TRNG I HC Y KHOA PHM NGC THCH

TRUNG TM HUN LUYN K NNG LM SNG

BNH VIN M PHNG

GIO TRNH HUN LUYN

K NNG LM SNG

NH XUT BN Y HC
2015
Ch bin:
PGS.TS.BS.CKII. Cao Vn Thnh

Tham gia bin son:

ThS.BS. Nguyn Ngc Phng Th
ThS.BSCKII. Bi Phan Qunh Phng
BS.CKI. Trnh Trung Tin
ThS.BS. on Hng Dng
ThS.BS. Nguyn Minh Lun
ThS.BS. Nguyn c Qunh Vy
BS. Trn T Trinh
 LI NI U

Trong o to Y khoa, hun luyn k nng lun c vai tr rt quan trng, quyt nh
s thnh bi trong thc hnh lm sng, ng thi h tr hiu qu gip ngi hc hiu su sc
hn nhng kin thc c tnh hn lm. Chnh v vy m chn l hc phi i i vi hnh
ngy cng c c v.
Hin nay, khi nim Hun luyn k nng Y khoa c m rng hn v c tnh
lng ghp phong ph nhm tn dng ti a cc c hi gip ngi hc tip cn tng bc v
st vi thc t nht, c duy tr trong sut qu trnh hc tp, rn luyn nng cao kin thc
hay cp nht k thut mi trc khi ngi hc t tin v c trch nhim c th thc hnh
chnh thc trn ngi bnh ti cc c s y t khm cha bnh.
Hun luyn k nng Y khoa c nhiu cp v ngy cng a dng do s tin b c v
k thut ln phng php tip cn hay truyn t. Trong , Hun luyn k nng Y khoa tin
lm sng vn l c bn v quan trng nht. Ti cc quc gia c nn gio dc Y khoa truyn
thng v pht trin, Hun luyn k nng Y khoa tin lm sng rt c coi trng v u t
vi qui m ln, cng lc vi b cc k nng c bn gm: k nng giao tip, k nng thm
khm, k nng xt nghim, k nng th thut v k nng iu tr. Ngoi ra, cn c b sung
bi mt s cc k nng mm cn thit khc, gip ngi hc t tin hn, c nng lc thc hnh
tt hn khi tip xc vi bnh nhn tht v trong nhng tnh hung lm sng tht. Mc d vy
cng cn u nhng kin tranh lun v kh nng ng dng k nng lm sng trc tip
ngay trn ngi bnh hay khng nhm gim thiu nhng khon u t tn km v cc qui trnh
hun luyn cng phu.
Ti Vit Nam, h thng cc Trng i hc, Cao ng v Trung cp chuyn nghip
c tham gia vo cng tc o to ngun nhn lc y t c tri di t Bc vo Nam vi s
tham gia ca c h thng o to Qun v Dn Y, Cng lp v T thc cha k n tro lu
v xu hng quc t ha cc c s o to Y, Nha, Dc ang c pht trin th vic hun
luyn cc k nng Y khoa s l mt ni dung th v v ng quan tm hn lc no ht v s
tr thnh cng c hun luyn k nng c hiu qu, cht lng trong o to ngun nhn lc y
t cung cp cho hn 1.250 Bnh vin cng v 170 Bnh vin t nhn cng 30.000 phng
khm t trn ton quc. Xa hn na rt cn vn ti thc hin k hoch o to nhn lc Y
t cht lng cao phc v c trong mi trng quc t ngay Vit Nam hoc cc nc
khc trong khu vc hay trn th gii.
Trc yu cu v nhim v mi ca cng tc Hun luyn k nng Y Khoa dnh cho
tt c cc i tng l hc sinh, sinh vin, hc vin sau i hc ca chuyn ngnh sc khe
nh Bc s Y khoa; iu dng; H sinh; K thut Y hc, vic tng cng u t o to
cn b ging; c s vt cht, thit b chuyn dng v xy dng chng trnh ph hp, c tnh
chuyn su v cp nht phc v hun luyn k nng y khoa l ng thi tch cc v cn thit.
Vi tinh thn quyt tm v nng ng trong thc thi nhim v hun luyn k nng Y khoa,
ngy 01 thng 9 nm 2015 Trung tm Hun luyn K nng Y khoa Bnh vin M
phng thuc Trng i hc Y Khoa Phm Ngc Thch chnh thc c thnh lp. Tin
thn ca Trung tm l n v hun luyn k nng Y khoa tin lm sng giai on 2005
2011; B mn hun luyn k nng Y Khoa Skillslab giai on 2011-2015 kt hp vi
n v Lab m phng giai on 2011- 2015. Trung tm hnh thnh v xy dng k
hoch hot ng nhm thc hin nhim v i mi cn bn, ton din gio dc v o
to, vi trng tm l ci tin su rng phng php hun luyn k nng Y khoa. Ly sinh
vin lm trung tm; M rng phng thc hun luyn theo i (TeamWork) v lng gi
theo cu trc khch quan (OSCE); Ch trng o to Ging vin chuyn trch; Hon thin v
ng b c s v trang thit b hun luyn k nng; Tin ti lin kt v chun ha quc t
Nh vy, cng vi cc ni dung m Trung tm Hun luyn K nng Y khoa Bnh
vin M phng cn thc hin th vic bin son Gio trnh hun luyn k nng y khoa l
ph hp. Trong qu trnh bin son, mc d tp th cc Ging vin c c gng nht nh
hon chnh tp bi ging nhng kh trnh khi nhng hn ch. Ban bin tp mong nhn c
cc kin xy dng t pha cc ng nghip v hc sinh, sinh vin, hc vin kp b sung
hon chnh hn na cho gio trnh.
Ban Bin tp chn thnh cm n Ban Gim Hiu v cc Phng Ban chc nng ca
Trng i hc Y Khoa Phm Ngc Thch; Nh xut bn Y hc chi nhnh TP.H Ch Minh
cng ton th cc c gi ng vin, gip v to iu kin thun li cho vic hon
thnh tp gio trnh ny.

Trn trng./.

THAY MT BAN BIN TP

TRNG TRUNG TM

PGS.TS.BSCKII. Cao Vn Thnh

 MC LC

Trang
Li ni u
Danh mc hnh
Danh mc bng
Bi 1. K nng giao tip trong y khoa ............................................................................... 1
Bi 2. Khm ton trng.................................................................................................... 13
Bi 3. Phn tch du hiu sinh tn ................................................................................... 31
Bi 4. Khm u mt c - tuyn gip .............................................................................. 45
Bi 5. Khm mch mu ngoi bin ................................................................................. 51
Bi 6. Khm tim .............................................................................................................. 61
Bi 7. Khm phi............................................................................................................. 74
Bi 8. Khm tuyn v ...................................................................................................... 88
Bi 9. Khm bng ............................................................................................................ 96
Bi 10. Khm hu mn trc trng .............................................................................. 112
Bi 11. Khm 12 i dy thn kinh s no.................................................................... 119
Bi 12. Khm cm gic v phn x ............................................................................... 132
Bi 13. Phn tch cc xt nghim thng quy ............................................................... 141
Bi 14. Phn tch in tm c bn ............................................................................ 149
Bi 15. K thut s dng cc thuc ng kh dung .................................................... 159
Bi 16. Phn tch phim X-quang ngc thng ................................................................ 172
Bi 17. K nng phng m c bn ................................................................................ 183
Bi 18. Cc mi khu ct ch phu thut c bn ........................................................ 193
 DANH MC HNH
Trang
Hnh 1.1. Tin trnh giao tip ............................................................................................ 2
Hnh 1.2. T l tc dng ca mt thng ip .................................................................... 3
Hnh 1.3. Cc kiu biu hin khun mt ........................................................................... 4
Hnh 1.4. Cc kiu sp xp ch ngi ................................................................................. 5
Hnh 1.5. Trnh t pht trin k hoch qun l cho bnh nhn ........................................ 7
Hnh 1.6. Cch hi triu chng c nng ............................................................................ 9
Hnh 1.7. Cch hi cc triu chng lin quan n h c quan .......................................... 9
Hnh 2.1. Dng i pht c................................................................................................ 17
Hnh 2.2. Dng i ct ko ................................................................................................ 17
Hnh 2.3. Dng i kiu nga ........................................................................................... 18
Hnh 2.4. Dng i do tn thng cm gic su ............................................................... 18
Hnh 2.5. Dng i do tn thng tiu no ....................................................................... 18
Hnh 2.6. Dng i Parkinson ........................................................................................... 19
Hnh 2.7. T th nm Fowler .......................................................................................... 19
Hnh 2.8. Khm kt mc mi mt...................................................................................... 19
Hnh 2.9 Mng tay lm hnh mung. .............................................................................. 20
Hnh 2.10. Vim khe ming .......................................................................................... 20
Hnh 2.11. Cng mc mt vng ....................................................................................... 21
Hnh 2.12. Vng da lng bn tay ..................................................................................... 21
Hnh 2.13. Bch bin ....................................................................................................... 22
Hnh 2.14. Hnh dng c th theo ch s vng eo ........................................................... 24
Hnh 2.15. Dng ngi Marfan ....................................................................................... 25
Hnh 2.16. Du vo da ..................................................................................................... 26
Hnh 2.17. Du mt trng ................................................................................................ 26
Hnh 2.18. Du hiu ph, n lm..................................................................................... 27
Hnh 2.19. o p lc tnh mch cnh .............................................................................. 27
Hnh 2.20. Ph d ng (ph mch) .................................................................................. 28
Hnh 2.21. V tr cc nhm hch ngoi bin .................................................................... 29
Hnh 3.1. Nhp th ko di (sighs) .................................................................................. 32
Hnh 3.2. Nhp th kiu Cheyne Stokes ....................................................................... 33
Hnh 3.3. Nhp th kiu tc nghn .................................................................................. 33
Hnh 3.4. Nhp th Kussmaul .......................................................................................... 33
Hnh 3.5. Nhp th Biot ................................................................................................... 33
Hnh 3.6. Tng hp cc kiu th ..................................................................................... 34
Hnh 3.7. Thay i thn nhit trong ngy........................................................................ 34
Hnh 3.8. Biu mch bnh thng .............................................................................. 37
Hnh 3.9. Biu mch yu, nh .................................................................................... 37
Hnh 3.10. Biu mch ny mnh, bin cao ............................................................ 37
Hnh 3.11. Biu mch 2 nh ...................................................................................... 37
Hnh 3.12. Biu mch xen k ..................................................................................... 38
Hnh 3.13. Biu mch i ........................................................................................... 38
Hnh 3.14. Biu mch nghch ..................................................................................... 38
Hnh 3.15. Cc v tr bt ng mch................................................................................ 38
Hnh 4.1. Nang gip li ................................................................................................. 46
Hnh 4.2. Cc nhm hch vng c .................................................................................. 48
Hnh 4.3. Gii phu tuyn gip........................................................................................ 49
Hnh 5.1. Da bn chn kh, nt ....................................................................................... 52
Hnh 5.2. Da cng bn chn tm ti do tc ng mch .................................................... 52
Hnh 5.3. Hoi t cc u chi trong bnh Beurger .......................................................... 52
Hnh 5.4. Tm cc u ngn trong bnh Raynaud ........................................................... 53
Hnh 5.5. S kho st nhit da .................................................................................... 53
Hnh 5.6. Khm s ng mch quay ng mch tr - ng mch cnh tay ................. 54
Hnh 5.7. Test Allen ........................................................................................................ 54
Hnh 5.8. Khm s ng mch cnh ng mch i ng mch khoeo
ng mch mu chn ng mch chy sau ................................................ 55
Hnh 5.9. Nghim php nhp nhy u mng ................................................................. 56
Hnh 5.10. Buergers test ................................................................................................. 56
Hnh 5.11. H thng tnh mch chi di ......................................................................... 57
Hnh 5.12. Cc hnh dng ca dn tnh mch chi di ................................................... 58
Hnh 5.13. Nghim php Trendelenburg ......................................................................... 59
Hnh 5.14. Du hiu Horman .......................................................................................... 59
Hnh 6.1. Gii phu tim ................................................................................................... 61
Hnh 6.2. Hi chng Marfan ........................................................................................... 64
Hnh 6.3. Ngn tay di trng ........................................................................................... 64
Hnh 6.4. Tm cc ngn tay ............................................................................................. 64
Hnh 6.5. Du mi tn ch v tr tnh mch cnh ngoi ni r ......................................... 65
Hnh 6.6. Xanthelasma .................................................................................................... 65
Hnh 6.7. Cch c lng p lc tnh mch cnh trong .................................................. 65
Hnh 6.8. Khm quan st vng ngc ............................................................................... 66
Hnh 6.9. S mm tim ..................................................................................................... 66
Hnh 6.10. S vng y tim S rung miu ..................................................................... 67
Hnh 6.11. Cu to ng nghe ........................................................................................... 68
Hnh 6.12. Chu chuyn tim ............................................................................................. 68
Hnh 6.13. V tr cc van tim ........................................................................................ 68
Hnh 6.14. Va nghe tim va s mch cnh xc nh chu chuyn tim ...................... 69
Hnh 6.15. Cc dng m thi ........................................................................................... 70
Hnh 6.16. Cc hng lan ca m thi ............................................................................ 70
Hnh 6.17. Du hiu ph chn ......................................................................................... 71
Hnh 7.1. Phn chia cc thy phi ................................................................................... 75
Hnh 7.2. Cc mc gii phu ........................................................................................... 75
Hnh 7.3. Cc ng tng tng (mt trc)................................................................ 75
Hnh 7.4. Cc ng tng tng (mt bn) .................................................................. 76
Hnh 7.5. Cc ng tng tng (mt sau) ................................................................... 76
Hnh 7.6. Quan st bnh nhn ........................................................................................ 77
Hnh 7.7. Quan st bn tay .............................................................................................. 77
Hnh 7.8. Ngn tay bnh thng ...................................................................................... 77
Hnh 7.9. Ngn tay di trng ........................................................................................... 77
Hnh 7.10. Ngn tay tm nhun nicotine......................................................................... 77
Hnh 7.11. Nhp th bnh thng .................................................................................... 78
Hnh 7.12. Nhp th Kussmaul ........................................................................................ 78
Hnh 7.13. Nhp th Cheyne-Stockes .............................................................................. 78
Hnh 7.14. Nhp th Biot ................................................................................................. 78
Hnh 7.15. Th chm mi ............................................................................................... 79
Hnh 7.16. Cc hnh dng bt thng ca lng ngc ...................................................... 79
Hnh 7.17. Vo ct sng .................................................................................................. 80
Hnh 7.18. Ct sng bnh thng v g .......................................................................... 80
Hnh 7.19. V tr gii phu ca kh qun v cch s kh qun ......................................... 81
Hnh 7.20. Cc v tr s rung thanh mt lng v cch s rung thanh
bng mt lng bn tay, mt tr bn tay v mt lng bn tay ........................ 81
Hnh 7.21. S bin gin n ca lng ngc pha sau lc th ra v ht vo .................. 82
Hnh 7.22. S bin gin n ca lng ngc pha trc ................................................ 82
Hnh 7.23. Cch g phi .................................................................................................. 83
Hnh 7.24. Cc v tr g pha trc v pha sau ............................................................ 83
Hnh 7.25. Cc v tr nghe phi mt trc v mt sau.................................................. 84
Hnh 8.1. Gii phu hc tuyn v .................................................................................... 88
Hnh 8.2. V tr tuyn v v cch phn chia vng ........................................................... 89
Hnh 8.3. Bc l vng khm............................................................................................ 89
Hnh 8.4. Quan st cc bt thng v .......................................................................... 90
Hnh 8.5. Cc t th ca bnh nhn trong thm khm tuyn v (bc nhn).................. 90
Hnh 8.6. T th ca bnh nhn trong thm khm tuyn v (bc s) ........................... 91
Hnh 8.7. Bn tay thm khm v ..................................................................................... 91
Hnh 8.8. Thm khm s tuyn v .................................................................................. 91
Hnh 8.9. Cch khm tuyn v theo hnh xon c, theo hnh ziczac............................... 91
Hnh 8.10. Cc nhm hch quanh v .............................................................................. 92
Hnh 8.11. Khm hch vng nch ................................................................................... 92
Hnh 8.12. Nhn qua gng tay gi cao (t khm tuyn v)........................................ 92
Hnh 8.13. Nhn qua gng (t khm tuyn v) ............................................................. 93
Hnh 8.14. Nhn qua gng tay chng hng (t khm tuyn v)................................. 93
Hnh 8.15. S tuyn v t th nm (t khm tuyn v) .................................................. 93
Hnh 9.1. Phn chia vng bng theo 9 vng.................................................................... 97
Hnh 9.2. Phn chia vng bng theo 4 vng.................................................................... 97
Hnh 9.3. V tr cc im au v tam gic Chauffard Rivet ......................................... 98
Hnh 9.4. V tr cc im niu qun................................................................................. 98
Hnh 9.5. V tr cc im sn ct sng .......................................................................... 98
Hnh 9.6. T th bnh nhn ............................................................................................. 99
Hnh 9.7. Quan st thnh bng ...................................................................................... 100
Hnh 9.8. V tr cc so m thng gp......................................................................... 100
Hnh 9.9. Quan st thnh bng theo chiu nm ngang .................................................. 100
Hnh 9.10. Nhn khi u vng bng ................................................................................ 101
Hnh 9.11. Cc v tr nghe ng mch bng .............................................................. 101
Hnh 9.12. Nghe ting c mng bng vng gan ............................................................ 102
Hnh 9.13. Nghe ting c mng bng vng lch ........................................................... 102
Hnh 9.14. Nghe ting c ch ........................................................................................ 102
Hnh 9.15. G bng ....................................................................................................... 102
Hnh 9.16. Bng bng ln ............................................................................................. 103
Hnh 9.17. Xc nh chiu cao gan................................................................................ 103
Hnh 9.18. o chiu cao gan gia bng ..................................................................... 103
Hnh 9.19. o chiu cao gan ng trung n .......................................................... 103
Hnh 9.20. Cch s khm bng: s nng, s su .......................................................... 104
Hnh 9.21. Nghim php Murphy ................................................................................. 104
Hnh 9.22. im Mc Burney ......................................................................................... 104
Hnh 9.23. Nghim php rung gan ................................................................................ 105
Hnh 9.24. S lch ......................................................................................................... 105
Hnh 9.25. Phn lch to ............................................................................................ 105
Hnh 9.26. Du hiu sng v ......................................................................................... 106
Hnh 9.27. Du hiu c tht (Psoas sign) ...................................................................... 106
Hnh 9.28. Du hiu c bt ............................................................................................ 107
Hnh 9.29. Thot v bn trc tip v gin tip ............................................................... 107
Hnh 9.30. V tr thot v bn, thot v i .................................................................... 108
Hnh 9.31. Thm d l bn ............................................................................................ 108
Hnh 9.32. p lc y khi thot v qua l bn nng ................................................... 109
Hnh 10.1. Cu trc gii phu trc trng hu mn ..................................................... 112
Hnh 10.2. Cc t th khm hu mn trc trng ........................................................ 113
Hnh 10.3. T th bnh nhn v v tr thm khm ......................................................... 114
Hnh 10.4. Khm hu mn trc trng (Nhn) ............................................................. 114
Hnh 10.5. Cc tn thng vng hu mn .................................................................... 115
Hnh 10.6. Thm khm hu mn bng dng c ............................................................ 115
Hnh 10.7. Qui c theo mi gi trong thm khm hu mn trc trng ....................... 116
Hnh 10.8. Thao tc thm khm trc trng bng ngn tay ............................................ 116
Hnh 10.9. Thm ng r bng que............................................................................. 117
Hnh 10.10. nh lut Goodsall..................................................................................... 117
Hnh 10.11. Phn loi r hu mn theo Park................................................................. 117
Hnh 11.1. Bng o th lc ............................................................................................ 120
Hnh 11.2. Tn thng h thng th gic ...................................................................... 121
Hnh 11.3. n soi y mt ........................................................................................... 122
Hnh 11.4. y mt bnh thng ................................................................................... 122
Hnh 11.5. Khm phn x nh sng............................................................................... 122
Hnh 11.6. S hng hot ng c mt .................................................................... 123
Hnh 11.7. S phn b cm gic ca dy thn kinh tam thoa ....................................... 124
Hnh 11.8. Khm phn x gic mc .............................................................................. 124
Hnh 11.9. V tr gii phu cc c nhai.......................................................................... 125
Hnh 11.10. Khm phn x cm .................................................................................... 125
Hnh 11.11. Hnh nh ca ngi lit dy thn kinh VII ................................................ 125
Hnh 11.12. Khm vn ng c mt.............................................................................. 126
Hnh 11.13. Nghim php nghe m thoa ....................................................................... 126
Hnh 11.14. Rinnes test ................................................................................................ 127
Hnh 11.15. Webers test ............................................................................................... 127
Hnh 11.16. Khm dy thn kinh s IX ......................................................................... 128
Hnh 11.17. Khm c c m chm ............................................................................. 128
Hnh 11.18. Khm c thang .......................................................................................... 128
Hnh 11.19. Bnh nhn b lit dy XII .......................................................................... 129
Hnh 12.1. Cc dng c khm phn x gn c, cm gic .............................................. 132
Hnh 12.2. Khm cm gic au ..................................................................................... 133
Hnh 12.3. Khm cm gic t th khp ......................................................................... 133
Hnh 12.4. Dng c m thoa.......................................................................................... 134
Hnh 12.5. Khm cm gic nhn bit ch vit .............................................................. 134
Hnh 12.6. Cc im khm phn x gn c chi trn ...................................................... 135
Hnh 12.7. Cch khm phn x gn c nh u ............................................................. 136
Hnh 12.8. Cc t th khm phn x gn c tam u .................................................... 136
Hnh 12.9. Khm phn x trm quay............................................................................. 136
Hnh 12.10. Khm phn x gn c t u i ............................................................... 137
Hnh 12.11. Cch khm phn x gi t th nm ........................................................... 137
Hnh 12.12. Cc cch khm phn x gi t th ngi v nghim php Jendrassik ........ 138
Hnh 12.13. Cc cch khm phn x gn gt ................................................................ 138
Hnh 12.14. Cc v tr khm phn x da ........................................................................ 138
Hnh 12.15. Cch khm phn x da gan bn chn (tm du Babinski).......................... 139
Hnh 14.1. Giy ghi in tm ................................................................................... 150
Hnh 14.2. Cch nh chun bin ............................................................................. 150
Hnh 14.3. Cc kiu nh chun bin ....................................................................... 151
Hnh 14.4. Cc chuyn o ngoi bin .......................................................................... 151
Hnh 14.5. Cc chuyn o trc ngc ......................................................................... 151
Hnh 14.6. Cc thnh phn ca sng in tim ............................................................... 152
Hnh 14.7. Thay i sng R v sng S cc chuyn o trc ngc ........................... 153
Hnh 14.8. Cch tnh nhp tim ....................................................................................... 155
Hnh 14.9. Cch tnh trc QRS...................................................................................... 156
Hnh 15.1. My phun kh dung...................................................................................... 161
Hnh 15.2. Cu to bnh xt nh liu ............................................................................ 163
Hnh 15.3. Dng c phun khng bung m ................................................................ 164
Hnh 15.4. K thut phun khng bung m ................................................................ 165
Hnh 15.5. K thut phim c bung m khng mt n................................................ 165
Hnh 15.6. K thut phun c bung m c mt n ...................................................... 166
Hnh 15.7. Cch nhn bit lng thuc cn li trong bnh
bng cch th vo nc ............................................................................... 167
Hnh 15.8. Bnh xt nh liu km thit b m liu ...................................................... 167
Hnh 15.9. Cc loi bnh ht bt kh ............................................................................. 167
Hnh 16.1. T th chp sau trc PA ......................................................................... 172
Hnh 16.2. T th chp trc sau AP ......................................................................... 173
Hnh 16.3. S khc nhau gia mc ht vo khi chp X-quang ngc thng.............. 174
Hnh 16.4. Qui c mu trong phim X-quang .............................................................. 174
Hnh 16.5. Cc vng trn phim X-quang ngc thng.................................................... 175
Hnh 16.6. Hnh nh ng th trn phim X-quang ngc thng .................................. 176
Hnh 16.7. T l bng tim/lng ngc ............................................................................. 177
Hnh 16.8. Bng tim hnh chai nc (Water bottle) ...................................................... 177
Hnh 16.9. Bng tim hnh git nc .............................................................................. 177
Hnh 16.10. Cc vin bng tim...................................................................................... 178
Hnh 16.11. Meniscus sign trong trn dch mng phi.................................................. 178
Hnh 16.12. Du Silhouette sign ................................................................................... 179
Hnh 16.13. Trn kh di da vng c, trn kh trung tht ............................................ 179
Hnh 16.14. Dy dnh mng phi .................................................................................. 180
Hnh 16.15. Trn kh mng phi (P).............................................................................. 180
Hnh 16.16. Bng kh nh phi .................................................................................... 180
Hnh 16.17. Khi p-xe phi vi mc nc-hi ........................................................... 180
Hnh 16.18. Khi u cnh rn phi (T) ........................................................................... 180
Hnh 16.19. Lim hi di honh ................................................................................. 181
Hnh 16.20. Hch rn phi (T) ph i .......................................................................... 182
Hnh 16.21. Cc cu trc bt thng ngoi c th ........................................................ 182
Hnh 17.1. Cc thi im ra tay .................................................................................. 184
Hnh 17.2. Cc bc ra tay thng quy ...................................................................... 184
Hnh 17.3. Cc thao tc ca ra tay v khun ............................................................... 187
Hnh 17.4. Cc thao tc mc o chong v khun......................................................... 188
Hnh 17.5. Cc thao tc ci o chong .......................................................................... 188
Hnh 17.6. Thao tc mc p chong mang gng v khun c ngi ph...................... 189
Hnh 17.7. Thao tc t mang gng v khun ................................................................ 190
Hnh 17.8. Thao tc tho gng....................................................................................... 191
Hnh 18.1. Cu trc si ch ............................................................................................ 194
Hnh 18.2. Thi gian tan si ch .................................................................................... 195
Hnh 18.3. Cu to kim phu thut ................................................................................ 196
Hnh 18.4. Cu to ui kim ......................................................................................... 196
Hnh 18.5. Hnh dng thn kim ..................................................................................... 196
Hnh 18.6. Cu to mi kim .......................................................................................... 197
Hnh 18.7. Cc hnh dng kim phu thut ..................................................................... 197
Hnh 18.8. Thng tin bao ch phu thut ....................................................................... 197
Hnh 18.9. Mi n khu da .......................................................................................... 199
Hnh 18.10. Mi Blair Donati khu da ....................................................................... 199
Hnh 18.11. Mi ch U khu da ................................................................................ 199
Hnh 18.12. Mi khu lin tc n gin (Simple Continuous Sutures) ........................ 200
Hnh 18.13. Mi khu lin tc c kha (Continuous Lock Sutures) ............................. 200
Hnh 18.14. Mi khu lin tc m ngang
(Continuous Horizontal Mattress Sutures)................................................. 200
Hnh 18.15. Mi khu cho lin tc (Gross Sutures) .................................................... 201
Hnh 18.16. Mi khu lin tc di da.......................................................................... 201
Hnh 18.17. Mi khu n di da ............................................................................... 201
Hnh 18.18. Mi khu ln mp...................................................................................... 202
Hnh 18.19. Mi khu vng........................................................................................... 202
Hnh 18.20. Mi khu chu lc ...................................................................................... 202
Hnh 18.21. Ct ch bng dng c ................................................................................. 203
Hnh 18.22. Ct ch bng tay (cch 1) ........................................................................... 203
Hnh 18.23. Ct ch bng tay (cch 2) ........................................................................... 204

