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KHAM PHOI

BS. NGUYN MINH LUAN


Bo mon hun luyn k nng y khoa
Trng i hc Y khoa Phm Ngc Thch

MUC TIEU
- Cac moc quan trong e xac nh cac ranh gii,

nh khu cua long ngc.


- Thc hien c tham kham phoi theo trnh t :
nhn, s, go, nghe.

nh khu giai phau hoc long ngc

Cac moc giai phau


Hm trn c

Xng c.
Hom tren c.
Goc Louis

Xng n

Xng c (gc Louis)

B sn

nh khu giai phau hoc long ngc


Cac ng tng tng
Mat trc ngc:
o
o
o

ng gia xng c.
ng trung on phai, trai
ng nach trc.

nh khu gii phu hc lng ngc


ng gia xng c
ng nch trc

ng trung n

nh khu giai phau hoc long ngc


Cac ng tng tng

Mat ben: hong

ng nach gia
ng nach trc
ng nach sau

nh khu giai phau hoc long ngc

ng nach trc
ng nach gia
ng nach sau

nh khu giai phau hoc long ngc

Mat sau lng

ng gia cot song

ng xng ba vai phai va trai

nh khu giai phau hoc long ngc

ng gia xng b vai

ng gia ct sng

Cac ranh gii cua phoi va cac thuy phoi


Mat trc

Mat ben

Mat sau

TTP: thuy tren phai; TGP: thuy gia phai; TDP: thuy di phai, TTT: thuy
tren trai ; TDT: thuy di trai

Nhn:

Kham lam sang

Tm cac dau hieu lien quan benh ly ng ho hap:

Bieu hien net mat: lo lang, bon chon, ngu ga


Thay oi mau sac da:
Xanh tm: mong, moi, ay li.
o bng: mui, go ma, dai tai.

Tnh mach co noi


Th chum moi (th th ra).

Ngon tay dui trong.

Nhn:

Kham lam sang

Tm cac dau hieu lien quan benh ly ng ho hap:

Nhn

Kham lam sang

Kieu th: Bnh thng: eu an, tan so 16 20 lan /p

Cac kieu th bat thng:


Kieu th bat thng co chu ky
Th Kussmaul
Th Cheyne Stokes

Nhn

Kham lam sang

Kieu th bat thng khong co chu ky


Th Biot: Nhp th khong eu, luc cham luc
nhanh, luc th nong luc th sau co luc ngng th

Th ra gang sc: ky th ra keo dai, gong cac


c co, vai, khoang lien sn. Th chum moi.
Ht vao gang sc: co dau hieu co keo c lien
sn, tren on khi tat nghen ng th ln hay
ng th nho.

Nhn

Kham lam sang

Khung xng long ngc

BT: LN can xng hai ben, di ong eu theo nhp th.


Cac bat thng: Xng c b nho len (c ga) hay
lom xuong (c hnh pheu), long ngc hnh thung.

Nhn

Kham lam sang

Cac xng di ong co oi xng


khong
C ong cua goc c sn: BT
goc c sn m khoang 900,
khi ht sau vao goc nay m
rong ra.
C ong nghch thng: khi co
s ep c hoanh do tnh trang
kh phe nang nhieu.

Nhn

Kham lam sang

Kiem tra cac cung sn sau

+ Cac cung sn sau co hp vi


ng thang gia cot song
thanh mot goc 450 khong?
+ Cac xng sn co di ong tach
ri ra ky ht vao hay khong
(mang sn di ong).

Nhn

Kham lam sang

Co LN hnh thung khong.

So sanh khoang cach trc sau va


khoang cach ben cua long ngc lap
t so:
BT = Khoang cach trc sau/ Khoang
cach ben 1/2 en 5/7

Khoang cach ben

LN hnh thung khi t so tren 1/1

Khoang cach trc sau

Nhn

Kham lam sang

BN ht vao co co keo cac c ho hap


phu
+ Co co keo c c on, co that c co
hay hom c on b hom vao, co keo
cac c lien sn
+ T the lam noi cac c ho hap phu la
BN ngoi thang, chom nhe ve pha
trc, ngoi tren ghe 2 tay chong
thang len au goi hay t len ban
kham.

