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Da trn cun s 200 triu chng ca Y3

2
nd
edition


















BIN SON:
NHM SINH VIN Y4, Y5, Y6





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LI TA:
Cun sch ny ch l do 1 nhm sinh vin bin son, nn cha nhiu thiu st.
Nhng thng tin c tng hp t nhiu sch v chng ti u c ch thch ngun
ca nhng thng tin . Chng ti mong mun n s c ch cho cc bn trong t
thc tp lm sng sp ti.
Nu cc bn pht hin ra nhng li sai trong sch, hoc c ch no thc mc, xin
hy phn hi li cho chng ti, chng ti c th sa cha kp thi. Hoc trong
qu trnh hc mn Ni Khoa ny, cc bn thy c nhng thng tin no hay mun
chia s, nhng cu hi thi lm sng hay, thm ch nu bn thy triu chng no
cha hi lng v tm huyt mun son li th chng ti cng sn sng tip nhn,
cun sch ngy cng hon thin, gip tt nht cho cc th h sinh vin tip
theo!
Mi kin ng gp gi v email: khanhduong88@gmail.com












09/2010

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Mc lc:
Chng 1: Tng qut ............................... ..07
Chng 2: Tim mch......35
Chng 3: H hp..101
Chng 4: Tiu ha143
Chng 5: Huyt hc.197
Chng 6: Thn tit niu....225
Chng 7: C xng khp.263
Ph lc 1.281
Ph lc 2.283
Ph lc 3.291

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CHNG I
TNG QUT



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Thiu Oxy m khng tm: thiu
mu
Khng thiu oxy m tm: a hng
cu
1. DA XANH TM DA XANH BC THIU
MU:
DA XANH TM:
NH NGHA
- L tnh trng xut hin khi lng Hb kh >5g/dl hoc >33% (lu , ng vi tnh trng Hb
kh tng th lng Hb xy ho cng gim, tuy nhin phi c nh ngha theo Hb kh, ch
c ngm hiu l xanh tmxut hin trong tnh trng
thiu xy).
- Ch con s tuyt i l >5g/dl l quan trng v c gi
tr hn khi c s thay i v hm lng Hb mu ch s
phn trm ch tham kho.
- Tnh trng xanh tm khng t l thun vi tnh trng thiu
oxy t chc. Vn c trng hp gim cung cp oxy cho
t chc m khng xanh tm v ngc li.
V D
- Khi thiu mu: do lng Hb gim nn khng c Hb trao i Oxy ti phi,
dn n gim Hb02 trong mu ng mch. Khi n cc m, t bo tng s dng
oxy nn t l Hb kh tng cao, nhng khng c xanh tm v nng Hb kh thc
ra vn thp. (trng hp ny c triu chng Da bc mu)
- Bnh a hng cu: Do s lng Hb cao nn khi ln phi khng trao i ht vi
oxy, dn n tng Hb kh ngay trong mu ng mch. Nu c ri lon h hp th
rt d b xanh tm hn ngi bnh thng, v s lng Hb kh vn cao.
PHN LOI
Xanh tm trung ng:
Th hin s km bo ha mu ng mch, SaO2 <85% xy ra ch yu trong cc tnh trng
suy h hp cp v mn.
Nguyn nhn do: ri lon 1 trong 4 giai on ca qu trnh trao i kh:
- RL lu thng kh (COPD, vim ph qun mn, HPQ, tc ph qin do d vt, TD-TKMP,vv);
- RL trao i qua mng khuch tn (Vim phi, ph phi do tim, ph phi do nhim c,
bnh m lin kt, thay i t V/Q,vv);
- RL vn chuyn xy trong mu (bnh Hb: Met Hb, Sulf Hb, cc bt thng chui Hb v
cc enzym; bnh tim: cc shunt bt thng; bnh mu: a hng cu,vv);
- RL chuyn ho oxy t bo (thc ra y l nguyn nhn thiu xy nhng khng gy ra xanh
tm)

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HbCO khng gy xanh tm v
HbCO khng phi l Hb kh
Lu : HbCO khng gy ra xanh tm, v HbCO khng
phi l Hb kh, trn lmsng bnh nhn b ng c
CO da vn hng ho nh thng, thm ch hng ho
hn.
N xut hin u tin cc vng da mng hoc nim mc nh mi, u li, di li,
mng tay chn, mi mt di, tuy nhin n c th xy ra bt c ni no trn da v nim
mc.
Xanh tm ngoi vi:
Th hin s chm chp, gim hoc tc tun hon ngoi vi:
- Shock (tt c cc loi shock tr Shock nhim trng giai on u (shock nng))
- Gim cung lng tim (nht l suy timmn)
- Co mch (do lnh, do St, u tit Adrenalin, ri lon Thn kinh thc vt,vv)
- Huyt khi tt mch Thuyn tc mch mu
Khng c ni xanh tm ngoi vi l loi xanh tm ch khu tr ngoi vi m thi v n c th
nh hng rng (3 nguyn nhn u), tuy nhin xanh tm ngoi vi khng bao gi nh hng
nim mc. in hnh, thng thng xanh tm ngoi vi thng xut hin nhng khu vc khng
c che y nh ngn tay, ngn chn, mi, tai. Cn mt trong m v di li vn .
i vi xanh tm ngoi vi: Ci thin tun hon ti ch (khng shock lnh xy ra, tng ti
mu ngoi vi bng cch tng cung lng tim bnh nhn suy tim, lm gin mch, gii quyt
huyt khi...) s ci thin c triu chng.
Ngun: SLB - YDH
METHEHOGLOBIN:
- L 1 dng Hb trong st trong nhn Heme dng Fe3+ thay v Fe2+nh mnh thng. V
th, n khng c kh nng vn chuyn v phn phi O2 cho t chc.
- Bi v Hb l 1 cht vn chuyn chnh O2 ca c th, nn khi 1 lng ln Hb chuyn thnh
MetHb s dn n tnh trng XANH TM do thiu O2.
- Tuy nhin, bnh thng vn c 1 lng nh MetHb trong mu (<3%) v s c h thng
reductase chuyn v li Hb bnh thng ( Fe3+ Fe2+).
NGUYN NHN
- Di truyn:
o Type 1: thiu enzym reductase hng cu ( l 1 enzym kh c tc dng chuyn Fe3+
v Fe2+).
o Type 2: thiu enzym reductase lan ta, tc l hon ton khng c enzym reductase
trong c th.

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- Mc phi: ph bin hn, do c th tip xc 1 s tc nhn ha hc v thuc nh:
o Thuc gy m nh Benzocaine v Xylocaine.
o Benzene.
o Mt s khng sinh ( Dapsone iu tr phong, chloroquin st rt).
o Nitrites ( dng bo qun tht).
TRIU CHNG
- Xanh tm.
- Mu mu socholate do tng lng Hb kh.
IU TR
- Truyn tnh mch Xanh Methylene ( Methylene Blue) l liu php vng, c tc dng hot
ha h reductase.
- Acid ascorbic : l 1 tc nhn kh c dng nh liu php h tr.
Ngun: Internet
SULFHEMOGLOBIN:
- L 1 bnh him, xy ra khi Sulfur gn vi phn t Hb. Khi S- lin kt vi Fe2+, Hb khng
cn kh nng vn chuyn O2 na.
- Sulfhemoglobin l 1 dng Hb c mu xanh, khng vn chuyn c O2 v gy ra tnh trng
xanh tm 1 nng rt thp.
NGUYN NHN
- Ung thuc cha sulfonamides (v d qu liu Sumatriptan).
- Do tip xc ngh nghip vi ha cht cha sulfur.
- 1 s thuc khc nh acetanilid, phenacetin, nitrates, trinitrotoluene.
TRIU CHNG
- Da, nim mc tr nn xanh.
- Cng thc mu cho thy hng cu bt thng.
IU TR
- T lnh do s sn xut hng cu t ty xng dn dn thay th nhng hng cu gi.
- Truyn mu trong nhng trng hp nng.
NGUN : WIKIPEDIA, SLB-YDH, MEDLINE PLUS, MEDICINENET

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DA XANH BC THIU MU
NH NGHA
- L s gim lng hemoglobin (gim c Hb xy ho v Hb kh l nhng cht to ra mu
cho mu) mu ti n khu vc da hoc nimmc, to nn 1 mu ti. Nguyn nhn c th
do bnh l, shock cm xc, stress, thiu mu, di truyn. R nht l mt v lng bn tay. N
c th pht trin t t hoc t ngt, ph thuc vo nguyn nhn.
C CH
- Thiu Hb : bnh thiu mu cc nguyn nhn tr Thiu mu huyt tn v triu chng Vng da
ni bt hn.
- Gim ti mu ngoi vi: gim cung lng tim, huyt khi ng mch, co mch ngoi vi,
chn p khoang (compartment syndrome).
(Cc bn s thc mc ti sao c ch Gim ti mu ngoi vi ging vi Xanh tmngoi vi,
thc ra nguyn nhn ny ban u c triu chng Xanh tmdo Hb kh, suy tun hon ngoi vi l
nguyn nhn chnh gy ra tnh trng . Ngc li, da bc mu l do s gim hoc cn tr s
dy chuyn ca Hb k c kh v khng kh ra ngoi vi nn mi gy ra triu chng , chnh v
vy ni n Da bc mu th ngh ngay n thiu mu, t ngh n cc nguyn nhn khc)

2. NT NHN ( NT SAO, NT MCH):
M T
- Kch thc: 0,5- 1 cm.
- Trung tm nh ln, xung quanh cha ra nh
chn nhn v bng ln, n vo khng bin
mt. (cn phi m t c)
- V tr: mt, c, vai, ngc, cnh tay, lng bn
tay, nim mc ca mi v mi.
- 1 nt hoc nhiu nt.
C CH
- Gin mch, mu cc mch mu rng lm
cc mch mu l r di da.
NGUYN NHN
- Hu ht cc trng hp l do x gan: gim thi gian bn hy ca estrogen tng estrogen
trong mu (nhiu nt)

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- Hng ban: n tay vo th bin
mt
- Xut huyt: n tay vo khng
bin mt (bnh st xut
huyt)
- Cc trng hp tng estrogen khc : Mang thai, thuc nga thai. Chng thng xut hin vo
thng th 2,3 khi mang thai, sau ln dn, nhn ln v bin mt khong 6 tun sau khi sinh.
- ng 1 s cht gy gin mch ( histamin, leukotrien, serotonin)
- HC nhim c gip.
- Thnh thong cng gp ngi gi, nhng t v nh (c l lin quan n ni tit t, c bit
l estrogen v progesteron).

CHN ON PHN BIT
- Gin mch:
Rng: Hng ban, bin mt khi tay vo (thng
hn, st pht ban, thp khp cp)
Su: Nt nhn
X GAN
Nhiu nt nhn xut hin l du xc nhn ca x gan. Tuy nhin, chng l nhng du hiu
mun, s lan rng v to ca cc nt nhn l ch im bnh ang tin trin, cn thm khm cc c
quan khc pht hin x gan nh tng p tinh mch ca, lch to, nn ra mu, vng da, ban


Tng quan v Tnh trng mt nc v nc trong
c th:
Nc trong c th tn ti 2 khoang: Ni bo (trong t bo) v Ngoi bo (mu,khoang c th
v khong k). Ngoi ra cn khoang th 3 nh: khoang mng phi, mng bng
Lng nc trong c th cng c 2 dng ri lon chnh: Mt nc v nc.
V vy c th tm gn nh sau:
- nc gi l Ph, nc ni bo c Ph no, Ph nim mc, Ph vim, Ph t bo ca 1
c quan no , cn li danh t Ph dng ch nhng ri lon ca nc ngoi bo.(v
vy mt cch tng i nhc n Ph l ni n nc ngoi bo)
- Mt nc ngoi bo th hin du hiu bnh l v tim mch v du n hi da
- nc ni bo gy triu chng no c ch (ph no)
- Mt nc ni bo gy triu chng no kch thch (teo no)

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4. TNH TRNG MT NC.
Trong phn ny, bn cnh vic m t triu chng ca 3 loi mt nc, chng ti ch trng thm
vic gii thch mt s ri lon in gii.
NGUYN NHN
LOI MT
NC
NGUYN NHN C CH LM SNG
NG
TRNG

- Mt mu
- Tiu chy
- Nn ma
- Mt 1 lng nc v Na+ nh
nhau.
- V th khng c s thay i ca
p lc thm thu v nng Na+
huyt tng.
- Khng c s dch chuyn nc
gia ni bo v ngoi bo: nc b
mt ch yu ngoi bo, trong khi
ni bo vn bnh thng.
- Da kh, nhn nheo, n hi da gim
(du Casper), mt trng, np vo da
mt chm
- Du chng tim mch: Gim lu lng
tim, nhp tim nhanh, mch yu, mt
mi, t hi gian lm y mao mch
gim.
- Shock gi m th tch nu mt nhiu
nc.
- Lng nc tiu gim suy t hn
cp.
U TRNG
- Mt mt lng dch nhc
trng: ra m hi, i tho
nht, li tiu thm thu (tng
glucose niu)
- Ch mt nc: nc bc hi
qua da.
- a vo c th mt lng
dch u trng: thuc cha
nhiu Na, truyn NaHCO3,
ung nc mui
- Do mi trng ngoi bo l mi
trng u trng, nc s dch
chuyn t ni bo ra ngoi bo.
- Nng Osmol mu s tng.
- Nng Na s tng.
- Du chng Tim mch v n hi da
nh trn, c km theo:
- Tng thn nhit, lo lng, hn m.
(Triu chng no dng kch thch)

NHC
TRNG
-H Na mu
-Mt mt lng dch u
trng.
-a vo c th mt lng
dch nhc trng:ung
nhiu nc, x gan, hi
chng thn h.
- Mi trng ngoi bo l mi
trng nhc trng, nc s dch
chuyn t ngoi bo vo ni bo.
- Nng Osmol mu gim.
- Nng Na+ mu gim.
- Du chng Tim mch v n hi da
nh trn khuynh hng dn n
ngt, t t hn m.
- Tng p lc no ty ( do nc c xu
hng i t ngoi bo ni bo ph
no) cc Triu chng no dng c
ch.








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TM TC DI DNG S
BNH THNG:

NG TRNG:
1. Mt mt lng Na v H2O tng ng nhau

2. a thm vo mt mt lng Na v H2O tng ng nhau:




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NHC TRNG
1. Mt mt lng Na+ nhiu hn so vi H2O

2. a vo mt lng nc nhiu hn so vi Na+:


U TRNG
1. Mt mt lng nc nhiu hn so vi Na+: mt nc u trng

2. Thm vo 1 lng Na+ nhiu hn so vi nc:



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KT LUN:

DUNG DCH SALINE (0.9%)
- y l dung dch c p sut thm thu xp x bng vi huyt tng. N c s dng
truyn cho nhng bnh nhn b mt dch c cha Na+ (mu, tiu chy, ra m hi) duy tr
huyt p bnh thng.
- Khi truyn vo, hu ht saline s i vo khong k v vo trong t bo, mt phn nh s gi
li trong lng mch (cn nh l th tch lng mch ch chim 1/3 th tch ngoi bo, v th
tch ngoi bo chim th tch ngoi bo) v lm nng huyt p ln.
- Mt s dung dch khc cng c th c s dng nhng gi c hn bao gm Ringers latate
v albumin 5%.
TRUYN DCH CHO BNH NHN B H NA+ MU:
- Bt c nguyn nhn g gy h Na+, th vic iu chnh Na+ mu tr v mc bnh thng cn
c thc hin mt cch chm ri trong 24h u.
- Nu vic iu chnh Na+ mu qu nhanh, s gy ra tnh trng hy myelin cu no, 1 bnh
l khng phc hi c.
PHN LOI MC MT NC THEO IMCI (INTERGRATED
MANAGEMENT OF CHILDHOOD ILLNESS)
- IMCI l mt chng trnh lng ghp x l cc bnh thng gp tr em, s c hc Nhi
khoa.
- , ngi ta phn loi mt nc tr em nh sau:






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Hai trong 3 du hiu sau:
- Li b hoc kh nh thc.
- Khng ung c hoc
ung rt km
- Mt trng.
- Np vo da mt rt chm
MT NC NNG
Hai trong 3 du hiu
- Vt v, kch thch.
- Mt trng.
- Ung ho hc, kht.
- Np vo da mt chm.
C MT NC
Khng cc triu chng trn KHNG MT NC
Da vo s phn loi nh vy, ta c th bit c cc du hiu nng ca mt nc, giai on u
bnh nhn s vt v kch thch, rt mun ung nc, nhng sau , bnh nhn s tr nn li b v
khng ung nc c na.
MT S HI CHNG C LIN QUAN N RI LON
IN GII:
HI CHNG ADDISON (Adrenal insufficiency):
- Nguyn nhn thng gp l do s ph hy v thng thn c ngun gc t min.
- C ch bnh sinh ca nhng ri lon in gii: thiu ht Aldosterol v nhng hormon khong
khc.
- Lm sng:
o H Na+ mu v tng K+ mu:
Do vai tr ca Aldosterol l gi Na+ v bi tit K+, by gi thiu Aldosterol
s gy mt Na+, v gi K+ (xemminh ha)
Mt mt lng Na+ u trng trong nc tiu.
Cc triu chng ca mt nc.
o Gi ion H+, gy ra acid chuyn ha.
Do mt hot ng ca bm H+/K+ ATPase.


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Addison: nhc nng v thng
thn
Conn: cng aldosterol tin pht
Thuc li tiu quai Furosemide
(Lazix) l mt loi thuc c s
dng nhiu iu tr suy tim. C
ch tc dng ca thuc l c ch
hot ng ca bm Na+, K+, 2Cl-,
t lm gim ti hp thu nhng
cht ny. Ngoi ra, thuc cn c
s dng iu tr tng Ca+ mu
theo 1 c ch ring.

HI CHNG CNG ALDOSTEROL TIN
PHT (HI CHNG CONN)
- Do u tuyn vng cu ca v thng thn (vng
cu tit ra aldosterol)
- C ch bnh sinh ca nhng ri lon in gii:
tng hot ng ca aldosterol
- C ch ca cc triu chng lm sng:
o Tng ti hp thu Na+ v t tng bi tit
K+, H+.
o Tng ti hp thu Na+ s lm tng Na+ mu.
o Tng bi tit K+ s lm gim K+ mu
o Tng bi tit H+ s dn n nhim kim
chuyn ha.
- T ta suy ra cc triu chng lm sng:
o Tng huyt p do gi mui.
o Tiu nhiu v yu c do h K+ mu.
o Cn lm sng c: Tng Na+, h K+, nhim kim chuyn ha.
HI CHNG BARTTER:
- Dch t hc: thng gp tr em.
- C ch bnh sinh:
o Ri lon thn khng c kh nng ti hp thu Cl- bm Clo ( Na+ - K+- 2Cl-)
C ch ging nh thuc li tiu
quai.
o T mt Na+, K+ v Cl- trong nc tiu:
Mt Na+s gy ra h Na+ mu.
o Lng Na+ ng lng xa s nhiu hn,
t lm tng s ti hp thu Na+ ti v tr
(nh Aldosterol), t tng bi tit K+
v H+:
Gy ra h K+ v nhim kim chuyn ha.
o Tnh trng h K+ s kch thch s sn xut prostaglandin ti thn.
Gy tng sn t thc cnh cu thn.
Tng tit renin v gy ra cng aldosterol.
- Triu chng:
o Huyt p bnh thng (khng phi tng huyt p), do tnh trng gin cc tiu ng
mch ngoi bin do prostaglandin.
o Yu c do h K+ mu.
- iu tr:
o Thuc li tiu gi K+: gim bt s mt K+
o Thuc khng vim non steroid (NSAIDs: non steroid anti inflamatory drugs):
lm gim bt s tng hp ca prostaglandin.

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Lu : Nu lng dch mt l nhc trng (mt nc nhiu hn mt mui), ngi ta gi l mt
nc u trng, ngc li nu lng dch mt l u trng (mt nc kmtheo mt rt nhiu
mui), ta gi l mt nc nhc trng.
Ngun: SLB- YDH

Tng quan Ph:
nh ngha: Ph l sng n phn mm do nc trong m k (NCS HYD Hu)
i vi a phn cc trng hp Ph, ngi ta nhn thy bin i lng nc trong Ni bo
thng biu hin triu chng chm hn so vi bnh cnh Ph, v vy cc triu chng no do mt
hay nc ni bo t c nhc n.
Ph c 3 loi chnh:
- Ph ton: thng lin quan n s ri lon cc loi p lc lng mch-khong k m
nguyn nhn t cc c quan m bnh l ca n nh hng n ton thn nh tim, gan, thn.
- Ph khu tr: thng gp l nhng ri lon do tng tnh thm thnh mch : vim, d ng,
phn v; Ph do tc nghn lu thng tun hon khu tr: Ph o khoc (do tc TM ch
trn), ph bch mch (do giun ch); Ph do lng ng cht peptido-glican: Ph nim
- Ph t th: c th gp nhng ngi phi nm lu, khng c kh nng thay i t th trong
mt thi gian di.
Nhng triu chng 5,6,7 ch yu ni v ph ton:

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Kochar's Clinical Medicine for Students, 5th Edition
5. PH DO SUY TIM
M T
- Gim lng mu v tim phi trong suy tim phi gy mu ngoi vi ph ngoi vi.
- Gim lng mu v tim tri trong suy tim tri gy mu phi ph phi
PH TRONG SUY TIM PHI:
C CH: (Trong mi triu chng Ph thng c nhiu c ch phi hp, cn nm C ch chnh
v cc c ch ph hiu cho ng)
- C ch chnh:- Suy tim phi mu tnh mch Tng p lc thy tnh ti mao mch ngoi
vi C ch chnh + c ch khi u.
- C ch ph: Gim ti mu thn hot ha h RAA tng gi nc gi mui tng p
lc thm thu ngoi bo.
- Nhng c ch khc:
o Gim p lc keo do gan gim tng hp Protid (giai on sau x gan tim).
o Tng tnh thm thnh mao mch ngoi vi ch yu do thiu O2, toan chuyn ha v
tn thng t bo biu m mch mu v mt vi th, gy gin mch.


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KHM:
Ph trong suy tim phi:
- V tr:
o Ph chi di l ch yu
o Lc u ph t v ch xut hin v chiu sau khi ngi bnh ng lu mt i vo sng
sm khi ngi bnh ng dy. Gin tip phn nh chc nng tng mu ca mt tim b
suy cng km hn sau mt ngy phi lm vic
c im:
- Ph mm, n lm (khng c gi l ph trng cng, 1 s sch ghi l ph tm song trn lm
sng chng ti nhn thy khng tht s tm lm).
- Giai on sau c trn dch a mng, Rivalta(-).
- Ngh ngi, n nht, tr tim, li tiu gim ph.
Triu chng km theo:
- Gan to, mm, n tc (c 2 giai on: Gan n xp v X gan tim). C th to thm hoc nh bt
ty theo mc gng sc.
- Tnh mch c ni, phn hi gan, tnh mch c dng tnh.
- Kh th.
PH TRONG SUY TIM TRI:
- Suy tim tri s gy mu phi, t gy ph phi.
- Tuy nhin, vo giai on cui khi c 2 bung tim phi v tri u suy th s gy ra ph ngoi
bin nh trong suy tim phi.
Ngun: Ni c s - YHN, SLB YHD

6. PH DO SUY THN:
Ph trong suy thn cn phn bit r 2 dng, v c c ch khc nhau, l ph do hi chng
thn h v ph do vim cu thn (cp hoc mn).
PH DO HI CHNG THN H:
C ch:
- C ch chnh:Do gim p lc keo huyt tng.
o Do mt Protein qua thn gim p lc keo trong mu nc trong lng mch i vo
m k.
- C ch ph: T gim th tch trong lng mch gim lng mu n thn hot ha h
RAA gi nc gi mui Ph.

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M t:
- c im:
o Ph xut hin t ngt, rt to v pht trin rt nhanh.
o Ph trng, mm, n lm.
o Ch n nht khng gim ph (v c ch gy ph l gim Protein mu)
- V tr:
o u tin xut hin mi mt, mt ri cc ni khc.
o Khng c s lin quan v thi gian trong ngy hoc t th ngi bnh (1 s ti liu
m t ph bui sng lc bnh nhn ng dy, c l lin quan n s gim mc lc cu
thn sinh l trong qu trnh ng, cng lm tng qu trnh gi mui, nc trn nn
mt bnh thn c t trc).
o Tuy nhin, nu ph to km theo bnh nhn nm lu, ph c xu hng tp trung nhiu
cc vng thp nh lng v mt sau i, c bit c kh nng gy trn dch nhiu nn
c khi xut hin C chng trc khi xut bin ph ton thn.
- Triu chng km theo:
o Trn dch mng phi, trn dch mng bng (trn dch mng bng xy ra nhanh c th
gy cn au bng cp). Khi c trn dch mng bng lng ln cng thc y lm tng
ph hai chi di do lm tng p lc bng, cn tr lu hi mu ca tnh mch ch
di.
o Nc tiu cha nhiu protein (>3,5g/ngy).
o Tc lng mu tng, Protein mu gim, Lipid mu tng.
o Ure, cre khng cao nu cha c suy thn.
PH DO VIM CU THN CP V MN
C CH:
- Gim thi Na v nc do thn gim lc (tng lng Na c trong c th, tuy nhin xt
nghim c th thy Na bnh thng hoc khng tng l do nc)
M T
c im:
- Ph xut hin t t, c th t hoc nhiu.
- Ph mm, trng, n lm.
- Ch n nht lm gim ph r rt.
V tr:
- Xut hin u tin mi mt, mt ri n ni khc.
- Ph thng xut hin vo bui sng lc ng dy.
Triu chng km theo:
- Thng km theo tng huyt p, protein niu, hng cu niu.
- C th trn dch mng phi v c trng nu ph nhiu.

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24


- Nc tiu t. C th khi pht suy thn cp trong bi cnh ca vim cu thn cp.
IU TR LI TIU TRONG HI CHNG THN H:
- Trong hi chng thn h, khi s dng li tiu, phi cn nhc liu lng, loi thuc v th tch
huyt tng bnh thng hoc gim nh. S dng li tiu ba bi, khng ng ch nh c
th khi pht suy thn cp (trn nn c hay khng c suy thn mn trc ), cng lm nng
thm bnh cnh hin ti.
Ngun: Ni c s - YHN, Bnh hc thn SH

7. PH DO X GAN:
C CH
C ch chnh:
- Do tng p tnh mch ca (ni chnh xc l Tng p lc thu tnh khu tr ti TM Ca).
- Do gim p lc keo huyt tng (Gim tng hp albumin).
C ch ph:
- Tng p lc trong bng do dch bng nhiu gy ph 2 chn.
- Chc nng gan suy yu nn gim ging ho cc cht steroid nh MineroCorticoid v
GlucoCorticod gy ng nhiu mui v nc, gin mch, gim sc bn thnh mch.
- Ngoi cc c ch trn th ph hai chi di cn l do hu qu ca dch bng lm cn tr hi lu
mu tnh mch ch di.
C IM PH DO X GAN
- Mc khng bng ph do suy tim phi.
- Ph trng, n lm.
- Thng km theo C trng vi dch thm v tun hon bng h kiu ca ch.
- (C trng (bng) l mt danh t ring gi mt loi ph ch khu tr trong bng, phc
mc)





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25


KHM
HI CHNG SUY GAN:
- Chn n, n chm tiu y bng.
- Ph n: Ri lon kinh nguyt. n ng: V ln, lit dng, teo tinh hon, gim kh nng
tnh dc...( gan suy, lm tng thi gian bn hy ca cc hormon sinh dc c bit l
estrogen). Vn ny kh t nh nn khi khm thng b b qua, tuy nhin n li rt c gi
tr trong bi cnh bnh.
- Chy mu chn rng, chy mu cam, chy mu di da (gim tng hp cc yu t ng mu,
gim t prothrombin).
- Lng tc d rng.
- Mng tay khum, ngn tay di trng: gp trong x gan mt tin pht (bnh Hanot - mt bnh
t min, c th n c hoc phi hp vi cc bnh khc nh vim tuyn gip t min, bnh
kh tuyn...Cng vi x gan tim, l hai bnh x gan nhng khng bao gi tin trin n ung
th gan.. ).
- Vng da (ty nguyn nhn m c vng da nh hay nng. V d: Trong x gan mt, bnh
Wilson th da rt vng, ngc li trong x gan do vim gan mn th t vng hn..).
- Thiu mu.
- Nt nhn ngc v lng
- Hng ban lng bn tay.
- Vim dy thn kinh ngoi bin
HI CHNG TNG P TNH MCH CA:
- Tun hon bng h kiu ca ch hnh u sa rn hoc ch ch phi hp.
- Lch ln: lc u mm, v sau x ha tr nn chc hoc cng chm (+).
- C trng: th t do.
- Tr.
- Tnh mch trng thc qun.
NOTE:
- Ngoi 3 loi ph thng gp trn, ta cn c th gp cc loi ph khc do: suy dng, suy
gip, basedow (ph nim), ph do giun ch (ph bch mch, n au), ph do d ng (ph
Quinke)...
Ngun: Ni bnh l YDH, Ni c s - YHN




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26



8. LN TUYN GIP
Nhn: Phn bu gip ln:
0 : Tuyn gip ko ln.
Ia : Nga c vn khng thy, ch s mi thy.
Ib : Nga c vn nhn thy c ( <5m)
II : Nhn thy c bu gip khi c t nhin khong cch nh
hn 5m.
III : ng xa hn 5m vn nhn thy bu gip.
Thc s khng cn nh bng chia trn v i vi mt bnh nhn Basedow th tuyn gip ln
hay khng khng quan trng bng tnh cht tuyn gip nh th no, v th cc bn nn hc theo
cch chia n gin sau:
0: khng ln
1: Ln m khng r
2: Ln nhn rt r
S: c 2 cch khm tuyn gip l:
1. ng sau bnh nhn, dng ngn 1,2,3,4 ca 2 bn tay m ly c bnh nhn ri y ra pha
trc: cch ny c u im l cc u ngn tay rt nhy, tuy nhin t lm v khng thy c
tuyn gip
2. ng trc bnh nhn, dng ngn 1 ca 2 bn tay m c bnh nhn ri khm: nhc im l
ngn 1 khng nhy bng cc ngn khc, tuy nhin vn thng lm do nhn c tuyn gip
khi khm.
Khmc 2 thy, cng nh eo tuyn gip, khmthu bn ny th c gng y thu bn kia qua
d khm hn.
M t:
- Kch thc: c lng kch thc tuyn gip. Cn thn s vo b di, nu khng c b di
th c th tuyn gip ko di tn sau xng c.
- Hnh dng: Xem th tuyn gip ln u hay khng iu n v xem th eo tuyn c b nh
hng ko. Nu c 1 nt no th m t v tr, kch thc, tnh cht v s di chuyn. Cng phi
xem th i khi c tuyn gip u c nt ( hn).
- Tnh cht: C th khc nhau nhng phn khc nhau ca tuyn gip. Tuyn thng cng
trong bu gip n, nh cao su trong bnh Hashimoto, nh trong carcinoma, calci ha
trong u nang hoc x ha.
- Nhy cm au: y l 1 c im ca vim tuyn gip (bn cp hoc him hn l c sng m)
hoc l chy mu trong u nang hoc carcinoma.
- S di ng theo nhp th.

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27


- S thy rung miu, s nng lanh ca tuyn gip: nu thy co rung miu tng ng vi s tng
sinh mch mu, nu s thy nng thi nghi ng tuyn gip b vim.
Nghe:
- Nghe ting thi bu nguyn nhn l do tng s cung cp mu ( do tng chuyn ha) trong
cng gip hoc thng thng l do s dng thuc khng gip.
- Chn on phn bit vi thi ng mch cnh.
nn c, ting ng mch cnh bin mt lin.
Ngun: Oconnor clinical examination
1 S DU HIU QUAN TRNG KHI THM KHM TUYN GIP
- Du Pemberton:
o Bo bnh nhn nng 2 tay ln cng cao cng tt. Ch 1 lc sau quan st du hiu xung
huyt v xanh tm mt. Km theo l du hiu suy h hp ( kh th) v m th
wheeze (stridor) (bo bnh nhn ht th su nghe). Quan st tnh mch c c s cng
phng. Du ny nh gi s ln ca tuyn gip. Du hiu ny thng gp trong bu
gip n, bu gip a nhn...
- Du Stellwag:
o Co ko mi trn ca mt khi bnh nhn nhn bnh thng.
- Du Von Graefe:
o Bt ng vn gia vn ng ca nhn cu vi m trn khi nhn xung (dng ngn tay
hoc cy bt t trc mt bnh nhn ri t t di chuyn xung, sau xem s di chuyn
ca m mt khi mt ca bnh nhn c nhn theo. Du hiu dng tnh khi c b cng mc
xut hin gia b m mt trn v ng t)

Hnh: Du Von Graefe
- Du Moebius:
o Sai lch ca s xoay nhn cu.
- Du Joffroy:
o Bt ng vn gia trn v m trn ca mt tc l mt np nhn trn khi a mt nhn ln.
Ngun: Ni c s - YDH


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28



9. HCH BCH HUYT LN
KHM
- V tr : h chm, trc v sau tai, dc M Cnh, di hm, di cm, h thng n, nch,
khoeo, bn.
o Hch bn thng ngh n da liu, ung th hch, bnh l c tnh vng tiu khung.
- Th tch v mt (hch ung th trong bnh Hodgkin thng to hn, hch trong di cn ca ung
th thng nh).
- Hnh th:
o Trn nhn: lao hch.
o Khng u: ung th (do dnh vo nhau hoc vo t chc xung quanh)
- Di ng: hch trong bnh bch huyt di ng r rng. Ung th th di ng giai on u, giai
on sau dnh vo t chc su ht di ng.
- au: Vim hch thng au, nng. Hch ung th v trong cc bnh khc th khng au. Nhng
nu c chn p thn kinh th vn c au.
C ch: vim nhim (cc hch gc thng ln, n khng au, di ng...l trng hp kh
thng gp trong cc bnh l nhim trng cc vng tng ng. Trong trng hp ny, hch s
tr li bnh thng sau khi bnh l nhim trng c chm dt mt cch t nhin hay do kt
qu ca iu tr), cc nguyn nhn c tnh ( tin lng xu).
NGUYN NHN
Vim hch cp tnh:
- Vim nhim 1 vng: vim hng hch di hm, nht i hch bn, Zona ngc
hch nch.
- Bnh dch pht ban : hch ni nhiu ni, c, nch, bn, hch to di ng d dng. Khng au,
lnh tnh.
- Nhim khun c tng bch cu n nhn: hch ni ln nhiu ni, khng au, i ng, mt
chc

Vim hch mn tnh:
- Hch do c a: Nhng ngi gy yu.
- Hoa liu:
o Giang mai giai on 1: Gn ch xm nhp ca xon khun, c 4- 5 hch, hi rn, di ng,
khng au. Giai on 2 th c th gp mi ni.
o Bnh Nicolas- Favre ( hch to bn( Qu xoi)).
- Lao hch: lc u hch thng 2 bn c trc v sau c c n chm, sau ni lan ln hch sau
gy v xung h thng n. t gp nch hoc bn. Ni thnh tng chui.
- Hch ung th:

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29


Hch di n tri (Virchow): ung
th bng.
Hch di n phi: ung th phi
v thc qun.
Hch quanh ng mch ch: ung
th tinh han.
Hch nch: ung th v.
Hch nch (Irish), hach quanh rn
(Sister Mary J oshep), u bung trng
(Krukenberg) : gp trong K d dy.
o U lympho khng Hodgkin:
o Ung th hch do di cn.
- Bnh v mu:
o L x mi kinh th lympho hch to 2 bn nhiu ni: c, nch, bn, th tch thay i.
o L x mi cp : di hm +c ( Hodgkin).
- Hch to trong bnh sarcoidose ( kmgan, lch to, tng Ca mu v Ca niu)
- Lupus ban ri rc (c th kmtheo lch to).
KHM 1 BNH NHN C HCH LN
Da vo nhng d kin sau c th khu tr chn on:
- Tui:
o Nu bnh nhn < 30 tui, khm thy hch ln, th thng l bnh lnh tnh (vim chng
hn) (80% trng hp)
o Nu bnh nhn > 30 tui, khm thy hch ln, th thng l bnh c tnh (60% trng
hp)
- Khm thy hch au: y l 1 ch im ca vim (v d do nhim khun)
o Khu tr: l v tr tp trung ca bch cu gp trong nhim khun, v d nh vim hng.
Nhng v tr thng gp: hch c trc, hch bn.
o Lan ta:
Ch im ca 1 bnh h thng.
V d: bnh tng bch cu n nhn nhim khun (infectious mononucleosis,
bnh lupus ban h thng (SLE)
- Khm thy hch khng au thng l ch im c tnh
o Hch thng chc v dnh cht vo m xung quanh.
o Nu khu tr:
L v tr di cn ca ung th: v d nh di cn hch nch ca ung th v.
U lympho horkin
o Nu khng khu tr:
Di cn trong bnh leukemia (ung th bch cu, hay cn gi l bnh mu trng)
U lympho follicular B cell
MT S V TR HCH DI CN THNG GP
- Hch di cm: Di cn ca ung th t bo vy
(squamous cell carcinoma) nn ming.
- Hch c: di cn ca nhng khi u u v c (thanh
qun, tuyn gip, mi hu)
- Hch di n tri (hch Virchow):
o Cc khi u bng (v d d dy, ty)
- Hch di n phi:
o Di cn ca ung th phi v thc qun.
o U lympho Horgkin

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30


- Hch nch: ung th v.
- Hch mm trn rng rc:
o 1 bn: thng l do nhim khun bn tya, u lympho khng Hodgkin.
o 2 bn: bnh sarcoidose.
- Hch rn phi 2 bn:
o Ung th phi.
- Hch trung tht:
o Ung th trung tht.
o U lympho Horgkin (c bit l th x ha nt)
o T cell lymphoblastic lymphoma
- Hch hch nhn (amydal)
o Di cn ca ung th t bo vy ca ming.
- Hch xung quanh ng mch ch:
o Di cn ung th tinh hon.
o U lympho Burkitt.
- Hch bn:
o Ung th dng vt v m h, vng tiu khung.
Ngun: Ni c s - YHN & Bs XunTi













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10. NGN TAY CHN HNH DI TRNG,
NGN TAY KHUM MT KNH NG H
NGUYN NHN
Ph bin
Tim mch
Bnh tim xanh tm bm sinh
Vim ni tm mc nhim khun.
H hp
Ung th phi ( thng l ung th t bo khng nh)
Bnh phi sng m mn tnh:
Gin ph qun.
p xe phi.
Vim m mng phi.
X ha phi t pht
Km ph bin
H hp
X ha phi thy
Bnh bi phi amiang.
U trung biu m mng phi (Loi u x lnh tnh) hoc u x mng phi
Tiu ha
X gan ( c bit l x gan mt tin pht bnh Hanot)
Bnh vim rut.
Tiu chy m (celliac)
Ng c gip
Gia nh hay t pht
Him
U thn kinh
Mang thai
Cng tuyn cn gip th pht



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32





KHM LM SNG

Cch 1: o gc gia nn mng v mng:
- Bnh thng : 160
o

- Nu n ln hn 180
o
( 1 s sch ghi l 190
o
) th l
ngn tay di trng ( minh ha).
Cch 2: o T s v chiu cao ca t ngn xa (Distal
phalangeal depth) v gian t ngn gia xa
(interphalangeal depth).
- T s ny bnh thng <1.
- Nu t s ny >1, th l ngn tay di trng.
Cch 3: (lm sng)
- p 2 mt mng ca 2 u ngn tay ca 2 bn tay vo nhau, thng th gc m gia 2
mng nh hoc bng 0, nu gc m ln th chnh l ngn tay khum mt knh ng h.
(Cch ny cha c tr s c th nhng c th p dng con s >=30
0
)
C CH: hin cha c gii thch c th, tm thi theo 1 s gi thuyt nh:
- Lng ng cc cht, tng sinh mng xng ca GH-like trong mng tay di trng.
- Tng sinh mch mu trong mng tay khum mt knh ng h.
Ngun: Professional guide to signs and symptoms, Oconnor clinical examination

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33


MCV(mean corpuscular volume):
th tch trung bnh hng cu,
dng phn loi thiu mu.
MCHC(mean corpuscular
hemoglobin concentration):
lng Hb trong 1lt hng cu.
MCH (mean corpuscular
hemoglobin): lng Hb trong mi
hng cu

MNG TAY KHUM MT KNH NG H
V NGN TAY DI TRNG L 1 HAY 2?
- Thy c m t y l 2 du hiu khc nhau
- Nhng theo ti nhn thy n ch l 1 triu chng m thi, bi l nhn vo ngn tay di trng, ti
thy n cng khum ging mt knh ng h ()
- Y vn cng ch nhc ti 1 thut ng l clubbing hay clubbed finger, theo Wikipedia c vit
Nail clubbing also known as "Drumstick fingers," "Hippocratic fingers," and "Watch-glass
nails"
(Lu : y ch l kin ch quan ca nhm bin son)
BNH L TIU HA NO C NGN TAY DI
TRNG (1 cu hi thi lm sng):
- Bnh quan trng nht cn nh l bnh X gan mt tin pht ( bnh Hanot) l 1 bnh c c ch
t min gy ph hy v lm x ha nhu m gan v ng mt ngi ta thng khng tm thy
du hiu nhim khun v ng mt.
- 2 bnh cn li l vim rut v bnh Celliac.
Ngun: Clinical examination Oconnor, Professional signs and symptoms

11. MNG TAY LM HNH THA:
NGUYN NHN
- Thiu mu nhc sc (hng cu nh)
THIU MU NHC SC
Cn lm sng:
- Thiu mu MCV<80m
3
.
- iu ny c v gy thc mc v theo nhiu bn MCH
mi l thng s nh gi thiu mu nhc st (tc l

NI C S

34


lng Hb trong hng cu gim), nhng hu ht ti liu, ngi ta s dng MCV, tuy nhin
ph thuc vo cc giai on khc nhau m c nhng s bin thin khc nhau v MCH,
MCHC.

Nguyn nhn:
- Thiu st ( nguyn nhn ph bin nht).
- Mt mu mn ( tr, chy mu tiu ha... cng gy thiu st).
- Thiu mu trong cc bnh vim mn tnh
- Thalassemia.
- Thiu mu nguyn bo st ( ru, Isoniazid, ng c ch) Km ph bin nht.
(Cc thay i trong thiu mu s c trnh by phn huyt hc)
Ngun: Pathology


NI C S

35










CHNG II
TI M MCH


NI C S

36



NI C S

37


12. KH TH DO SUY TIM KHI GNG SC
THNG XUYN
nh ngha : Kh th l cm gic kh khn,vng mt trong khi th ca bnh nhn. Bnh nhn
thng cm gic ngt ngt, thiu khng kh phi th nhanh v nng, phi ngi dy th
Kh th lm thay i cc c im, hot ng th bnh thng ca bnh nhn nh:
- Tn s th
- Thi gian ca th ht vo,th ra.
- S phi hp v tham gia ca c h hp
C ch:
- ng vai tr ln nht l hin tng xung huyt phi ( dch khong gian bo hoc trong ph
nang (xem s bn di).
- Trong suy tim, kh th l do tr tun hon, tng p lc trong cc mao mch phi, chn p vo
cc tiu ph qun v c th c thot dch vo ph nang lm hn ch qu trnh trao i kh gia
ph nang v mao mch phi.
c im kh th do suy tim
- Kh th dai dng mn tnh, t nh ti nng.
- Ch yu kh th hai th, trong hen tim cng c th c kh th ra l ch yu.
- Kh th hn khi gng sc.
o Trong suy tim phi cn kh th t t din tin trong mt thi gian di, bnh nhn c th
thch nghi c.
o Trong suy tim tri, cn kh th c th xy sau mt gng sc hoc vo ban m ( h ph
giao cm cng tnh hn so v h giao cm) nh: cn kh th trong hen tim v ph phi
cp. Trong suy tim khi nm bnh nhn thy kh th hn ngi, d th hn t th Fowler.
- Kh th nhanh nng, c th c nhp tim nhanh, hi hp, nh trng ngc, ph..
- Kh th gim khi bnh nhn ngh ngi, n nht, dng tr tim, li tiu.
PHN SUY TIM DA VO MC KH TH (THEO NYHA):
1
- Bnh nhn c bnh tim nhng khng cm thy kh chu, khng kh th khi
gng sc, hot ng bnh thng so vi la tui
2 - Kh th khi gng sc
3 - Kh th khi hot ng trung bnh, khng kh chu khi ngh ngi.
4 - Kh th ngay c khi ngh ngi hay hot ng nh
HI BNH NHN KH TH
- Bnh nhn bt u kh th khi no?
- t ngt/t t, kh th nhanh/kh th chm, mt th/hai th, tng cn/lin tc ?
- Hon cnh xut hin ( bnh nhn ang lm g th thy kh th/ t nhin)

NI C S

38


- Triu chng km theo ?
- Lm gim cn kh th : thay i t th, th oxy, thuc,...?
- Nu kh th khi nm, bnh nhn thng phi k bao nhiu gi k u cho d th?
- Tin s: nhi mu c tim, ung ru, kh th kch pht vo ban m ? ho? Khc m?











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39


KH TH KHI NM
- L kh th xy ra khi bnh nhn nm. Cn khi bnh nhn ngi dy hoc t th Fowler hoc
k rt nhiu gi th thng thy d chu hn.
- Nu khng c kh th nm bnh nhn t c du hiu suy tim tri.
Khi nm, mu t tnh mch ch di v tim nhiu hn, mu ln phi cng nhiu, tim suy nn
khng th gii quyt c tnh trng mu phi. Tng p lc tiu tun hon, gy ra kh th.
Ngoi ra, khi tim suy thng km tng trng lng( tim to ra ) nn khi nm tim ln phi, cn
tr qu trnh trao i kh phi.
KH TH V M
nh ngha: l cn kh th kch pht v m(Paroxysmal Nocturnal Dyspnea), l nhng t kh th
kch pht km theo l ho thng xy ra vo ban m (c th do ban mc tnh trng cng ph giao
cm, tr thnh yu t thun li khi pht cn kh th) v thng nh thc bnh nhn sau khi bnh nhn
i ng khong 1 3h, bnh nhn phi ngi dy th th, th rt nhanh, hn hn, cm gic thiu khng
kh nng.
Nguyn nhn: Do tng p lc ng tnh mch ph qun dn n s chn p ng dn kh. Bnh
thng cc tnh mch ph qun mu vo c hai tmnh: tm nh phi qua tnh mch n v tm nh
tri qua tnh mch phi su. Suy tim tri lmcho p lc tng rt cao trong nh tri, dn n mu trong
cc tnh mch phi su lm cng cc tnh mch ph qun. Nu qu cng chng c th v, bnh nhn khc
ra mu. Km theo l tnh trng ph m k phi s dn n s cn tr ng dn kh tng dn. Hn na
v mcn c s tng hot h ph giao cm cng lm tng tnh trng co tht. kh th khi nm, triu

NI C S

40


chng s gim bt khi bnh nhn ngi dy, cn bnh nhn b kh th kch pht v m thng ln cn ho
v kh th thm ch sau khi h ngi dy. Hen tim cng c lin h mt thit vi kh th kch pht v m,
c c trng bi ting th rt do s co tht ph qun.

Ngun:Harrison
PHN BIT KH TH TRONG BNH TIM MCH V
KH TH TRONG BNH V H HP

- Kh th do tim rt kh phn bit vi kh th do bnh l phi v nhng nguyn nhn khc.
- Cn hi k tin s v nhng bnh l tim mch mc trc y m c th gy ra tnh trng suy
tim.
o Tin s nhi mu c tim gim sc co bp ca tm tht tri ngh n suy tim tri.
o Tin s tng huyt p suy tim tri.
o Tin s ung nhiu ru nng Ngh n bnh c tim do ru ( alcoholic
cardiomyopathy).
o C s xut hin ca kh th nm gi nhiu hn kh th do suy tim hn l kh th
do bnh l v phi
PHN BIT HEN TIM V HEN PH QUN
Hen Tim Hen Ph Qun
Kh th hai th, kh th nhanh nng Kh th th th ra, kh th chm ( giai on
u cha suy h hp)
C tin s bnh tim mch C tin s d ng, bnh h hp
Phi m Phi sng ( kh ph thng)
Tng huyt p Huyt p bnh thng
C rale m dng ln nh nc thy triu (khi
giai on ph phi cp)

- Tuy nhin, l nhng trng hp in hnh. Trn lm sng c nhng trng hp rt kh phn
bit. Khi chng ta cn phi thm khm t m, kt hp cc xt nghim thch hp c c
chn on.


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13. HO RA MU TRONG HP VALVE 2 L
NH NGHA
- Ho ra mu ( hemoptysis): Mu t pha di thanh qun c tng ra ngoi sau khi ho
NH GI HO RA MU
- Mu c thc s xut pht t ng h hp hay khng ? phn bit vi nn ra mu, chy mu
hu hng, ming..
PHN BIT HO RA MU V NN RA MU
BIU HIN HO RA MU NN RA MU
Tin triu
Nguyn nhn
Hnh thi
Biu hin
Thnh phn km theo
Triu chng km theo
pH
Ho
Bnh l tim phi
C bt
ti
Ln m
Kh th
Thng pH kim
Bun nn, nn
Bnh tiu ho
Khng c hoc bt t
Nu sm, hay nu , mu b c ph
Ln thc n
Bun nn
Thng pH toan
NGUYN NHN GY HO RA MU
BNH NG H HP
- Lao phi - 81%
- Gin ph qun - 8.4%
- K phi, K ph qun 3.3%
(3 nguyn nhn ngh n u tin khi bnh nhn ho ra mu)
- Vim phi, vim ph qun
- p xe phi.
- Nm phi, sn l phi.
- Hi chng Goodpasture.
BNH L TIM MCH
Cc bnh lm tng p lc tun hon phi:
- Hp valve 2 l.
- Suy tim tri do cao HA.
- Bnh tim bm sinh
- Tc ng mch phi, v phnh ng mch phi

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BNH V MU
- Bnh bch cu cp
- Bnh a chy mu
- Gim tiu cu tin pht, th pht ( st xut hut)
- Cng lch.
- Suy gan ( gim yu t ng mu)
- Suy thn ( hi chng tng ure mu)
- ng mu ri rc trong lng mch.
- Thiu Vitamin C.
CHN THNG NGC, D VT NG TH, TH THUT PHI- PH QUN
V CN - 1,63%.
Hi chng Goodpasture: Bnh l t min do khng th khng mng y cu thn, mng y ph nang gy xut
huyt phi v vimcu thn
Ngun: Ni c s - YDH.
CC BC NH GI V THEO DI BNH NHN HO
RA MU


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43


(Ngun:Answer.com)
UI KHI HUYT TRONG HO RA MU
- ui khi huyt l 1 khi nim tng trng, ngha l n khng c hnh dng nht nh m
ch m t s kt thc ca mt qu trnh ho ra mu.
- Trong trng hp ho ra mu ko di nhiu ngy:
o S lng mu ho ra gim dn.
o Sau c mu sm ri cui cng l en.
ui khi huyt.
o Khi c ui khi huyt l chm dt 1 giai on ho ra mu.
HO RA MU TRONG HP VALVE 2 L
Nguyn nhn: Do v ch ni tnh mch phi v tnh mch ph qun hu qu trc tip ca tnh
trng mu nh tri lm tng p lc tnh mch v mao mch phi
C ch:
- Do tng p tiu tun hon s lm cho cc mao mch ph nang cng nh cc mao mch trong
phi cng t, gin ra, thnh mch mng hn. Di p lc mu ln ng thi dng chy b chm
li s y hng cu, huyt tng vo trong lng ph nang.
- ng mch ph qun nhn mu t hai ngun: MC v cc ng mch gian sn nui phi.
Tnh mch ph qun mu v tnh mch n ri v tim phi( chim khong 1/3 ). T cc ph
qun cp ba th mu tnh mch ph qun c tnh mch phi thu nhn. l cc shunt tri phi
sinh l. Do s thng ni m khi p lc tiu tun hon tng s tng vic m cc shunt v to
nn cc mch bng h ni tnh mch ph qun vi tnh mch phi. Cc mch mu nh nm gia
hai h thng c p lc cao s rt d v. Mu vo trong cc tiu ph qun gy ho ra mu.
Tnh cht :
- Thng ho ra mu tng t mt nn him khi gy ra t vong
- Khi tin trin hp van hai l nng ln lm tng sc cn cho tun hon phi (gy suy tim
phi) hoc khi xut hin h/ hp van ba l cc triu chng ho ra mu, ph phi cp gim i v
tn s v trm trng (gim s chnh lch p lc gia i v tiu tun hon)
Chn on phn bit
Nhi mu phi: khc m mu sm ( do kmtheo mt phn nhu m phi hoi t)
- L hu qu ca tnh trng tc mch phi: bnh cnh thng cp tnh, au ngc d di, kh
th. Cc mch mu b tc gy tn thng ni mc mch mu v phn ng ra xung quanh
gy gin mch, thot mch dn n tnh trng d vim nhim, hu hoi nhu m nn bnh
nhn khc m km theo nhu m hoi t.

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44


Ph phi cp: Thng gp trong suy tim tri: do lu lng tun hon t tim tri gim t ngt
trong khi tun hon tim phi cn bnh thng hoc tng do yu t bn ngoi ( truyn lng dch
ln) dch trn ngp ph nang khc ra bt hng.
HI CHNG GNG SC TRONG HP 2 L
- Kh th khi gng sc.
- Ho ra mu.
- Hen tim.
- Ph phi cp.

14. AU THT NGC
M T
( y chng ti m t c im ca cn au tht ngc n
nh)
- V tr : sau xng c .Thng bo bnh nhn dng mt ngn
tay ch vo ch au nht, trong trng hp ch chnh xc vo
vng mm tim, au nhi thong qua thng khng phi do
nguyn nhn mch vnh. .
- Cng : au d di lm bnh nhn ht hong c cm gic
nh sp cht
- Tnh cht : nn, chn ngc, co tht, bp nght
- Hng lan :
o Hng lan ln mt trong cnh tay tri n ngn tay tri
4, 5.
o C th lan ln vai ra sau lng, ln c, hm, rng
o Thm ch xung vng thng v
- Hon cnh xut hin : xy ra khi nhu cu oxy v cht dinh dng cho tim tng ln:
Khi gng sc, mt hoc gim khi ngh ngi, hoc dng thuc gin vnh (trinitrin).Mt s thuc
gin mch ngoi vi khc nh thuc chn canxi lmgim mu tnh mch tr v tim nn lm gim
hot ng c tim nn cng lmgim cn au.
- Sau cm xc
- Tri lnh
- Hoc mt cn nhp nhanh
- Sau mt ba n thnh son

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45



Thi gian: thng rt ngn : vi giy n vi pht. Nu cn au ko di qu 30 pht, c kh
nng tt mch vnh, bo hiu cn nhi mu c tim.
Gi tr chn on : c tnh trng thiu nng mch vnh
PHN LOI
Cn au tht ngc

n nh Khng n nh

in hnh Khng
in
hnh
in hnh Khng
in hnh


au tht ngc n nh ( vi cn au tht ngc in hnh m t trn): xy ra do s hp trn 75%
mt hay hp nhiu nhnh ca ng mch vnh. Lu lng vnh c th cung cp oxy cho nhu
cu c bn ca c tim nhng khng khi tng nhu cu - khi gng sc, do vy cn au gim khi
ngh ngi (do gim nhu cu).
au tht ngc khng n nh (hay au tht ngc thay i hoc tng dn):
L cn au tht ngc c t nht 1 trong 3 c im:
- Mi khi pht cn au tht ngc nng (<2 thng) v/hoc cn au xy ra >=3 cn/ngy
- au khi ngh ngi hoc l ch khi hot ng rt nh nhng
- Cn au tht ngc tng tin: thuc loi n nh nhng gn y au nng hn, au ko di hn,
hay xy ra hn v vi gng sc nh hn trc
(Ngun: sch Bnh hc ni khoa - H Y Dc Hu - Tp 1)

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Cn au tht ngc khng n nh xy ra khi ngh ngi l 1 du hiu nguy him. N th hin
cc mu ng c hnh thnh v tr mng x va (m t bn di), nu khng iu tr s
dn n nhi mu c tim v nhng tn thng khng phc hi.
20% tin trin n nhi mu c tim cp trong 3 thng
Thiu mu c tim th im lng
Co tht vnh (cn au ngc Prinzental) - xy ra do s co tht t ngt mch vnh ti hoc
gn mng x va. p ng rt nhanh vi thuc gin vnh.
Nhi mu c tim: Cn au trong cn ko di trn 30 pht, c th c tin s cn au tht ngc
trc hoc khng c. au d di lan ta khp lng ngc c cnh tay tri ngn 4, 5 bn tay.
- Khng ht cn au khi dng thuc gin vnh nhanh nh nitroglycerin
- Da vo in tim c 3 c im c bn
o Sng Q hoi t
o Sng ST chnh tn thng
o Sng T thiu mu
- Cc men tim tng do hoi t c tim
o Troponin
o CK
o CKMB
o LDH
AU THT NGC IN HNH V KHNG IN HNH







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Lu lng
vnh gim
Oxy nui dng c
tim gim
S loi tr cc
sn phm cn
o thi gim
Sn phm chuyn
ha nhiu acid
lactic, histamin
Kch thch cc u dy
thn kinh cm gic
PHN X AU
Chuyn ha ym kh
PHN BIT CN AU THT NGC N NH V KHNG N NH.

n nh Khng n nh
D on trc D on trc c Xy ra ngu nhin, khng d on
trc c
Yu t lm d Sau gng sc hoc xc cm mnh Khng c yu t lm d, thm ch c
th xy ra lc ngh ngi.
Ko di Thng ch ko di trong vng vi pht Ko di lu hn ( >10pht)
Vai tr ca Nitroglycerin c lm du bi Nitroglycerin Khng lm du bi Nitroglycerin
Mc trm trng Trm trng hn, nguy c tin n
nhi mu c tim
C ch gy au trong nhi mu c tim
AU THNG V V CN AU THT NGC
i vi bnh nhn au thng v, cn loi tr trng hp l au tht ngc trc khi ngh
n au d dy. Nht l nhng trng hp nhi mu c tim vng sau di c th khi pht vi
au vng thng v. Nu khng ch c nhng chn on v iu tr kp thi th s a li
nhng hu qu nghimtrng, thm ch c tnh mng bnh nhn.
Lm sng cp cu: Mt bnh nhn (khong trung nin) vo vin vi triu chng c au
thng v, th cn phi khm k v bnh tim mch: Hi k tin s, nghe tim, o ngay ECG (lu
cc chuyn o DII, DIII, aVF) gin bit. Nu cn nghi ng c th yu cu lm xt nghim
men tim.