 DANH MC BNG
Trang
Bng 2.1. Thng tin thu thp c t vic quan st v mt ngi bnh ......................... 14
Bng 2.2. Thng tin thu thp c t vic quan st v bt tay ngi bnh .................... 14
Bng 2.3. Nguyn nhn gy thiu mu............................................................................ 20
Bng 2.4. Phn bit tm trung ng v tm ngoi vi ....................................................... 21
Bng 2.5. Nguyn nhn gy vng da ............................................................................... 21
Bng 2.6. Tiu chun tha cn v bo ph da theo BMI ............................................... 23
Bng 2.7. Bng kho st mc nh hng n vn suy dinh dng....................... 24
Bng 2.8. Nguyn nhn suy dinh dng ......................................................................... 25
Bng 2.9. Nguyn nhn gy bo ph................................................................................ 25
Bng 2.10. Nguyn nhn gy mt nc c th................................................................ 26
Bng 2.11. Phn ph................................................................................................... 27
Bng 3.1. Tn s mch theo tui ..................................................................................... 36
Bng 3.2. Tiu chun huyt p ngi trn 18 tui (Theo JNC VII-2003) ...................... 40
Bng 3.3. Tiu chun huyt p theo Hip hi tng huyt p Anh Quc (BHS) .............. 41
Bng 3.4. Thang im Glasgow ...................................................................................... 42
Bng 6.1. Chc nng h tun hon .................................................................................. 62
Bng 6.2. Cc bc khm tim ......................................................................................... 63
Bng 7.1. Cc ting th phi ........................................................................................ 86
Bng 13.1. Cc gi tr ca cng thc mu ..................................................................... 142
Bng 15.1. Tin li v bt tin ca tng loi kh dung ................................................. 160
Bng 16.1. Du chng phn bit t th AP hay PA ...................................................... 175
Bng 16.2. Du chng phn bit bn T hay P ............................................................... 176
Bng 18.1. Phn loi ch phu thut theo tnh tan ......................................................... 193
Bng 18.2. Thi gian tan v lc gi m ca cc loi ch .............................................. 194
Bng 18.3. ln ca si ch gim dn ....................................................................... 195
 Bi 1
K NNG GIAO TIP TRONG Y KHOA

MC TIU
Sinh vin cn nm c:
KIN THC
+ Hiu c tin trnh giao tip v cc yu t gy nh hng
+ Nh cc chc nng ca giao tip bc s bnh nhn
+ Nh cc yu t nh hng n giao tip bc s bnh nhn
K NNG
Thc hin c k nng thu thp thng tin
THI
Nhn thc c tm quan trng ca giao tip bc s bnh nhn trong thc
hnh y hc.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 05 pht
+ Gii thiu ni dung bi ging: 45 pht
+ Thc hnh ng vai: 120 pht
+ Ging vin tng kt cui bui: 10 pht
Trc khi ng vai
Chun b trc bng kim, cc tnh hung ng vai.
Nu mc tiu bi hc.
Nu phng php hun luyn: ng vai.
Nu cch lng gi: bng kim.
Giao nhim v c th cho sinh vin.
Chiu bng video minh ha.
Trong lc ng vai
Ging vin: quan st.
Sinh vin:
+ ng vai thy thuc, vai bnh nhn theo tnh hung c a ra.
+ Quan st, quay video trong khi sinh vin khc ng vai.
Sau khi ng vai
Sinh vin:

1
 + Vai thy thuc: t nhn xt, nh gi v k nng giao tip ca mnh trong qu
trnh thc hnh.
+ Vai bnh nhn: pht biu cm xc sau khi ng vai.
+ Chiu li bng video.
+ Tho lun.
Ging vin:
+ Nhn xt chung.
+ Rt ra bi hc c ch v k nng giao tip vi bnh nhn.

NI DUNG
1. I CNG
1.1. K nng giao tip c bn
Giao tip l qu trnh tc ng qua li gia con ngi vi con ngi th hin s tip
xc tm l gia ngi vi ngi thng qua con ngi trao i thng tin, trao i cm
xc, tc ng v nh hng qua li ln nhau.
Giao tip l mt tin trnh, trong ngi ny tm cch thay i thi (v/ hoc)
hnh vi ca ngi kia.

Hnh1.1. Tin trnh giao tip

Giao tip c li (Verbal communication) v Giao tip khng li (Non-verbal

communication).
Cc thng ip khng ch truyn i bng m thanh v tip nhn bi thnh gic, m
cn thng qua cc iu b, c ch, nt mt c tip nhn bi th gic.

2
 Tc gi Albert Mehrabian pht hin ra rng trong tng tc dng ca mt thng ip
th li ni (xt v mt ngn t) ch chim khong 7%, thanh m (tc l ging ni, ng iu,
cc m thanh m thm) chim 38%, cn ngn ng khng li chim n 55%.
Giao tip c li mang li thng tin, giao tip khng li cng c n tng, cm xc
ca ngi nhn thng tin khin cho h i n kt lun c chp thun, tin tng vo thng
tin v ngi mang n thng tin hay khng. Xt v d: cng mt ni dung din gii v
phng php iu tr, nhng bc s ni chuyn r rng, khng km cc m thanh m , c
t th t tin s to nim tin vi bnh nhn hn khi so snh vi bc s trnh by di dng,
ni chuyn ngt qung, ging ni yu t, khi trnh by khng nhn bnh nhn.

Hnh1.2. T l tc dng ca mt thng ip

Cc thnh phn ca giao tip khng li:

C ch (gesture): tc dng to n tng b sung cho ngn t. Cc c ch thng
dng nh: gt u th hin s ng , lc u, gi mt ngn tay ci hng ln th
hin s khen ngi
V mt (biu hin khun mt- facial expressions ): th hin cc cm xc nh vui
v (ci), tc gin (chau my, trng mt, mm mi), bun b (mi trn hi sp
xung, hai khe ming hng xung).
Giao tip mt (eye-contact): nhn vo nh mt ca ngi i din, c bit vo lc
ni hoc nghe cc thng tin quan trng, to ra cm gic ch vo cuc ni
chuyn, v tn trng ngi i din, nn trnh ci nhn chm chm.
V b ngoi (appearance): kiu tc, trang phc.
T th (posture): dng ng, dng ngi, v d: khoanh tay trc ngc khi ni
chuyn thng gy n tng l ngi kh bt chuyn.
Ging ni (voice): tc ni, nhng ting v ngha m thm vo, ging ni m
i, hoc to ln, s nhn ging.

3

Hnh 1.3. Cc kiu biu hin khun mt

1.2. Tm quan trng ca giao tip trong y khoa

R rng l giao tip tt mang li s chm sc tt hn cho cc bnh nhn.
Sau y l cc li ch m cc bc s giao tip tt c c:
Giao tip tt gip thu thp thng tin v tnh trng ca bnh nhn chnh xc, ph
hp hn, c s thng hiu ln nhau, iu dn n cc chn on chnh xc hn.
C cc bng chng cho thy rng cc bc s c hun luyn k nng giao tip
chn on chnh xc c bit vi cc trng hp lin quan n tm l hn cc bc
s khng c hun luyn.
Pht hin cc vn v cm xc trn bnh nhn v p ng ph hp. Bnh nhn ca
h nhn c s hi lng trong qu trnh chm sc, v gim bt lo u v cc vn
lin quan n bnh tt, cng t c phn nn v cc s xut trong cha bnh hn.
Bnh nhn ca h ng v tun th iu tr tt hn.
Tuy vy, cc nghin cu cng cho thy khng phi tt c cc bc s u c k nng
giao tip tt.
Khng thiu nhng kin cho rng kh nng giao tip l kh nng tri ph, c ngi
kho n kho ni hn ngi khc. Nhng cc nghin cu cho thy K nng giao tip c
th c ci thin thng qua vic hun luyn. Nh vy, trng Y phi ng vai tr chnh
trong vic pht trin k nng giao tip cho cc bc s tng lai.

2. K NNG GIAO TIP TRONG Y KHOA

2.1. Cc vn chnh trong giao tip y khoa
Giao tip trong y khoa hm cha nhiu i tng giao tip vi nhau trong mi
trng lm vic ngnh y, nh: thy thuc vi bnh nhn, thy thuc v thn nhn ngi
bnh, gia cc nhn vin y t vi nhau phn chnh yu l giao tip gia thy thuc v
bnh nhn.
2.1.1. Cc yu t nh hng n cht lng giao tip Thy thuc Bnh nhn
V pha bnh nhn
+ Triu chng c nng hin ti (v th cht)
+ Tnh trng tm l (bnh nhn c th c sn bnh v tm l hoc lin quan n
cht lng chm sc y t, v d: bnh nhn bc bi v nm ghp ging c th
phn ng vi bc s hoc nhn vin y t khc)
+ Kinh nghim v chm sc y t (trong qu kh - hin ti)

4
 V pha bc s
+ c hun luyn v k nng giao tip
+ T tin vo kh nng giao tip
+ Cc c im tnh cch
+ Yu t th cht (s mt mi)
+ Yu t tinh thn (lo lng, bun, tc gin)
V khng gian xung quanh
+ Khng gian ring t
+ Cm gic thoi mi: nh sng, nhit , ting n
+ Sp xp v tr ngi ph hp

Hnh 1.4. Cc kiu sp xp ch ngi

2.1.2. Chc nng hay l mc ch ca giao tip thy thuc - bnh nhn
(H.de Haes and J. Bensing 2009)
Fostering the Relationship (Cng c quan h BS BN/ Thit lp quan h tt)
Gathering Information (Thu thp thng tin ca BN)
Providing Information (Cung cp thng tin cho BN)
Helping the Patient with Making Decisions (Gip BN quyt nh)
Supporting Emotions (Nng , cn bng, cm xc cho BN)
Helping Patient with Behavior Change (Gip BN thay i hnh vi)

2.1.3. Giao tip Thy thuc l trung tm - Bnh nhn l trung tm

Thy thuc l trung tm
Truyn thng giao tip y khoa t bc s ng vai tr chnh trong vic t vn cho
bnh nhn, ngha l t ch n cc mi quan tm v kh nng hiu ca bnh nhn v bnh
trng ca h v bnh nhn khng tham gia vo qu trnh quyt nh phng php iu tr.
Bnh nhn l trung tm
+ Ngy nay a s bnh nhn mun c mt mi quan h m h c quyn/phn
trch nhim. Bnh nhn mun bit nhiu hn v tnh trng bnh ca h v
c tham gia vo quyt nh iu tr. C bng chng cho thy bnh nhn l
trung tm trong qu trnh t vn tng mc hi lng v tng kh nng theo
ui iu tr.
+ Tuy nhin, trong mt s bi cnh c th nh bnh nhn cp cu th cch tip
cn Thy thuc lm trung tm s ph hp hn.