Nhn

Kham lam sang

Cot song va vung lng

Nhn nghieng: tm dau hieu cot song lng gu


hay lom cot song vung that lng

Nhn

Kham lam sang

Tm dau hieu veo cot song

+ Nhn pha sau lng: ng thang


noi cac mau gai cot song co
thang khong.
+ Nhn pha trc:
. Xem khoang cach gia hong va
khuyu tay hai ben.
. Quan sat o cao thap cua hai vai.

Kham lam sang

Kh quan

Dung ngon tay cai va ngon tro s len kh quan


e xac nh kh quan nam gia hay lech mot
ben

Kham lam sang

Tm rung thanh
Rung thanh co nhng ac iem sau:

Ting noi tram tao thanh rung thanh hn


giong noi cao.
n rung thanh yeu hn nam.
tre con thanh ngc mong nen rung thanh ro
ngay ca khi giong noi cao.
Rung thanh ngi gay ro hn ngi beo.

Kham lam sang

Tm rung thanh
Nguyen tac kham:
Ap sat long ban tay len vung ngc
can anh gia rung thanh yeu cau
BN phat am mot, hai, ba moi khi
s tm rung thanh.
anh gia rung thanh bang cach ap
cung luc 2 tay tren ngc BN

Kham lam sang

Tm rung thanh

V tr s tm rung thanh
Pha trc: bat au kham t nh phoi i dan
xuong di ha on.
Pha sau: bat au kham t nh phoi i dan xuong
ay phoi.
Rung thanh tang trong hoi chng ong ac phoi
Rung thanh giam khi co tran dch, tran kh mang
phoi, kh phe thung.

Kham lam sang

Tm rung thanh

V tr s tm rung thanh

Kham lam sang

Tm rung thanh

V tr s tm rung thanh

Kham lam sang

Khao sat cac c ong cua khung sn

Vung ngc tren: ap sat 2 ngon tay cai


gan nhau vao ng gia. Yeu cau BN
ht sau va cham, e cho 2 ban tay di
ong, chu y s di chuyen cua 2 ngon
tay.
Vung gia ngc: at ban tay, ngon cai
lien sn 5, cac ngon con lai om sat
ra ng nach gia.

Kham lam sang

Khao sat cac c ong cua khung sn

Khao sat b sn: at ngon tay cai


ng gia moi b sn sat vao sun
sn, chu y s di chuyen cua 2 ngon cai
khi benh nhan ht vao
Vung ay ngc: cung nh cach tren.
at ngon tay khoang xng sn.
Xem s di chuyen cua 2 ngon tay cai
(bnh thng: 35cm). Chu y tm xem
s dan n LN co oi xng khong.

Go

Kham lam sang

Ky thuat

1 ban tay ap sat lng BN, ngon gia ap sat vao


thanh ngc theo khoang lien sn. Go bang
ngon gia ban tay th 2 thang goc xuong ngon
gia cua ban tay kia.
2 ban tay nen at thang goc vi nhau
Nen go bang tay, lac co tay, khong s dung lc
ca canh tay.

Go theo th t t tren xuong.

Go oi xng.

Go

Kham lam sang

Ky thuat

Go bang lc co tay

Cach at hai ban tay trong luc go

Go

Kham lam sang

V tr go

Mat trc: go doc theo ng trung on, theo


tng khoang lien sn.
Mat ben: go doc theo ng nach gia.

Go

Kham lam sang

V tr go

Mat sau:

+ Go nh phoi doc ng xng ba


vai.
+ Go xuong dan khi tieng go uc.
+ Xac nh s di ong cua c hoanh
da vao s mat am vang cua tieng
go va so sanh ky ht vao toi a va
ky th ra toi a. BT c hoanh di
ong khoang 46cm.

Go

Kham lam sang

V tr go

Go vung nh phoi

Go mat sau lng

Go mat trc phoi

Go xac nh s di chuyen cua b di phoi mat


lng

Go

Kham lam sang

anh gia tieng go

Bnh thng: go trong


Bat thng: go vang, go uc nhng vung
bnh thng go trong.
1/ Vung uc cua gan khoang lien sn 5 tr
xuong b sn
2/ Vung uc cua tim
3/ Vung go trong khoang ban nguyet Traube
gan da day

Nghe phoi

Kham lam sang

Dung cu dung nghe phoi va ong nghe

Chuong: nghe cac am co tan so thap nghe


tieng ru tam trng cua hep van hai la tot.

