit chi, co git, c du hiu thn kinh khu tr, nu nng
c th c hn m.
- Nhim khun c xng khp gp trong vim khp cc loi, vim c, ct tu vim.
Thng km theo au nhc xng khp, hn ch c ng, nhn thy sng nng au
ch tn thng.
- Nhim khun pht ban nh si, thu u, u ma. Thng km theo vim long
ng h hp, au mnh my, da mn hoc nc mng m.
- Thng hn giai on khi pht; st xut hin dn dn, mi ngy mt tng, sau 6-7
ngy nhit mi ln 39- 40 C. c bit nhit mch phn ly. Hay km chy mu
cam v ri lon tiu ho: bing n, bun nn, nht l tiu chy hay to bn. Khm thy
lch hi to, khm h chu phi c ting ng c. Trong thi k ny ch cy mu thy
trc khun Eberth mi xc nh c chn on.
- Bnh st rt: y st xut hin t ngt bng mt cn rt run ko di c khi ti 1-2
gi, sau nhit ln dn n 39- 40 C, c khi n 41 C, da nng ran. St ko di
na gi hoc vi gi, cn st gim nhanh, bnh nhn v m hi, nhit h, tinh thn
tr li tnh to, ch cn hi mt. Bnh km theo lch to v ang vng st rt lu
hnh, trng hp ny chng ta phi tm k sinh trng st rt trong mu mi chn on
chc chn.
- Cm: bnh nhn st, nhc u, au mnh, ho au hng s mi. Khm thc th khng
c triu chng g r rt, chn on da vo yu t dch t c dch lu hnh v sau khi
loi tr tt c cc nguyn nhn k trn.
- Nhng nguyn nhn khc ngoi nhim khun: say nng, say nng, st sau tim
148
chng, bng, chy mu, gy xng, chn thng, chn thng s no, cc bnh mu
c tnh, ung th, ri lon ni tit (cn cng gip), trc khi c kinh, dng khng sinh
lu ngy.
3. 2. St ko di
3. 2. 1. Thm khm lm sng
- Nu c lch to nn ngh n nhim khun mn tnh, leucemie, u lymph bo, bnh
tng vng (reticulose). Cc bnh h bch mch, h lymph.
- Nu c gan to nn ngh n u gan nguyn pht hay th pht, p xe gan u ng mt.
- Nu c ting thi tim, m do tn thng van tim, cnh gic vi bnh Osler (vim
ni tm mc bn cp). Nu thy tinh hon to v au, c th c u tinh hon, lao sinh
dc, tit niu.
Thm khm h tr b sung
- Khm y mt pht hin lao k.
- Thm trc trng xem c u tin lit tuyn, cc u vng trc trng. o in tim nu
nghi thp tim.
3. 2. 2. Xt nghim cn lm sng
3. 2. 2. 1. Siu m tim pht hin vim ni tm mc, ngoi tm mc.
3. 2. 2. 2. Siu m bng tm cc khi u bng hay sau phc mc. Soi trc trng sigma
pht hin u, p xe, vim i trng, lot, vim ti tha.
3. 2. 2. 3. X quang:
- Chp Xquang lng ngc tm lao phi, di cn ung th, sarcoidosis. Chp rut cn
quang nu nghi c ung th tiu ho, vim cui hi trng, vim i trc trng chy
mu.
- Chp Xquang ng tit niu c cn quang pht hin nhim khun tit niu mn,
hoc p xe thn.
- Chp X quang xng pht hin ct tu vim, u xng. Chp ng mt cn quang
pht hin bnh ng mt. Chp bch mch pht hin cc hch quanh ng
mch ch, khung chu hoc sau phc mc.
- Chp nhp nhy c quan (scintigraphie) nhm pht hin cc u, nhim khun. Chp
phi khi nghi c tc mch phi nhiu ni.
- Chp ct lp t trng bng khi cn pht hin chnh xc u hoc p xe cc tng hoc
sau phc mc, hch mng treo.
3. 2. 2. 4. Xt nghim mu:
- Huyt , tc mu lng, tm k sinh trng st rt khi nghi nhim khun,
leucemie, u ht (granuloma) di cn xng. Tm khng th khng nhn pht hin
luput ban ri rc bn cp.
- Tm yu t dng thp nu nghi vim khp dng thp.
- Cy mu trong iu kin a kh v k kh nu nghi nhim khun mu, vim ni
149
tm mc bn cp. Cy dch no tu tm nguyn nhn vim mng no do lao hoc vi
khun. Tm vi khun trong nc tiu khi nghi c nhim khun ng tit niu kinh
din.