5
2.1.4. Nhng vn c th trong giao tip thy thuc bnh nhn
Khai thc bnh s: k nng thu thp thng tin.
T vn: k nng cung cp thng tin, gip bnh nhn ra quyt nh, gip bnh
nhn thay i hnh vi.
Thng bo tin xu: k nng cung cp thng tin, nng n nh cm xc cho
bnh nhn.
2.2. Cc vn kh trong giao tip y khoa
Giao tip vi tr em, vi ngi v thnh nin
Giao tip khi c sai st y khoa
Giao tip vi ngi khng c hay km kh nng giao tip hiu qu (do l do th
cht hoc tinh thn)
+ Th cht: Chm pht trin/ Cm, ic/ L ln do tui gi
+ Tinh thn: Trm cm/ Lo u, hong s/ Tc gin, hung hng.
2.3. Cc kha cnh khc ca giao tip y khoa
Giao tip vi ng nghip: bao gm bc s v nhn vin y t khc
Giao tip vi cp trn
Giao tip vi gia nh v thn nhn ngi bnh
Giao tip vi cng ng.
3. K NNG THU THP THNG TIN (Khai thc bnh s - The medical history)
Khai thc bnh s l mt giai on quan trng trong quy trnh khm v iu tr ca
bc s.
c c thng tin ca bnh nhn chnh xc, y phc v cho vic chn on
v iu tr, bc s (hoc sinh vin y khoa) cn lm tt cc vic sau:
Thit lp mi quan h tt vi bnh nhn
t cu hi r rng v chnh xc
Lng nghe ch ng.
Trong bi ny s gii thiu cu trc bnh s thng dng. Tuy nhin, cn bit rng
mt s bc s thuc cc c s y t khc nhau c th s dng cc cu trc c thay i i ch.

Hnh 1.5. Trnh t pht trin k hoch qun l cho bnh nhn

3.1. Thit lp mi quan h tt vi bnh nhn

Nhng c tnh nn tng thit lp mi quan h tt vi bnh nhn: thng cm, chn
thnh, chp nhn.
Thng cm l s nhn bit r rng chnh xc cm xc ca ngi khc, v th hin
s nhn bit ny.
Chn thnh l thi quan tm mt cch t nhin xut pht t nhu cu ca bnh
nhn hn l n v nhim v, c gng lm cho xong vic, hoc c n cha mc
ch v li.
Chp nhn l vi thi tn trng bc s to ra mt mi tng giao mang tnh h
tr (supportive relationship), trong bnh nhn cm thy an tm t c th bc
l nhng ni lo u, bc xc ca mnh. Tuy nhin, tn trng, chp nhn khng c
ngha l tn thnh, ng tnh. Ngc vi chp nhn l k th, ph phn.

3.2. t cu hi chnh xc, d hiu

S dng hp l dng cu hi ng, cu hi m, cng nh cc cu hi thm d, lm
r cc thng tin.
Cu hi m: cu hi m c dng hi v nhng thng tin chung chung. Loi
cu hi ny c dng khi m u cuc phng vn hoc khi mun i ti.
Cu hi m c u im gip khai thc c NHIU THNG TIN hn. Ngi tr
li s cm thy LI CUN V GN KT hn trong cuc ni chuyn. H c th
t nhin by t kin, suy ngh v mong i ca mnh. Khuyt im l: ngi
c hi c th s ni nhiu, mt thi gian v i khi kh kim sot c ni
dung cu chuyn. i khi h ni v nhng vn khng cn thit.

7
 Cu hi ng: cu hi ng thng c tr li bng mt t hoc mt cu ngn.
Khuyt im l thng tin gii hn. Ngi tr li t c c hi by t kin, cm
xc. Ni dung cuc ni chuyn hon ton ph thuc vo ngi hi. Ngi hi c
th to nh hng cho ngi tr li.
Tuy nhin, khi cn khai thc thng tin trong mt thi gian ngn: cc chn thng do
tai nn, cc trng hp bnh cp cu, th cu hi ng c vai tr quan trng. Mt
khc, sau giai on hi nhng cu hi m, bc s trc tip ch vo vn c
bit thu c trong sut giai on hi cu hi m bng vic s dng cu hi
ng. (Xem v d v cu hi ng v cu hi m cui bi).

3.3. Lng nghe ch ng

Khi bc s lng nghe hiu qu tc l bc s tp trung hiu c ni dung cng nh
cm xc ca bnh nhn. Th hin s tp trung lng nghe bng giao tip c li v khng li.
Trnh ngt li bnh nhn khi khng cn thit.
Nhng li thng gp khi lng nghe bnh nhn:
Hi qu nhiu cu hi mt lc
Khng ngi bnh k li chuyn theo ngn ng ca h
Ngt li bnh nhn khng cn thit
Khng nm bt c nhng biu hin giao tip c li v khng li quan trng ca
bnh nhn.

3.4. Cu trc ca bnh s

Thng tin c bn v bnh nhn: tn, tui, chng tc, ngh, ni , tnh trng hn nhn
M t vn hin ti: khai thc cc triu chng c nng v din bin (xoay quanh
l do nhp vin, hoc than phin chnh)
Lc qua cc c quan (Review of body systems)
Tin s y khoa ca ngi bnh
Tin s gia nh
Cc vn v i sng x hi.

3.4.1. M t cc triu chng c nng

Bng cch t cu hi, bc s (hoc sinh vin y khoa) c th m t y , chnh xc
cc triu chng c nng phc v cho chn on. Ni dung cc cu hi xoay quanh mt
triu chng c minh ha qua hnh di y.

8
 Hnh 1.6. Cch hi triu chng c nng

3.4.2. Lc qua cc c quan

Phn ny, bc s s t cu hi mt cch h thng, hng n cc h c quan trong
c th. Mc ch l pht hin cc triu chng m bnh nhn qun k ra do cho rng triu
chng khng quan trng hoc khng lin quan n triu chng chnh. Sinh vin cn phi
lp ra th t cc h c quan v cc cu hi lin quan, m bo hi y .

Hnh 1.7. Cch hi cc triu chng lin quan n h c quan

9
3.4.3. Tin s y khoa ca ngi bnh v gia nh
Tin s y khoa ca ngi bnh: trong phn ny, bc s cn thu thp cc thng tin
v bnh l mc km theo phng php, kt qu iu tr, cc chn thng v di
chng sau . Thng tin v cc thuc ang s dng, cc thuc m bnh nhn d
ng cng rt quan trng.
Tin s gia nh: thng tin ny quan trng v:
+ Ngh n cc bnh l c tnh di truyn
+ Hiu c cc lo lng ca bnh nhn c th xut pht t bnh l ca cc thnh
vin trong gia nh
+ Cn hi n: cha, m rut; anh, ch, em rut; cc con rut.
3.4.4. Cc vn v i sng, x hi
V l do hn hp v thi gian, cc bc s b qun phn thng tin ny. Tuy nhin, y cng
l thng tin quan trng gip cho chn on v iu tr bnh nhn chnh xc v ph hp.
C nhiu bnh l lin quan n li sng: ht thuc l, ung ru bia, ch n, cng
thng ko di trong cng vic.
Tnh trng bnh l cng gy nh hng tiu cc ln cht lng sng v cc quan h
x hi ca bnh nhn: hn ch giao tip, mt vic, thay i cm xc, thi quen, nh hng
i sng tnh dc

3.5. Cc tnh hung minh ha

3.5.1. Cu hi ng Cu hi m
Bc s ch s dng cu hi ng
+ Bs.A: Ti thy ghi ch nhp vin ca ng l au ngc. ng cn au khng?
BN: Khng, gi th khng
+ Bs.A: ng au d di hay m ?
BN: C l l m
+ Bs.A: N c lan xung cnh tay ca ng khng?
BN: Ti ngh l khng
+ Bs.A: N c nng ln khi ng gng sc khng?
BN: Khng c
Bc s s dng cu hi m
+ Bs.B: Ti c thng bo l ng b au ngc. ng hy ni k hn v cn au?
+ BN: Ch, cn au bt u ngc v n xut hin mi khi ti lm vic. N l
cn au ngm gia ngc. N xut hin vi ln gn y v lun lun vo
lc ti lm vic.
+ Bs.B: ng cho ti bit iu g mang cn au n?
BN: Vng. Ti ngh v iu ny. Gn y ti rt bn rn, v cn au dng nh
xut hin khi ti gp rt hon thnh cng vic. N cng xut hin khi ti lo lng v
iu g . (Ngun: Margaret L, Robert B Communication Skills for Medicine, 2nd
Edition, Churchill Livingstone, p 15, Case example 2.2).

10
3.5.2. Hi bnh s bnh nhn au ngc
Tnh hung: Bnh nhn nam, 56 tui, n phng khm vi than phin au
gia ngc.
Bng kim 1 trnh by cc vn cn hi theo th t v cu trc, bng kim 2
trnh by cc yu cu v ngn ng khng li cn t.
BNG KIM 1
Ni dung Cu hi gi Ni dung tr li
M u: Cho bc, ti l bc s Huy, ti s ph trch ca bnh ca bc. Ti
Cho bnh nhn s hi bc nhng thng tin lin quan n bnh ca bc, bc tr li
T gii thiu chnh xc s gip ti chn on v iu tr kp thi cho bc.
Khai thc thng tin Hi tn, tui, ngh nghip, ni - Nguyn Vn An
hnh chnh - 56 tui
- Nhn vin ngn hng
- Tp H Ch Minh
Bnh s:
- M t vn hin - Bc n y khm v kh chu g? - Ti b nhng cn au gia
ti: au ngc - Bc hy k chi tit din bin ca ngc.
- Sau y l cc c cn au? - Ti au gia ngc t 3 ngy
im cn khai thc nay, au khong 5 pht th ,
- Cn au c lan i v tr khc khng?
ca mt cn au: cm gic nh p cht.
- Bc c thy yu t g c bit lm
+ Hng lan cn au xut hin? - Ti cm gic au lan ln hm
+ c tnh - Cn au s gim (bt) khi bc lm v vai bn tri.
+ Mc g? - Khi c sc nh khi i b
+ Khi pht v din tin nhanh, leo ln cu thang, hoc
- Bc c biu hin g khc cng lc
khi n qu no th cn au xut
+ Yu t khi pht/ cn au khng?
hin
yu t lm tng - Khng tnh nhng cn au trong 3
gim au ngy va qua, trc y c nhng - Khi ngh ngi.
+ Cc triu chng i cn au tng t khng? - Trong cn au ti c cm gic
km (Ch triu - Trc khi n y khm, bc s hi, hi hp, v m hi.
chng i km vi au iu tr g cha? - Cha tng c cn au tng t.
ngc: i, kh th, kh - C ung thuc gim au
kh, ho, nh trng Panadol nhng khng bt au.
ngc)
+ Cn au tng t
trc y?
+ iu tr nh th no
trc khi n khm?
Tin s bn thn: - c chn on tng huyt p
- Cc bnh mc - Bc tng mc cc bnh g ? cch y 3 nm bnh vin
trc y qun, nhng t ngng iu tr
hn 1 nm nay.
- Bc tng nhp vin v bt c l - Cha tng nhp vin v cc
do g trc y khng ? nguyn nhn khc
- Bc c tng b chn thng hay - Ht thuc l : mi ngy khong 1
- Cc thi quen sinh tai nn g khng ? gi, ht t lc 20 tui n hin nay.
hot - Bc c ht thuc l khng ? - Ch ung khong 2-3 lon
- Bc c ung ru khng ? bia/tun.
- Bc c tp th dc khng ? - Khng tp th dc v khng c
- Cng vic ca bc c cng thng thi gian.
khng ?

11
Tin s gia nh - Cha, m rut khng ai b tng
huyt p hay bnh tim mch.
- Cc loi thuc ang - Hin ti khng ung bt k
s dng thuc g.
-Tin s d ng thuc - Khng d ng thuc.
Kt thc:
Tm tt li nhng
im chnh.
Cm n bnh nhn,
ngh bnh nhn
i thm kt qu
khm v xt nghim
chn on.

BNG KIM 2

Tc ni va phi
m lng nghe
Ging ni
Ging ni chc gn, t tin
Tri chy
Giao tip bng mt C nhn vo bnh nhn khi trao i.
Mm ci khi cho hi
Nt mt
Ph hp vi tnh hung giao tip v cm xc ca bnh nhn
C ch C ch ph hp vi ni dung giao tip, t nhin
T tin
T th
Thn thin

TI LIU THAM KHO

1. Margaret L, Robert B Communication Skills for Medicine, 2nd Edition, Churchill
Livingstone.
2. Haes, H. de, Bensing, J. Endpoints in medical communication research, proposing a
framework of functions and outcomes. Patient Education and Counseling: 2009, 74(3),
287-294.
3. McManus C, Vincent C A, Thom S. Teaching communication skills to clinical students.
British Medical Journal 306: 1322-1327.
4. B Y T. Kin thc - thi - k nng cn t khi tt nghip Bc s a khoa. Nh xut
bn Y Hc, 2006.
5. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam. K
nng giao tip Thy thuc- Bnh nhn. K nng y khoa c bn. Nh xut bn Y hc
TPHCM, 2009, tr.13-20.
6. Graham Douglas, Fiona Nicol, Colin Robertson (2013). Macleods Clinical Examination,
13st edition.
7. James Thomas, Tanya Monaghan (2014). Oxford Handbook of Clinical Examination and
Practical Skills, 2nd edition.
8. Lynn S. Bickley, Peter G. Szilagyi (2013). Bates Guide to Physical Examination and
History taking, 7th edition.
9. Owen Epstein et al (2009). Pocket Guide to Clinical Examination, 4th edition.

12
 Bi 2
KHM TON TRNG

MC TIU
1. Bit cch chun b phng khm v cc qui trnh cho mt bui thm khm.
2. Bit ly du hiu sinh tn (mch, nhit , huyt p, nhp th, tri gic).
3. Bit nh gi dng i, t th.
4. Bit nh gi mu sc da nim.
5. Bit nh gi mi ca c th v mi hi th.
6. Bit nh gi tnh trng dinh dng.
7. Bit nh gi tnh trng mt nc.
8. Bit nh gi tnh trng ph.
9. Bit cch khm hch ngoi bin.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 120 pht
+ Gii thiu mc tiu v ni dung bi ging: 10 pht
+ Gii p thc mc l thuyt: 20 pht
+ Ging vin khm mu: 30 pht
+ Sinh vin thc hnh: 60 pht
+ Chn 02 sinh vin khm, nhm cn li quan st v nh gi: 20 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. I CNG
Khm ton trng l bc u tin ca thm khm thc th. Nhn l phng php
chnh c s dng trong khm ton trng, kt hp vi s, nghe v ngi.
V d nh thng qua vic quan st cch n mc ca bnh nhn (NHN), ngi thy
thuc c c thng tin v tnh cch, trng thi tinh thn v hon cnh x hi ca ngi
bnh. Bnh nhn tr tui n mc khng tm tt c th gi nhng vn lin quan vi
ru hoc nghin ma ty... qun o bnh nhn cao tui b vy bn phn hay nc tiu c
th do h khng th t chm sc bn thn v bnh tt, khng th t i li c, sa st tr tu
hoc cc bnh tm thn kinh khc bnh nhn bing n c th mc qun o rng thng
thnh che giu s st cn. Bnh nhn c hnh xm c th b nhim cc bnh cc bnh ly
qua ng mu nh nhim vim gan siu vi B, C

13
 Mt s bnh c biu hin c trng, nu quan st k ngi bnh, ngi thy thuc s
c c hng chn on ngay ln u tip xc. To xng bt ton l mt di truyn tri,
nhim sc th thng, lm cho xng mng mnh v d v, cng mc c mu xanh dng
do vic to thnh collagen bt thng. Trong x cng b, da b dy cng lm cho b mt da
mt np nhn, b mt v cm, ngi bnh kh h ming, hn ch vn ng, da kh v hay
b nga, c th km theo cc m ri lon sc t loang l
Quan st v mt ngi bnh (NHN) cng cung cp cc thng tin c ch cho chn on.
Bng 2.1. Thng tin thu thp c t vic quan st v mt ngi bnh
c im Chn on
t/ Khng biu l cm xc Parkinson
V mt bn chn, hong ht Cng gip
V mt v cm, t/khng tip xc mt Trm cm
V mt v cm, da nht nht v ph Nhc gip

Tng t, thng qua vic cho hi v bt tay ngi bnh (S), ngi thy thuc
cng thu thp c cc thng tin v tnh trng bnh tt ca h.
Bng 2.2. Thng tin thu thp c t vic quan st v bt tay ngi bnh
c im Chn on
Bn tay lnh, v m hi Lo lng
Bn tay lnh, kh Hin tng Raynaud
Bn tay nng, v m hi Cng gip
Bn tay v m hi, to To u chi
Tip xc nc thng xuyn
Da kh, sn Lao ng tay chn
Nhc gip
Chn thng
Bn tay, ngn tay bin dng
Vim khp dng thp

Cc thnh phn chnh ca khm ton trng l: nh gi du hiu sinh tn; nh gi

dng i, t th; nh gi mu sc da nim mc; nh gi mi ca c th; nh gi tnh
trng dinh dng; nh gi tnh trng mt nc; nh gi tnh trng ph v khm hch
ngoi bin. Cch nh gi du hiu sinh tn s c trnh by ring.

2. CHUN B PHNG KHM - QUI TRNH MT BUI KHM

2.1. Chun b
2.1.1. Phng khm
Rng ri, thong mt, nh sng trng - khng cha ( d dng quan st mu st
da, nim, kt mc), c rm kn xung quanh.
Trnh m thanh n xung quanh c th giao tip gia nhn vin y t v bnh nhn.
Nhit phng khng qu lnh hoc qu nng, phng nn thong mt, trnh b hi.
Ging khm c cao va phi bnh nhn c th t bc ln, nn s dng
loi ging khm khng c cc cnh ging nng cao. Gh khm nn s dng
loi c ta lng.

14
2.1.2. Nhn vin y t
Trang phc cng tc chnh t TRANG THIT B CN THIT

Giao tip theo qui tc cho hi, t nh - ng nghe

Trc khi khm phi gii thch cho - n pin
bnh nhn v c s ng ca bnh - My o huyt p
nhn. Ch nn bc l vng cn khm,
- Ba phn x
cc vng khc nn c che bng tm
chn trnh b lnh. - Gng tay sch

Nn cho ngi thn ca bnh nhn ra - Nhit k

khi phng khm, ch tr trng hp - Cy li
bnh nhn s hi hoc theo yu cu ca - Knh lp
bnh nhn. Nu bnh nhn cn nh, cn
- m thoa
c cha m hoc ngi gim h bn
cnh. - Cn trng lng
- Thc o chiu cao, thc dy
2.2. Qui trnh mt bui khm
Thng thng, vic khm s bt u t
khi ngi bnh xut hin trc mt ngi khm. Coi ngi bnh n khm trong
tnh trng thoi mi hay bc dc, dng v khe khon hay yu mt, khun mt
ti tnh hay mt mi
Khm dng i (thng bng, trng tm trong khi i), t th ng (thng bng,
trc xng, g vo, bin dng chi..).
Cho ngi bnh ngi ly du hiu sinh tn (mch, nhit , huyt p, nhp
th), quan st vng mt ghi nhn cc bt thng (mu sc da, tn thng da, cc
du hiu thn kinh ngoi vi nh mo ming, h mi mt), quan st vng c ghi
nhn trng thi tnh v trng thi c nut vi nc nh gi tuyn gip c
phnh hoc ni u xut hin v di chuyn theo nhp nut. Khm s - g - nghe cc
c quan pha trc (khm thn kinh, nghe phi mt trc, nghe tim, khm c
xng khp chi trn).
Di chuyn ra sau ngi bnh nhn t th ngi, s - n thm khm tuyn gip v
hch vng c, c th tn dng nghe phi vng sau lng, s - n ct sng v cc c
vng ngc lng.
Sau , chuyn bnh nhn sang t th nm nga ti ging khm v bt u t pha
trn u v i dn v pha cui bn chn (khm u mt c, khm ngc, khm
bng, khm mch mu, khm hch ngoi vi, khm c xng khp chi di).
Ngi khm thng ng bn phi (P) ca bnh nhn. Nh th s thun tin cho
vic thm khm v phn ln mi ngi thun tay (P), d quan st tnh mch cnh
ni bn (P), thn (P) thng d s hn, v bn khm thng t ng khm
bn (P).
Nn khm theo tng c quan vi cc du hiu bt thng ghi nhn c ti c
quan , sau khi hon tt ton b bui khm s tng hp cc du hiu theo
tng hi chng a ra chn on.