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X va mch vnh au tht ngc
n nh.
Cc mu ng hnh thnh au
tht ngc khng n nh
C CH GY RA CN AU THT NGC KHNG N NH


Minh ha c ch gy ra cn au khng n nh
Cn au tht ngc khng n nh thng do s v ra ca 1 mng x va trong ng mch
vnh.
- Trn nn ca v tr v ny trn mng x va ,
cc mu ng thng s c hnh thnh, vo to ra 1
s tt nghn cc b ng mch.
- Tuy nhin, cc mu ng ny li khng n
nh, n c th ln ra ri . V v th, gy ra 1 cn au
n ri i khng d on trc c v khng h lin
quan n s gng sc.
o Cc mu to ra cht hp au tht
ngc
o Cc mu tan i hoc tri i ht cht hp ht au
- Khng lin quan n gng sc: khi no c cc mu ng au, ht cc mu ng ht
au
- Nu cc mu ng gy ra s tt nghn hon ton ng mch (xy ra ph bin), s gy ra cn
nhi mu c tim v gy ra nhng tn thng khng phc hi cho c tim.
- Hay ni cch khc, nguy c xy ra nhi mu c tim l rt cao bnh nhn c cn au tht
ngc khng n nh.
- Cn au tht ngc khng n nh l 1 cp cu y khoa.
Ngun: http://heartdisease.about.com/cs/coronarydisease/a/unstableangina.htm

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t v mng x va hnh thnh
nt tiu cu Hi chng vnh cp
HI CHNG VNH CP
- Hi chng vnh cp (acute coronary syndrome) bao
gm nhi mu c tim c ST chnh, nhi mu c tim
khng c ST chnh v cn au tht ngc khng n
nh.
- Nguyn nhn do s nt v ca mng x va, hnh
thnh huyt khi do tiu cu v co tht mch mu.
- Bnh cnh lm sng gm c au tht ngc lc ngh ngi, au tht ngc mi xy ra, nhi mu
c tim c ST chnh v au tht ngc sau nhi mu c tim.
SUY MCH VNH (SMV)
- SMV l hin tng tc nghn mt phn hay ton b ng mch vnh, do x va ng mch
hoc do co tht mch vnh. Hu qu dn n thiu mu nui dng cho c tim.
- X va ng mch vnh l do lng ng m lp di ni mc ng mch vnh. Tnh trng
x va tin trin dn dn lm hp ng mch hoc hnh thnh cc mu ng gy thuyn tc
trong lng mch. Gy cn au tht ngc, nhi mu c tim v cht t t.
- Suy mch vnh c ngha rng hn hi chng vnh cp.
PHN LOI AU THT NGC KHNG N NH THEO BRAUNWALD
c im
I au ngc khi gng sc:
Mi xy ra, nng, tin trin nhanh
au ngc mi trong vng 2 thng
au ngc vi tn s dy hn
au ngc gia tng khi gng sc nh
Khng c au ngc khi ngh trong vng 2 thng
II au ngc khi ngh, bn cp:
au ngc khi ngh xy ra trong vng 1 thng nhng khng
phi mi xy ra trong vng 48 gi
III au ngc khi ngh, cp:
au ngc xy ra trong vng 48 gi
Cc hon cnh lm sng
A au ngc th pht: xy ra do cc yu t khng phi bnh
tim mch nh thiu mu, nhim trng, cng gip trng,
thiu xy...
B au ngc t pht
C au ngc khng n nh sau NMCT: trong vng 2 tun
sau NMCT

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15. TNH MCH C NI TNH MCH CNH
TRONG
( y chng ti m t cch o p lc tnh mch
c (J ugular venous pressure (J VP)).
Tnh mch c ni l php nh tnh, o p lc
tnh mch c l php nh lng. C s tng
ng trong 2 phng php.
T VN :
- Do khng c valve gia tm nh phi v tnh
mch cnh trong. Nn mc cng phng ca
tnh mch ny c th cho ta bit c p lc trong tm nh phi.
- Tnh mch cnh trong nm pha sau c c n chm ri tin vo nguc gia u c v u
n ca c v th ch c th khm tnh mch ny khi cc c c t th hon ton gin.

- Tnh mch cnh ngoi nng hn v d nhn thy hn. Tuy nhin, khng nn khm n nh gi
p lc nh phi v n ngon ngho v b nghn 1 phn khi i vo lp mc su c.



NI C S

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PHN BIT NG MCH CNH V TNH MCH C
NG MCH CNH TNH MCH C
- Di chuyn ra pha ngoi - Di chuyn vo trong
- 1 nh (nhp p) trn mi nhp tim - 2 nh (nhp p) trn mi nhp tim (nhp
xoang)
- S thy c - Khng s thy c
- Mch p khng b nh hng khi ta
nn c
- Mch p gim i hoc bin mt khi ta
nn c
- Khng ph thc vo nhp th - Chiu cao ca mch thay i theo nhp th
- Khng ph thuc vo t th bnh nhn - Thay i ph thc vo t th bnh nhn
- Khng ph thuc vo p lc bng - Tng ln cng vi p lc trong bng.
(Tnh mch c c 2 nhp p trn mi nhp tim: nh th nht khi tm nh phi co, ngay trc ting tim th nht. nh th 2 do
s y ca tm nh phi trong sut thi k tm thu khi valve 3 l ng)
Thng nh gi TM cnh trong phi hn TM bn tri:
- TM cnh trong phi phn nh trc tip tnh trng nh phi
- TMC tri c th b gp, bi nhiu cu trc xung quanh v bi MC (nu MC gin).
- TMC bn tri phi chy vng sang bn phi trc khi vo nh phi v th khng phn nh
chnh xc p lc trong nh phi.
BNH THNG
- p lc trung bnh trong tm nh phi bnh thng l 7mmHg ( 9cmH20).
- Do gc c cao hn tm nh phi khong 5cm, v th mch p ca tnh mch c (jungular venous
pulse) nhn thy khng cao hn 4cm trn gc c.


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52



- Khi bnh nhn t th ngi, s khng thy mch v n b n pha sau xng n v xng
c.
- Khi bnh nhn t th fowler, gii hn trn ca mch s ngang mc xng n. Nu khng
thy mch, chng ta c th n nh vo bng ca bnh nhn 1 vi
giy t lm tng lng mu tr v tim, v lm tng p lc
trm tht phi, t chiu cao ca mch tnh mch c c th tng
ln khong 2-3cm.
BNH L:
Nu t th Fowler, mch p ca tnh mch cnh trong cao
hn 4cm trn gc c c tng p lc trong tm nh phi.
CCH KHM
-
Bnh nhn t th Fowler 45
o.
- m bo cc c c bnh nhn phi gin hon ton bng cch cho bnh nhn gi u ln 1 ci
gi.
- Nhn c bnh nhn t pha bn phi.
- Xc nh mch p ca tnh mch cnh trong ( nu cn thit c th lm phn hi gan tnh mch
c).
- c tnh chiu cao (cm) t nh trn ca nhp p v gc c cho ta nh gi p lc ca tnh
mch.
- Nu cn thit, c th iu chnh t th bnh nhn mch ni r hn.

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53


Gan ln + phn hi gan tnh mch
c (+) Suy tim phi


LU NHI KHOA
- Tnh mch cnh ni rt kh nh gi ( i khi khng th) phn ln tr nh do chng c c
ngn v dy (m). Ngay c vi nhng a tr tui i hc th, vic o lng tnh mch c
ni i khi khng ng tin cy do gc c khng c cng khong cch ( 5-7 cm) trn nh phi
nh ngi ln.

16. PHN HI GAN TNH MCH C
CCH KHM
- T th bnh nhn nh trn
- t bn tay ln vng h sn phi, p trong vng t nht
10 giy (thi gian phi lng mu t gan v TMC
nhiu), ngi bnh th bnh thng
KT QU
- Bnh thng: TMC cng ln mt t ri li tr v bnh thng
- Phn hi gan TMC (+) TMC phng to hn trong sut thi gian lm nghim php. Tnh
mch ni lu hn, khi th tay ra tnh mch xp tr v bnh thng lu hn
NGHA
- Bnh thng cc tnh mch trn gan cng nh cc tnh mch ngoi bin mu vo tnh mch
ch v nh phi ri a xung tht phi tht phi bm mu ln phi, thc hin chc nng

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54


trao i kh. Khi chc nng ny ca tht phi b gim st gy ra tnh trng tr tun hon, tng
p tnh mch h thng. Mu li gan, ngoi bin. Khi n vo gan lm tng lng mu tr v
nh phi nhiu tuy nhin do chc nng tng mu ca tht phi b suy gim nn khng th tng
ht lng mu thm vo trn nn mu li nh phi lm tng p lc ti nh phi, tnh mch ch
cng nh cc tnh mch ngoi vi khc.
NGOI L
- Gan to, nhng phn hi gan tnh mch c m tnh: Gp trong hi chng Budd-Chiari, s cn
tr mu tr v tim khi lm nghim php phn hi gan-TMC l do tnh mch trn gan b chn p
(c th do khi u bn ngoi chn vo, huyt khi, kn sn l gan, p xe.., gn v tr ca tnh
mch trn gan vo tnh mch ch di)
- H ba l tnh mch c p theo nhp tm thu (do mu tr v gan tng t trong tm thu do
van ba l b h)
- Gan to, tnh mch c ni nhng khng suy tim phi: ( gi suy tim phi, tng t nh hp van
hai l l trng hp gi suy tim tri ) gp trong :
Vim mng ngoi tim co tht ( Hi chng Pick ).
Hi chng p tim cp.
Trong hai hi chng ny thc cht tim phi cha suy nhng do tim b
dch, t chc x lm cn tr s gin ra ca tim trong th tm trng, gia
tng p lc trong cc bung tim. Nn lng mu tim nhn v trong th tm
trng gim xung, gy mu gan, cc tnh mch ngoi bin ( gi l
suy tm trng).
Trong hi chng chn p tim cp do trn dch mng ngoi tim khi ht vo,
tnh mch c phng to hn (nghch thng)- Du Kussmal. Km theo tam
chng Beck ( huyt p ng mch h, p lc tnh mch tng, ting tim
m, xa xm), trn ECG c du hiu giao lu in th, trn siu m c du
sp tht phi..
Do khi ht vo tng lng mu v TMC nhiu hn, nhng do tht phi hn ch trong vic
y do trn dch nn lm cng lm tng p lc nh phi cng nh p lc tnh mch ch.
KHI NO KHNG LM PHN HI GAN TNH MCH C
- Khi tnh mch c ni t nhin khng lm phn hi gan tnh mch c na.
- Khi suy tim m gan khng ln.
Ngun:Bs.XunTi



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17. XC NH MM TIM
NHN:
- Bnh thng mm tim p trn khong gian sn 4-5 , trn ng trung n tri
- Khi tht tri gin ln, mm tim p thp xung di (gian sn 5-6), chch ra ng
nch trc.
- Din p ca tim c bn knh khong 1-2cm. Tht tri gin din tim p rng.
- Tht phi ln c th nhn thy mm tim p mi c.
S
- Ngi bn phi bnh nhn, bnh nhn nm nghing bn tri, s tt nht th th ra.
- Thy thuc dng bn tay p ln vng trc tim. Ngn tr v ngn gia xc nh gian
sn 4, giao im gia gian sn 4 v ng trung n tri.


THAY I V TR CA MM TIM
Sinh l : thay i t th thay i v tr ca mm tim
Bnh l:
- Trn dch mng ngoi tim: khng s thy mm tim
- Bnh l tim to ra: mm tim thp xung di hoc ra ngoi ng trung n.
- Trn dch, trn kh mng phi mt bn, dy dnh mng phi v mng tim mm
tim b y lch sang mt bn ( trong trng hp ny, kh qun cng b y lch)
- Dy dnh mng tim, dnh vi phi tip cn lm din tim nh li v mm tim khn
thay i khi thay i t th
- Trn dch mng bng, hoc mt khi u to trong bng c honh b nng ln
mm tim t th nm ngang.


NI C S

56


THAY I V CNG KHI S
- Mm tim p mnh: gp trong cng kch thch ( Basedow, cng giao cm, h van
MC), ph i tht tri do hp valve ng mch ch, tng huyt p hay thng lung tri
phi ( cn phn bit vi din tim p rng do s gin tht tri trong h valve ch, h
valve 2 l)
- Mm tim p yu: bnh nhn bo ph, thnh ngc dy, kh ph thng, trn dch mng
ngoi tim, xp phi, tim p yu.
MT S BT THNG KHC
- Din tim p kiu vm Bard: gp trong h van MC- mm tim p v tr thp, sang
tri mnh, di vo lng bn tay trong tm thu, rt mnh v pha lng ngc trong tm
trng.
- Du p ca MC trn hm c
- Nhp p bn phi do phnh quai MC
- Du chm phu ( gian sn 2 bn tri): do phu phi gin (thng gp trong suy tim
phi)
- Du Hazer: do tht phi gin hay ph i, khi t ngn tay di gc sn mi c tri
v hng ln trn, (c th cn phi ht su mi thy bnh nhn mp ph, thnh ngc
dy)
Cn phn bit vi: nhp p ca ng mch ch hoc gan p : hng p t
sau ra trc (nhp p c hng t tri sang phi, t trn xung di )
Rung miu:
- Cm gic xc gic do dng mu xoy mnh (tc dng mu i nhanh) vo cc bung tim,
ccmch mu ln xung ng do dng mu v chm lm rung cc cu trc van, thnh c,
thnh mch mu ln c truyn n tay nh cm gic s ln lng mo
- C cm gic rung miu khi cng ting thi 4/6
- Gi tr c rung miu tn thng thc th
o Rung miu tm thu: pht sinh t ting thi tm thu. Gp trong:
mm tim: h 2 l
van MC (GS 3 bn tri, GS 2 bn phi v hmtrn xng c) hp
van MC (rung miu thng lan ln pha bn phi c ri xung mmtim)
van MP (GS 2 tri hoc thp hn) hp van MP (thng l rung
miu ti ch nhng cng c th lan ta ln pha c tri)
( mmtim, khm t th nghing tri, y tim khm t th nghing ra trc)
o Rung miu tm trng pht sinh t ting rung tm trng gp trong hp van
2 l
o Rung miu lin tc, mnh ln cui thm thu thng lin tht (rung miu tm
trng thng khu tr vng GS 3 , 4 bn tri)

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57


P KIU VNG BARD TRONG H VALVE NG
MCH CH NNG
- Gp trong h valve ng mch ch nng.
- Mm tim p thp, chch sang tri.
- Mm tim p mnh, di vo lng bn tay lc tm thu, rt mnh v pha lng ngc
lc tm trng.
p di dng vm ca tc gi BARD
BNG TM TC CC DU HIU KHI S MM TIM V DIN TIM.

M T
NGHA BNH L
Cng mm
tim
p mnh
Ph i tht tri Tng huyt p


Hp valve M ch


Shunt tri phi


Cng kch thch Basedow


Cng giao cm

p yu
Bo ph


Thnh ngc dy


Kh ph thng


Trn dch mng ngoi tim


Bn thn tim p yu
V tr mm tim

Xung di v ra ngoi
Ph i v gin tht
tri

Lch ra ngoi trung n tri
Trn dch mng phi


Trn kh mng phi


Ct b phi.


Xp phi

Nm ngang
Tng p bng Trn dch mng bng


(C honh nng
ln) Khi u ln trong bng.
Din tim
p rng
Gin tht tri H ch.


H 2 l
Rung miu
Tmthu
Mm tim H 2 l


valve ng mch
ch Hp valve ng mch ch


valve ng mch
phi Hp valve ng mch phi

Tm trng
Hp valve 2 l


H valve ng mch ch


H valve ng mch phi.

Rung lin tc
Thng lin tht.


Cn ng ng mch
Cc bt thng
khc
Thy tim p cnh c tri
(Harzer)
Ph i v gin tht
phi Tng p phi

Du chm phu
Suy timphi

Din tim ku vng Bard
H valve ng mch ch

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18. GAN TO TRONG SUY TIM
(Khmgan ln c m t k hn phn tiu ha)
- Gan to trong suy tim l do suy tim phi hoc suy
tim ton b cn tr mu tun hon tr v tim
phi mu ti gan gan to.
C IM
- Gan to u gim khi ngh ngi hoc iu tr tch
cc vi thuc li tiu (khi gan to va) gan n
xp.
(Tuy nhin gan mu lu ngy gan thiu Oxy ko di hoi t t bo nhu m gan
quanh tnh mch trung tm tiu thy hnh thnh t chc x (b gan sc, mt chc)
+ khng nh li khi iu tr bng thuc li tiu x gan tim)
- B t
- Mm, mt nhn
- n vo au tc, phn hi gan tnh mch c dng tnh
( Hay ni ngn gn: Gan to b t mt nhn n au tc)
19,20: Ni triu chng 17.

21,22. MCH NY, MCH YU (tru mch)
NH NGHA: Mch ngoi vi m ta bt c (mch quay, mch cnh,) l do sng mch
c truyn ra t mch p ca ng mch ch trung tm c c b s co bp, tng mu ca
c tim.
MCH NY: c ch l do :
- Tng th tch tng mu tm thu tht tri ( H van MC, bnh l c th tch tm thu cao bt
thng , block nh-tht, h van hai l, thng lin tht)
- Tng ng tun hon : lo lng,thiu mu, tp luyn, st,
- Mu thot nhanh bt thng qua khi ng mch (cn ng ng mch, l d ng- tnh mch
ngoi vi)
- Gim sc cn ngoi vi
- Ch nhi khoa: Mch ny c th l bnh thng tr nh do cc ng mch nm nng di
da. N cn c th l do cn ng ng mach nu shunt tri phi ln.

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MCH YU :
- Do gim th tch tm thu tht tri, gim p lc mch p, tng sc cn ngoi vi.
- Do gim sc cn ngoi vi nh trong trng hp try mch.
MCH YU DO TRY MCH :
- L do gim sc cn mu ngoi vi m c ch ch yu l s gin t ngt ca h thng tiu ng
mch. Nhng nguyn nhn thng gp :
Xut pht t trung tm vn mch : nh nhim c, nhim khun.
Ti mch : ng c thuc gin mch, chc rt qu nhanh dch t trong c th (dch bng,
dch mng phi..)
LM SNG
- Huyt p tt
- Xay xm, ti mt, bn rn tay chn, nhp tim nhanh, yu, thiu oxy no
1 S DNG MCH BT THNG KHC
Mch khng u Ngoi tm thu
Lon nhp hon ton
Rung nh
Mch nh Hp l kht
Hp valve ng mch ch
(Mch ln nhanh xung chm)
Mch nh nh Tt huyt p
Mch ny mnh, cng
cng Tng huyt p
Mch ny mnh, chm su H valve ng mch ch.
Mch Kussmaul
(Mch nghch thng)
Trn dch mng ngoi tim
Hen ph qun, COPD
(gy kh th nng)
Mch lun phin Suy tim nng
(1 nhp bnh thng, 1 nhp
yu)
Mch nhp i
(2 nhp i lin, sau l
khong ngh di) Ngoi tm thu


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Ngun: Ni c s - YDH
MI NH HA
MCH BNH THNG

Mch bnh thng khi bt, ta c cm gic nh 1 ci g nh vo u ngn tay.

HP VALVE NG MCH CH


Do c s cn tr dng mu ra ng mch ch. Nn khi bt mch, ta khng c cm gic nh 1 ci
g nh vo u ngn tay na, m c cm gic nh c 1 ci g vut ve u ngn tay (), 1
ci y nh nhng.
Bn cnh , ta c th s thy rung miu ch yu ng mch cnh trong bn tri.
(NOTE: Nu ng mch cnh p chm hn so vi mm tim, khi c th d on vng valve
hp <1cm2 ( c hiu 100%))
H VALVE 2 L V THNG LIN THT

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- c im chung: Th tch tng mu tng, nhng p lc mch bnh thng.
(p lc mch: hiu gia huyt p tm thu v huyt p tm trng)

Th tch tng mu tng trong h valve 2 l l do 1 lng mu ln tr v tm tht trong thi k
tm trng, lng mu t tnh mch phi v lng mu b tro ngc trong thi k tm thu.
Trong thng lin tht, tm tht tri nhn mu thm t shunt t tht phi chuyn sang.
Theo nh lut Starling, tm tht tri s tng sc co bp, tng mu mnh hn trong
Mch ny rt mnh.

MCH TRONG H VALVE NG MCH CH, CN NG NG MCH
- c im chung: th tch tng mu tng, p lc mch cng tng.
H ch: Huyt p tm thu rt cao, do 1 th tch mu ln c tng ra. Th tch mu ln ny l
do 2 ngun: mu t tm nh tri v mu pht ngc t ng mch ch trong thi k tm trng.
Theo nh lut Starling, tht tri s tng co bp.
Tuy nhin, huyt p tm trng li thp, v c 1 lng mu pht ngc tr li tm tht tri
(thng <50mmHg)
Cn ng ng mch: c ch tng t
Mch di rt mnh vo u ngn tay sau chm xung (bin mt) 1 cch nhanh
chng, hay gi thut ng l mch ny mnh chm su.

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(Mch ny mnh chm su d bt nht bng cch a tay bnh nhn chch thng ln tri.
Khi huyt p tm trng s gim xung).NOTE: Nu o huyt p tm trng khi chch thng
cnh tay ln tri < 15mmHg so vi t th truyn thng bnh nhn c l b h valve ch)
MCH DI I (PULSUS BISFERIENS)
- Tc l c 2 nhp p trn mi nhp tim khi bt mch. Trong 1 nhp u thi k tm thu, v 1
nhp gia thi k tm thu.
Nguyn nhn: Do tc dng mu chy rt nhanh qua valve ng mch ch. Ti nh cao
nht ca dng chy, do hiu ng Bernoulii (hiu ng ht, ging khi 1 on tu i ngang qua
th n s to ra 1 p lc m pha sau n ht nhng vt xung quanh vo) lm gim t ngt
p lc vch ca ng mch ch t gy ra 1 ting p th 2.
Khi c mch di i, gi bnh l kt hp gia h ch nng km theo hp ch tng
i.
- nhn bit mch di i, bt mch nh nhng ng mch cnh, cnh tay, ng mch quay
hoc i. (Mch d bt nht ng mch cnh). Cng lc y lng nghe ting tim bnh nhn nu
c 2 nh bt lc th tm thu. Nu c bn s cm thy c mch i gia ting tim th nht v th
hai.
(H ch 1 th tch mu ln c tng ra, hp ch vn tc dng mu tng ra ln) Hoc
trong trng hp valve ng mch ch kt hp vi ph i c tim


MCH LUN PHIN

- Ngha l nhng mch mnh v mch yu lun phin nhau, th hin th tch tng mu lc cao
lc thp.
- Gi tinh trng suy tim tri.

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Tin lng xu.
C CH:
- Trong suy tim tri, phn xut tng mu ( ejection fraction) s gim ng k, v gy ra s gim
th tch tng mu, v lm tng th tch cui tm trng. T s to ra c ch b tr c th
m bo cung lng tim khng i Kt qu l trong thi k tm thu tip theo, do c tim gin
ra qu mc s tng sc co bp theo nh lut Frank Starling. Gy ra 1 nhp mnh hn.
MCH NGHCH THNG (KUSSMAUL)

C ch:
- Ht vo gim p lc nh P ( tng p sut m )v p lc trong khoang mng tim tng lng
mu tnh mch tr v tng kch thc tht P y vch lin tht v bn T gim th tch
nht bp ca tht T v lu lng tim (chn p tim lm gim s ph thuc ln nhau ca tht)
- L mch m thi k ht vo, mch gim i ng k, nguyn nhn l do s tng p lc m trong
lng ngc, ht mu v tim, hn ch s tng mu t tht tri. Nu mch nghch thng c hiu
huyt p tm thu k th vo v th ra >10mmHg Bt thng.
Gp trong:
- Chn p tim cp: do trn dch mng ngoi tim, vim mng ngoi tim co tht.
- Bnh phi nng: Hen, COPD...




TM TC 1 S SNG MCH BT THNG:

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23. TING TIM BNH THNG :
CC NGHE TIM
4 thnh im chnh

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- Ch rng mi thnh im khng phi l hnh chiu v tr ca cc van trn thnh ngc m l v
tr cc sng m di mch nht ln thnh ngc t van tng ng
(Khng hon ton tuyt i : v d thi tm trng trong h van MC thng nghe r mm
tim hn y tim)
Cc v tr khc
- ng mch c 2 bn ting thi trong hp van MC
- Vng di xng n nghe ting thi lin tc trong cn ng ng mch
- B tri b phi xng c
- Vng trong mm tim cc triu chng ca van hai l thng r vng ny
- Vng nch lng
- Vng b vai ct sng
T TH NGHE TIM
- Nm nga v c th lm mt s ng tc gng sc
- Nm nghing tri lm r thm cc triu chng xut hin mm tim nh rung tm trng
trong hp hai l, ting thi tm thu trong h hai l.
- Ngi ,ci ngi ra trc, 2 tay dui thng th ra ri nn th nghe r ting thi tm trng
trong h van ng mch ch.
- ng dy lm gim cung lng tim, phn bit c T3 bnh l hay sinh l.Khi ng, lm
gim th tch tht tri, a s ting thi gim tr hai ngoi l l ting thi ca bnh c tim ph i
tr nn to hn v ting thi ca sa van hai l s di ra v thng tng cng .
- Nm chn cao lm tng lng mu v tim, nghe r cc ting tim bnh l c ngun gc tht phi
nh: ting thi tm trng trong h van ba l, ting thi tm thu trong hp van ng mch phi.

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Nn th phn bit ting c mng
tim vi mang phi
- Ngi xm, lm tng c lng mu tnh mch tr v ln lc cn ng mch ton phn v nh vy
lm tng hu ti tht, a s ting thi tr nn to hn nhng
ting thi ca bnh c tim ph i va sa van hai l thng
nh i v c th bin mt. Du hiu ngi xm thng
gp trong t chng FALLOT. Trong F4 c s thng thng
gia hai bung tht, mu ng mch ch nhn i nui c
th l mu ca c hai tht c bo ha oxy thp (do nhn
mu ngho oxy t tht phi) gy ra triu chng kh th (ty mc t nh ti nng). Khi ngi
xm lm tng p lc trong bng lm tng p lc bn ngoi tc ng ln ng mch ch bng
lm tng p lc bn trong bung tht tri, gim c dng mu ngho oxy t tht phi chy qua.
Lm tng bo ha oxy mu ng mch gy ra cm gic d th hn.

CC BC PHN TCH TING TIM
- Nhp tim : u hay khng u, nu khng u th do h hp hay do tim. Nu c ngoi tm thu
th nh gi tn s ngoi tm thu/nhp ; nhp tim
- S lng ting tim : nhp 3, nhp 4
- Cc ting tim bnh thng.
- Cc ting bt thng
- Cc ting thi



CC YU T BN NGOI NH HNG N NHP TIM
Nn th : nghe c cc ting thi c cng yu do nhp th c th che lp(nht l khi c cc
rale phi).Ngoi ra nn th cn l phng php n gin v quan trng c th phn bit

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67


c ting c mng tim hay ting c mng phi nu ting c mang phi th khi nn th s
mt.Ngc li ting c mng tim vn cn
Nhp h hp : nh hng n p lc bn trong lng ngc nh hng n huyt ng ca tim
(NOTE : H hp c th gy lon nhp ngi ln ht vo lm tng nhp tim/ th ra lm tng
nhp tim.)
(Phn nh hng ca h hp n ting tim l 1 phn hay, c chng ti m t phn ring bn
di)
Tc dng ca dc l
- Thuc co mch nh : phenylephrin,methoxanthin...
- Thuc gin mch :amyl nitrit, trinitrin
- Cc ting thi tro ngc nh ting thi tm trng do h van ng mch ch, ting thi tm thu
do h hai l th thuc co mch s lm gia tng ting thi. V thuc s lm tng sc cn ngoi
bin, lm tng hu gnh, tng p lc mu ng mch vo k tm trng, lm mu pht ngc li
tm tht nhiu hn (i vi h cc van bn nguyt). Hoc do lm tng p lc ng mch nn ko
theo th tch tng mu tm thu gim, gia tng p lc trong bung tht, tng lng mu t tht ln
nh (i vi van nh tht ).
- Thuc gin mch c tc dng ngc li.
- Ngc li cc ting thi tng mu s mnh hn khi dng thuc gin mch v yu i khi dng
thuc co mch.
CC TING TIM BNH THNG V BNH L
T1,T2, c th c T3 sinh l
T1 :
Nghe ti a mm, trm, di
Trn tm thanh c cc thnh phn :
- C tim co v cng ra trong u tm thu
- ng van 2 l
- ng van 3 l
- Ct mu tng ln ng mch tng gia tc khi di chuyn
Cng T1 ph thuc vo:
- V tr l van 2 l khi bt u tm thu
- Tc tng mch p ca p lc tht tri
- C hoc khng c bnh ca van hai l
- S lng m.khng kh hay dch gia tim v ng nghe
T1 to hn:

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- Tm trng b rt ngn do nhp tim nhanh.
- Lu lng nh tht gia tng do cung lng tim cao hay ko di do hp van hai l( T1 to
trong hp van hai l thng biu th l van d un cong v cn m lc bt u co ng
th tch do p lc nh tri tng.)
- Nh co i trc tht co bng mt khong cch ngn bt thng ( biu hin trn ECG l
PR ngn )
T1 gim cng :
- Dn truyn km qua thnh ngc: ngi bo, thnh ngc dy, trn dch mng ngoi tim.
- Tng chm mch p p lc tht tri
- PR di.
- ng van khng hon ho v gim cht liu trong van: h van hai l, ba l, vim c tim,
vim ni tm mc gy ph n cc l van nh tht.
c bit :
- T1 cng yu khi l trc van hai l ng im v cng v vi ha, ngay c khi c hp van
hai l r rt.
- T1 tch i sinh l: do bnh thng valve 3 l ng mun hn valve 2 l <0.03s
T2
Nghe ti a y tim, cao,gn
Thnh phn :
- ng valve MC (T2C)
- ng valve MP (T2P)
Phn bit T2C, T2P
- T2C nghe r lin sn 2 bn phi v mm tim
- T2P nghe r lin sn 2 bn tri
T2 tch i sinh l : c th nghe c nhng ngi tr : do thi gian tng mu tm thu tht tht
phi di hn tht tri khong 0.02-0.03s nn van MP ng mun hn valve MC. Khi ht vo su
thi gian ny c th ko di hn, c th nghe c ting T2 tch i sinh l.

Gim Cung lng tim gim (mt nc, gim th tch
mu..)
Gim chc nng tht tri
Block nh tht cp 1( PR ko di)
H van hai l do thp tim
Tng Tng cung lng tim (st, cng gip, ...)

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T3 sinh l
- Ting u tm trng, do s y tht nhanh v th ng, mu t nh xung tht lm tht gin
nhanh v mnh, lm rung cc cu trc trong bung tim
- Sau T2C khong 0.12-0.2s (sau T2P) (phn bit vi T2 tch i sinh l )
- Thng nhng ngi tr tui khi nm , ng dy th mt T3 sinh l do gim lu lng mu v
tim. Khc vi T3 bnh l l ting nga phi ( du gallop ) u tm trng, khng mt khi ng.
- Nghe T3 bn tri : mm tim, nghe bng u nh ca ng nghe, vo th th ra, v bnh nhn
nm nghing tri.
- T3 bn phi nghe r b tri xng c hoc ngay di mi c vo th ht vo.
- Phn bit vi ting clack m valve hai l (ni sau)
NHP TH V TING TIM
NH HNG CA NHP TH N TING THI V S TCH I CA T2 SINH
L.
Hu ht ting thi v cc ting tim bnh thng, bt thng xut pht t bn phi tim u
tng ln khi ht vo. Ngc li cc ting tim xut pht t bn tri tim u gim i khi ht vo.
V d:
- Ting thi tm thu ti valve ng mch phi do hp valve ng mch phi s tng ln khi ht
vo.
- Ting thi tm thu ti valve ng mch ch do hp valve ng mch ch s gim i khi ht vo.
Gii thch:
- Khi ht vo, lm tng p lc m trong long ngc, v th c xu hng ht mu v tim phi nhiu
hn, v ngn cn mu ri tim tri.
Tng th tch tng mu (H van MC..)
Hp van hai l
Khong PR ngn li (nhp tim nhanh)
U nhy nh (him gp)
Thay i Rung nh
Ngoi tm thu
Block nh tht hon ton

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- Do 1 lng mu ln v tim phi cc ting tim xut pht t bn phi s to hn. Mu t tng ra
khi tim tri ting tim xut pht t tim tri s nh hn.
Khi ht vo, T2 sinh l tch i rng hn.

Gii thch:
- Ting T2 gm 2 thnh phn, 1 thnh phn do ng valve ng mch ch ( A2), 1 thnh phn do
ng valve phi (P2).
- A2 thng n trc, P2 n sau: l do l v p lc trong ng mch ch ln hn ng mch
phi, v th valve ng mch ch c xu hng ng trc valve ng mch phi.
- th ht vo, s lm gim p xut bn trong lng ngc (lm cho n m hn), t c tc dng
ht mu t tnh mch ch trn v tnh mch ch di vo cc bung tim bn phi. Phi chng ta
nh 1 thng m khi gin ra ng vai tr l 1 ci my ht ht, ht mu t 2 tnh mch ch vo
tm nh v tm tht phi. T l tng th tch tht phi tng th tch mu tng qua valve
ng mch phi thi gian tng mu lu hn lm chm s ng ca valve ng mch phi
P2 n mun hn.
- Hn na, th ht vo, cc mch mu phi gin ra lm gim p lc trong ng mch phi
gp phn gii thch s n mun ca P2.
Nghim php Valsava lm gim hoc mt s tch i ca T2.
- Nghim php Valsava: th ra ht sc, ri nn th (mc ch lm tng p lc trong lng ngc).
- Do p lc trong lng ngc tng gim s y 2 tht.
- Nn nh rng: khi lm nghim php Valsava a s ting thi gim v di v cng . Hai
ngoi l l ting thi tm thu trong bnh c tim ph i thng tr nn to hn v ting thi tm
thu trong sa van hai l tr nn di hn v to hn.

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1 S BNH L LIN QUAN N S TCH I CA T2


T2 TCH I RNG:
c nh ngha l 2 thnh phn A2 v P2 cch xa nhau t nht l 60ms (bnh thng: 30 -40ms)
Gp trong (ch yu l cc bnh l lmcho thnh phn P2 n mun hn):
- Bnh l lm chm s kh cc tht phi : Block nhnh phi.
- Nhng bnh l lm tng th tch mu trong tht phi lm ko di thi gian tng mu ca tht
phi: Thng lin tht, thng lin nh.
- Nhng bnh l lm tng gradient p lc qua valve ng mch phi: Hp ng mch phi
- Nhng tnh trng gy ra suy tim phi cp hoc mn: Tng p phi nguyn pht giai on sau,
cc mu ng phi.
T2 TCH I C NH ( khng c s thay i th ht vo ln th ra)
Thng lin nh.
Gii thch:
- Thng lin nh, do p lc bn tm nh tri cao hn nh phi, nn mu c xu hng i t nh tri
qua nh phi ( shunt tri phi).
- tim bnh thng, thi k ht vo, lng mu v tht tri s t hn so vi thi k th ra (do thi
k ht vo, p lc m trong lng ngc s tng ln, lm mu ht v pha tht phi nhiu, kmtheo
cc mch mu phi gin ra, cha nhiu mu gim lng mu v tim tri, ngc li, th th
ra cc mao mch phi co li, tng mu xung timtri)

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- Trong thng lin nh, lng mu v tht tri s khng gim i th ht vo v thm ch cn nhiu
hn hn do th ht vo, mu t cc tnh mch ch c ht v tm nh phi, t lm tng p
lc nh phi v lm gim bt lng mu i t nh tri sang nh phi. Lng mu khng i qua
nh phi s c tng xung tht tri, v th c xu hng duy tr 1 th tch mu khng i
tm tht tri th ht vo.



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TING T2 TCH I O NGC

- L ting T2 tch i theo th t P2A2 thay v A2P2.
- Dng nh lun lun do s ng li chm ca valve ch.
Nguyn nhn:
- Ri lon dn truyn lm chm s kh cc tht tri: block nhnh tri hon ton v 1 s dng
ca hi chng Wolff-Parkinson White ( WPW)
- Hp valve ng mch ch: lm tng gradient p lc qua valve ng mch ch. p lc tm tht
tri tng qu cao lm cho thi gian p lc tht tri gim xung valve ng mch ch
ng li ko di ra.
- Tng huyt p km tn thng c tim.

24.TING TIM TH NHT ANH
L 1 du hiu trong hp hai l
NGHE R :
- Mmtim
NGUYN NHN
- Valve 2 l dy, x cng, vi ho do tn thng ng t ngt cc l valve p vo nhau khi ng
- Mu dn v tht t trong giai on cn b, tht tri p ng bng cch tng co bp tmthu
ngn nghe gn.

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KHI NO T1 KHNG CN ANH NA TRONG HP 2
L
- Khi valve vi ha nng.
- Khi c h 2 l phi hp
- Khi c h ch phi hp
- Khi valve b gim di ng.
Ngun: Ni tim mch Thy Minh
KHONG P R V LN CA
T1
- Sng P th hin tm nh co lm tng p lc trong tm nh tri.
- S co ny ca tm nh lm cho valve 2 l m rng hn vo cui
thi k tm trng.
- Sng R th hin tm tht co. Khi p lc tm tht vt qu p lc
tm nh. S lm cho valve 2 l ng li, to ra ting T1.


A. Nu P- R ngn, tm tht tri co trc khi tm nh tri c thi gian gin ra v gim p
lc n xung. V p lc nh cn cao nh vy, p lc tm tht mun vt qu p lc nh
ng valve 2 l th phi cn 1 thi gian lu hn v t ti 1 p lc rt cao, to ra 1 s
gim tc t ngt ca dng mu v to ra 1 m thanh ln.
B. Nu khong P R di, tm tht co mun hn so vi trng hp A trn, tm nh c
thi gian gin ra v h p lc n xung. V th tm tht khng cn thi gian lu
vt p lc tm nh, v ti thi im p lc tm tht vt p lc tm nh, p lc 2 bn
cng khng cao lm, to ra s di chuyn ca l valve chm hn, m thanh du hn.
(NOTE: ngi ta cn gii thch nh sau, ting T1 ln trong trng hp khong P R ngn l
do ti thi im tm tht co, l valve 2 l ang m rng v pha tht. V h v l valve nh 1
cnh ca, cnh ca m cng rng th khi ng li th ting ng ca cng to. Cn trng hp

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khong P R di, th ti thi im tht co, nh c phn gin ra, 2 l valve khng m rng m
c phn co li v pha nh. V th khi ng cnh ca li th ting to ra nh hn. Nhng iu
ny ny c v khng chun bng gii thch trn, v c th xy ra trng hp cnh ca m rng,
nhng vn tc ng ca yu, th chc chn ting cng khng to)
LON NHP TIM V TING T1
Thay i ca ting T1 trong mt s ri lon nhp
Block nh tht 1:

- L dng Block trong khong PR c nh v lun ln hn 0.2ms.
- Do PR ko di nn ting T1 rt nh.
Block nh tht 2 Mobitz 1:








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- L dng block trong khong PR dn dn ko di ra, nhp sau di hn nhp trc, cho n
khi mt lun 1 nhp.
- Do khong PR ko di ra dn dn nh vy, nn ngi ta ngh ting T1 s nh dn, nh dn
cho n lc mt 1 nhp. Tuy nhin, nu PR qu di (>0.36s), do lng mu t tm nh tri
tip tc xung nh tri, p lc trong nh tri khng gim na, valve 2 l vn m rng, v
th ting T1 c to hn 1 x.
Phn ly nh tht:


- L dng Block trong nh p theo ng nh, tht p theo ng tht (P v QRS khng c s
tng quang).
- Nu P ting n gn QRS ting T1 to. P tin xa QRS ting T1 nh li.
- V th ta s nghe thy ting T1 thay i tht thng.




Trong block nhnh tri:

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L dng block do c ri lon lm chm dn truyn in
th vo tht tri, nn lm tm tht tri co bp chm li.
Ting T1 nh li.
c im:
QRS >1.0 s
Phc b QRS m V1, V2
Phc b QRS dng V5, V6 km theo c mc






25. TING TIM TH 2 MNH VALVE
NG MCH CH
Gp trong:
- Bnh l lm tng p lc ng mch ch: tng huyt p ting T2 ging nh ting
trng.
- Nhng tnh trng gy tng huyt ng h tun hon: cng giao cm, ng c gip, vn
ng vin...
- Nhng bnh l lm tng lng mu qua ng mch ch: T chng fallop.




26. TI NG CLAC M VALVE 2 L (opening-snap)

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Gp trong hp valve hai l
- V tr: nghe r mmhoc trong mm
- m sc: cao, nghe gn (phn bit vi
T3 trm, v n sau clack m valve
hai l)
- Thi gian: sau A2 khong 0.04-0.12s nn thng b ln vi P2 gian sn tri, nhng r dc b
tri xng c (phn bit vi T2 tch i)
- Nguyn nhn: do valve hai l x nhng cha cng , cc mp valve khi m tch ra khi nhau gy
ting clack, cho thy valve cn mm, mt i trong hp van hai l kht.
- Khng thay i theo nhp h hp.

MI QUAN H GIA KHONG THI GIAN T2 CLC V
MC TRM TRNG CA HP VALVE 2 L

- p lc tht tri khi gim xung thp hn p lc ng mch ch valve ch ng li Ting
A2. Sau p lc tht tri tip tc gim, cho n khi thp hn p lc nh tri valve 2 l m
ra ting Clc.
- Ting A2 tng ng vi lc valve ng mch ch ng xy ra sm hn thi im m valve 2
l 1 x. Thi im t lc ng valve ng mch ch n lc m valve 2 l gi l thi k gin
ng th tch (isovolumic).
- Trong hp 2 l cng nng, s cn tr dng mu t nh tri xung tht tri cng ln, v th p
lc trong nh tri cng cao.

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- Khi p lc nh tri cao, p lc trong tm tht tri khng cn gim xung qu thp m valve 2
l. V th khong cch t A2 ti ting Clc m valve s ngn li.




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Kt lun: Hp 2 l cng nng, khong cch t A2- OS cng ngn li. Tc l thi
gian t ting T2 n ting clack cng ngn chng t van hai l hp cng kht. Do khi
van cng hp kht th p lc mu trong bung nh tri cng cao ( do van hp, mu
xung tht tri t, li nhiu nh tri). Nn sau khi tht tri va tng mu i ( thi
k cui tm thu u tm trng)p lc trong tht tri va gim xung th vi p lc
cao trong bung nh lm m nhanh v mnh van hai l. Van m cng sm nu p lc
trong nh tri cng cao.
PHN BIT A2 P2 V A2 - OS
NHNG IM GING NHAU
- Ting Clc m valve thng nghe c v tr gia mm tim v b tri xng c, hoc ngay ti
b tri xng c. V y cng l v tr thng nghe thy ca P2.
- Khong cch t A2 P2 v A2 OS cng khng khc nhau nhiu lm.
CCH PHN BIT
- Ting clc thng nghe mm tim to hn khu vc b tri xng c. Ngc li P2 li nghe r
b sn tri
- thi k ht vo, ting OS s tr nn du hn, nh hn trong khi ting P2 s to hn.
- Nu T2 c dng b 3 nghe b c tri c s xut hin ca OS.
- Nu khong cch gia 2 ting T2 rng hn khi ng dy, th l ting OS.
- Da vo T1, nu n m du, th thnh phn th 2 ca T2 c th khng phi l ting OS. Nu T1
anh, th thnh phn th 2 l ting T2 c th l OS.
(Nhc li quy lut: nhng m thanh xut pht t bn phi tim s to hn th ht vo, v
ngc li nhng ting xut pht t bn tri s nh i th ht vo)

27. TING THI
CC NGUYN NHN GY RA TING THI.

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(A) S cun xoy ca dng mu chy vi tc cao trong lng mch c khu knh khng i.
(B) v (C): c s cht hp ti ch hoc mu chy vo 1 khu vc c khu knh ln hn, cng
lm cho dng mu tr nn cun xoy mc d vn tc dng mu khng cao.
(D) Kt hp ca (B) v (C), v d nh gin ng mch ch sau hp valve ng mch ch, to
ra s cun xoy ca dng mu d tc rt thp.
PHN LOI
- Ting thi tng mu (EJECTION MURMUR).
- Ting thi pht ngc (REGURGITANT MURMURS).
TING THI TNG MU:
- L ting thi do dng mu c tng qua cc valve t chim trong thi k tm thu (valve ng
mch ch v valve ng mch phi).
- Chng bt u sau T1. Ting thi t valve ng mch ch kt thc trc A2, t valve phi kt
thc trc P2. (Nu ni chung l kt thc trc T2 l khng chnh xc)

N c dng hnh qu trm (crescendo decrescendo).

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Gii thch:
- ln ca ting thi ti valve ph thuc vo 2 yu t, vn tc v gia tc ca dng mu qua
valve.
- Trong hp valve ng mch ch, giai on u p lc trong tm tht tri tng chm, vn tc
dng mu qua valve tng chm v v th ting thi s bt u nh nhng. Hn na, trong giai
on u, sau khi p lc tm tht tri vt qu p lc ng mch ch, cn 1 thi gian ngn na
n c th thng c qun tnh ca mu ng mch ch ang tnh trng tnh (ging nh
cng 1 lc y chic xe, lc u xe tng tc chm, sau xe mi chy nhanh c).
- Vo gia thi k tm thu l lc tm tht co bp mnh nht, vn tc v gia tc ca dng mu tng
ln ting thi mnh hn.
- Sau tm tht gim co bp dn, vn tc dng mu gim xung v kt thc lc ng valve t
chim.
TING THI PHT NGC
- Trong ting phi pht ngc, ngi ta chia thnh ting thi pht ngc thi k tmthu v ting thi pht
ngc thi k tm trng.
THI PHT NGC K TM THU:
- L ting thi to ra do dng mu chy ngc t ni c p lc cao ca tim n ni c p lc thp
qua nhng l bt thng trn tim.

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Gp trong trng hp:
- H valve 2 l.
- H valve 3 l
- Thng lin tht.
- Cn ng ng mch
(Cn ng ng mch ngi ta thng xp vo thi lin tc)
THI PHT NGC THI K TM TRNG.
- H valve ng mch ch.
- H valve ng mch phi.
Thi pht ngc thng c dng hnh ch nht (pansystolic).




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27.TING THI TM THU VALVE 2 L:

THI DO H VALVE 2 L.
- V tr: t ti a mm (gian sn 4-5 trn ng trung n
tri)
- Hng lan: lan ra nch ri c th ra sau lng, khng thay i
theo t th (nu ln th c th lan qua bn phi)
- m sc: th rp, c khi m du nh ting hi nc pht
- Thi gian: bt u cng lc vi T1, kt thc cng lc vi T2, chim ton b th tm thu( hnh
ch nht trn tm thanh )
- Nguyn nhn: mu tro ngc t tm tht tri ln nh tri trong thi k tm thu do valve 2 l
ong khng kn.
SA VALVE 2 L ( Hi chng clic thi tm thu, HC Barlow, HC van ri tm, HC l van
cun).

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- L hin tng 1 hoc c 2 l ca valve 2 l b bung ln v pha nh tri trong thi k tm thu.
Nguyn nhn ph bin:
a. Hi chng Marfan (bnh m lin kt)
b. Suy chc nng c nh do nhi mu c tim.
c. Bnh c tim ph i tt nghn (lmp lc trong tht tri qu cao)
d. Thng lin nh.
Sa van hai l c th lm cng qu mc cc c nh, nn lm cho cc ct c b ri lon hot ng,
thiu mu ca c tht vng di ; t dy chng v dn dn vnh van hai l, vi ha cng lm
cho van h thm, b my van cng hn, to nn vng xon bnh l.
Ting tim trong sa valve 2 l:
- Ting thi trong sa valve 2 l cng l ting thi pht ngc thi k tm thu.
- Ting thi ny thng xut hin mun trong thi k tm thu do p lc tm tht tri phi t n
1 ngng nht nh c th y l valve 2 l v pha nh tri. Ting thi thng kt thc cng
vi A2.
- C 1 ting Click m valve trc ting thi. Ting click tng mu r nht trong sa van hai l. Do
l van b bung khi tm thu. y l du hiu quan trng gip phn bit sa hay h van hai l.
- Ting click gia hay cui th tm thu l triu chng quan trng nht. Ko di 0,14s hay lu hn
sau ting tim u tin. C ch to ra ting click l cng t ngt ca cc dy gn tim vn b
trng v ko gin. Ting click cn c th c gy ra bi l van hai l b sa xung khi n t ti
s dy chuyn ti a.
- Ting click v ting thi xut hin sm hn khi ng, khi lm nghim php Valsava hay khi ht
amyl nitrate. V cc can thip ny c tc dng lm gim th tch tm tht v lm tng cng mc
sa van hai l. Ngc li, ngi xm li lm tng th tch tht tri cui tm trng v ng thi
lm gim mc sa xung ca cc l van hai l. Khi phc hp ting thi-ting click xut hin
mun hn v c th bin mt.

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28.TING THI TM THU
DO HP VALVE NG
MCH CH

L ting thi tng mu (crescendo decrescendo).
- V tr: t ti a gian sn II bn phi, hoc GS III bn tri
- T th nghe: bnh nhn ngi ci ngi ra trc
- Hng lan: lan ln c, di khi xung mm tim (phn bit vi ting thi tin tm thu trong hp
valve hai l)
- m sc: th rp
- Cng : ting thi mnh dn ln n na th tm thu th li gim xung, hnh nh qu trm
trn tm thanh
- Thi gian: bt u ngay sau T1, kt thc trc T2, tm thanh ) .
- nh hng ca nhp th: tng ln khi th ra (ngun gc: bn tri tng ln khi th ra)
- Nguyn nhn: mu t tht tri tng vo ng mch ch qua ch hp tng gia tc.



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29.TING THI TM TRNG TRONG
NG MCH CH.
- V tr: nghe r nht Erb-Botkin
- Hng lan: lan ln c, di khi xung mm tim (phn bit vi ting thi tin tm thu trong hp
valve hai l)
- m sc: m du, xa xm
- Cng : nh, nghe bng phn mng ca ng nghe. nghe r hn cho bnh nhn th ra ri
nn th sau ci ngi ra trc ( phn y tim nm st lng ngc hn)
- Thi gian: xy ra sau T2, chim mt phn th tm trng hoc ton b th tm trng tu mc
h
- Nguyn nhn: dng mu tro ngc t MC v tht tri trong tm trng do l van ng mch
ch ng khng kht. Hu qu ca s tro ngc ny lm tng th tch tm thu tht tri nn lm
l van MC tr nn hp so vi lu lng ny nn c th nghe thy ting thi tm thu i km vi
ting thi tm trng.


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30. RUNG TM TRNG TRONG HP 2 L:

V tr: nghe r mm tim (nghe r hn bng u chung ca ng nghe, khi bnh nhn nm
nghing tri)
- m sc: trm v th (nghe nh ting v di trng trn mt trng cng)
- Thi gian: xy ra sau T2, thng theo sau ting clack m valve hai l, v ko di n cui tm
trng v tr thnh ting thi tin tm thu
- Nguyn nhn: van hai l b hp , lm lng mu t nh xung tht b xoy lm rung cc cu trc
ca tim
- Phn bit vi :
o Rung Flint
RUNG FLI NT (Austin Flint Murmur).
- L ting thi gia thi k tm trng hoc u tm thu m thp, nghe nh ting rung, nghe
r nht mm tim. N thng gp trong h valve ng mch ch nng.
C CH:
Dng mu tro ngc t ng mch ch xung to p lc ln b mt ca valve 2 l lm cho n
b y ln pha trn, to ra s hp tng i ca valve 2 l
(Xem hnh minh ha bn di)
(NOTE: Thc t khi lmsiu mtimcho 1 s bnh nhn b rung FLINT, ngi ta thy l trc
ca valve 2 l c rung. Cho nn ngi ta tng ngh rng, rung Flint l do dng mu chy mnh

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lm l trc valve 2 l rung. Tuy nhin, c 1 s bnh nhn c valve 2 l rung nhng li khng c
rung Flint, ngc li 1 s bnh nhn c rung Flint nhng l trc valve 2 l khng rung)
Cng c thm cho 2 gi thuyt trn:
- Thng thy nhng tn thng (cc mu ng) v tr l trc ca valve 2 l do dng mu chy
nhanh.
- Trn siu m bnh nhn b rung Flint c hp valve 2 l.

TRIU CHNG C NNG, THC TH CA HP 2 L
KHT
- C nng: hi chng gng sc
o Kh th khi gng sc.
o Ho ra mu
o Hen tim
o Ph phi cp
- Thc th:
o T2 mnh tch i
o Rung tm trng chim ht k tm trng
o Thi gian t T2 n clac m valve 2 l cng ngn th hp cng kht.
o Thi Gramham Steel
- Cn lmsng:
o ECG bao gi cng c dy tht (P)

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HP 2 L TRN SIU M

PHN HP 2 L TRN LM SNG

KHI NO DNG CHNG NG TRONG HP 2 L
- Gin nh tri.
- C rung nh
- C cc mu ng
X QUANG CA HP 2 L



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31.TING THI TM THU CHC NNG:
GP TRONG:
Van tim khng b tn thng m do gin cc vng van, hu qu ca gin cc bung tim. V d
trong hp van hai l, lm gin bung tht phi gy h vng van ng mch phi, to ra ting thi
Graham-Steel.
Gim nht ca mu, hay gp trong thiu mu.
Thay i lu lng mu qua van: cng gip, st, c thai, van ng mch tr nn hp tng i
so vi lu lng mu ln (v d thng lin nh, h van MC)

PHN BIT TING THI THC TH L TI NG THI CHC NNG (C NNG)
Ting thi thc th Ting thi chc nng
V tr - C c 5 van tim - Hay c van hai l v
valve MC,
Thi gian - Tm thu, tm trng, lin
tc
- Ch yu l thi tm thu,
nhng t khi chim ton b
tm thu.Him khi gp ting
thi tm trng
Cng ,m sc - Thng mnh r, th rp,
3/6
- Thng nh, m du, t khi
mnh , 3/6
Hng lan - Lan xa theo dng mu - t lan
Rung miu - C rung miu khi thi mnh - Ting thi d mnh cng
khng c rung miu
Tnh cht thng
xuyn
- C thng xuyn , khng
thay i theo t th.
- C th thay i , thm ch
mt i khi ht su, thay i t
th v sau kt qu iu tr.

38.RUNG NH:
nh ngha:
- RN l ri lon nhp nhanh trn tht c trng bi s hot ha nh khng ng b lm cho suy
chc nng c hc ca nh.
- RN gn lin vi s gia tng nguy c t qu, suy tim v t l t vong do mi nguyn nhn,
nht l ph n.
Phn loi RN: c nhiu cch phn loi

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- Da trn ECG.
- Da trn ghi thng tm mc hay ni bung tim bn in hc hot ng ca nh.
- Da vo lm sng.
C ch:
Thuyt t ng:
- Gi thuyt RN khu tr c ph hp vi m hnh thc nghim ca aconitine ( cy ph t )
v RN to ra bng to nhp trong lon nhp tim ch tn ti trong nhng vng c nh b c
lp.
.Thuyt a sng nh ( do Moe v cng s a ra)
- Nh l c ch vo li ca RN. Moe cho rng phn on ca cc sng thng lan truyn qua
nh dn ti s duy tr cc sng con. Theo m hnh ny, s lng ca cc sng trong bt k
thi im no ph thuc vo thi k tr, khi c v tc dn truyn cc phn khc nhau
ca tm nh.
Cc yu t tham gia vo RN
- Lin quan tng sinh, duy tr RN: vim, thn kinh thc vt, thiu mu nh, dn nh, thay i
cu trc lien quan n tui, dn truyn lch hng ( anisotropic)
- Tng trng lc giao cm, ph giao cm c th khi pht RN.
- C lin quan cht ch gia hi chng ngng lc ng, tng huyt p v RN.
Nguyn nhn:
- RN phi phc: cc nguyn nhn tm thi nh ru, phu thut, in git, nhi mu c tim,
vim mng ngoi tim, vim c tim, thuyn tc mch phi hay bnh l phi khc, cc ri lon
chuyn ha, cng gip.
- Khng km bnh tim( 30-45% RN kch pht, 20-25% RN bn b) xy ra bnh nhn tr m
khng c bnh l no.
- Bnh ni khoa kt hp vi RN
Bnh phi.
Bnh tim mch : bnh van tim ( thng gp nht l bnh van hai l ), suy tim, tng
huyt p, bnh mch vnh.
RN c th phi hp vi bnh c tim ph i, bnh c tim gin, tim bm sinh ( in hnh
l thng lien nh ngi ln ), amylosis, hi chng Pick.
Bnh tim khc: sa van hai l, tm ph, gin v cn nh tri.
Hi chng Pick-Wick.
- RN gia nh.
Triu chng:
Lmsng : RN c biu hin lm sng a dng, c th t ht hay phi s dng thuc ct cn.
Sau mt thi gian xc nh c : s lng, di cn, tn sut, kiu khi pht v p ng iu
tr

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C nng :
- nh trng ngc, chong vng, kh chu, ngt, kh th au ngc, mt mi, u c quay
cung hay ngt hay c th c biu hin ca bin chng tc mch ( huyt khi c hnh
thnh theo tam chng Wirchow: mu, ri lon chc nng ni mc v tng yu t ng
mu) hay t suy tim nng ln.
- a niu c th lin quan n s gii phng peptid li niu nh, t bit l khi bt u hay kt
thc RN
- Nu rung nh nhanh th cc triu chng c nng khng r rng.
Thc th :
- Nghe tim lon nhp hon ton (khng u v tn s, bin , lc nhanh lc chm), mch quay
khng trng vi nhp tim.
- C th thy c bnh van tim, bnh c tim, suy tim.
- Trong cung nh c th thy cc triu chng tng t ngoi tr nhp tim c th u, c th
nhn thy song rung tnh mch nhanh tnh mch c.
Huyt p:
- Thng thp , thay i qua cc ln o.
Cn lm sng:
ECG:
- ECG ngoi tr: ( Holter ) rt tt pht hin, theo di RN.
- Sng P v ng ng in c thay th bng cc sng f (tn s rt cao 350-600ln/pht)
- p ng tht : cc phc b QRS thay i nht v bin , ch yu l cc khong RR rt thay
i- on di on ngn.

Chp Xquang phi:
- nh gi bung tim ln, pht hin bnh phi nn v ging mch phi.
Siu m tim hai chiu:

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- nh gi kch thc nh tri, tht, dy thnh, bnh van tim..
Xt nghim nh gi chc nng tuyn gip, thn, gan, in gii .
- Peptid li tiu Na type B (BNP ) v peptid li niu nh (ANP ): u lin quan vi RN. ANP
thp lin h vi s thoi ha t bo c nh (khi RN dai dng). BNP cao c th bo hiu tc
mch hay RN ti i ti li
Siu m thc qun.
Thm d in sinh l.