- Lm phn ng ngng kt v cc phn ng huyt thanh trong trng hp nghi
thng hn, ph thng hn, bnh do Bricella. Phn ng Paul Bunnel Davidson
nu nghi bnh tng bch cu n nhn nhim khun. nh lng antistreptolysin O
trong trng hp thp khp cp.
3. 2. 2. 5. Tm amibe trong phn nu nghi c l amibe. Tm cc khng th AIDS nu
nghi c hi chng suy gim mc phi.
3. 2. 2. 6. Xt nghim t chc hc
- Sinh thit hch nu nghi u lympho, Hogdkin, u hch, di cn ung th, vim hch do
lao, bnh nm.
- Chc sinh thit gan pht hin ung th tin pht hoc th pht gan, lao gan, bnh
nm histoplasma, bnh brucella, bilhazia, sarcoidosis.
- Sinh thit Daniel chn on hch tung tht. Sinh thit ng mch thi dng nu
nghi c bnh Horton.
3. 2. 3. Cc bnh hay gy st ko di
3. 2. 3. 1. Nhim khun ton th
- Do vi khun: vim ni tm mc nhim khun, lao, Brucella, Salmonella, nhim mu
no m cu, nhim lu cu mu (listeria), bnh virus vt, st Q (do Rickettsia Barneti).
- Do xon khun: bnh do Leptospira, st hi quy.
- Do virus: n nhn nhim khun. Nhim virus Coxsrkie, AIDS.
- Do k sinh trng: amibe, st rt, Leishmania, Bilharzia, Toxoplasma, xon khun
trypanosom.
- Do nm: Histoplasma, cocidioidomyces.
3. 2. 3. 2. Nhim khun ti ch
- Bng: p xe vng bng, vim ti mt, vim ng mt, p xe gan, nhim khun vng
khung chu.
- Vng tit niu: vim b thn, vim thn b thn, vim ty quanh thn, p xe thn,
vim tin lit tuyn,
3. 2. 3. 3. Do ung th: cc ung th thn, gan, tu, phi, i trng, Ewing sarcoma. Di
cn ung th. Bnh mu c tnh nh leucemie, a u tu xng, Hdgkin, U lymph. Cc
ung th khc nh u hc t, sarcoma lan to xng.
3. 2. 3. 4. Bnh to keo, bnh h thng: lupus ban ri rc, vim nt quanh ng
mch, x cng b, vim a c, bnh lymph ht Wegener (vim mch mu, hoi t
dng u ht ng h hp trn v di). Vim ng mch t bo khng l (polymialgia
Rheumatica).
3. 2. 3. 5. Bnh khp do thp: thp khp cp, vim khp dng thp, Chauffar- still.
150
3. 2. 3. 6. St do dng thuc: dn xut t Hydantoin, allopurinol, barbituriate, phn
ng Herxheimer.
3. 2. 3. 7. Cc nguyn nhn khc cc nguyn nhn ny gy st t khi nh vim gip
trng bn cp, lon m ng rut, phng tch ng mch, mt s th x gan, u mch
sng ho, vim cui hi trng. St r hn nh vim cui hi trng, thiu mu huyt
tn, tc mch phi nhiu ni.
3. 2. 4. Cn lu nhng nguyn nhn hay gp nc ta
- Nu st ko di, nhit c ng biu din hnh cao nguyn cn cnh gic: bnh
thng hn, leptospirosis, lao, vim ni tm mcbn cp lot si.
- Nu nhit giao ng cn ngh n nhim khun mu do t cu, lin cu, no cu,
hoc cc vi khun khc. Cnh gic vi cc nung m su nh p xe gan, p xe di
c honh, nung m thn.
- Nu st c chu k cn ngh n st rt v st hi quy.
4. Kt lun:
- St l hin tng bnh l rt ph bin v l nhng phn ng ca c th i vi cc
tc nhn gy bnh.
- Chn on st d nhng tm nguyn nhn kh v quan trng v n quyt nh cho
hng iu tr. St ko di thng phc tp, kh gii quyt v nhiu nguyn nhn, v
vy mun chn on phi thm khm k, thng phi s dng nhiu xt nghim cn
lm sng.
TI LIU THAM KHO:
- Triu chng hc chung, (2003), St", Ni khoa c s, Trng i hc Y H Ni,
cc B Mn Ni. Nh xut bn Y hc, H Ni, Tr. 29-39.