15
 Trong trng hp bnh nhn gi, khng th ngi, c th khm u, c, ngc trc
theo t th nm nga u cao. C th xoay bnh nhn sang mt bn nghe
phi pha sau lng.
Ghi nhn cc phng tin theo di h tr ngi bnh (my monitor theo di
sinh hiu, th oxy, sonde d dy, sonde tiu, ng dn lu).

C BIT
LUN PHI RA TAY TRC KHI BT U
THM KHM BNH NHN

Ra tay v cho hi bnh nhn

Kim tra li thng tin c nhn v ghi nhn dng v bn ngoi:
+ Bnh nhn c khe?
+ Bnh nhn t i c?
+ Dng i c bt thng?
C cc du hiu cnh bo tnh trng nguy cp? Kh th? Chng mt, Mt
thng bng?
Bnh nhn c s dng cc dng c h tr h hp khng (dy th oxy, mt n
khng th li, my tr th...)? ang t thng tiu hay ng thng d dy? C
dng bm tim in?...
Kim tra du hiu sinh tn (mch, nhit , huyt p, nhp th, tri gic)
nh gi dng i, t th
nh gi mu sc da nim mc
nh gi mi ca c th v mi ca hi th
nh gi tnh trng dinh dng
nh gi tnh trng mt nc
nh gi tnh trng ph
Khm hch ngoi bin

3. NH GI DU HIU SINH TN
Xem bi Du hiu sinh tn
4. NH GI DNG I, T TH
4.1. Dng i
Quan st dng i cung cp thng tin v chc nng h thn kinh v c xng khp,
gp phn quan trng cho chn on. Nhn chung, c 6 dng i bnh l c bn sau:
4.1.1. Dng i lit cng na ngi hay dng i pht c
Gp trong cc bnh l gy tn thng bn cu i no mt bn, i din vi bn lit.
Do chn lit dui cng nn khi bc i, trnh bn chn qut t, bnh nhn vng bn
chn sang bn to thnh mt vng cung, ng thi tay gp khuu tay v dn st vo thn.

16
 Hnh 2.1. Dng i pht c

4.1.2. Dng i lit cng hai chi di hay dng i ct ko

Thng do tn thng hai bn r ty hay do tn thng thn kinh ngoi bin, rt t
khi do tn thng c hai bn bn cu no.
c im ca th bnh ny l c tnh trng tng trng lc c vng hai chi di m
ch yu l cc nhm c dui ca chn. Ngi bnh c th i c, nhng hai i i st vo
nhau, u gi va vo nhau, bn chn kh nhc ln khi mt t, to dng i ct ko.

Hnh 2.2. Dng i ct ko

4.1.3. Dng i do bnh l thn kinh - c hay dng i kiu nga

Gp trong cc bnh l gy tn thng nron vn ng thp (lit dy thn kinh hng
khoeo ngoi). Khi i, chn bn lit gi cao, bn chn r xung v khi t bn chn xung
th mi chn chm t trc, sau mi n gt chn. Ngoi ra, c th gp trong tn thng
c nh bnh lon dng c, bnh c ngn chi...

17
 Hnh 2.3. Dng i kiu nga

4.1.4. Dng i do tn thng cm gic su

Cn gi l dng i gt, gp trong tn thng ct sau ty do bnh Tabs, do thiu mu
i hng cu, do chn p ty sau. Khi i, lun dng mt kim tra, lng chn ra trc,
p mnh gt xung t, tng ln khi nhm mt.

Hnh 2.4. Dng i do tn thng cm gic su

4.1.4. Dng i do tn thng tiu no

Bnh nhn ng khng vng, dng chn , chao o v mi hng. Khi i, lo o
nh say, dang tay, dang chn gi thng bng, ng ra sau, bc ngn, khng u v
khng nng thm ng k khi nhm mt.

Hnh 2.5. Dng i do tn thng tiu no

18
4.1.5. Dng i Parkinson
Bnh nhn i khng vung vy tay, ton b c th ca bnh nhn di chuyn nh mt
khi, ngp ngng, cng nhc, na ngi trn c xu hng lao v trc, bc i ngn v
nhanh dn nh chy ui theo trng tm ca chnh mnh.

Hnh 2.6. Dng i Parkinson

4.2. T th
Bnh thng, bnh nhn nm u ngang hoc k mt gi. Nm u cao hoc na
nm na ngi (t th Fowler) thng gp bnh nhn b suy tim, suy h hp.
T th nm c sng, cong lng tm thng gp trong cc trng hp au vng
bng (vim ty).

Hnh 2.7. T th nm Fowler

5. NH GI MU SC DA NIM
Mu sc da nim c th cung cp cc thng tin v tnh
trng sc khe chung hoc gip chn on mt bnh l c th.
Cn tm cc du hiu xanh xao, tm trung ng hay tm ngoi
bin, vng da v cc mu da bt thng khc.

5.1. Xanh xao

V mt xanh xao thng l du hiu ca thiu mu
nng. Cn quan st thm kt mc mt, ging mng chn v
tay. Yu cu bnh nhn nhn ln v dng ngn tay ci ko nh Hnh 2.8. Khm kt mc
mi mt di ca h xung quan st kt mc hng hay nht mi mt
mu. Bnh thng kt mc c mng li cc mao mch mu /hng chim trn nn trng.
Nu mng li mao mch ny gim do thiu mu s biu hin chuyn dn sang mng hng
nht ti trng. Vim khe ming v mng lm hnh mung l du hiu c trng ca thiu
mu do thiu st.

19
 Tuy nhin, xanh xao l mt du hiu khng ng tin cy nhng bnh nhn b sc hoc
nhng ngi c bnh mch mu. Co mch ngoi bin hay gim cung lng tim cng c th
gy ra triu chng xanh xao ca da v kt mc (mc d khng c thiu mu). Khi c thiu
mu, cn hi thm triu chng ri lon tiu ha, thi quen i tiu, chu k kinh nguyt

Hnh 2.9. Mng tay lm hnh mung Hnh 2.10. Vim kho ming

Bng 2.3. Nguyn nhn gy thiu mu

GIM SN XUT HNG CU

(S lng hng cu t hoc gim cht lng hng cu)
Thiu mu do thiu st
Thiu mu do thiu vitamin B12, a.folic
Thiu mu do thiu men G6PD
Thiu mu do tn thng ty hoc t bo gc
Thallasemia

TNG PH HY HNG CU
Hng cu hnh lim
Thallasemia
Nhim trng, thuc
c t: nc rn, nc nhn,
c cht t gan, thn
Min dch
Ri lon ng mu, tn huyt
Lch to

MT MU
Vim lot d dy t trng
Tr
Ung th
Thuc khng vim non-steroid
Ri lon kinh nguyt

5.2. Tm ti
L tnh trng da v nim mc c mu xanh, xut hin khi nng hemoglobin kh
trong mu t nht l 2,5 g/dL. Tm va l triu chng c nng, va l triu chng thc th.
Thng thy r mi, nim mc ming, nn cc mng v c th c da. C th do gim
PaO2 nh trong suy h hp hoc do tun hon chm li nn O2 c tch nhiu khi HbO2
cc m (suy tim, sc). Tm c chia lm hai loi theo nguyn nhn bnh sinh:

20
 Tm trung ng: do bo ha oxy trong mu ng mch gim. Tm xy ra c
da v nim mc (li c mu tm). Gp nhng bnh nhn c bnh l gim thng
kh phi, bnh tim c shunt phi-tri hoc c bnh l v mu (bt thng
hemoglobin).
Tm ngoi bin: tm cc ngn tay, ngn chn, khng tm li. Nguyn nhn l
do gim ti mu ngoi bin. Gp trong suy tim, sc, hin tng Raynaud, bnh
mch mu ngoi bin, thi tit lnh.
Lu rng khng th c tm trung ng m khng c tm ngoi vi. Tuy nhin, tm
ngoi vi c th ch xut hin n thun.
Bng 2.4. Phn bit tm trung ng v tm ngoi vi
Yu t phn bit Tm trung ng Tm ngoi vi
V tr Da nim Da
Lnh u chi Khng C
a hng cu C Khng
Ngn tay di trng C Khng
Si m, th oxy Khng ci thin C ci thin

5.3. Vng da
Vng da dng ch sc t mu vng trong m c th c cha elastin (da v nim
mc) v xy ra khi lng bilirubin huyt tng > 34 mol/L (> 2 mg/dL). Thng gp
trong bnh l gan mt hay tn huyt.
Cn kim tra tnh trng vng da di nh sng t nhin (nh sng trng) trnh tnh
trng m mu do nh sng n gy nn. Cn quan st vng da t thay i mu sc do nng
(da mt trong cnh tay, lng bn tay) xem s i mu vng ca da. Khng nn nhm ln
vi vng da do nhim caroten (carotenaemia) bng cch hi bnh nhn xem c n nhiu cc
loi u , c rt khng Ngoi ra, c th yu cu bnh nhn ngc nhn ln v quan st
cng mc, nu cng mc c mu vng th c xem l bnh nhn c tnh trng vng da.

Hnh 2.11. Cng mc mt vng Hnh 2.12. Vng da lng bn tay

Bng 2.5. Nguyn nhn gy vng da

Trc gan: ch yu l do tn huyt

St rt
Thalassemia
Thiu men G6PD
Thuc, mt s c cht
Bnh t min

21
 Ti gan: do gan khng chuyn ha c bilirubin
Vim gan do virus, do ru
X gan
Hi chng Crigler-Najjar, Gilbert
Ung th
Sau gan: do tc mt
Si ng mt trong gan, si ng mt ch
U u ty, u ti mt, u ng mt ch
Vim ng mt

5.4. Cc mu da bt thng khc

Gp trong nhiu bnh l khc nhau hoc do mt s
thuc gy nn. Da c mu xm en trong bnh st, da c
mu xm bc trong ng c bc v da c mu trng trong
bnh bch bin cn phn bit bch bin v bch tng.
Bch bin (vitiligo): l bnh gim sc t da khu tr,
t pht vi biu hin l cc dt trng. Bnh c tnh
gia nh, hu ht bnh nhn u khe mnh, nhng
c cc bnh kt hp khc nh bnh tuyn thng
thn, i tho ng, thiu mu, thiu sn ty. Trong
bch bin, t l vim mng mt chim khong 10%.
C ch bnh sinh cha r. Tiu bn m hc ca Hnh 2.13. Bch bin
ngi b bch bin cho thy ch da b bch bin
khng c t bo sc t. Ngi bnh khng nn coi bnh bch bin ch kha
cnh thm m n thun m cn ch ti cc bnh i km.
Bch tng (albinism): l bnh gim sc t di truyn, tnh ln vi biu hin gim
sc t ng u da, tc v vng mc. Bch tng him khi ch biu hin da,
nhng c th ch biu hin mt mt cch n thun. C ch bnh sinh c lin
quan n vai tr ca men tyrosinase trong vic chuyn ha tyrosin thnh DOPA.
Biu hin ca bnh bch tng l da b gim hay mt hn sc t, tc bc. Ngi
bnh s nh sng, b git nhn cu. Khm ghi nhn y mt v mng mt trong
sut. Hu qu l bnh nhn b gim th lc, khng chu c nh sng mt tri, da
nhy cm vi tia cc tm v d b ung th da vng tip xc vi nh sng. Ngi
bnh cn mang knh mt, khn che nh sng mt tri.

6. NH GI MI C TH V MI HI TH
Mi ngi u c mt mi t nhin, do tc ng ca vi khun trn tuyn m hi. C
th thay i mi ny bng cch s dng ln kh mi, cht kh mi hoc nc hoa. M hi
qu nhiu v km v sinh c nhn lm tng mi hi ca c th, c th km vi qun o d
hoc dnh nc tiu. Mi hi qu mc c th gp trong nhng trng hp nh ngi ln
tui, b thng, bnh tm thn nng, lm dng ru hoc ma ty, khng th t v sinh c
nhn do b khuyt tt
Mi thuc l cn st li thng lan ta khp da, tc v qun o. Cn sa cng c th
c xc nh bi mi. Mi ca ru c th nhn bit qua hi th ca ngi bnh, c bit
l vo bui sng, gi tnh trng nghin ru.
Hi ming c th l hu qu ca vic phn hy thc n cn st li nm gia cc rng,
vim nu, vim mi v cc khi u ng mi.

22
 Mt s mi c trng khc:
Hi th c mi hng c bit nh mi qu thi: gp trong hn m gan
Hi th c mi to thi do nhim ceton acid: gp trong hn m do i tho ng
Hi th c mi khai do tng ur mu: gp trong suy thn nng
Hi th c mi thch cao, mi hi gp trong gin ph qun
Hi th c mi phn gp trong r d dy - trc trng

7. NH GI TNH TRNG DINH DNG

Tnh trng dinh dng ca c th l mt du hiu rt quan trng ca bnh v thng
hay b b qua trong qu trnh thm khm lm sng. Ch cn mt s thao tc n gin c
th d dng thc hin vic nh gi tnh trng dinh dng ca ngi bnh.
Nhn ngoi hnh chung xem th trng gy hay mp, hi bnh nhn xem gn y cn
nng tng ln hay st gim. St cn s thy hp g m, c tay nh, lm rnh xng sn,
l r cc mc xng chu
Cn tnh ch s khi c th (BMI: Body Mass Index) lc u v mi tun trong giai
on bnh cp. Bnh nhn ngoi tr cn c theo di BMI mi thng.

7.1. Ch s khi c th - BMI (Body Mass Index)

bt u thm khm lm sng, ngi khm phi lun kho st v cn nng v
chiu cao ca bnh nhn. D liu ny rt quan trng, gip chng ta bit c thng tin v
tnh trng dinh dng v c chng lng m trong c th. nh gi c ch s ny,
ngi ta a ra thng s BMI, c tnh nh sau:
Trng lng (kg)
BMI =
Chiu cao (m)2

Bng 2.6. Tiu chun tha cn v bo ph da theo BMI

2
Ch s BMI (kg/m )
Mc bo ph
Ngi chu Khng phi ngi Chu
Suy dinh dng <16 <16
Thiu cn < 18,5 < 18,5
Bnh thng 18,5 22,9 18,5 24,9
Tha cn 23 24,9 25 29,9
Bo ph 25 29,9 30 39,9
Qu bo ph 30 40

Vi nhng bnh nhn c nh gi l bo ph, cn t vn v vn dinh dng v

ch tp luyn th dc u n.
Nu bnh nhn c vn v dinh dng, ch s BMI cnh bo thiu cn, cn hi mt
s thng tin sau:

23
Bng 2.7. Bng kho st mc nh hng n vn suy dinh dng
Cc cu hi im ghi nhn c
Bnh nhn khng tin mua thc n 4
Bnh nhn n t hn 2 ba mi ngy 3
Bnh nhn n t rau qu, sn phm t sa 2
Bnh nhn c ung 3 ly bia hay ru mi ngy 2
Bnh nhn c ang bnh v lm thay i lng thc n ang dng 2
Bnh nhn c mc bnh rng ming lm kh n 2
Bnh nhn st 5kg trong 6 thng gn y 2
Bnh nhn khng sc khe t n ung 2
Hu ht thi gian, bnh nhn n mt mnh 1
Bnh nhn ung 3 toa thuc mi ngy 1

Nu tng im:
0 2: Tt, ch cn kim tra li dinh dng sau 6 thng
3 5: Trung bnh, cn kim tra li dinh dng sau 3 thng
6 : Dinh dng km, cn t vn chuyn khoa dinh dng.

7.2. o dy da
Bng cch gp da to thnh np gp v dng dng c o dy da (calipers) chuyn
dng ghi ch s. C nhiu tiu chun o dy da nh: 3 thng s (i, bng, ngc),
4 thng s (i, bng, eo, cnh tay), 7 thng s (i, bng, eo, ln, ngc, cnh tay, vai)
Ch s tnh ton trung bnh ny i vi nam trong khong 20mm v n trong khong
30mm.

7.3. Ch s vng eo
Ch s vng eo gip tin lng cho cc bnh l tng huyt p, khng insulin
bnh nhn i tho ng type 2 v bnh l ng mch vnh. Vng eo nam > 94cm hay
n > 80cm c xem l c yu t nguy c.
Hnh dng c th cng l mt yu t
khc h tr cho vic nh gi nguy c bnh
Nu c dng hnh qu l, ngha l t
l eo/hng 0,8 (n) hay 0,9
(nam) th c tin lng tt
Nu c dng hnh qu to, ngha l
t l eo/hng > 0,8 (n) hay > 0,9
(nam) th l tin lng xu cho tnh
trng gia tng bnh l ng mch
vnh hoc hi chng chuyn ha. Hnh 2.14. Hnh dng c th theo ch s vng eo

7.4. Cc biu hin bt thng

7.4.1. Dng ln
Dng ln thng c lin quan ti vn di truyn trong gia nh, cn hi chiu cao
ca b m v anh ch em trong gia nh. Mt s bnh l t nh cng nh hng n chiu
cao sau ny. Mt s nguyn nhn kh chn on gy ra dng ln ngi tr nh nhim
toan ng thn, bnh l tuyn gip, ri lon hp thu rut Nhng nguyn nhn gy mt

24
xng lm gim chiu cao cng cn phi ghi nhn (gy xng, long xng, khing vc
nng). Nhng ph n sau tui mn kinh nu chiu cao gim hn 5cm cn c nh gi
v vn long xng.
7.4.2. Dng cao
Dng cao bt thng s t gp hn dng ln v
thng do di truyn. Mt s nguyn nhn lm tng
chiu cao t bin l:
Hi chng Marfan: ngi bnh thng rt
cao, mnh khnh v lng khp. V hi chng
Marfan nh hng n cc xng di nn
cnh tay, chn, ngn tay v ngn chn c th
khng cn i v di vi phn cn li ca
c th.
Hi chng ngi khng l do u tuyn yn
(pituitary gigantism)
Thiu nng sinh dc (hypogonadism)
7.4.3. Suy dinh dng
Thng suy dinh dng do bing n, nhng mt
s trng hp suy dinh dng do tng n do bnh l
(nhim c gip, bnh i tho ng type 1, bnh
Hnh 2.15. Dng ngi Marfan
rut non) hoc do ri lon lo u, trm cm, nghin
ru, cht ma ty.

Bng 2.8. Nguyn nhn suy dinh dng

- Bnh nhn b bnh nng - Chn thng

- Bnh l c tnh - Sau phu thut
- Bnh chuyn ha (suy thn) - Bnh tm l (trm cm, chn n tm
- Bnh tiu ha (bnh rut non) thn, x hi c lp)

- Nhim trng huyt

7.4.4. Bo ph
Nguyn nhn do d tha m trong c th kt hp vi tnh trng khng hot ng th
dc y . Mt s bnh l c th gy ra bo ph do tch nc. Thng bo ph s i km vi
tnh trng tng huyt p, tng cholesterol trong mu, i tho ng type 2, bnh l ti mt
v thng d gy chng ngng th khi ng. Bo ph s lm gim tui th i khong 7 nm.
Bng 2.9. Nguyn nhn gy bo ph
- Bo ph sinh l (n nhiu) - Do ni tit (suy gip, hi chng Cushing)
- Do di truyn (hi chng Prader Willi, - Do thuc (corticosteroids)
Lawrence Moon Biedl) - U hoc tn thng vng h i

8. NH GI TNH TRNG MT NC C TH
ngi trng thnh, 60-65% trng lng c th l nc. Nc hin din trong tt
c cc cu trc ca c th (cc c quan, khoang ngoi bo, m k, mch mu).