39. DU KO CHUNG:
- Thng gp bnh nhn ln tui
- ng mch cnh tay do x va nn tr nn cng , chy ngon ngoo v ny p mnh nhn
nh con giun un trn mt da du ko chung
- V tr: khyu tay, thi dng

MT S VN V TNG HUYT P
( y chng ti xin gii thch mt s vn thng hay thc mc v cc thy c thng hi thi
trong bnh tng HA)
NH NGHA TNG HUYT P?

1 S TRNG HP HA KHNG CAO NHNG VN CHN ON L CAO HA?

DU KO CHUNG:

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- L ch imca x va
- Nhn thy khuu tay, thi dng.
CCH LM TH THUT OSLER TRONG O HUYT P:
- o huyt p s b loi tr khong trng Korotkoff
- Sau bm bng cun trn tr s huyt p tmthu.
- Khong trng Korotkoff l pha imlng gia pha 1 v pha 2 trong 5 pha ca korotkoff
Cch lm trn c ly t bi ging ca thy.
1 s ti liu khc, chng ti tm thy 1 th thut khc cng gi l th thut Osler (Osler
maneuver) c s dng loi tr tnh trng gi tng huyt p (pseudohypertension). Chng ti
s m t k phn di y:
GI TNG HUYT P:
- L trnh trng HA khi o gin tip bng my o HA (ci thng dng bnh vin) cao hn nhiu nu
so snh vi HA o trc tip bng cmbin p lc t trong lng mch bnh nhn (HA tht).
- Nguyn nhn l do ng mch qu x cng, nn khi m ln qu HA tht s ca bnh nhn th vn
thy mch p.
KHI NO TH CHNG TA NGHI NG GI TNG HA?
- Chng ta nghi ng tnh trng gi tng HA nu nh HA bnh nhn o c qu cao so vi
nhng biu hin lm sng: V d nh o c HA l 200mmHg trong khi khng c du
chng dy tht tri trn ECG, khng thy tim tri ln trn X quang, khng c suy thn,
khng c biu hin vng mc
- Sau khi bm my o ln qu HA tm thu, ng ra lc ny mch p ca mch quay bin
mt nhng ta vn s thy c mch quay. y l 1 dng bin th ca th thut Osler, c ch
tng t nh th thut Osler nh c m t di y.
TH THUT OSLER:
- Dng ngn tay tr vo ng mch quay pha trn. Mc ch l lm cho mch quay
bin mt
- Ngi bnh thng khi ta s pha di, s khng cm nhn thy mch quay.
- Th thut Osler dng tnh khi ta vn s thy mch quay pha di ch th hin
thnh mch x cng.
5 PHA CA KOROTKOFF
- Pha 1: xut hin ting p (ly y lm tr s huyt p tmthu)
- Pha 2: ting p v ting thi.
- Pha 3: ting thi mnh dn
- Pha 4: ting thi yu dn.

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- Pha 5: mt (ly y lm huyt p tm trng)
(Ly t bi ging ca thy c)
Lu : 5 pha m t trn khc vi 1 s sch chng ti c c vi m t nh sau: Pha 1: xut
hin ting p. Pha 2: ting p v ting thi. Pha 3: ch c ting p. Pha 4: m thanh nh li.
Pha 5: bin mt.
KHI NO LY PHA 4 LM HUYT P TM TRNG
- Ph n c thai.
- Tr em
- H valve ng mch ch.
KHI NO TH NGHI NG TNG HA TH PHT?

PHN SOI Y MT CA KEITH WAGENER BAKER

PHN TNG HA V PHN CHIA GIAI ON TNG HA
(Lu : y l 2 nh ngha khc nhau)
Phn :


Phn giai on:

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V d: Bnh nhn c HA l 140 90, khm khng thy c tn thng g c quan ch. Xp
v phn loi bnh nhn nh th no?
- Tng Huyt p 1( nh ) giai on 1.
PHN TNG HUYT P THEO JNC7 V S KHC BIT CA N VI PHN
NGY NAY.

- S khc bit ca J NC 7 l h a vo thm phn Tin tng HA v gp 2 v 3 vo vi
nhau thnh 2
- Ngy nay J NC 7 khng cn c s dng
TNG HUYT P C TNH, TNG HUYT P KHN TRNG, TNG HA CP
CU
TNG HUYT P C TNH:


TNG HUYT P CP CU (emergency):

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- L tng HA c km theo tn thng nng n c quan ch v c nguy c t vong cn can thip ngay
trong vng 1h.
- Tiu chun chn on: >= 2 tiu chun:
Tng HA t ngt hoc ko di vi HA tm trng >= 120mmHg.
Ph gai th
Suy thn tin trin.
Ri lon chc nng thn kinh: bnh no do tng HA.
Suy tim.
TNG HUYT P KHN TRNG (urgency)
- L tng HA c km theo du hiu chc nng v c nh hng n tng, nhng tnh trng tng HA
cn iu chnh trong vng 24h.
- Tiu chun:
HA tng cao >= 180/120 mmHg.
Khng km theo tn thng c quan ch.
GI L TN THNG C QUAN CH KHI:
- Dy tht tri (in timhoc siu mtim)
- Microalbumin niu (20-300mg/ngy)
- C bng chng siu mhoc X-quang v x va M lan rng (M ch, M cnh, M vnh, M
chu, M i)
- Bnh vng mc do THA III hoc IV theo Keith- Wagener.
HUYT P KP?
- Hiu p <=20mmHg


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99


BNG TM TT CC TING THI



Ngun: Decision making in medicine, St Louis, 1993, Mosby

NI C S

100




NI C S

101









CHNG III
H HP

NI C S

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NI C S

103


41. HO DO KCH THCH MNG PHI
GP TRONG
- Trn dch mng phi t do
Ho khan, ho khi thay i t th
Ho lm tng au ngc
- Trn dch mng phi khu tr: khng c du ho v au ngc khi thay
i t th
I KM
- Kh th:
Tu theo lng dch, nu mn tnh th khng kh th.
Tng ln khi nm nghing v bn khng trn dch.
- Ting c mng phi: kh, nng khng lan, mt khi nn th.
- Ting thi mng phi: l m thi truyn qua lp dch,nghe xa xm m du.
PHN LOI
DCH THM
- Suy tim phi, suy ton b
- Hi chng thn h, vim cu thn
- X gan mt b
- Suy dinh dng
DCH TIT
- Trn dch thanh t huyt: dch vng chanh ( trong hay hi c );
o Gp: do nhim khun
- Trn m mng phi : dch vng c, c nhiu bch cu thoi ha.
- Gp : Vimphi , Abscess phi , bi nhimVi khun t trn dch do Virus, Ung th Ph qun do b
bi nhim
- Trn mu mng phi: dch c nhiu Hng cu .
o Gp : K ph qun phi, Lao , Chn thng lng ngc.

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- Trn dch dng chp: dch c nh sa Dng chp t ng ngc vo mng Phi
- do Chn thng gy v ng ngc, Chn p or tt ng ngc.
m: l cht tit ca ng h hp gm c cht nhy , Hng cu , Bch cu, M ... c
tng ra khi ngH hp sau khi ho.


42.M NHY
GM: nhy , c th km theo hng cu , bch cu ,m ...
Nhn c th phn bit dc do m thng rt qunh,dnh vo thnh ng nh.
GP TRONG :
- Vim ph qun mn : nhy + m(c th mu do cc hng cu v cc fibrin thot ra trng ln
vo nn c ngi g l m mu g st)
- Gin ph qun : m 4 lp : (di trn: m c nc nhy m nhy bt )
- Hen ph qun : m ngc (cc ht nh ngc l do m khi nm trong cc ng tuyn bi c c li)

43.M M
GM : cht nhy , bch cu , vi trng , t bo hoi t , c khi ln mu v fibrin,thng c mi
rt hi.
GP TRONG : Abscess phi,vim m mng phi.



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44.M THANH DCH
GM : m lng ,trong v c bt,c bit l rt ng u.
NGUN GC: Ph huyt qun
GP TRONG : Ph phi cp, mn.
- Nu cp c bt hng do c ln hng cu.
- Nu mn th trong, nu bnh nhn c du hiu tng p phi th cng khng uc ni la cha n
mc ph phi v m trong ph phi mn kh phn bit nn d b b st.

45.M MU.
GM: ti , sm hoc bm en
GP TRONG :
- Ph phi cp(nu c nhiu mu) : m lng , hng
- Vim phi : lng t ,kh khc ,mu gh st
- Nhi mu phi : khng c bt , bm

46.C RA M
GP TRONG: Hi chng Nung M Phi ( 3 giai on )
- Nung m kn
- Khc c m
- Nung m h
Khc c m : bnh nhn ho c trng , au x lng ngc ,mt xanh , v m hi lnh khc 1
lng ln m m Giai on ny,c th bnh nhn c khc ra m hnh ng xu ( m tng t
mt ,c, nhiu,hnh trn nh ng xu (Ngun: Ni c s - YDH+)

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. 1 CCH KHC TIP CN TRIU CHNG KHC M.
Chng ta s khai thc triu chng khc m theo tun t nh sau: S lng loi m mu
sc m mi. Tng tnh cht 1 s gip ta khu tr chn on.
1. S LNG:
- Thng xuyn khc ra 1 lng m m ln v b nh hng bi t th: Gin ph qun.
- t ngt khc ra 1 lng ln m m: Abcess phi hoc vim m mng phi.
- 1 lng ln m nc km theo l nhng dy mu hng v kh th cp: ph phi.
- 1 lng ln m nc t tun ny sang tun khc: ung th t bo ph nang.
2. LOI M: (nh ni trn, y mnh ch ni li nhng nguyn nhn c trng )
Loi m M t tnh cht Nguyn nhn
Thanh dch Nh nc, trong, lng Ph phi cp
(serous) C bt, mu hng Ung th t bo ph nang
Nhy Trong, c mu xm Vim ph qun mn, COPD
(Mucous) Trng, nhy Hen ph qun.
M Vng, xanh Nhim khun ph qun, phi





Vim phi
Gin ph qun
X ha phi thy.
Abcess phi.
R st Mu r st Nhim khun ph cu




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3. MU SC M
- Trong, nhy : COPD khng bi nhim.

- Vng:
o +BCTT sng ( c mu vng) : nhim khun CP ng h hp di.
o +BC acid : Hen ( d ng).
- Xanh, m (BCTT cht).
o Nhim khun mn : t cp ca COPD, gin ph qun
(L do mm c mu xanh: trong c cha xc bch cu trun tnh b ly gii, kmtheo
l cc sn phm ly gii ca n: enzym Verdoperoxydase c mu xanh)
o m khc vo bui sng ca bnh nhn COPD cng c th c mu xanh do s
ng v m ca bch cu trung tnh.
- R st:
o Nhim khun ph cu khun giai on u.
- en:
o Bnh bi phi cng nhn lm ngh than.
4. MI
- Nu hi: Nhim khun vi khun k kh, thng gp trong gin ph qun, abcess phi,
vim m mng phi..
bnh nhn b gin ph qun khc ra m HI vo bui sng chng t h ang b ln t cp
bi nhim
Ton b thng tin dch t: Macleods clinical examination
BI NHIM TRONG GIN PH QUN
- Gin ph qun rt hay b bi nhim.

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- Nguyn nhn: do ph qun gin ln,vi khun vo d. Km theo l tnh trng tng tit
dch, s lu thng v hot ng ca h thng lng chuyn khng cn nguyn vn na do
qu trnh vim mn. Ngay c cu trc vi th ca ph qun cng b thay i t nhiu, s
thay i ca IgA tit, suy gim sc khng...Tt c cc yu t l iu kin thun li
cho vi khun xm nhp v gy bnh.
- c im: bi nhim hay ti i ti li ti cng 1 v tr.
TIP CN TRIU CHNG KHC M THEO Y H NI
Sau khi khai thc triu chng khc m, loi b cc nguyn nhn do cht tit t pha sau
mi, h xem xt khc m c tnh cht cp hay mn? Ri t nh hng chn on:
1. KHC M CP:







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2. KHC M MN:



nh ngha kh th : l tnh trng kh khn trong vic th ca bnh nhn

47.KH TH
NH NGHA KH TH:
L tnh trng kh khn trong vic th ca bnh nhn.
BIU HIN CA KH TH:
C th biu hin qua 3 hnh thc:
TH NHIU:
- Nhp th nhanh, nhng th tch kh lu thng vn gi nguyn, i khi gia tng hay gim 1 t.
- Trong tt c mi trng hp, th tch th ra trong 1 pht vn gi nguyn hay gia tng.
TH NHANH NNG.

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- Tn s th gia tng nhng th tch kh lu thng mi ln gim.
- Th tch th ra bnh thng nhng thng kh ph nang gim ( do khng kh vo phi mi ln
th t, khng lp y khong cht, l nhng khu vc khng tham gia trao i kh trong
phi gim trao i kh).
TH CHM:
- Tn s th gim, thng kh ph nang gim
A. KH TH RA.
Nguyn nhn : co tht cc tiu ph qun
Dng kh th:
- Thng kh th chm
Gp :
- Hen ph qun
- Vim ph qun cp.

B. KH TH VO.
Nguyn nhn : thng do tn thng ng hoc hp ng h hp trn
V d:
- Vim yt hu , thanh kh qun
- Bnh bch hu , chn p thanh , kh ph qun ln
V SAO TRONG HEN PH QUN LI KH TH RA
NHIU HN
2 l do:

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111


TH NHT:
Th ht vo l th ch ng, th ra l th ng.
- Ht vo, c th s dng mi c h hp bao gm c honh v cc c h hp ph- lm tng th
tch lng ngc ln to ra 1 p lc m ln trong lng ngc cc ph nang gin ra sc
ko khng kh vo phi mc d cc tiu kh qun ang tnh trng co li.
- Th th ra, l th th ng, do s n hi ca cc ph nang ph nang n ra th ht vo do p
lc m by gi co li y khng kh ra. Nhng by gi cc tiu ph qun ang co, c honh
cng ch co li 1 cch th ng khng ch ng co li nh kh ht vo, cc c h hp ph
khng c s dng nhiu trong th th ra kh y khng kh ra.
TH HAI:
- th ht vo, do p lc m trong lng ngc ko nhu m phi gin ra t nhiu cng lm gin
cc tiu ph qun ang co lm khng kh i vo d hn.
- Th th ra, khng c vic ny.
CN HEN PH QUN NHIM ACID HAY BASE H HP
Chng ta thng nhm ln rng, bnh nhn bnh hen do kh th nn CO2 trong mu tng, v th
bnh nhn s b nhim acid h hp. Nhng trn thc t tri qua cc giai on khc nhau.
- Giai on u: bnh nhn c gng th nhanh m bo thng kh cung cp O2 cho c
th. Do tng thng kh nh vy, nn CO2 trong mu bnh nhn c th bnh thng hoc gim (
khng phi tng). Thc t cho thy, s thng kh ca bnh nhn b Hen rt cao, nn km theo
l s mt nc qua ng h hp, trong liu trnh iu tr hen cp nng c truyn dch.
- Giai an sau: giai on suy kit, CO2 mu ca bnh nhn tng dn, tng dn. y l
du hiu xu, nu CO2 mu gim thp, cn chuyn bnh nhn n ngay HI SC CP CU (
Ni bnh l YDH)
CC TRIU CHNG KHC CA THANH QUN
- Co ko hmc
- Th kh kh

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- Ting ni thay i
LIN H KH TH RA V LNG NGC HNH THNG
L DO LNG NGC HNH THNG:
- Do khng kh vo m ta khng th ra ht c, lm bnh nhn cng c gng th mnh hn
duy tr thng kh. Khng kh i vo phi nhiu m th ra khng ht, gy ng, ngy ny qua
ngy khc, cui cng lm lng ngc ca bnh nhn phnh to ra LNG NGC HNH
THNG ( BARREL CHEST).
KHM BNH NHN B LNG NGC HNH THNG
- ng knh trc sau > 5/7 ng knh ngang ( bnh thng t l ny l 1:2)
- C honh h thp ( trn X quang).
- Xng c b y ra trc.
- Cc xng sn nm ngang.
Ngun:
Ni c s
- YDH









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113


Kh ph thng: lng ngc hnh
thng, xng sn nm ngang,
khong gian sn gin






X QUANG BNH NHN KH PH THNG
(Thng ra thi lm sng)
- Lng ngc gin rng.
- Hai ph trng sng hn bnh thng.
- C honh h thp.
- Khong gian sn gin rng, xng sn nm ngang.
- Tim hnh git nc.
- Gan sa Ngun: Professional Guide to Signs and Symptoms
1 S BNH L KHC C C CH GING KH PH THNG
TUN HON:
- 1 s bnh l lm tng th tch cui tm trng ca tm tht nh h valve ng mch ch, h
valve 2 l, shunt phi tri hoc tri phi... hoc
sinh l nh vn ng vin, ph n c thai. Tnh
trng tng th tch nh vy ko di s lm bung
tim gin ra, km theo tim phi dng 1 lc tng
mu mnh hn tng ht mu i nn c tim cng
c s ph i, ta gi l ph i gin (DILATED
HYPERTROPHY ) ( bnh c tim gin l 1 nh
ngha khc na: bnh l lm c tim gin ra).
- Cn ph i ng tm (CONCENTRIC
HYPERTROPHY), l tnh trng tng hu gnh

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nh tng huyt p, hp valve ng mch ch... lm tim s dng 1 cng ln tng mu i ph
i. Nhng do khng c tng th tch cui tm trng nn khng c s gin cc bung tim.
Lu nh:
- C 2 thut ng ting anh l dilated hypertrophy v dilated
cardiomyopathy. Thut ng u ngha l ph i gin nh c m
t trn, cn thut ng sau l bnh c tim gin, l 1 bnh l ni ti
ca c tim lm cho cc bung tim gin ra.
- Tng t nh vy hytrotrophic cardiomyopathy l bnh c tim ph
i.
TIU HA ( diverticulum):
- To bn lu ngy bnh ti tha ( l 1 ti phnh ra i trng v tr yu nht trn thnh ca
n).
(Ngun: wikipedia + medicinenet.com + webmd)

49.KH TH NHANH.
NH NGHA:
- Kh th c 2 th , kh th nhanh
GP TRONG : trong cc bnh lm gim th tch h hp
- Vimphi
- Trn kh , trn dch mng phi
- Suy tim
NHN XT:
- Trn lmsng chng ti nhn thy khng ch trong cc bnh lmgimth tch h hp nh vim phi, trn
kh trn dch mi lmbnh nhn kh th nhanh. V d, hen ph qun, 1 bnh l tc nghn ng dn kh
giai on u bnh nhn cng c th nhanh. Chng ti ngh ch cn tng PaCO2 trong mu l s kch

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115


thch trung tmh hp gy th nhanh, ch khi no bnh nhn kit qu, hoc tc nghn qu trmtrng th
bnh nhn mi kh th chm.

50.GIN LNG NGC 1 BN
GP TRONG
- Trn kh , dch 1 bn
KHM LM SNG:
- NH N : lng ngc gin rng hn, khong gian sn gin rng
- S : lin sn gin
- G : trn kh g vang ; trn dch g c
- NGHE: Rales m , n trong trn dch


51.DU CO KO
L du huy ng cc c h hp ph , thy :
- Trn v di xng c
- H thng n
- Cc khong gian sn
thng xy ra khi c kh th nhiu
V D:
- Hi chng kh ph thng ton th (KPT)
- Trn kh mng phi
- Hp tiu ph qun co tht
- COPD

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52.S - KHONG GIAN SN GIN.
CCH KHM
- Dng ngn tay ci ca bnh nhn t vo khong gian sn , nu vo c th khong gian sn
gin
GP TRONG
- Trn dch , kh mng phi
- Hi chng kh ph thng


53.S - KHONG GIAN SN HP
CCH KHM
- Dng ngn tr bnh nhn t vo khong gian sn , nu thy ko va th khong gian sn
hp
- Bnh thng : kch thc ( khong gian sn = ngn tr ) ca bnh nhn
GP TRONG:
- Xp phi , dy dnh phi, mng phi.

54.RUNG THANH (Vocal fremitus)
NH NGHA :

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117


Rung thanh tng tng ng vi
m ni
- m ni ca bnh nhn truyn qua thnh ngc v di
vo lng bn tay ca thy thuc t trn ngc bnh
nhn.
- Lng ngc c coi nh 1 bnh cng hng truyn m
thanh t thanh qun.
CCH KHM
- Bnh nhn ngi ngay ngn ,thy thuc t 2 bn tay ln 2 bn lng ngc i xng , cc ngn tay
nm ngang theo cc khong gian sn , lng bn tay p st vo lng ngc ,
- Bo bnh nhn m 1,2,3 ( i vi bnh nhn dng ngn ng l ting anh : 44 , 99 ninty nine,
forty four, sch Y H Ni 33, 44 Thng thng: 99 ) th ting ni ca bnh nhn s rung vo
lng bn tay ngi thy thuc
- Khm t trn di , t trc sau .
- Lun lun so snh 2 bn.
- (L 1 phng php khm kh)

KT QU:
- Bnh thng: m pht ra t thanh qun truyn qua thnh ngc, bn tay thy c hin tng rung
nh.
- Rung thanh tng: nhu m phi b thay th bi 1 m dn truyn tt hn ng c phi.
- Rung thanh gim hay mt: C dch hoc hi ngn cch gia mu m phi v tay ta.
- Trn dch mng phi.
- Trn kh mng phi.
Cn phn bit vi trng hp thnh ngc dy hoc cng m pht ra yu qu cng lm
rung thanh gim.
GI TR TNG NG: tng ng m ni (m vang ph qun vocal resonance).
KHM M NI (VOCAL RESONANCE)

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118


nh ngha ting ngc thm ca
sch ni trng khc vi nh
ngha ca Whispering
pectoriloquy ca Wikipedia
- Bo bnh nhn ni Ninety-nine hoc 1,2,3 v ta nghe cc khu vc khc nhau ca ngc v so
snh 2 bn
- Bnh thng: m ni nghe r v u c 2 bn.
- Nu c 1 khu vc vo tng hay gim th nguyn nhn
ging nh m t s rung thanh:
- Tng: ng c phi.
- Gim: trn dch, trn kh, dy dnh.
L do: vng ng c c xu hng truyn m tt hn.
TING NGC TH THM (WHISPERING PECTORILOQUY) THC RA
CNG CH L M NI
nh ngha ca sch ni trng: Ting ngc thm l mni ca bnh nhn n tai thy thuc
nghe th thm nh xut pht t thnh ngc bnh nhn, gp trong phi c hang.
nh ngha ca Wikipedia v whispering pectoriloquy ( chng ti tm dch l ting
ngc th thm, v nh ngha v whispering pectoriloquy khc vi nh ngha v ting ngc
thm ca trng):
Ting ngc th thm l 1 s tng ca M NI n 1 mc m ch cn bo bnh nhn th
thm, m ni ca anh ta cng c nghe r rng khi t ng nghe trn khu vc ng c phi.
- Nh vy, theo nh ngha v ting ngc th thm, th n khng phi l ting ngc thm theo
nh ngha ca sch ni trng.
M t ny v ting ngc th thm (whispering pectoriloquy) ch cho chng ta 2 :
Cch khm ting ngc thm:
- Bo bnh nhn th thm 1,2,3 ( c ting anh v ting vit).
- Thy thuc t ng nghe trn cc khu vc khc nhau ca phi bnh nhn.
- Bnh thng m th thm s khng nghe thy.
- nh gi mc ng c phi: gp trong vim phi hoc ung th phi.
Ting ngc thm khng ch gp trong phi c hang:

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119


- N ch gip nh gi tnh trng ng c phi.
- Vim phi.
- Ung th phi.
nh ngha ca Oconnor cng tng t nh vy:
i khi m ni to n mc m m th thm ca bnh nhn cng nghe thy r rng, m ny gi
l ting ngc th thm (whispering pectoriloquy).
Ngun: Wikipedia, Ni c s - YDH, Oconnors clinical examination
M D KU THC RA CNG L M
NI (AEGOPHONY)

nh ngha sch ni trng:
L mni truyn n tai thy thuc, nghe cao ging nh ting d ku, gp trong trn dch
mng phi.
nh ngha ny ng, nhng, cng khng ch gp trong trng hp trn dch mng
phi, v chng ti thng b nhm ln khng bit cch khm nh th no?
nh ngha ca Macleods clinical examination
m d ku l 1 m nghe nh ting be be ca con d khi nghe trn 1 khu vc ng c phi
hoc pha trn ca 1 trn dch mng phi. Nguyn nhn l do s tng dn truyn nhng m
thanh c tn s cao khi i qua khu vc phi bt thng v s lc b nhng m thanh c tng s
thp
nh ngha ti WIKIPEDIA
md ku l s tng ca m ni khi nghe phi, thng gp trong trng hp ng c phi
hoc x ha phi. Nguyn nhn l do s tng dn truyn ca nhng m c tn s cao khi i qua

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120


khu vc c dch, nh l cc nhu m phi bt thng, km theo nhng m c tn s thp s b
lc b i. Kt qu s nghe thy 1 m thanh nh ting be be ca con d.
CCH KHM M D KU:
Bo bnh nhn c e theo ting anh ( tc l i theo ting vit), v d nh Bee, chng ta s
nghe ging nh m a (tc l ay ting Vit), nh Bay
Ngun : Macleods clinical examination, Ni c s - YDH, Wikipedia

57-60. G ( PURCUSSION)
G:
- Trc tip: thng gy au cho bnh nhn t dng
- Gin tip : ph bin hn
CCH G GIN TIP
- Thy thuc dng ngn gia ca bn tay phi g ln lng
cc ngn tay ca bn tay tri t sn trn lng ngc ca
bnh nhn
- Cc ngn tay nm ngang theo cc khong lin sn
- G t trn di ; bn Phi bn Tri ; Trc Sau .
- V phi lun so snh 2 bn.
CC V TR G:
PHA TRC V BN CA THNH NGC:

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121






PHA SAU:

BNH THNG;
- 2 phi g trong , vng tim- gan g c
G VANG:
- C 2 phi : kh ph thng ton th ( KPT )
- 1 Phi or 1 vng: Trn kh mng phi
- Hen Ph qun (Hi chng hp ph qun do co tht )
G C: gp nhng cu trc c bn di:

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122


- c phi
- Xp phi
- Trn dch mng phi
- Dy dnh mng phi
Loi Gp trong
Trong - Phi bnh thng
Vang - Trn kh mng phi.
- Kh ph thng ton th.
c - ng c phi
- Xp phi
- X ha phi nng.
c nh - Trn dch mng phi
'Stony dull' - Trn mu mng phi.
Macleods clinical examination
TRN DCH MNG PHI
- T do : G c vng thp , m c thay i theo t th
- Khu tr : Ty v tr , ch yu pht hin bng X quang
V D
- vng nch : G c l lng vng nch
- TD mng phi trung tht : G pha sau thy vng c cnh ct sng , pha trc c triu
chng gi TD mng ngoi tim nhng ting tim vn r
- TD mng phi honh
- TD mng phi vng nh: kh pht hin
- TD rnh lin thy : g thy 1 ng dc l lng nmngang chch v pha di

Lm sng: L th yu, nhng c gi tr hng ti chn on trn dch mng phi trong mt
s trng hp.

NI C S

123


- Khi tit dch t, khong 200 300 ml, ngi bnh hi au bn c trn dch, khng kh th, vn nm
nga, u thp c, nhng c khuynh hng nmnghing v bn lnh trnh au .
- Khi lng nc trung bnh, khong 700-800ml ti 1lt 500 ngi ln, th c kh th nh, v ngi
bnh phi nmnghing v bn au.
- Khi nc nhiu, tnh trng kh th ni bt, ngi bnh phi ngi dy th nhanh, nng.
Triu chng thc th. Triu chng thc th l ch yu.:
y s ni v trn dch t do th trung bnh:
Nhn: lng ngc bn c trn dch hi nh ln, khong lin sn rng ra v km di ng.
Thng c ph nh lng ngc bn au trong trn m mng phi.
S: rung thanh gim nhiu hoc mt.
G: c r rt, nu g dc theo cc khoang lin sn, t trn xung di, c th thy ranh
gii trn ca vng c l mt ng cong parabn c im thp nht gn st ct sng, cao
nht vng nch, v i vng xung thp pha trc ngc. Ngi ta gi l ng cong
Damoisesu (trn film X-quang).
- Nu trn dch nhiu hoc c trn kh km theo th ng cong ny bin dn thnh
ng thng ngang, ngoi ra c th thy cc tng ln cn nh gan, tim, b y. Trn
dch mng phi tri lm mt khong Traube.
- Mt s tc gi cn nhn xt l mt vng g trong ca gc hp bi ct sng v ng
cong Damoiseau, gi l gc Garlaud. C th thy y l vng nhu m phi b nc
y vo trong.
Nghe:
- R ro ph nang gimnhiu hoc mt hn vng c.
- C th nghe ting c mng phi lc bt u v giai on rt nhiu nc.
- Nu trn dch t v c ng c phi, c th nghe thy ting thi mng phi v mt
s ting ran n hoc ran m.
Cc th khu tr:Trn dch mng phi c th khu tr mt vng. Lm sng thng kh chn
on, v phi c Xquang, kt hp vi chc d mi c th pht hin c.

NI C S

124


- Trn dch lin thu: khng gy kh th r rt, dch khu tr rnh lin thu. C th thy hi
chng ba gim l lng lng ngc.
- Trn dch th c honh: dch khu tr gia nn phi v c honh. Ngi bnh c th au
bng, nc. Khng r hi chng ba gim.
- Trn dch th trung tht: dch khu tr mt phn, hoc ton b gc phi- trung tht. Ngi
bnh thng kh th nhiu. C th ch g thy c mt vng cnh c hoc ct sng


TRN KH MNG PHI

Kh c th trn vo mng phi, xm chim ton b mng phi gi l trn kh
mng phi ton b, nu ch xm chim mt phn gi l trn kh mng phi cc b
(loi ny th hin rt m thm).
TAM CHNG GAILLARD:
- Rung thanh mt.
- G vang nh trng.

NI C S

125


- m ph bo mt.
X QUANG CA TRN KH
- Bn trn kh lng ngc phnh to.
- Phi bn trn kh sng hn bnh thng.
- Bn trong vng sng ny khng c hnh nh ca nhu m phi.
- Nhu m phi b p xp v pha rn phi.
- C honh y xung thp.
- Tim v kh qun b y v pha i din.
TRN DCH TRN KH PHI HP
I . TRI U CHNG:
1.Triu chng thc th: l cc triu chng phi hp, gm mt hi chng trn dch pha di, mt hi
chng trn kh pha trn. Triu chng ng k v c hiu l ting c ch khi ta lc ngi bnh(cn thn
vi ting c ch d dy khi i).
2.Triu chng Xquang: hnh nh nc v kh rt c hiu, phn cch nhau bi mt ng thng ngang ranh
gii gia lp nc v kh gi l mc hi dch.
I I . NGUYN NHN.
1. Trn kh trn dch mng phi: c th l: Tin trin ca mt trn kh mng phi lao: thng nht.
2. Trn mu trn kh mng phi: c th l do chn thng (dao m, b n): thng thng nht, ngoi nhng
nguyn nhn nh ca mt trn kh trn dch.
3. Trn m trn kh mng phi: c th l: - Do s nhim khun ho m ca mt trn kh trn dch. - Bin chng ca
mt pxe phi v vo mng phi. - Bin chng ca mt trn m mng phi v vo kh ph qun.
I I I. KT LUN
- Xquang l du hiu quan trng nht trong chn on trn kh hoc trn kh trn dch mng phi.
- V lm sng:

NI C S

126


+ Nn ch ti triu chng au ngc v ton thn nng mt ngi bnh phi nh lao, p xe, ho g v ngay c
i vi nhng ngi tr kho mnh(CH Y).
+Trn kh: ton b c th chn on c trn lmsng, da trn triu chng thc th: g trong l mt du hiu
quan trng.



61-62.R RO PH NANG TNG GIM.
R RO PH NANG
- L do khng kh i vo ph nang , xoy nh vo thnh ph nang .
- Nm ngoi vi lng ngc.
V tr nghe : Vng trc bn ca ngc v lng
Thi gian : sut k ht vo & u k th ra
Tnh cht : ting lin tc, m du v cng thp.
TNG DO LNG KH XOY VO NHIU HN
- Vng phi th b trn mc trn dch
- Xp phi 1 bn phi bn cn li th b.
MT HOC GIM :
DO GIM DN TRUYN
Ngi bo thnh ngc dy.
Trn dch mng phi hoc dy dnh mng phi
Trn kh mng phi
DO GIM DNG KH VO PHI

NI C S

127


Lan ta: COPD, hen ph qun, kh ph thng
Khu tr: Xp phi khu tr (khi u chn vo lm bt dung dn kh xp)

63. M THI
BIU TH BI 4 TNH CHT:
- Thi gian th.
- Cng .
- m .
- m sc.
PHN LOI
- Thi ng.
- Thi mng phi.
- Thi v.
- Thi hang.
THI NG.
M T
- Thi gian th: ht vo nghe r hn.
- Cng : mnh.
- m : cao.
- m sc: th.
NGUYN NHN:
L m thanh truyn qua ph qun gp mi trng c nn tng ln.
GP TRONG:

NI C S

128


PH BIN
ng c phi (vim phi)
KHNG PH BIN
X ha phi khu tr.
Pha trn ca 1 trn dch mng phi(*)
Xp phi (trong trng hp ph qun vn cn m rng)

Macleods clinical examination
THI MNG PHI
M T:
- Thi gian th: r k th ra
- Cng : m.
- m sc: xa xm.
NGUYN NHN
- m thi ng c bin i qua 1 lp dch mng ca mng phi.
GP TRONG
- c phi nm trong lp dch mng phi.
THI HANG
M T
- Thi gian th: k ht vo nghe r.
- m : cao.
- m sc: rng.
NGUYN NHN:

NI C S

129


- Do s truyn ting phi qua 1 hang rng trong nhu m phi.
GP TRONG:
- Hang lao.
- Abcess phi.
THI V
M T:
- Thi gian th: r k th ra.
- m : cao.
- m sc: ting kim kh chm nhau.
NGUYN NHN
- L m thi hang trong trng hp hang qu ln.
GP TRONG
- Trn kh mng phi lai khu tr.
Ni c s - YDH
R RO PH NANG C PHI THT S XUT PHT T PH NANG?
Trc y ngi ta ngh rng, ting r ro ph nang do xut pht t ph nang do
khng kh i vo ph nang, xoy nh vo thnh ph nang, cho nn t tn cho n l
r ro ph nang( vesicular sounds)
Tuy nhin ngy nay, ngi ta pht hin ra m thanh ny pht ra t cc ph qun (khng
phi ph nang), v h c xu hng gi m ny l mth (breath sound) nh trong sch ni
trng mnh.

NI C S

130


Nhng trn lm sng thy c vn thng s dng thut ng r ro ph nang m t
bnh.
C CH CA R RO PH NANG V M THI NG:
R ro ph nang v m thi ng u xut pht t ph qun.
R RO PH NANG
- Ngun gc ca r ro ph nang l do khng kh xoy vo cc ng dn kh ln m thanh
GC ny nghe ging nh m thanh khi ta t ng nghe kh qun c.
- Tuy nhin, nhu m phi bnh thng, c lp khng kh cc ph nang ng vai tr nh 1
mng lc, dn truyn m thanh rt km v th, m thanh ta nghe c trn phi bnh nhn
nghe xo xc, r ro, rt nh
M THI NG
- Gp khi nhu m phi bnh thng b thay th bi 1 loi nhu m dn truyn m thanh tt (c
th l do ng c, x ha phi, hoc xp phi m cc ng dn kh vn cn thng ( tc l
nhng trng hp m lp khng kh cc ph nang bin mt)).
- Khi , m thanh do s xoy ca khng kh vo cc ng dn kh ln s khng b lc bi
cc ph nang na.
- m thanh nghe c phi ny rt to, v tng t nh m thanh khi ta t ng nghe c.
m thi ng s c khng nh bng ting ngc thm ( bn cht u l do s tng dn
truyn m truyn m thanh).
( Tht vy, gi s khi chng ta thi vo 1 chai Coca cola, mthanh pht ra l t c chai
ch khng phi thn chai, khi ct ci c chai i, khi thi s khng pht ra m thanh na, lin
tng c chai l ph qun, thn chai l ph nang).
M THI NG V M TH TNG

NI C S

131


Tham kho 1 s sch , chng ti nhn thy h c xu hng cc m nghe c trn
thnh ngc thnh 2 loi:
m th ( breath sound).
- L m nghe c do s di chuyn ca dng kh trong cc ng dn kh.
- Theo nh ngha , h chia m th thnh 3 mc :
o m thi ng ( tng ng m th tng).
o m th bnh thng ( normal breath sound).
o m th gim hoc mt.
Cc m km theo ( added sounds).
Tc l ngoi mth ta cn nghe thy nhng m thanh no khc khng?
- Cc ting Rales.
- Ting th rt, wheezing.
- Ting c mng phi.
NGHA CA VIC PHN LOI NH TH NY:
- i vi cch phn loi nh th ny, h khng xy ra trng hp va c r ro ph nang tng,
va c m thi ng, v bn cht ca 2 m ny ging nhau u l m th.
- Gip cho vic m t bnh c n gin hn v c h thng hn.
- Gip cho chng ta nh hng c phi nghe nhng g khi t ng nghe ln phi bnh
nhn.

1 V D V M T BNH
Ri lon S dch chuyn trung tht
S di chuyn
ca thnh
ngc
G
m th (Breath
sounds)
m km theo (Added
sounds)
ng c
phi
Khng Gim khu
vc b nh
c mthi ng Rales.

NI C S

132


hng
Xp phi Dch chuyn v pha tn
thng
Gim khu
vc nh hng
c Gim hoc mt Khng c
Trn dch
mng phi
Timdch chuyn v pha i
din ( kh qun ch dch
chuyn nu trn dch ln)
Gim khu
vc nh hng
c nh Gim khu vc trn
dch, nhng tng
b trn
Khng c, nhng c
th nghe thy ting c
mng phi
Trn kh
mng phi
Kh qun dch chuyn v pha
i din nu trn kh di p
lc
Gim khu
vc b nh
hng
Vang Mt hoc gim
nhiu
Khng c.
Hen ph
qun
Khng Gim i xng
2 bn
Vang Gim hoc mt Wheeze
X ha
m k
phi
Khng Gim i xng
2 bn
Thng khng b
nh hng bi ho
v t th
Bnh thng Rales thy phi b
nh hng.


64-67.CC TING RALE
- Rale N
- Rale M
- Rale PH QUN ( rale rt rale ngy )
- m WHEEZING ( ting rt khu tr ) [wheezing : ting th kh kh, m ci ]
RALE N
M T:
- Rale 1 th nghe c cui th th vosu.
- Khng thay i khi ho.
- Ging ting ran mui.
- L rale ca ph nang.
GP TRONG hi chng ng c phi GY TIT DCH C TRONG LNG
PH NANG.
- Ph phi cp
- Vim ph qun nh
- Vim phi ( P)

NI C S

133


- X phi
(4 nguyn nhn c ly trong sch ni c s YHN)
C CH : do s tch i ca ph nang b dnh
RALE M
M T:
- Nghe c c 2 th, nh ting nc si.
- C rale m to, va, nh ht.
- Thay i khi ho(c im phn bit ran m).
GP TRONG: s tit DCH LNG trong lng ph qun.
- Vim ph qun a tit cht nhy.
- Gin ph qun.
RALE PH QUN (RT V NGY)

134


BAO GM
- Rale rt.
- Rale ngy.
M T
- L 1 ting lin tc.
- Nghe c th th ra, i khi c 2 th.
- C ngun gc t ph qun.
GP TRONG: Hp tiu ph qun hay co tht cc tiu ph qun.
- Hen
- Vim Ph qun mn tnh do tc nghn
- Gin ph qun
Nguyn nhn : do hp tiu ph qun hoc co tht tiu ph quN
M WHEEZING (TING RT KHU TR)
- Chn p kh qun hay cc ph qun ln.
C 1 NGHIM PHP PHN BIT RALE N V RALE M
Tr li:
- Cho bnh nhn ho ho vi ci.
- Rale n khng thay i khi ho.
- Rale m sau khi ho s thay i v tr.
- Ran n nghe khi bo bnh nhn ht su.


135


VIM PHI (HI CHNG NG C PHI)

Mc co gin ca thnh ngcGim.
Gc.
m th ( RRPN)m thi ng.
m km theoRales
m niTng( ngc thm).
Ngun: Macleods clinical examination

68.TING C MNG PHI
M T:
- Do l thnh v l tng b vim dy
- Khi th , 2 l ny c vo nhau nghe nh ting l kh chm nhau
- Nghe c c 2 th

136


GP TRONG
- Vim mng phi kh
- Giai on u v cui ca Trn dch mng phi
Phn bit
C MNG PHI C MNG TIM
Th rp
Th th ra ( ch yu ) nghe c
Nn th Mt
mdu
C 2 th nghe c
Nn th Vn cn nghe

70. KIN TP CHC D MNG PHI.
CH NH:
- Chn on xc nh c trn dch mng phi.
- Chn on nguyn nhn trn dch mng phi.
- iu tr:
Ht ht dch gii phng s chn p phi.
1 s trng hp trn dch mng phi mn tnh, sau khi ht ht dch, ngi ta bm cht gy
dnh mng phi chng trn dch mng phi ti lp.
Trn m: chc dch kt hp vi ra mng phi.
CHNG CH NH:
- Bnh nhn qu yu, suy h hp, suy kit nng.
- Ri lon chy mu v ng mu.
- Nhi mu c tim.
CCH CHC D:
TRC KHI CHC D

137


- Phi kim tra cc du hiu sinh tn trc khi tin hnh th thut
T TH CHC D : ( BN =bnh nhn )
- BN ngi trn ging ,tay bn pha chc d a ln cao ( T GP )
- BN ngi trn gh ta , 2 chn dng ra 2 bn , ngc t vo lng gh ,khoanh 2 tay ln trn ta
lng gh v cm trn 2 tay ( hay gp )
- BN nm nghing v pha phi lnh, u hi cao, cn k gi mng di lng v cnh tay bn
chc d a ln cao
V TR CHC D
- Dch: Thng chc khong gian sn VIII hoc IX trn ng Nch Sau
- Kh : Thng chc khong gian sn II III trn ng Gia Xng n (trung n )
TAI BI N:
Chy mu v au ti ch:
do chc phi b mch thn kinh gian sn.
- Mun trnh, cn phi chc kim lt ln b trn xng sn.
Chong ngt do lo s:
y l tai bin thng gp, do bnh nhn qu s hi hoc lm th thut lc bnh nhn ang i.
- Ch cn cho ung nc ng nng, mt lc l khi.
Tru tim mch do sc mng phi:
- Tai bin ny xy ra khi ht dch qu nhanh v qu nhiu.
- Cn phi tun theo ng cc thao tc k thut.
Trn kh mng phi:
- Thng do kh b ht vo qua kim, do khng m bo ht kn.
- Cng c th do chc vo phi gy v bng kh thng.

138


- Ch cn ht ht kh sau khi ht dch.
Ph phi cp:
- Cng c th xy ra khi ht dch qu nhanh v nhiu.
Chc nhm ph tng:
- Vo phi, vo tim, gan , rut, lch v d dy.
- Cn nm vng v tr gii phu v lm thn trng, trnh th bo.
Nhim trng:
- C th gy ra m mng phi.
- Cn phi tun th ng qui tc v trng trong th thut.
C th cn gp:
- Khi huyt, tc kh mch, d ng thuc, gy kim
Rc ri c th gp: trong khi ang ht, khng thy dch ra na.
- C th l ht dch.
- Nhng cng c th kim tin vo qu n nhu m phi.
- Do kim tri ra n thnh ngc.
C th do tc kim
Cn phi kim tra cc tnh hung ny iu chnh kim.

CH : Chc kim v tr B TRN XNG SN DI trnh chm TK - MM gian sn
Ngun: Benhhoc.com, Ni c s - YDH


139


71. HI CHNG TRUNG THT
NGUYN NHN
- U bu : Hch Bch Huyt , Tuyn c , Ph qun
- Abscess: Thc qun , Honh
LM SNG : ty theo v tr khi u c quan m c nhng biu hin khc nhau
- Mch mu : Nhc u ,kh th ; Mi tm , ph
- Thn kinh: Nc ct ; ni khn , tc ting
- Kh qun : ho , kh th , au ngc
- Thc qun : kh nut ,nghn ,nut au

72. HI CHNG HANG
NH NGHA
- Hi chng hang bao gm cc triu chng lm sng gay nn bi s c mt ca mt hoc
nhiu hang trong nhu m phi thi ra ngoi qua ph nang.
C CH HI CHNG
- Trc khi b hu hoi hon ton v thi ra ngoi ph nang, nhu m vng tn thng qua
giai on ng c. Hang phi bao gi cng c nhng vch gm nhng ph nang b ng
c, vch c th dy hay mng tu theo mc ca tn thng.hang lu ngy thng
c vch x cng v nhn. Hang mi c vch g gh gm nhng t chc ng c ho
nhuyn. Hang c th ng ringhoc thng vi nhau. Ngoi tn thng ca ph nang, ta cn
thy tn thng vim ph qun, mng phi v mch mu phi. Nhng nhnh nh ca ng
mch phi vch hang b vim c th phnh vo pha trong hang ( l phng ng mch
Rasmussen).
- Nhng thay i v gii phu bnh c th biu hin trn lm sng bng ba triu chng i
cng vi nhau: hi chng ng c, do nhu m phi b ng c gy nn, v hi chng hang,
do c khong trng trong lng nhu m phi b vim.

140


LM SNG:
Th in hnh: L trng hp c hi chng ng c kmtheo cc triu chng ca
hang. Ta thy:
- Rung thanh tng: mc tng tu thuc vo mt v b dy ca vch hang.
- G c: nu hang rng, ng knh ln hn 6 cm v gn thnh ngc th g s trong hn
phi bnh thng, nghe nh ting vang trng.
- Ting phi hang.
Th khng in hnh: L nhng trng hp trn lmsng khng biu hin nay hi chng
hang hoc khng thy, nguyn nhn l hang nh qu, hoc xa thnh ngc khng thng vi ph
qun.
- Nu vch hang mng qu: lm sng cng khng pht hin c ting thi hang, nu hang
su trong nhu m phi.
- Hang to, gn thnh ngc: c biu hin nh trn kh mng phi cc b: mt vng mt rung
thanh, g vang trng, mt r ro ph nang, c ting thi v.
- Hang nh qu, hoc khng thng vi ph qun: thng khng pht hin c lm sng.
nhng hang phi khng c biu hin lm sng gi l hang cm.
Nhng trn lm sng phc tp l: cn c hi chng gi nang
- L nhng trng hp c ting thi hang, nhng khng c hang trong nhu m phi.
Trong gin ph qun, ta c th thy hi chng hang mt hay c hai y phi. Ting thi hang
hay thi tng ngy tng gi, tu theo ph qun gin cha m nhiu hay t. Hi chng gi nang
trong gin ph qun gin to ra name trong mt vng nhu m phi vim kinh din gy nn. Cc
ph qun gin ng vai tr hmcng hng gia t chc phi ng c, iu kin cn thit gy
ra ting thi hang. Chn on phn bit vi hang thc ngha l hang trong nhu m phi, phi c
X-quang: chp ph qun bng cht cn quang lipidol s thy cc on ph qun gin phnh
vng c ting thi hang. gin phnh c th hnh tr, hnh ti, hnh bng trn. lmsng khng c
chn on quyt nh, nhng c mt chi tit ng ch l tnh trng ngi bnh tt, so vicc
triu chng thc th phi.

141


- Ph qun ln b ko lch v tr, trong x phi, cng gy ra ting thi hang, nghe r
pha sau, vng h trn gai. Trong nhng t vimcp xut hin thm cc ting rn kh,
rn t, nn cng lmta ngh nhiu ti hi chng hang,ngoi ra cn c th gpdo trn kh
mng phi khu tr,kn kh
C th phn bit bng X-quang:
- Hnh nh gi hang ca ph qun: Tia X qua thit din ngang ca ph qun to nn mt hnh
trn sng nh. Hnh ny i bn cnh, song song vi mt huyt qun cn quang gi l
hnhng nhm.
- Trn kh mng phi cc b: Trn phim c th thy trn kh to thnh mt gc nhn vi thnh
ngc, v vch trn kh thng mng, khc vi hang to thnh mt gc t vi thnh ngc v
c vch dy hn.
- Kn kh: Hnh nh cng trn nh hang nhng vch rt mng. Trn y l nhng hnh nh
thng thng c th lm ta chn on nhm hang phi. Nhng s phi hp vi lm sng l
cn thit: rt kh ngh ti hang phi mt ngi kho mnh, khng st,, khng khc nh.)


142















143



Chng IV

TI U HA








144



145


- au nh dao m vng
thng v
- Lan ra sau lng
- Amylase, lipase >3 ln bnh
thng.
- Nn xong khng au.
72.AU DO VIM TY CP
M t cn au thy c lun i hi chng ta m t c 9 tnh cht:
Hon cng- hng tnh v - chu, km gim kt.
Hon cnh xut hin: t ngt, au tng ln
khi n ung
Hng lan: lan ra sau lng ( c khi ln ngc
tri, c th nhm vi cn au tht ngc).
Tnh cht: au d di ,kiu xuyn thu
V tr: Thng v v quanh rn hoc h sn
tri tng ng vi vng ty
Chu k : khng c chu k.
Triu chng km theo:
Nn ( 70 -80% trng hp), nn xong khng au.
Bng trng: do lit d dy, rut.
Vt v, bt an, tot m hi, chong ( do au)
T th gim au:
Gp ngi ra trc gim au.
T th ngi xm hoc nm ph phc (t th Hi gio) c th gim au phn no
Nm nga au tng ln.
Ho, c ng mnh, th su u lm tng au.
Chn on: CT scanner , S
Xt nghim : amylase mu-nc tiu tng, lipase mu.
y l bnh cp cu ngoi khoa.
Nguyn nhn thng gp gy ra vim ty cp: cc nc phng Ty, si mt v lm
dng ru l nguyn nhn ca 80% cc trng hp vim ty cp phi nhp vin. Vit nam,
ngoi nguyn nhn kinh in nh trn th cn c mt nguyn nhn quan trng khc l do
giun chui ng mt-ty. Vim ty cp do si mt thng gp ph n nhiu hn nam gii.
i vi ni c s th 3 nguyn nhn chnh ca vimty cp cn nh l:
- Do giun.
- Do si.
- Do ru.
( theo ni c s v Wikimedia Foundation, Inc )

146


CC BNH NGUYN GY VIM TY CP:
1. Bnh l ng mt: si
2. Do ru( gy vimty cp v mn)
3. Sau phu thut nht l phu thut bng
4. Sau ni soi v chp ng mt ty ngc dng
5. Chn thng vng bng
6. Bin dng (tng triglycerid mu, tng calci mu trong cng
tuyn cn gip, suy thn, sau ghp thn, gan nhim m cp trong
thi k mang thai )
7. Di truyn
8. Nhim trng
9. Do thuc ( xc nh c nh: azathioprim, sulfonamid, li
tiu thiazide, furosemid, thuc nga thai estrogen, tetracyclin,
valproid acid)
10. Bnh ri lon m lin kt kmtheo vimmch (lupus h thng,
vimmao mch hoi t, ban xut huyt, gim tiu cu kmhuyt
khi )
11. lot d dy t trng xuyn thu
12. Ngn bng vater: trong bnh crohn, ti tha t trng
13. ng ty chia i: ng wirsung nh trong khi ng santorini tp
hn, do p lc trong ng wirsung gia tng to yu t thun li
cha xacho vim ty
14. Cc nguyn nhn cha xc nh c
( Theo Bnh tiu ha gan-mt _Hong Trng Thng )
AMYLASE V LIPASE
Trong vimty cp, amylase v lipase mu thung tng v y l 2 xt nghim quan trng
chn on xc nh.
AMYLASE MU.
- c hiu : 80% (amylase khng nhng c tm thy ty m cn 1 s c
quan khc nh nc bt, gan, rut non, thn, vi trng, v 1 s khi u khc)
- Bt u tng sau 4 -12h sau cn au, in hnh l sau 24 48h tng trn 4
ln mi c gi tr.
o Vim ty cp th ph : gim sau 3 -4 ngy.
o Vim ty cp th hoi t tng phn : 7 10 ngy.

147


Amylase huyt thanh ln hn 4 ln
bnh thng rt c gi tr chn an
vim ty cp sau khi loi tr
thng tng rng hoc nhi mu rut
(Thm d chc nng c s - YDH)
Lipase: c hiu hn v tn ti
lu hn amylase trong vim
ty cp.
Vim ty cp nng th amylase c
th khng tng my, i lc bnh
thng, thm ch c th gim
- Vim ty cp th hoi t qu nng n
amylase c th khng tng hoc
gim thp.
- Nng amylase huyt thanh bnh
nhn vim ty bnh thng trong
trng hp:
o Xt nghim mun sau 2 5
ngy.
o Bnh nhn b vim ty mn nhiu hn l vim ty cp
o C km theo tng triglyceride mu.
AMYLASE NIU:
- Amylase mu c thi tr qua ng tiu:
Tng chm hn , sau 2 3 ngy.
Cao nht vo ngy 4 5.
Thng xt nghim cho bnh nhn n mun (
>96h) chn on hi cu.
H S THANH THI AMYLASE
- c hiu hn Amylase mu ( 90%).
-Bnh thng ACR= 3,1. Trong vim ty cp ch
s ACR>5
LIPASE MU:
- Tng song song vi Amylase mu.
- c hiu hn amylase mu v ko di hn.
nhng nh lng phc tp v mt nhiu thi gian t p dng.
TRYPSIN MU
c hiu cho ty v ch c ty l c quan duy nht cha enzym ny.
Tuy nhin, vic nh lng n rt kh.
N thng c dng sn lc bnh x nang ty tr s sinh.

148


TIU CHUN RANSON TIN LNG VIM TY
CP:

Lc nhp vin (24h u)
1.Tui
2.WBC
3.Glucose
4.LDH
5.AST
>55 yr
>16,000/mm
3

>200 mg/dL
>350 IU/L
>250 IU/L
Trong vng 48 gi tip theo
Hematocrit gim
BUN tng sau khi truyn dch
Calci
PaO
2

Bicarbonat giamr
Lng dch cn truyn
>10 %
>5 mg/dL
<8 mg/dL
(1,9mmol/L)
<60 mm Hg
>4 mEq/L
>6 L
Tin lng:
- <3 du hiu = 0-9% t vong.
- 3 4 du hiu =11- 16% t vong.
- 5 6 du hiu = 33 40% t vong.
- >6 du hiu = 100% t vong.
1 BNH NHN VO VIN CH CN NHN T TH
BNH NHN LM SAO PHN BIT L VIM TY CP HAY
THNG TNG RNG.
- Vim ty cp: bnh nhn m bng la, vng vy.
- Thng tng rng: bnh nhn khng dm nhc nhch (au)
NH GI IU TR CI THIN
- Da vo ci thin triu chng au bng

149


- Khng phi da vo amylase
1 bnh nhn b au tng cn vng h sn phi,
hm nay t ngt au lan ra ton bng, km theo l m
rut gim, cn ch chn on g?Lm xt nghim g?
- Cn au qun gan do tc nghn ng mt ch gy bin chng vim ty cp.
- Cho bnh nhn lm amylase mu.
1 BNH L CN PHN BIT VI VIM TY CP.
- Nhi mu mc treo c triu chng au gn ging vi vim ty cp, au lan ton bng,
Nhng tnh trng nhim c ca h sm hn so vi vim ty cp, n au chung
chung ton bng.
- Trn thc t, chn an nhi mu mc treo l 1 chn on kh: ch c th da trn
tin s 1 bnh nhn cao tui, tng HA hoc i tho ng v loi tr tt c cc chn
on khc th mi ngh n chn on ny.
1 BNH NHN C AMYLASE MU TNG CAO
TRN 10 NGY.
- Cn ch n nang gi ty: l mt nang cha dch v cc m b tuy hy ca ty nm
xung quanh ty.
- Khm lm sng c th thy 1 khi vng thng v v amylase huyt tng tng cao
trn 10 ngy.
BNH NHN BNG, XT NGHIM DCH BNG C
AMYLASE TNG.
- Bng th pht do r r dch t nang gi ty.
- Thng thng bng s t bin mt

150


Vim ty mn: ri lon hp thu
(do thiu men ty) v i tho
ng type 1
MT A TR VO VIN CHN ON VIM TY
MN, CN CH ?
- X nang (cystic fibrosis) l nguyn nhn ph bin
nht gy vim ty mn tr em.
- Ru l nguyn nhn ph bin nht gy vim ty mn
ngi ln.
Ngun: Bnh tiu ha gan mt PGS. Hong Trng Thng

73.CN AU LOT D DY T TRNG
NGUYN NHN: cho n nay cha tm ra nguyn nhn chung cho lot, nhng ngi ta
thy c mt s yu t tham d vo, i khi chng phi hp nhau. Cc yu t ny cn c s
tham gia ca di truyn, yu t tm l,, ri lon vn ng v mi trng ( tit thc, thuc l,
thuc, HP).






LOT D DY:
- Hon cnh xut hin: lin quan n ba n, sau n 30 pht 2h, au nhiu
sau ba n tra v ti hn l n sng.
- Tnh cht: au rt bng, au tng ln lc i.
- V tr : thng v - nu lot mt sau au xuyn ra sau lng.
- Chu k:
o au tng t, mi t ko di 2 8 tun, cch nhau vi thng vi
nm.
o Gia tng theo ma ma ng.

151


Khi no acid xung t trng, khi
bnh nhn au (sau n 2 4h)
o Cc biu hin lm sng ca vim vng hang v xy ra trc lot c th
lm mt tnh chu k ny
- Triu chng km theo: ngho nn, c th nn ra mu, i cu phn en, bun
nn, nn ma, chn n
- Bin php gim au:
o Thuc khng toan hoc thc n.
khi c vim km theo th khng hoc au thm.
- Note: 1 s trng hp khng c triu chng v c pht hin khi c bin
chng.
Ngun: Ni bnh l - YDH
1 ngun thng tin khc gip chn on v tr lot nh
sau
au ngay sau n hoc sau 15- 1h : lot tm v b cong nh
au sau n 2-3h : lot hang v
au khng lin quan n ba n: lot mn v
LOT T TRNG: au c trng ca lot t trng thng r hn lot d dy v y
khng c vim phi hp.
Hon cnh xut hin:
- 2 - 4h sau khi n nhp 3 k.
- 1-2h sng (triu chng bnh nhn thng khai).
V tr: thng v.
Hng lan: Lan ra sau lng v pha bn phi ( 1/3 s trng hp).
Chu k : cc t bc pht r rng, gia cc k au khng c triu chng g
c.
Tnh cht: kiu qun tht ( khc vi au d dy l au kiu rt bng)
1 S THNG TIN KHC V LOT D DY T
TRNG
LOT V UNG TH HA.
- Ch c lot d dy mi c nguy c ung th ha, cn lot t trng rt him khi
b ung th ha.
- T l lot ung th ha 5 10% ( thi gian lot ko di 10 nm).