- McPhee Stephen J. , MD, & Pignone Michael. MD, MPH, (2004), Fever &
hyperthermia, Current medical diagnosis & treatment. Forty-third edition by Lange
Medical Books/McGraw-Hill, page 22-24.
- LeBlond Richard F. DeGowin Richard L. Brown Donald D, (2004) Vital signs,
Anthropometric Data, and Pain", in DeGowin s Diagnostic examination, eight edition
International Edition, Printed in Singapore. page 59-67.

151
K KH H M M B B N NH H N NH H N N I I T TH H O O N NG G
MC TIU:
1. Trnh by mt s t l i ng Vit Nam v trn th gii.
2. Trnh by c triu chng lm sng v cn lm sng bnh i ng.
3. Trnh by c tiu chun chn on i ng theo T chc Y t th gii 1998.
4. Trnh by c cc bin chng cp tnh v mn tnh ca i ng.
NI DUNG:
1. i cng: i tho ng l mt hi chng bnh l biu hin bi tng thng
xuyn v mn tnh nng ng mu do thiu insulin tng i hoc tuyt i v tn
thng chnh tuyn tu hoc ri lon tit insulin, hoc do cc nguyn nhn khc nhau
nh bnh t min, di truyn, bin i gen, bnh ca cc tuyn ni tit khc (tuyn yn,
tuyn gip trng, tuyn thng thn).
y l bnh ri lon chuyn ho thng gp, t l hin mc thay i tu theo
chng tc, a d, li sng v tui, M t l mc bnh khong t 3-7%[ ], Chu u,
c: 2-5% [ ], Chu nh Singapore 4, 7%, Thi Lan 6, 8%, Vit Nam t 1, 44%-2,
52% [1]. Bnh c khuynh hng tng nhanh trong nhng thp k ti.
Bnh thng glucose mu c iu chnh trong khong 0, 8-1, 1 g % (4, 4-6, 1
mmol/lt, theo phng php Folin Wu). Theo T chc Y t th gii 1998:
Glucose mu khi i 6, 1 mmol/lt ( 110 mg %, 110 mg/dl) v 7 mmol/l ( 126
mg%, 126 mg/dl): c ri lon glucose mu khi i.
Glucose mu khi i 7 mmol/lt ( 126 mg/dl): ngh n i tho ng, chn on
ch c khng nh qua t nht 2 ln xt nghim.
Ri lon dung np glucose khi sau 2 gi ung 75 gam ng, glucose mu 140 mg%
(8 mmol/lt) v 200mg% (11, 1 mmol/lt).
S iu chnh ng mu gi mc c nh trn trong c th nh cc tuyn
ni tit:
Cc tuyn ni tit c cc kch thch t lm tng ng mu:
Tuyn yn.
Tuyn gip trng.
Tuyn thng thn.
Khi cc c hin tng cng cc tuyn trn, s c cc biu hin lm sng ring
bit cho tng tuyn, ngoi ra cn lm tng ng mu. Ngc li khi cc tuyn
thiu nng s lm h ng mu.
Duy ch c tuyn tu tng tit kch t lm h ng mu. Cc t bo trong o
Langerhans tit ra insulin lm h ng mu, v glucagon lm tng ng
mu nhng l tc dng th yu. Khi suy tu tng s gy tng ng mu,
ngc li khi tu tng hot ng cng gy h ng mu.
2. Triu chng v chn on i tho ng
152
2. 1. Triu chng Lm sng:
2. 1. 1. Hi bnh:
Hi xem cn nng ca bnh nhn c gim st nhiu khng? c th gim my
kg trong my thng gn y ? C cm gic mt mi ?
Hi xem bnh nhn c cm gic kht nc ?, ngy ung bao nhiu lt nc?,
c cm gic kh mi?, kh ming? o s lng nc ung mi ngy.
Hi bnh nhn tiu c nhiu khng?, s lng nc tiu my lt/ ngy?, Trong
mt m i tiu my ln? S lng nc tiu mi ln nhiu hay t?. o lng
s lng nc tiu mi ngy.
Hi bnh nhn n c nhiu? Ba n my chn cm?, ngy n my ln?
2. 1. 2. Khm bnh:
Cn nng bnh nhn bao nhiu, o chiu cao, o vng eo, vng mng, tnh ch
s BMI
o huyt p, nhn ng mch khyu tay tm du hiu git dy chung, s
mch mu thi dng tm du hiu dy thng, s cc ng mch chy trc,
ng mch chy sau, ng mch quay. . tm xem mch c yu, c x cng?
