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Cu 1: Tip cn bnh nhn c tnh trng xut huyt.


1.1. Cc nguyn nhn gy xut huyt
Do tn thng thnh mch Tng tnh thm thnh mch Thiu vitamin C
Gim sc bn thnh mch + Nhim khun: NKH do
no m cu, t cu, Dengue,
st rt
+ Nhim c: aspirin, nc
rn, ha cht, ure huyt cao
+ Huyt p cao
+ i tho ng
Vim mao mch d ng Scholein-Henoch
D dng thnh mch Rendu-Osler
Do tiu cu Ri lon v s lng a) Gim tiu cu
- Ngoi bin:
+ Nhim vi khun, virus
+ Min dch: ITP, sau
truyn mu, gim TC ng
min dch tr s sinh,
bnh t min
+ Cng lch, DIC
+ Bnh u mch mu ln
- Nguyn nhn ti ty
+ Suy ty: bm sinh, mc
phi
+ Thm nhim ty: bch
cu cp, ung th di cn vo
ty
+ Xm ln ty: x ty,
xng ha
- Di truyn
+ Ri lon sinh mu tiu
cu
+ Khng c mu TC bm
sinh
b) Tng tiu cu
+ Tin pht
+ Th pht: BC kinh, HC
tng sinh ty, sau ct lch
Ri lon v cht lng a) Di truyn
+ Suy nhc tiu cu
+ Lon dng tiu cu
+ V ht tiu cu
+ Thiu yu t 3 tiu cu
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b) Mc phi
+ Thuc: NSAIDs, khng
sinh,
+ Ure huyt cao
+ U ty lan ta
Do nguyn nhn huyt tng ng mu ni sinh Hemophilia A, B
Thiu yu t XII
Cht chng ng
ng mu ngoi sinh Thiu yu t II, V, VII, X
bm sinh
Thiu vitamin K, suy gan
Ri lon sinh fibrin + Bt thng tng hp
+ Tng hy: DIC, HC tiu
fibrin cp
Nguyn nhn phi hp + Von Willerbrand
+ Bnh gan, thn, ung th
+ Bnh mu c tnh
1.2. Tip cn lm sng
a) Hi bnh s, tin s
+ Hon cnh: Xut huyt t nhin hay sau va chm, xut huyt sau truyn mu hay dng
thuc. Nu xut huyt sau va chm hoc XH ko di sau can thip, coi chng Hemophilia
+ Mc XH: XH da, nim mc (chy mu chn rng, chy mu li, mi,) hay xut
huyt ni tng (tiu mu, i ngoi ra mu/phn en, nn mu, nhc u, nn i, bt rt, kh
tip xc)
+ Cc triu chng lin quan n di truyn: tin s b XH tng t cha? T lc my tui?
d b bm da, chy mu ko di sau t tay, nh rng,?
+ Tin s bnh l mn tnh (vim gan mn, HCTH, HC km hp thu,), tin s vng da
+ Tin s sn khoa, s sinh, thai sn nu tr di 3 thng tui. tin s XH no, mng no?
+ Tin s gia nh
b) Khm: tr li cc cu hi
- Xc nh c xut huyt thc s hay khng?
Phn bit vi pht ban, bnh l da liu
- Tnh cht xut huyt
Triu chng Thnh mch Tiu cu Ri lon yu t ng mu
Cch xut huyt T nhin T nhin Gy ra
Hnh thi Chm, nt Chm, nt, bm mu Bm mu, t mu
V tr Da Da, nim mc C, khp
- Mc xut huyt?
+ Nh: ri rc da
+ Trung bnh: XH da ri rc + XH nim mc ri rc
+ Nng: XH nim mch nhiu ni, XH ni tng, XH no. Lc cn: nh gi tri gic, DH
sinh tn, mc thiu mu, theo di du hiu XH no, mng no: nhc u, nn vt, c cng,
l tr ln, khc tht, li b, thp phng cng tr nh
- Cc triu chng ca bnh nn
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+ St, thiu mu, vng da, gan lch c to khng, hch ngoi bin? cc bnh l v mu, gan,

+ D tt bm sinh, chm pht trin th cht, tm thn vn ng bnh l bm sinh

Phn bit xut huyt do bnh l ng mu-cm mu


c im LS Bnh l ng mu Bnh l cm mu
XH di da t gp Thng gp
Chy mu cam Thng t cc mch ln Thng t cc mch nh, ri rc
T mu phn mm Thng gp Him
Chy mu khp Thng gp, in hnh cho bnh t gp
Chy mu ko di Thng gp Him
Xut huyt nhng vt t gp Thng gp
gi trn da
Tin s gia nh Thng c Him
Gii Ch yu l nam Ch yu l n
1.3. Cn lm sng
a) Da trn cc xt nghim ng mu c bn, CTM

b) Nu nghi ng nguyn nhn no s lm xt nghim c hiu cho cc nguyn nhn :


tp trung tiu cu nu nghi ng gim cht lng tiu cu, D-Dimer nu nghi ng DIC, nh
lng yu t ng mu nu nghi ng Hemophilia hay thiu cc yu t ng mu,
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Cu 2: Phn bit cc nguyn nhn gy a mu?


a) Phn bit theo tnh cht phn

XHTH trn thng gy i ngoi phn en, mu nh hc n. Ngoi ra tr c th nn ra mu hay


cht nn mu c ph.

XHTH di thng gy mu dnh ngoi khun phn hoc mu ti trn ln trong phn,
thnh thong c th gy phn mu nu sm/ht d.