25
 Vic nh gi tnh trng mt nc trong c
th s h tr trong vic chn on bnh. Bnh
nhn thng ghi nhn t ung nc, c du hiu
kht nc, mi kh, mt trng, da gim n
hi (nhn da)... l nhng du hiu gi tnh trng
thiu nc c th. Cc tnh trng nhim trng
huyt, chy mu hoc tc nghn rut v nn cng
c th lm thiu nc c th. Cn kim tra tnh
Hnh 2.16. Du mt trng
trng bnh nhn c ang c truyn dch, nui
dng bng ng sonde d dy.
Nn kim tra thm bng du hiu vo da
(Casper), bng cch nh nhng nhc da vng mu
tay, gi mt lc. Nu sau khi th tay ra, da nhanh
chng n hi tr li th c ghi nhn l bnh
thng, nu np da tn ti lu v da t n hi th
c ghi nhn l c tnh trng thiu nc c th.
Tuy nhin, du hiu ny khng tin cy nhng
ngi gi do da mt tnh n hi bnh thng. Hnh 2.17. Du vo da
Bng 2.10. Nguyn nhn gy mt nc c th

Gim nhp Tng xut

- Chn n - Nn
- au hng - Tiu chy
- Bun nn - St
- L lot ming - Tiu nhiu (i tho ng, thuc li tiu,)
- Ra nhiu m hi (hot ng th lc)

Ngoi ra, mt s bin php khc gin tip gip nh gi thiu nc (do mt mu):
Du nhp nhy mng: thng nh gi tnh trng cung cp oxy cho m ngoi
bin, nu c tnh trng thiu mu do thiu th tch tun hon th s biu hin. Cch
lm nh sau: ngn tay ci bnh nhn c bp cht trong vng 5 giy, sau th
ra. Nu thi gian mu sc mng tay hng tr li > 2 giy c xem l thiu
oxy m ngoi bin do gim lu lng mu cung cp.
Mch nhanh: cng l du hiu ca mt nc do mt mu.
Huyt p thp: c th cho thy tnh trng thiu nc, gim th tch tun hon.
Du tnh mch c ni: thng xp khi c gim th tch tun hon, tng khi c qu
ti tun hon (ph phi).
9. NH GI TNH TRNG PH
Ph l tnh trng tch t dch trong cc m di da v bo hiu tnh trng mt cn
bng gia p lc thy tnh v p lc keo ca mao mch. C th ph ton thn, khu tr hay
ti ch. Nguyn nhn gy ph c th l do gim m mu (suy dinh dng, km hp thu,
hi chng thn h, x gan nng), do suy tim hay do u chn p...
Biu hin chnh ca ph l n lm cc m v tr nng nh mt trc xng chy. Triu
chng n lm c th khng r nu trng lng c th tng di 10-15%. Cn nhn ngn ci
ca ngi khm vo on xa mt trc xng chy ca bnh nhn trong vng 10 giy. Nu v
tr nhn to thnh vng trng v lu lp y th l du hiu ca ph Godet (+).

26
Bng 2.11. Phn ph
ph L gii
+ 0 Khng c du hiu ph
+ 1 Ph mc nh: n lm 2mm, bin mt nhanh
+ 2 Ph mc trung bnh: n lm 4mm, bin mt sau 10 15 giy
+ 3 Ph mc trung bnh nng: n lm 6mm, bin mt sau 1 pht
+ 4 Ph mc nng: n lm 8mm, bin mt chm sau 2 pht

Hoc mt s trng hp nm lu, dch ngoi bo tp trung vng trng v ta c th

kim tra bng cch n ngn ci vo vng trc xng cng ca bnh nhn.

Hnh 2.18. Du hiu ph, n lm

9.1. Ph ton thn

Hai nguyn nhn chnh gy ph ton thn l qu ti dch v gim m mu.
Phn bit bng cch o p lc tnh mch cnh (thng tng trong qu ti dch).

Hnh 2.19. o p lc tnh mch cnh

Nguyn nhn qu ti dch:

+ Truyn dch tnh mch qu nhiu
+ Bnh thn nh vim cu thn cp, lm gim lng nc tiu, tng th tch dch
ngoi bo v th tch tun hon km tng ti hp thu natri ng thn.
+ Suy tim gy ph do nhiu c ch khc nhau (hot ha h renin-angiotensin-
aldosteron), tng ti hp thu nc v natri
Nguyn nhn gim m mu:
Gy gim p lc keo dn ti thot dch ra m k v gy ph. Thng gp trong
(1) hi chng thn h gy mt m qua nc tiu (tiu m) hay (2) bnh l gan nh x
gan c chng.

27
9.2. Ph khu tr: c th do bnh l tnh mch, bch huyt, vim hoc d ng.
Nguyn nhn tnh mch
Tng p lc thy tnh trong lng tnh mch gy thot dch ra ngoi bo. Nguyn nhn
gm (1) huyt khi tnh mch su, (2) chn p t ngoi do u hoc mang thai, (3) suy van
tnh mch Nhng tnh trng lm gim hot ng bm bnh thng ca c nh lit na
ngi, bt ng ti ch gy tng p lc tnh mch do gim hi lu tnh mch. V vy, c
th gp ph bnh nhn nm bt ng ti ging, bnh nhn lit hoc ngi khe mnh
ngi mt ch trong thi gian di (chuyn bay ng di).
Nguyn nhn bch huyt
Thng thng, dch t m k quay li tun hon trung tm thng qua h thng bch
huyt. Bt k nguyn nhn no lm gim dng chy bch huyt nh tc nghn bn trong
hay chn p bn ngoi u c th gy ph khu tr (ph bch huyt). Nu tnh trng ny ko
di, m si tng sinh trong m k, lm cng m vng tn thng v khng cn triu chng
ph mm, n lm. Nguyn nhn ca ph bch huyt l gim sn bm sinh ca h bch
huyt chn, sau phu thut ung th c no vt hch vng nch (ph bch huyt tay), x tr
trong ung th vng chu (ph bch huyt chn), giun ch (ph chn voi).
Nguyn nhn do vim
Vim lm phng thch cc histamin, bradykinin v cytokine; gy gin mao mch v
tng tnh thm thnh mch. Du hiu nhn bit l sng, nng, , au.
Nguyn nhn d ng
Tng tnh thm mao mch gp trong trng hp d ng cp. Vng da d ng s ,
nga do phng thch ti ch ca histamin v cc ha cht trung gian gy vim nhng khc
vi ph do vim l bnh nhn khng au.
Ph mch l mt dng c bit ca ph d ng, nh hng n vng mt, mi v
ming. Ph c th tin trin nhanh v e da t vong nu lan n ng dn kh trn.

Hnh 2.20. Ph d ng (ph mch)

10. KHM HCH NGOI BIN
Cn coi khm hch ngoi bin l thao tc thng qui trong khm tng trng. Kim
tra ton b cc nhm hch ngoi bin theo tun t t trn xung.
Hch vng c nm dc theo mt trc v bn ca c v mt di ca hm (a). chi
trn, cc hch tp trung vng nch (b) v chi di, cc hch tp trung vng bn (c).

28

Hnh 2.21. V tr cc nhm hch ngoi bin

Ch c th nhn c cc hch ph i, ni g ln mt da hoc xung quanh hch

vim .
Dng cc u ngn tay nh nhng ln trn vng hch cn khm nh gi bn cht
ca hch nu pht hin.
Vng u - c: cn nga c, nghing u bnh nhn qua pha i din nhm bc
l r vng hch cn khm. Bnh nhn nn c khm t th ngi thoi mi
hoc nm u cao. Ngi khm ng pha sau s, tng t nh khm s tuyn
gip.
Vng nch: tay dang cao ln u, bc l r vng nch, nn khm t th nm u
bng. ng cng bn vi nch cn khm hch. Nu khm t th ngi, tay bnh
nhn cn c dang ngang 90o v c th lng bng cch dng tay ngi khm
nng tay bnh nhn.
Vng bn: t th nm u bng, chn dui thng. Khm dc di theo dy chng
bn v dc theo chiu ca tnh mch hin on hi lu.
Khi pht hin c hch vng tng ng, cn m t theo cc tnh cht sau:
V tr: gip nh gi c c quan tng ng gy nn.
S lng: bao nhiu hch s thy, nu qu nhiu c th nh gi theo tng cm hch
Kch thc: hch ch s thy khi kch thc to (>1 cm), i khi cc hch dnh vi
nhau to thnh tng cm hch vi kch thc c th s thy c.
Tnh cht: s thy hch trn lng, mm, thng l hch vim. Nu b mt hch
sn si, cng chc, khng u, thng l hch di cn.
au: biu hin cho tnh trng vim, cn kim tra thm cc du sng, nng,
Tnh c nh: nu hch pht hin dnh chc vo m xung quanh, t tnh di ng
khi y thng l hch c tnh.

29
TI LIU THAM KHO
1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam. K nng
giao tip Thy thuc - Bnh nhn. K nng y khoa c bn. Nh xut bn Y hc TPHCM,
2009, tr.13-20.
2. Graham Douglas, Fiona Nicol, Colin Robertson (2013). Macleods Clinical Examination,
13st edition.
3. James Thomas, Tanya Monaghan (2014). Oxford Handbook of Clinical Examination and
Practical Skills, 2nd edition.
4. Khm ton trng. Hun luyn k nng y khoa I. K nng iu dng c bn, i hc Y
Dc Cn Th, 2011, tr.136-240.
5. Lynn S. Bickley, Peter G. Szilagyi (2013). Bates Guide to Physical Examination and
History taking, 7th edition.
6. Owen Epstein et al (2009). Pocket Guide to Clinical Examination, 4th edition.

30
 Bi 3
PHN TCH DU HIU SINH TN

MC TIU
1. Ly c du hiu sinh tn (mch nhit huyt p nhp th, nh gi tri gic).
2. Phn tch c ngha cc thng s ca du hiu sinh tn.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 120 pht
+ Gii thiu mc tiu v ni dung bi ging: 10 pht
+ Gii p thc mc l thuyt: 20 pht
+ Ging vin khm mu: 10 pht
+ Sinh vin thc hnh: 60 pht
+ Chn 02 sinh vin khm, nhm cn li quan st v nh gi: 10 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. I CNG
Du hiu sinh tn l nhng triu chng khch quan, c o bng cc thit b, k
thut khc nhau nhm nh gi nhng chc nng c bn ca c th sng.
Du hiu sinh tn l nhng triu chng khng th thiu trong bnh n v khi tin
hnh trnh by bt k vn g v bnh nhn. Vic nh gi cc du hiu sinh tn ca bnh
nhn khng nhng cung cp nhng thng tin v cng gi tr cho chn on m cn gip
cho ngi thy thuc xc nh mc nng ca bnh, theo di hiu qu iu tr, pht hin
bin chng ca th thut, phu thut v nhn din sm tnh trng bnh chuyn nng. Khi
bnh cha n nh, cn theo di st du hiu sinh tn.
Gi tr bnh thng ca cc du hiu sinh tn thay i theo tui, gii, cn nng, mc
vn ng v trng thi tinh thn C 4 du hiu sinh tn c in l mch, nhit ,
huyt p v nhp th. Ngy nay, mt s tc gi c cp thm nhng du hiu sinh tn
khc nh tri gic, bo ha oxy theo mch p (SpO2) hay mc au
Tt c cc du hiu sinh tn nn c o t th ngi (nu iu kin cho php). Cn
cho bnh nhn ngi ngh t nht 5 pht trc khi ly du hiu sinh tn.

2. PHN TCH TN S TH - KIU TH

Tn s th v kiu th l nhng ch s n gin nhng rt quan trng, gip nh gi
nng ca cc bnh l cp tnh v tin lng bnh (ca bnh l h h hp v bnh l
ngoi h h hp).

31
2.1. Tn s th
Tn s th bnh thng (khi ngh ngi hon ton) khong 16 - 20 ln/pht ngi
trng thnh.
Nhp th chm: < 12 ln/pht
Ure mu tng
+ Tn thng thn (tng huyt p, i tho ng)
+ Tc/hp ng mch thn
+ Gim th tch tun hon (mt mu, bng, i, tiu chy mt nc)
Tng p lc ni s
+ Tc nghn h thng tnh mch xoang no: huyt khi tnh mch, tn thng
t tnh mch cnh, hi chng chn p tnh mch ch ln, tng p lc bung
tim phi
+ Ri lon ni tit: bo ph, hi chng Cushing, hi chng Addison, suy gip,
suy tuyn cn gip
+ Khc: chn thng no kn
c ch h hp
+ Ng c ru
+ Thuc an thn (Benzodiazepines)
+ Cht ma ty nhm opioid (morphin, heroin)
+ Thuc nhm cholinergic
Nhp th nhanh: > 24 ln/pht
Do sinh l hay chuyn ha: st, au, bo ph, h ng huyt, yu c h hp, cng
chng bng,
Do bnh l tim mch: suy tim sung huyt, thiu mu, cng gip, thuyn tc phi
Do bnh l h hp: vim phi, bnh phi tc nghn mn tnh (COPD), hen ph
qun, trn kh mng phi, bnh m k, ph phi, khng kh thiu Oxy hoc
nhiu CO2
Do thn kinh: u no, bnh gan no
Do thuc: tng giao cm (amphetamines, Cocaine), Salicylates, Anticholinergics,
gy o gic (Ketamine, PCP - phencyclidine), cn sa.

2.2. Mt s kiu th bt thng

Nhp th ko di (sighs): l tnh trng ht vo khng t ch, km th tch kh lu
thng tng t 1,5 n 2 ln so vi bnh thng. y l triu chng bo hiu c
tnh trng tng thng kh. Nguyn nhn thng do lo lng, trm cm, sau n no
hoc sau gng sc th lc

Hnh 3.1. Nhp th ko di (sighs)

32
 Nhp th Cheyne Stokes: trong chu k th c: bin ht vo tng dn n ti
a sau gim dn - tip theo l giai on ngng th - ri bt u mt chu k
mi. Gp trong u no, vim mng no, vim phi.

Hnh 3.2. Nhp th Cheyne Stokes

Nhp th kiu kh: c th th ra ko di. Thng gp trong bnh phi tc nghn

mn tnh (COPD), hen ph qun (asthma), vim ph qun mn (chonic
bronchitis).

Th th ra ko di

Hnh 3.3. Nhp th kiu tc nghn

Nhp th Kussmaul: bnh nhn ht su vo-ngng th-th ra-ngng th-thi gian

ngng th gia th ht vo v th ra khong 30 giy. Gp trong toan huyt mn,
vim mng no, u no, xut huyt no.

Hnh 3.4. Nhp th Kussmaul

Nhp th Biot: nhp th khng u, lc chm lc nhanh, lc th nng lc th su,

c lc ngng th. Gp trong trng hp bnh tim c rung nh.

Hnh 3.5. Nhp th Biot

33
 Hnh 3.6. Tng hp cc kiu th

3. O THN NHIT
Thn nhit l mt ch s phn nh tc chuyn ha c bn, nh gi tnh trng
nhim trng v p ng chuyn ha vi gng sc ca c th Thn nhit c o bng
cch s dng mt nhit k thy ngn hoc in t. Vic ghi nhn thn nhit khc nhau ph
thuc vo v tr ly nhit.
Nhit bnh thng o ming l 37C, trc trng cao hn 0,5C v nch thp
hn 0,5C.
Ngoi ra, nhit c th cn thay i theo ngy - m, vi nhit bnh thng cao
nht t 10 gi sng n 6 gi chiu v thp nht t 2 n 4 gi sng.

Gi hot ng v lm vic Gi ngh ngi v ng

G

Hnh 3.7. Thay i thn nhit trong ngy

34
3.1. Tng thn nhit (Hyperthermia)
Nguyn nhn GHI NHN
+ Nhim trng thng gp nht St khi no?
+ Chn thng: bng, sc nhit St bao lu?
St lin tc hay tng cn
+ Thuc: khng sinh, khng histamin,
C gim khi dng thuc h st?
thuc gy nghin
C km cc triu chng khc
+ Bnh l: cng gip, vim khp, (ho, au hng,...)
ung th (phi, gan)
Lm sng ghi nhn l st khi thn
nhit o ming > 37,8oC
Cn phn tch cc dng st nh sau:
+ St lin tc, dai dng c th l mt du hiu ca s tng thn nhit c tnh, st
do dng thuc (v d: halothane, suxathonium), st pht ban, hoc st thng
hn hoc l du hiu gi ca bnh bch huyt v nhim trng sinh m.
+ St cao tng t xy ra bnh nhn b bnh Hodgkin v c c trng bi
st 4-5 ngy lin tc, sau tr v bnh thng trc khi st quay tr li. Cn
lu , st cao v st tng t cng thng gp trong nhim trng ng mt
hoc vim i b thn.
Nhng du hiu cnh bo st cn phi nhp vin theo di:
+ St cao > 38,3oC khng gim sau dng thuc
+ St lin tc 2 ngy d dng thuc h st dng ung
+ St, au u nh ba b
+ St km tiu chy mt nc
+ St km kh th, th dc
+ St km gim hoc mt thc
+ St km tm ti
+ St km quy khc nhiu (tr em)

3.2. H thn nhit (Hypothermia)

H thn nhit l khi o nhit lng trc trng < 35C v thng l do tip xc
vi lnh hay do c ch trung tm iu nhit khi c s suy yu ca thc (say
ru qu mc hoc dng ma ty qu liu), bnh nhn b lnh da, run c, cng c.
Tr nh tui hoc ngi gi km suy gip, Parkinson, Alzheimer, tn thng h
i (trung khu iu ha nhit)
Khi nhit c th <27C, bnh nhn s ri vo mt thc, hn m.

4. BT MCH V M TN S MCH
Mch ngoi bin l ch s gip nh gi lu lng mu n nui cc c quan nh
u, chi trn, chi di mch gim l du hiu cho thy gim lng mu n nui c
quan. Khi mch mt (khng bt c mch), cn phi tm v iu tr nguyn nhn ngay lp
tc v nguy c cao gy hoi t c quan tng ng.
Bt mch quay l ng tc bt mch thng dng nht khi kt hp vi nghe ting
tim, vi 2 ngn tr v ngn gia, n nh vo v tr ng mch quay. Vi mch p u, s

35
m tn s mch trong 15 giy ri nhn 4 ln ra tn s mch trong mt pht. Nu mch
p chm, qu nhanh hoc khng u, nn bt trong 1 pht.
Mch bnh thng dao ng trong khong 60 100 ln/pht.
Bng 3.1. Tn s mch theo tui (Ngun: Normal Vital Signs, Medscape Updated: 2015)
Khong tui Tn s nhp mch
S sinh 100 160
0 5 thng 90 150
6 12 thng 80 140
1 3 tui 80 130
3 5 tui 80 120
6 10 tui 70 110
11 14 tui 60 105
15 20 tui 60 100
Trng thnh 50 - 80

4.1. Tn s nhp mch

4.1.1. Mch nhanh
Khi ngh ngi > 100 ln/pht hoc khi ng > 90 ln/pht
Nguyn nhn:
+ Hot ng th lc
+ Thiu mu
+ St
+ Thuc
+ Bnh l: cng gip, bnh l tim gy thiu mu c tim
+ Cht kch thch giao cm: thuc l, cafein, amphetamines
+ Nghin ru
+ Stress
+ Bt thng v hot ng tim:
Rung nh
Nhp nhanh kch pht trn tht, hi chng Wolff-Parkinson-White, c ghi
nhn qua in tm .
Nhp nhanh tht do c cc pht nhp bt thng trn thnh tm tht.
Rung tht, to cc nht bp c tim tn s nhanh nn khng hiu qu v nguy
c gy t vong nu khng pht hin v x l kp thi.
4.1.2. Mch chm
Khi nhp mch < 60 ln/pht
Nguyn nhn:
+ Thuc: nhm c ch beta, chng ri lon tm thn
+ Bnh l tim gy thiu mu, tn thng c tim, tng huyt p

36
 + Suy gip
+ Vim khp dng thp (RF), lupus ban h thng (SLE)
+ cht st (hemochromatosis)
+ Bt thng v hot ng tim
Block nh tht (Block AV) I II III
Block nhnh

4.2. Dng mch

Bnh thng, p lc mch dao ng t 30-40mmHg, ng nt sng quan st trn
monitor mm mi, trn, dc thoi. Cc dng mch khc c cp bn di.