152


MEN I (MULTIPLE ENDOCRINE
NEOPLASIA)
- Ph i tuyn yn
- Ph i tuyn cn gip.
- Ph i tuyn thng thn.
- Ph i o langerhans.
- U tng tit Gastrin.
VI IU V AU TRONG BNH D DY-T
TRNG
- L du hiu quan trng v thng xuyn c
- C tnh cht chu k ( trong lot d dy t trng) hoc khng ( vim ,ung th...)
- Cm gic: au tc hoc rt bng, m . Khng c cm gic au qun
- Hng lan: thng lan ln ngc or sau lng
- nh hng ca ba n: kh r rt, c th lam tng ln or gim i.
- Thi gian ko di: thng ko di mt hai tun cho mi t au, au thng
ti ph
Note: au do nguyn nhn d dy khng bao gi km theo st
v ri lon i tin. (b v ri lon i tin bao gm tiu chy, to
bn...). (Ngun: ni c s-dh y H
Ni )
HI CHNG ZOLLINGER ELLISON ( U TNG TIT
GASTRIN).
- Dch t hc v c ch bnh sinh:
o Phn ln l do u t bo o ty (pancreatic islet cell tumours).
o Khi u ny tit gastrin v gy ra tng tit acid d dy.
o C lin quan n MEN I (Multible endocrine neoplasia) trong 20 30% cc
trng hp.
- Lm sng:
o au thng v km theo st cn.
o Lot:
Hu ht l mt lot t
trng n c
Nhng cng c th l nhiu
lot
o Tng tit acid gy ra tiu chy.
o Ri lon tiu ha
Acid tit qu nhiu s lm
mt i mi trng kim t
trng lm cho men ty khng
hot ng c gy ra ri
lon tiu ha v tiu chy.
- Cn lm sng:

153


o BAO, MAO v t s BAO/MAO u tng.
o Nng Gastrin trong huyt tng > 1000pg/ml
- Nghi ng hi chng Zollinger Ellison khi:
o Nhiu lot t trng nhng v tr thng gp.
o Lot khng vi iu tr.
o Lot pha xa ca on I t trng.
o Lot d dy km theo tiu chy.
o Tin s gia nh c cc khi u tuyn yn hoc cn gip
BAO V MAO V CH S BAO/MAO
Xt nghim acid dch v bao gm vic o lng acid c bn (basal acid output BAO), lng acid ti a (maximal acid
output (MAO) v t l BAO : MAO. BAO l lng acid trong dch v c ly thng qua ng thng d dy trong 1h mt
d dy rng thc n, hiu n gin l lng acid m d dy tit ra trong 1h. Bnh thng < 5mEq/gi. MAO l lng acid
cng c ly nh trn nhng khc ch l ngi ta dng pentagastrin kch thch ri mi tin hnh ly dch v. Bnh
thng MAO khong 5 20 mEq/gi. T s BAO: MAO khong 0.20 : 1
BNG SO SNH LOT D DY T TRNG
c im so snh Lot d dy Lot t trng
T l 25% 75%
Dch t Nam: n = 1:1
Ht thuc l khng gy ra lot d dy nhng lm
chm s lnh so.

Nam: n = 2:1
Nguy c tng ln vi MEN I
Tng nguy c trong x gan, COPD, suy thn, cng tuyn cn gip.
Helicobacter pylori Khong80% cc case T 90-95% cc ca.
C ch bnh sinh Tn thng hng ro nim mc do H.pylori
Thiu mu nim mc (do gim PGE), tro ngc
dch mt, chm s lm vi d dy, BAO v MAO
bnh thng hoc gim.

Tn thng hng ro nim mc do H. pylori
Tng sn xut acid.
BAO v MAO u tng.

V tr Thng l 1 lot n c b cong v nh ca
hang v (cng l v tr ca ung th)

Thng l 1 lot n c mt trc ca phn th nht ca t trng, cng c th
l 1 lot mt sau (nguy c thng vo ty)

Bin chng. Chy mu (ng mch v tri)
Thng.
Chy mu (ng mch v t trng)
Thng (lim hi di c honh, cn au lan ln vai tri)
Hp t trng (gy ngn cn thc n t d dy xung), vimty
Lm sng au rt bng thung v sm sau khi n.
au thng v tng ln khi n

au thng v rt bng khong 1- 3h sau khi n.
au thng v gim i khi n


154


Si mt vim ng
mt, ti mt s c tam
chng Charcot: au, st,
vng da
Chn an Ni soi: 90 95% trng hp.
Cn phi sinh thit lot d dy (1 4 % c tnh)
Baryt: pht hin 70 80%
Ni soi: pht hin 90 95% trng hp.
Khng cn sinh thit, v khng bao gi c tnh (ung th)
Baryt: pht hin 70 80% trng hp.
BAO, basal acid output; COPD, chronic obstructive pulmonary disease; MAO, maximal acid output; MEN, multiple
endocrine neoplasia; PGE, prostaglandin E
VIM D DY TNG P CA HAY BNH D DY
TNG P CA.
- Khng c thmnhimt bo vim.
- Gp sau tht tnh mch thc qun gin.
- Nimmc d dy dy ln, rc, xut huyt thnh tng m trong nim mc (Mozaic)
Rapid review of pathology
74. au vim ti mt
V tr: h sn phi
Hon cnh xut hin : bt u bng au ,st
Hng lan : ko lan
Tnh cht: tng cn ,qun tht
n im au ti mt v Murphy (+)
75. au qun gan
Nguyn nhn : si ti (t hn ) hoc ng mt
V tr : H sn phi hoc Thng v
Hon cnh xut hin : t ngt
Hng lan : ln b vai phi hoc lan ra sau lng
Tnh cht : au kiu nghin nt ph tng
T th gim au : khng c
Din bin : khng theo chu k ,ko di 12-24h
Triu chng km theo: St , lnh run , i ma
BNH NHN TC MT, VNG CH NO TRC?
- Vng kt mc mt. Do kt mc mt nhiu elastin, c i lc vi bilirubin.

155


p xe gan tam chng
Fontan: au, St, Gan ln

76. AU P XE GAN
Mc :
Nh : Cm gic nng n , cn cn tng lc mt
Nng:
au qun, xuyn ln vai P, tng ln khi c ng mnh hoc th su, tnh cht trin
min, ko di, khng thnh cn
C tam chng Fontan : St + au h sn P + Gan to
n k sn au (Ludlows sign).
Chn on: SIU M
77. AU VIM RUT CP
Cn au qun bng +nn ma+ i chy nhiu ln
Ton thn c du hiu nhim khun , nhim c , or mt nc
78. PHN L.
Cn phn bit l amip v l trc khun.
L TRC KHUN.
- Xy ra thnh dch, gp nhiu tr em.
- Phn lng, rt t, hoc ch ton mu, mu sm nh mu c hoc nc ra tht.
- Hi chng nhim trng nhim c vi st cao, au bng qun d di.
- i tiu tin nhiu ln 15 20 ln/ngy km mt rn v au hu mn.
L AMIP.
- Ch xy ra l t.
- Phn nhy mu, thng th mu ch dnh quanh phn c mu ti, km mt
rn v au hu mn sau i tin.
- Khng c hi chng nhim trng, nhim c, hoc nh. C au dc khung i trng.
Ngun: Bi xut huyt tiu ha Bnh tiu ha PGS.Thng.

156


79.PHN EN
Do xut huyt tiu ho cao: d dy, t trng
Phn mu ti : do xut huyt tiu ho thp hoc chy mu ( cao or thp or both ) qu
t
Mt s thng tin:
- Phn en thng chng t chy mu t thc qun, d dy or t trng, song cc
thng tn hng trng , hi trng ngay c i trng na cng c th gy ra a phn
en min l thi gian vn chuyn d dy rut di. Chng 60ml mu gy ra
ch a mt ln phn en
- Mu en ca phn th pht sau chy mu rut do mu tip xc vi acid chlorhydric
to ra hematinphn ging hc n
- Chy mu d dy rut, ngay c khi ch c pht hin bng test vi th dng tnh
cng l biu th mt bnh c nguy c nghim trng cn c tip tc thm d
- Mt s trng hp phn en ( sau khi ung cht st, bismuth, hoc cam tho) or c
mu ( n c ci ng, or tim tnh mch sulfobromophtalein) l bnh thng
Ngun: harrison
80- 82. KHM LI:
Li c chc nng vn ng, v gic (v gic ca chng ta c th phn bit c 5 v khc
nhau), gp phn vo pht m
BNH THNG:
- li hng, hi t, khng nhn, gai li r u, gai hnh i hoa xp hnh ch V
phn i li thnh 2 vng: thn li, cung li
Mt li



157


Cch khm li:bo bnh nhn h ming rng, l li ra bn ngoi v cong li ln(
nhn mt di li)
Bnh l:
1- Li trng bn ( cu 80): trong hi chng nhim trng, v d: thng hn.
2- Li , kh ( cu 81): gp trong hi chu ng nhim trng, c bit: thng hn.
3- Li : nhim khun, a hng cu, suy gan .
4- Li mt gai: trong thiu mu
5- Lot phanh li: trong ho g
6- Li thm en trong tng ure mu, addison, thiu vitamin PP
7- Nim mc di li vng (cu 82):
Hong m ( vng da)
X gan, tc mt



vim li li b nhim nm candida
MT S THNG TIN KHC :
Khi lng li:
To u trong bnh to cc vin cc, bnh suy gip trng.
Teo mt bn li do lit dy thn kinh di li.
Cc khi u bt thng ca li (lnh tnh v c tnh).
( Ngun www.ykhoanet.com)
83. KIN TP THM TRC TRNG (
DIGITAL (FINGER) RECTAL EXAMINATION)
L ng tc cn thit ,bt buc khi khm tiu ho c bit l ngi nam > 40t

158


T TH KHM:
Bnh nhn nm ph phc:2
chn qu hi ging , mng cao
vai thp Thy thuc ng i
din vi hu mn bnh nhn .
Bnh nhn nm nghing: chn
di dui ,chn trn co ,thy
thuc ng sau lng ,thp hn
mng bnh nhn
Bnh nhn nm nga: 2 chn
co ,dng rng ( ging t th sn
khoa) ,thy thuc ng bn
PHI bnh nhn . cho php
thm khm k cc c quan
trong chu hng ph n v
thnh trc ca trc trng.
CCH KHM:
Thy thuc mang gng cao su ,bi parafin lm trn gng , a ngn tr mang gng t
t nh nhng vo hu mn bnh nhn
Dng 2 ngn tay ... ko dn v banh cc np nhn hu mn ra ng thi bo bnh
nhn rn nh ( nh i a) dn cc np nhn hu mn
Phi xoay ngn tay sao cho c th thm khm c ton b chu vi ca bng trc
trng
C th thm khm c tin lit tuyn ; t cung ; bung trng.
BNH THNG :
Trc trng rng ,khi n vo cc ti cng mng bng ko gy au,rt tay ra ko thy mu,m
nhy
CC BT THNG C TH PHT HIN
Chn an cc khi u trc trng v cc dng khc ca ung th
Chn on cc bnh v tuyn tin lit, c bit l u x tin lit tuyn v ung th.
Chn on vim rut tha v cc dng khc ca hi chng bng cp.
kho st trng lc ca c tht hu mn trong i cu khng t ch - gp cc ri
lon v thn kinh nh chn thng ty sng.
Kho st cc c quan bn trong ca ph n.
kho st cng v mu sc ca phn trong to bn.
nh gi tr.
Chun b soi hu mn, trc trng.
Ngun: Ni c s - YDH, Wikipedia

159


Bng lm hnh thuyn
Suy mn.
Lao mng bng th x dnh.
THM KHM TRC TRNG- M O PH N
ph n:
- Thng dng t th sn khoa.
ngi ta c th va thm khm trc trng m
o nh gi nhng ri lon ca c trc trng v
m o.
Bc s a 1 ngn tay vo m o, 1 ngn tay vo
trc trng. Tay cn li n nh vo vng h v.
Gip bc s cm nhn v kho st cc c quan
vng chu hng 1 cch d dng.
l 1 thm khmsn khoa thng quy.
84.BNG LM HNH THUYN
- Suy mn , lao mng bng th x dnh ....
Bnh thng:
Bng thon,trn ,du + thnh bng ngang
xng c c ng nhp nhng theo nhp
th,rn lm
Ngi bo or ph n c thai nhiu bng
b ra 2 bn , trn da bng c vt rn
Cch khm bng
A. Nguyn tc:
- S nn nh nhng t vng khng auau
- t st c lng bn tay vo thnh bng, khng nn ch dng 5 u ngn tay
- Bo bnh nhn th u, s nhp nhng theo ng tc th ca bnh nhn
- Bnh nhn khng n ng tc khm ca thy thuc, khng ln gn bng m
bng phi tht mm
B. Phng php s nn
- Dng mt bn tay
- Dng 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 nghing 2 bn, t th
ngi hoc ng

160


85, 86.TUN HON BNG H ( prominent
veins).
M T CHUNG V TUN HON BNG H.
- Nu c 1 nguyn nhn no gy cn tr tun hon mu v tim, mu s tm
cch chy qua cc vng ni tc l cc tnh mch nng, lm cc tnh mch
ny gin ra, ni r di da, gi l tun hon bng h.
- Nhng nguyn nhn ny c th l do:
o Tc tnh mch ch trn: u chn p, huyt khi.
o Tc tnh mch ch di: u chn p, huyt khi.
o Tc tnh mch ca: huyt khi tnh mch ca, x gan, u chn p tnh
mch ca
TUN HON BNG H CA CH.
- Do gin tnh mch nng bng ca vng ni tc gia tnh mch ca ch.
- Gp bnh nhn:
o X gan.
o Hi chng tng p tnh mch ca.
o Hp tnh mch ca bm sinh.
o Bnh Banti.
o Hi chng Budd- Chiari.
- Biu hin:
o Cc tnh mch ni r na bng trn t rn tr ln.
o c bit khi bnh nhn ngi, ho, rn.
TUN HON BNG H CH CH:
- Nguyn nhn:
- Do tc tnh mch ch di
o Huyt khi.
o Chn p do u hoc do bng qu ln.
- Biu hin:
o Tnh mch ni r bng di t cung i tr ln.
TUN HON BNG H CH TRN:
- Nguyn nhn:
- Do tc tnh mch ch trn:
o U chn p.
- Biu hin:
o Cc tnh mch ni r ngc, chy ngc xung di rn v tim.
Ngun: Ni c s - YHN.

161



CCH XC NH HNG CHY CA DNG MU
TRONG TUN HON BNG H
Trong tun hon bng h ch - ch v tun hon bng h ca ch, mu s chy ngc t
di ln. Nhng trong tun hon bng h ch trn, mu li xy ngc t trn xung di
rn ( YHN).
Mun xc nh mu chy theo hng no, ta lm nghim php sau:
a. t 2 ngn tay nh nhnh
ln tnh mch.
b. Ngn tay th 2 s vut dc
tnh mch y ht mu
ra khi tnh mch .
c. Ngn tay th 2 nhc ra
khi tnh mch.
+ Nu mu lm y tnh
mch tr li nhanh chng
chiu ca dng chy s l
ngc t di ln ngn tay
ang bt pha trn.
+ Nu mu lm y tnh mch chm chiu ca dng chy s l chiu ngc li
d. C th nhc ngn tay th nht ra.
NGHA CA VIC XC NH HNG CA
TUN HON BNG H
(Hnh bn cnh).
1. Tnh mch b sn khng c ngha trn lm
sng.
2. Tnh mch hnh chn con sa gp trong tng p
tnh mch ca.
3. Gp trong tc tnh mch ch di.
Gii thch:
Trong tng p tnh mch ca:

162


Mu chy t ca ch qua cc tnh mch rn.
Chiu s cha xa xung quanh rn ( nh 2) nhng him.
Thng thng ch 1 hoc 2 tnh mch vng thng v l thy c.
Trong tc tnh mch ch di:
Chiu dng chy t di ln trn.
phn bit vi tng p tnh mch ca, phi xc nh chiu cc tnh
mch di rn:
Tng p ca: chiu xung di.
Tc TM ch di: chiu hng ln trn.
Ngun: Clinical examination Talley & Oconnor, 5th edition.
NOTE:
Phn bit THBH vi trng hp ngi gy,suy mn ,c th thy 1 s mch mu l r v mt
lp m bng di da

87.THNH BNG CNG VIM PHC
MC.
NHN:
- Khng thy thnh bng di ng theo nhp th.
- Trng hp in hnh thy r cc mi c thng to ni ln.
S:
- Thy r s phn ng ca cc c, thnh bng cng cng, khng th n lm
xung c.
- Cng n mnh, thnh bng co cng cng r.
MC CO CNG:
- C th co cng va, co cng r rt thm ch co cng tuyt i nh s vo
mnh g hay bc tng. y l mc cng nht, thng gp trong thng d
dy t trng. Chnh ion H t d dy kch thch mnh phc mc gy ra triu
chng , lc ny c th cha c vim phc mc. Tuy nhin, c nhng trng
hp thng d dy t trng nhng khng c triu chng ny (bnh nhn gi
yu, suy kit, thng bt, bnh nhn n mun,..).
- Mc ph thuc :

163


Bng ngoi khoa
Mt bnh nhn co cng thnh bng,
phn ng thnh bng hoc cm ng
phc mc gi chung 1 t l bng ngoi
khoa th hin mt tnh trng kch
thch phc mc thng gp trong vim
phc mc hoc chy mu trong.
Co cng thnh bng l mc nng
nht
Nguyn nhn gy bnh.
Th trng bnh nhn.
Tnh trng ca thnh bng.
Cc thuc iu tr.
NGUYN NHN:
- Ch yu gp trong VIM PHC MC.
- Ngoi ra 1 s nguyn nhn khc nh:
1 s hi chng sau phc mc: t mu sau phc mc, gy ct sng, gy xng
chu, v thn
Bnh l cp tnh ca bng : chy mu trong, xon u nang bung trng.
Bnh xa phc mc: Vim thy y phi, gy nhiu xng sn, chy mu
mng tim.
Ngun: Ngoi c s
NOTE:
- Bn ni ch cn nh thnh bng cng l gp
trong vimphc mc hoc chy mu trong.
Ngoi c s i hi nh cc nguyn nhn
khc.
CHN ON PHN BIT:
- Ngi c bp.
- Ngi nhy cm.
PHN NG THNH BNG CM NG PHC MC
Cn phn bit co cng thnh bng vi phn ng thnh bng v cm ng phc mc, mc d
nguyn nhn ging nhau nhng biu hin khc nhau.
PHN NG THNH BNG:
- L tnh trng chng ca cc c thnh bng khi thy thuc khm.
- Ngha l bng vn mm, vn di ng theo nhp th, nhng khi n su th mi thy s
chng i ca c bn di.
- Mc nh hn so vi co cng thnh bng.


164


CM NG PHC MC:
- Dng ngn tay n nh vo t t.
khng c du hiu chng nhng bnh nhn rt au.
( Lu : c 1 s sch m t du ny khi ta n su, bnh nhn khng au, nhng t ngt th
tay ra, bnh nhn li rt au)
Ngun: Ngoi c s - Hc vin Qun Y.

88.DU HIU RN B
KOENIG
NGUYN NHN:
- Du hiu c trng ca tc rut c hc.
DU HIU:
- Trong cn au hoc khi kch thch thy quai rut
ni ln v di chuyn tng t.
C CH:
- Khi b tc rut c hc, nhu ng rut tng cng
chng li tr ngy cc sng nhu ng di
chuyn trn thnh bng.
- L du hiu quan trng phn bit tc rut c hc v tc rut c nng.
- Tuy nhin, nu tc rut c hc n mun, trng lc rut gim dn cc sng nhu
ng gim ging tc rut c nng.
1 S DU HIU C TRNG:
- Hp mn v: Du Bouveret rn b vng thng
v t TRI sang PHI.
- Tc rut non thp: du rn b trn bng.
- Tc i trng thp: Du rn b theo dc khung
i trng.
CHN ON PHN BIT:

165


- Phn bit triu chng rn b vi hin tng thnh bng mng, yu, cng c th
quai rut co bp chuyn ng ging rn b, nhng bng khng chng, khng au.
TC RUT C HC V TC RUT C NNG
TC RUT C HC:
- L tnh trng tc rut m tc nhn gy tc l 1 vt cn tr ( tc l 1 nguyn nhn c
hc) chim 95- 97% trng hp tc rut rut tng nhu ng DU HIU RN
B
- Tc rut do bt:
Khi u thnh rut.
Khi u t ngoi chn p vo.
- Tc rut do tht: tin lng nng, do nguyn nhn gy tht p c
mch mu gy hoi t rut
Xon rut, lng rut.
Thot v nght.
TC RUT C NNG:
- Do ri lon hot ng ca h thng thn kinh iu khin nhu ng rut, lm cho
rut b lit, khng cn nhu ng cc cht trong lng rut khng di chuyn c
rut khng c nhu ng KHNG C DU HIU RN B
TAM CHNG TC RUT
au bng tng cn.
Nn.
B trung i tin.
( d nh: au Nn B Chng)
Ngun: Ngoi c s- hc vin Qun Y, Ngoi c s - YDH

166


BNH HP MN V BM SINH (Congenital pyloric
stenosis)
- L mt bnh di truyn a yu t vi t l 1:500 tr em sinh ra i, tr nam tri hn so
vi tr gi.
- Nguyn nhn: ph i c vng mn v.
- Triu chng lm sng:
o Nn vt dch d dy, khng c dch mt 2 4 tun sau khi sinh
o Mn v ph i c th s thy thng v.
CC NGUYN NHN GY TC RUT
Nguyn nhn Tho lun
Dnh Nguyn nhn ph bin nht gy tc rut non.
Thng gp nht l tc rut do dnh sau m, lc ni mc t cung,
sau x tr.
Bnh Crohn on cui ca hi trng b hp li do tnh trng vim ca thnh
rut.
Tnh trng dnh thanh mc gia cc quai rut cng gy ra tc

Teo t trng Thng teo v tr di ch vo t trng ca ng mt ch
C mi lin quan n hi chng Down.
M b a i (do tr khng th nut nc i c)
Nn ra dch mt ngay sau sinh.
Hnh nh 2 bng hi trn X quang bng thng: 1 d dy v 1
on gn t trng.

Lit rut do
si mt
Thng xy ra ngi ph n gi v vim ti mt mn tnh v si
mt.
S c 1 ng r gia ti mt v rut non, si mt s i vo rut
non v b tc li valve hi manh trng gy tc rut.
X quang bng thng s thy hi ng mt.


167


Bnh
Hirschsprung
Do mt cc t bo hch m ri di nim mc Meissner v m
ri Auerbach on cui ca rut gi (trc trng, i trng xch
ma) lm cho rut mt nhu ng.
Hu ht l bm sinh. Hirchprung mc phi gp trong bnh Chagas.
Thng gp mt hch v tr trc trng v on xa i trng xch ma.
on rut pha trn s gin ra v c nhu ng.
C mi lin quan n hi chng Down.
C du hiu tho cng (bnh nhn b to bn do on rt di b
mt nhu ng, phn li pha trn, nu phn pha di b tng ra
th bnh nhn s i cu phn t, gi l tho cng)
Bin chng: c th gy vim rut i vi on rut gin pha trn
(nguy c thng)
Chm an: sinh thit trc trng)

Thot v bn
gin tip.
Nguyn nhn ph bin th 2 gy tc rut non.
Thng gp nhng ngi mang vc vt nng nhiu.
Rut non b tut v mc kt vo trong ng bn gy tc rut.

Lng rut tr em, on cui hi trng s b lng vo bn trong manh trng.
Nguy c gy ra tc rut v thiu mu. Chn an bng triu chng
au bng d di, tr khc tht v i cu phn mu, v c th s thy
1 khi lng.
ngi ln: lng rut thng th pht sau polyp hoc ung th.

Lit rut do
phn su
1 bin chng gp tr s sinh do bnh x nang.
Phn su thiu NaCl s ng cc li v
Xon rut Rut s b xon li gy tc.
V tr i trng xch ma l v tr thng b xon ngi gi trong
khi manh trng li l v tr thng b xon thanh nin tr.
Yu t nguy c: to bn trng din, ph n c thai, s dng thuc
nhun trng.



168


89.VNG AU D DY T TRNG
au thng vng Thng v ngang mc mi c or cch xa mi c bn phi( T trng) ,bn
tri ( d dy)

90. IM AU TI MT
V tr: giao im ca b ngoi c thng to v b sn phi.
Ngim php Murphy:Ta n t t - Bnh th vo t t - Bnh ngng th v au >(+);Gp
Vim ti mt
Ti mt ni to ko cn mn Murphy
n vng ti mt au + Murphy (+) Vim ti mt
n vng ti mt au + Murphy (-) Vim ng mt

91. IM AU RUT THA
(Mac Burney)
- 1/3 ngoi ng ni Rn Gai chu trc trn bn
phi.
- Mt s sch miu t l im ngoi ng ni
Rn Gai chu trc trn bn phi.

1 S IM AU RUT THA NGOI IM MAC
BURNEY.
- im Clado: Giao im ng ni 2 gai chu trc trn v b ngoi c thng
to bn phi.
- im Lanz: Ch ni 1/3 ngoi v 1/3 gia ca ng ni 2 gai chu trc
trn bn phi.
C IM CN AU RUT THA:

169


- V tr:
au thng v v vng rn.
Sau 1 12h, au khu tr h chu phi.
- c im:
au va phi, khng thay i.
i khi c nhng cn co tht tri ln.
- Triu chng km theo:
Chn n: hng nh vi vim rut tha n mc nu khng c chn n
xem li chn on.
Nn ma : 75% bnh nhn.
Trn 95% bnh nhn chn n l triu chng u tin, sau l nn
ma.
- Cc triu chng khc:
Ton thn : st, BC tng.
Thm trc trng, m o thy ti cng au.
Phn ng thnh bng h chu phi.
Ngun: NgCS Hc vin Qun Y, Ngoi bnh l YDH

92.VNG U TY - NG MT CH
(Clauffard Rivet)
CCH XC NH:
- Ly 1 gc 45 :
- nh rn.
o 1 cnh l ng gia.
o Cnh cn li chch v pha
phi.
- a bn tay vo nh hnh v bn b
ngn th nht v ly khu vc ca ngn
th 2 v th 3.
NGHA:

170


au vng ny gp trong:
o Vim ty.
o Si ng mt ch.

93. IM AU UI TY ( Mallet Guy)
V TR :T b ngoi c thng to tri ,trn ng ngang rn o ln 3 khot ngn tay
CCH KHM:
- bnh nhn nm nging P
- n tay hng v pha ct sng
CCH KHM IM UI TY V L DO PHI LM
NH VY (Hi thi lm sng)
o Ty l 1 c quan nm sau phc mc, c che ph pha trc bi d dy v
cc c quan khc trong bng, nn cch khm n, nht l im ui ty c
khc so vi cc c quan khc, c th y:
bnh nhn nm nghing phi.
n tay hng v pha ct sng.
o L do phi lm nh vy l c th y d dy ra pha trc, tay hng v
pha ct sng, tc l hng v pha ui ty, nh th d chm n hn.

94. IM SN SNG ( MAYO ROBSON ).
Hay cn gi l im thn ty
V TR:
Gc gia xng sn 12 v ct sng.
NGHA:
Bnh v thn ty: vim ty cp.
Bnh v thn: vim ty quanh thn

171


(Lu , bnh v thn ty th ch au im sn sng bn tri).
IM SN SNG IM SN LNG H
SN LNG
Chng ta phi phn bit 3 nh ngha ny, i khi nhm ln. Tuy nhin phn ra cho phc tp
nh vy, nu au cc v tr th c th gp 1 trong 2 bnh: bnh v thn ty hoc bnh
ca thn.
IM SN SNG:
M t trn.
IM SN LNG:
Nm gia gc xng sn
12 v khi c tht lng.
au trong vim ty cp,
vim ty quanh thn ch
yu l vim ty cp.
H SN LNG:
ch gp nhau ca b di
xng sn 12 v b ngoi khi c lng c 1 vng trng h sn lng.
au gp trong ch yu cc bnh v thn:
Si thn.
Thn m.
Vim ty quanh thn.
Vim thn b thn cp.
Cc tn thng khc.
Khi khm, cn so snh 2 bn v nh ch c bn tri mi lin quan n cc bnh v TY.
Ngun: Ni c s - YDH, Ni c s - YHN


172


95.TING C CH D DY LC I
CHN ON HP MN V.
THI IM LM:
- Lc sng sm, bnh nhn cha n ung g.
CCH LM:
- Bnh nhn nm nga, t ng nghe vo vng thng v.
- 2 bn tay vo 2 cnh chu, lc mnh v u sang 2 bn.
NGHA:
- Nu nghe thy ting c ch nh lc 1 ci chai nc hp mn v.
Ngun : ngoi c s - Hc vin Qun y.
TING C CH D DY CH C NGHA KHI NO?
(1 cu hi thi lm sng).
- Ch c gi tr khi lm vo lc i, thng l lc sng sm khi bnh nhn cha n
ung g.
- Nu lm trn bnh nhn bnh thng lc mi n xong ta cng c th nghe thy ting
c ch ny.

NGHIM PHP NO MUI CHN ON XC NH - PHN BIT HP MN V
C NNG, THC TH.
(C hi thi lm sng, cng nh thi hc k l thuyt ni c s)
HP MN V C NNG: l dng hp mn v do ph n nim mc d dy on cui
hang v gn mn v trong vim d dy.
HP MN V THC TH: Do c hp thc th ti c tht mn v - bm sinh hoc mc
phi (mc phi do di chng ca lot d dy gy so x co ko).



173


CCH LM:
- Bui sng nhn i t sonde d dy, ht ht dch v:
+>100ml : dch gia tng.
- Bm 750ml nc mui ng trng, sau 30 pht ht ht dch v:
o >200ml : bt u c hp.
o >300 400ml : hp va.
o >500ml : hp nhiu.
o >600 ml : hp kht.
(Thy c hi c th tng con s)
PHN BIT HP C NNG THC TH:
- Nhn n 3 ngy truyn dch ( mc ch l tnh trng vim d dy gim bt)
nim mc t ph n li.
- Lm li nghim php no mui:
o Kt qu nh c : hp thc th.
o Gim nhiu hoc tr li bnh thng hp c nng.
Ngun: ni bnh l YDH, bi vim d dy.

96. KIN TP THNG D DY T
TRNG
Thng d dy : t ng thng vo d dy ly dch d dy dng gi v s lng v cht lng
+Dng c :
ng Einhorn
cc thy tinh c chn ; chia ;loi 200ml
bm tiu 200ml
mt s ng nghim
du parafin
+Tin hnh sng sm lc di (cha n v ung), ngi bnh ngi thoi mi v dc chun b t tng t trc

174


t nh u ng Einhorn dc chm du parafin t trc cho trn qua ming ngi bnh, khi vo
n hng , bo ngi bnh th u v nut dn, va nut ta va y nh cho n mc 45 or 50cm th
dng li v vo n d dy
Sau dng bm tim ht dn nc dch d dy hoc t nhin n chy ra

Bnh thng: Bt thng
S lng Lc i khng qu 100ml, trung bnh 40ml

Lc i nhiu hn 100ml: d dy a tit, dch t
trngtro ln. Hp mn v: dch d dy rt nhiu
c ln thc n t nhiu hm trc cha tiu
Mi:

khng mi
Mu: khng mu or hi trng c Vngor xanh: do dch t trng tro
ln
hng: mu mi chy
trong d dy
Nu en: mu chy
trong d dy lu
dich d dy c mu thng ni ln
tn thng thc th ca d dy:
vimlot , k..

trong: trong hoc hi trng c khng c ln thc n
Ngoi ra chn on cc bnh ca d dy, khi thng d dy ta cn tin hnh lm th nghim: htamin, insulin
Thng t trng: ging nh thng d dy, t ng thng vo t trng, ly dch t trng, mt, ty sau nh gi
cc thay i v cht lng v s lng chn on cc bnh v gan mt ty
+Dng c:
ng Einhorn
Bm tiu 20ml
Mt s ng nghim
Du parafin
Dung dch magie sunfat 30% : 30ml
Du lc or du oliu :20ml
+ Tin hnh: nh ly dch d dy. Sau khi ng thng vo n d dy: ngi bnh nm nghing qua phi, sau
30 pht n 1 gi, u ng Einhorn vo n t trng, xc nh c chc chn bng tnh cht dch ht ra( th
vi giy qu) v s ht c mt ra, sau bm thm cht magie sunfat hoc du lc kch kch tit mt.
+Bnh thng: ta ly dc 3 loi mt
Mt A: mu vng nht v trong, lng chng 20ml, l mt ng mt
Mt B: xut hin sau khi kch thch bng bm magie sunfat or du lc. mt B mu xanh or vng sm
rt qunh , lng 40-60ml: mt l ca ti mt
Mt C tip theo mt B mu vng nht hn v it qunh hn mt B, l mt t gan xung
+Bnh l:

175


Khng ly c mt or ng mt cha vo ti t trng. Mun bit c vo n t trng hay cn trong d
dy ta kim tra bng giy qu( nu phn ng kim: vo ti t trng, phn ng toan : cn trong d
dy), c th kim tra bng Xquang nu c iu kin
Hoc ng thng vo n t trng nhng ng mt b cn tr, mt khng xung c: u u ty, si
mt, u ng mt...
khng c mt B: ti mt b loi do teo hoc do si lm tc ng ti mt
Khi ht mt c thy bn mt hoc nhng si nh: gp trong si ng mt

97. HI CHNG TO BN
nh ngha: l s kt hp ca s gim tnh vn chuyn phn ca rut + s gim s lng
nc trong phn (<70 %)
Nguyn nhn :
Ngoi b my tiu ho:
Tm l thi quen : ngi , nn
Ngh nghip: ngi lu t vng , nhim c Pb
n ung : qu nhiu or qu t rau , thiu cht b , ung t nc ,nhiu nc ch
c,coffee, n T d gy to bn
Thuc : thuc vao bc nim mc d dy-cha d dy ; morphine , thuc c Fe ; chng
co tht
Ton thn : st ko di , nm bt ng ko di; RL in gii : Tng Ca mu , h K
mu
Ni tit : i ng , Suy gip
Thn kinh : Tn thng mng no , tng p lc s no , Parkinson
Ti b my tiu ho
i trng:
o Phnh bm sinh, ri lon trng lc , qu di .
o Cc bnh Vim i trng mn tnh , i trng chc nng, Khi u T cn tr co
bp
Tr , Nt hu mn a au ko i
Khi u bng : t cung ...
Dy dnh : vt ngang qua T v d nh dy dnh sau m
Lm sng :
a kh ,rn nhiu dng c honh
Nhu ngy mi i cu 1 ln
Phn rn , it nhy , c khi c mu of nim mc hu mn

176


Nhc u , trng ngc , n ung km
Thay i tnh tnh , cu gt khi bn ko di
Khm bng thy nhiu u phn cng ,ln nhn T sigma, T xung
Cn lm sng:
Ni soi trc trng - i trng +sinh thit
o Ch nh : > 45t to bn xut hin or nng thm or +triu chng phi hp : i
cu ra mu ,hi chng l , gy nhanh.
o Cn ni soi i trc trng +sinh thit loi tr ung th.
Xqung khung T c Baryt
o p lc Trc trng - kim tra bng phn x hu mn - trc trng ( Loi ra bnh
Phnh T bm sinh)
o thi gian lu chuyn trc trng

98.HI CHNG L
Cn phn bit r hi chng l v bnh l ( do trc khun hoc amip). Bnh l c hi chng
l, nhng hi chng l th do nhiu nguyn nhn khc nhau.
NH NGHA:
- L nhng ri lon v i tin v nhng cn au c bit m nguyn nhn l do nhng tn
thng thc th i trng v trc trng.
LM SNG:
Hi chng l c c trng bi 3 triu chng chnh:
RI LON I TIN:
- i tin nhiu ln, mi ln ch ra 1 t phn, c khi khng ra phn.
RI LON PHN:
- Phn t, thng c cht nhy, nim dch vi m nhy, mu ti.
- Hoc mu ln nim dch nh nc ra tht.
AU QUN MT RN:
- Trc khi i ngoi thng au qun tng cn dc khung i trng,
vng i trng xch ma v trc trng.

177


- Sau l mt rn phi i i tin ngay.
- Khi i thy au but hu mn.
CC TRIU CHNG KHC:
- Nn.
- Bng si.
- Bn tc rut.
NGUYN NHN:
- L amip ( Entamoeba histolytica).
- L trc khun ( Shigella, c bit l trc khun Shiga).
- K trc trng ngh n khi gp hi chng l ko di ngi gi
- K i trng sigma, khi u quanh trc trng ( c t cung)
Note : Phi thm trc trng cho nhng bnh nhn c hi chng l > 40 tui pht hin sn
K Trc trng
CN LM SNG:
Soi ti phn : tm Amip ng , T bo
Cy phn tm Trc Khun Shigella
Soi Trc trng , i trng sigma +sinh thit khi nghi ng ung th bnh nhn ln
tui.
Chp i trng Cm quang
PHN BIT L AMP V L TRC KHUN
L Amip (Entamoeba histolytica) L trc khun ( Shigella (shiga) )
1.Dch t L t Thnh dch
2.au Dc theo khung i trng Ton bng
3.S ln i a 10-20 ln / ngy >30 ln / ngy
4.Tnh cht
phn
Mi ,nhy ln t mu ti Nc mu thm ging nc tht
5.St Khng c hoc nh i vi tr em
do trung tm iu nhit cha hon
thin
Cao >39 o C
C du hiu Nhim trng-Nhim
c
6.Du mt nc Khng c or nh R
7.Du Abscess
Gan
D c Khng c
Ngun : K sinh trng y hc YDH

178


1 NH NGHA KHC V HI CHNG L CA Y H
NI
- L 1 th c bit ca to bn m nguyn nhn nm i trng v trc trng hu
mn, vng chung quanh trc trng, hu mn, cng gn trc trng bao nhiu, cc
triu chng cng in hnh by nhiu )
- nh ngha ny l v hi v l khi xem l l 1 dng c bit ca to bn v trong to
bn s ln i cu t, nhng cng ng xem xt v chnh xc trong l lng phn rt
t .

99.NN RA MU
Nhng tn thng ng tiu ho t dy chng Treitz tr ln thc qun, cht nn c mu ti ,
mu bm tng mng hay dch nu en , thng ln vi thc n v dch d dy
Lm sng :
Triu chng bo trc
Cn co ,kh chu
au bng ,sau lm ging
Bun nn ri nn ra mu , thc n ,dch v
Thng nn + i cu phn en
i khi ko c triu chng bo trc trong trng hp chy mu t TM trng Thc qun
Chn don phn bit: (khi ko thy cht nn , tnh cht dch nn ko in hnh)
Ho ra mu:
- C ui khi huyt
- C ho khc m
- Ho ra mu ti ln bt ko km thc n v dch v
- pH ca cht thi kim - khc vi pH acid ca dch v d dy
Chy mu t Hu hng D dy Nn ra
- Mu y l mu ti , c khi c mu bm c ln thc n v dch v
- Chn on rt kh , phi da vo hi bnh s t m v phi khm lm sng Tai- Mi-
Hng

179


Hi chng Gilbert:
gim thu nhn bilirubin
gin tip.
Hi chng Crigler
Najjar: gim hoc mt
enzym glucuronyl
transferase.
Hi chng Dubin
Johnson: Ri lon bi
tit mt Tng bil trc
tip km theo sc t en
t bo gan.
Hi chng Rotor: cng
ri lon bi tit mt
nhng khng c sc t
en t bo gan


100. I CU RA MU
Chy mu t thc Qun tr xung u gy i cu ra mu .c
3 dng :
Mu ti :
Chy mu thp : i trng, trc trng, hu mn
Chy mu cao : nhng t, thng km theo nn ra mu
ti v tnh trng chy mu rt nng
Mu bm :Chy mu cao : d dy t trng - ng mt
Phn hc n hay b c f , thm vo bng c nh hng ,
th vo nc lm nc c mu hng or
C th km or ko km nn mu
Phn mu bm c th do chy mu rut non -rut gi bn
P
Mu n : chy t ,mt thng ko nhn bit c , Phn bit bng phn ng Weber- Meyer
Chn on phn bit :
Phn to bn : phn en xm ; kh cng + du to bn
Phn do ung thuc c Carbon , Bismusth : phn xanh , en , kh .

101.HI CHNG VNG DA TT MT.
C CH
- Do tc mt mt ko xung c ng tiu ho li h thng ng mt li
gan thm vo mu
- Tng Bil lin hp l ch yu
LM SNG
- Gan to ( 1-->5;6 cm)
- Lc u b trn nhng nu ko di tc mt thy mt gan chc hn ,mt nhn
- Ti mt to *

180


Trng hp ti mt ko to trong tc mt l do ti mt b Vim dnh , x ho ko th to ra khi
mt. ( hiu r hn da vo nh lut Couvosier m t triu chng 103).
- Mt mi ,mt ng ,suy yu c th
- Nga ton thn do s ng acid mt gy kch thch cc u mt dy TK di da
- Nhp tim chm: 50-60 ln /pht , or lon nhp tim (do mui mt kch thch du TK X)
- Phn bc mu or trng nh phn c ( do tc mt hon ton hay ko )
CN LM SNG
Mu : bilirubin trc tip v gin tip u tng cao, nhng bilirubin trc tip tng
nhiu hn.
Phn : t StercoBil , bc mu
Nc tiu : c sc t mt , mui mt
Siu m gan mt
Soi t trng
NGUYN NHN
Si mt : hay gp
- Si ng mt ch
- Giun chui ng mt
- Vim x cng c Oddi
- Khi u bng Vater
- K ng mt . u tu
- Hch cung gan do K ni khc di cn n ng mt
- Vng da mt ko do U thng do si ng mt
Si ng mt: khi bnh in hnh bi mt bnh cnh vim ng mt cp vi tam
chng Charcot (au ; st ; vng da-mt)
o Gan ln,ti mt ln v au
o C hi chng nhim trng
o Siu m v chp ng mt ngc dng c si ng mt
o Do vim ng mt
o Hp c Oddi
o Vim dnh sau phu thut ,nht l phu thut ng rut
NGA TRONG TC MT?
- Nga ton thn.
- Khng p ng vi cc thuc chng nga (v d nh khng histamine...)


181


NHNG TH CN KHM CA 1 BNH NHN B VNG DA
1. Tm cc du hiu ca 1 bnh gan mn tnh:
- Bn tay : ngn tay di trng, ban , mng m trng ( leukonychia).
- Thn trn, u, c v cnh tay : nt nhn .
- Chng v to n ng.
- Hi chng suy t bo gan.
- Hi chng tng p lc tnh mch ca.
2. Tm cc du hiu ca bnh no gan:
- Rung v cnh, bt chun chun (tin hn m gan).
- Hi th mi amoniac.
- Ri lon thc.
3. Tm du hiu da bc mu do thiu mu:
- Thiu mu tan mu.
4. Tm cc du hiu gim cn:
- Ung th gan di cn.
5. Tm du hiu nghin ru ( hi th mi ru).
6. Khm bng tmgan to, lch to, bng ( g c thay i theo t th), tun hon bng h hnh chn con sa khu
vc rn.
7. Khm mt c chn v xng chy tmdu hiu ph.
8. Tm cc du gi trn da do nga vng da tt mt.
9. Tm cc du hiu ch im vim gan B:
- Cc du tim chch trn cnh tay.
- Du xm mnh
- Truyn mu.
10. Khm phn bc, trng trong vng da tc mt hon ton.
11. Phn tch nc tiu: vng m trong vng da tc mt.
Lu : mt s ha cht (toluen), thc n (c rt, u : hay gp tr em) cng c th gy vng da nhng khng vng
kt mc mt.
Macleod clinical examination

182


LM SAO BIT BNH NHN TNG BILLIRUBIN
TRC TIP HAY GIN TIP?
- Ngi ta da vo t s % ca billirubin trc tip
o % Billirubin trc tip = billirubin trc tip / Billirubin ton phn.
- Nu % billirubin trc tip > 50%: gi l tng billirubin trc tip.
- % billirubin trc tip = 20 50%: tng c billirubin trc tip ln gin tip ( y gi
s c bilirubin ton phn tng)
- Nu billirubin trc tip = tng billirubin gin tip.
CHN ON NGUYN NHN GY VNG DA DA VO BILLIRUBIN
Loi tng bilirubin Bnh l
Tng billirubin gin tip (cha lin hp)
Bil trc tip <20%
Tng sn xut billirubin gin tip Thiu mu tan mu: V d: bnh hng cu hnh cu, bt ng nhm
mu Rh v ABO.
Gim thu nhn bilirubin gin tip vo t bo gan hoc
ri lon qu trnh lin hp billirubin gin tip
Hi chng Gilbert : l mt bnh l di truyn ph bin m c ch l
do khuym khuyt qu trnh lin hp billirubin gin tip (gim hot
ng ca men glucuronyl transferase); vng da thng xy ra lc i
hoc tng ln khi ung ru hoc dng phenobarbital.
Hi chng Crigler-Najjar: Mt bnh l di truyn do thiu ht enzym
glucuronyl transferase.
Vng da sinh l tr s sinh: thng xy ra vo ngy th 3.
Vng da do sa m

Tng hn hp (c trc tip ln gin tip)
Bil trc tip ~ 20-50% Vimgan do virus
Tng billirubin trc tip
CB >50% Gim s tit mt vo trong ng mt trong gan do thuc (v d nh
thuc nga thai ng ung oral contraceptive pill.
X gan mt tin pht
Hi chng Dubin J ohnson: khim khuyt di truyn lm cho mt
khng tit c vo ng mt trong gan c (khim khuyt bi tit
mt), t bo gan s c nhng sc t en.
Hi chng Rotor: ging nh hi chng Dubin Johnson nhng t
bo gan khng c sc t en.
Gim bi xut mt ra ng mt ngoi gan do si mt ng mt ch.
Ung th u ty


183


MNG M TRNG V X GAN(LEUKONYCHIA)
M t:
- Nn mng tr nn sng hn, l s bt thng ca nn mng ch khng phi mng.
- Thng gp l mng tay ca ngn ci v ngn tr.
Gp trong:
- Mng m trng l 1 du hiu ca tnh trng
gim Albumin mu, nguyn nhn c th do:
o Bnh gan.
o Suy dinh dng.
o Cc ri lon km hp thu protein.
o Hi chng thn h.

102.GAN TO
BNH THNG: Gan nm di vm honh
B trn: gian sn V -ng trung n Phi ; gian sn VI
-ng nch trc.
Cao: 6-12 cm - ng trung n ; 4-8 cm b Phi xng c
GAN LN :
B trn :vt qu gian sn V -ng trung n Phi
B di:vt qu b sn
PHNG PHP KHM GAN:
1. Phng php s b di gan dng u cc ngn tay:

184




2. Phng php s b di gan dng cnh bn tay.


Ghi ch: i vi bnh nhn bo, c thnh bng dy, s gan bng c hai bn tay (t hai
bn tay chng ln nhau s ).





185


3. Phng php mc gan:

- Ngi khm ngi cng chiu, bn phi bnh nhn.
- Dng 2 tay mc vo b sn.
- Bnh nhn ht th su.
4. Phng php gi da.5. Phng php
rung gan:

186




Cc hnh nh c ly t slide ca c Xun Tnh















187


NGUYN NHN
1. THEO C QUAN TN THNG.
BNH NHU M GAN MN TNH
Bnh gan ru.
Vim gan t min.
Vim gan virus.
X gan mt tin pht.
UNG TH
Ung th t bo gan nguyn pht
Ung th di cn th pht.
SUY TIM PHI
RI LON V MU
Lymphoma
Leukemia
X ha ty xng
a hng cu.
HIM GP
Amyloidosis
Hi chng Budd-Chiari
Bnh ri lon d tr Glucose ( v d nh Von Gieke)

Ngun: Macleods clinical examination








188


2. THEO LN V TNH CHT:
GAN LN
RT LN
o K gan di cn
o X gan ru (thm nhim m)
o Tng sn tu xng
o Suy tim phi
o Ung th t bo gan
LN VA
o Cc nguyn nhn trn
o Nhim sc t st
o Bnh mu -e.g. leukaemia mn, U lympho
o Gan nhim m th pht sau i tho ng, bo ph, cht c
o Thm nhim bt
LN VA PHI
o Cc nguyn nhn trn
o Vim gan
o Tc mt
o Nang sn.
o Nhim virus HIV
GAN CNG CHC BT THNG
- Ung th biu m tb gan
- X gan
- Nang sng, U ht (e.g. sarcoid), amyloid, nang gan, gan nhim m
GAN AU.
- Vim gan
- Gan ln nhanh v d: Suy tim phi, hi chng Budd-Chiari (thuyn tc TM trn gan)
- Vim mng ngoi tim co tht gy p tim cp
- K t bo gan
- Abscess gan
- Tc mt / vim ng mt
GAN P THEO NHP TIM
- H van ba l
- Ung th t bo gan ( tng sinh mch mu)
- Bt thng mch mu.
- Cng gp trong suy tim phi.

189


H 3 L KHM GAN THY G?
- Gan p theo nhp tim. Cn phn bit vi du Hatzer.
3-BNG TM TT SO SNH TRIU TRNG MT S NGUYN NHN GAN
LN HAY GP NHT:
Nguyn
nhn
B v mt
gan
au Vng da Mt Nhim
khun
Du hiu
c hiu
Apxe gan
amip
Mt nhn
khng u
(++) (-) Mm (++) -Tin s
kit l
-Tc dng
c hiu
vi emetin
v dn xut
Gan to do
suy tim
Mt nhn,
u
(+) tc (-) Mm (-) -phn hi
gan tnh
mch c(+)
-du hiu
suy tim
K gan
nguyn
pht
Ln nhn,
khng u
(-) (-) hoc
(+)
Cng (-) -Gan to
nhanh
-ton thn
suy sp
X gan giai
on gan
ln
To u, b
sc v
nhn
(-) (-) Cng (-) -Tng p
tnh mch
ca
-Du hiu
suy gan
Apxe gan
do nguyn
nhn ti
ng mt
Mt nhn,
u
(+++) (+++) Mm (+++) -Tin s
nhiu t
au, st,
vng da
-Ton
trng
nhim
khun, suy
sp

190



KHM GAN
-Mc d m t l thuyt nhiu phng php nh vy, nhng trn lm sng, cc thy c
thng ch dng phng php s b di gan bng u cc ngn tay hoc cnh bn tay l
ph bin. Di y l m t tun t ca phng php ny.
T th bnh nhn: bnh nhn nm nga, hai chn hi co ln
u tin, s vng h chu phi. Nu chng ta
bt u ngay vng h sn phi, c th chng ta
s pha trn b di ca 1 gan rt ln.
S dng u cc ngn tay hoc b quay (pha
xng quay) ca bn tay phi ( b trong ca ngn
tr) m t hnh pha trn, c 2 trng hp u c
gng gi bn tay phng trn bng bnh nhn. Khng
nn cc ngn tay chch ln 1 gc vi bng bnh
nhn v chng ta c th c 1 cm gic sai v b di
ca gan.
Gi bn tay c nh v bo bnh nhn ht vo 1 hi
tht su. C gng cm nhn b di ca gan khi n
i xung trong th ht vo.
Di chuyn bn tay dn dn ln pha trn khong 1cm ri lp li nh trn cho n khi ta s
thy b di ca gan.
Sau khi s thy b di ca gan, ta tip tc chng minh liu c phi l gan ln hay
ch l gan sa m thi, thng xy ra bnh nhn b lng ngc hnh thng trong COPD,
kh ph thng hay hen ph qun. Gan g c trong khi phi g trong, v th ta s xc nh
b trn ca gan bng cch g ln trn xc nh b trn ca gan. Thng th 3 4
xng sn cui s g c. Nu khu vc c h thp xung, ngh n kh ph thng,
hoc gan co li ( xy ra trong x gan
giai an cui)
o chiu cao ca gan di b sn
nh gi mc.
Ngun: Macleods clinical examination

103. TI MT TO


191



NH LUT COURVOSIER.
- Nu vng da + ti mt ln v tr tc ng mt ch hoc do u chn p
- Nu vng da+ti mt khng ln si mt
- Note: nh lut ny khng ng vi chu
Gii thch:
- Do cc nc pht trin si ti mt l si cholesterol v vim ti mt mn tnh
- Vit nam l si hnh thnh ng mt ch. khng c hin tng vim ti mt
mn tnhti mt ln.
CCH KHM
V tr: giao im ca b ngoi c thng to v h sn phi:
Tnh cht: Ti mt bnh thng khng s thy. Khi n xng phng ln, th y l 1
du hiu quan trng.
- S thy 1 khi phng cng, phng v di ng theo nhp th.
- Khi gan ln hoc khi ti mt ln 1 cch ton th, n c th c s thy ko nhng
vng h sn phi na, m c th vng tht lng, hoc thm ch h chu.
- Cn chn on phn bit vi thn ln.
NGUYN NHN
- Khi u vng u ty hoc bt c khi u no gy
chn p ng mt ch, phn ng pha trn cng nh
ti mt b gin ra ( nh lut Courvoisier)
- Polyp nim dch ti mt: Do c 1 vin si c ti
mt, mc d mt khng vo c ti mt na,
nhng cht nhy tip tc c tt vo bn trong ti
mt, lm n gin ra v c th s thy c.
- Ung th ti mt ( carcinoma): ti mt cng nh ,
cc khi lm nhm, khc vi nhng trng hp
trn, ti mt cng u.
DU HIU MURPHY
- Trong trng hp vim ti mt cp, bnh nhn thng rt au. Tuy nhin kh s thy
ti mt, iu ny th hin ti mt vim b bao ph bc li bi mc ni ln.
- Bo bnh nhn th su, tay ta vn s ti mt nh bnh thng. th ht vo, ti 1
mc no , bnh nhn t ngt ngng th v au.
- Du hiu ny khng c trong vim ti mt mn hay cc ca si mt khng phc tp.

192


- Nu ti mt ln, chng ta khng cn lm nghim php Murphy ch lm khi khng
s thy ti mt.
Ngun: Hutchisons clinical methods 22
nd
edition.
104. BNG:
Bnh thng trong khoang mng bng khng c hoc c rt t dch, ph n c th c
khong 20ml ty thuc vo chu k kinh nguyt. Khi gia l thnh v l tng ca mng bng,
v mt nguyn nhn no , xut hin dch, ta c hin tng bng hayc trng. Dch c th
nhiu hoc t:
Nu chim ton bng gi l bng ton th (hay t do). C th gp trong x gan c trng, hi chng thn h, suy tim, vim ty cp
Nu dch ch chim mt phn bng, do c hin tng dnh nhau ca l thnh v l tng phc mc mt s v tr, gi l bng khu tr.
Thng gp trong lao mng bng (c du hiu bn c Dame g vng trong v vng c xen k).
Dch bng tu theo nguyn nhn khc nhau, c th l dch trong, dch vng chanh, m, dng trp, mu
C trng khng phi l mt bnh, m ch l mt hin tng, mt triu chng do rt
nhiu nguyn nhn khc nhau gy nn.
I. KHM BNG:
1. Bng ton th, lng dch nhiu v trung bnh.
1.1. Nhn
1.1.1. Ngoi da:
- Da bng cng bng, rn y, phng hoc li ra nu qu nhiu dch.
- Tu theo loi nguyn nhn, c th c tun hon bng h: l nhng tnh mch di da bng ni to, cng, ngon ngoo. Ta phn
bit hai loi tun hon bng h:
o Tun hon bng h ca ch: tnh mch ni r na bng trn rn tr ln. Nguyn nhn thng do tng p lc tnh
mch ca (x gan, tc tnh mch trn gan, tc tnh mch ca).
o Tun hon bng h ch ch: tnh mch ni r t bng qua h sn phi ln ngc, hoc t bn qua bng ln ngc.
Nguyn nhn do tc tnh mch ch di (huyt khi, u ngoi chn p...). (xem thm phn tun hon
bng h)
- Bng phng cao hn ngc hoc cng b ra hai bn khi nm. Bng s ra pha trc v xung di khi ng hoc ngi.
1.1.2. Hnh thi bng.
- Nu dch qu cng, c th phnh qua nhng ch c thnh bng yu to thnh nhng ti nc ngay di da (s bng).
1.2. S:
1.2.1. S bng hai tay s thy bng cng nu lng dch nhiu.
1.2.2. Tm du hiu sng v xc nh lng dch trong bng.
Mt bn tay t gia bng (tay ngi ph khm hay tay ngi bnh).
Mt bn tay bn ny ca thy thuc t vo mt bnh vng mn sn ca ngi bnh:
Cn mt bn kia ca thy thuc p v nh vo mn sn bn kia ca ngi bnh.
Nu trong bng c nc, tay t s c cm gic nh nhng t sng di vo sau mi ln p v ca tay kia. Du
hiu sng v ch c khi lng dch trong bng nhiu hoc trung bnh, v l th t do.
1.2.3. Tm du hiu chm :
Ly tay n nhanh vo thnh bng, s ng vo mt vt cng ri bin mt ngay, ging nh cc hay qu trng ni
trong nc. Du hiu chm dng tnh chng t c mt khi u t do ni trong dch c trng ( thng l lch to)

193


1.3. G:
- G l phng php xc nh bng (c trng) chc chn nht. Ngi bnh nm nga,ta g t vng rn ra xung quanh theo hnh nan hoa,
nu c c trng, ta thy trong phn trn v c hai bn c vng thp. Gii hn ca vng c l mt ng cong, mt lm quay ln
trn. Tu theo lng nc nhiu hay t, m gii hn vng c rng hay hp (hnh di).