Mang: nghe cac am co tan so cao, do o nghe


am th cua phoi tot hn.

Nghe phoi

Kham lam sang

Chu y khi nghe phoi:


a/ Th manh vao ong nghe nghe am on ao.
b/ Chuong:
+ Chuong an vao thanh ngc khong sat:
nghe tieng on ao

Kham lam sang


+ Chuong khong an sat vao da thanh ngc, nghe
tieng giong nh tieng co mang phoi, mang tim.
+ Chuong an len nhng vung da co long, toc:
nghe tieng giong nh ran no.
+ Cac am tao ra bi c, day chang, cac khp BN
qua gay co the tao tap am. nhng BN qua
gay nen dung chuong nho, ap sat chuong vao
thanh ngc

Nghe phoi

Kham lam sang

Nghe tieng th

BT khi ht vao, dong kh qua mui vao phe


quan tao thanh am th cua KQ tho rap, ln,
nghe ro KQ.
Am th KQ i vao cac PQ: nghe ro vung
can xng c, ro th ht vao.
Am th PQ phe nang: nghe ro khoang lien
sn 1,2 vung lien ba cot song.

Nghe phoi

Kham lam sang

Nghe tieng th
R rao phe nang: am th nhe, tram, th ht vao dai
hn th th ra, nghe em du, th th ra t khi
nghe c.

Mat trc phoi: Nghe t nh xuong doc theo


ng trung on
Mat ben: i doc theo ng nach gia
Mat sau: BN a 2 tay ra trc. Nghe vung nh
trc, i doc theo b trong xng ba vai

Nghe phoi

Kham lam Nghe


sangmat trc phoi

Nghe tieng th

Nghe mat trc phoi

Nghe mat sau phoi

Nghe phoi

Kham lam Nghe


sangmat trc phoi

Nghe tieng th

Nghe mat ben phoi

Nghe mat sau phoi

Nghe phoi Kham lam sang


Cac ac iem am th
Tieng th

Thi gian

Cng o

R rao phe
nang

Tieng th th
ht vao keo dai
hn th th ra

Em du

Tng
oi
thap

Khap hai phe trng


nghe ro ngoai bien

Phe quan phe


nang

Thi gian tieng


th th ht vao
va th th ra
bang nhau

Trung bnh

Trung
bnh

Phe quan

Thi gian am
th ra keo dai
hn la ht vao

To, on ao

Tng
oi cao

pha trc: khoang


lien sn 1 va 2
pha sau: vung lien
ba cot song
vung can xng c

Kh quan

Thi gian tieng


th th ht
vao va th ra
bang nhau

Rat to, on
ao

Tng
oi cao

Am sac

V tr nghe bnh thng

co doc kh quan

Nghe phoi

Kham lam sang

Nghe tieng th
Chu y: Nghe s bien oi cua am th:
a. R rao phe nang/ tieng th kh quan.
b. Ty so thi gian ht vao / th ra.
c. Cac tieng th phu them vao:
Ran rt, ran ngay, ran no
d. Tieng co mang phoi.

Nghe phoi

Kham lam sang

Nghe tieng noi


Khi nghe tieng th co nhng vung nghi ng bat
thng, co the kiem tra lai bang cach nghe, tm s
bien oi bat thng cua tieng noi vung nghi ng
benh so vi ben lanh.
Yeu cau BN em mot, hai, ba, em to (khi nghe
tieng kh quan), em th tham (khi nghe tieng ngc
tham)

Nghe phoi Kham lam sang


Nghe tieng noi

+ Tieng noi kh quan: vung phoi ong ac, tieng


noi se nghe co cng o manh ro rang hn so vi
pha phoi lanh.
+ Tieng ngc tham: vung phoi ong ac, tieng
noi th tham se nghe ro hn so vi pha phoi lanh.
+ Tieng de keu: yeu cau benh nhan phat am ch
I nghe vung phoi ong ac am noi nh E.

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