Hnh 3.8. Biu mch bnh thng

Mch ny yu, nh: nhnh ln c th chm, nh ko di. Thng p lc nh, nguyn

nhn do (1) gim th tch nht bp (suy tim, gim th tch tun hon, hp ng mch
ch nng) v (2) tng khng lc ngoi bin (lnh, suy tim mt b nng).

Hnh 3.9. Biu mch yu, nh

Mch ny mnh, bin cao: mch tng v gim t ngt, ch yu cm nhn

c nh ca mch. Nguyn nhn do (1) tng th tch nht bp v hoc gim
khng lc ngoi vi nh st, thiu mu, cng gip, h ch, r ng tnh mch
(fistulas), cn ng ng mch; (2) tng th tch nht bp do nhp tim chm nh
trong block nh tht hon ton v (3) gim n hi ca thnh ng mch ch
nh x va ng mch, x cng ng mch (mch mu ca ngi ln tui).

Hnh 3.10. Biu mch ny mnh, bin cao

Mch hai nh (Bisferiens): mch c hai nh tm thu. Nguyn nhn gm h van

ng mch ch n thun, hp h van ng mch ch v t gp hn l trong bnh
c tim ph i.

Hnh 3.11. Biu mch 2 nh

Mch xen k (Alternans): nhp vn u nhng mt nhp mnh xen k mt nhp

yu. D nhm vi mch ny thng nhng c s khc bit khi quan st qua
monitor, c mch ny mnh c mch ny yu hn. Nguyn nhn do suy tht tri
v thng nghe tim c km ting T3.

37
 Hnh 3.12. Biu mch xen k

Mch i (Bigeminal): l mt dng ri lon nhp, d nhm vi dng mch xen k.

Mch i l do mt nht bp tim bnh thng xen k vi mt nhp ngoi tm thu.
Th tch ca nht bp ngoi tm thu th t hn so vi nht bp bnh thng.

Nht bp n
sm
Hnh 3.13. Biu mch i

Mch nghch (Paradoxical Pulse): cng mch gim khi ht vo. Nu khng
r th o huyt p. Huyt p tm thu gim hn 10mmHg khi ht vo. Nguyn
nhn: chn p tim cp hay vim mng ngoi tim co tht v bnh phi tc nghn
mn tnh.

Th ra Ht vo

Hnh 3.14. Biu mch nghch

Ngoi v tr bt mch quay, c th bt mch cc v tr khc nh:

Hnh 3.15. Cc v tr bt ng mch

38
5. O HUYT P
Huyt p l p lc ca dng mu tc ng ln thnh ng mch, gip nh gi nguy
c b bnh tim mch v cung cp thng tin quan trng v huyt ng hc bnh nhn b
bnh cp tnh hoc chn thng. n v o huyt p l mmHg. ngi bnh thng,
huyt p ng mch c th thay i: ban ngy cao hn ban m, tui gi cao hn tui tr,
n thng thp hn nam. Khi vn ng, gng sc th lc, cng thng thn kinh, xc ng
mnh u c th lm huyt p tng ln. Ngc li khi ngh ngi, th gin lm huyt p
h xung

5.1. Nhng lu khi o huyt p

Phng phi yn tnh, m (trnh gy run git c)
Bnh nhn nn c ngi ngh ngi ti ch khong 05 pht, khng c s dng
cc cht gy kch thch (ru, tr, c ph, thuc l) trong vng 30 pht trc .
Dng c o huyt p m bo hot ng tt, chiu rng ti hi phi ph c
khong 40% cnh tay (12-14cm), chiu di khong 80%.
Tay c t trn bn (t th ngi), ngang mc tim hay ngang trn mt ging
khm. Tay th lng, khng gng c, khng gp khuu tay.
Trnh o trn nhng tay c cu ni chy thn, ph tay nghi do tc bch mch, c
phu thut hay tn thng mch mu trc .
Cn bm p lc thm 30 mmHg k t khi khng nghe c mch. Tip tc x hi
n khi nghe m ting p thay i hoc mt hn (trong a s trng hp) th
l huyt p tm trng.
Tc x p lc l 2-3mmHg/giy.
Nhng trng hp ch s cao > 140 mmHg (tm thu) hay > 90 mmHg (tm
trng), cn c o li huyt p ln 2 sau khi ngh ngi ti ch 2 pht.
Nhng trng hp c tin cn ngt xu, chng mt t th, gim th tch mu. Cn
o huyt p t th nm v ng.

5.2. Mt s vn thng gp khi o huyt p

Huyt p hai tay khc nhau: khi khc bit > 10 mmHg, cn loi tr hp ng
mch di n. Lc ny, huyt p tay cao hn c s dng.
Chn sai kch c my o huyt p: ti hi nh s lm huyt p o c cao hn
thc t v ngc li.
Khong trng huyt p: gn 20% bnh nhn tng huyt p ln tui c ting
Korotkoff sau khi xut hin th bin mt mt lc (gia huyt p tm thu v tm
trng). V vy, nu khng nghe c ting u tin (huyt p tm thu), th huyt
p tm thu ghi nhn c s thp hn thc s.
Thay i huyt p theo t th (xem phn h huyt p t th).
Rung nh: lm cho vic o huyt p kh hn do giao ng nhiu gia cc nhp
tim. Nn x ti hi chm 2 mmHg mi nhp v o li ln 2 nu cn.

39
 CCH KIM TRA H HUYT P T TH

Bnh nhn nm ngh ngi trong 5 pht

Ghi nhn mch v huyt p t th nm
i bnh nhn sang t th ng
Ghi nhn li mch v huyt p t th ng thi im 1 pht 3 pht
+ Bnh thng nhp tim s tng 10 25 nhp/pht
+ Huyt p tm thu gim 5-10 mmHg
+ Huyt p tm trng tng 5 10 mmHg
H huyt p t th l khi huyt p tm thu gim > 20 mmHg hoc huyt p
tm trng gim > 10 mmHg

QUI TRNH O HUYT P

M trn cnh tay c o
cnh tay ngang tim
Kch thc bng qun ph hp, qun quanh bp tay trn np khy khong
2,5cm
Bt mch quay hoc cnh tay xc nh mch cn p.
Kha van, bp huyt p n khi khng cn bt c mch p
t ng nghe vo v tr khy tay, bm thm 20-30 mmHg
X bao huyt p tc 2-3mmHg/giy, khi nghe ting p u tin, l
huyt p tm thu
Tip tc x bao hi n khi ting p thay i hoc mt hn (a s trng
hp) th l huyt p tm trng.

Bng 3.2. Tiu chun huyt p (ngi trn 18 tui) (Theo JNC VII-2003)

Huyt p tm thu Huyt p tm trng

Loi
(mmHg) (mmHg)
Bnh thng < 120 <80

Tin tng huyt p 120 139 80 89

Tng huyt p
1 140 159 90 99
2 160 100

40
Bng 3.3. Tiu chun huyt p theo Hip hi tng huyt p Anh quc (BHS)

Huyt p tm thu Huyt p tm trng

Loi
(mmHg) (mmHg)
Thp < 120 < 80
Bnh thng < 130 < 85
Bnh thng cao 130 - 139 85 89
Tng huyt p
I (nh) 140 159 90 99
II (va) 160 179 100 109
III (nng) > 180 > 110
Tng huyt p tm thu
nguyn pht
I 140 159 < 90
II > 160 < 90

Khi ch s huyt p tm trng v tm thu khng cng nm trong mt loi, chn loi
cao hn.
5.3. Nguyn nhn gy tng huyt p
Thuc (khng vim steroid hoc non - steroid, thuc nga thai ung )
Bnh l thn (m niu hng cu niu, thn a nang, thn nc hay u thn)
Bnh l ng mch thn (Renovascular disease) nh hp ng mch thn bm
sinh hay tc ng mch thn do huyt khi
U t bo a chrome (Phaeochromocytoma) nh u tuyn thng thn
Hi chng Conn (chng tetany, yu c, a niu, h K+ mu)
Hp eo ng mch ch lm dng mu xung chu i gim, mch yu
Hi chng Cushing
5.4. Cc yu t thc y chng tng huyt p
Bo ph
Nghin ru (> 3 n v/ngy)
n mn
t vn ng th dc
Mi trng sng p lc (stress)
5.5. Bin chng ca tnh trng tng huyt p
t qu (stroke), cn thiu mu no thong qua (TIA), mt tr nh, phnh ng
mch cnh
Dy tht tri (LVH), suy tim
Nhi mu c tim (MI), cn au tht ngc, bc cu ng mch vnh (CABG) hoc
nong mch vnh
Bnh l mch mu ngoi vi (PVD)
Ph gai th (papilledema), xut huyt vng mc (fundal hemorrhages)
m niu, suy thn (tng creatinine mu)
5.6. Yu t nguy c tc ng ln bnh tim mch
Tui
Gii

41
 Tin s gia nh
Ht thuc l
Bnh l i tho ng
Ri lon m mu
5.7. T vn cho ngi bnh b tng huyt p
Gim trng lng v vng eo (Nam < 90cm; N < 80cm)
Tp th dc u n (t nht 30 pht/ngy, lin tc trong tun)
Ch n ung lnh mnh
Gim mui (khng qu 2g mui/ngy)
Gim ru bia (cht c cn) (khng qu 1 lon bia; khng qu 5 ly ru vang
(30ml/ly); khng qu 2 ly ru mnh (30ml/ly)
Trnh ht thuc l v ht khi thuc
Trnh ung cafe
Gim p lc cng vic (stress)
Theo di thng xuyn huyt p ti nh v ti khm nh k
Nhn s h tr t ngi thn v bn b

6. NH GI TRI GIC
nh gi tri gic l phn cng vic khng th thiu bnh nhn b bnh l cp tnh.
Tri gic thay i c th gp trong nhiu bnh l ca nhiu h c quan khc nhau (ng
dn kh, h h hp, tun hon, ni tit).
nh gi tri gic (tnh to khng tnh to) thng qua: bnh nhn t khai bnh, t tr
li cc cu hi mt cch r rng, chnh xc. Hay tnh trng ni sng, la ht bt thng, ni
khng c hoc . Trn lm sng, thng dng thang im Glasgow nh gi tri gic.
Bng 3.4. Thang im Glasgow

p ng im
Mt (E: eyes) -
- M mt t nhin 4
- M mt khi gi, khi ra lnh 3
- M mt khi c kch thch au 2
- Khng m mt 1
Tr li (V: verbal) -
- Ni, tr li ng cu hi 5
- Tr li ln ln, mt nh hng 4
- Tr li khng ph hp cu hi 3
- Tr li , khng thnh ting, khng hiu c 2
- Nm im, khng tr li 1
Vn ng (M: motor)
-
- Vn ng ng theo mnh lnh
6
- Vn ng thch hp vi kch thch (kch thch au: gt tay ng ch)
5
- Vn ng khng thch hp vi kch thch (kch thch au: gt tay khng
4
ng ch)
3
- p ng kiu co cng mt v: Gp cng hai tay
2
- p ng kiu dui cng mt no: Dui cng t chi
1
- Nm im, khng p ng

42
 Cch tnh im: (E + V + M): im thp nht l 3, im cao nht l 15.
Glasgow 3 - 4 im: tng ng vi hn m IV
Glasgow 5 - 8 im: tng ng hn m III
Glasgow 9 - 11 im: tng ng vi hn m II
Glasgow 12 - 13 im: c coi l hn m I

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam. K
nng giao tip Thy thuc- Bnh nhn. K nng y khoa c bn. Nh xut bn Y hc
TPHCM, 2009, tr.13-20.
2. Graham Douglas, Fiona Nicol, Colin Robertson (2013). Macleods Clinical Examination,
13st edition.
3. James Thomas, Tanya Monaghan (2014). Oxford Handbook of Clinical Examination and
Practical Skills, 2nd edition.
4. Lynn S. Bickley, Peter G. Szilagyi (2013). Bates Guide to Physical Examination and
History taking, 7th edition.
5. Owen Epstein et al (2009). Pocket Guide to Clinical Examination, 4th edition.

BNG KIM

KHM HCH NGOI BIN

Khng thc hin Thc hin
STT NI DUNG
0 im 1 im
1 T gii thiu
Nu r mc ch khm
2 Ra tay
Chun b t th bnh nhn
3 Hi cc v tr au
4 Nhn cc nhm hch v vng da xung quanh
S cc nhm hch:
5 1.Nhm hch vng u Mi nhm hch
(mang tai, di hm, di cn nh gi
cm) - Nhit
- S lng
6 2.Nhm hch vng c
- Kch thc
7 3.Nhm hch thng n - Hnh dng
8 4.Nhm hch nch - B mt
- Di ng
9 5.Nhm hch bn
- chc
10 Tm tt kt qu
Cm n bnh nhn

43
 KHM CT SNG V DNG I
Khng thc hin Thc hin
STT Ni dung
0 im 1 im
T gii thiu
1
Nu mc ch khm
2 Yu cu bnh nhn ci bt o d quan st
Hi: cm gic au c, cng c, yu c.
3 Hi: kh nng leo ln cc bc thang
Hi: kh nng mc qun o
Quan st, nhn xt khi bnh nhn ng thng
- T pha trc
4
- T pha sau
- T pha bn
5 Yu cu bnh nhn xoay c
6 Yu cu bnh nhn xoay thn ngi
7 Yu cu bnh nhn ci ngi, tay chm sn
8 n chn cc t sng
9 Yu cu bnh nhn bc i v quan st
Tm tt cc du hiu
10
Cm n bnh nhn

O HUYT P V TR NG MCH CNH TAY

Khng thc hin Thc hin
STT Ni dung
0 im 1 im
T gii thiu
1
Nu mc ch khm
Chun b t th bnh nhn
2
K tay nh o huyt p ng t th
Kim tra v tr ng mch cnh tay
3 (Lu : trng hp bnh nhn c ni thng ng
tnh mch th khng ph hp o huyt p,
phi i tay)
4 X hi trong bao qun ti a
5 Kim tra kch c bao qun
6 t bao qun ng v tr
Va bm hi, va bt mch cnh tay, bm n
7
khi khng cn bt c mch
8 Bm thm 30mmHg
9 t ng nghe ng v tr ng mch cnh tay
10 X hi vi tc 2mmHg/giy
Nghe cc ting Korotkoff ghi s Huyt p
11
tm thu v tm trng
Thng bo kt qu vi bnh nhn
12
Cm n bnh nhn

44
 Bi 4
KHM U MT C TUYN GIP

MC TIU
1. Thc hin c cch hi bnh khi khm bnh l u mt c, tuyn gip.
2. Thc hin c cch khm hch c v v tr cc nhm hch.
3. Thc hin c cch khm tuyn gip v cc bnh l vng c.

I TNG A IM PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 10 pht
+ Gii thiu ni dung bi ging: 25 pht
+ Ging vin khm mu 02 ln trn m hnh v sinh vin tnh nguyn: 40 pht
gm 15 pht khm mt lt v 25 pht khm c gii thch.
+ Sinh vin thc hnh: 50 pht
+ Chn 02 sinh vin khm, nhm cn li quan st v nh gi: 40 pht
+ Ging vin tng kt cui bui: 15 pht.

NI DUNG
1. I CNG
Khm u mt c l khm nhng bnh l phn mm vng u v c sau khi loi
tr cc bnh l v ngoi thn kinh, mt, tai mi hng v rng
Khm vng u v c tng qut nhm pht hin nhng bnh l sau:
da u: bu b di da u, bu mu
mt:
+ Bu b vng trn, m, di tai
+ Bu mu mt
+ Bu si thn kinh mt
+ Bu tuyn nc bt mang tai
sau tai v gc hm: bu tuyn nc bt di hm, hch gc hm: thng l
biu hin di cn ca ung th vm hu, ung th amydale.
c:
+ Trc v gia c l bu tuyn gip
+ Nang gip li: gc c hm, ngay gia c.

45
 + Nang bch huyt: c mt bn c, gc
c n, thng sau t vim nhim
ng h hp.
+ Hch c dc c c n chm hoc sau
gy thng do vim hay lao.
+ Hch thng n: thng l di cn ca
ung th ng tiu ho, ung th phi
+ Bu m c: nm ngang theo ngn
c hay dc theo hai c c n chm m
thnh thong mt s bnh nhn n,
mp, i khm v ngh mnh b bu c.

2. KHM VNG U MT C
2.1. Hi bnh
Hnh 4.1. Nang gip li
Gii: c th gp bnh l vng u c c
hai gii
Tui: mi la tui
Thi gian khi bnh: rt quan trng bit y l bnh bm sinh lnh tnh, c t
lu v din tin chm. Khc vi thi gian khi bnh ngn, bu to nhanh thng
l bu c.
Tin cn m: bit khi u vng u, c l u ti ch hay di cn mt ni khc ti.
Tin cn chn thng: xc nh cc bin dng ca xng hm, trn
Tin cn rng nu: xc nh cc hch vim hm
Cc triu chng c nng nh:
+ Nut: kh hoc nghn, sc hay nut au
+ Ni: khn ting, mt ting hay ni nh. ung th tuyn gip giai on tr,
bnh nhn thng ni khn ting cng nh gp ung th thanh qun.
+ Nhai: kh khn hoc au
+ Th: kh hoc rt.

2.2. Khm thc th

2.2.1. Nhn: xc nh
V tr khi u hoc tn thng: c, gy, mt, u
Mu sc khi u: bnh thng, , l lot
Hnh dng: trn u hay nham nh
D dng xng hm, m, trn
Du bm tm quanh mt mi sau chn thng mt
Lit cc thn kinh mt:
+ Thn kinh VII (do ung th tuyn nc bt hay chn thng) s khng nhn
trn, mm mi c.
+ Thn kinh XII: u li lch v pha tn thng.
+ Thn kinh X qut ngc: do ung th gip bnh nhn ni khn.

46
2.2.2. S: c nhng tn thng khng nhn thy nhng s s cm nhn c bng cch
dng cc ngn tay nh ln vng cn khm.
S bit tnh cht khi u:
+ Cng, mm
+ Di ng, dnh
+ C chy mu khng
+ Gii hn r khng
S hc ming: cn mang gng r y li
S mi bn cnh c: u bnh nhn nghing v bn khm c c n chm
gin, d khm hch.
S mt ngoi thanh qun: bnh thng, thanh qun c th y lc qua li c d
dng vi ting ro ro ca cc lp sn, ta gi l triu chng Moore dng tnh. Khi
c ung th thm nhim, thanh qun dnh cng, lc s mt triu chng Moore.
S mch mu c: cm nhn rung miu nhng ca basedow cha iu tr n nh.
S tuyn gip: bnh nhn nut, u tuyn gip s di ng theo nut ta s c cc
di, nu khng thy v khng s c cc di d bu gip to, c th l bu
gip thng xung trung tht.
2.2.3. Nghe: bng ng nghe, xc nh c hoc khng c m thi vng khi u phn bit
l bu hay mch mu bt thng nh phnh ng mch cnh, r ng tnh mch cnh,
bi gin tnh mch c nng.
2.2.4. o: o chu vi quanh vng c mt mc xc nh.