2.Bng ton th lng dch t:
- Chn on kh hn so vi bng t do dch nhiu. Bng cch nhn hoc s tm du hiu sng v, kh pht hin. Chn on xc nh y,
ch yu bng cch g phi hp vi thm m o trc trng v nht l chc d c trng ht ra c dch.
o G. Ngoi cch g t th nm nga, ta ngi bnh nm nghing sang hai bn, ri g, ta s thy c pha thp v khi nm
nghing nc s ng phn thp.
o Thm m o, trc trng: ta thy ti cng cng, n pha trn bng xung c cm gic nc chm vo u ngn tay, nu
ph n ta s thy t cung d di ng hn bnh thng.
o Trong nhng trng hp kh xc nh, ta c th chc d bng ht nc chn on.
3. Bng khu tr.
Do mng bng b dnh nhiu ch, khu tr dch mt vng m khng lan rng ton th bng.
o Nhn: bng phng khng u, khng c tun hon bng h, rn khng thay i.
o G: thy bng ch c, ch trong xen k nhau, khng thay i theo t th.
o S: thy c nhng ch cng nh c nc, ch cng thnh mng hi au do mng bng b dnh. Du hiu sng v cng c th
dng tnh khi lng dch qu nhiu.
o Chc d nh nhng: nhng vng nghi l c dch c th ht ra dch.
II. CHN ON PHN BIT.
- i vi loi bng khu tr:
o Cn phn bit vi mt s khi u, hch to bng.
- i vi loi bng ton th, cn phn bit vi mt s bnh sau
o Bng bo nhiu m: da bng dy, rm lm, g khng c hin tng c vng thp v khng c du hiu sng v.
o Bng chng hi: G trong ton b, khng c du hiu c vng thp, khng c du hiu sng v.
o B i bng quang to: ngi bnh tc i, g thy c vng h v, gii hn vng c cong li ln trn, thng i bng s xp.
o Ph n c thai: Hi ngibnh thy tt kinh, thm m o thy c t cung mm, thn t cung to.
o U nang, nht l u nang nc bung trng:
o G s thy c gia, xung quanh thy trong, gii hn vng c v trong l mt ng cong li ln trn.
- i vi trng hp kh chn on, ta c th chc kim bm mt t hi vo bng ri chp Xquang.
- Nu c trng ton th, hi s t li di c honh.
- Nu l u nang bung trng th hi s t li ranh gii trn u nang m khng c di c honh.
Ta cng c t h cho ngi bnh ung t barit ri chiu Xquang xem v tr ca d dy: trong c trng, d dy v tr bnh thng; trong u
nang nc, d dy b y ln trn, ra pha trc, pha sau hoc sang bn.

194


III. NGUYN NHN.
chn on nguyn nhn ca bng, ta cn phi thm khm cc b phn khc, nht l b my tiu ho, tm cc triu chng khc, ng thi lm cc xt
nghim cn lm sng, v nht l cn phi chc d dch bng nhn nh.
BNG TM TT CC NGUYN NHN THNG GP CA BNG
BNH Tnh cht th
dch
Rival
ta
Protein
dch bng
T bo c im lm sng
X gan Vng nht hoc
trong
(-) <30g/l Ch yu l t bo
ni mc
-tun hon bng h.-lch to.-xut huyt
ng tiu ha
Nguyn nhn do cc
bnh tim
dch bng trng
trong hoc mu
vng nht
(-) <30g/l Ch yu l t bo
mng bng,
monocyte
c im bng y l c trng bao
gi cng i i vi ph ton thn, bng
nhiu th ph nhiu, bng t th ph t.
ng thi vi bng, ngi bnh c cc
du hiu ca suy tim phi nh tm mi,
kh th, tnh mch c ni, gan to.
Cc bnh thn.

dch bng trng
trong hoc mu
vng nht
(-) <30g/l Ch yu l t bo
mng bng,
monocyte
Nhng bnh thn gy ph nhiu nh
vim cu thn bn cp, thn nhiu m,
dch c th thm vo bng gy bng.
c im chung l bng t, xut hin sau
ph, ngi bnh c nhng du hiu
khc v thn v bao gi bng cng km
theo ph ton thn.
Suy dinh dng dch bng trng
trong hoc mu
vng nht
(-) <30g/l Do n ung km, c bnh . mn tnh gy
Suy dinh dng: suy mn. Lng
protein trong mu gim, gy ph ton
thn v bng.
Lao mng bng.
.

vng chanh hoc
mu
(+) >30g/l c rt nhiu bch
cu lympho
-Bng ton th: dch bng thng t, gp
ngi tr tui, c du hiu nhim lao.
- Bng khu tr: do mng bng x dnh nhiu
ch, g bng ch c ch trong, c du hiu
bn tc rut, c du hiu nhim lao
Ung th trong
bng: ung th cc
tng trong bng
nh gan, d dy,
hch, mc treo.. c
th kch thch mng
bng gy bng.
Dch bng y
vng chanh hay
mu
(+) >30g/l Trong dch c th
tmthy t bo ung
th, nhiu t bo
hng cu
Dch bng khi chc tho th dch bng
ti pht nhanh chng.

Vim mng bng do
vi khun sinh m: vi
khun c th gy
vim mng bng v
to nn bng.
dch chc d vng
chanh hoc c
m
(+) >30g/l Dch chc d thy
vi khun v nhiu
bch cu a nhn
hoc t bo m, t
bo hng cu
Ngi bnh c tnh trng nhim khun
nng (vim mng bng do thng rut
tha, thng d dy, v pxe gan).

3.2. Hi chng
Demons Meigs

C u nang bung trng, trn dch mng
phi v c trng. Khi ct nang bung
trng, hin tng trn kh mng phi v
c trng s ht. Nguyn nhn v c
ch hin nay cha r.
(Ngun Wikimedia, dieuduong.com.vn, ni c s DHYDH v DHYHN


195


CC XT NGHIM NH GI CHC NNG GAN

Xt nghim im cn lu
nh gi hoi t t bo
gan

Alanine transaminase
(ALT)
Enzym c hiu cho hot t t bo gan
C trong bo tng ca t bo gan
ALT >AST: vim gan do virus.
Aspartate transaminase
(AST)
C trong ty th ca t bo gan
Ru s gy tn thng ti th: AST > ALT vim gan do
ru

nh gi mt
-glutamyl transferase
(GGT)
Tc ng mt trong hoc ngoi gan.
Nhng cht hot ha h thng cytochrome P-450 (v d: ru):
lm tng GGT
Alkaline phosphatase
(ALP)
Nu GGT bnh thng m ALP tng: s tng ALP ny khng
c ngun gc t gan (v d nh qu trnh to xng s lm tng
ALP (osteroblastic activity)
Tng GGT v ALP: tc mt

Bilirubin
Bil lin hp <20% Tng Bilirubin khng lin hp: V d: Thiu mu do tan mu
Billirubin lin hp 20-50% Tng Billirubin c hn hp ln lin hp (V d:vim gan do
virus)
Billirubin lin hp >50% Tng billirubin lin hp (V d: tc mt)
Tng billirubin khng lin
hp trong nc tiu:
Tng billirubin khng lin hp: tan mu, vim gan do virus.
Nu khng c billirubin khng lin hp trong nc tiu: tc
mt
Chc nng t bo gan
Albumin Albumin c sn xut t gan.
H albumin mu: bnh l gan nng (v d: x gan)
Prothrombin time (PT) Hu ht cc yu t ng mu c sn xut t gan.
Tng PT: bnh l gan nng.
Blood urea nitrogen
(BUN)
Chu trnh Ure xy ra gan.
Gim BUN: x gan

196


Amoniac Amoniac c chuyn ha gan to thnh ure.
Tng amoniac mu: x gan, hi chng Reye
Chc nng min dch
IgM Tng trong x gan mt tin pht
Khng th khng ti th Tng trong x gan mt tin pht
Khng th khng t bo c
trn
Vim gan do t min.
Khng th khng nhn Vim gan do t min
Cht ch im ung th
-Fetoprotein (AFP) Ung th t bo gan.



197






CHNG V

HUYT HC




198



199


105 106: CNG THC MU HUYT
BNH THNG V BNH L:
Mi ti liu c nhng gii hn khc nhau, y chng ti ly gii hn ca sch ni trng:
1. Hng cu:
Nam 4,1 5,4.10
12
/l.
N 3,8 4,9. 10
12
/l.

2. Bch cu:
T bo bch cu T l % Tr tuyt i (/mm
3
)
Trung tnh 40 75 1500 7000
a acid 1 5 50 500
a baze 0 0,5 10 50
Lympho 20 40 1000 4000
Mono 3- 7 100 900

3. Tiu cu:
- Bnh thng: 150 400. 10
9
/l.
- Tng: >500.10
9
/l.
- Gim: <100.10
9
/l.
MT S MC CN NH CA TIU CU
<100: thi gian chy mu tng ln.
<50: chy mu (t mu, u mu) ngay c i vi 1 s ng dp nh, thng thng.
<20: chy mu t nhin, xut huyt

107 108: TY
CCH LM:

200


V tr chc:
Gai chu sau trn hoc xng c.
Xng c thng t s dng v tm l s hi ca bnh nhn.
gai chu: ngi ln thng chc gai chu sau trn, tr em chc gai
chu trc trn.
Gy t:
Bng Xylocain.
CH NH:
- Cc thiu mu khng hi phc.
- Gim bch cu trung tnh.
- Gim tiu cu khng c nguyn nhn ngoi vi.
- Tm cc t bo non ngoi vi.
- Tm cc ung th di cn.
- Tm k sinh trng.
CHNG CH NH:
- C cc ri lon v ng mu ( hemophilia...)










201



TY V SINH THIT TY
Mc d cng thc mu cho ta kh nhiu thng tin, i khi chng ta cn phi xem xt ngun
gc ca mu ty xng, xem qu trnh to mu c xy ra bnh thng khng, c 2
phng php l phng php chc ht ( ty ) v sinh thit ty.
SO SNH GIA TY V SINH THIT TY


TY (chc ht) SINH THIT
Thun li
- Nhanh

- Cho bit s lng ca cc
t bo khc nhau.
- Cung cp bnh phm
lm cc xt nghim xa hn:
xt nghim di truyn hc,
m t bo
- Cho bit c cu trc ca
t bo v m m
- Th hin tt c cc t bo.

- C th c lm khi chc
ht khng ht ra c ( dry
tap)
Yu im
- Khng th hin c tt
c cc t bo ( do 1 s t
bo lympho b dnh vo kim
ht)
- Chm

- Ty gip cho chng ta kho st cc t bo ty tch ri, cho bit c s lng cng
nh t l ca cc dng t bo ty, t cho chng ta nh gi c ty giu hay ngho,
qu sn hay d sn ty, suy ty
- Sinh thit ty tc l ly lun 1 mnh ty gip chng ta nh gi c cu trc cng nh
cc thng tn ty xng nh x ty, thm nhim ty bi cc t bo ung th

202


108. THI GIAN CHY MU, THI GIAN
NG MU.
NGHA:
Thi gian chy mu
- Xc nh cc ri lon do tiu cu v sc
bn mao mch
Thi gian ng mu
- Xc nh cc ri lon do cc yu t ng
mu
GI I THCH:
1. THI GIAN CHY MU.
- c tnh t lc bt u rch vo da v mu chy cho n lc mu ngng chy.
a. Cc s kin din ra sau khi rch vo da:
- Hot ha yu t VII ca con ng ng mu ngoi sinh nh vo
thromboblastin ca m v hot ha yu t XII ca con ng ni sinh bi s
tip xc vi collagen.
- Tiu cu kt dnh vo yu t von Willebrand trn t bo ni m b tn thng
thng qua receptor ca n.
- To tn hiu kch thch tiu cu tit ra ADP v tng hp thromboxan A2 gy
ra s kt dnh tiu cu.
to ra cc mu ng tm thi thi gian chy mu chm dt y.
b. Thi gian chy mu ko di khi:
- C bt c ri lon no nh hng n s hnh thnh cc mu ng tm thi.
Thiu tiu cu.
Thiu yu t von Willerbrand ( bnh Willerbrand) tiu cu khng th
dnh vo cc t bo ni m.
Bnh nhn ung aspirin ( c ch thromboxane A2 khng cho tiu cu
kt dnh)
Suy thn ( gy ri lon cht lng ca tiu cu do s bt hot
phospholipid tiu cu)

203


BNH NHN B CHY MU TR LI (REBLEEDING)
SAU PHU THUT HOC NH RNG
Tiu cu kt dnh to nt tiu cu tm thi s lm chm dt s chy mu.
Tuy nhin, y ch l cc mu ng tm thi, khng c tc dng bo v lu
di, sau cn c thm thrombin chuyn fibrinogen thnh fibrin n nh
nt tiu cu ny th mi to ra cc mu ng vng chc cm mu vnh
vin.
nhng bnh nhn c ri lon v ng mu khng to thnh c thrombin
s khng to c cc mu ng vng chc, cho nn bnh nhn thng s b
chy mu tr li sau phu thut hoc nh rng hoc nhng ng dp rt nh.
2. THI GIAN NG MU:

- Cc mu ng tm thi lmchm dt thi gian chy mu.
Lc ny 2 con ng ng mu c hot ha, to thnh thrombin, hot ha
fibrinogen thnh fibrin v to thnh cc mu ng vng chc thi gian ng mu.
Gi tr ca thi gian ng mu (Tc) trn lm sng:
- Gi tr ca Tc rt hn ch, v ch 1 lng nh thrombin cng lm ng
fibrinogen, n thng c s dng trong cc xt nghim tin phu.
- Mc khc Tc cng khng nhy:
o Tc khng ko di bnh nhn ang dng thuc khng ng hay
bnh nhn gim tiu cu nng.
o Ngay c bnh nhn b Hemophilia, thi gian Tc vn c th bnh
thng.
- Tc cng khng c hiu v thiu bt b yu t ng mu no cng c th lm
thi gian ng mu ko di.
- Tc bnh thng khng c ngha l c ch ng mu vn bnh thng.

C 3 phng php c hiu hn nh gi s ng mu: thi gian Quick,
thi gian Cephalin kaolin, v nh lng cc yu t ng mu.

204


THI GIAN CO CC MU (T THY LM TRN LM
SNG)
Co cc mu l giai an cui cng ca qu trnh cm mu v ng mu, ph
thuc vo men retractozym ca tiu cu, men ny c th thy c chc phn
chung ca tiu cu.
Cc mu sau khi ng, si huyt s co li v qua nhn bit c vai tr ca
tiu cu v si huyt.
Bnh thng: cc mu co hon ton sau 1 3h.
Bnh l: Sau 3h, cc mu khng co hoc co khng hon tan.
Gp trong:

- Bnh gim tiu cu khng r nguyn nhn.
- Bnh suy nhc tiu cu ( bnh Glanzmann).
- Bnh a hng cu.
Cc trng hp khc:
- Cc mu co sn si: nhim c nng v cc bnh v gan.
- Cc mu co b nt vn: gim fibrinogen.
- Cc mu co rt nhanh, rt mnh: phn huyt thanh nhiu hn cc mu gp trong
thiu mu nng (cc mu co nh do thiu hng cu) v khi c tc mch sau phu
thut, nht l phu thut ct lch.
Ngun: Ni c s - YHN

111. THI GIAN QUICK (thi gian
PROTHROMBIN) V T PROTHROMBIN
NH NGHA:
Thi gian Quick: l thi gian ng huyt tng vi s can thip ca calci v thromboblastin
a t ngoi vo.
Thi gian prothrombin: nh
gi cc yu t V, VII, X, II v
fibrinogen.
INR: l thi gian prothrombin
c chun ha theo di
bnh nhn s dng warfarin

205


Chng c dng kho st ng mu theo con ng ngoi sinh ( II, V, VII, X v
fibrinogen).
GII THCH 1 S THUT NG:
- Thi gian Prothrombin v thi gian Quick: l 1, tnh theo n v l giy, bnh
thng l t 11 13giy.
- T prothrombin: l 1 t s % c tnh bng thi gian Prothrombin ca bnh
nhn chia cho thi gian prothrombin trung bnh bnh thng ( Patients
PT/MNPT) ( mean normal prothrombin time). T Prothrombin bnh thng l
80% - 100% ( thng s ly t Ni c s - YHN)
- INR ( international normalized ratio): cng chnh l t prothrombin nhng
c chun ha theo di nhng bnh nhn s dng warfarin (c m t
bn di)
NGHA:

- Kho st s ng mu theo con ng ngai sinh ( tc l cc yu t II, V, VII, X v
fibrinogen).


Hnh 1: S n gin

206



Hnh 2: S y .
Thi gian Quick ko di trong cc trng hp sau:
- Bnh nhn s dng Warfarin (c ch s to thnh cc yu t ng mu ph thuc
Vitamin K II, VII, IX, X).
- X gan, suy gan (khng tng hp c ci yu t ng mu )
- Thiu Vitamin K (km hp thu, ri lon khun ch rut, ct hng trng).
Thi gian Quick c lm trong trng hp:
- Theo di bnh nhn s dng thuc chng ng warfarin
- nh gi chc nng gan.
- Chn on thiu yu t VII.
Ngun: Ni c s - YHN, Pathology.


207


CCH XT NGHIM T PROTHROMBIN
(Cu hi thi lm sng)


- S dng huyt tng ca bnh nhn.
Mu c trch vo bn trong 1 ng nghim cha Citrate l 1 cht chng ng c
tc dng gn vo Ca
2+
trong mu. Ri sau c quay ly tm loi b hng cu ra.
- Sau 1 lng tha Calci c thm vo, loi b tc dng ca Citrate, lm cho
mu c th ng tr li.
Sau nhng yu t m (yu t 3 hay thromboplastin) c thm vo,
Thromboplastin t chc s hot ho VIIVIIa, hot ho X Xa +(V +
Phospholipide + Ca) bin Prothrombin thnh thrombin ri thrombin li bin
Fibrinogene thnh Fibrin lm ng mu.
Nu thiu 1 trong cc yu t VII, X, V, II v I th s lm thi gian Quick ko di.
Ri h tnh thi gian mu mu cn ng li thi gian Prothrombin.
- T prothrombin l thi gian prothrombin ca mu chng chia cho kt qu ca bnh
nhn.
( Nhc li sinh l: Yu t m, hay thromboplastin l yu t hot ha con ng ng mu
ngoi sinh. Cn collagen ca thnh mch l yu t hot ha con ng ni sinh, ngi ta
cho thromboplastin hot ha con ng ngoi sinh).
Ngun: Wikipedia

208


INR
- Do kt qu ca thi gian Prothrombin
(tnh bng giy) c s khc nhau gia
cc labo xt nghim do h s dng
nhng h thng phn tch khc nhau.
Nhng h thng ny s dng nhng yu t m (thromboplastin) t cc nh
sn xut khc nhau v cho ra nhng kt qu khc nhau. V th INR c a
ra c th tiu chun ha cc kt qu, sao cho cc labo khc nhau cng xt
nghim th cho ra nhng kt qu ging nhau.
- Mi nh sn xut cc yu t m (thromboplastin) phi n nh 1 ch s gi l
ISI (international sensitivity Index: ch s nhy quc t) cho nhng yu t
m m h sn xut. Ch s ny bnh thng t 1.0 n 2.0.
- V INR c tnh nh sau:


PT test: thi gian prothrombin ca bnh nhn
PT normal : thi gian prothrombin bnh thng.
Gi tr bnh thng: 0.9 1.3.
i vi bnh nhn ang s dng Warfarin: 2.0 3.0.
>5: nguy c chy mu rt cao.
<0.5: nguy c hnh thnh cc mu ng rt cao.
NOTE:
thng thy h s dng INR khoa tim mch trong theo di bnh nhn s dng Warfarin
chng ng mu trong lp valve gi, nhng bnh nhn ny phi dng chng ng Warfarin
sut i - cn cc khoa khc c xu hng s dng t Prothrombin thay th.
Ngun: Wikipedia.
Yu t ng mu ph thuc Vitamin K:
II, VII, IX, X, cht khng ng protein
C v S

209



TEST KOLLER
(Cu hi thi hc k)
T VN :
Gan cn c Vitamin K tng hp nn cc yu t ng. Vitamin K l 1
vitamin tan trong m, nn mun hp thu c Vitamin K th phi hp thu
c m. M mun hp thu phi c mt t gan xung.
V vy, trong vng da tt mt, bnh nhn khng hp thu c vitamin K
khng tng hp c cc yu t ng mu t prothrombin vn gim.
(Lu : cc yu t ng mu ph thuc vitamin K hu ht l cc yu t tham gia vo
con ng ng mu ngoi sinh II, VII, IX(ni sinh), X)
MC CH: chn on phn bit bnh nhn vng da l do SUY GAN hay l do TC
MT.
CCH LM:
Trc khi lm ta xt nghim t Prothrombin.
- Sau tim cho bnh nhn Vitamin K 30mg.
Sau 24h, ta lm li xt nghim t Prothrombin.
KT QU:
Nu t prothrombin tng ln gan vn cn
kh nng tng hp cc yu t ng mu gan cha b suy, nguyn nhn gy
vng da l do tt mt gy thiu Vitamin K.
Nu t prothrombin vn khng tng gan suy nn khng tng hp c
yu t ng mu t prothrombin gim khng phi do thiu Vitamin K
Ngun: Wikipedia, Ni c s - YHN, Ni c s - YDH
NH LNG YU T V XT NGHIM THAY TH
TEST KOLLER
Trn bnh nhn b bnh gan, sau khi xt nghim t prothrombin gim, ta ngh n 2
chn on phn bit: suy gan hoc vng da tt mt (gy thiu Vitamin K).
Con ng ngoi
sinh: Yu t VII
Con ng ni sinh:
yu t XII, XI, IX,
VI I I

210


T prothrombin nh gi chc nng ng mu
theo con ng ngoi sinh bao gm s tham gia ca
cc yu t: II, V, VII, X l cc yu t do gan sn
xut.
Cc yu t ph thuc Vitamin K gm cc yu t
II, VII, IX, X.
c 1 yu t, tham gia vo con ng ng mu
ngoi sinh, do gan sn xut v s sn xut n khng
ph thuc Vitamin K yu t V.
Xt nghim yu t V c th nh gi c chc
nng gan, v loi tr c trng hp thiu vitamin K.
Yu t V gim chng t chc nng gim, yu t V gim
khng phi do thiu vitamin K
NH GI YU T NG MU CON NG NI
SINH THI GIAN CEPHALIN KAOLIN(THI GIAN
THROMBOPLASTIN TNG PHN)


PT: prothrombin time.
PTT: Partial thromboplastin time.
NH NGHA
- L thi gian ng mu ca huyt tng, sau khi c thm vo Cephalin-
Kaolin (Cephalin-thay phospholipide tiu cu; Kaolin-cht din hot hot ho
tc th yu t XII) v canxi
- Thi gian Cephalin-Kaolin bin i tng t Tc v Howell khi thiu mt trong
cc yu t ng mu, ngoi tr gim tiu cu nng th thi gian Cephalin-Kaolin
Heparin
Lm tng hot ng ca
antithrombin, gip trung ha
hu ht cc yu t ng mu
serine protease bao gm: XII,
XI, IX, X, prothrombin(II),
thrombin, t ngn nga qu
trnh ng mu.
Thng th tc dng ny xy ra
nhanh chng (phn bit vi
heparin)


211


Cc mu ng tm thi: c
n nh bi fibrinogen
Cc mu ng vng chc: c
n nh bi fibrin.
vn bnh thng (v thmphospholipide tiu cu vo) cn Tc v Howell ko
di.
- Cephalin-Kaolin bnh thng = 50 giy, ko di khi bnh ln hn chng 8-15
giy.
NGHA
- nh gi cc yu t ng mu ca con ng ni sinh bao gm: XII XI
IX VIII X V II I.
- S dng theo di bnh nhn s dng Heparin v cc bnh l thiu ht yu t
ng mu.
NH HNG CHN ON NGUYN NHN XUT
HUYT DA VO LM SNG
- Da vo qu trnh ng mu chng ta bit rng
ng mu k u (thnh mch, tiu cu kt dnh
thnh nt tiu cu) c tc dng lm chm dt
qu trnh chy mu, cn qu trnh ng mu
(ni, ngoi sinh) c tc dng to ra thrombin
chuyn fibrinogen thnh fibrin lm n nh nt
tiu cu, to cc mu ng vng chc.
- Nu bnh nhn b ri lon ng mu k u,
ngha l tn thng thnh mch, gim tiu cu
hoc gim cht lng tiu cu, bnh nhn s
khng hnh thnh c cc mu ng tm thi,
cho nn thng s biu hin di dng xut
huyt t nhin nh nt xut huyt, chm xt
huyt, mng bm mu...1 v d quan trng l
trong bnh st xut huyt, th nh bnh nhn s
biu hin chm xut huyt, th nng s l mng
xut huyt, xut huyt t nhin nh nn ra mu,
tiu mu...
- Nu bnh nhn b ri lon qu trnh ng mu. Do qu trnh cm mu (tiu cu, thnh
mch) vn bnh thng, nn s to thnh cc mu ng tm thi vn bnh thng,
nhng bnh nhn s khng to thnh cc mu ng vng chc cm mu vnh vin
c. t ra tnh hung bnh nhn c phu thut hoc nh rng, s c chy mu
nhng cm c do cc mu ng tm thi, nhng n s chy tr li (Rebleeding) do
cc mu ng khng vng chc. Cho nn, biu hin lm sng ca ri lon qu
trnh ng mu thng l ti xut huyt sau phu thut, nh rng, t mu c do
ng dp, t mu cc khp ln nh khp gi (nht l tr em do ng tc b).
- Tuy nhin, nh hng trn ch mc tng i, v nu mc nng th cng kh
phn bit l do tiu cu hay ri lon qu trnh ng mu, v u xut huyt t nhin
c.
Ri lon tiu cu, thnh mch:
nt xut huyt, chm xut huyt,
mng bm mu.
Ri lon ng mu: ti xut
huyt, t mu c, khp.

212


NH HNG CHN AN THIU HT YU T
NG MU DA VO XT NGHIM CN LM SNG
- Thi gian Quick ko di, CK bnh thng
o CK bnh thng, ngha l cc yu t XII,
XI, IX, VIII, X, V, II, I bnh thng.
o Quick ko di nn 1 trong cc yu t sau s
bt thng: VII, X, V, II, I.
o Kt hp 2 d kin trn suy ra yu t VII b
thiu ht.
- Thi gian Quick bnh thng, CK ko di:
o L lun tng t nh trn. Quick bnh
thng nn VII, X, V, II, I bnh thng.
o Cc yu t tn thng c th l XII, XI, IX, VIII.
Thiu XII: bnh Hageman.
Thiu XI: bnh Rosenthal
Thiu IX: bnh hemophilia B
Thiu VIII: bnh hemophilia A
o Nu nh lng cc yu t trn bnh thng, th nguyn nhn l do thiu ht
cc yu t tip xc: HMCK, prekellikrein (xem s trn)
- Thi gian quick ko di, CK ko di:
o Tn thng con ng chung.
o Yu t X, V, II, I.
BNH NHN MUN S DNG WARFARIN TH
TRC HT NN CHO BNH NHN S DNG HEPARIN.
- Warfarin l mt thuc khng ng theo c ch l c ch enzym epoxide reductase, t
ngn cn qu trnh carboxyl ha cc yu t ph thuc vitamin K. Tuy nhin, kh
nng khng ng s khng xy ra ngay lp tc v nhng yu t ng mu ph thuc
vitamin K ( c carboxyl ha) trong mu vn cn. Mun cho tc dng khng
ng c xy ra hon ton phi cn t nht 3 4 ngy cc yu t cn li trong
mu c tiu th ht.
- iu ny gii thch ti sao bnh nhn lc u nn cho c heparin v warfarin, v
heparin c tc dng ngay lp tc c ch cc yu t ng mu nh lm tng hot ng
ca antithrombin.



213



112. DU DY THT
NGHA
- nh gi sc bn mao mch.
CCH LM
Dng my o huyt p o huyt p ti a
v huyt p ti thiu,
Sau ta duy tr huyt p trung bnh
trong vng 5 pht.
Tho my o huyt p v theo di trong vng 5 pht vng da cnh tay v
cng tay.
KT QU:
Bnh thng: Da cng tay v bn tay hi tm nh, 1 lc sau tr v nh c.
Bnh l: Xut hin trn 7 chm xut huyt, tuy nhin kt qu thng c ghi
l dng tnh t (+) n (++++) (thng s c ly t sch Huyt hc c s -
YDH)
NGUYN NHN:
- Sc bn mao mch gim trong:
o Gim tiu cu.
o Vim mch d ng.
o Thiu cc vitamin C, PP.
- i khi xt nghim cng dng tnh trong trng hp bnh tiu cu (ri lon chc nng
tiu cu), bnh von Willebrand
- Tuy nhin, cn nh l y ch l 1 xt nghim th s, ch c gi tr gii hn.
Ngun: Ni c s - YDH
113. HI CHNG CHY MU.
(Xem sch ni c s - hi chng xut huyt, thy c m t y ).
Du dy tht: Dng th thm
d nguy c xut huyt, c lm
thng quy cho nhng bnh
nhn b st vo phng cp cu
loi tr st xut huyt

214



114. HI CHNG THIU MU:

Ngi ta phn bit thiu mu cp tnh, thiu mu mn tnh v c tan mu cp tnh.
THIU MU CP TNH:
Nguyn nhn:
- Chn thng mt mu nng.
Lm sng:
- Da, nim mc: da xanh, nim mc nht nht, lng bn tay trng bch.
- Tim mch: nhp tim nhanh, c th c ting thi tm thu do thiu mu.
- Huyt p:
Mt >1l, HA ng mch gim di mc bnh thng.
Mt >1.5l, try mch khng o c HA.
- H hp: Kh th, nhp th nhanh.
- Thn kinh: au u, hoa mt, chng mt. Thong ngt hoc ngt.
- C v khp: mi cc c, i li kh khn.
THIU MU MN TNH.
Nguyn nhn:
- Tr.
- Xut huyt tiu ha.
- Rong kinh, a kinh
Lm sng
- Da, nim mc: da xanh xy ra t t, nim mc nht nht.
- Mng tay: kh, mt bng, c kha, c th c mng tay lmhnh tha.
- Tim mch: nhp tim nhanh, c th c thi tm thu thiu mu. Ngi gi: thiu mu nui
tim cn au tht ngc.
- H hp: kh th khi gn sc, nhp th nhanh.
- Thn kinh: Nhc u, hoa mt, chng mt, tai, thong ngt. Bnh nhn thng c
nhng cn bun b lin min do thiu O2 no.
- C xng khp: mt mi, i li kh khn.

215


- Tiu ha: n km, gy st.
- Sinh dc: n c ri lon kinh nguyt. Nam: sinh l km hoc mt.
Nhn chung, triu chng ca thiu mu mn cng ging thiu mu cp, ch khc ch
triu chng xy ra t t, nn bnh nhn c thi gian thch nghi.

CN TAN MU CP TNH
Nguyn nhn:
- Bm sinh:
Mng hng cu: Bnh hng cu hnh cu ( thiu spectin), hng cu
hnh elip
Ri lon chuyn ha hng cu: thiu G6PD, thiu Pyruvate kinase.
Ri lon Hemoglobin: bnh hng cu hnh lim, bnh thalassemia.
- Mc phi:
+Thiu mu tan mu t min:
Tin pht.
bnh Lupus ban ,
Hi chng Evans ( khng th khng tiu cu, v khng th gy
tan mu).
+Tan mu tr s sinh:
Bt ng Rh.
Bnh tan mu do h ABO tr s sinh.
+Phn ng truyn mu bt ng nhm mu.
+Thuc:
Penicilline.
Methyldopa.
Lm sng
Thiu mu t nhin tng ln.
St cao km rt run.
au bng.
Vng da, vng mt tng ln r rt.

216


Lch to ra.
C th c bin chng thn v tim.
Nc tiu sm mu.
Phn vng.

Cc triu chng ca cn tan mu cp tnh ging nh cc triu chng ca thiu mu cp.
Km theo l cc triu chng do s c qu nhiu hemoglobin trong mu gy c cho thn,
v s chuyn n thnh bilirubin t do v sau l bilirubin lin hp: vng da, nc tiu sm
mu, phn vng.
TIP CN MT S XT NGHIM CHN ON
THIU MU
XT NGHI M HNG CU LI:
- L 1 marker cho php chng ta nh gi s to hng cu ca ty xng c bnh
thng hay khng?
- Kt qu c th hin di dng % (bnh thng < 3%)
- Hng cu li tng trong trng hp thiu mu:
o Kt qu % hng cu li cn c iu chnh cho ph hp vi mc thiu
mu.
o Kt qu hng cu li iu chnh (corrected reticulocyte count) = (Hct bnh
nhn/45) x kt qu hng cu li, trong 45 th thin Hct bnh thng.
o V d:
Hct =15%, xt nghim hng cu li l 18%
Kt qu hng cu li iu chnh l 15/45 x 18% =6%
(S d chng ta cn kt qu hng cu li iu chnh l v: T l % hng cu li = s hng
cu li /s lng hng cu ngoi vi. Trong trng hp mt hng cu qu nhiu, cng mt
mc p ng ca ty xng, cng 1 s lng hng cu li th t l % s tng ln mt
cch khng ph hp, cho nn chng ta cn iu chnh v ging nh trng hp bnh thng
l Hct = 45%)
- Nu kt qu hng cu li iu chnh > 3%:
o Ty xng p ng tt vi thiu mu, s to mu din ra hiu qu.
o V d: thiu mu tan mu, thiu mu thiu st p ng tt vi iu tr st.
- Nu kt qu hng cu li iu chnh < 3%:
o Ty xng p ng km i vi mt mu, s to mu din ra khng hiu qu.
o V d: thiu mu bt sn, thiu mu thiu st khng iu tr.
ST HUYT THANH:

217


- Trong mu, st c gn vo 1 protein vn chuyn ca n gi l transferrin.
o Transferrin c gan tng hp.
- Xt nghim st huyt tng nh gi lng st gn vo transferrin.
- Lng st bnh thng l 100 g/dL
- St huyt thanh gim trong:
o Thiu mu thiu st.
o Cc bnh l mn tnh.
- St tng trong:
o Bnh l tha st.
FERRITIN HUYT THANH:
- Ferritin l dng d tr st trong c th.
o St v ferritin c d tr cc i thc bo ty xng.
o Tuy nhin, nng ferritin huyt tng li c mi tng quan thun vi
ferritin c d tr trong cc i thc bo, cho nn chng ta c th nh gi
ferritin huyt tng nh gi d tr st ca c th.
o S tng hp ferritin cc i thc bo s tng ln trong trng hp vim:
Do Interleukin 1 v TNF alpha.
- Gim ferritin:
o Tc l gim d tr st ca c th
o Chn on xc nh ca thiu mu do thiu st.
- Tng Ferrtin:
o Thiu mu trong cc bnh l mn tnh.
o Bnh l tha st.
TIBC (TOTAL ION BINDING CAPACI TY): KH NNG GN ST TON PHN
- Hu ht st trong huyt tng c gn vo transferrin.
- TIBC nh gi kh nng gn st, cho nn d hiu chng ta c th xem TIBC chnh
l transferrin.
o Transferrin tng th TIBC tng
o Transferrin gim th TIBC gim
MI LIN QUAN GIA FERRITIN V TRANSFERRI N:
- Ferrtin v transferrin c mt mi lin quan nghich:
o Nu nh d tr st trong c th tng (Ferritin tng) th gan s gim sn xut
transferrin xung.
o Cn ngc li, nu d tr st gim (ferritin gim) th gan s tng sn xut
transferrin.
RDW:
- Th hin s phn s v kch thc ca hng cu (c th hiu nh phng sai trong
ton hc)

218


- Nu RDW tng: th hin kch thc hng cu to nh khng u, kch thc ca n
phn b trong 1 di rng, c con th qu to, c con th qu nh.
o V d: trong thiu mu do thiu st, RBC s tng do nhiu hng cu c kch
thc nh, 1 s khc th c kch thc bnh thng.
- RDW nh: th hin cc hng cu c thch thc u nhau.
BO HA ST (%)
- Th hin bao nhiu % ca transferrin c st gn vo.
o bo ha st = st huyt tng / TIBC x 100 (hiu TIBC chnh l
transferrin)
- Gim bo ha st:
o Thiu mu thiu st.
o Thiu mu trong bnh l mn tnh.
- Tng bo ha st:
o Bnh l tha st (Ion overload disease)
TIP CN NGUYN NHN GY THIU MU DA
VO CN LM SNG



219


Gii thch:
- Thiu mu nhc sc c 5 nguyn nhn l thiu st, thiu mu mn, bnh l mn tnh (
vim khp dng thp, suy thn mn...), thiu mu mn ( rong kinh, chy mu tiu ha),
thalassemia ( bnh do bt thng tng hp chui alpha v beta), v thiu mu nguyn bo st
(ngha l st vo hng cu, b bt gi li ti th, nhng v l do no n khng lin hp
c vi protoporphyrin to thnh nhn Heme hng cu cha nhiu st).
- Thiu mu u sc: gp trong 2 bnh l thiu folate v thiu B12 lm cho qu trnh tng
hp DNA ca hng cu. Hng cu tng hp nhng khng phn chia c
- Thiu mu bnh sc: ta phi xt nghim thm hng cu li: Nu hng cu li tng,
chng t ty xng cn p ng sn xut hng cu non, ngha l ty xng vn cn kh
nng sn xut hng cu non, nn chng ta s ngh n nhng bnh l lin quan n hng cu,
hoc nguyn nhn ngoi vi.. Hng cu li gim ty xng cha kp sn xut: mt mu
cp, thiu nguyn liu ( Fe): thiu st giai on u (giai on sau s l thiu mu nhc sc)
hoc ty xng khng cn kh nng tng hp: Bnh thiu mu bt sn.
Ngun: Pathology.
115. LCH LN.
KHM LCH LN:


220



Trnh t khm ( ging nh bn khm gan)
Bt u t h chu phi, bo bnh nhn th su v chng ta t t n su. C gng
cm nhn lch khi chng di chuyn xung pha di th ht vo v chm vo
ngn tay (hnh a)
Ri li di chuyn tay cho ln pha h sn tri tng 1-2cm nh vy ri lp li th
thut nh vy.
Chng ta cm nhn b sn dc theo chiu di ca n v v tr ca gc lch c th
thay i.
Nu khng s thy c gc lch, bo bnh nhn nghing sang phi ri lp li th
thut.
S bng bn tay phi, trong khi tay tri n vo xng sn tri pha sau( hnh
B)










221


NGUYN NHN LCH LN:
RI LON V MU
U lympho
Leukemia c bit l th ty mn tnh
X ha ty xng
a hng cu
Thu mu tan mu.
Tng p tnh mch ca
Nhim khun
Tng bch cu n nhn nhim khun
St rt.
Bnh Brucella
Kala azar
Vim ni tm mc nhim khun bn cp
Thp khp
Vim khp dng thp (Hi chng Felty)
Lupus ban h thng
Him gp
Sarcoidose
Amyloid
Ri lon v d tr glycogen

Theo: Macleods clinical examination








222


NH HNG CHN AN BNH L THEO SCH NI TRNG:


Gii thch 1 s bnh l:
- CMV: cytomegalovirus.
- MNI ( infectious mononucleosis) bnh tng bch cu n nhn nhim khun.
- Bch cu kinh v bch cu cp (acute leukemia v chronic leukemia): l bnh ung
th mu hay ung th ty xng ( hay gp trong phim
Hn Quc) c c trng bi s qu sn bt thng
ca cc t bo mu m thng thng l bch cu.
Leukemia l tn gi chung ca rt nhiu bnh (
leukemia cp th ty, leukemia cp th lympho,
leukemia mn th ty, leukemia mn th lympho).
- Hemochromatose (hemochromatosis)- bnh nhim
sc t st m: nguyn nhn do s tch ly st trong c
th, cc c quan thng b nh hng l gan, tim,
tuyn ni tit. S tch ly st qu nhiu trong c th
c th do di truyn hoc th pht sau: ch n tha st, truyn qu nhiu mu, lc
mu trong thi gian di, bnh gan mn tnh: x gan ru, vimgan C.
- Bnh Gaucher: bnh di truyn do s tch ly ca m trong t bo vo 1 s c quan (
do thiu beta- glucosidase)
- Hi chng Budd- chiari: l 1 bnh cnh lm sng gy ra do s tt nghn ca tnh
mch trn gan, v d nh huyt khi, khi u, nang sng... Thng biu hin bng tam
chng: au bng, bng, gan to.

223


HI CHNG FELTY
(Cu hi lm sng)
1 bnh nhn b vim khp dng thp, em phi thm khm thm c quan no ngoi
khp?
P N
Lch.
HI CHNG FELTY
c nh ngha l s xut hin ca 3 bnh l: Bnh vimkhp dng thp, lch
ln v bch cu gim 1 cch bt thng.
Tn xut xut hin: Gp <1% cc bnh nhn b vim khp dng thp.
Nguyn nhn vn cha c bit r, nhng hay gp ph bin nhng bnh nhn
b vim khp dng thp trong thi gian di.
Bnh nhn c nguy c cao b nhim khun do bch cu gim qu thp.
X GAN V GIM 3 DNG T BO MU
- X gan gy tng p ca l nguyn nhn ph bin nht gy ra cng lch.
- Khi cng lch, tt c cc t bo hng cu, bch cu v tiu cu u b bt gi v tiu
dit, v th gy gim c 3 dng t bo mu.
- Lm sng:
o Lch ln.
o Gim cc t bo mu ngoi vi: thiu mu, gim tiu cu, gim bch cu trung
tnh n c hoc kt hp.
o Phn ng ty xng b tr.
- iu tr: ct lch


224









225






CHNG VI
THN
TI T NIU


226





227


116. TIU NHIU
- >2l / 24h (i tiu nhiu ln nhng s lng i tiu mt ln bnh thng)
Sinh l Bnh l
Ngoi thn Ti thn
Tng ngun nc nhp:
- ung nc nhiu
(thi tit nng
nng, ..)
- truyn nhiu nc
Lin quan n h thn
kinh t ch- t ng:
cng thng thn kinh,
stress, ung nhiu do
ngun gc thn kinh
- Li tiu
- Tng glucose mu, i tho
ng (tng p sut thm
thu nc tiu)
- i tho nht th trung
ng (tuyn yn gim sn
xut ADH)
- Cng gip (gy tn ng
mu-ng niu)
- Tng calci niu (cng
tuyn cn gip)
- Thng thn sn xut
khng aldosterol (bnh
Addison)
- Mt kh nng c c nc
tiu do thn gim p ng
vi ADH:
+ i tho nht th thn,
do khim khuyt gen quy
nh receptor ca ADH
+Sau nhim c 1 s cht
v d lithium
+Tn thng m k thn
mn tnh, bnh thn tro
ngc, hoc bnh thn do
d ng 1 s cht.(Thn
khng ADH)
- vim thn x
- Suy thn mn: giai oan
u
- Vim ng thn cp (suy
thn cp
Suy thn mn giai on u v a niu.
- Sch SLB c u cp n suy thn mn giai on u thng c a niu, ch n giai
on cui mi thiu niu v v niu. Tuy nhin mnh ngh theo nh ngha suy thn mn:
L hu qu ca cc bnh thn mn tnh gy gim st t t s lng ca nephron
chc nng lm gim dn mc lc cu thn. Khi mc lc cu thn gim xung di
50% th gi l c suy thn mn. Vi nh ngha nh vy, khi s lng nephron chc
nng gim t t lmgim mc lc cu thn th khng c l do g gy ra A NIU ht.
- Tuy nhin, SLB YDH a ra gii thch l khi m cc nephron tn thng nhiu th cc
nephron cn li s phi m nhim khi lng cng vic bi tit nh khi thn bnh
thng. V phi chu 1 p lc lc ln, cc nephron ny ph i v v khi lng cc cht
ha tan a n y rt nhiu nn gy ra tnh trng li tiu thm thu, hu qu l tiu
m v tiu nhiu. ( trang 206).

228


- Ngoi ra, nu suy thn mn giai on u do vimthn b thn mn th ngi ta cn
nhc n s phn ly chc nng cu thn - ng thn l nguyn nhn gy ra a niu. Tc
l, do hot ng b tr giai on u nn cu thn vn duy tr c hiu sut lc,
nhng do t chc k (trong c ng thn) b tn thng do qu trnh vimmn nn kh
nng ti hp thu mui, nc b gim st. Gy ra triu chng a niu trn lmsng. Giai
on sau th hin tng ny khng cn na do chnh bn thn cc cu thn cng b tn
thng v gim chc nng (theo Harrison)
Ngun: SLB YDH, Harrison
SUY THN CP (HOI T NG THN CP) GIAI
ON SAU C TIU NHIU.
- Lm sng ca suy thn cp (hoi t ng thn cp chia thnh 4 giai on. Nhng giai on
u bnh nhn s biu hin thiu niu, gy ra ph, tng huyt p v hi chng tng ure
mu
- Tuy nhin, khong vo tun t 3 ca v niu, bnh nhn t ngt tiu nhiu, c khi ln
ti 10lt/ngy, rt nng n, v c th gy ra tnh trng h K mu. Bnh nhn c th cht v
2 nguyn nhn: Try mch hoc h K mu.
- y gi l du hiu phc hi ca suy thn.
- Nguyn nhn ca hin tng ny c gii thch l do trong giai on phc hi ny th
chc nng cu thn (lc) phc hi trc, nhng chc nng ng thn phc hi sau (ti hp
thu). Thn lc c nhng cha ti hp thu c s gy ra tiu nhiu.
- Xt nghim nh gi t trng nc tiu (trong 10 thng s nc tiu) l mt xt nghim
n gin nhng rt c gi tr theo di kh nng hi phc ca chc nng ng thn. C th
l trong giai on a niu lc u t trong rt thp, nhng ngy sau nu theo di thy t
trng tng ln v tr v bnh thng l mt du hiu tt.
- Bnh cnh lm sng thng lm cho bc s lng tng: 1 bnh nhn vo vin v suy thn
cp, iu tr ch yu l li tiu, hn ch nc, v dng thuc h K mu trong nhiu ngy.
t nhin 1 ngy n, bnh nhn t ngt tiu nhiu, nu bc s lm sng khng ch m
vn duy tr liu trnh iu tr c, bnh nhn c th cht v try mch hoc h K mu (mi
hm qua tim thuc h K mu, hm nay bnh nhn h K ri t vong)
A NIU PHN BIT GIA VIM THN B THN
MN V CP
1 s nh ngha:
- Vim cu thn: l tn thng cu thn.
- Vim mch thn: tn thng mch thn.

229


Aminoglycoside (hay cn gi l
aminoside) gm nhng thuc nh
streptomycin,gentamycin,amikacin,
kanamycin l mt loi thuc thng gp
gy c cho thn gy suy thn cp. Trong
nhm ny th neomycin l thuc c cho
thn nht.
- Vim thn b thn: tn thng ch m, t chc k ca thn do vi khun xm nhp.
Trn gii phu bnh thy tn thng ng thn, i b thn.
o Vim thn b thn cp: xy ra cp tnh vi nhim trng rm r.
o Vim thn b thn mn: do cc yu t nguy c cha c gii quyt, tnh
trng vim thn b thn c tin trin, ti i ti li gy ra vim thn b thn
mn.
- Trong vim thn b thn mn, 1 triu chng quan trng cn nh l triu chng tiu nhiu,
do tn thng ng thn, trong khi cu thn vn lc. Nu giai on cui, khi m c cu
thn ln ng thn u tn thng, bnh nhn s b thiu niu.
- Nu khng gii quyt yu t nguy c, vim thn b thn mn s tin trin ti suy thn
mn.

117. THIU NIU + V NIU.
- Thiu niu l tnh trng nc tiu nh hn 500ml/ngy, c ti liu a ra s lng nc
tiu t 300-700ml/ngy cng c coi l thiu niu
- V niu l mc nng nht ca thiu niu. L khi hon ton khng c nc tiu tit
xung bng quang. nhn mnh tnh trng khn trng ca v niu, c th coi lng
nc tiu <300ml/ngy l v niu (c sch a ra con s l < 100ml/ngy, y l im
cha thng nht gia cc ti liu)
- Nguyn nhn ca thiu niu c phn loi gm nguyn nhn trc thn, ti thn v sau
thn.
o Thiu niu do nguyn nhn trc thn v sau thn th thng thng cha
c, nhng n c th dn n s tn thng ti thn.
o Tuy nhin, thiu niu do nguyn nhn tai thn th n dai dng hn v c th
khng cha c.
Nguyn nhn:
Trc thn: bao gm tt c cc nguyn nhn lm gim lu lng mu n thn dn n suy
thn:
- Gim lu lng tun hon: mt mu,
bng, dng li tiu, chy nhiu m hi,
bnh Addison( gim aldosteron), mt qua
tiu ha.
- Tim: Bnh suy tim xung huyt( gim
mu n thn, thn s phn ng li y
chang nh trng hp mt mu).
- Gim p xut keo huyt tng: hi chng
thn h, tnh trng d ha.
- Shock, hp ng mch thn.
- St rt c tnh

230


Ti thn:
- Bnh m k ca thn: hoi t ng thn cp ( do thiu mu n thn).
- Bnh v vim mch:
- Vim thn k d ng: Do 1 s thuc nh Penicillin, Gentamicin gy p ng d ng
ti ng thn, thng thng c thm cc biu hin ngoi da nh nga, my ay. Chn
on bng cch o bch cu acid, IgE trong nc tiu.
- 1 s sc t nh myoglobin, hemoglobin cng gy c cho thn, v vy phi hi tin s
bnh nhn xem gn y h c b dp c hay l tnh trng tang mu nh trong trng
hp truyn nhm nhm mu.
- Bnh U ty: Protein Bences- J ones.
- Cc si ti thn, nh si Oxalate do ng c ethylene Glycol. Si Urate do Gout.
- Cc cht c:
o Thuc gim au : aspirin
o NSAIDs.
o Aminoglycosides.
o Amphotericin B.
o Cc cht phng x.
o Cc cht cn quan dng trong chp CT, cho nn gi s bnh nhn b suy thn
kiu ny phi hi xem tin s c i chp CT hay khng?
o Cyclosporin.
o Ng c mt c trm, gan cc
Sau thn: ch yu do si, u bng quang, tin lit.
SI THN 1 BN C GY RA THIU NIU KHNG?
- S di chuyn ca vin si c th gy ra 1 phn x thn thn, gy co tht i b thn,
co tht mch mu thn c 2 bn. Phn x ny gii thch c c ch gy v niu ca cc
trng hp si 1 bn (SLB YDH).
PHN BIT SUY THN TRC THN V TI THN
T BUN/CREATININ
- Bnh thng: BUN/Creatinin = 10/1.
BUN: blood urea nitrogen. Bnh thng urea v creatinin s c lc t do qua cu thn
v ch c urea l c ti hp thu tr li ng ln gn, cn creatinin c bi xut thm
na nhng vi s lng rt t, cho nn ngi ta mi ly creatinin lm ch s nh gi
mc lc cu thn v n chnh xc hn, mt khc nng urea thng hay ph thuc vo
ch n nhiu hay t cc hp cht cha Nit ( mc d khng tuyt i).

231


Khi suy thn trc thn:
- Gim lu lng mu ti thn thn gim lc dn n gim bi xut urea v
creatinin, c 2 u tng cao trong mu.
- Tuy nhin, urea s tng cao hn nhiu do urea s c tng ti hp thu ng ln
gn: l do v thn gim lc, dch lc cu thn di chuyn chm trong ng thn, lm ng
ln gn c nhiu thi gian hn ti hp thu urea, lm urea tng cao trong mu. (
on ny c hi thi lm sng: nu urea tng cao, creatinin ch tng khng ng k th
gp trong trng hp no? Tr li l suy thn trc thn).
o Do vy t BUN/Creatinin s tng cao hn: >15/1.
o Thn suy, lm gim bi xut c ure, ln creatinin.
o Chc nng ng thn gim, gim s ti hp thu ca urea.
c ure v creatinin u tng cao trong mu u nhau.
BUN/Creatinin <15.
Bnh nhn b shock gim th tch mu vo vin vi tnh trng thiu niu, BUN =
80mg/dl, Creatinin = 2mg/dl, tin lng?
Nhn thy: BUN/Creatinin = 40, nh vy l cha c tn thng thc th ti thn,
bnh nhn ch cn iu tr bng cch b dch.
Tin lng s xu khi BUN/Creatinin gim xung thp < 15. Ngha l khi do
tnh trng gim lc qu lu, thn khng c cung cp nhu cu Oxy v cht
dinh dng, nn by gi c tn thng thc th ti thn, thng gp l hoi t
ng thn cp.
Hoi t ng thn cp tin lng xu, v tnh trng thiu mu ngoi tn thng ng
thn cn gy tn thng mng y cu thn. Khi mng y b tn thng, nephron
s khng c kh nng phc hi c na.
BUN V CREATININ
- BUN (blood urea nitrogen) l lng nit trong mu di dng urea. BUN thng
c tnh theo n v mg/dL M (nhn thy M thng hay s dng n v mg/dL,
thay v mmol/l, nh trong n v ng mu vy). Tuy nhin, nc ta th khng s
dng ch s BUN m thng s dng urea hn di n v l mmol/l. chuyn t
dng BUN (mg/dL) sang mmol/L ca urea, th ta chia cho 2.8 (v mi phn t ure c
2 nguyn t nit, m mi nguyn t nit c trng lng phn t l 14g/mol)
Urea (mmol/L) =BUN (mg/dL c nito) / 2.8

2 ch s ny c ngha ging nhau.

232


- Creatinin l sn phm chuyn ha cui cng ca creatin ca c.
Chng ta c th s dng bng phn bit sau:
Ch s Suy thn chc nng Suy thn cp thc
th
Ure mu Tng Tng
Creatinin mu Bnh thng hoc tng
t
Tng
Ure/Creatinin mu >100 <50
FENa <1% >1 2%
Na/K niu <1 >1
Ure niu/Ure mu >10 <10
Cre niu/Cre mu >30 <30
Thm thu niu /thm
mu mu
>2 <2
Bng phn bit trn c ly sch Ni bnh l ca trng, chng ti cn tm thy 1 bng
phn loi khc nh sau:
Bng 9-4 Xt nghim nc tiu suy thn chc nng v suy thn thc th nguyn
nhn ti thn
Xt nghim Suy thn chc nng Suy thn cp nguyn
nhn ti thn
Nng Osmol nc tiu
(mOsm/kg)
>500 <400
Na niu (mEq/L) <20 >40
T s creatinin nc tiu
huyt tng
>40 <20
Ch s suy thn (RFI) <1 >2
Phn xut bi tit Na <1 >2
Cc cht cn lng Bnh thng hoc thnh
thong c cc tr ht
C cc tr ht mu nu,
mnh vng t bo
GII THCH MT S THNG S.
Na niu thp trong suy thn chc nng

233


Bnh nhn i tho ng bin
chng nguy him nht l thn.
Microalbumin niu l 1 du hiu ch
im ca 1 bnh thn ang tin trin.
Bnh nhn i tho ng pht hin
thy c microalbumin niu thng
s c k ngay thuc c ch men
chuyn. N s lm chm i tin trin
ca bnh thn i tho ng. C
ch l do n lm gim p lc lc cu
thn bng cch co tiu ng mch
n, gin tiu ng mch i do c
ch ATII. Thuc c ch th th AT II
cng c s dng,c bit l i
tho ng type 2
- Trong suy thn chc nng, cho d mt mu hay hp ng mch thn hay bt c
nguyn nhn no gy gim th tch mu ti thn, thn s p ng li bng cch tng
ti hp thu Na v t tng ti hp thu nc c gng lm tng th tch mu ln. T
s lm cho Na trong nc tiu gim.
- Ngc li, trong suy thn ti thn, chc nng ni
ti ca thn mt, thn khng cn kh nng ti
hp thu Na na, cho nn Na niu tng (ging nh
tnh trng s dng li tiu)
T trng nc tiu v osmol
nc tiu trong suy thn chc nng:
- Khi m lng mu ti thn gim, thn s c gng
lm c c nc tiu gi nc cho c th, v th
cho nn nc tiu s c c hn, t trng cao hn
v nng osmol cao hn. C th trong suy thn
chc nng, nng osmol nc tiu >500, cn suy
thn thc th th nng osmol <400.
- Ngc li, trong suy thn ti thn, thn khng cn kh nng c c nc tiu na,
cho nn t trng nc tiu s gim (<1.015) v nng osmol cng s gim (<350)
PHN XUT BI TIT Na.
FENo =
No nc tiu
No uyt tng

Crcotinin nc tiu
Crcotinin uyt tng


THNH THONG 1 S BNH NHN VO VIN C
XT NGHIM UREA GIM, CN LOI TR CC NGUYN
NHN SAU








234


Nguyn nhn Gii thch
Tng th tch huyt tng Ph n mang thai, hi chng SIADH
Tng th tch huyt tng tng tc lc cu thn
gim urea mu
Qu trnh tng hp urea gim Bnh nhn b x gan, hi chng Reye, suy gan cp
Chu trnh urea xy ra gan b ri lon gim urea
mu
Ch n thiu protein Kwashiorkor (suy dinh dng th ph)
SIADH: syndrome of inappropriate antidiuretic hormone.
BNH NHN C THANH THI CREATININ GIM,
CN LOI TR NHNG NGUYN NHN SAU
Nguyn nhn Gii thch
Tng th tch huyt
tng
Ph n mang thai, hi chng SIADH
Tng th tch huyt tng tng tc lc cu
thn gim urea mu. Cao nht vo cui thng
th 3
Giai on u ca
bnh thn i tho
ng
Tiu ng mch i ca cu thn b co li do tnh
trng x ha do hyaline, dn n tng tc lc
cu thn v gim thanh thi creatinin.
Tng tc lc cu thn s gy ra s ph hy
cu thn.
Biu hin u tin ca s ph hy ny l
microalbumin niu.
Nu pht hin thy c microalbumin niu, bnh
nhn cn c iu tr bng thuc c ch men
chuyn (captopril)

235



SUY THN CHC NNG V SUY THN TRC
THN?
- Thnh thong c sch ta thy h cp n suy thn chc nng, mt s sch khc li
ni suy thn trc thn.
- 2 nh ngha ny l 1, ni v tnh trng thiu niu do gim lng mu ti thn do
cc nguyn nhn nh mt mu, mt dch trong tiu chy.
- Ni l suy thn, nhng trn thc t thn cha suy, ngha l nu bnh nhn c b
dch y , thn s lc tr li. Tuy nhin, khi tnh trng gim ti mu thn din qua
qu lu, khi thn s khng oxy v cht dinh dng sng, gy ra 1 tnh trng
gi l hoi t ng thn cp, lc ny thn mi suy tht s (c th c gi l suy thn
ti thn ri), v cho d truyn dch vo th bnh nhn cng khng tiu c.
- Khi c sch nc ngoi, suy thn trc thn c dng ch PRERENAL
AZOTEMIA. Azotemia ngha l tnh trng tng Urea v creatinin trong mu (azot
bao gm cc hp cht c cha Nit). y do thn cha suy nn ngi ta khng
dng l PRERENAL FAILURE, m ch mi tng urea v creatinin do thn gim lc
thi, nn ngi ta mi dng azotemia (azot: gc azot). Khi no bn c thy RENAL
FAILURE, th c ngha l thn b suy 1 cch thc th.
TIP CN 1 BNH NHN VO VIN V TNG SUY
THN CP


236


Si thn l nguyn nhn hng u
gy tiu mu

119. TIU MU
L s xut hin ca HNG CU trong nc tiu
nh ngha:
- Sch ni: l s hin din ca > 10 hng cu/mm3 xt
nghim m t bo nc tiu.
- Sch sinh l bnh: Tiu mu c xc nh khi c
nhiu hn 5 hng cu / vi trng phng i v c t nht trn 2
mu nc tiu phn tch.
- Sch ngoi c s: l s hin din ca hng cu trong
nc tiu vi s lng > 3hng cu/vi trng.
Ngi ta phn bit i mu niu khoa m i mu thn hc:
i mu niu khoa:
- Do tn thung gii phu v mch mu v ng tit niu ( t tiu i thn n niu
o).
i mu thn hc:
- Do bnh cu thn
- i mu ngun gc cu thn thng khng c cc mu ng, do c h thng tan
fibrin trong ng thn (urokinase).
NGUYN NHN:
Hng cu niu trc thn:
- Rt him, c th gp trong bnh cnh ri lon ng mu nng n, gy xut huyt
ton thn v nhiu ni tng, trong c thn
Hng cu ti thn:
- Khi tn thng bt k on no ca nephron u c th lm chy mu vo lng
ng thn
- Trong vim cu thn, vim k thn, vim ng thn hng cu niu l mt triu
chng ca mt phc hp gm tr niu, protein niu v bch cu niu
- Trng hp c vim m thn th hng cu niu l mt triu chng i km vi
triu chng chnh l c bch cu, bch cu thoi ha v t bo m nc tiu

237



Hng cu niu sau thn:
- Do v mch mu vo ng dn niu, hay gp khi c si, vim nhim( i b thn,
niu qun, bng quang v niu o ) hoc do chn thng. Nghim php 3 cc gip
chn on v tr xut huyt: ng dn niu di (cc u), bng quang ( cc th 3 )
hay t niu qun tr ln ( c 3 cc ). Ngy nay, ni soi bng quang thay th cho
vic lm nghim php 3 cc trong chn on v tr chy mu, c nhy v c
hiu cao hn trong chn on v c th can thip iu tr.
KHI NIM V TR NIU
- L cu trc vi th trong nc tiu c hnh tr, do ptotein b ng vn li theo khun
ca lng ng thn
- Nu c tm thy trong nc tiu th chn on chc chn c tn thng t cu thn
iu kin xut hin tr:
- Nng protein trong nc tiu cao
- Lng nc tiu tng i thp, chy chm trong lng ng thn c thi gian hnh
thnh tr
- C nhng thay i ha-l nc tiu gip cho protein d ng li (v d, gim pH)
Hay gp tr niu trong bnh vim cu thn, thn h nhim m
Tn gi:
- Nu tr n thun ch cu to t protein, c gi l tr trong, rt hay gp trong bnh
thn h nhim m, bnh a u ty xng,Trn c s mt tr trong, nu c bch cu
bm vo th c tn l tr hat (hay gp khi vim cu thn); ngoi ra c th gp tr
hng cu (khi c hng cu niu ng k), tr m (trong bnh thn h nhim m), tr
lin bo(do t bo ng thn bm vo)
CHN ON XC NH V CHN ON PHN BIT:
XC NH:
Xt nghim t bo m trong nc tiu.
>10 hng cu/1mm3 xt nghim m t bo nc tiu.
Xt nghim m t bo trong nc tiu phi c thc hin sau khi ly nc
tiu cho php xc nh thm s hin din ca tr hng cu: l bng chng ca
i mu c ngun gc cu thn.