Phn c mu ln nhy hoc km theo nhiu nc thng do nguyn nhn vim nhim rut.

b) Cc nguyn nhn thng gp theo la tui

b di 2 thng tui: tr s sinh 2, 3 ngy tui, a mu thng do thiu vitamin K.


Ngoi ra, vim rut non hoi t, xon rut cng l nhng nguyn nhn gy a mu

b b m:

Tiu chy do nhim vi khun: salmonella, vi khun l, E. Coli

Lng rut cp tnh: Tr thng au bng tng cn, i tin ra phn c mu ln nhy. Trng
hp ny thng xy ra nhng tr di 2 tui. (thng gp t 6-18 thng, vo ma ng xun)

Khng hp vi sa ang dng:c th gy vim i trng gy chy mu.

Vim lot ti tha Meckel

To bn do thc n n dm thiu cht x

b t 2 5 tui: To bn gy nt k hu mn l nguyn nhn hay gp. Ngoi ra cn do:


vim rut, lng rut, vim ng mt

b i hc: Tr tip xc vi mi trng l, li ang tui hiu ng nn d b nhim


khun: vim rut do amip, l, vim i trng chy mu

Xut huyt tiu ha do bnh Schonlein Henoch, do v u mu: him gp hn.

c) Phn bit da trn triu chng km theo:

Nt k hu mn
Khm c th thy vt nt ra hu mn, xut hin khi a tr i
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phn rn, ln. BN c th c au, nhn mt, rn khi i ngoi, c mu


dnh ngoi khun phn hoc khi chi, c tin s to bn.
Khng dung np
sa/protein u nnh Thng gp tr s sinh, do nhy cm qu mc vi protein trong
u nnh hoc sa b, thng xut hin sau khi cho tr ung thm
sa CT. C th xy ra tr b m do b m ung sa b/u nnh.
Thng khi sau 1 tui.

C th c nn, tiu chy km theo.


Bnh vim rut Crohn Km tiu chy, chn n, st cn.
Tiu chy do nhim trng Sau khi n n khng hp VS/ung khng sinh. C th km st,
au bng.
Polyp Gp tr 2-10 tui. Tr i ngoi phn mu, khng au.
Lng rut , bnh a mu t ngt, au bng, st, c th li b.
Hirschsprung
Bnh l ng cm mu Xut huyt di da, c, khp km theo.
d) Cn lm sng:
+ Xt nghim phn tm hng cu, bch cu, vi khun, virus (Rota,)
+ Ni soi i trc trng, ni soi d dy nu nghi ng xut huyt tiu ha, u, polyp,
+ Siu m, chp bng khng chun b nu nghi ng lng rut, bnh Hirschsprung,
+ Bilan vim nu nghi ng nhim khun, ng mu, CTM nu nghi ng bnh l ng cm
mu
Cu 3: Phn bit cc nguyn nhn gy gim tiu cu?
a) Phn bit trn lm sng

Bnh s Thi gian din bin, mc xut huyt

Triu chng xut huyt Xut huyt da t nhin hay km theo c xut huyt ni tng, thi
im khi pht, hon cnh khi pht gip nh hng nguyn nhn bm sinh hay mc phi.

Triu chng ton thn: St, au xng, st cn, mt mi gi bnh l ton thn, v d nh
bnh l c tnh, bnh t min (SLE,)

Cc xt nghim mu trc : tin s c tiu cu thp gi bnh bm sinh hoc mn tnh.


XN trc y TC bnh thng gi bnh l mi mc.

Cc bnh i trc ITP thng i sau nhim virus, i khi sau khi tim vc xin MMR.

Thuc dng Heparin, ha tr, mt s khng sinh v thuc chng ng kinh.

Bnh l nn Ung th, sepsis, bnh tim bm sinh, t min, bnh gan, cng lch

Tin s gia nh Gi nguyn nhn di truyn, v d HC Wiskott-Aldrich


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Tin s i n vng c nguy c st rt

Tin s dinh dng km hp thu hoc ch n hn ch (restricted diet) c th gy gim


tiu cu.

Khm nh gi v tr, mc XH, khm i khm li nhiu ln theo di

Biu tng trng Thp ci gi hi chng suy ty xng di truyn (inherited bone
marrow failure syndromes)

Hch Gi bnh c tnh hoc cc bnh l tng sinh xm ln ty xng khc (HC thc bo
mu,)

ic hoc c thy tinh th gi bnh lin quan n gen MYH9

Bng Lch to, km hoc khng km gan to gi leukemia, lymphoma, bnh gan mn c tng
p TM ca, nhim virus.

Chi th - Sng khp gi bnh h thng. Ngn ci thiu sn gi HC Fanconi.

b) Phn bit trn CLS

Cng thc mu: Gim tiu cu km tng th tch tiu cu (MPV) thng km bnh l gy
tng hy. Gim c HC, BC gi nguyn nhn gim sinh ti ty xng.

Tiu bn mu n:

Cn xem xt kch thc, hnh thi tiu cu. Tiu cu to gi hi chng gim tiu cu t bo
ln bm sinh (congenital macrothrombocytopenia syndrome), tiu cu nh gi hi chng
Wiskott-Aldrich.

Cc t bo khc: c t bo blast gi leukemia, hng cu b xon vn, t on gi bnh l


vi mch (HUS, DIC, TTP)

Test Coombs khi nghi ng hi chng Evans

nh gi ty xng (huyt ty , sinh thit ty xng) khi nghi ng suy ty hoc bnh l
gy xm ln ty

D-Dimer khi nghi ng DIC

Xt nghim gen, NST nu nghi ng bnh l di truyn hoc lin quan ti gen nh HC Fanconi,
bnh lin quan n gen MYH9