Bnh l mch mu ln: cc tn thng x va cc mch mu ln v va, gp
sm v nhiu bnh nhn T.
Suy mch vnh: au tht ngc, nhi mu c tim, vi c im l triu chng
ngho nn, kn o nn phi lm in tm mt cch h thng cc bnh nhn
T.
Hp hoc vim tc ng mch chi di gy au cch hi, hoc nng hn l
hoi t, nn phi bt mch chi, nu pht hin mch yu nn kim tra bng
Doppler,
Tai bin mch mu no thong qua hoc nhn no, xut huyt no.
Cao huyt p: rt hay gp bnh nhn T trn 40 tui v c ch cn cha
r.
Bnh l vi mch: cc tn thng mao mch c trng l dy mng y mao
mch khp c th, quan trng nht vn l y mt v cu thn.
Tn thng y mt do T l nguyn nhn gy m lo kh nhiu cc nc
ang pht trin. Gm 2 nhm chnh
Tn thng vng mc n thun: Vi phnh mch, xut tit, xut huyt, ph
im vng
Tn thng vng mc tng sinh: Mch mu tn to, vim y mt tng sinh,
c th t ngt chy mu trong thu tinh th, xut huyt nng trong vng,
bong vng mc, gim dn th lc.
* Cc tn thng mt khc: c thu tinh th, teo gai th, tng nhn
p mn tnh, lon mu
153
Cn lu : Nn ngh n v cn xt nghim xc nh chn on l i tho ng
khi bnh nhn c cc bnh cnh lm sng sau:
H/c lm sng c in ca i tho ng.
Bo ph (ch s khi, ch s eo/mng).
Nhim khun hay ti pht.
Mt s bnh tim mch (vim tc ng mch, nhi mu c tim, tng huyt p).
Tin s gia nh c ngi thuc trc h b i tho ng.
Ph n c tin s con trn 4kg, hoc thai cht trong t cung.
Xt nghim trong cc bnh cp tnh m c ng mu cao lc i, hoc c
ng niu dng tnh, hoc khi c tng triglycerid mu.
2. 1. 3. Khm tm cc bnh c th gy tng ng mu:
Bnh tuyn tu(vim tu mn, si tu, K tu).
Bnh ni tit (h/c Cushing, Acromegalie, Basedow, U tu thng thn).
Do dng thuc ko di nh: corticoid, li tiu thiazide, hormone tuyn gip
Mt s hi chng di truyn ca n nh: Down, Klinefelter, Turner, Wolfram.
2. 1. 4. Khm tm bin chng ca tiu ng:
Hi xem c triu chng nhim trng ng tiu nh tiu lu?, tiu but?.
Hi xem c triu chng au ngc?, c du hiu thiu nng vnh?
Hi cm gic t b, nhc mi chn?
Khm rng: xem rng c lung lay
o th lc, nu mt m cn soi y mt.
Khm bn chn xem c ch no au, mt cm gic? Lot gan bn chn: gim
nhn cm kiu bt tt ngn. Tng sng ho mnh bn chn, gia cc
mng sng ho c cc lot su.
Vim a dy thn kinh: Tn thng thng i xng, hay gp chi di,
vng ngn chi, ri lon cm gic, gim v mt phn x gn xng. Bnh l
thn kinh do i tho ng: Do tn thng cc mch mu nui thn kinh
(vasa nervorum) v ng sorbitol lm bin i cn bng trong t bo thn
kinh bao Schwan v gy tn thng t bo thn kinh ngoi bin v tk thc
vt. Nhng ri lon t bo thn kinh hay gp v cng rt sm. Thn kinh ngoi
bin: Tn thng mt dy hoc mt nhnh: xut hin au, cm gic au t
pht v thng xut hin ban m, i li c cm gic au, cm gic au
thay i: nh rt bng, kin b, kim chm, nng bng, hoc lnh gi, nhng
cm gic ny thng xut hin phn xa ca chi, cc ngn. Km theo l gim
phn x gn xng ri lit; Cc tn thng c th gp cc thn kinh s no
(III, IV, V, VI, VII) chi trn hoc chi di.
Tn thng thn kinh thc vt.
* Tim mch: H huyt p t th, nhp tim nhanh, mt thch nghi vi thay
154
i t th hay nhp th.
Ri lon tit m hi; cn v m hi.
Tit niu, sinh dc: Lit dng, xut tinh sm.
Tiu ho: y bng kh tiu, au d dy, a lng.