238



PHN BIT:
- Cc trng hp i mu gi, nc tiu c th mu do:
o Hemoglobin, myoglobin ( gip c), porphyrin ( porphyrin niu).
o Dng thuc : metronidazole, rifampicine.
- Xt nghim m t bo nc tiu cho php loi tr cc trng hp khng c s
hin din ca hng cu.
Ngoi ra cn cn phi chn on phn bit tiu mu vi:
o Chy mu trong chu k kinh nguyt ph n.
o Chy mu niu o.
CHN AN NGUYN NHN:
I MU I TH:
o S lng hng cu > 300.000/pht.
o Lm sng: Tiu ra mu lu c cn v mu cc, nc tiu mu
u bi: thng do niu o, tin lit tuyn.
Cui bi: do bng quang:
i mu niu khoa.
Ton bi: c th t niu khoa hay t nhu m thn.
i mu i th thng thy trong cc bnh l cu thn:
Bnh Berger.
Vim cu thn tin trin nhanh c tng sinh ngoi thnh mch.
I MU VI TH:
- Cn chn an xc nh bng que th v m t bo nc tiu:
- Hng cu trong nc tiu >5000/pht.
- Bnh thng c 1-3 t bo mu trong 1 vi trng, tuy nhin, ngi ta dng
phng php m hng cu trn 1 vi trng khng nh tiu mu:
o 3 Hng cu/ vi trng : dng tnh (++)
o 5 hng cu/ vi trng : dng tnh ( +++).

239


- Cn phng php m cn Addis ( tnh s hng cu trong 1 pht nh trn)
khng cn p dng nhiu.
BNH BERGER
BNH BERGER: Tn khc: bnh thn IgA, hay bnh Berger.
nh ngha: L 1 ri lon ca thn c c trng bi s xut hin ca hng cu trong nc tiu. c gy ra
bi tnh trng vim nhng cu trc ni ti ca thn v s lng ng ca khng th IgA nhu m thn.
Nguyn nhn:
- Bnh thn IgA ( bnh Berger) l 1 dng ca vim cu thn tng sinh mng. Xy ra khi c s lng ng
1 cch bt thng ca khng th IgA tch t trong cc mch mu nh ca thn. V cc cu thn tr nn
b vim.
- Tnh trng ny c th xy ra cp tnh, hoc c th tin trin chm chp trong nhiu nm ( vim cu
thn mn tnh).
- Nhng yu t nguy c bao gm: c tin s c nhn hay gia nh b bnh thn IgA hoc ban Henoch
Schonlein,1 bnh h thng, do tnh trng vim mch xy ra nhiu b phn khc nhau ca c th, v
c th gy ra nhng tn thng thn rt ging tn thng ca bnh Berger.
- Bnh c th xy ra mi la tui, nhng thng gp n ng t 20 35 tui, nam/n = 3/1.
Triu chng:
- C nhng t tiu mu lp i lp li, thng l tiu mu i th, c th c tiu mu vi th. Hng cu
trong nc tiu thng mo m.
- Cc triu chng khc:
o +Protein niu: thng < 3g/24h, him c hi chng thn h.
o + Tng huyt p.
o +Suy thn mn.
o + Tng IgA huyt tng.
o +B th mu bnh thng.
Chn an xc nh:
- Sinh thit thn:
o Trn knh hin vi hunh quang: thy lng ng
Tin lng:
Bnh thn IgA tin trin chm. Trong nhiu trng hp, n khng h tin trin. Cc yu t tin lng nng:
- Protein niu nhiu.
- Tng huyt p sm.
- Nam gii.
- C x ha khong k hoc thng tn mch mu trn sinh thit thn.
V c khong 25% bnh nhn b bnh thn IgA s tin trin n suy thn mn trong vng 25 nm.

240


Bch cu niu (i m) nhng cy
vi khun khng mc, gp trong cc
vim niu o do Chlamydia
trachomatis, lao, vim thn k do
thuc

TIU M
- C nhiu t bo m trong nc tiu( bch cu trung tnh).
- lu c ln cn m trn y ng nghim.
- Cn m gm : BCTT, t bo biu b, biu m, vi khun, si t huyt, cht nhy.
- i m thng km theo i mu lm nc tiu c mu sa socola rt d nhm ln
vi i mu, i dng chp.
Nu :
- >10 bch cu /ml or 5000 bch cu/ pht c
nhim khun.
- >30 bch cu/ vi trng i m.
Nguyn nhn:
- Qu trnh vim c nhim khun thng thng.
- Qu trnh vim khng c nhim khun.
- Qu trnh vim c hiu nh lao, nm, niu o.
Gp trong:
- Vim niu o: ch yu do lu cu, c th km theo i but.
- Vim tuyn tin lit: i but, i lu, i kh, i ngt qung, i nh git, gp
ngi cao tui.
- Vim bng quang: c hi chng kch thch bng quang: i but, i lu km i m.
- Thn m: do tc nghn gy nc thn nhim khun m, c th c p xe
do nhim khun ngc dng hoc sau nhim khun huyt.
- i m v khun: c m hoc bch cu niu nhiu nhng cy vi khun thng khng
mc. Gp trong: d vt lt vo bng quang, si khng nhim khun, chlamydia lao
thn, o thi thn ghp, dng nhiu khng sinh, dng cyclophosphamid.
Phn bit vi tiu dng chp, i cht nhy mucin, i cn phosphate calci ( soi knh hin
vi thy cn, tinh th)
Ngun: Ni c s - YHN
TI U HEMOGLOBIN HUYT SC T
- Bnh thng [Hb] nc tiu : 1-4mg/100ml.
- Nguyn nhn: tan mu cp, Hb to ra nhiu khng kp chuyn thnh billirubin.
- Ch yu do nguyn nhn trc thn nguyn nhn ti thn v sau thn l rt t, khng ng
k.
- Gp trong:
o St rt nng : thng do P.Falciparum cn gi la st rt c tnh gy v hng cu

241


o Nhim khun C.perfringens ( vi khun gy hoi th sinh hi), y l loi vi khun
sn xut c t ph hy mng hng cu gy tan mu trong mch v tiu Hb
o Nhim c:
+Asen, ng: Do cc cht ny gn vi nhm sulfydryl mng hng cu lm
gim sc bn hng cu
Bnh nhn chy thn nhn to chu k c th b tan mu do dch
lc cha ng i ra hemoglobin.
+Amphotericin ( thuc khng nm) : gn lipid mng hng cu gy tan
mu cp.
+Chloramin( cht kh khun nc ung) :
Cht ny cng c dng trong nc lc mu thn nhn to.
+ c rn.
o Truyn nhm nhm mu: triu chng ch im l bnh nhn ang c truyn mu
th c shock.
o i Hb do vn ng:
Chy xa, cha quen vn ng hng cu chuyn ng qu nhiu ln qua
cc mch nh vt qua xng cng chn thng tan mu.
i Hb kch pht do lnh: l bnh t min, him gp. Trong mu bnh nhn c
khng th IgG p ng vi lnh kt hp vi khng nguyn nhm mu
P, hot ho b th qu mc gy tan mu trong mch.Biu hin lm sng l sau nhim
lnh bnh nhn rt run, st, au bng, au lng, au cc bp chi v i ra Hb

o i hemoglobin kch pht v m - Gp bnh nhn c Hi chng Marchiafava-
Mecheli
HI CHNG MARCHIAFAVA MECHELI.
c im:
L 1 tnh trng thiu mu tan mu mn tnh.
Trong huyt tng thng xuyn c tng Hemosederin.
C t i hemoglobin niu kch pht v m.
Triu chng: Bnh thng gp tui 30- 40, thiu mu mn tnh nht nht, xanh
xao,mt mi, au lng, au bng, au vng trn mi c, i Hb.Hb mu tng sau khi ng,
ban ngy nc tiu trong. Xt nghim vo sng sm th nc tiu , c Hb nhng ko c
hng cu.

242


Nguyn nhn: Nguyn nhn do thiu yu t DAF( decay accelerating factor) mng t
bo DAF l yu t thc y qu trnh bt hot nhng phc hp b th trn mng t bo,
khi thiu DAF, b th bm vo t bo hng cu, to iu kin cho i thc bo tiu dit
hng cu.
Ngun : NCS- YHN
10 THNG S NC TIU
Trong cc xt nghim nh gi bnh l thn tit niu, c 1 xt nghim l 10 thng s nc
tiu. Chng ti xin gii thch mt s thng s trong 10 thng s ny (c ni lm ti 11 thng
s)
THNG S GII THCH
T trng nc
tiu
nh gi long hoc c ca nc tiu.
Nu t trng nc tiu tng thng th hin kh nng c c
nc tiu ca thn tng, thng gp trong suy thn trc thn
(prerenal azotemia), lng nc n thn gim lm thn phi
tng ti hp thu.
Nu t trng nc tiu gim khi m kh nng c c nc tiu
ca thn b suy gim. V d nh trong suy thn mn hoc giai
on sau ca suy thn cp
pH Ph thuc vo ch n v tnh trng acid baze ca bnh nhn.
Ngi n chay thng c pH nc tiu kim (citrate c
chuyn ha thnh bicarbonate); ngi n tht th thng c pH
acid (do cc acid hu c c trong tht)
pH kim + mi ca amoniac: Nhim khun PROTEUS.
Protein Pht hin albumins (khng phi globulin)
Glucose c hiu ch pht hin glucose, khng pht hin fructose v cc
cht ng khc.
Nhy n mc pht hin 1 lng khong 30mg/dL.
Bnh nhn tng glucose mu +glucose niu: i tho ng.
Bnh nhn c glucose mu bnh thng +glucose niu: ngi
mang thai (do h c ngng ti hp thu glucose ca thn thp
hn)
Ketones Pht hin acetone, acetoacetic acid
Keton niu gp trong: nhim keton do i tho ng, tnh trng
cht i (Starvation), ch n cha nhiu keton, ph n mang
thai (du hiu bnh thng), ng c ru isopropyl.

243


Billirubin Pht hin billirubin lin hp (tan trong nc)
Tng billirubin trong nc tiu: vim gan do virus, vng da do
tc mt.
Urobillinogen Bnh thng ch c 1 lng nh (lm cho nc tiu c mu)
(-)
Urobillinogen (-), billirubin (+) vng da do tc mt.
Urobillinogen (+), billirubin (-) vng da do tan mu.
Urubillinogen (+), billirubin (+) vim gan.

Mu Pht hin hng cu, Hb, v myoglobin.
Tiu mu: si thn
Hemoglobin niu: tan mu.
Myoglobin niu: do chn thng dp c.
Nitrite: L ch im ca nhim khun tit niu i vi nhng vi khun
c kh nng chuyn i nitrate thnh nitrite, v d nh E.coli.
Bch cu Gp trong: vim niu o, vim bng quang, vim thn b thn.
Tuy nhin, c 1 s trng hp nhim khun m bch cu niu
li m tnh: vim niu jo do Chlamydia trachomatis, lao, vim
thn k do thuc

Bch cu niu v nitrite niu l 2 ch s quan trng chn on nhim khun
tit niu

120. Cn au qun thn:
Nguyn nhn: tt nghn tng p cp tnh trn ch tt nghn gin ng bi niu.
Gp trong : si niu qun ( common), cc mu ng, hoi t tiu i thn, b thn do
lao hoc bm sinh, chn p bn ngoi nh u tiu khung, x ha sau phc mc, ung th
hch vng tht lng.
Khm cn au qun thn, khm c 9 yu t:
Hon Cng Hng Tnh V Chu, Km Gim Kt
Hon cnh: khi pht t ngt sau lm vic gng sc.
Cng : au mnh, tng dn.

244


Hng lan: au sau lng, lan ra pha trc di ti h chu, mt trong i.
Tnh cht : au qun, vn xon.
V tr : Vung hng sau lng.
Chu k: au thnh tng cn, mi ngy vi ba cn, ngoi cn cn au m vng
hng.
Triu chng km theo: hong ht, lo lng, ko st, c th bun nn, hoc nn, c th
c tiu mu.
Bin php gim au : khng c t th gim au
Kt thc : i tiu s lng nhiu.
- Phn bit:
Bn phi nhm vi :
Cn au qun gan:
au rut tha
Bn tri nhm vi: Cn au tht ngc: nhng trng hp khng in hnh, cn au
tht ngc khng lan ln cnh tay m lan xung bng.Hay ngc li, c cn au qun
thn khng lan xung di m lan ln ngc, vng trc tim.Trng hp ny him
SAU CN AU QUN THN THNG C TIU
NHIU
- Vin si di chuyn xung c nn lng nc tiu b ng do tc nghn s c
chy xung.
- Do tc nghn s nh hng n chc nng ng thn (c chc nng ti hp thu). Khi b
tc nghn, chc nng ng thn s gim i, v th sau khi ht tc nghn, thn gim ta
hp thu, nn lng nc tiu nhiu hn.
VIN SI C VNG RA NGOI HAY KHNG PH
THUC VO NHNG YU T NO?
- Kch thc, hnh dng ca vin si.
- Nhng ch hp trn ng i ca niu qun.
- S c tht ca c vng niu qun.
- C ph n do vim hay khng?
- C nhim trng hay khng?

245


X TR CP CU 1 TRNG HP AU QUN
THN, THUC NO C U TIN? CHO GIN C HAY
KHNG VIM?
- Nhiu sinh vin b hiu nhm l au qun thn l do s co tht niu qun, cho nn u
tin s s dng nhng thuc lm gin c nh paraverin, buscopan...
- Nhng trn thc t, 1 loi thuc cn c u tin hn l thuc khng vim (NSAIDs).
Trong qu trnh vin si di chuyn c vo thnh niu qun s lm cho niu qun ph
n, vim v sng ln lm tc nghn hon ton niu qun, bnh nhn s ln cn au
qun thn. Ta s dng NSAIDs lm cho on niu qun bt ph n, bt vim,
bt sng th tnh trng tc nghn s c gim bt, bnh nhn s bt au.
- Cn loi tr bnh l mch thn trc khi s dung NSAIDs. V c th khi pht suy
thn cp sau khi s dng thuc trn bnh nhn c bnh l mch thn (xem thm phn
Suy thn cp)
- Vic s dng thuc gin c th cn c cn nhc k, v l m vin si nh, c th
c tng ra ngoi m mnh dng gin c th cng lm cho vin si b mc kt.
NSAIDs: Non steroid anti inflammation drugs: Khng vim khng steroid.
IU TR NI KHOA I VI SI THN
Tiu chun theo quy tc ba s 5 (theo GS.Nguyn Bu Triu):
- Kch thc vin si <5 mm.
- Vin si cch bng quang <5cm.
- Vim si tn ti ti 1 v tr trong qu trnh tng khng qu 5 ngy, v sau 5 ngy m
thy vin si khng di chuyn th c th n dnh vo nim mc hoc 1 nguyn
nhn no lm cho vin si khng tng ra ngoi c.
iu tr bng ung nhiu nc, li tiu v mt s thuc lm tan si.
C NN CHO BNH NHN UNG NHIU NC
TNG VIN SI I TRONG CN AU QUNG THN CP?
- au qun thn l do tc cp.
- Khi cha gii quyt c tc nghn th cho bnh nhn ung nhiu nc s cng lm
tng p lc pha trn ch tc, bnh nhn cng au v nguy him.
- Ch cho bnh nhn ung nhiu nc khi gii quyt c ch tc, v iu kin
ch nh iu tr ni khoa tng si.

246


121. Cc im au thn v niu qun:
tm im au niu qun do si. Khi 1 hn si di chuyn t trn thn xung thng thng
c th mt kt 5 im:
- im c ca i thn (Ch ni b thn, niu qun)
- Niu qun bt ngang ng mch chu
- Niu qun bt ngang ng dn tinh
- Niu qun vo lp c ngoi bng quang
- Niu qun vo bng quang,
- Pha trc:
- im niu qun trn:
o Ngang rn gp b ngoi c thng to.
o Tng ng vi im ni b thn niu qun.
- Niu qun gia:
o 2 u on 1/3 gia ni 2 gai chu trc trn.
o Tng ng vi niu qun vt qua ng mch chu.
- Niu qun di:
o Bnh nhn nm nga, thm trc trng: 10h v 2h.
o Bnh nhn nm chng mng: 4h v 8h.
- Pha sau:
o im sn lng:
Giao ca b di xng sn 12 v b ngoi c cnh sng.
au gp trong vim ty cp.
o im sn sng:
Gc xng sn 12 v ct sng.
Ngun: Ni c s - YDH - YHN

247



122. CU BNG QUANG:

Nguyn nhn:
- Do nc tiu bng quang gm cc bnh nh u x tin lit tuyn, ung th tin lit
tuyn hay si bng quang.
Cch khm:
- Nhn: Khi trn vng ln vng h v trn xng mu nh qu cu gi l Cu Bng
Quang.
- S: Khi u trn, cm gic cng, gy tc cho bnh nhn, khng di ng c khi ln tn
rn Phn bit vi u nang bung trng, u t cung.
- G: c hnh trn li ln trn.
- Khi vim th n im trn xng mu au
- Thm trc trng, m o thy c khi trn, nhn .
- Thng tiu: C nc tiu ra xp khi U khng nh chc chn nht.
Phn bit:
- C thai
- U x t cung
- U nang bun trng.

248


PHN BIT B TIU V V NIU.
- B tiu: l tnh trng thn c bi xut nc tiu nhng bnh nhn khng tiu ra c.
- V niu: thn khng bi xut c nc tiu nn bnh nhn khng tiu c.
PHN BIT B TIU CP V B TIU MN:
Ngun: Ni c s YHN Ngai c s YDH

123. Thn to:
- Gp trong thn nc, thn m, thn a nang, ung th thn, thn to b.
- Cch khm:
Gm nhn v s l quan trng nht:
+Nhn:
Bnh nhn ngi lng cn i, quay lng v pha thy thuc.
Quan st hai h lng c th y ln 1 bn hoc 2 bn biu hin thn to.
ng thi, nhn vng bng, v vng tht lng xem c ph n, u hay
khng?
+S: gm 2 t th l t th bnh nhn nm nga v nm nghing:
Nm nga:
B tiu cp B tiu mn.
Hon ton khng tiu c
Trc khi b BTC c th c tiu
kh
au tc tiu d di (tiu hay l
cht)
Cu BQ cp: khi g cng, trn
u, n gy au d di
C th c tiu trn (miction par
regorgement)

Tiu c mt phn nc tiu
Tiu kh hoc khng
au tc tiu t hoc khng au
Cu BQ mn: khi g khng cn
i, mm, n t au.
S: o nc tiu tn d sau khi i
tiu


249


Thy thuc ngi bn phi hay bn tri tu theo khm thn phi hay
thn tri.Hai ngi ngi gn nhau trnh phi gng sc.Ngi bnh
nm yn, th u, mm bng, s lc ngi bnh th ra v khi cc
c mm, d s.Cc phng php s:
Dng mt hay hai bn tay n tht su ra pha sau tm khi u su
cn nh, n nh nh ln pha trn khi khi u to, nng
Dng hai tay, mt tay lun xung pha di, vng h tht lng, mt
tay t trn bng pha i din, hai tay p dn st vo nhau
Trong khi s, ch cm gic au ca ngi bnh v phn ng bng.
- Tm du hiu chm tht lng: dng mt tay t pha sau vng h tht lng, cn bn
tay kia s nh v n ln khi u. Nu thn to s c cm gic chc chc bn tay.Du
hiu ny rt quan trng chn on thn to
- Tm du hiu bp bnh thn: ngi bnh nm nga, chn dui thng, mt tay t
vng h tht lng, mt tay trn bng, vng mn sn. Tay trn yn, tay di
dng ngn tay n v ht mnh ln, ri lm ngc li, tay di yn, dng u ngn
tay trn y xung, lm khi ngi bnh bt u th ra.Cn y nhanh v hi mnh
nu y chm s khng c kt qu.Khi c thn to, tay trn c cm gic nh c cc
chm vo ri mt i
Nm nghing:
Ngi bnh nm nghing, mt chn dui.Mun khm thn bn no th
nm nghing bn i din, thy thuc ngi sau lng.V d mun
khm thn bn phi, ngi bnh nm nghing v bn tri, thy thuc
ngi sau lng, dng tay tri t h tht lng, tay phi t pha
bng.Ngn tr cch xng sn 10 khong 2 khot ngn tay.Khi
ngi bnh ht vo su, thn c y xung, ta s thy thn
Ngi bnh c th nm nghing nh trn nhng nm hi cong cc
c c chng hn, k mt gi vo mn sn pha trn, thm khm
c d hn.Phng php ny rt tt trong trng hp thn thay i
ch hoc thn qu to
Trong cc phng php s nn trn, phng php bp bnh thn
l tt nht khm thn to v n n gin v chnh xc, khi c du thn to
thng khi u l thn to.Tuy nhin c trng hp bp bnh thn khng
c hoc khng chc chn, phng php nm nghing s b sung thm.
Bng cc phong php s trn y, nu c thn to hay sa thn, ta s s
thy. Nu thn khng to, v tr bnh thng khng s thy thn.
Ngun: Ni c s - YDH

250



124. PROTEIN NIU:
- Ngi bnh thng khng c hoc c t protein niu, dng vt.
- K thut thng thng khng xc nh c ngi khe mnh 150- 200mg/24h.
- Tuy nhin,bng min dch phng x, ngi ta xc nh lng ny ch l 20mg/24h.
NGUYN NHN
Ngi ta phn lm 2 loi:
Protein niu thong qua:
L loi protein niu khng xy ra thng xuyn, lng t:
- Protein niu t th gp thanh thiu nin khi ng lu >1h, nm s ht ch khng
nh l protein niu t th khi m protein niu ny bin mt sau khi cho bnh nhn
nm ngh 2 gi.
- Ph n c thai: nht l 3 thng cui km theo tng huyt p v ph th rt c kh nng
b nhim c thai nghn. Tuy nhin, nu protein niu c pht hin ngy t u th
c th b bnh thn t trc.
- Protein Bence Jones: gp trong bnh a U ty xng. Ngi trn 60 tui khng c
hi chng thn h th ch nh tm protein ny. Tuy nhin, Protein ny khng c hiu
trong bnh ny, 10% bnh nhn Macroglobulinrmia( bnh Waldenstrom) cng c
Bence Jonces.
- Gng sc.
- St cao.
- Suy tim phi.
- Nhim trng ng tiu.
Protein niu phn loi theo mc :
- Protein niu thp < 1g/24h:
o Lnh tnh
o Vim thn, b thn.
o Vim thn k.
o Thn a nang.
o X mch thn.
- Trung bnh, 1-3g/24h:
o Bnh cu thn.
- Cao, >3,5g tr ln:
o Hi chng thn h.


251


KT LUN
- Protein niu thp th gp nhng bnh v thn, nh m k hay b thn..., Protein niu
trung bnh th gp bnh cu thn nh vim cu thn cp or mn, hay bnh thn i
tho ng. Protein niu cao gp Hi chng thn h
NHNG PHNG PHP S DNG NH
LNG PROTEIN NIU
- t nc tiu
- S dng acid sulfosalicylic (SSA): c th pht hin c c albumin ln globulins (v
d nh protein Bence jonces)
- S dng que th c tetre bromophenol: ch pht hin ra albumin cn globulin th
khng, cho nn nu s dng que th ny cho bnh nhn b a u ty xng th thng
m tnh.


125. Glucose niu:
C ch:
- Bnh thng nc tiu khng cha glucose bi v thn c kh nng ti hp thu
glucose t dch lc cu thn vo trong mu. Glucose niu dng nh xy ra l do tng
glucose mu, gp trong i tho ng khng iu tr. Him gp hn l do 1 nguyn
nhn ni ti thn khi thn khng c kh nng hp thu glucose, tnh trng ny gi l
glucose niu th thn.
- Glucose niu thng km theo tnh trng mt nc, nguyn nhn l do li tiu thm
thu.
Nguyn nhn : i tho ng, n nhiu ng, ng kinh, ngng ng thn thp, ng
c( CO, As, Morphin), bnh Tabes, U no nhim trng.
Ngun: Wikipedia.

252


128. X-quang thn tit niu khng chun b
bnh thng v bnh l (ASP):
- Tht tho 2 ln, chp phim thng, phim nghing
- Kch thc phim: phi ly ton b ng tit niu, b trn phim xng sn 11,
b di qu b di khp mu.
- Bnh thng:
Thn nm st b ngoi c y chu, hnh qu u,b thn cong u nh ht u, b
ngoi li, b trong lm.
Chiu cao thn(t cc trn- cc di) tng ng chiu cao ca 3 t sng tht
lng. Kch thc thn 3*6*12
- Bnh l:
C si cn quang thn, si niu qun, si bng quang.
Xem bng thn ln.
Pht hin cc tn thng xng(ct sng, xng chu, xng i): long xng, c
xng do ung th di cn(tin lit tuyn, bng quang).
- Ch nh chp khng chun b:
Cn au qun thn.
Suy thn cp tnh.
Suy thn mn tnh.
au bng cha r nguyn nhn.
Chp X-quang thn tit niu khng chun b khc chp bng khng chun b ch l c tht
tho.

130.Chp thn c thuc cn quang qua
ng tnh mch ( IVU: Intravenous
Urography).
- Chun b bnh nhn: tht tho tt nh trong chp ASP
- Phng php: chp 1 phim thng trc, sau tim thuc cn quang tnh mch, p
bng.
- Phng tin: thuc cn quang c iode ho tan trong nc (Telebrix, Visotrax,...),
liu lng 1-2mg/kg; tim TM nhanh

253


- Giai on p: sau khi tim thuc ngi ta chp 1 phim. Sau chp 1 phim 3 pht, 5
pht, nhng phim chm hn mi 15 pht nh gi chc nng bi xut cht cn
quang ca ng thn, khi thn suy, mc lc cu thn gim th s o thi s km i v
s hin hnh cn quang b chm li v m nht.
- Giai on b p: chp ngay quan st 2 niu qun, cui cng chp bng quang.
Gii thch:
- Ngi ta p bng gi cho thuc ng li b thn hin hnh h thng i b
thn. Tuy nhin, nh gi hnh thi i, b thn ngi ta phi so snh vi phim b
p khi nhm hnh nh cn quang i b thn vi gp niu qun do p.
- Giai on b p, thuc bt u chy xung niu qun v bng quang nhiu, khi
quan st s s hn.
Bnh thng:
- Thi gian hin hnh bng thn l 5-6 pht, i v b thn l sau 15 pht ( thng s ch
l tham kho, mi sch c 1 thng s khc nhau).
- Qu thi gian ny chng t c s bt thng ca chc nng bi xut thn.
ngha:
- nh gi chc nng bi xut ca nc tiu. Nu thn hin hnh chm, chng t
chc nng bi xut nc tiu ca thn km. Thn hon ton khng hin hnh ngi ta
gi l thn cm.
- nh gi hnh thi h tit niu t thn cho n bng quang, gip pht hin:
Thn sa, thn nh, thn nc, m, si thn, cc d tt bm sinh, bt
thng niu qung, bng quang.
Chng ch nh:
Tin s d ng thuc cn quang.
Suy thn nng.
ang c tnh trng mt nc, gim th tch.
Tng huyt p c tnh.
Hai thn nc nhiu. Trong trng hp ny khng nn tin hnh chp thn c p v
c th gy v thn.
Mang thai.
( 2 chng ch nh u thng c hi thi, 4 chng ch nh sau tham kho t bnh hc thn sau i
hc YDH)
Lu :
- Khi thn suy 4, khng nn chp UIV, v s khng c hiu qu, hn na, thuc
khng o thi c qua thn s gy c hi t chc( Iod).
- Cht cn quang ng thi cng gy c thmcho thn.

254


133. in gii bnh l:
Ch cp n 4 ri lon chnh: tng Na mu, gim Na mu, tng K mu, gim K mu:
A.Gim Na mu:
- Nng Na mu <135m
- Hi chng H Na mu gi:
o Tng lipid mu
o Tng protein mu.
o Tng glucose mu ( lm tng osmol huyt tng ht nc t ni bo ha long Na)
- Nu nghi ng bnh nhn b h Na mu, ta cn phi xc nh ln lt nh sau:
Th tch ngoi bo:
o Tng :
Suy timxung huyt
Hi chng thn h
X gan
Suy thn
nhng tnh trng ny lmgim lng huyt tng trong lng mch Tng ADH thn
tng ti hp thu nc
o Gim:
Li tiu
Mt qua da ( ra m hi, bng..)
Mt qua tiu ha: nn, a chy.
Bnh thn mt Na.
Bnh Addison
T nhng tnh trng ny, bnh nhn ung nc nhc trng vo v gy ra h Na mu.
o Bnh thng:
Tiu nhiu do thn kinh
Nhc nng gip
SIADH ( xem di).

Hi chng SIADH ( syndrome of inapropriate secretion of ADH, tit ADH nhiu, khng thch hp)
o L tnh trng c s tng khng thch hp ca p xut thm thu ca nc tiu ( >100mOsm/L) trong
tnh trng p xut thm thp ca mu li thp.
o Trn lmsng, th tch huyt tng bnh thng.
o Gim Osmol ngoi bo ( khong k v ni mch)
o Thn, tuyn yn, tim, gan bnh thng c, khng thy bnh l.
B. tng Na mu:
- Khi Na >140.
- Nguyn nhn:
o Mt nc ngoi thn, nhng bnh nhn khng b dch nhc trng ( ung nc) : mt qua da, m hi,
bng, st, tp th dc hoc nhim khun ng h hp.
o Mt qua tiu ha: Tiu chy osmol: V d nh bnh nhn tiu chy do thiu lactase, lactose gi trong
lng mch ko nc. Hoc bnh nhn b km hp thu tng osmol trong ng tiu ha mt nc.
Hoc 1 s dng nhim khun.
o ng kinh v dp c lm cho t bo tng hp thu nc nn cng gy ra tng Na mu.
o Mt nc qua thn: Bnh i tho nht thn hoc trung ng.
o Li tiu thm thu: Keton mu trong i ng, hn m do tng osmol trong i ng type 2, li tiu
manitol...

255


- Triu chng: Ch yu l cc triu chng v thn kinh: ng lm, mt mi, nga ngy, d kch ng, ng kinh,
hn m. i tho nht th c thmtriu chng i nhiu na.
C. H K mu:
Nguyn nhn:
- n thiu K.
- K i vo t bo qu nhiu:
o Kim mu: H+ t t bo i ra v thay vo K+ i vo t bo.
o Tng insulin tng K+ i vo t bo vi glucose.
o Hot ng giao cm
o Thiu B12.
- Mt qua tiu ha: nn ma, i ng, ht dch d dy.
- Mt qua thn:
o Hi chng cng Aldosterol nguyn pht ( Conn) lm tng ti hp thu Na ng xa v ng gp
thay vo l tng o thi K.
o Li tiu.
o Keton niu.
o Hi chng Cushing ( cortisol~ aldosterol)
o Hi chng Bartter:
Thn mt kh nng ti hp thu Na, Cl quai Henle, t lm tng osmol nc tiu tng
lng nc tiu gim V mu thn tit renin tng aldosterol ti hp thu Na o
thi K.
Triu chng:
Thng xy ra khi K <2,5-3 mEq/l.
Yu c, lit c, ri lon nhp tim, sng U trn ECG, sng T phng, tiu ra
myoglobin, i tho nht.
D. Tng K mu:
Nguyn nhn:
- Ung nhiu, truyn nhiu K( thng kmtheo gim bi tit th K mi tng ln).
- K t ni bo ra ngoi bo
o Gi tng K mu: Th pht sau tan mu, hay nhng chn thng trong chc tnh mch ( chng hiu, c
th do tan mu nn K thot ra ngoi nhiu hn, v hng cu cha rt nhiu K)
o Nhim Acid mu : Ngc li nh ni trn, H+ i vo t bo, K+ i ra.
o Gim Insulin: cng ngc li vi trn.
o Phn hy m : dp c, dng thuc tan khi u, ng kinh, tp th dc nng.
o Lit chu k: tng nh K (<5,5), chn on bng nhng cn lit chu k v tin s.
- Gim s bi tit t thn:
o Suy thn.
o Gim aldosterol: thuc c ch men chuyn, heparin( cht ny lmgim sn xut aldosterol)
o Nhc nng thng thn ( Addison)
o Li tiu gi K : triamterene, amiloride, spironolactone.
Triu chng:
- Yu c bt u khi K >6,5.
- S dn truyn in th trong tim b ri lon, thng s dn n ri lon nhp tim v....DEAD.
- Gim thng kh ph nang.


256


KT LUN HAY
Glucose thng vo t bo cng vi K+, nn:
- Nu c nhiu insulin, glucose s ko K+vo nhiu hn, cho nn s gim K+mu.
- Nu thiu insulin, th K+s li ngoi bo, dn n tnh trng tng K+.
- iu tr tng K+ mu, ngoi vic truyn Ca2+ chng lon nhp, ta thng
truyn thm glucose v insulin ko K+vo t bo.
- D nhin trong trng hp ny, chng ta mi ch lm gim K+mu, ch vn cha
a c K+ ra ngoi c th, sau chng ta cn s dng cc thuc c th a
K+ ra ngoi c th nh CaCl.

136. HI CHNG TNG URE MU:
Lm sng:
6 triu chng: Thn Kinh Tiu ha H hp Tim mch Huyt hc Thn nhit.
Thn kinh:
- Nh:
o Mt mi, nhc u, hoa mt, chng mt, mt ng, rui bay.
- Va:
o L m, ni m, vt v.
- Nng:
o Hn m, co git ( ph no), ng t co, phn ng nh sng km.
o Khng c thn kinh khu tr,
o Khng c mng no.
Tiu ha:
- Nh:
o n mt ngon, y bng, chng hi.
- Nng hn:
o Bun nn, nn ma, li en.
o Ming hng l lot, mng gi xm mu.
o a chy


257


H hp:
- Th hi mi amoniac.
- Kussmaul hay l Cheyne Stokes.
- Ting c mng phi, ting c mng ngoi tim( do N2 thot ra khi mch mu vo
trong mng).
Tim mch:
- Mch nhanh, nh, tng huyt p.
- Giai on cui ca suy thn th c th gy try mch.
- C th c vim mng ngoi tim, trn dch, trn mu mng ngoi tim (do cc azot
nng cao trong mu thm vo khoang mng ngoi tim khi pht qu trnh vim v
khun ). Khi lc mng bng l ch nh c u tin la chn hn so vi chy
thn nhn to mc d hiu sut lc ca n khng bng chy thn. V trong chy thn
nhn to, bnh nhn phi dng Heparin chng ng. Khi c vim mng ngoi
tim, trn dch mng ngoi tim nu vn s dng chng ng th c nguy c trn mu
mng ngoi tim. Lm trm trng thm bnh cnh lm sng.
Huyt hc:
- Nit thot ra ngoi thnh mch vo cc t chc, ko theo hng cu v huyt tng
cng ra:
o Vng mc th gy vim vng mc v chy mu vng mc
o Chy mu di da v nim mc.
o Chy mu tiu ha: i cu phn en.
o Chy mu mng no, mng ngoi tim.
- Thiu mu thng gp nhng bnh nhn tng Ure mu, nng nh ty giai on, suy
thn cng nng, thiu mu cng nng.
Thn nhit:
- Thn nhit gim.
- Triu chng xy ra sm nht l tiu ha v thn kinh, cc triu chng khc c th c
hoc khng c. Trong ting c mng ngoi tim c coi l ting gi bo t, tin
lng bnh nng.
Trn cn lm sng:
o Ure v cre mu tng.
o D tr kim gim:
Do hin tng acid mu
( 1 s acid nh phosphoric, sulfuric sinh ra t chuyn ha protit b
li)
Bnh thng c th to nhiu NH3 trung ha acid, cc cht kim
c nh Na s c gi li trong c th, cn cc base v NH3 s
trung ha cc cht thi ra. Trong suy thn, NH4OH sn xut ra

258


khng y . Cc cht kim c nh Na s thy ch cho NH3 v vy
gy acid mu.
o Ri lon cc cht in gii:
PO4 tng
Ca gim. ( 2 ci trn ny l do gim Vit D)
K tng.
Na, Cl gim.
CC NGUYN NHN GY THIU MU TRONG SUY
THN
o Gim s sn xut ca Erythropoietin.
o c ch gy suy ty mt cch trc tip do tnh c ca urea.
o Gim i sng ca hng cu.
o Tng s mt mu.
o Thiu st v thiu folate.
o Gy s khng vi erythropoietin.
( Nguyn nhn 1, 2, 3,4 thng c hi thi)

TNG UREA MU V NHP TH CHEYNES-
STOKES
Nhp th Kussmaul l do s nhim acid mu, nhp th Cheyne- Stokes do tn thng trung
tm h hp (tin lng nng).
C 2 yu t khi pht cho nhp th ny:
- S kit qu ca trung tm h hp sau 1 thi gian kh th ko di.
- S thiu O2 ti trung tm h hp do suy tun hon
PHN BIT SUY THN CP V T CP CA SUY
THN MN:
-Tnh cht mn tnh ca suy thn mn c 3 tiu chun:
Tiu chun tin s: tin s bnh thn, nh lng c tng Cre truc y.

259


Tiu chun hnh thi: Kch thc thn gim < 10 cm trn siu m hoc <
3t sng trn phim chp bng khng chun b.
Tiu chun sinh ha hc:
- Thiu mu ng sc hng cu bnh thng.
H Calci mu do thiu Vit D hot tnh ( Calcitriol).
Tuy nhin vn c ngoi l
Suy thn mn c thn ln:
Thn nc c 2 bn.
Thn a nang.
i tho ng.
Amylose.
Suy thn mn khng c h Calci mu:
Myelome.
Sarcoidose.
Suy thn cp nhng li c h Calci mu:
Hy c vn.
Hi chng hy khi u.
Suy thn cp nhng li c thiu mu:
Hi chng tan mu ( suy thn cp do Hemoglobin)
Shock chy mu.
PHNG TRNH COCKROFT GAULT V PHNG
TRNH MDRD (Modification of diet in Renal Disease study)
NH GI THANH THI CREATININ TRONG SUY THN
MN
- Phng trnh Cockroft Gault:



260


Bnh nhn ph, khng s dng phng
trnh Cockroft Gault c tnh tc
lc cu thn c v khi lng bnh nhn
s tng ln
- Phng trnh MDRD:

Theo cc ti liu cho thy phng trnh MDRD c ly t 1 nghin cu v vic iu chnh
ch n nhng bnh nhn b bnh thn ( Modification of diet in Renal Disease study)
c cho l ch s ng tin cy hn c lng tc lc cu thn bnh nhn suy thn
mn.
- Tht vy, theo v d thy c a ra, trong
phng trnh Cockroft Gault c tnh thanh thi
Creatinin da vo Creatinin huyt tng c s dng
thng s l khi lng ca bnh nhn, iu ny c v
khng khch quan trong bnh nhn b suy thn mn,
bi l nu nh h b ph th cn nng ca h tng ln,
v khi ht ph th cn nng ca h gim xung. Nh
vy nu bnh nhn b ph th thanh thi creatinin s
tng cn ngc li th thanh thi s gim.
- Li khuyn t thy c: Trong cc bnh n thng thng, chng ta c th s dng
phng trnh Cockroft Gault c lng thanh thi creatinin. Cn trong cc
bui trnh bnh, bo co khoa hc nn s dng phng trnh MDRD c lng tc
lc cu thn.
Ngun: Ni c s YDH, bnh hc ni sau i hc YDH,, sinh l bnh YDH.

137. HI CHNG THN H (phn ny l 1
ch ln, cc bn c sch ni bnh l)
PHN BIT HI CHNG THN H N THUN V
PHI HP.
HCTH n thun HCTH phi hp
Thng xy ra ngi tr Xy ra ngi ln
Tng HA (-) Tng HA (+)
Gim chc nng thn (-) Gim chc nng thn (+)
iu tr p ng tt vi corticoid p ng chm hay khng p ng
Sinh thit thn: tn thng ti thiu Tn thng mng y v t bo c chn
in di protein: chn lc Khng chn lc

261


BNH NHN B HI CHNG THN H NHNG C
PROTEIN NIU <3.5g/24h?
- Bnh nhn b suy thn
NHNG THNG S CN THEO DI BNH NHN
B HI CHNG THN H
- Tnh trng ph.
- Lng nc tiu.
- Cn nng.
- Tc dng ph ca thuc.



262







263






CHNG VII

C XNG
KHP


264




265


Lu : triu chng au trong cc bnh v C- Xng- Khp
1. Phn nh r ngun gc t u? (C, xng, m mm khc)
2. Khai thc theo trnh t trnh b st : SOCRATES (8)
[S]ite V tr (s lng, i xng ?)
[O]nset Khi pht: (t ngt, t t)
[C]haracter Tnh cht
[R]adiation Hng lan
[A]ssociations Triu chng km theo
[T]iming/duration Tn sut (ko di, chu k)
[E]xacerbation or alleviation Yu t lm tng hay lm gim
[S]everity Cng (theo thang 1-10)


138. AU C:
- Trc tin cn xc nh ng l au c (d nhm vi au xng, gn, dy chng,
khp)
- Bnh l ca c thng t gy au c, thng do vim c
- Nguyn nhn:
o au khu tr ( vim c)
o au lan to ( kh xc nh, gp trong mt s bnh ton thn (Lupus, vim a
c, hoc bnh thn kinh)
o Nhim khun: ( do virus coxackie,CMV..;vi khun- ph cu, Mycoplasma,
k sinh trng- sn mang,)
o Chn thng: rch, dp nt c
o Thuc, ru (statins, zidovudine)

139. CHUT RT
- L s co cng khng ch ng mt c hoc mt nhm c, khi pht t
ngt, cm gic rt au , to t th c nh chi cha c
- Lu y khng phi l triu chng bnh c
Thng xut hin ban m (t th c nh lu), khi lnh t ngt, khi
gng sc, trong thai k hoc xut hin t nhin

266


Do mt nc, mt in gii(gim Ca++, gim K+, gim Mg++), ri
lon thn kinh c, thuc (li tiu, (-) Ca++, an thn )
Cc ri lon in gii c th gy ra chut rt hay tetany ca c,
c bit l h canxi mu hoc h kali mu (v d: ra m hi qu nhiu
m khng c b p, bnh nhn suy thn mn).
ph n, s hnh kinh cng gy ra chut rt (hay gp ban m)
mc nht nh ti vng bng gy au lan ta ra tht lng v i. L
do l mu phi chy qua c t cung nhiu hn.
c bit lu nu bnh nhn c triu chng nh chut rt, co rt
bn tay, bn chn km theo du Chvostek (+) (g vo dy tk Mt v
tr trc di di tai thy mi bn nhch v pha g) =>ngh n H
Canxi mu => phng ng kinh, lon nhp tim
Chvostek (+)
(Professional guide to sign and symptoms 5
th
edition)

140. CO RT C
- nh ngha: L tnh trng si c gim v c kch thc v chiu di, lm gim sc
co c, hn ch vn ng, bin dng chi.
- Nguyn nhn:
Tn thng thn kinh (t, chn p): thng khu tr tng vng.
Khng s dng c trong thi gian di (bnh xng khp, bnh l phi nm
di ngy, ngi gi)
Bnh l (lon dng c): teo c ng u v i xng
- Gii hn vn ng thng km theo teo c, bin dng khp vnh vin.
V d: tn thng c cng chn sau lm bn chn lun dui bn chn
nga

267



141.AU XNG
Tnh cht:
au su
Lan dc chiu di ca xng
au tng khi hot ng hoc nn bp vo xng.
Bnh xng
Vim xng, u xng => khu tr
Long xng => au lan to nhiu ni nht l ct sng, cnh chu
Bnh khc
Cc bnh mu (l-x-mi cp, a u tu xng, bnh huyt sc t, thiu mu
huyt tn) : thng au nhiu xng di v ct sng.
Ung th ni tng (ung th ph qun gy h/c thp khp, h/c cn u)

142. LONG XNG (osteoporosis)
- nh ngha: l mt tnh trng c trng bi s suy gim mt ca xng, gim s rn
chc ca n v kt qu l xng d gy.
- Triu chng lm sng rt m thm v ch bt u khi c gy/bin dng xng
Gy d gy v kh lin xng: xng chi trn, xng chu, gt chn, bn chn
(khi i cu thang)..
Bin dng, xp, gy t sng ( cc t sng tht lng)
- Chn on:
o chiu cao gim so snh vi thi gian trc ( + nu mt > 3cm)
X- Quang pht hin tng thu quang, xp t sng.
- S rn chc ca xng trong c th ty thuc vo:
. Yu t di truyn (60-80%)
. Lng kch thich t trong c th, (oestrogen n v testosterone nam)
. Hot ng, vn ng thng xuyn

268


. Thc n hng ngy


Gim thu quang
Bm cht cement vo phc hi t sng b
xp
Xp t sng

Chp DXA (Enegy X-ray Absorptiometry) o BMD (Bone Mineral Density)
c khong xng
- Nguyn nhn:
+Nguyn pht:
- c tnh di truyn ty theo dn tc
- Oestrogen thp: dy th mun, mn kinh sm, kinh nguyt tht thng.
- Testosteron thp
+Th pht:
- Ch sinh hot, ngh nghip: n t cht cha Canxi (sa, daua, phoma ..)
v vitD, t tip xc nh sng mt tri.
- Bt ng lu, ngh nghip, ri lon ni tit (cng gip, cng tuyn sinh
dc v thng thn, bnh to u chi)
- Bnh thn: do thi nhiu Ca, chy thn nhn to
- Thuc: steroid, heparin

143. AU KHP:
- Triu chng c nng thng gp nht trong bnh l v C Xng Khp.
- Thm Khm: + Kim tra theo trnh t SOCRATES ( ch gii phn u)
1. SITE (V tr) mt s v tr c gi tr chn on:

269


au chn ngn ci (Goute),
Cc khp nh hai bn tay (vimkhp dng thp),
Khp vng chu (vimct sng dnh khp), cc khp ln nh khp ct sng,
khp hng (lao xng khp),
Khp gi (thoi ha khp, chn thng sn chm., dy chng, vim khp do lu
cu)
* Cn phn bit vi au vng khng phi khp (gn, bao gn, dy chng, au c,
xng, au do thn kinh)
V d: au vng chu c th do: au khp hng, vim c y chu,hoc do tn
thng mch i
2. ONSET (Khi pht)
Vim khp do tinh th (gout v gi gout) thng xut hin cp tnh, au tin trin
nhanh chng v thng km theo sng khp b nh hng.
Vim khp nhim trng: cn au thng khi pht v tin trin trong vng 1-2 ngy..
c bit trong vim khp do vi khun sinh m (nh t cu,..), khp rt au.
au tng cn xy ra trong 1-2 ngy mt hay nhiu khp thng c gi l thp
khp ti pht.
3. CHARACTER (Tnh cht)
Phn bit vi cm gic nhc mi cc khp trong cc bnh ton thn (cm, st, ri
lon thn kinh chc nng, ung th, thiu mu..)
C nh hay tng t?
i xng hai bn, lin quan n vn ng, thi tit khng?
4. RADIATION (Hng lan)
+ au ct sng:
- au cc on sng c khc nhau, thng gp nht l vng lng, hoc tht
lng
- Thng l au c gii
- Hng lan: l hu qu ca kch thch r thn kinh
au ct sng c: lan ln u, vai, c th xung cnh tay (do m ri
thn kinh cnh tay chi phi)
au ct sng tht lng: lan vng ra pha trc theo cc dy thn kinh
lin sn, au kiu co tht
Hi chng kch thch r thn kinh: au tng ln khi ho,rn mnh, ht
hi (do tng p lc ni tu)


270


+ au khp hng:
au vng bn hoc mng
Lan ra mt trc hoc mt sau ngoi ca i, c th xung khp gi
(d nhm vi au khp gi)
+ au khp gi:
Thng gp au mt trong
Lan xung cng chn
+ au khp vai:
Kh xc nh v tr: trc hoc mt sau, mm vai
Lan ln c hoc xung cnh tay
5. ASSOCIATION (Lin quan km theo)
Hi cc tin s v cc bnh khp hoc cc bnh ton thn.
Biu hin ton thn: St, suy sp, gy st, cc tnh trng nhim khun v.v..
Khm cc du hiu km theo nh sng khp, bin dng khp, trn dch khp,
gii hn vn ng v.v...
Du cng khp bui sng: kh vn ng khi mi ng dy, sau th
thy khp mm tr li d vn ng hn . Khi thi gian ko di (>1
gi) => Vim khp dng thp
Du ph r khp: khi mi dy thng thy khp (ct sng, gi) kh
vn ng. Sau vi ng tc khi ng th du hiu ny mt i => hay
gp trong Thoi ha khp
6. TIMING (Thi gian, din bin):
* Din bin:
Di chuyn: vim t khp ny sang khp khc, trong khi khp c khi hon ton
(thp khp cp)
Tin trin: tng dn ti mt khp, tin sang khp khc khp c vn cn au (cc
bnh khp mn tnh)
C nh: Tn thng ch c nh ti mt khp v nng dn ln (lao khp, thp khp,
d dng khp..)
Ti pht: xut hin tng t, ko di mt thi gian ri khi, sau ti pht (thp
khp cp, goute cp tnh, chy mu khp do bnh Hemophillia, bnh Scholien-
Henoch)


271


PHN BIT 1 S DNG AU KHP.

(A)Vim khp dng thp (i xng, c khp ln ln khp nh, chi trn v chi di). (B)Vim khp do bnh
vy nn (khng i xng, thng gp nhng khp ln nhiu hn nhng khp nh, v c vim khu vc
quanh khp gy ra vim ngn (C) Vim ct sng (cc khp trc, khp ln nhiu hn khp nh, khng i
xng). (D) Vim xng khp ( i xng, c khp ln ln khp nh).
7. EXACERBATION (Yu t lm tng)
Phn lm 2 loi:
au do vim (thp khp, vim m, vim lao..) au lin tc, c xu hng tng
nhiu v m, km theo cc du hiu nh sng, nng, .
au c tnh cht c gii (thoi ha, d dng): au tng khi vn ng , lao ng,
gim v ht khi ngh ngi.

8. SEVERITY (Mc )

272


- nh gi theo thang nhn (10 ) do bnh nhn t nh gi


- nh gi bng dng c t nn vo khp (ch s Ritchie)
Dng que u trn t vo b din khp
0: khng au
1: c au
2: au + nhn mt
3: au + nhn mt + ng tc chng i
Thng p dng cho b/n vim khp dng thp
- Ngoi ra c th nh gi au theo s ln dy trong m, s thuc gim au
s dng, mc nh hng n cc ng tc trong sinh hot










273


CC NGUYN NHN GY AU KHP

TON TH
Nhim khun Virus: Rubella, quai b, vim gan B.
Vi khun: staphylococci, lao, Borrelia
Nm
Sau nhim khun Thp khp cp, vim khp do phn ng (hi chng Reuter ).
Vim Vim khp dng thp, lupus ban h thng, vim ct sng dnh
khp, bnh x cng b.
Thoi ha Vim xng khp.
Khi u Tin pht: u xng (osteosarcoma), u sn (chondrosarcoma)
Di cn: t phi, v, tin lit tuyn.
nh hng ca cc khi u khc: bnh xng khp ph i.
S hnh thnh cc
tinh th
Gout, gi gout
Nguyn nhn khc Chn thng
Hi chng au x c (Fibromyalgia syndrome)
Hi chng Sjgren (bnh t min ca cc tuyn ngoi tit: gm
kh nim mc (ming, mt, mi, da, m o..) + vim khp
Hi chng qu di ng
KHU TR
Vim gn Vim gn achille
Vim ti thanh
mc
Vim ti thanh mc mu chuyn
Chn p thn kinh Hi chng ng c tay
7. SNG KHP DO VIM:
* Khi pht hin triu chng sng khp cn a ra nhng nhn nh sau y:
V tr v s lng
- V tr: mt hay nhiu khp, cc khp nh ngoi bin hay cc khp ln gc chi, ct sng
th nhng on no? i xng hay khng i xng.y l mt d kin kh quan trng
gp phn nh hng nguyn nhn.
- S lng:
-

274


Phn loi
Tnh cht
i xng
Nguyn nhn Triu chng km theo
Mt khp Vim khp do
nhim trng
St, mt mi,kh chu, cc nhim trng khc
c th da, hng, ng tiu ho.
Gout Cc Tophi, cc triu chng ca suy thn nu c
Vim xng khp
Mt s khp (2-4
khp)
Khng i
xng
Hi chng Reiter Vim niu o, lot ming hoc c quan sinh
dc, Vim kt mc, vim mng mt, cc biu
hin khc nh bnh l dy chng gt/vim mc
gan bn chn., ban
Vimct sng dnh
khp

Bnh vy nn Vy nn trn da, lm mng
Vim xng khp
Nhiu khp i xng Vim khp dng
thp
Hin tng Raynauds, cc ht thp khp di
da, vim thng cng mc,kh mt, vim mng
phi
Lupus h thng
hoc lupus ban
Hin tng Raynauds, ban dng cnh bm,
rng lng tc, st, vim thng cng mc
Vim xng khp
Tnh cht sng:
- C sng u, cn xng hay khng?
Khng u (ch sng nhiu li ra khc thng, c ch sng t) : bnh
thoi khp hoc gout
Sng u c hai bn khin cho ngn tay c hnh dng ging hnh thoi :
vim khp dng thp
- Triu chng vim km theo:nng, , au gp trong sng khp do vim
- Kh thy cc khp su nh khp hng, khp vai
- Rt r cc khp nng nh khp gi
Thng sng v tr trn khp v l v tr ca ti cng hot dch ca c t u
i
Thng km theo du hiu vim: nng, , au
T chc xung quanh khp c ph n, ti v bao hot dch c th b vim,
C khi c dch trong khp (trn dch khp)
- Phn bit vi sng khp khng do vim:

275


Thng thay i do cc u xng, sn khp, bao khp... (ch yu l mc thm
xng trong thoi khp, lon sn xng, sn; di chng chn thng, ri lon
chuyn ha.,khi u....)
Thng khng c biu hin vim.