3. KHM HCH VNG C

3.1. Hi bnh
Thi gian c hch
Hch c i km bnh l vng hng, tai hoc sau cc bnh ung th tiu ho, phi
Cc triu chng au, st, n lnh v chiu, st cn hay i km cc bnh nhn lao
hch, lao phi
Nu hch b ming hay c du ct t, cn hi k bnh nhn c i t, ct l
vng hch
C ung thuc g trc khi n khm

3.2. Khm thc th: dng ngn tay 2 3 s vo vng c, lu cc nhm hch vng c sau.
Hch di tai
Hch sau tai
Hch vng chm
Hch gc c hm
Hch di hm
Hch di cm
Hch nng trc c c n chm
Hch c sau: dc b trc c
Chui hch su, kh khm, v su mt trong c c n chm

47
 Hch h thng n: gc to bi c c n chm v xng n. nhm
hch ny, nu bn tri thng l di cn ca cc ung th ngc bng.

Hnh 4.2. Cc nhm hch vng c

4. KHM TUYN GIP

Tuyn gip l tuyn ni tit quan trng nm c, m st mt trc v mt bn ca
kh qun c hnh ch H, gm hai thu tri v phi ni nhau bng mt eo. Trong mt s
trng hp tuyn gip cn c thm thy thp.
Tuyn gip tit nhiu hormon m chc nng chnh l iu ho cc chuyn ho mc
t bo, cc cht dinh dng khp c th.
Bnh thng tuyn gip cn nng t 20 - 30 gram, khng nhn thy, khng s thy.
Khi bnh n to ra t 3 - 4 cm hoc 15 - 20 cm.
Tuyn gip c th b nhng bnh sau:
Thiu nng gip: chc nng tuyn gip gim
Bu gip cng gip: chc nng tuyn gip tng
Vim tuyn gip: chc nng tuyn gip bnh thng hoc tng
Ung th tuyn gip dng nh, nang, tu: chc nng tuyn gip bnh thng, tng
hoc gim.

4.1. Hi bnh
L do vo vin: a s bnh nhn nhp vin v l do bu c, mt s nhp vin v
mt hay kh th
Bnh s: cn khai thc k:
+ Thi gian c bu
+ Thi gian bu gy ra nhng thay i v tim mch, chuyn ho, thn kinh
+ Cc bnh i km
+ C ang mang thai khng?
+ Tin cn gia nh: thi quen n ung, ni

48
4.2. Khm lm sng
Tuyn gip gm:
Thu phi Sn gip
Thu tri
Thy gip ca
Eo tuyn gip tuyn gip
Tr tuyn gip
Thy T v P tuyn gip
Sn gip
Eo gip
Kh qun.
Kh qun
4.2.1. Nhn
Xc nh: Hnh 4.3. Gii phu tuyn gip
+ V tr: tuyn gip nm gia, gn gia so vi kh qun, trn hm c, di
xng mng
+ Tnh di ng theo nut
+ Cc di s kh xc nh khi bu thng trung tht
Phn loi:
+ Th nhn: n nhn hay a nhn, nhn c hay nhn dng nang, trong cha
dch hay mu
+ Th lan ta:
1: ch thy bu khi bnh nhn nut, bu di ng theo nut
2: bu gip l r di da
3: bu l ra khi vng c
Mt li: gp trong cng gip, loi tr trng hp li mt gia nh, mt li do
cn th
Dui 2 cnh tay bnh nhn ra: xem u ngn tay c run khng.
4.2.2. S
Ngi khm ng hoc ngi i din vi bnh nhn, dng ngn tay ci hai bn tay
s nh vng bu gip, s tng thy v bo bnh nhn nut xc nh cc tnh cht:
Di ng theo nut
Bu gip lan to, n nhn hay a nhn
Nhn cng, mm, b mt lng hay g gh
Gii hn r hay m h
Di ng hay dnh
n vo au hay khng?
C hoc khng c rung miu.
4.2.3. Nghe
Khi cng gip hay Basedow cha iu tr n, nghe tuyn gip c m thi tm thu.
Nghe tim: nhp tim u, tn s 60-100 ln/pht bu gip n thun v nhp tim
trn 100 ln/pht cng gip cha iu tr hiu qu.
4.2.4. o: o chu vi tuyn gip v tr ln nht.

49
TI LIU THAM KHO
1. Barbara Bates. Physical Examination and History Taking, Chapter 7, 1995.
2. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit nam. K nng
y khoa c bn. Nh xut bn Y hc TPHCM, 2009.
3. Graham Douglas, Fiona Nicol, Colin Robertson (2013). Macleods Clinical Examination,
13st edition.
4. James Thomas, Tanya Monaghan (2014). Oxford Handbook of Clinical Examination and
Practical Skills, 2nd edition.
5. Lynn S. Bickley, Peter G. Szilagyi (2013). Bates Guide to Physical Examination and
History taking, 7th edition.
6. Owen Epstein et al (2009). Pocket Guide to Clinical Examination, 4th edition.
7. Sabiston- Textbook of Surgery. Chapter 23, 1997.
8. Ti liu Hun luyn k nng dnh cho sinh vin. B mn Hun luyn k nng i hc Y
Dc Cn Th, 2011.
9. Ti liu Hun luyn k nng y khoa. B mn Hun luyn k nng i hc Y Dc TP. H
Ch Minh, 2005.

BNG KIM

0 im: Khng thc hin. 2 im: Gn y : trn 50%.

1 im: Khng y : di 50%. 3 im: Thc hin k, thao tc ng, y .

STT NI DUNG 0 1 2 3
Khm vng u c
1 Hi bnh
2 Khm thc th: nhn
3 Khm thc th: s
4 Khm thc th: nghe, o
5 M t kt qu thm khm
Khm hch u c
6 Hi bnh
7 V tr cch nhm hch
8 Khm thc th: s
9 M t kt qu thm khm
Khm tuyn gip
10 M t gii phu tuyn gip
11 Hi bnh
12 Khm thc th: nhn
13 Khm thc th: s
14 Khm thc th: nghe, o

Tng cng: / 42 im.

50
 Bi 5
KHM MCH MU NGOI BIN

MC TIU
1. M t c cc bc trong k nng khm mch mu ngoi bin.
2. Thc hin ng cc thao tc khi khm mch mu ngoi bin.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 90 pht
+ Gii thiu mc tiu bi ging: 5 pht
+ Gii thiu ni dung bi ging, xem video clip: 20 pht
+ Sinh vin chia thnh nhm, mi nhm hai em, mt sinh vin thao tc, mt sinh
vin khc quan st v ghi nhn trn bng kim, sinh vin khm tng k nng
(nhn, s, nghe), khi no thnh tho s i sang phn khc: 40 pht.
+ Chn 02 sinh vin biu din cc k thut khm, nhm cn li quan st v nh
gi: 20 pht.
+ Ging vin tng kt cui bui: 5 pht.

NI DUNG
1. KHM H NG MCH NGOI BIN
V gii phu: cc ng mch ln thuc h thng ng mch trung tm nh ng
mch ch ngc, ng mch di n, ng mch ch bng, ng mch chu nm su
bn trong cc khoang ca c th (ngc, bng), chng ta khng th thm khm trc tip
c. Chng ta ch c th thm khm trc tip cc ng mch ngoi bin nh ng mch
chi trn (ng mch quay, ng mch tr, ng mch cnh tay), ng mch chi di (ng
mch i, ng mch khoeo, ng mch mu chn, ng mch chy sau), ng mch vng
u mt c (ng mch cnh, ng mch thi dng nng).
V chc nng: h ng mch mang mu bo ha oxy t tim n cc m trong c
th. ng mch gip cc chi pht trin bnh thng, gip nhit da lun m. Tnh trng
tc hp ng mch chi s gy teo chi, da tm lnh, hoi t da.

1.1. Nhn: ngi khm ng bn phi hoc chn ging quan st bnh nhn
Nhn tng qut: Bnh nhn c tnh to khng? Bnh nhn kh th khng? Bnh
nhn c tm khng? Tm ngoi bin hay tm trung ng?
ln ca chi: chi teo nh trong trng hp suy tun hon ngoi vi mn tnh (tc
hp ng mch mn tnh); c th teo c cnh tay, c cng tay, c cng chn, c
i cng nh m di da.
S thay i ca da v mng:

51
 + Da mu vng nht, lng mc u l tun hon bnh thng. nhng ngi lao
ng chn tay nhiu, cc chi tip xc vi nh mt tri nhiu th da c mu nu
nht v mt lng.
+ Da v nng hn trong trng hp dn ng mch.
+ Da tm ti v nht, lng tha chng t tun hon ng mch km lu
thng lm chi b thiu dng.

Hnh 5.1. Da bn chn kh, nt. Hnh 5.2. Da cng bn chn tm ti do

tc ng mch.

+ Trong cc trng hp c u hoc phnh ng mch, ta thy mt u trn ng

i ca ng mch.
+ Mt s ng mch ngoi nng nh ng mch thi dng, ng mch cnh
tay, ng mch quay c khi ngon ngoo v p nhp nhng ging nh con
giun un trn mt da. Nhng trng hp ny c th thy nhng ngi x
cng ng mch km tng huyt p (Du git dy chung).
+ Pht hin ch lot hoc hoi t do thiu dng: Xy ra khi chi b thiu mu
ti ch lm cho cc phn xa ca chi (ngn tay, ngn chn, cc mng) khng
c dinh dng ri b lot, kh mng, rng mng hoc hoi th tng t
ca ngn tay, ngn chn. Loi ny ch yu gp trong bnh vim tc ng
mch (Bnh Buerger) v trong cc trng hp ri lon thn kinh vn mch
(Bnh Raynaud).

Hnh 5.3. Hoi t cc u chi trong bnh Beurger

52
 Hnh 5.4. Tm cc u ngn trong bnh Raynaud

1.2. S
Kho st nhit da: trc khi s mch mu, ta cn xem nhit chi ca
ngi bnh. Thng ta s bng mu bn tay v vng ny nhy cm vi nhit
xung quanh hn. V ma rt, nn khm ngi bnh trong phng m. Bnh thng,
da ngi c dinh dng s hi nng, nu da lnh l do tun hon ng mch
km nh trong bnh Raynaud, bnh vim tc ng mch

Hnh 5.5. S kho st nhit da

S ng mch
+ ng mch quay: bng mt lng ca u ngn tr v ngn gia, s mch quay
cnh ngoi mt gp c tay. Khm mch quay nh gi tn s tim v nhp
tim. Nu nghi ng c bt thng ng mch cnh tay, cn khm mch quay
hai bn cng lc so snh ny v thi gian ko di ca mch. Cn khm
mch quay v mch i cng lc nu nghi ng hp eo ng mch ch. Khi c
hp eo ng mch ch, khng ch ny ca ng mch i gim m mch
i cn n chm hn ng k so vi mch quay.
+ ng mch tr: s mt gp pha trong c tay. Thng kh s c mch tr.
C th dng test Allen nh gi ng mch tr. Cch thc hin test Allen:

53


Hnh 5.6. Khm s ng mch quay ng mch tr ng mch cnh tay

Ngi khm quan st mu sc da lng bn tay bnh nhn v ghi nhn.

Ngi khm xc nh v tr ng mch quay v ng mch tr ca bnh nhn.
mnh hai ng mch bng cch dng hai ngn tay ci hoc ba ngn 2, 3, 4
ca hai bn tay.
Bnh nhn nm cht bn tay li trong 5 giy, sau th ra.
Ngi khm quan st mu sc da lng bn tay bnh nhn s thy da trng nht
hn so vi ban u do thiu mu.
Ngi khm th ngn tay ng mch tr, quan st: nu thy mu sc da lng
bn tay phc hi < 7 giy, tc l test Allen m tnh, ng mch tr bnh thng.
Nu thi gian ko di hn 7 giy hoc mu sc da khng phc hi, test Allen
dng tnh, ng mch tr b tc hp.

Hnh 5.7. Test Allen

+ ng mch cnh tay: bng mt lng ca u ngn tr v ngn gia, s mch

cnh tay v tr 1/3 trong np gp khuu.
+ ng mch cnh: mch cnh gn tim nn phn nh hot ng ca tim tt
nht. Bt mch cnh bnh nhn bng cch t mt lng nh ngn tay 2, 3, 4
ca ngi khm ln sn gip ca bnh nhn, sau ko nh ra pha sau bn s
gp c c n chm, n xung l v tr ca ng mch cnh.
+ ng mch i: bt mch i nh gi hot ng ca tim cng tt nh mch
cnh. Khi c bnh l ca ng mch ch hoc ng mch chu, th mch i
thng mt hay gim. Khi khm, bnh nhn nm trn ging phng, bc l

54
 vng cn khm. Ngn ci hoc ngn tr v gia ca ngi khm t ti im
gia ca ng ni t gai chu trc trn v xng mu.
+ ng mch kheo: mch khoeo nm su trong h khoeo nhng c th bt c
khi p ln mt sau xng i. Bnh nhn nm trn ging phng vi u gi
hi cong. Ngi khm dng cc ngn tay ca mt bn tay p ln trn cc u
ngn ca mt bn tay cn li ang t trn h khoeo sau khp gi. Khm
mch khoeo ch yu nh gi bnh l mch ngai vi, nht l ngi c
triu chng au cch hi.
+ ng mch mu chn v ng mch chy sau: ch yu nh gi bnh l mch
mu ngoi vi, mc d c th dng nh gi tn s v nhp mch nh trng
hp bnh nhn ang gy m. Bt ng mch mu chn dc theo mt bn ngoi
ca gn dui di ngn ci. Bt ng mch chy sau ngay pha sau mt c trong.

A
C

D E

Hnh 5.8. Khm s ng mch cnh (A) ng mch i (B) ng mch khoeo
(C) ng mch mu chn (D) ng mch chy sau (E)

Mt s nghim php khm ng mch:

+ Nghim php y mao mch (Nghim php nhp nhy u mng
Capillary Refill Time): ngi khm dng ngn tay n vo ging mng ca
ngi bnh trong 5 giy ri b ra, quan st nu nn mng hng tr li < 2 giy
l bnh thng. Nu bt thng, thc hin tip Buergers test.

55
 Hnh 5.9. Nghim php nhp nhy u mng Hnh 5.10. Buergers test

+ Buergers test: nh gi suy ng mch. Bnh nhn nm nga, nhc hai chn ln
cao 45o so vi mt ging v ch s thay i mu da. Sau , yu cu bnh nhn
thng hai chn xung v ong a ti ging. Quan st, nu mu sc da tr li
nh ban u < 10 giy l tnh trng cung cp mu ca ng mch bnh thng.

1.3. Nghe mch

Cc ng mch c th nghe c thng l nhng ng mch c kch thc
ln nh ng mch ch, ng mch phi, ng mch cnh, ng mch i.
Trng hp bnh l hp ng mch: khi t ng nghe v n nh vo ng
mch, ta c th nghe c mt ting thi tm thu ngn. C ch pht sinh ting
thi ny l do dng mu i vi tc nhanh t ch hp ra ch rng.
Trong trng hp cng gip, ta nghe c ting thi tm thu khi t ng
nghe b mt tuyn do tuyn to ra v cng chc nng nn mu ti nhiu v
chy nhanh.
Trong trng hp c cc l thng ng-tnh mch, ta nghe mt ting thi lin
tc v dng mu xoy i qua ch thng v c s thay i p lc khi i t ng
mch sang tnh mch.
Khi nghe nhng ng mch nng di da, khng nn n mnh ng nghe
khng to ra tp m gi do n.

1.4. o p lc mu ng mch (o huyt p)

S d mu chy trong ng mch c l do khi tim bp, mu t tht tri b y vo
ng mch di tc dng ca mt p lc khi tim lm vic to ra, ng thi cng do lc co
bp ca thnh mch lm cho mu tip tc lu thng. Kt qu ca hai lc : lc y ca
tim v lc co bp ca thnh mch to nn mt p lc mu lu thng gi l huyt p ng
mch. V th, ngay sau th tm thu, huyt p ng mch cao nht gi l huyt p ti a; n
thi k tm trng dng mu tip tc chy ti cc mao mch nhng chm hn. Tuy tim
khng bp m mu vn chy c v trong h thng mch vn duy tr c mt p lc
chng mc nht nh thng c sc cn ca thnh mch, l huyt p ti thiu. Nhng
im cn lu khi o huyt p l:
M trn cnh tay c o.
Cnh tay ngang tim, t th th gin.
Kch thc bng qun ph hp vi chu vi vng cnh tay.

56
 Xc nh huyt p tm thu bng tay trc khi p ng nghe.
Gim p lc bng qun t t, khong 2-3 mmHg/giy.
Huyt p tm trng c xc nh da vo pha 5 ca Korotkoff (mt hn m).

2. KHM H TNH MCH NGOI BIN

Hnh 5.11. H thng tnh mch chi di

H tnh mch dn mu sau khi trao i cht c quan v tim. Tnh mch v ng
mch thng i song song vi nhau. c bit, tnh mch chi di c ba h thng: tnh
mch nng, tnh mch su v tnh mch xuyn. Cc tnh mch chi di c thm h thng
van gip ngn khng cho dng mu khng chy ngc xung li. Trong tnh trng suy van
tnh mch hoc dn tnh mch, cc van tnh mch khng ng kn, mu chy ngc li, dn
n vic mu chn gy ph chn.

2.1. Nhn
Ph: thng vng mu chn v mt c trong.
Tnh mch dn: cho bnh nhn ng, quan st s dn to ca tnh mch hin ln.
Lot da: cc vt lot t, chi ph do tnh trng tr mu (hnh nh ngc vi lot
da do bnh l ng mch).
+ PHN CEAP trong dn tnh mch (Clinical state Etiology - Anatomic
classification - Pathophysilogic classification). Trn thc hnh lm sng, chng
ta ch yu phn loi da vo yu t C:
0: ch c triu chng t, d cm chn.
1: tnh mch dn hnh mng nhn, li ti di da.
2: tnh mch hin dn.
3: c ph chn.
4: c thay i mu sc da.
5: c lot da lnh.
6: c lot da cha lnh.

57
 Hnh 5.12. Cc hnh dng ca dn tnh mch chi di.

2.2. S
Ph chn: ph mm, n lm, l du hiu ca suy dn tnh mch mn, cn loi tr
nguyn nhn do tim, gan, thn. c im ph chn do bnh l tnh mch l ph t
vo bui sng, tng dn vo bui chiu, ph nhiu khi phi ng lu, ngi lu.
Ph s gim khi bnh nhn ngi, nm gc chn cao.
Trong trng hp c r ng - tnh mch, ta s thy rung miu da gn ch r.
Tnh mch dn, s cng, n au, da nng : nghi ng kh nng c huyt khi
tnh mch.

2.3. Mt s nghim php c bit

Trendelenburg Test: gip nh gi chc nng ca van cc tnh mch xuyn cng
nh ca tnh mch hin. Nng chn bnh nhn cao 90o lm cn mu trong lng
tnh mch. Garrot ngang phn trn i bt tnh mch hin ln nhng khng c

58
 bt ng mch i. Yu cu bnh nhn ng dy. Quan st kh nng y tnh
mch. Bnh thng, tnh mch hin y chm, khong 35 giy, v mu phi chy
t ng mch qua mao mch ri mi n tnh mch. Nu tnh mch c y
nhanh l do van ca tnh mch xuyn mt chc nng. Sau khi bnh nhn ng c
khong 20 giy, tho garrot v quan st tnh mch. Bnh thng, khng c vic g
xy ra v van c kh nng ngn c dng tro ngc. Nu tnh mch phnh ra hn
chng t van ca tnh mch hin mt chc nng ngn c dng tro ngc.