Cc bin chng nhim khun: rt thng gp, v l nguyn nhn gy t vong
nht trong iu kin Vit nam, Cn khm tm cc triu chng:
Nhim khun da, nim mc, mn nht, vim c, hu bi, vim m chn rng,
nhim khun c quan sinh dc ngoi, nhim khun nng bn chn, nhng
nhim khun ny dai dng, hay ti pht v nng nn cn iu tr sm.
- Nhim nm ming, np v, nch bn, m h, quy u.
- Nhim khun tit niu: triu chng kn o, vim bng quang, vim niu
o, vim thn b thn cp, thng ti pht, c th dn n vim i b thn mn
tnh ri suy thn. Vim b phn sinh dc.
- Lao hay thng gp bnh nhn T, c bit tp 1, triu chng kn o,
din bin tim tng.
C hn m do nhim toan-ceton?: cc du hiu bo trc nh mt mi, chn
n, au bng, bun nn, nn ma. Sau t t i vo l m, hn m. Tnh
trng ri lon tri gic ph thuc vo tnh trng mt nc do tng thm thu li
niu v nhim ceton. Nu khng iu tr kp thi s i vo hn m su. Hn
m tin trin t t khng c du hiu thn kinh khu tr, khng c co git- hn
m yn tnh.
Du hiu mt nc r v nng: mi kh, da kh, vo da (+), nhn cu mn,
tru mch.
Ri lon h hp kiu nhim toan: th su, c th ri lon nhp th kiu
Kaussmal, hi th mi aceton.
Xt nghim nc tiu c ceton nhiu, ng niu nhiu ng mu tng cao.
Gim Na
+
v K
+
mu, Hct v protid mu tng (v mt nc), tnh trng nhim
toan (d tr kim gim, pH mu gim <7, 3).
Hn m do tng thm thu.
Ch yu xy ra ngi c tui, T tp 2, t gp.
Triu chng lm sng: bnh nhn mt mi, l sau hn m, c du hiu
thn kinh khu tr, i khi c co git.
Mt nc ton thn rt nng, c th st.
Khng c du hiu nhim toan-ceton.
- Xt nghim: ng huyt thng rt cao 8g-15g/l, Na
+
v Cl
-
mu tng, p
lc thm thu tng> 350 mosmol/kg (bt 280-300)
Hn m do nhim acid lactic.
Rt him gp Vit Nam, tin lng nng, phn ln xy ra bnh nhn T
155
Iu tr bng Biguanid nht ngi c tui suy thn.
Triu chng lm sng:
hi pht t ngt, au lan to khp ton thn, au bng, au ngc, au c chut
rt.
Ri lon tiu ho: Bun nn, nn, a chy.
Ng g, c ng bt thng, mt thc, hn m tin trin nhanh n III.
Kh th nng kiu Kaussmal (nhim toan chuyn ho).
Mt nc ton th rt nng, tru mch.
Xt nghim:
Acid lactic tng cao t 2 mmol/l (18mg%) n 8 mmol/l hoc hn, nng a.
lactic cng tng tnh trng hn m cng nng v khng hi phc. Bnh thng nng
a. lactic trong mu l 0, 62-1, 33 mmol/l hoc 5, 6-12mg%. Bnh nhn c tnh
trng nhim acid chuyn ho.
Hn m h ng huyt do qu liu thuc?: cm gic i, mt l, ra m hi,
nu hn m c triu chng babinski (+), phn x gn xng tng.
Bnh l thn do i tho ng: giai on sm c tiu m vi th (20-
500mg/24h. Sau mt thi gian di c th c tiu m i th (>500mg/24h), c
cao huyt p, ph trng hp in hnh l h/c Kimmelstiel-Wilson, cui cng
l suy thn.
TI LIU THAM KHO:
Ni khoa c s tp II (2001), Nh Xut bn Y hc H Ni. .
Nguyn Thy Khu, (2003) Ni tit hc i cng NXBYH, . Trang 335.
Thi Hng Quang, (2001) Bnh ni tit. NXB Y hc H Ni.
Trn c Th, (2002) Bnh hc ni khoa tp 1, - i hc Y H Ni - NXBYH, . Trang
258.
Foster. W. Daniel(1998), Diabetes mellitus, Harrisons Prniciples of Internal medicine,
Mc Graw Hill 14
th
edition CD-ROM.
Umesh Masharani, MB, BS; MCRP, UK (2004), Diabetes Mellitus & Hypogycemia,
Current medical diagnosis & treatment. Forty-third edition by Lange Medical
Books/McGraw-Hill, page 1146-1190.