146. TRN DCH KHP GI
Tng s lng dch trong khp do s tng tit ca mng hot dch (gp trong
vim), trn mu do xut huyt ...(cc bnh v mu nh Hemophillia)
Pht hin bng du bp bnh xng bnh ch (patella tap)
Cch lm: nhm y dch trn pha c t u i v tp trung di xng bnh
ch, sau n nh vo xng bnh ch lm dch b p qua 2 bn, qua cm
nhn lng dch nhiu hay t
o Bnh nhn nm nga, hai chn dui
o Dng 1 tay p v trt t pha trn i v xng bnh ch v duy tr p
lc vo pha trong. Dng ngn tr v gia ca tay cn li nh ln
x.bnh ch.
Dng tnh khi thy cm gic sng nc p kh v hai bn +
xng bnh ch chm vo u di xng i ri ny li
o Khi lng dch nhiu khng thy du hiu ny

Ti liu: Bate guide to physical examination chapter 15.
GII HN C NG DO KHP

276


- Quan trng trong nh gi chc nng vn ng ca khp
- Bnh nhn khng t lm c mt s ng tc ca khp v ct sng do au (vimkhp),
dnh khp, tn thng thn kinh, c xng .
Ct sng vng c : gii hn mt s hot ng c gi tr chn on:
ng tc : ci, nga, nghing thng do tn thng t t sng C3 tr
xung
ng tc xoay : tn thng t sng c 1,2
Vng ngc: nh gi s hn ch vn ng bng gin lng ngc (bnh thng
4-6cm)
Vng tht lng : nh gi bng hai nghim php : Nghim php ngn chn chm
t, nghim php gin tht lng.
Khp hng : hn ch ng tc ngi xm, dng i, ln xung xe p..
Khp gi: kh khn trong ng tc gp dui (i ng), ngi, leo cu thang..
Khp vai: Gi lng, gi tay, chi u..
- Phn gii hn hot ng do thp khp:
1: Kh nng hot ng bnh thng
2: C th thc hin cc hot ng thng thng, nhng c cm gic khng thoi
mi hoc hn ch mt hay nhiu khp
3: Ch lm c mt t cc hot ng ngh nghip hoc t chm sc
4: Hon ton hoc gn nh hon ton khng c kh nng lm bt c hot ng
no.
Ngun: Clinical examination: A systematic guide to physical diagnosis

147. LNG LO KHP
Bin hot ng ca khp v ct sng ln hn bnh thng
Nguyn nhn
o Sinh l do tp luyn
o Bnh l khp mn tnh lm dn dy chng, bao khp (vimkhp dng thp)
o Bnh l thn kinh (hi chng tiu no, giang mai,...)
o Bnh l ton thn ( Ehlers-Danlos)
nh gi bng nghim php : du rt ngn ko, du lachman, du lc lc khp
1.Du rt ngn ko:

277


Bnh nhn nm nga, gi gp 60
Bc s ngi c nh bn chn ca b/n
2 tay nm ly phn trn xng cng chn t t ko ra v y vo
ko c nhiu => t dc. Cho trc
y c nhiu => t dc. Cho sau
(du ngn ko +)
o Lu : lun phi so snh 2 bn mi

2. Du Lachman
kim tra t dc. Cho trc
- Bn nm nga, chn gp khon 20-30
Bc s dng 1 tay gi c nh i, tay cn li ko phn trn cng chn
v pha trc
Ko ra thy khng li t ngt chng t dc cn nguyn vn
Khi khng cn cm thy cng chn b khng li r rng =>t dc.
Cho trc (nghim php (+))


278


3. Lc lc khp gi
Bn nm nga, chn dui
Bc s dung mt tay nm pha trong phn di i, cn mt tay nm pha
ngoi phn trn cng chn
Nh nhng y cng chn vo trong v ra ngoi.
Nu khng cm gic dng li r khi =>tn thng dc. Bn pha i din
vi tay y

Hnh: kim tra vi t th dui hon ton, v gp nh 30

148. CC IM AU KHP
- Ct sng:
n im au c gi tr chn on v tr tn thng
Khm t th nm sp, n vo cc gai sau ct sng hoc phng php g dn t xa
(t trn nh u xung vi u hi nga)
- Khp hng:
Ch yu au vng bn (1/3 ngoi, di cung i) : lan xung mt trc i, tng
ng vi u xng i
im mu chuyn ln: thng do chn thng trc tip
im c xng i (nm pha trn mu chuyn ln)
Dng phng php g dn t xa vo u di xng i t th gp gi.
- Khp gi (n im au c gi tr chn on)

279


au hai bn khp: tn thng dy chng bn, sn chm
Vng bm tn ca mt s gn c: li cu trong xng
i, phn trc u trn xng chy
Ngay chnh gia khp (v tr xng bnh ch): nhuyn
sn x. Bnh ch, vim khp, vim mng hot dch
Pha sau: vim khp, nang Baker (nang tp trung hot
dch hnh thnh sau khp gi)
- Khp vai:
im mt trc khp b cnh tay
im khp qu n
im khp c n



149. TING LC CC KHI DUI (Ting lo
xo)
C th nghe hoc s thy c do mt khp hoc t chc cnh khp b th rp trt
ln nhau
Hay gp trong thoi ho khp gi
Nhng vn c th thy khp bnh thng => t gi tr chn on

150. TEO C DO BNH KHP
Cc bnh khp mn tnh l hn ch vn ng u c th dn n teo c vng quanh
khp
bnh khp c tnh trng vim xy ra th qu trnh teo c cng nhanh.
Thm khm bng quan st, ch nhng vng c ni r (c Delta, c vng mng,..) :
khi teo cc c vng u b xp xung
Tt nht dng thc o hai bn, so snh vi ngi lnh.



280






281


PH LC 1 : CC VN LIN QUAN.


I .Cc phn loi trong tim mch:

1.TIMI: lu thng dng chy / chp ng mch vnh
0: Khng c cht cn quang.
1: C t cht cn quang, sau ch tc khng c cht cn quang phn xa.
2: C cht cn quang phn xa.
3: Dng chy lu thng bnh thng.
2.Ngoi tm thu tht :
0: Khng c.
1: Thu < 30 ci/gi, m trong 1 pht hay 5 pht.
2: Dy >=30 ci/gi
3: a dng : trn cng mt chuyn o, ngoi tm thu c hnh dng khc
nhau.
4A: Chm 2
B: Chm 3
5: R/T.
3.KI LLI P ( suy tim cp / nhi mu c tim )
I: Kh th
II: Kh th, T3, ran m 1/3 ph trng.
III: Kh th, hen tim, ph phi cp.
IV: Shock tim-shock do nguyn nhn ti tim ( HATThu < 90 mmHg,
thiu niu, v m hi, vt v..).
4.Vanghan William : thuc chng lon nhp
I: c ch knh Natri
A : Quinidine
B : Lidocain
C : Flecain dng trong hi chng Brugada.
II: c ch beta.
III: Ko di thi k tr.
IV: c ch Canxi.
5.Phn suy tim chu u:
A : C yu t nguy c nhng cha c biu hin lm sng suy tim.
B : C tn thng ti tim nhng cha c biu hin lm sng ca suy tim.
C : C tn thng ti tim, c biu hin lm sang ca suy tim.
D : Suy tim cn liu php ( phng thc h tr )
CTR : ti ng b tim.

282


ICD : my ph rung cy.
6.Hp van hai l
a.Trn siu m:
Bnh thng din tch van hai l : 4-6 cm
Hp nh > 2,5 cm.
Hp va 1,5-2,5 cm
Hp kht 1-1,5 cm
Hp rt kht < 1cm
b.Lmsng :
I: Hp nhng cha c triu chng lm sng.
II: Hp c hi chng gng sc.
III: Hp, suy tim phi cn p ng iu tr.
IV: Hp, suy tim phi khng p ng vi iu tr ni khoa.
7.Hp van ng mch ch ( trn siu m) :
Bnh thng din tch van ng mch ch 2-4 cm
Hp nh 1,2-2 cm
Hp va 0,7-1,2 cm
Hp kht <0,7 cm
8.au tht ngc n nh ( theo hi tim mch Canada ):
I : au tht ngc khi gng sc mnh.
II: au tht ngc khi i b > 2 dy nh, >2 tng.
III: au tht ngc khi i b < 2 dy nh, <2 tng.
IV: au tht ngc khi lam vic nh.










283


PH LC 2: 1 S HI CHNG C
CP TRONG TP TI LI U NY
I I .Hi chng Schlein Hench: bnh t min, thng gp ngi tr. C hai
th:

1.Th Schlein c cc ban xut huyt tay chn dng mang giy ng v
gng tay.
2.Th Hench ban xut huyt rut non l ch yu, mt s t d dy,
i trng.
Bnh nhn c st, nhim trng, au bng, a phn mu thng ti hay
bm, tiu mu vi th hay i th.

I I I .Hi chng Reuter (vim khp phn ng ):
Vim niu o, lot ming hoc c quan sinh dc, vim kt mc, vim
mng mt, cc biu hin khc nh bnh l dy chng gt, vim mc gan bn
chn, ban Thng gp tr em hn ngi ln, th pht sau mt s bnh
nhim trng nh: si, thng hnC ch bnh sinh nghing v thuyt t
min. Cc virus, vi khun gy bnh khi pht mt qu trnh p ng min dch
mnh v sai lc. C th sn xut cc khng th chng li tc nhn gy bnh,
trong c nhng khng th c cu trc tng hp vi cc t bo ca cc c
quan, chng tr thnh cc t khng th chng li c th. Gy nn cc biu hin
bnh a dng v khng th d on trc c. Ngi ta cha tm thy c
cc yu t nguy c r rng c bin php phng nga hiu qu. C th bnh
lin quan n tui , gii, dn tc, a d
I V.Hi chng Pick-Wick :
+Gp ngi bo ph.
+Kh th.
+Hng ho v tm phi hp.
+Bun ng sau khi n, ng g
+C th lin quan n hi chng ngng th lc ng.

V.Hi chng ng c tay (carpal tunnel syndrom ):
1.L mt tp hp cc triu chng ca mt bnh thn kinh ngoi bin
thng gp, nht l ph n, do nhiu nguyn nhn khc nhau.
2.S lc v gii phu, sinh l: ng c tay l khong trng nm gia
xng c tay v cc dy chng bao quanh cc gn gp ca bn tay. Thn kinh
gia l thn kinh hn hp, chui qua ng c tay cng vi cc gn c. Va truyn
cm gic t ngoi bin v trunng ng, va truyn mnh lnh t trung ng

284


n cc c bn, ngn tay. V chui qua mt ng hp ging nh chui qua mt
ng hm cht chi nn thn kinh gia d b chn p nu cc gn c b sng
ph
3.Triu chng: Bnh nhn cm thy au c tay. au lan xung ngn ci,
tr, gia v na trong ngn tay eo nhn. Bnh nhn cng cm thy t, ging
nh kin b hoc kim chm. Cm gic au v t cng lan ln cng tay. Bnh
nhn thng phi lc bn tay bt kh chu. Triu chng tng thm vo ban
m, lm bnh nhn kh ng. Dn dn mt cm gic cc ngn, ngn tay ci
c th b yu, teo c m ci. Triu c th xy ra hai tay nhng thng nng
hn tay thun.
4.Nguyn nhn:
+Gy xng c tay
+D dng
+T thp
+Thai k
+Nhc gip
+i tho ng
+Hot ng ca tay nhiu: nh my, vn hnh my ca
5.iu tr:
+Np c tay
+Thuc ung: NSAIDS, Corticoid
+Siu m.
+Phu thut.
+iu tr cc bnh lin quan.

VI .Hi chng Sjgren (hi chng Gougerot Sjgren hay bnh kh tuyn):
L mt bnh c nguyn nhn t min. c trng bi s xut hin cc t
khng th chng li cc t bo tuyn ca c th nh: t bo tuyn nc bt,
tuyn lGy nn cc triu chng kh mt, thiu nc bt, au khp, tuyn
nt bt mang tai sng to,..Bnh c th n c, nhng thng phi hp vi
cc bnh t min khc nh: vim tuyn gip t min, vim gan t min, Lupus
ban ri rc, hi chng CRESTChnh cc bnh phi hp ny gp phn to
nn bnh cnh lm sng a dng, nh hng n chc nng ca nhiu c quan
trong c th. Cho n nay, vn chn on v iu tr vn cn nhiu kh
khn. Nu th bnh n thun th c th kt hp liu php c ch min dch vi
iu tr triu chng (nh nc mt nhn to gim c cm gic kh mt..,),
theo di cht ch tin trin ca bnh. Th bnh phi hp th kh khn hn
nhiu, mc d c nhiu tin b trong y hc c p dng (c ch min dch c
hiu, lc huyt tng,..) nhng vn cha gim c cc bin chng c th dn
ti t vong.

285



VI I .Hi chng CREST:
Bao gm:
+Calcinois: cc nt vi ha da, mch mu, phi, cc c quan khc..
+Raynauds phenomenon: hin tng Raynaud.
+Esophageal involvement and dysphagia: chng kh nut v cc tn thng
lin quan n thc qun.
+Sclerodactyly (sclrodactylie ): chng x cng ngn tay, c th c hnh nh
ngn tay hnh khc di ln, Gottrons sign (shiny plaques may occur over the
joint of the hand tm mng ph qua khp tay ).
+Telangiectasia (tlangiectasie ): gin mao mch cc v tr khc nhau.
Khong 60-70 % bnh nhn x cng b ton th c hi chng ny. Ngoi ra,
cn gp trong cc bnh to keo khc nh: Lupus ban ri rc, vim da c
(dermatomyositis), vim a c..

VI I I .Hin tng v bnh Raynaud ( do Maurice Raynaud m t nm 1862):
1.Raynaud kh him gp, l hin tng co tht mnh lit cc mch mu
n da, nht l cc ngn tay khi b kch thch bi cc stress tm l hay nhit
lnh. Ngoi ra, c th chn, vnh tai, chp mi.
2.Nguyn nhn: cha r, mt vi tc gi a ra gi thuyt dy truyn, hai
tc gi Fowler v De Talks a ra thuyt thn kinh khi ghi nhn c s bt
thng trn in no bnh nhn Raynaud.
3.Sinh l bnh: Bnh thng, thn nhit tay chn gim khi c th tip
xc vi nhit lnh. Phn ng ca c th l co cc mch mu di da, gim
lu lng mu n ngoi bin nhm duy tr c thn nhit. Nhng nhng
bnh nhn ny c s co tht mnh lit v ko di cc mch mu n da khi gp
cc stress tm l v/hoc khi tip xc vi nhit lnh. S co tht din ra
trong vi pht n vi gi, gim ti mu n m, gy nn cc biu hin lm
sng ca bnh.
4.C hai loi Raynaud:
a.Nguyn pht: c gi l bnh Raynaud (Raynauds disease) thng gp
hn loi th pht, xy ra ph n tr di 40 tui, sng x lnh. Khng c
bnh nn hay mt nguyn nhn khc gy co mch, triu chng lun i xng
gia hai bn ca c th.
b.Th pht: c gi l hin tng Raynaud (Raynauds phenomenon) .
Tuy t gp nhng triu chng phc tp v trm trng hn. C cc yu t nguy
c l ht thuc l, cc bnh to keo, bnh Buerger, thuc chn beta,
ergotamine
5.Triu chng in hnh l s thay i mu sc da 3 pha: ti nht, xanh
tm v . Khi mch mu co tht mnh lit lm cho da ti nht, thiu mu. S

286


co tht ca c hu mao mch ngn cn mu tr v. S tip xc ko di gia
hng cu v t bo t chc lm tng t l Hb kh. Lm cho mu da chuyn sang
tm, bnh nhn au nhc nhiu, cm gic t rnSau , cc mch mu gin
ra, da tr nn l do hin tng ti ti mu.
6.Chn on da theo tiu chun ca Tina (Tina R.Desai, Ryan Headley
2006 Raynauds phenomenon, ASC Surgery: Principal and Practice, WedMD
):
-Thay i mu sc ba pha in hnh nh trn khi gp lnh hay cc yu t
kch thch khc.
-Thay i mu sc hai pha ti i ti li nhiu ln.
-Thay i mu sc mt pha v yu c khi gp lnh.
7.iu tr vn cn l vn nan gii, ch yu l trnh tip xc vi cc yu
t nguy c nh khng ht thuc l, trnh b lnh, gim ti thiu cc stress tm
l trong cuc sng..
a.iu tr ni bng cc thuc: chn canxi, chn alpha, gin mch..,trnh cc
thuc c th khi pht cn co tht mch nh thuc chn beta, estrogen..
b.iu tr ngoi: ct hch giao cm (tng t nh trong bnh Buerger ), ct
lc khi c bin chng lot, hoi t u chi.

I X.Hi chng Budd Chiari: tc tnh mch trn gan do chn p t bn ngoi
ca khi u c tnh, p xe gan do amip, t mu, kn ca sn. Cc t bo gan b
hy hoi do thiu oxy v xoang gan gin, lt mu, cui cng l x ha v x
gan.

X.Hi chng Evans: vng da tan huyt, xut huyt gim tiu cu do Lupus ban
ri rc. Ngoi ra cn c th gp trong cc bnh to keo khc. Nguyn nhn
lin quan n cc p ng min dch sai lc, to nn cc t khng th chng
mng hng cu, tiu cu. Kt hp vi hi chng khng phospholipid, hi chng
Libman Sacks (vim ni tm mc do Lupus ) l mt th nng v ni ln
thng tn a dng ca bnh Lupus.

XI .Hi chng khng phospholipid
1.L s kt hp ca cc hi chng sau:
-Huyt khi.
-Sy thai lin tip.
-Gim tiu cu min dch.
-To khng th chng phospholipid mng t bo.
2.Triu chng a dng:
-Tan huyt.
-Huyt khi.

287


-Gim tiu cu.
-Ph i van tim.
-Vim m li xanh tm.
-au u kiu Migraine.
-Ma git.
-Bnh l ty sng thong qua

XI I .Du Casper: thy thuc dng hai ngn tay (ngn ci v ngn tr ) vo vo
da bng bnh nhn, nng c t chc di da ln. V tr song song vi c thng
bng bng, cch rn khong 2-3 cm. Sau bung tay ra, bnh thng da
nhanh chng tr li trng thi ban u (thi gian di 2 giy ). Nu trn 2 giy
m da vn cha tr li nh lc u (vn cn nhn ), ta ni n hi da gim hay
du Casper (+). y l du hiu gp trong mt nc.

XI I I .Bnh sarcoidose (hay sarcoid, hay cn c gi l bnh BBS Besnier
Boeck Schauman):
1.y l bnh ca h thng lin vng ni m, m theo quan im hin
nay n c xp vo nhm bnh t min. c trng ca bnh l s thm nhim
lan rng ca dng t bo Lympho cc c quan trong c th theo c ba ng:
ng mu, ng bch huyt v ng k cn. Thng gp nht l phi v
trung tht. Gy nn hch ln, tuy nhin cha phi l tn thng gii phu
bnh quan trong nht. M iu khin ngi ta quan tm n bnh ny chnh l
s tn thng khng hi phc cc c quan. S thm nhim t bo Lympho khi
pht mt qu trnh vim mn khng c hiu. V chnh qu trnh ny l nguyn
nhn dn n s ph hy cc c quan.
2.Bnh cnh lm sng rt phong ph ty qa trnh vim xy u th
c quan no. Bnh nhn c th vo vin trong bi cnh ca vim ph qun mn,
gin ph qun nu u th xy ra phi, vim gan mn, x ganThm ch,
bnh nhn c th vo vin v cc triu chng thn kinh nu c s thm nhim
no, mng no. Trn phim CT-scans s no c th c hnh nh ging t mu
ngoi mng cng, chn on phn bit i khi cng cn c t ra nu bnh
nhn c tin s chn thng.
3.Chn on giai on mun cn phi da vo tin s, lm sng v
t bit l cn lm sng. Ngoi cc xt nghim cc c quan b bnh th phim X-
quang phi c mt gi tr nht nh gi cho chn chn on. C th thy hnh
nh thm nhim phi lan ta, hch rn phi, hch trung tht ln. Sinh thit
Daniel ( sinh thit t chc b trc c bc thang ), lm gii phu bnh c th
thy s thm nhim t bo Lympho. Ngy nay, nh s pht trin ca ni soi,
ngi ta c th tin hnh ly mu bnh phm phi hay trung tht mt cch
chnh xc. Tuy nhin n cng khng hon thay th c k thut Daniel. V

288


ngi ta nhn thy c s lin quan gia phi, trung tht v t chc trc c bc
thang. S lin quan l c s ng dng k thut sinh thit Daniel vo chn
on cc bnh phi, trung tht ni chung (v d trong ung th ph qun phi,
bnh l hch trung tht..). Ti sao li c s lin quan cho n nay vn cha
c gi thit no gii thch c r rng.
4.iu tr bnh giai on mun l mt iu kh khn. Cc thy thuc
phi c s cn nht c nn s dng thuc c ch min dch hay khng. V d:
bnh nhn vo vin vi triu chng ca vim ph qun mn, c chn on l
bnh BBS, khi s dng thuc c ch min dch s tng nguy c bi nhim
phi, lm nng thm triu chng lm sngS dng thuc c ch min dch
trong giai on u t ra rt hiu qu, bng vic cho Corticoid c th ngn nga
c tin trnh vim mn cc c quan, trnh c cc thng tn khng hi
phc. Nhng chn on c bnh giai on sm khng phi d, ngay c
cc nc c nn y hc pht trin.
Cho n nay, bnh BBS vn cn l mt vn nan gii nhng rt may
l t l bnh trong cng ng ni chung cng thp.

XI V.Bnh Banti: nguyn nhn cha r rng, x lch (t chc x pht trin), x
ha tnh mch lch, tnh mch ca. Gy tng p lc ca trc xoang, v sau
cng dn ti x gan. Cn phn bit vi hi chng Banti: x tnh mch lch v
tnh mch ca trc, sau tin n x lch. Gy tng p lc ca trc xoang
n thun.
XV.Bnh Wilson ( cn c gi l bnh x gan da hun ng hay vng da
nhn u ):
Bnh dy truyn theo gen ln, do khim khuyt gen m trch tng hp
ceroplasminogen. y l mt protein c chc nng vn chuyn ng trong c
th. Bnh thng, ng l mt nguyn t vi lng cn cho c th, c hp thu
ch yu t thc n, lng tha c o thi ra ngoi. t c s cn bng
gia hp thu v o thi l nh vai tr ca protein ti ceroplasminogen. Khi
thiu protein ny dn n s tch t ng trong c th, gy nn thng tn a
dng cc c quan. Hai thng tn trong s ng s nht l thng tn no
v gan. ng li gan gy hy hoi t bo gan, tin trin thnh x gan mt
b. Nhng bnh nhn thng vo vin trong bi cnh ca cc ri lon thn kinh
(yu lit, ri lon tm thn, vn ng,..) m khng c tin s bnh r rng trc
. V khi thng l qu mun, no b tn thng khng hi phc.
Vng xanh l cy mt do ng tch t gic mc (vng Kayser
Fleischer ) l mt du hiu c trng, c th xut hin giai on sm ca
bnh. pht hin bnh sm khng phi l d v giai on u bnh thng m
thm, khng c triu chng g ni bt nn bnh nhn thng khng ch n.
Vn iu tr vn cn gp nhiu kh khn, s dng thuc thi ng cng

289


khng ngn nga hon ton c tin trin nng thm ca bnh. iu tr triu
chng kt hp vt l tr liu, phc hi chc nng thn kinh cng khng em li
c cuc sng d chu hn cho bnh nhn l my. Trnh cc thc n cha
nhiu ng (nht l cc loi u, c bit l u tng tn bnh l vng da
nhn u xut pht t y ) l bin php bt but.
Theo di cht ch nhng i tng m trc trong gia nh tng c
ngi mc bnh l mt bin php quan trng. Gip pht hin sm ngi mc
bnh, can thip vo giai on thch hp, gim c cc bin chng. T vn
trc hn nhn gp phn gim ng k t l mc bnh trong cng ng ni
chung.

XVI .Bnh Von Gierke: ri lon chuyn ha glycogen do thiu men Gluco-6-
Phosphatase, gy tch t glycogen trong gan, lch v cc c quan khc. Tn
thng gan c th dn ti x gan mt b.

XVI I .Bnh Ehlers-Danlos: l bnh l ton thn ri lon tng hp thnh phn
collagen ca m lin kt. Dn n cc triu chng nh: lng lo khp do bao
khp, gn c, dy chng yu, khng m nhn c chc nng bnh thng; d
xut huyt do thnh mch yu collagen l thnh phn quan trng cu to nn
thnh mch, iu ny cng gii thch c triu chng d chy mu trong bnh
thiu vitamin C v nh chng ta bit vitamin C l yu t gip tng hp
collagen - (pht hin bng du Lacet), nng hn c th xut huyt t nhin
(chy mu rng, xut huyt tiu ha).s



290





291


PH LC 3: T IN HI CHNG
A
Adamkiewicz (Adamkiewicz Albert, bc s ngi Ba lan)
Cc du hiu ca tc nghn ng mch thn nn gy thiu mu hnh ty: yu hai chn km
mt cm gic chim u th gy ri lon c vng (mt trng lc hoc co tht; Nu rt nng
th c th lit mm khng hi phc 2 chn km mt cm gic hon ton.

Adams-Stokes (Adams Robert v Stokes William, cc bc s I reland)

(Cn gi l hi chng Morgagni-Adams- Stokes, bnh Adams-Stokes) Ri lon kch pht ti
mu no do cn nguyn tim mch: mt thc t ngt, thng km co git kiu ng kinh.
Trc thng c cm gic nng ngc, chng mt. Trong cn thy c nhp chm r, thm
ch v tm thu, bnh nhn gim trng lc c, ti nht, xanh tm. Ngay c sau cn cng co
khuynh hng nhp tim chm. in tm thy block nh - tht cc mc . di khi rung tht
dn ti t vong.

Addison (Addison Thomas, bc s ngi Anh)

Suy thng thn mn tnh, thng do lao: u oi chm chp, mt mi, bing nn. Da nhng
ch l ngoi qun o b nm li (do lin h ngc ni tit t v thng thn vi trung gian
tuyn yn).Bnh nhn bun nn, nn i, tiu chy, khuynh hng h ng huyt, chm nhp
tim, gim trng lc c. Tang Na v K trong mu.


Adie (Adie William, bc s ngi Anh)

(Cn gi l hi chng Weill - Reys - Adie, Adie - Holmes, Kehrer - Adie, Saenger, tng
trng lc ng t gi Tabes). L bnh di truyn tri theo nhim sc th thn
(Autosoma): thoi ha chn lc cc hch r sau ty sng v hch mi (ciliary): Phn x
ng t km, gim hoc mt phn x gn xng. Ph n b nhiu hn, thng tui 20-
30.

AI DS (Cn gi l SI DA, hi chng suy gim min dch mc phi -
AIDS: Acquired ImmunoDeficiency Syndrome)

Bnh do nhim virus HIV, truyn qua ng quan h tnh dc (tinh dch v cht tit m
o),ng mu (truyn mu, dng chung kim chch) v m truyn cho con trong bo
thai. Virus tn cng v tiu dit t bo min dch (Lympho T4). Giai on bnh ko di vi
thng ti vi nm. Bnh nhn d b bnh nhim trng v st dai dng, tiu chy v nhim
nm Candida, ung th da.

Alzheimer (Alzheimer Alois, nh tm thn hc ngi c)

292



(Cn gi l bnh Alzheimer, hi chng Heidenhain, sa st tr nng trc tui gi). Sa st tr
nng trc tui gi, dng di truyn tri theo nhim sc th thn (autosoma) khng in hnh:
ri lon tr nh tng dn, mt tr nh, mt nh hng, mt dng ng tc(apraxia), mt
ngn ng (aphasia), mt nhn thc (agnosia), mt vit (agraphia). Thng c c l ln, o
gic, gim thc, tng ng, t ng tnh (automatismus). Bnh khi u vo tui khong
55. No teo lan ta.

Anton-Babinski (Anton Gabriel, nh thn kinh hc v tm thn hc
c; Babinski Francois F., nh thn kinh hc Php)

(Cn gi l du hiu Anton, hi chng Anton, mt nhn thc thn th na ngi
hemiasomatognosia). Phc hp cc du hiu ca tn thng bn cu no phi: bi na ngi
tri km ri lon cm gic su v nng, bn manh pha bn tri, hai mt quay sang phi,
bun ng. Bnh nhn coi nh tnh trng bnh ca mnh, thmch hng cm
(euphoria), i khi bnh nhn khng mun tha nhn l mnh b lit na ngi.

Argyll-Robertson (Robertson Douglas M.C.L.Argyll, nh nhn khoa
ngi Scotland)
(Cn gi l du hiu Argyll-Robertson)
Ri lon chc nng ng t do can nguyn thn kinh trong cc bnh l khc nhau ca h thn
kinh: ng t khng phn ng vi nh sng, nhng li phn ng tt khi hi t v iu tit (xa
gn). Phn ng vi cc kch thch cm gic v tm l b suy gim. Co ng t. ng t khng
u hoc d dng ng t.

Arnold-Chiari (Arnold J ulius v Chiari Hans, hai nh bnh l hc
ngi c)

(Cn gi l bnh Arnold-Chiari, d dng Arnold-Chiari, h ng tip ng thn kinh ca
tiu no)No ng thy do tc nghn, cc du hiu tiu no vi tht iu (ataxia) v rung git
nhn cu (nystagmus). Du hiu chn p thn no v ty sng, lit cc dy thn kinh s, chng
co cng c (tetany) hoc cc co git kiu ng kinh, nhn i (song th), bn manh. Cn c
cc d dng s v xng sng.






293



B
Babinski-Nageotte (Nageotte J ean: nh bnh l hc ngi Php)

Hi chng lit giao bn: na ngi cng bn tn thng c mt phi hp ng tc (tht
iu) kiu tiu no, rung git nhn cu, co hp ng t, mt b tht lm vo, sp mi. Bn
pha i din vi tn thng c bi na ngi v ri lon cm gic. Do tn thng phn
tip ni gia cu no v hnh ty.

Banti (Banti Quido, nh bnh l hc ngi I talia)

(Cn gi l hi chng Senator-Banti, thiu mu do lch, hi chng thiu mu gan-lch)

Phc hp cc du hiu trong chng gan-lch to: thiu mu, gim tiu cu, gim bch
cu, x gan ca, tr trong l lch v tng p lc ca. Thng ph n di 35 tui.

Basedow (Basedow Karl A. von, bc s ngi c)
(Cn gi l bnh Basedow, bnh Basedow- Graves)

Cc du hiu c trng trong nhim c gip trng: bu gip, li mt, nhp tim nhanh.

Behcet (Behcet Hulushi, nh da liu hc ngi Th nh k)

(Cn gi l hi chng Adamantiades-Behcet, bnh Behcet...)
Bnh nhim trng d ng hi qui mn tnh: vim mng mt gy au, ni ban dng pt trong
ming, pht ban dng pt hay lot vng sinh dc, v vim mo tinh hon ti pht. C cc
biu hin thp v vim tc tnh mch. C th i tiu ra mu hoc chy mu ng tiu ha.
Thng c sng ph tuyn nc bt v nc mt.

Bechterev (Bechterev Vladimir, nh thn kinh v tm thn hc
ngi Nga)

Hu qu ca tai bin (ngp mu - apoplexie): tng trng lc c na ngi, tng tnh kch
thch ca c, co git c. Thng b khi tn thng th vn v bo (corpus striatum v globus
pallidus).

Bechterev - Strumpell Marie (Strumpell Adolf, nh thn kinh
hc ngi c; v Marie Pierre nh thn kinh hc ngi Php)

(Cn gi l bnh Bechterev - Strumpell - Marie, vim ct sng dnh khp - Ankylosing
spondylitis)


294


L bnh l vim mn tnh ca h thng dy chng v khp ct sng: bnh nhn b g
phn lng trn, au nhc kiu r thn kinh, cc khp ln t b tn thng, bnh nhn hi
ci. Cng hay c tn thng tim v vim mng mt - th mi. X quang ct sng "hnh cy
tre". Tng tc lng mu v tang Calci mu. Thng nam gii, tui trung nin, c th di
truyn kiu tri theo nhim sc th thn (Autosoma)


Bell (Bell Charles, nh gii phu hc, sinh l v phu thut ngi
Scotlen)
(Cn gi l lit Bell, lit mt t pht) Lit dy thn kinh mt ngoi vi.

Benedikt (Benedikt Moritz, nh thn kinh hc ngi c)

(Cn gi l bnh Benedikt, hi chng trung no) Lit giao bn trong tn thng nhn :
tng ng ngoi thp cng bn, lit cc dy vn nhn, tang trng lc c ton thn, tng
phn x gn xng bn lit. Tht iu cng bn v run chi di bn i din.

(Claude) Bernard-Horner (Bernard Claude, nh sinh l hc
ngi Php; Horner J ohann Friedrich, bc s nhn khoa ngi
Thy s)

(Cn gi l tamchng Horner, hi chng Hutchinson, hi chng Mitchell)

Phn x ng t khi tn thng cc hch giao cm khu vc C8-D2, bao gm c hch sao.
Xut hin co ng t, sp mi v lm mt. Thng cng c ri lon tit nc mt, ra m
hi, h nhn p, i khi c pha tp mu sc mng mt.

Biermer

(Cn gi l thiu mu Biermer...)
Thiu mu do thiu Vitamin B12. Bn cht l do nim mc d dy thiu yu t ni
trong
dch tit, nn nim mc d dy khng c kh nng hp thu B12. Da mu vng nht nht,
mng chn tay v tc d b gy, bing n, t li, v sau c vim li Hunter. Thng c
thiu nh chp khng vi Histamin.

Trng hp nng c ri lon chc nng ty sng. Trong mu c thiu mu t bo khng l
tng sc, hng cu khng u, hng cu bin dng, bin i nng huyt cu t. Trong
ty xng c nhiu t bo khng l, mu ngoi vi c chm a baz ca hng cu, h bch
cu. Cng cn thy r cc t bo to mu ngoi ty, ch yu trong gan v lch, tng
bilirubin mu, tng cholesterol mu.

Thng ngi cao tui.


295


Bouveret (Bouveret Lon, bc s ngi Php)

Nhp tim nhanh kch pht km h huyt p trong cn, bn chn v cm gic s hi, i khi
chng mt. Trng thi ngt xu, i khi bun nn v nn. Ngy nay n thuc v hi chng
WPW v CLC, hay l hi chng P-Q ngn.

Brown-Squard (Brown-Squard Charles, nh sinh l hc ngi
Php)

Du hiu tn thng ty sng mt bn theo chiu ngang: lit cng km ri lon cm gic su
cng bn tn thng, gim cm gic nhit v au bn kia.

Budd-Chiari (Budd George, bc s ngi Anh; Chiari Hans, nh
bnh l hc c)

Tc nghn cc tnh mch gan: trng hp cp tnh c bun nn v nn i ra mu, i khi
thm ch hn m gan; Trng hp mn tnh c au bng trn tng dn, gan to v i khi c
lch to. Nhanh chng c c trng. dn dn c ri lon chc nng gan, vng da nh ch hi.
Tng cholesterol mu. Cc bin th lm sng ph thuc vo nh khu tn thng ca cc tnh
mch gan.

C
Caplan (Caplan Anthony, bc s ngi Anh)
Phi hp vim a khp dng thp vi bnh bi phi silic.

Charcot I (Charcot J ean Martin, nh lm sng hc Php)

(Cn gi l chng khp khing cch hi, vim ni mc ng mch tc nghn -
endarteriitis obliterans)

Ri lon v i: khp khing cch hi (tng lc ri ht) v au bp chn, nguyn nhn l
thiu ti mu y cho cc bp tht khi i li. Chn tr nn trng nht, da lnh v cc
ngn xanh tm. Mch ngoi vi b yu. V sau c th hoi t cc on b bnh. da s bnh
nhn l n ng v nghin thuc l.

Hi chng Buerger: ngi tr tui di 40, nguyn nhn do vim v cn lm xt nghim
t chc hc. Ngi trn 40 l va x ng mch.

Charcot I I
(Cn gi l bnh Charcot, bnh x ct bn teo c)

Thoi ha cc neuron vn ng trung ng v ngoi vi gy ra lit c: khi u yu v teo
cc c nh bn tay, sau teo cc c cng tay v cnh tay. ng thi c cc du hiu co
cng v tng phn x gn xng km du hiu thp hai chn. Hai chn thng c d cm,

296


cm gic lnh, au v cc co git c. Bnh tin trin khng ngng. Dn dn cc c c -
mt b tn thng v bnh nhn khng th nhc u, mt biu l cm xc, ri lon nut v
tiu tin.

Charcot I I I
(Cng cn gi l bnh Charcot)

Bnh l thoi ha tin trin xng v khp: thoi ha sn, ph i cc phn ring l ca
cc khp, gai xng v gy xng t pht. Thng c khi b cc bnh l thoi ha
ty sng, rng ty v bnh tiu ng.




Charcot I V
(Cn gi l tamchng Charcot)

Tam chng c bn ca bnh x ri rc: run khi ch , ging ni kiu bng n, rung git
nhn cu.


Charcot-Marie (Marie Pierre, nh thn kinh hc Php)

(Cn gi l bnh Charcot-Marie-Tooth. bnh teo c tin trin do dy thn kinh)

Bnh di truyn tri theo nhim sc th thn, cng c (t hn) di truyn ln. L bnh teo c do
thn kinh: bnh thng bt u trc khi dy th, teo cc c nh bn chn v ng chn cn
i 2 bn, to nn bn chn nga vo vo (pes equinovarus). ti khu vc b bnh mt phn
x gn xng. V sau cng c th c cc c tay b teo. Him khi teo c lan ln trn u gi
hoc trn khp khuu tay. C run ch . Mt s trng hp c tng hng cu, lit cc c
mt, li mt v teo mt. Tip theo c g lng v vo lng. Bnh mn tnh, thng n ng b
nhiu hn.

Conn (Conn J erome W., bc s ngi Anh)

(Cn gi l cng aldosteron nguyn pht) Cng aldosteron nguyn pht thng khi c khi
u tng sn v thng thn: mt mi ton thn, tiu chy, yu c theo chu k, thm ch hon
ton bt ng, t b, cc du hiu ca tetany trong khi Ca trong mu bnh thng. Cao huyt
p, tiu albumin, tng Kali niu, gim Na v Cl trong nc tiu, tiu nhiu, phn ng kim ca
phn. Thng khng ph. Tng aldosteron trong mu v nc tiu. Nu bnh khi pht tr
em, th thng ngng ln v pht trin ni chung. Mt s th bnh p ng tt vi dexa
methason .

Crohn (Crohn Burrill, bc s M)


297


(Cn gi l bnh Crohn)

Vim theo phn on mn tnh on cui ca hi trng: bnh thng khi u tui 15-35 v
thng n ng. Biu hin bng tam chng c trng sau: au na bn phi ca bng,
tiu chy ti i ti li hoc trng din, kit sc r. i khi trong t kch pht cp tnh
c cc du hiu ging nh trong vim rut tha cp. on rut tng ng ta thy cc vt
so vi nhng vng vim nm xung quanh, do vy t t dn ti hp ng rut non. Trong ta
thy bch cu chuyn tri trong giai on tng bch cu cp, tng tiu cu, thng c thiu
mu nhc sc. Tng tc mu lng, gim hot tnh prothrombin, gim Na v Ca trong
mu. Phn nhim m. Bnh nhn c th b bin chng vim tch m ti ch, c l d,
thng, v hp nng.

Cushing I (Cushing Harvey W., nh phu thut thn kinh ngi
M)

Du hiu c khi u gc cu tiu no: lit cc dy s V, VI, VII, VIII, IX cng bn vi tn
thng. Cc du hiu tiu no v du hiu chn p vo tiu no.


Cushing I I : u mng no xng bm

Cc du hiu do khi u phn gia ca xng bm: lit mt, d cm vng trn mt,
li mt mt bn, teo dy th nguyn pht cng bn tn thng, o gic thnh gic v
khu gic do chn p vo hi hi m. Thay i c tnh.


Cushing II I

Cc du hiu do c khi u tiu no c tnh tr em: nhanh chng xut hin no ng thy
do tc nghn. Thng c di cn vo ty sng gy lit chn tay. Trong giai on cui s c
hi chng tn thng ty ct ngang hon ton.

Cushing I V
(Cn gi l bnh Cushing, bnh Icenko-Cushing)

Phc b cc triu chng cng v thng thn nguyn pht hoc th pht: bo ph vi thn
mnh to ln v chn tay nh b, mt trn nh mt trng, cc vt rn da (ch yu da bng),
tng hng cu, xanh tm u chi, tng ng huyt km theo tiu ng, h Calci mu v
tiu long xng. Cn c yu mt ton thn, teo cc tuyn sinh dc, v kinh v lit dng. Tr
em b thiu nang sinh dc, n ng b n ha, ph n b rm lng. Gim kh nang khng
vi nhim khun. Gim sng to v b trm cm.

D

298


Djerine-Klumpke (Djerine-Klumpke Augusta, nh thn kinh hc
ngi Php)

Phc hp cc triu chng do tn thng cc r C7, C8 v D1. Lit cc c cng tay v cc
c nh gan bn tay. Ri lon cm gic mt trong tay. Thng c ri lon vn mch, tng
hoc gim tit m hi, tht (lm) mt, sp mi v co ng t.

Djerine I (Djerine J oseph J ., nh thn kinh hc Php)

Phc b cc du hiu trong bnh bch hu lm gi nh ti thoi ha ty sng: tht iu v
ri lon cm gic su.


Djerine I I

(Cn gi l khp khing cch hi ty sng ca Djerine)

Chng khp khnh tm thi do bnh giang mai ca h tun hon hoc do vim ng mch
huyt khi tc nghn: cc chng bi v lit khc nhau.

Djerine-Lavalpiquechef

Mt dng ca vim a dy thn kinh do ru: cc du hiu ca gi thoi ho ty sng vi ri
lon cm gic nng, cm gic v t th thn th km tht iu.

Djerine-Roussy (Roussy Gustave, nh bnh l hc ngi Php)

(Cn gi l hi chng i th)

Ri lon cm gic v th lc mt bn do bnh l i th: bn manh cng tn, Tng phn x
da v phn x gn xng bn i din. Ri lon cm gic su, d cm na ngi, au na
ngi. Thng c teo h thng c xng mt bn v ng thi mt cm gic xng.

Djerine-Sottas (Sottas J ules, nh thn kinh hc Php)

(Cn gi l bnh Djerine, lon dng c di truyn)Bnh teo c do cn nguyn thn kinh,
dng di truyn tri theo nhim sc th thn(autosoma): teo c tin trin cn i, pes varus
(vo trong) thm ch equinovarus (bn chn dui vo vo - bn chn nga). Cc si thn
kinh to ra v au c th s thy c di da. Ch teo co ri lon dinh dng v ri lon
cm gic. Du Romberg dng tnh. Thng c tht iu, rung git nhn cu, lit cc c
mt, ng t khng u. Cc nvi (nevus) v cc u x thn kinh di da. Bnh thng khi
pht tui thiu nin, hng tnh nam mnh.

Down (Cn gi l bnh Down)

Dng bnh km tr tu bm sinh, do c 3 nhim sc th cp th 21: tr tr tm tr, thng

299


nht l ngu n m cm xc vn cn tng i c bo tn. Bnh nhn l nhng ngi hin
lnh v a u ym. Tm vc nh b, nhiu np nhan, vim kt mc m mt, mi ngn,
li to v c rnh, tng tit nc bt. Mt c trng ging nh l h xic. Da lnh, ngn
ngn, ngn quo, gim trng lc c, bng to v nho, km pht trin sinh dc. Thng c
d tt bm sinh tim. Chim t l 1/600-1/900 tr s sinh. C mt s t trng hp l do
chuyn v nhim sc th.


Duchenne I (Duchenne de Boulogne Guillaume B.A., nh thn kinh
hc ngi Php)

(Cn gi l tabes dorsalis - giang mai ct sau ty sng)

Cc bin i kiu thoi ha ca thn no, cc r sau v phn lng (sau) ca ty sng: cc
cn au d di ton thn, tht iu tng dn, mt cc phn x, mt kh nng nut v
ri lon tiu ha. Ri lon chc nng bng quang, lit dng. Thng nht l biu hin ca
giang mai giai on 3. a s bnh nhn l nam gii trung nin.




Duchenne II

(Cn gi l lit Duchenne, lit hnh no tin trin)

Cc du hiu tn thng thn no km teo cc c lng: thng khi u bng kh c ng
li, nhanh mi li khi ni chuyn v khi n. V sau c teo li, lon vn ngn,
thm ch mt kh nng ni. Ri lon nut, nhy mt, ri lon tit nc ming. Mt phn
x hu (vm ming), ci nh khc. Trong giai on cui c ri lon tun hon v h hp,
Bnh tr em 3-4 tui.

Duchenne-Aran (Aran Francois, bc s ngi Php)

(Cn gi l bnh Duchenne-Aran, teo c ty sng tin trin)

Teo c ty sng tin trin ngi ln: teo c cn i hai bn v lit, phn x gn xng
mt hoc rt yu. Biu hin lm sng khi u bng yu cc c nh bn tay, sau l
gim kho lo, tay, kh nng c ng bn tay b km i, c cc co git c bn tay. Bnh
tin trin khng ngng v lan rng dn. Cui cng l cc du hiu ca lit hnh no.

Duchenne-Erb (Erb Wilhelm H., nh ni khoa v thn kinh hc
ngi Php)

(Cn gi l lit Erb)

300



Tn thng cc r C5 v C6: mt chc nng dn dn ca cc c delta, nh u v c cnh
tay (brachialis), mt phn c c di gai (infraspinatus),i khi c c di
n(subclavius). Khng th dng vai v co khyu c. Bn tay t th quay sp. C ng
ca c tay v cc ngn tay bnh thng. Khng c ri lon cm gic hoc ch rt nh mu
tay.

Duchenne-Griesinger (Griesinger Wilhelm, nh thn kinh hc v
tm thn hc ngi c)
(Cn gi l bnh Duchenne-Griesinger, lon dng c gi ph i)

Bnh lon dng c di truyn kiu ln lin kt vi nhim sc th X: khi u bng teo c
ngc, sau l cc c bng v chi th. Mi mt nhm c khi u u b ph i v cng
chc, sc c gim dn v ri tr thnh teo c. Khng th ng dy m khng xoay hng (?),
dng i ong a, thng c g vo lng, bn chn nga, mt phn x gn xng, mt cht
khong ca xng, suy tim. Trong mu tng aldolase v creatinphosphokinase. Ch c tr
trai 2-6 tui.

Dumping hi chng trn ngp (To dump: vt nm xung)

(Cn gi l hi chng sau ct d dy)

Phc b cc ri lon tiu ha v tun hon sau khi n bnh nhn ct d dy cao: khong 15
pht sau khi n, bnh nhn cng y thng v, bun nn v nn i, tot m hi, nng
bng, mt mi, kh chu v run chn tay, nh trng ngc, au u, c th ngt xu.

Dupuytren (Dupuytren Guillaume, nh phu thut ngi Php)

(Cn gi l bnh Dupuytren, chng co cng Dupuytren)
Bnh do tn thng t chc lin kt: mc gan tay b ngn v nhn li, gy co cng cc ngn
tay, ch yu l pha tr.
E
Erb (Erb Wilhelm H., nh ni khoa v thn kinh hc c)

(Cn gi l bnh teo c tin trin, lon dng c Landouzy-Djerine)

Bnh lon dng c di truyn th nin thiu: khi u l kh leo thang gc, dng i d dm,
teo c cn xng hai bn, xng b vai nh ra, qu n tht lng, thng cng hay c gi ph
i h c.Gim cc phn x. Ming tr ra. Tng aldolase trong mu, gim creatinin trong
nc tiu. Bnh khi pht vo tui dy th. Hng tnh nam mnh. Nu tn thng u th
m ri cnh tay th di truyn thng l tri theo nhim sc th thn. Nu tn thng u
th m ri cnh tay th di truyn thng l ln theo nhim sc th thn. i khi cng c

301


di truyn lin kt vi nhim sc th X.

F
Fallot (Fallot Etienne Louis A., bc s Php)
(Cn gi l t chng Fallot)

D dng tim v mch mu ln hay gp: ng mch ch chuyn sang phi, thiu ht vch
ngn tm tht, hp ng mch phi v ph i tm tht phi. Cc du hiu lm sng c
bn c ngay khi tr cn ang b: xanh tm, kh cho tr n, chm pht trin v kh th
vi bt k mt gng sc no, tng hng cu, cc ngn tay hnh di c. Nghe tim tht ting
thi tm thu, ting T2 yu trn phi. Khong 50% trng hp do di truyn tri theo
nhim sc th thn

Fanconi (Fanconi Guido, nh nhi khoa ngi Thy s)

Bnh ty xng tr nh, di truyn ln theo nhim sc th thn, vi rt nhiu cc bt thng:
thiu mu t bo khng l cng (tng) sc tng tin mn tnh, gim bch cu, gim tiu cu,
thiu sn thm ch bt sn ty xng km theo tng sinh t chc m. Sc khng c hc v
thm thu ca hng cu vn bnh thng. Bnh nhn nh ngi, nhi tnh, gim thiu sinh dc,
s nh, thng c tng phn x, mt nh, lc mt. Cn c cc tt ca chi trn, thn v ri lon
nhim sc t.

Fisher (Fischer Miller, nh thn kinh hc ngi M)
(Cn gi l hi chng Fisher Miller)

Mt th ca Guillain-Barr: tht iu c hai bn r, lit mt c hai bn, dn dn mt phn
x gn xng, i khi c lit mm khng cn xng.

Fischer (Fischer H., bc s da liu ngi c)
(Cn gi l hi chng Buschke-Fischer)

Phc b cc d dng ngoi da: khi pht tr em, da gan v mu tay chn tng lp sng v
tng tit m hi. Nm mng chuyn sang bong mng. Tc tha v lng tha. u chp ca
ngn tay v ngn chn to ra do ph i u xng.Thng c chm tr tu, kh da, lo ha
sm, ph mi mt. C th do suy chc nng tuyn gip bm sinh.

Foix (Foix Charles, nh thn kinh hc Php)

Huyt khi, khi u hoc phnh mch trong xoang bm gy bi hoc lit dy III, IV v
mt phn dy V, li mt, ph mi mt v kt mc, m, lit mt, au dy thn kinh V.

Foville (Foville Achille L., nh thn kinh hc v tm thn hc
Php)

302


(Cn gi l chng lit na ngi giao bn cu no di)

Phc hp cc phc b tn thng cu no: lit VI v VII kiu ngoi vi cng bn, mt
bn i din mt kh nng xoay vo trong.

Froin (Froin Georges, bc s Php)

Nhng bin i ca dch no ty do tc nghn khoang di nhn, nguyn nhn: do khi
u, lao mng no, vim ct sng hoc vim mng no ty. Hm lng albumin tng cao.
Dch no ty nhanh chng ng li, c mu nhim sc vng. Lng t bo thay i khng
nhiu. Cng lc nu ly dch no ty qua chc di chm, th li c thnh phn bnh
thng.

G
Gastaut (Gastaut Henri, nh thn kinh hc Php)

(Cn gi l hi chng Lennox, hi chng Gastaut-Lennox)

Cc cn co git ng kinh do bnh no tr em, c trng bng chm pht trin tr tu, cc
c khng kim sot c, v hnh nh khc bit trn in no . y khng phi l 1
bnh ring bit v c nhiu nguyn nhn gy c hi chng ny: chn thng, ngt th
khi sanh, nhim trng h thn kinh trung ng hoc bnh chuyn ha...Thng khi pht
trc 4 tui v khng c cch iu tr no t ra vng bn, 80% s b ng kinh tip khi ln
tui. Thuc tt nht l Valproat hay Felbamat, nu bnh tr l th xt phu thut ct th
chai (corpus callosotomy).

Gerstmann (Cn gi hi chng ca hi gc - gyrus angularis)

Qu trnh bnh l no vng nh: mt c ch trong khi vn cn th lc, mt vit trong
khi vn cn c ng bn tay tt, mt m, ri lon nh hng trong khng gian v thn th
ca chnh mnh.

Goodpasture (Goodpasture Ernst, nh bnh l hc M)

Nhim hemosiderin phi km vim thn tiu cu. Thng ngi di 40 tui. Bnh nhn b
ho, ho ra mu lp i lp li, v sau xanh tm, nhp tim nhanh, kh th, tiu albumin,
tiu mu, tr niu. C th tm thy khng th chng li mng nn ca tiu cu thn. Cui cng
cht do nhim ure huyt.

Guillain-Barr (Guillain Georges v Barr M.J ., cc nh thn kinh
hc ngi Php)

(Cn gi l hi chng Strohl, hi chng Landry-Guillain-Barr)


303


Bnh vim a r v dy thn kinh, vi yu bi km gim hoc mt phn x. C th d cm.
Lit leo dn ln. Dch no ty c protein tng cao, trong khi t bo bnh thng hoc tng t
(phn ly albumin - t bo).

H
Hageman (Hageman l tn ca mt bnh nhn)

Thiu yu t ng mu XII (cn gi l yu t Hageman) trong bnh di truyn ln theo nhim
sc th thn (autosoma): thi gian chy mu ch b ko di nh hoc hon ton bnh thng,
th nghim Rumpel-Leed dng tnh. Thi gian ng mu b ko di. Co cc mu bnh
thng. Thng khng c xu hng chy mu t pht. Thng ch pht hin bnh khi tnh c
b chn thng hoc xt nghim mu ng v mu chy.

Hashimoto (Hashimoto Hakaru, nh bnh l hc ngi Nht)

(Cn gi l bnh Hashimoto, bu gip Hashimoto)

Bu tuyn gip do vim t min dch mn tnh: tuyn gip b au v dn dn to ra, giai
on u c tng chc nng, v sau chc nng bnh thng, ri nhc nng gip. Bnh
ch yu n trn 40 tui. Bnh c bit hay c Nht v M, nhng cc nc khc t
gp hn.

Heiner (Heiner Douglas C., nh d ng hc nhi khoa M)

Bnh do d ng vi sa b tr em: cc khi thm nhim ln khc nhau trong phi, i
ch c xp phi, thiu mu nhc sc, thng tiu chy. Th trng chung chm pht trin.
Trong huyt thanh c khng th chng sa b. Nhng bin i trong phi c tnh cht
hemosiderin.

Henoch (Henoch Eduard H., nh nhi khoac)

(Cn gi l ban xut huyt Henoch, ban xut huyt bo pht)

Cc ban xut huyt rng v i xng hai bn thm nhim c di da, nhng nh khu ch
yu mt pha dui ca chn tay. V sau c mn nc cha mu chy bn trong,
thng c tiu ra mu. Trong mu: thiu mu ng sc, tng bch cu, tng bch cu
trung tnh, bch cu chuyn tri v tng gammaglobulin huyt. Trong ty xng: s lng
ln cc t bo li dng tng bo (plasmatic) v cc bch cu i toan. Tin lng i khi
khng tt (xem thm hi chng Schonlein-Henoch).

Herxheimer (Herxheimer Karl, nh da liu hc ngi c)

(Cn gi bnh Pick, bnh Herxheimer, bnh vimda gy teo lan ta tin trin)

Bnh teo da t pht: da nhim mu cm thch tm , trn ban u xut hin cc nt nh,

304


sau l cc mng thm nhim mm nho. Chuyn dn sang teo. Bin i ch yu mu tay,
chn, khp khuu v khp gi. Da b teo d dng b nt rch v to nn cc vt phng. y
l tnh trng tin ung th. Bnh nhn thng xuyn c cm gic lnh cc chi th b bnh. C
lng t mn.

Hirschsprung (Hirschsprung Harald,nh nhi khoa ngi an
mch)

(Cn gi l bnh Hirschsprung, bnh to i trng bmsinh)

Bnh to i trng di truyn ln theo nhim sc th thn: ngay t tr hay b to bn, bng to
km trng bng, tc rut tht thng. Cn bing n, thiu mu, chm ln, nhi ha. Bng
trc trng thng rng. Trn X quang i trng xung v i trng sigma gin rng.

Hodgkin (Hodgkin Thomas, bc s ngi Anh)
(Cn gi l bnh Hodgkin, bnh lympho ht c tnh)

Cc u lympho (lymphoma) c tnh km theo cc bin i t chc hc c trng. Khi u
cc hch to ln khng au, c bit l c pha bn tri, v sau cc hch khc cng
to ln, sau yu mi, st, tng sc t da, nga. V sau gan v lch cng to v c c trng.
Thiu mu c trng, gim lympho bo, tng bch cu i toan, tng bch cu n nhn ln.
Chc ht hch lympho 90% trng hp thy c t chc ht vi cc t bo Sternberg.
Tng bch cu i toan bin thin. Trong nhiu trng hp c th l bnh di truyn ln theo
nhim sc th thn(autosoma).

Hoffmann (Hoffmann J ohann, nh thn kinh hc c)

(Cn gi l bnh c do thiu nng gip trng)

Bnh c nhng bnh nhn thiu nng gip trng: ph i c, cc co git c gy au, gi
tng trng lc c.

Horton I (Horton Bayard T., bc s M)

(Cn gi l bnh Horton, cluster headache - au u theo chui)

y l mt bnh thuc Migraine (migren): cc cn au mt bn vng thi dng, mt v
hm trn, i khi sau t. Cc cn t xut hin t ngt v ch trong thi gian ngn. Cc
cn kch pht nh vy thng v m, sau khi ng khong 1-2 ting, v ko di nht
cng ch khong 1 gi. Trong cn, na mt bn c: chy nc mt, ph mi mt, chy
nc mi v nght mi kh th. Giai on khng c cn ko di khong vi thng. Thng
ch ngi ln tui b. Hng tnh nam. C th kch thch cn bng chch Histamine v
ct cn bng adrenalin.

Horton I I

305



(Cn gi l bnh vim ng mch thi dng) Cc du hiu ca vim ng mch nt khu tr
vng ng mch thi dng. Khi u l nhng triu chng ton thn nh: bing n, gy st,
ra m hi ban m, au thong qua trong c v khp, st nh. Sau vi ngy n vi tun s
c au d di vng thi dng, i khi ton b u. au tng ln khi nhai. Tip theo c ri
lon v nhai, nut, ph vng thi dng. ng mch thi dng dy ln, nhy cm vi s n,
v ngon ngoo. St, tng tc lng mu, tng bch cu nh, thiu mu nhc sc. Thng
ngi gi 50 tui. Thng c huyt khi hoc tc mch vng mc km theo du hiu
chy mu, c th m c 2 mt hoc bn manh. Thng c bin chng lit cng na ngi.

Huntington (Huntington George, nh thn kinh hc M)

(Cn gi l bnh Huntington, ma git Huntington, ma git tin trin di truyn)

Bnh him gp, teo tiu no do di truyn vi cc ri lon kiu tng ng v gim trng lc,
di truyn kiu tri theo nhim sc th thn. Bnh thng khi u tui 30-45. Ma git
phi hp vi ma vn, dng i khng vng vng, khng cn i. Ging ni chm v khng
hiu c. Trong trng hp nh th cc c ng ch cn tt. C th thy gim trng
lc c, d cm v au cho thy c vn ca i th thm vo. Cn c th ri lon thn
kinh thc vt, kit sc, tiu ng, n qu ngon ming. V sau c thiu nng tm tr.

Hutchinson I (Huntington J onathan, bc s phu thut, nhn khoa
v da liu ngi Anh)

(Cn gi l tamchng Hutchinson)

Tam chng c trng ca giang mai bm sinh:
1) Bin dng cc rng nanh trn, xu hng khuyt rng, thiu sn lp ng rng.
2) Vim gic mc nhu m.
3) Nghng ngng tai do m o.

Hutchinson II (Cn gi l bnh Hutchinson)

Cc ban do nh sng ti pht mn tnh, ch yu vng l da ca c th. Bnh thng
khi u vo ma xun v kt thc vo ma thu. Bnh ch yu ngi tr.

Hutchinson II I (Cng cn gi l bnh Hutchinson)

Bnh ngoi da him gp tr em: cc u mch nh lan rng ra pha ngoi vi, cn trung
tm tr nn trng v da b teo. Cui cng to thnh cc vt ng tm mu hoc nu.

I to (I to M., bc s Nht)

Phc b cc d dng, nhiu kh nng do di truyn tri theo nhim sc th thn. C cc
vn hoc cc di mt mu c bit trn da ngc hoc chn tay. Mt sc t biu hin ngay

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sau khi sanh. Cng cn gim trng lc c ton thn, cc khp lng lo. Tr tr v tr tu v
in no bnh l. Lit chn tay, mt lc, mt sc t mng mt. Bt thng xng s v
t sng, lon sn rng, vnh tai thiu sn.

J
J ackson I (J ackson J ohn H., nh thn kinh hc Anh)

(Cn gi l lit na ngi v li giao bn, hi chng Schmid)

Tn thng thn no do ri lon tun hon, b phn trn ca hnh ty: Lit dy thn kinh
li kiu ngoi vi cng bn tn thng km theo teo li, lit chn tay bn i din. C
th ri lon nhn cm v t th thn th v tht iu. i khi c ri lon nut, pht m do
ri lon h c hng.

J ackson I I

(Cn gi l ng kinh Jackson, ng kinh cc b, ng kinh mt phn, ng kinh Bravais -
Jackson, ng kinh v no)

Cc cn co git khu tr bnh nhn c tn thng no: cc cn co cng - co git mt nhm
c nht nh m khng c mt thc. Trng hp nng th cc co git s lan sang bnh i
din v gy mt thc. C th lit cc c ko di trong vi gi. Trong khi co git hay
c ri lon cm gic hoc th lc hay thnh lc.

J acob-Creutzfeldt (J acob Alfons v Creutzfeldt Hans G., cc nh
thn kinh hc c)

(Cn gi l bnh J acob-Creutzfeldt, thoi ha no - th vn - ty sng)

Bnh l thoi ha ca no, tiu no, cc nhn xm nn no v ty sng. Thng khi pht
mun, biu hin bng yu hai chn, au v cng dn hai chn. Lon vn ngn, ri lon nut,
du hiu thp v cc ri lon tm thn. i khi c cc bt thng v sc t, tng sng ha
da, ri lon i cu. Cn nguyn nghi do virus.

K
Kahler (Kahler Otto, nh ni khoa ngi A)

(Cn gi l bnh Kahler, a u ty)

Bnh l c tnh h thng ca ty xng v h bch huyt, vi cc khi u ca cc t bo
tng bo. Bnh thng khi u vo tui trung nin vi au nhiu v ko di trong cc
xng, ch yu ct sng, khung chu v xng i. Khi s nn v g vo xng gy
au. V sau c bin dng v gy xng bnh l, tiu long xng ton thn v cc b.
Trong mu c paraprotein, v ty theo thnh phn i din nhiu nht m ta gi l u tng

307


bo gamma, alpha hay beta. Trong 50% trng hp nc tiu c protein Bence-Jones. Trong
mu: thiu mu nhc sc, tng bch cu, ch i khi c tng tng bo trong mu. Trong
ty xng: c cc t bo dng ty in hnh, ging nh cc t bo tng bo khng in
hnh. Tin lng khng tt. in hnh l tam chng Kahler: tiu long xng c km gy
xng t pht, protein Bence-Jones, suy mn.

Kaplan-Klatskin (Kaplan Herbert v Klatskin Gerald, cc bc s
ngi M)

Lin kt gia bnh sarcoidosis, bnh vy nn, v bnh thng phong (gout): cc vt chm
(eczema) nga, cc cn thng phong lp i lp li v cc biu hin ca bnh sarcoidosis.

Kaposi (Kaposi Moritz, bc s da liu Hungary)

(Cn gi l bnh Kaposi, sarcoma Kaposi...)

Bnh c tnh ca h thng t bo t chc li: cc hch nh kch thc di 2 cm, mu
ti hoc pht xanh, cc hch ny thng khng au v t li thnh nhm. Ban u cc hch
ny cng, c th bin i thnh cc mn rui, i khi t bin mt. Vng xung quanh hch
bv gin mao mch. Biu hin ch yu chn v tay. Cc hch lympho to ra, mc ln cng
vi t chc lin kt di da, thiu mu tng dn v suy mn. St nh. V sau cc hch
trung tht cng to ra. Gn y ngi ta thy bnh nhn AIDS (SIDA) hay b bnh ny.

Kennedy (Kennedy Frederic M., nh thn kinh hc M)

Phc hp cc triu chng v mt bnh nhn c qu trnh bnh l h s trc hoc tn
thng thy trn: teo dy thn kinh th gic nguyn pht bn tn thng, ri lon th lc
cho ti mc m hn, cn bn i din th c ph gai th, i khi c c ri lon khu gic.

Kienbock (Kienbock Robert, bc s X quang ngi A)

(Cn gi l bnh Kienbock, nhuyn xng bn nguyt)

Bnh di truyn tri theo nhim sc th thn, gy hoi t xng bn nguyt ca bn tay: au
d di c tay, au tng mnh khi s nn vo xng bn nguyt, ph t chc xung
quanh. Trn phim X quang thy xng bn nguyt c cc tng sng v vt gy khng u.
Bnh thng ngi 20-30 tui, ch yu l tay phi. Tin s c chn thng.
Kimmelstiel-Wilson (Kimmelstiel Paul, nh bnh l hc M;
Wilson Clifford, bc s ngi Anh)

(Cn gi l bnh x cng tiu cu thn do tiu ng)

Bnh l tiu cu thn bnh nhn tiu ng lu ngy: ph, cao huyt p, protein niu, tng
ur huyt, bnh l vng mc do cao huyt p v tiu ng. Bnh tng tin khng ngng v
dn dn gim nhu cu s dng insulin. Xut hin x cng tiu cu thn. Tin lng khng

308


tt.

Klinefelter (Klinefelter Harry F., bc s ngi M)

Bnh di truyn ca tinh hon lin kt vi nhim sc th X, kiu gen l XXY: ngi n ng
tr pht trin bnh thng nhng c au v khng thng xuyn, thiu sn tinh hon, thiu
tinh trng hoc t tinh trng. Lng tc mc bnh thng.

Klippel (Klippel Maurice, nh thn kinh hc ngi Php)

Cc biu hin ca nghin ru mn tnh: vim a dy thn kinh, tn thng nhu m gan, hi
chng Corsakoff. Sau khi ngng ru th cc du hiu thn kinh thng gim dn, nhng
tn thng gan s khng th gim hn c.

Klippel-Feil (Cn gi l bnh Klippel-Feil)

Cc d dng di truyn tri theo nhim sc th thn km tt t sng: c rt ngn (c ch),
ranh gii mc tc h thp xung, c ng xoay u sang bn b hn ch, ngc hnh ci
phu. Cn c vim dy thn kinh do chn p, thng c ri lon th do d tt t sng gy
nn. Trn X quang thy c rt nhiu cc d tt ca t sng, t sng ch c mt na,
t sng hnh vt, cc tt nt t sng, g vo lng. Xng sn cng c d tt, vm
hng tch i, d tt bm sinh ca tim, c thm thy phi, bt sn c c n chm, chng
cong ngn, chng dnh ngn, rng mc chm, tt tha rng, ng tai trong km pht trin,
ic, bnh rng ty, tt l hu mn.

Konig I (Konig Franz, nh phu thut c)

(Cn gi l bnh Konig)

Bnh nhiu kh nng do di truyn tri theo nhim sc th thn gy hoi t v khun
phn trong ca u di xng i. Thng xut hin au trong giai on ang ln nht l
lc dy th. Ph nh v hn ch vn ng khp gi v khp khing nh. Trn X quang thy
cc nh trong sut. V sau c cc mnh xng mc tch ri ra mt trong ca u
di xng i. Bnh thng hai bn, tin trin vi nm, cui cng phc hi t pht
hon ton. Bnh hng tnh nam.

Konig I I

Cc du hiu ca hp hi manh trng: cc cn au bng km theo lun phin gia to bn v
tiu chy. Trng bng ko di, si bng vng hi manh trng. Thng c bnh lao hoc
bnh Crohn.

Korsakoff (Korsakoff Sergei S., nh tm thn hc Nga)

(Cn gi l hi chng mt nh Korsakoff)
Phc b cc ri lon tm thn trong cc bnh l no khc nhau, v d chn ng, nhim

309


trng, nhim c, c bit l ru. Khng c kh nng nh v hin ti cng nh qu kh,
gim kh nng tp trung t tng, mt nh cc s kin mi xy ra gn y km theo
chng ba chuyn, mt nh hng khng gian v thi gian, yu ui suy nhc, kit sc,
i khi sng khoi.

Kozevnikoff (Kozevnikoff Alexej J ., nh thn kinh hc Nga)

(Cn gi l ng kinh Kozevnikoff, ng kinh tng phn (cc b) lin tc)

Biu hin ng kinh bng cc co git c ko di mt s nhm c nht nh, i khi
thm ch c co git ton th. i khi c lit v d cm, sau c co cng v teo c.

Kugelberg-Welander (Kugelberg Eric v Welander Lisa, cc nh
thn kinh hc Thy in)

(Cn gi l bnh Wohlfart-Kugelberg- Welander, teo c b vai - mc)

Bnh di truyn theo kiu c tri ln ln, theo nhim sc th thn (autosoma), gy teo c ty
sng cc nhm c gc chi: teo cc c gc chi do bnh l t bo sng trc ty sng v
cc si vn ng. Khi u tui nh 3-4 tui, t khi tui ln hn.

Kussmaul (Kussmaul Adolf, nh ni khoa c)

(Cn gi l bnh vimng mch nt, hi chng Kussmaul-Meier)
Bnh c trng bi tin trin a dng: st, tng bch cu, tng bch cu i toan, tnh trng
ton thn nng km suy mn. Ri lon tiu ha vi cc cn au bng, c rt nhiu chy mu
mao mch, huyt khi i khi gy tc mch, phnh mch. C du hiu vim a c v
vim a dy thn kinh. Cc hch nh v cng, t khi c hch ln, s nn c di da dc
theo mch mu. Thng c du hiu ca vim thn: protein niu, hng cu niu, cao huyt
p. Cc biu hin suy tim, i khi c bin chng no nh co git, lit na ngi, ri lon
ngn ng, bn manh, tng ng.

L
Landry (Landry J ean B.O., bc s Php)

(Cn gi l hi chng Landry-Kussmaul, bnh lit Landry, lit leo ln cp tnh)

Khi u c d cm hai chn, st nh. Sau vu gi hoc vi ngy xut hin lit mm, mt
phn x gn xng. Lit nhanh chng tin trin ln cc c thn mnh, hai tay, li v hng,
mt v c honh. Khi lit ti c honh s gy t vong. Dch no ty tng albumin m t
bo khng tng nhiu (phn ly albumin - t bo). y l bnh cnh rt cp tnh ca hi chng
Guillain-Barr.

Lindau (Lindau Arvid, nh bnh l hc Thy in)


310


(Cn gi l bnh Lindau, u mch vng mc tiu no)

Bnh di truyn tri theo nhim sc th thn (autosoma), gy cc d dng nguyn bo mch
nhiu ch: cc u mch dng nang tiu no, vng mc v tuyn ty, thn a nang. Hi
chng ny khc vi hi chng Hippel-Lindau ch thn a nang v tuyn ty c nang.

Little I (Little William J ., bc s phu thut v chnh hnh M)
(Cn gi l bnh Little, lit hai chi di co cng tr em, lit hai chi di do bnh no)

Bnh lit co cng hai bn tr em sau chn thng khi sanh: phn x gn xng tng r,
co cng cc c khp khi i v ng. Thng c cc c ng kiu ma vn hoc ma git,
lon vn ngn, pht m chm, i khi c cc cn ng kinh, thiu nng tr tu. Co cng v
ri lon pht trin chn tay. Xng bnh ch nm trn cao. Cng cn c th nguyn nhn
do di truyn ln theo nhim sc th thn (autosoma).

Little II (Little Ernst G. Graham, nh da liu hc ngi Anh)

(Cn gi l hi chng GrahamLittle, hi chng Lassueur-Little...)

Bnh da a dng cha r cn nguyn vi chng dy sng gy teo dng nang: rng lng tc
gy teo vng nch v mu. i ch to nn cc ngoi ban kiu ging nh lichen phng, lon
dng mc chn tay.

Loffler I

(Cn gi l chng tng bch cu i toan Loffler, hi chng Kartagener)

Thm nhim t bo i toan trong phi trong thi gian ngn:st nh thong qua trong khi
ton trng tt, ch i khi c mt mi, ho nh, v m hi ban m. Nghe phi triu
chng rt ngho nn. Trong mu tng bch cu i toan r. X quang thy cc m thm
nhim c kch thc v nh khu khc nhau, v thng bin mt nhanh chng. i khi cng
thy cc m thm nhim tng t cc c quan khc. Thng c ph thong qua cc
khp v ban . Bnh lnh tnh, thng vo thng 7 v 8 ( chu u).

Loffler I I

(Cn gi l vimmng trong timLoffler)
Vim mng trong tim to m x gy tn thng ch yu tm tht phi. Cho l do nguyn
nhn d ng: suy tim tin trin m khng tm thy du hiu thc th r rt no, i khi
c ting thi tm thu, v sau cnga phi, tim to ra r, ECG thy sng T m km theo du
hiu tng gnh c 2 tht. Tng bch cu i toan r, khng st, yu mt ton thn, kh th,
lch to. Tin lng xu.

Louis-Bar (Louis-Bar Denise, n bc s Php)

(Cn gi l tht iu gin mao mch, gin mao mch no - mt - v da)

311


Phc hp di truyn ln theo nhim sc th thn (autosoma) tr em: ri lon dng i v
dng ng. Trn mt c cc vt mu c ph sa, gin mao mch kt mc mt, vim xoang
tai pht v nhim trng ng h hp, tng tit nc ming. Chp no thy gin rng no
tht IV, teo tiu no. Tin lng xu.



Lyell (Lyell A., bc s da liu Anh)

(Cn gi l tiu biu b hoi t cp tnh dng nh phng do nhimc d ng)
Bnh da nghim trng vi khi pht cp tnh, tin trin cp tnh v kt thc bng t vong:
st cao, da c cc ban ln, xut hin trong vng vai gi v chuyn mu pht xanh. Nhanh
chng to nn cc phng nc, biu b b bong ra ging nh trong bng II. Cng c biu
hin tng t nim mc ha. Sau khi bong da, xut hin cc vt trt km tit
dch ln mu. Trong mu c tng bch cu, i khi gim bch cu. Vim thn.

M
Mallory-Weiss (Mallory G. Kenneth, nh bnh l hc M; Weiss
Soma, bc s M)

Cc vt rch nim mc vng chuyn tip thc qun vo d dy: nn i ti pht, v sau
nn i ra c mu. Du hiu X quang m tnh, khi ni soi thy cc vt rch nim mc chiu
di 2-4 cm, ch yu nm gia thc qun v tm v. Thng thy nht trong nhng ngi
nghin ru.

Marfan I (Marfan Antonin B., bc s nhi khoa Php)

(Cn gi l hi chng Marfan-Achard)
Phc b di truyn tri theo nhim sc th thn:
A) Cc d dng thuc l phi gia (trung b):
a) Xng: ngc hnh ci phu, ngc g, vo lng, g lng, bin i yn bm, chn
tay di mt cch bt thng v cc ngn nh nhn. Li xng, gai i, cc ngn chn ci
quo ra, tch i vm hng, thiu rng;
b) Thiu sn h c v m m, cc khp lng lo;
c) D tt bm sinh ca tim, ti phnh ng mch ch, tnh mch di da gin rng,
s lng lp li cc thy phi;
d) Mt cn tn ti mng ng t, bnh c, thiu lng mi, nhn cu ln, cng mc
xanh;
e) Mi to, mt hnh chim, lon sn vnh tai, din mo gi
ci.
B) Cc bin i ngoi b:
a) Thy tinh th lc ch, tt khng c thy tinh th;
b) Cc biu hin ca h thn kinh trung ng: ng t c kch thc khc nhau
khng phn ng vi nh sng v hi t, ri lon cc phn x, cc du hiu thp, rung git

312


nhn cu, no ng thy, teo no;
c) Tng chiu cao c th, chn tay c u ngn ln, ri lon kinh nguyt, i tho
nht, nhi ha; d) Chm pht trin tm thn.

C) Cc bin i thuc l phi trong (ni b): rut qu di, thiu sn rut.




Marfan II

Lit hai chn co cng bnh nhn b giang mai bm sinh: lit hai chn co cng khng
km ri lon dinh dng v cm gic. teo dy thn kinh th gic.

Marion (Marion Henri, bc s Php)

(Cn gi l bnh Marion, tc c bng quang)

Hp l ra khi bng quang tr em: bnh pht sinh do cn nguyn nhim trng ng niu,
x ha bng quang, b tiu, nhim trng ngc dng ln thn. Trn X quang thy r c dng
tro ngc t bng quang ln niu qun. Ty theo giai on bnh cn c nhng bin i
tip theo. Cn phu thut gii phng ch hp kp thi.

Martin-Albright (Martin Eric, nh ni khoa Thy s; Albright
Fuller, bc s M)

(Cn gi l chng gi thiu nng cn gip)
Chng gi thiu nng cn gip trng gia nh km h Kali mu, kh nng do di truyn ln
lin kt vi nhim sc th X: tm vc nh, th cht gim sn, bo ph, mt trn, chng
dy da, thiu sn men rng v chng rng rng, chn tay ngn. Tetany tim n hay l r
nhng khng p ng vi parathormon. Thiu nng tr tu. Trong mu gim Calci ko di,
tng phosphat mu. Phosphatase bnh thng.

Matzdorff-Lhermitte (Lhermitte J ean, nh thn kinh hc Php)

(Cn gi l hi chng th Luys, hi chng cc nhn di i th)

Phc b cc ri lon thn kinh khi nhn Luys b kch thch hoc tn thng: cc c
ng kiu ma git mt na c th, lon vn ngn, lon ngn ng, thng c ph na
ngi. Tng trng lc c nh v c c khi ng.

McArdle (McArdle B., bc s nhi khoa Anh)

(Cn gi l bnh c do glycogen)


313


Mt loi bnh glycogen di truyn ln theo nhim sc th thn (autosoma): au trong bp c
ngay c khi vn c nh v thy c ngay khi cn nh, mt mi nhiu, yu sc, myoglobulin
niu thong qua, v sau c teo c, suy tim. V sau yu c cc c trn. Bnh do thiu ht
phosphorylase c, glycogen khng phn tch c v ng li trong c.





Melkersson-Rosenthal (Melkersson Ernst G., bc s ngi Thy
in; Rosenthal Curt, bc s c)
(Cn gi l chng lit mt ti din, hi chng hch gi)

Mt kiu lit dy thn kinh mt: u tin thnh thong, sau l b trng din chng ph
mt v mi, lit dy mt ti din, d cm ngn tay, ri lon nut lp i lp li, khuynh hng
b migren, tng tit nc mt, tai. i khi c km bnh l kiu thp v/hoc cc hch c
to ra.

Mendelson (Mendelson Curtis L., bc s gy m ngi M)

(Cn gi l vimphi do ht dch v)

Ht phi dch acisd d dy khi gy m: khong
2-5 gi sau khi ht phi dch v, bt u c kh th kiu hen suyn, xanh tm, st, nhp tim
nhanh, ran m v thm ch c th ph phi, sc. X quang: biu hin tn thng phi tng
i nh, i khi vim ph qun phi tng .

Mnire (Mnire Prosper, nh ni khoa Php)

(Cn gi l bnh Mnire, chng chng mt m o)

L tn gi chung ca cc ri lon tin nh: tai, chng mt kch pht, thng c rung git
nhn cu ngang. V sau c th c ri lon thnh lc khng phc hi do tn thng tai
trong. i khi tng tit nc ming, nn i.

Menzel (Menzel P, bc s ngi c)

Tam chng trong u c tnh hng: hch c sng to, thnh lc gim, au dy thn kinh s V.

Millard-Gubler (Millard Auguste v Gubler Adolphe M., cc bc s
Php)
(Cn gi l lit na ngi giao bn thp)

Mt kiu lit na ngi giao bn: lit dy thn kinh mt kiu ngoi vi mt bn v lit

314


chn tay bn i din.

Morgagni-Adams-Stokes

(Cn gi l hi chng Adams-Stokes, bnh Adams-Stokes




N
Neumann I (Neumann I sidor, bc s da liu ngi A)

Cc mn nc hnh thnh t pht da v nim mc ming, c quan sinh dc v nch:
cc mn nc nhanh chng v ra v thay bng tht u nh (papiloma) ca t chc ht. Thng
c thuyn gim ko di.

Neumann II (Neumann Ernst, nh bnh l hc c)

Cc khi u lnh tnh ca nu rng (li rng) tr ang b: rt nhiu cc khi u nh khng
au dc theo b ca xng hm, sau s mc rng sa vi cc khim khuyt men
rng. Bnh bm sinh, c i tnh n.

Nevin (Nevin Samuel, nh thn kinh hc Anh)

(Cn gi l bnh teo no do xp)

Bnh no trc tui gi cha r nguyn nhn: bt u vo khong 50-70 tui, ri lon
th gic tng dn ti m, ri lon ngn ng, lit vn ng, cc du hiu tiu no, gim tr
nng, cc cn co git. Vi th thy teo t bo no km s to thnh cc cu trc ging nh
bt bin trong t bo sao.

O
Osler (Osler Willim, nh ni khoa Anh-M)
(Cn gi l hi chng Rendu-Osler, bnh Osler, chy mu do gin mao mch di truyn)

Bnh di truyn tri theo nhim sc th thn (autosoma) gy gin mao mch da v nim
mc: gin mch ch yu mi v nim mc li, rt nhiu cc u mch c cc phn khc
ca thn th. Thng chy mu cam v nn c mu v cc biu hin chy mu tiu ha khc,
tiu ra mu. V sau c gan to v c trng.


315


P
Paget (Paget J ames, nh ngoi khoa Anh)

(Cn gi l bnh Paget, vimxng bin dng)

Lon dng xng ca 1 hoc nhiu xng, nhiu kh nng di truyn lin kt nhim sc
th X hoc kiu tri theo nhim sc th thn (autosoma): giai on tin triu c kiu st
thp khp. Cc ri lon kiu thp khp c th ko di nhiu nm. Khi b tn thng xng
s th s s to ra, i khi c b mt s t. Hay c gy xng t pht. Nu ta n nhng phn
xng s b ph i th c th to nn nhng triu chng thn kinh, i khi ri lon th gic
hoc ic. X quang: dy mng xng, bin dng, gy xng. Bnh thng bt u lc tui
gi, tin trei63n chm chp. Hng tnh nam.

Pancoast (Pancoast Henry K., nh X quang hc M)

(Cn gi l hi chng Pancoast-Tobias, u Pancoast)

Khi u c tnh nh phi km ri lon thn kinh giao cm c: gim tit m hi khu tr,
ch yu l c, vai v ngc. Du hiu Horner dng tnh. au nhiu 2 tay, ngc v vai
ging nh cn au tht ngc nhng khng p ng vi thuc gin vnh. Thng c teo c v
t b tay. Khi u xm ln phn mm ca c v thng xm ln c t sng v xng sn.
Dn dn suy mn.

Parinaud I (Parinaud Henri, nh nhn khoa ngi Php)

Vim kt mc dng ht l ra ngoi, mt bn v lnh tnh: st, ph mi, kt mc c cc
ht mu vng kch thc nh u kim, gic mc thng khng b nh hng. Ph kn o
tuyn mang tai av2 hch c. Khi bnh sau khong 4-5 tun. Bnh do Leptotrix v do nhiu
loi ng vt truyn bnh.

Parinaud II

Ri lon kh nng nhn theo chiu thng ng trong tn thng c no sinh t: ri lon kh
nng di chuyn nhn cu theo chiu dc (thng ng), mt phn ng vi nh sng, hi t
chm, i khi rung git nhn cu. Nguyn nhn hay gp nht l u bu.

Parkinson (Parkinson J ames, nh phu thut v kho c hc
ngi Anh)

(Cn gi l bnh Parkinson, chng lit rung)

Tn thng h thng ngoi thp t pht, i khi l hu qu ca nhim trng hay nhim
c. Bnh nhn b cng , nt mt n nh mt n, gim vn ng, i vi t th
cng xung, ging ni n iu, run in hnh u v tay, tng tit m hi v tng tit

316


nc ming. C th trm cm, gim dn tr tu, khuynh hng o gic. bnh thng
hay c nht tui 50-60.

Penfield (Penfield Wilder G., nh phu thut thn kinh Canada)

Phc b cc du hiu kch pht trong u bu ca di i th: cc cn co git, cao huyt
p, rung git nhn cu, chy nc mt v chy nc ming, li mt, gim nhit , nhp tim
nhanh, th chm.

Pick I (Pick Arnold, nh thn kinh hc v tm thn hc c)

(Cn gi l bnh Pick, sa st tr nng trc tui gi)

Teo c gii hn ca v no v bn cu i no, km theo cc bin i v nhn cch. Bnh
thng khi pht quanh tui 55. Nu tn thng thy trn s c chng th lnh m, ngho
nn cm xc, thu hp phm vi nng lc, t duy v vn ng. Nu tn thong ch yu
phn nn ca thy trn s c khoi cm bnh l, suy gim kh nng ph phn, mt km
ch o c. Nu tn thng thy thi dng s c chng lp li v c x, li ni v ch
vit. C o gic ngn hn, chng ba chuyn, cho ti trng thi l ln v bt an v tm thn
vn ng. i khi c cc ri lon ngoi thp nh: gim biu cm nt mt, cng kiu
parkinson. Thng c teo cc c nh bn tay. in no : gin rng cc no tht. Ngi ta
gi thit bnh do di truyn tri theo nhim sc th thn.

Pick II (Pick Friedel, nh ni khoa v bc s Tai-Mi-Hng c)

(Cn gi l bnh vimgan gi x gan, x gan do tim)

X gan do vim mng quanh tim: cc du hiu ca tr tnh mch, c trng, trn dch mng
phi, ph hai chn, kh th, xanh tm. Cc khm xt tip theo cho thy c hin tng tr
do vim mng quanh tim v suy tim mc nng vi tin trin mn tnh. Khi t ng thng
thy p lc tnh mch tng cao trong c hai tnh mch ch.

Prinzmetal (Prinzmetal Myron, bc s tim ngi M)

(Cn gi l hi chng Graybiel, cn au Prinzmetal)

Cn au tht ngc xuy hin vo lc ngh ngi, thng c ri lon nhp tim, cm gic s
hi, tot m hi, bt an. in tim trong cn: cc du hiu r rng ca thiu mu di
thng tm mc, ngoi cn th khng cn thy cc du hiu ny.

Q
Quincke (Quincke Heinrich I., nh ni khoa ngi c)

(Cn gi l hi chng mc - thn kinh, ph mch thn kinh, bnh Bannister, ph Quincke)


317


Ph mch thn kinh trn nn tng d ng, i khi d ng: ph cp tnh mt, nht l mi
v mi mt, chn tay v b phn sinh dc ngoi. Thng c nn i, tiu chy, au u v c
ph phi. Khi ht cc du hiu ph th thng s tiu nhiu. C khuynh hng ti pht. i
khi ng thi vi cn hoc sau cn c km cc biu hin d ng khc, nh hen ph qun,
migren...

R
Racine (Racine W., bc s ngi Thy s)

Phc b cc triu chng trc k kinh: ph c tuyn nc bt, cng v ph tuyn sa. Cc
du hiu t ht i khi c kinh.

Raeder (Raeder J .G., nh thn kinh hc Na uy)

(Cn gi l hi chng giao cmcn dy V, hi chng cn au dy V)

Biu hin ca au dy thn kinh cn dy V: au d di mt bn, au theo nhp p khng
ti no tr c trong mt. Bun nn, nn v co ng t. au thng bt u t sng
sm v ko di cho ti bui tra. Thng ph n hay b hn.

Raymond (Raymond Fulgence, nh thn kinh hc Php)

(Cn gi l lit na ngi giao bn vi lit dng mt)

Lit khng c nh bnh nhn c tn thng nhn dy VI (dng mt- a mt ra ngoi pha
thi dng) v b thp trc khi bt cho: lit na ngi cng bn, lit dy VI bn i din
(?).

Raynaud (Raynaud Maurice, nh ni khoa ngi Php)

(Cn gi l bnh Raynaud, bnh hoi th Raynaud, hoi th cn i)

Ri lon tun hon kch pht tay v chn, cn i hai bn, km cc du hiu hoi th th
pht: cc cn co tht ng mch gy au cn i c hai bn, ch yu ngn tay, km theo
t b v thay i mu sc. Trn da c cc mn nc, hoi th th him hn. i khi thy c
cc du hiu ny mi, tai, cm. Dng phng php soi mao mch thy rt nhiu cc mao
mch cun ngon ngoo, thm ch to thnh nt tht. i khi trn X quang c xng sn
c. B bnh a s l ph n.

Recklinghausen (Recklinghausen Friedrich D. von, nh bnh l
hc c)
(Cn gi l bnh u x thn kinh)

Bnh h thng ca cc m thn kinh, di truyn kiu tri theo nhim sc th thn (autosoma).

318


Thng khi pht vo tui thiu nin, biu hin bng cc vt sc t mu c ph sa, rt
nhiu cc u x thn kinh khng au. C cc u t bo thn kinh m (neuroglioma) khu vc
cc r thn kinh. Cc u x trong no v ty s gy cc triu chng thn kinh ty theo khu
tr ca chng. Ngay c trong xng cng c nhiu biu hin thoi ha v cc d dng.

Recklinghausen-Engel (Engel Gerhard, bc s c)

(Cn gi l bnh Recklinghausen, cng cn gip trng nguyn pht, vimxng dng si
c nang)

Cc lon dng xng lan ta km theo cc nang v cc nhm t bo khng l trong xng.
Bnh khi u tui 20-40 vi cc du hiu khng in hnh: au trong xng, tiu
nhiu. Dn dn hn ch vn ng, xut hin gy xng t pht. Trn X quang: mt Calci
cho ti teo dng ht, cc nang, u cc xng di c cc nhng t bo khng l, tiu
long xng, g lng. Trong mu tng Calci, h Phosphat, tng Phosphatase, thn b calci
ho. Nguyn nhn l cng cn gip trng nguyn pht.

Refsum (Refsum Sigvald B., nh thn kinh hc ngi Na uy)

(Cn gi l vima dy thn kinh mt iu ha ng tc di truyn)

Bnh di truyn kiu ln theo nhim sc th thn (autosoma): vim vng mc sc t km
chng qung g, vim a dy thn kinh mn tnh, lit tng dn phn di c th, phn
x gn xng gim hoc mt, tht iu tiu no, mt khu gic, tng s lng dch no ty.
Lon sn khp cn i c hai bn, cc bin i xng ging nh trong bnh vy c
(ichthyosis). in tm : nhp tim nhanh, cc bin i ti cc lan ta, i khi ri lon dn
truyn.

Reiter (Reiter Hans, nh v sinh hc ngi c)

(Cn gi l bnh Reiter, tamchng Reiter, vimniu o do vima khp, vimniu
o thp khp)

Tam chng: vim niu o, vim kt mc, vim a khp. Tin s c vim rut thng
thng, i khi l. Bing n, gy st, bun nn v nn i, st, kch thch nim mc mi
v kh qun, nhng cng c c vim m h, vim qui u, thng cng c vim mng phi,
vim mng no, vim gn - bao gn, i khi vim thn. Cn c vim kt mc, vim mng
mt th mi, ni my ay, herpes, lon dng mng km chy mu chn mng. Vim a
khp c tin trin nng n. X quang: cc bin i xng, c th cho ti mc phn hy xng.
Bnh ch yu n ng tui 20-
40. Tin trin mn tnh vi cc t ti pht/

Robertson (Robertson Douglas M.C.L. Argyll, nh nhn khoa ngi
Scotland)

(Cn gi l du hiu Argyll-Robertson)

319



Ri lon chc nng ng t do cn nguyn thn kinh trong cc bnh l khc nhau ca h
thn kinh: ng t khng phn ng vi nh sng, nhng li phn ng tt khi hi t v iu
tit (xa gn). Phn ng vi cc kch thch cm gic v tm l b suy gim. Co ng t. ng
t khng u hoc d dng ng t.

Rosenthal (Rosenthal R. L., bc s M)
(Cn gi l bnh Rosenthal, hi chng PTA)
Bnh a chy mu typ C (thiu ht prothromboplastin, yu t Rosenthal). Bnh
di truyn kiu ln theo nhim sc th thn (autosoma): chy mu d dng ngay c sau
mt chn thng nh, v d chy mu mi, sau phu thut, sau nh rng. Rong kinh.
Thng khng c chy mu vo trong khp v di da. Mu: tiu cu bnh thng, thi
gian ng mu ko di nh, ri lon ti to thrombokinase.

Roussy-Lvy (Roussy Gustave, nh bnh l hc Php; Lvy
Gabrielle, bc s Php)

(Cn gi l bnh Roussy-Lvy, chng lon iu ha vn ng di truyn mt phn x)

Bnh tht iu gai (ty sng) - tiu no do di truyn tri theo nhim sc th thn (autosoma):
ngay t khi mi bt u tp i c tht iu, d dng bn chn, vo lng, Teo tng dn
cc c pha di ca cng chn. Xut hin ci gi l chn cng c. Mt phn x gn
xng tt c cc chi th. i khi du Babinski (I) dng tnh, ri lon cm gic su, gim
kh nng phi hp vn ng chi th, yu sc c, chm chp l . i khi lc mt, c
thy tinh th, thiu nng tr tu.


S
Sheehan

(Cn gi l hi chng Simmonds-Sheehan, suy mn do tuyn yn)

Thiu nng thy trc tuyn yn: teo cc c quan sinh dc trong v ngoi, v kinh, thiu
sn t cung. Cc bin i bt u xy ra ph n sau khi sanh. Khng mc lng, da mng,
teo tuyn gip, gim chuyn ha v gim thn nhit, gim ng huyt, d xc cm, thiu
mu nh, gim Na mu. Cn c gim 17- ketosteroid v 11-ketosteroid, v c gonadotropin
trong nc tiu. Tin lng xy v s teo nhiu tuyn.

Sheldon (Sheldon J . M., nh nhi khoa ngi Anh)

(Cn gi l hi chng bo ph ca ngi m)

Ri lon ni tit t khi mang thai, v sau pht trin thnh bnh tiu ng: khi mang thai
ngi m nhanh chng tr nn bo ph, bo ph ko di c sau khi sanh, tr sanh ra c cn

320


nng ln hn bnh thng. Thng v sau s pht trin thnh bnh tiu ng.

Shy-Drager (Shy George M. v Drager Glenn A., cc nh thn kinh
hc M)

(Cn gi l h huyt p t th do lon vn ng - lon thn kinh thc vt)

Bnh l no ty, c th di truyn tri theo nhim sc th thn (autosoma): h huyt do t
th (khi ng thng), ri lon tiu tin, tn thng no-ty v tiu no tng tin. Yu v teo
c. Soi hin vi ch yu thy ch tn thng nhn lng ca dy X km s gim dn v s
lng cc t bo trc hch ca cc ct sau ty sng.

Schmidt I (Schmidt Adolf, nh ni khoa ngi c)

(Cn gi l hi chng Avellis-Schmidt)
Mt kiu lit giao bn thng thy sau tn thng pha lng ca hnh ty: lit mn hu
v dy thanh cng bn, lit c c n chm v thang cng bn, lit na ngi bn i din.

Schmidt I I (Schmidt Martin B., nh phu thut ngi c)

(Cn gi l hi chng Martin Schmidt, hi chng suy tuyn gip - thng thn, hi chng
ba tuyn)

Thiu nng tuyn gip v v thng thn trong bnh tiu ng: tng sc t da v nim
mc, mi mt, kh da, gim huyt p, ngt xu, bing n, nm i, tiu chy, v kinh, lit
dng, tiu nhiu. Mu: hm lng Na bnh thng, K tng,Glucose tng. Nc tiu c
ng. Bn cht l tn thng do min dch c 3 tuyn: tuyn gip, thng thn v ty.
Cng cn c th di truyn ln theo nhim sc th thn.


Schmitt (Schmitt H.G., nh phu thut ngi c)

Tn thng ct sng do chn thng ca ngh nghip: rt thng ngi cu th, mt mi,
au kiu gi bnh thp hoc gi r vng sau t, ct sng c v gia hai xng b vai.
Nguyn nhn l cc bin i kiu thoi ha, thm ch c th b t ri vi gai sng.

Schonlein-Henoch (Schonlein J ohannes L., nh ni khoa v
Henoch Eduard H., nh nhi khoa, ngi c)

(Cn gi l ban xut huyt Schonlein- Henoch, ban xut huyt gimtiu cu nguyn
pht)

Ban xut huyt do d ng nhim c: cc vt ging nh my ay, ban a dng, xut huyt
di da ch yu da chn tay, v cn c xut huyt nim mc. Kch thc cc vt xut
huyt bng u ghim hay ht u. Cn c ph, au khp, au bng km cu phn en. Tiu ra

321


mu v albumin niu. i khi tng bch cu i toan v tng bch cu. Mu chy v s lng
tiu cu bnh thng. Thng c cc biu hin d ng khc : my ay, ph Quincke...Thng
bnh nhn l n. Hay ti pht v thuyn gim. i khi c th di truyn tri theo nhim sc
th thn (autosoma).

Schroeder (Schroeder Henry A., bc s M)

(Cn gi l bnh cao huyt p ni tit)

Cao huyt p ngi c ri lon ni tit t: nhanh chng b bo ph (vo thi k mn kinh
hoc sau sanh), cao huyt p, thot mu ra y mt, ng cong glucose mu bt thng, ph
i xng trn, rm lng, c cc vt rn da. Gim lng Na v Cl trong m hi.

Sicard (Sicard Roger, nh thn kinh hc Php)

(Cn gi l chng au dy thn kinh li hu t pht)

au dy thn kinh li hu: au d di t ngt mt bn mn hu khi n thc n cng,
ming n nng hoc lnh, i khi thm ch sau khi ngp hoc ci to. au ko di khong
2 pht. au lan xuyn ra li , hm di, tai bn , i khi c mt.

Sjogren I (Sjogren Henrik C., nh nhn khoa ngi Thy in)
(Cn gi l hi chng Mikulicz-Sjogren, vimgic kt mc kh)

Bnh h thng mn tnh vi suy tt c cc tuyn ngoi tit: kh nim mc, vim kt mc,
vim gic mc, gim tit nc mt, vim mi, vim hng - kh qun, vim m h, vim m
o, kh ming, to tuyn mang tai. Gim toan d dy, bnh ti mt mn tnh, bnh ty. Teo
tuyn m hi v nhn, kh da, vim da do nh sng, s nh sng, gin mao mch. Ri lon
Calci ha ca rng v xng, vim a khp mn tnh, vim ng mch km theo hoi th
chn tay. Paraprotein mu, thiu mu nhc sc, gim Fe huyt thanh. Bnh nhn a s l
ph n thi k mn kinh. Thng c thuyn gim v ti pht. Bnh c th do di truyn ln
theo nhim sc th thn (autosoma), nhng hin nay a s cho l do t min.

Sjogren I I (Torsten Sjogren, nh tm thn hc Thy in)

(Cn gi l hi chng Torsten Sjogren)

Nhiu kh nng l bnh di truyn kiu ln. c thy tinh th km thiu nng tr tu:
c thy tinh th c hai bn, chm pht trin ton din, tht iu tiu no, mt trng lc c,
no nc ni.

Sudeck (Sudeck Paul H.M., nh phu thut c)

(Cn gi l hi chng Sudeck-Kienbock, teo Sudeck, long xng Sudeck)

Teo cc xng nh bn tay v chn sau chn thng do cn nguyn thn kinh: Trong giai

322


on I da bn tn thng v nng, ph v yu c; lng v mng mc nhanh hn. Trong
giai on II c xanh tm v lnh, da teo v bng, au t pht trong xng khi ngh
ngi v c sau gng sc, cng khp, teo c, mng b nt rch. X quang mt xng xp
tng . Trong giai on III au s t i, nhng hu nh khng th c ng khp c.

Sydenham (Sydenham Thomas, bc s ngi Anh)

(Cn gi l bnh Sydenham, ma git nh, ma git do thp, ma git Sydenham)

Tn thng th vn do vim - nhim c gy ra cc cc ri lon vn ng kiu tng ng -
gim trng lc lan ta. Bnh ch yu tr em, biu hin bng cc c ng ma git in
hnh v c ng nt mt bt thng (kiu nh b mt nhn nh), hi kch ng v tm l,
khng tp trung t tng, gim hot ng. Tr n hay b nhiu hn. Ma git thng kt hp
vi cc dng khc ca bnh thp khp cp, nht l vi vim mng trong tim.

Takayasu (Takayasu Michishiga, bc s Nht bn)

(Cn gi l bnh Takayasu, vimng mch cnh tay - u)

Vim ng mch gy tc nghn khu vc thn cnh tay - uL khng s c mch
tay, mch chn bnh thng, h huyt p na trn c th trong khi li cao huyt p
na di c th. Nhp tim nhanh, tng mn cm vi phn x xoang cnh vi khuynh hng
ngt xu, ting thi quai ng mch ch, ri lon th gic theo chu k thm ch m thong
qua. Cng c th tn thng vng mc vnh vin do thiu ti mu. i khi thay i dinh
dng ca da v c, thm ch teo. rng rng, nghe km, thm ch ic.
Tay-Sachs (Tay Waren, bc s nhn khoa Anh v Sachs Bernard
P., nh thn kinh hc M)

(Cn gi l bnh Tay-Sachs, chng ngu n Tay-Sachs)
Bnh di truyn ln theo nhim sc th thn (autosoma) gy ngu n v m tr em: bnh
khi pht ngay thng tui th 4-6. Gim th lc tng dn ti mc m hon ton, thiu
nng tr tu c th ti mc ngu n, cc co git kiu co cng - co git, ma vn, ma
git, co tht xon vn. Thoi ha vng mc v teo dy thn kinh th gic. Bnh ko di
khong 2-
3 nm. Thng cht do cc bnh gian pht do thiu izoenzym A.

Thomsen (Thomsen Asmus J .T., bc s c)

(Cn gi l bnh Thomsen, tng trng lc c bmsinh)

Mt kiu tng trng lc c, bnh di truyn kiu tri theo nhim sc th thn (autosoma),
cng c kiu ln theo nhim sc th thn nhng t hn. Bnh tng biu hin ngay sau khi
sanh, tr kh b, nt mt cng , cc bp tht ph i r (c bp Hercules), tng tnh
kch thch ca c.

Tinel (Tinel J ules, nh thn kinh hc Php)

323



Chng to u chi khng r nguyn nhn, c cc cn au kch pht cc on cui ca
chi th (cc ngn) m khng c ph v hng ban.

Tolosa-Hunt (Tolosa Eduard, bc s M v Hunt William E., nh
phu thut thn kinh M)

Vim xoang hang hay phn trn mt: au pha sau nhn cu mt bn, lit tm thi cc
dy vn nhn, i khi nhn i. Thng gp ngi tiu ng.

Tourette (Gilles de la Tourette Goerges E.A.B., nh ni khoa ngi
Php)

(Cn gi l hi chng Gilles de la Tourette, bnh Gilles, bnh Tourette, ma git bin thin)

Tn thng th vn gy tng ng: cc tic, bt thng biu cm nt mt (nhn nh), kht
mi, khc nh, git vai, gt lc u, ng tc nhy lp i lp li, vng tc, lp. Khi b kch
thch thm ch c cc c ng kiu ma git. Trc thng c cc lch lc trong cm
xc v tnh dc. Cng c th c yu t di truyn.

Troisier-Hanot-Chauffard (Troisier Emile, Hanot Victor v
Chauffard Anatole, cc bc s Php)

Bnh tiu ng trong x gan v x ty, lch to v tng sc t da: cc vt mu xm trn da
mt, b phn sinh dc v chn tay, tng porphyrin trong nc tiu, thng c teo bung
trng, lit dng v cc ri lon ni tit t khc. C tr tun hon ca km c trng, cc
du hiu th tng chy mu. Mu tng Fe. Thng n ng trn 40 tui. C dng di truyn
tri theo nhim sc th thn (autosoma), v c dng do nhim c, nht l vi cc cht c
cha ng.

Trotter (Trotter Wolfred, nh phu thut Anh)

(Cn gi l tamchng Trotter)
Phc hp cc triu chng khi c cc khi u nh trong mi hng: au hm di, li v
tai mt bn. Tai cng bn gim thnh lc v mn hu cng bn km c ng. V sau
xut hin chng co kht hm, ph tuyn mang tai m thng b coi l vim tuyn mang tai
mt bn.

Trousseau (Trousseau Armand, nh ni khoa ngi Php)

Vim tc tnh mch bnh nhn c ung th ni tng: vim tc tnh mch t pht cp tnh.
iu tr kt qu km, vim thng t bin mt khi loi b c khi u ni tng.

Turner-Kieser (Turner J ohn W., bc s ngi M v Kieser W.,
bc s ngi c)

324



(Cn gi l hi chng Turner, bnh lon sn c - xng - ty di truyn)

Bnh lon sn cc t chc trung b phi, di truyn tri theo nhim sc th thn (autosoma):
thiu sn xng bnh ch, xng khy tay km sai khp u xng quay, lon sn mng,
to thnh cc chi xng cn xng hai bn cc xng chu. Cn c lon sn cc chi trn,
ph i xng trn, i khi c nhiu vt chm cnh bm. Mt s trng hp c thiu cht
st v cc du hiu thn kinh.

Ullrich I (Ullrich Otto, nh nhi khoa ngi c)

(Cn gi l tnh trng Bonnevie-Ullrich mt bn)

Vt chm cnh bm mt bn c th, thng chn tay, rt nhiu cc thiu sn hoc
bt sn ca c. Cc du hiu khc tng t nh trong hi chng Bonnevie-Ullrich.
Ullrich I I

(Cn gi l bnh lon dng c mt trng lc x ha di truyn)

Nhiu kh nng di truyn kiu ln theo nhim sc th thn (autosoma), gy bnh c c x
ha mt trng lc: Bnh thng c ngay sau khi sanh, h c bp yu nho, c bit l cc
phn xa (bn v ngn), h c tr nn cng v co tht cng, xut hin g vo, kh c ng
cc khp, c bit l cc khp gc chi (vai hng). Cng c th tn thng dy s, yu mt
ton thn. Bnh v sau thng khng pht trin, nhng thng cht sm do bnh gian pht.

V
Volkmann I (Volkmann Richard von, nh phu thut c)

(Cn gi l d dng Volkmann)

Bnh di truyn tri theo nhim sc th thn, gy sai khp c hai mt c, mt c trong di
lch ra trc, cc c bp chn b teo, xng i xoay ra ngoi, thng khuyt tt xng
mc, i khi bt sn hon ton. Tt ngn chi, bt sn xng quay.

Volkmann I I
(Cn gi l lit Volkmann, lit do thiu mu)
Co cng cc ngn tay hoc ngn chn do tn thng h c, hu qu ca ri lon tun hon.
Thng thy ngi tr tui sau khi gy xng canh tay. u tin c ph bn tay, da b xanh
tm v nht nht km gim cm gic, ri lon dinh dng cc ngn tay. Di khy hay to
thnh cc vt so su, cc ngn tay to thnh dng mng vut chim.
W
Waldenstrom I (Waldenstrom J an G., nh ni khoa Thy in)

(Cn gi l ban xut huyt tng globulin mu, ban xut huyt lon protein mu nguyn

325


pht)

Cc ban xut huyt chu k km tn thng kiu d ng mch mu do paraprotein mu:
ban xut huyt nh mn tnh, nht l 2 chn. Mu ng v mu chy bnh thng.
Tng cao r rt gamma globulin, tc mu lng. Bnh tin trin theo chu k.

Waldenstrom I I

(Cn gi l bnh i globulin mu)

Nhiu kh nng di truyn tri theo nhim sc th thn (autosoma): mt mi, ti nht, kh
th, to cc hch bch huyt ton thn, cc du hiu th tng xut huyt thy c trong vng
mc, tai trong, h thn kinh trung ng, h tiu ha. Mu ng v mu chy b ko di.
Tng thi gian prothrombin, co cc mu bnh l, paraglobulin mu, i globulin mu, th
nghim Sia dng tnh. Tng tc lng mu r. i khi to gan v lch. Mu: thiu mu r,
hay l thiu mu ng sc, tng bch cu lympho, gim tiu cu. Trong ty xng i khi
c tng cc t bo tng bo. Bnh hay c n ng 50-70 tui.

Waterhouse-Friderichsen (Waterhouse Rupert, bc s ngi Anh
v Friderichsen Carl, bc s an mch)

(Cn gi l bnh Waterhouse-Friderichsen, nhimtrng mng no cu c tnh)
Nhim trng tin trin d di vi suy thng thn: khi u t ngt vi st cao, au u,
nn i, au bng, tiu chy, xanh tm khng n nh tng dn. Trong vng vi gi xut
hin chy mu di da v nim mc, ngt xu, co git. Cc du hiu ri lon ng mu mao
mch. Thng tr em v ngi b ct b lch. Nhim trng thng l m no cu,
nhng cng thng c b do ph cu hoc lin cu.

Weber (Weber Hermann D., bc s Anh- c)

(Cn gi l hi chng Weber-Leyden, lit Weber, lit na ngi giao bn vn nhn)

Du hiu tn thng thn no: lit chn tay c du hiu tn thng thp bn i din, lit
cc c nt mt bn i din tr cc c trn. Lit cc c li. Lit cc c vn nhn cng
bn.

Welander (Welander Lars A., nh thn kinh hc Thy in)

(Cn gi l bnh c pha ngoi vi mun do di truyn)

Bnh c di truyn kiu tri theo nhim sc th thn (autosoma): bnh khi pht quanh tui
40-60, yu c tng dn, teo cc c dui v c nh ngn chi tt c cc chi th. Ni tri
ln l yu cc ngn tay, dn ti t th gp cc ngn. Cc phn x gn yu dn, nht l phn
x Achille. Cc c gn trung tm nh u, c, lng th him khi b.



326


Wenckebach (Wenckebach Karel F., nh ni khoa ngi H lan)
(Cn gi l chu k Wenckebach)

Khong P-Q trn ECG dn dn di ra, cho ti mc mt hn phc b QRS. Hin tng ny
lp li theo chu k.

Werdnig-Hoffmann (Werdnig Quido, nh thn kinh hc A v
Hoffmann J ohann, nh thn kinh hc c)

(Cn gi l bnh Werdnig-Hoffmann, teo c ty sng tin trin tr em)

Bnh teo c tun tin: bnh bt u vo cui thi k tr b m. Teo c tng dn i,
khung chu, lng, v sau c khi c b vai cnh tay. Phn x yu hoc mt, nhng cm
gic bo ton. Trong giai on mun c du hiu hnh no. C ng th dn dn b hn
ch, trng hp nng ch cn th bng c honh.

Werlhof (Cn gi l bnh Werlhof- Wichmann, bnh gi a chy
mu)

Biu hin lm sng ca xut huyt gim tiu cu: chy mu ln t ngt nim mc, ch
yu l mi ming, cng c th (t hn) vo ng tiu ha, bng quang, ph n th bng
huyt. Chy mu di da biu hin bng cc m xut huyt c cc kch thc khng u.
Mu: thiu mu th pht, gim tiu cu, tiu cu bnh l, cc dng cha trng thnh, tiu
cu khng l... Mu chy b ko di, mu ng bnh thng, co cc mu ko di hoc khng
c. Trong ty xng tng t bo nhn khng l (megakaryocyte) vi khuynh hng bt
thng. Lch hi to. Bnh thng tr em v thanh nin.

Wernicke I (Wecnicke Karl, nh thn kinh hc v tm thn hc
c)
(Cn gi l sa st tr nng Wecnicke)

Mt dng suy yu tm thn tui gi: ri lon tip thu, khoi cm, ng ngnh, ba chuyn
rt nhiu.

Wernicke I I (Cn gi l bnh no Wecnicke)

Bnh no rt nng tin trin ti cht. C tam chng: lit vn nhn, nhn i, mt phn x,
ri lon thc. Ngoi ra cn c tht iu tiu no, co git, ri lon thc vt, bnh l ni tit
thng km bo ph. Thng ngi nghin ru mn tnh, thiu Vitamin B1 v x gan.

Wernicke-Mann (Mann Ludwig, nh thn kinh hc c)
(Cn gi l lit na ngi Wernicke-Mann)
Lit trung ng khi tn thng bao trong: bn i din b lit cng chn tay, li v
mt, nhng c trn cn bo ton (do nhn phn b thn kinh kp). Bnh nhn c dng ng
v i c bit gi l t th Wernicke-Mann.

327




Westphal (Westphal Carl F.O., nh thn kinh hc v tm thn hc
c)

(Cn gi l bnh Westphal, lit chu k)

Lit nho chn tay kch pht, nhiu kh nng c tnh di truyn tri theo nhim sc th thn.
Lit mm, tin trin thng l t ngt, c bit l v m. Phn x gn xng gim hoc
mt. Tin triu: cm thy nng chn, cng thng v, bun nn. Trong cn lo s. Trng
hp nng c th tn thng c c tim v h c ni tng. Mu: h Kali.

West (West W.J ., nh nhi khoa Anh)
(Cn gi l bnh no git c tr emc lon nhp cao th)

Co git tr em biu th bng mt lot co c kiu gp. in no c lon nhp. Bnh
biu hin tui khong 2 tui. V sau mang c trng ca bnh ng kinh. Thng c ri
lon tr tu.

Willebrand-J urgens (Willebrand Erik A. von, bc s Phn lan v
J urgens Rudolf, nh huyt hc c)

(Cn gi l bnh gi a chy mu di truyn)

Bnh di truyn tri theo nhim sc th thn (autosoma) gy gim tiu cu vi cc biu hin
ca th trng chy mu. Bnh biu hin tui cn ang b, biu hin tui dy th t c
hn. Chy mu da, nim mc, mi, li rng, cn vo ng tiu ha th t hn. Nguy
him tnh mng khi chy mu t vt thng, v d khi nh rng. Lch khng to. S lng
tiu cu bnh thng, hnh dng cng bnh thng, ch c i khi gim nh. Nhng trong ty
xng c t bo nhn khng l vi cc du hiu thoi ha km cc khng bo. Kh nng
kt tp ca tiu cu gim, thi gian chy mu ko di, nhng ng mu v co cc mu bnh
thng. B bnh ch yu l ph n v h bnh cng nng hn.

Wilson (Wilson Samuel A. Kinnier, nh thn kinh hc Anh)

(Cn gi l bnh thoi ha gan - u, bnh Wilson)

Bnh di truyn kiu ln theo nhim sc th thn gy thoi ho gan v nhn u: khi u
bng run khi vn ng ch tng tin dn, ging ni kiu bng n, gim biu cm nt
mt, thn mnh ra trc, co cng chn v tay, cc c ng kiu ma git, ri lon tm
l, thiu nng tr tu. Du hiu chn on l vng mu xanh l cy quanh mng mt, gi l
vng Kayser-Fleischer. X gan, lch to nh, ri lon chuyn ha saccharid vi cc biu
hin bnh tng insulin, tiu ra aminoacid, tng bi tit Cu ra nc tiu v tch ly ng
trong gan v cc hch nn no. Trong mu the::610:: ceruloplasmin, do vy ng s
tng lin kt vi albumin v t lin kt ny s d dng gii phng ra cc c quan. Dng

328


Penicilamin lm cho tin lng kh ln.

Wolff-Parkinson-White (Wolff Louis, bc s M; Parkinson J ohn,
nh tim mch Anh; White Paul D., nh tim mch M)

(Cn gi l hi chng Kent, hi chng W-P- W)

D dng dn truyn trong tim: c khuynh hng nhp nhanh kch pht, chn on da vo
ECG thy khong P-Q ngn li v phc b QRS rng ra km sng delta. Khi nhp tim
nhanh c th l do xung ng truyn qua ng bn cnh - cu ni Kent.

Wright (Wright I rving S., bc s M)

(Cn gi l hi chng c ngc nh)

Ri lon tun hon v phn b thn kinh chi trn do chn p b mch thn kinh ti nch:
nu bnh nhn a tay ra sau u th mt mch, gan bn tay b xanh tm li, cc ngn tay
trng nht, au ngc lan ln b vai. Thng thy ngi km tp luyn sau mt gng sc
ch yu chi trn.

Y
Young (Young Frank G., nh ni tit hc Anh)

Cc du hiu tng tit somatotropin: tng tit sa trong giai on mang thai, bo ph, tr s
sinh c trng lng ln qu 4 kg, thng thai cht lu. V sau khi mn kinh hay b tiu
ng.

Youssef (Youssef Abdel F., nh ph khoa ngi A rp)

(Cn gi l chng kinh qua ng tiu sau m t cung, ng thng bng quang - t cung
sau m caesar)
C ng thng gia bng quang vi t cung sau khi m caesar phn di: khng km gi
c nc tiu, tiu ra mu trong thi k hnh kinh.

Z
Zollinger I (Zollinger Hans U., nh bnh l hc Thy s)

(Cn gi l vimtiu cu thn trong mao mch)

Hi chng thn h gy bin chng vim tiu cu thn: tiu ra mu, tiu ra protein, ri lon
protein mu, tng cholesterol mu, ph. Cc biu hin c th ko di sau vi nm.


329


Zollinger I I (Cn gi l vim thn k)

Vim thn k khng nhim trng.
Zollinger-Ellison (Zollinger Robert M. v Ellison Edwin H., cc
nh phu thut M)

Khi u tuyn ty ca cc t bo D (A1) ca tuyn ty sn sinh ra gastrin (gastrinoma) vi
cc lot d dy ti i ti li. au lp i lp li vng bng, tiu chy, bnh l lot thng
xuyn ti pht, nng v chy mu vo trong ng tiu ha, tng tit dch v v tng acid.
Tin lng ph thuc c tnh ca khi u v lun lun l nghim trng


Ngun: Sangbsdk



330


Nhm bin son:
- Khnh, Nguyn, Lim(Y4C), Xun Ti (Y5B), anh Huy Nht (nt)
- Cao Nguyn, Huy (Y4B), Xun Tr, Duy Thnh (Y4A), T Trang (Y4C), Hng Linh (Y5C)
- Khoa, Lc, in, Vinh, P.Thy Linh, Phi Chi (Y5B), Th Giang, B Ni, Vn Tm (Y4C), Vit
Sn, Huy Tun, Ha (Y4A), Ngc Chu (Y5A), H Dung Bya (Y5D)
Nm hc: 2009 2010
Tham gia chnh sa :
- Khnh (Y5C), Xun Ti (Y6B), Nguyn Hong (Y5B), Phc Minh (Y4C), Nguyn (Y5C),
Thnh (Y4A), Minh Hng (Y5A),
Nm hc 2010 - 2011