Hnh 5.13 Nghim php Trendelenburg

Du Homan: gp bn chn v pha lng bn chn s au bp chn khi bnh

nhn vim tc tnh mch bp chn.

Hnh 5.14. Du hiu Homan

TI LIU THAM KHO

1. James Thomas, Tanya Monaghan (2008). Peripheral Vascular System Examination.
Oxford Handbook Of Clinical Examination And Practical Skills, 1st Edition, pp 80-86.
2. Lng Quc Vit (2004). Khm Mch Mu Ngoi Bin. Bi Ging Triu Chng Hc Ni.
Trng i Hc Y Khoa Phm Ngc Thch, tr 65-70.
3. Neel L Burton & Kuldip Birdi (2006). Peripheral Vascular System Examination. Clinical
Skills For Osces, 2nd Edition, 2006, Station 19, pp 45-55.
4. Owen Epstein (2003). Peripheral Vascular System. Clinical Examination, 3rd Edition, pp
161-170.

59
 BNG KIM KHM NG MCH

0 im: Khng thc hin 2 im: Gn y : (trn 50%)

1 im: Khng y (di 50%) 3 im: Thc hin k, thao tc ng, y

STT NI DUNG 0 1 2 3
1 T gii thiu bn thn, hi thng tin bnh nhn
NHN
ln ca chi
2
Mu sc ca da v mng
C lot hoc hoi th do thiu dng
S
Kho st nhit da
3 S cc ng mch
Nghim php y mao mch
Buergers test
NGHE: ng mch cnh, ng mch i, tuyn gip, o
4
huyt p.
5 KT LUN

Tng cng: /10 im

BNG KIM KHM TNH MCH

0 im: Khng thc hin 2 im: Gn y : (trn 50%)

1 im: Khng y (di 50%) 3 im: Thc hin k, thao tc ng, y

STT NI DUNG 0 1 2 3
1 T gii thiu bn thn, hi thng tin bnh nhn
NHN
Ph chn
2
Tnh mch dn: Cho bnh nhn ng: quan st s dn to
ca tnh mch hin ln.
S
3
Trendelenburg test, Du Homan
4 KT LUN

Tng cng: ../8 im

60
 Bi 6
KHM TIM

MC TIU
1. Sinh vin nh cc bc khm tim.
2. Sinh vin nh cc mc gii phu b mt quan trng trong khm tim.
3. Sinh vin thc hin v din gii c cc thao tc khm tim.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 90 pht
+ Gii thiu mc tiu bi ging: 5 pht
+ Gii thiu ni dung bi ging, xem video clip: 20 pht
+ Sinh vin chia thnh nhm, mi nhm hai em, mt sinh vin thao tc, mt em
khc quan st v ghi nhn trn bng kim, sinh vin khm tng k nng (nhn,
s, nghe), khi no thnh tho s i sang phn khc: 40 pht.
+ Chn 02 sinh vin biu din, nhm cn li quan st v nh gi: 20 pht
+ Ging vin tng kt cui bui: 5 pht

NI DUNG
1. I CNG
Gii phu ngi v sinh l y khoa l nhng kin thc khoa hc c bn lm nn tng
cho nhng kin thc cao hn v lm sng. Vic hiu bit v cu trc gii phu v hot
ng chc nng ca tim l rt cn thit cho vic hc tp k nng thm khm tim.
H tun hon bao gm c tim v mch mu, thc hin chc nng vn chuyn v phn
phi mu n khp c th.

Hnh 6.1. Gii phu tim

61
Bng 6.1. Chc nng h tun hon

- Vn chuyn v phn phi mu n ton b c th: thng qua vn chuyn dinh dng,
hormon n cc m, ly i cc cht thi ca qu trnh chuyn ha.
- Tham gia vic iu ha cn bng ni mi
- Chu s iu ha ca nhiu yu t thn kinh, th dch

Tim bnh thng c mm tim lch sang pha tri so vi xng c. Khi c tim co
ngn trong th tm thu s lm mm tim xoay nh v chm vo thnh ngc, l l do c th
khm thy mm tim p.
C bn van quan trng i vi hot ng lu chuyn mu trong tim, gip cho dng
mu ch di chuyn mt chiu, l hai van nh tht: van hai l bn tri, van ba l bn phi,
v hai van i ng mch: van ng mch ch, van ng mch phi. Khi tm tht co bp,
van hai l v van ba l s ng li, gip cho mu t tm tht khng i vo tm nh, s ng
hai van nh tht to ra Ting tim th nht, k hiu l T1. Khi tm tht th gin, mu tr v
tm tht t tm nh, ng thi van ng mch ch v van ng mch phi ng li to
nn ting tim th hai, k hiu T2.
Thc t, cc hot ng bn tim tri s din ra sm hn bn tim phi, ngha l van hai
l s ng li trc van ba l, v van ng mch ch s ng trc van ng mch phi.
Tuy nhin, s cch bit ny l qu nh nhn ra qua cc phng tin thm khm thng
thng. Trong mt s trng hp, s cch bit trc sau ko di s gy ra hin tng tch
i ca ting tim, gi l T1 tch i, T2 tch i.

2. NGHA LM SNG CA KHM TIM

Hot ng chc nng ca h tun hon rt quan trng i vi sng cn ca c th.
Khm h tun hon i hi s t m, cn thn, pht hin chnh xc cc triu chng chn
on ng v iu tr kp thi. Tim l c quan nm su trong lng ngc. Khm tim gm
cc thao tc: nhn, s, nghe. Nghe thng l phn quan trng nht. G tim ngy nay t hoc
khng c s dng do s pht trin ca cc k thut chn on hnh nh nh X-quang
phi thng, siu m tim...

3. QUY TRNH KHM TIM

3.1. T th thch hp cho vic thm khm tim
Bnh nhn nm nga, u cao 45o, c c th gin. Ngoi ra, phng khm cn m
p, nh sng v ring t v khi thm khm, bnh nhn khng mc o bc l
vng khm c y .
Ngi khm ng bn phi bnh nhn.

3.2. Cc bc thm khm: nh v thc hin y cc bc trong quy trnh khm tim
gip vic thm khm c h thng, trnh b st cc triu chng.

62
Bng 6.2. Cc bc khm tim

CC BC THM KHM TIM

y l cc yu cu bt buc i vi sinh vin Y nm 2 trong chng trnh ging dy K

nng y khoa c bn. i vi cc i tng khc, ty mc tiu thm khm lc bt hay b
sung cc thao tc ph hp.
- Quan st tng trng
- Quan st v khm bn tay
- Bt mch quay
- Quan st v khm vng mt c:
+ Kt mc mt, cng mc
+ Mi, li
+ Tnh mch cnh bn phi
+ Bt mch cnh
- Quan st lng ngc vng trc tim
- S vng trc tim: mm tim, vng y tim, cnh c, thng v
- Nghe cc van tim
- Nghe c, nch, hai y phi
- Khm bng
- Khm ng mch ngoi bin
- Kim tra du hiu ph

4. TIN HNH
4.1. Quan st tng trng
Ngi khm nn ng t pha chn bnh nhn quan st ton b hnh th bnh nhn
nh gi nhng iu sau:
Nhn th trng: th trng pht trin cn i khng (Hi chng Marfan: ngn chn,
ngn tay di hn bnh thng, chiu di si tay > chiu cao), suy kit (gp trong
cc bnh l c tnh, suy tim nng), mp ph?
Bnh nhn c kh th khng? m nhp th bit c th nhanh khng, kiu
th? C cnh mi php phng khng? Th u hay khng u? C co ko c h
hp ph khng? C tm khng?
nh gi tinh thn: n nh, ht hong, lo s, v m hi (gp trong ph phi cp,
try tim mch, nhi mu c tim).
Nhn t th bnh nhn: bnh thng, bnh nhn nm u ngang hoc k 1 gi.
Nu bnh nhn nm u cao hoc na nm na ngi, ngi m gi l du hiu
bt thng.

63
 Bnh nhn hi
chng Marfan
c chiu di
si tay ln hn
chiu di thn
ngi

Hnh 6.2. Hi chng Marfan

4.2. Quan st v khm bn tay

Nhn bn tay c mt lng v mt mu bn tay: nh gi mu sc da c tm khng? C
sang thng Janeway, nt Osler, cc bt thng v mng tay, ngn tay di trng ? S bn
tay v nh gi: tay m hay lnh? C hin tng tng tit m hi tay?

Hnh 6.3. Ngn tay di trng Hnh 6.4. Tm cc ngn tay

4.3. Bt mch quay

Xem bi Khm mch mu ngoi bin.

4.4. Quan st v khm vng c

Kim tra kt mc mt, mu sc cng mc c th pht hin ra cc triu chng ca
thiu mu, vng mt. Dng tay ko nh m di v yu cu bnh nhn ngc nhn ln
quan st.
Nhn xung quanh mi mt c th pht hin cc u vng, gi l Xanthelasma.
Kim tra mu sc mi, li. Yu cu bnh nhn h ming v nhn mu sc li,
nim mc ming.

64
 Quan st tnh mch cnh bn phi, cn cho bnh nhn quay u sang tri va phi:
c th quan st thy tnh mch cnh ngoi ni v xung ng theo nhp ca tnh
mch cnh trong.
Khi thy tnh mch c ca bnh nhn ni t th u cao 45, nn c lng p
lc tnh mch cnh trong.

Hnh 6.6. Xanthelasma

Hnh 6.5. Du mi tn ch v tr tnh

mch cnh ngoi ni r

Hnh 6.7. Cch c lng p lc tnh mch cnh trong

65
4.5. Quan st vng ngc
nh gi s cn i lng ngc, c u hay khng, so m c, tun hon bng h

Bin dng xng c So m c

Hnh 6.8. Khm quan st vng ngc

Nhn mm tim
+ nh sng tip tuyn thnh ngc gip quan st c tt hn.
+ Bnh thng, mm tim p lin sn IV-V trn ng trung n tri, ng
knh 1-2 cm v li ra trong th tm thu. Nu khng nhn thy, cho bnh nhn
nm nghing sang tri (mm tim c th lch ra ngoi 1-2 cm).
+ Nhn mi c c p theo nhp tim hay khng? Nu mi c p theo nhp tim
gi l du hiu Harzer (+), gip ngh n ln tht phi.
+ C p bt thng khng?

4.6. S tim pht hin

V tr chnh xc mm tim p, s bng c lng bn tay, p st vo vng mm tim
ca bnh nhn tm v tr p r nht ca mm tim. Nu nm nghing, mm tim
lch sang tri khong hai khot ngn tay. Khi suy tim, tim to ra th mm tim
ngoi ng trung n tri v c th xung thp n lin sn VI, VII. Mm tim
p nh thng gp trong hp van hai l. Mm tim ny mnh l du hiu ca ph
i tht tri. Mt s trng hp khng s c mm tim nh thnh ngc dy, kh
ph thng, trn dch mng ngoi tim, tim nm bn phi...

Hnh 6.9. S mm tim

66
 A B

Hnh 6.10. S vng y tim (A) - S rung miu (B)

S phn thp b tri xng c

+ Bnh nhn nm thn cao 30o. Ta t ngn tay 3, 4, 5 trn khoang lin sn 3,
4, 5 b tri xng c th thy ny cng lc vi mm tim. Nh vy, c dy
thnh trc tht phi.
+ Du Harzer: ta t ngn ci vo gc sn c tri, lng ngn tay hng v vai
tri, bn ngn cn li t trn vng mm tim. Nu ny cng lc vi mm tim
p l dy thnh di tht phi, tc l du Harzer (+), gi dy tht phi.
S vng y tim (khoang lin sn 2 tri - khoang lin sn 2 phi): p mnh
khi phnh ng mch ch trn xoang Valsalva, quai ng mch ch qua phi, h
van ng mch ch
S hm trn c: mch p mnh hoc c rung miu trong bnh cn ng ng mch,
hp van ng mch ch, hp van ng mch phi, thn chung ng mch
S rung miu ti cc vng ca tim, hay thy rung miu mm tim, rung miu lin
sn III-IV tri, ni c cc ting thi c cng 4/6... rung miu l cm gic
mt vng c tim rung p vo thnh ngc khi ta t bn tay ln vng ngc .
Cm gic rung ny ging nh khi ta s tay vo lng mo. Nu xut hin th tm
thu gi l rung miu tm thu v xut hin th tm trng gi l rung miu tm
trng.

4.7. Nghe tim

Nghe tim l phng php khm quan trng xc nh mt s bnh l tim mch,
nht l bnh van tim. Nghe tim phi c thc hin rt chu o, trong phng yn tnh, xc
nh chnh xc cc tp m tim trong cc th tm thu v tm trng. Nghe tim phi phi hp
vi bt mch xc nh mch ht. Trong lon nhp hon ton, tn s tim thng cao hn
tn s mch.
Nghe tt c cc van tim, sau nghe k li nhng v tr c tp m bnh l.
Bnh nhn thng nm nga, khm trong phng yn tnh. Mt s trng hp cn cho bnh
nhn nm nghing tri hay ngi dy ci ngi ra trc. Nghe tim nh gi:
Tn s tim (nhanh hay chm, u hay khng u).
Cc ting tim: T1, T2 v cc ting bt thng.
Cc ting thi bnh l.
4.7.1. Cu to ng nghe gm ba phn
Dy ng nghe: nghe r, chiu di nn di 30 cm, ng knh 3-4 mm, vch
dy ngn tp m.

67
 Phn mng: dn truyn cc m c tn s cao trn 300 Hz nh T1, T2, m thi tm thu
Phn chung: dn truyn cc m c tn s thp, t 30-150 Hz nh r tm trng,
T3, T4. Khng n mnh xung da bnh nhn to lp mng lm mt tc dng ca
chung.

Hnh 6.11. Cu to ng nghe Hnh 6.12. Chu chuyn tim

4.7.2. Cc van tim

L ni m cc sng m t cc van tim truyn ra thnh ngc c nghe r nht,
khng phi l hnh chiu ln thnh ngc ca van tim. C bn van tim, vi v tr bnh
thng nh sau:
van ng mch ch: lin sn hai b phi xng c.
van ng mch phi: lin sn hai b tri xng c.
van ba l: lin sn 5 st b tri xng c.
van hai l: mm tim, vo khong lin sn 4, 5 trn ng trung n tri.

Hnh 6.13. V tr cc van tim

Trnh t nghe tim ty tc gi. C th l mm - van ba l - dc b tri xng c -

van ng mch phi- van ng mch ch hoc ngc li. Nu ch nghe nhng vng
ny, c th thiu st trong pht hin triu chng. V vy, cn nghe thm dc b phi xng
c, vng c, nch, vng thng v bnh nhn b kh ph thng...
Bnh thng, trong mt chu chuyn tim, nghe c hai ting tim T1 v T2, i khi
nghe c T3 sinh l.

68
 T1: tn s thp (35-100Hz), m trm. Cc bt thng ca T1 l tng cng
(cng giao cm, gng sc, cng gip, thiu mu), gim cng (gim chc
nng tht tri, hp van ng mch ch nng, thnh ngc dy, trn dch mng
ngoi tim), tch i ting T1 thng nghe anh, gn trong hp van hai l.
T2: tn s cao hn (100-150Hz), thi gian ngn hn, gm hai thnh phn ch v
phi. Cc bt thng ca T2 l tng cng (tng p ng mch phi, cng
giao cm, tng cung lng tim), gim cng (hp kht van ng mch ch,
gim cung lng tim), tch i
T3: ting u tm trng, vo lc y tht nhanh, n sau T2 ch 0,12 n 0,2
giy. T3 nghe trm, r mm tim v trong mm. T3 sinh l gp ngi tr tui
v t gp ngi ln tui, mt i khi ng do gim lng mu v tim, cn T3
bnh l khng mt i.
4.7.3. Xc nh chu chuyn tim
Khng da vo bt mch quay v cch sau ting tim t 8-12% giy.
Da vo mm tim (th tm thu ng vi lc mm ny) hoc da vo bt mch cnh.

Hnh 6.14. Va nghe tim va s mch cnh xc nh chu chuyn tim

4.7.4. Trnh t phn tch ting tim

nh gi nhp tim u hay khng
+ Nu khng u c lin quan n h hp khng? Nu khng, tc l do tim
+ C khng u mt cch u n khng (gp trong ngoi tm thu nhp i, nhp
ba..) hay lon nhp hon ton (gp trong rung nh)
m tn s tim
+ Tn s tim bnh thng 60 - 100 chu k/pht. Nu tn s < 60 chu k/pht l
nhp tim chm. Nu tn s > 100 chu k/pht l nhp tim nhanh.
+ Nu nhp u, m trong 15 giy v nhn 4 c c tn s tim trong 1 pht.
Nu nhp khng u, phi m c pht. Nu c ngoi tm thu, phi m xem
bao nhiu ln trong mt pht c iu tr ph hp.
Nhn nh 5 tnh cht ca ting tim theo trnh t cc nghe va nu trn
+ V tr
+ Cng : mnh, m

69
 + m sc
+ Thi gian
+ nh hng ca h hp: r
hn th ht vo
Nhn nh 7 tnh cht ca
m thi
+ V tr nghe r nht
+ Thi gian: th tm thu,
tm trng, c hai th...
Hnh 6.15. Cc dng m thi
+ Hnh dng: trn, trm
+ Cng : theo Freeman Levine 1933, c 6 :
1/6: rt nh, kh nghe, thng ch nghe c trn tm thanh .
2/6: nghe c ngay khi t ng nghe, nhng nh.
3/6: nghe r nhng khng c rung miu.
4/6: cng mnh km theo c rung miu.
5/6: c cng rt mnh, c rung miu, t chch na ng nghe vn cn nghe.
6/6: lan khp lng ngc, c rung miu, khi t loa ng nghe cch khi lng ngc
mt vi milimet vn cn nghe c.
+ m sc: th rp, m du, m nhc
+ Hng lan
H van hai l: m thi lan ra nch, sau lng
H van ng mch ch: m thi lan xung mm tim
Hp van ng mch ch: m thi lan ln ng mch cnh
Hp van ng mch phi: m thi lan ln phn trn b tri xng c, xng n

Hnh 6.16. Cc hng lan ca m thi

+ Cc yu t nh hng n ting thi: khi thay i t th hay lm mt s nghim
php nh bnh nhn nm nghing sang tri (m thi, ting tim van 2 l nghe r
hn), bnh nhn ngi dy ci v pha trc (m thi ca van ng mch nghe r
hn), bnh nhn ht su nn th (ht vo: m thi van 3 l nghe r hn)...

70
 * Cc nghim php ng (sinh vin tham kho)
Nghim php Carvallo: phn bit m thi xut pht t tim phi hay tri.
+ Nghe tim khi bnh nhn ht th bnh thng.
+ Yu cu bnh nhn ht th su v chm, nghe cui th ht vo.
+ Mu v tim phi nhiu, m thi tim phi tng Carvallo (+)
Nghim php Valsalva: phn bit m thi xut pht t tim phi hay tri.
+ Nghe tim khi bnh nhn ht th bnh thng.
+ Yu cu bnh nhn nn th, rn mnh tng p lc lng ngc, m thi tim
phi tri u gim.
+ Cho bnh nhn th bnh thng. p lc dng trong lng ngc c gii
phng, mu v tim bnh thng, mu v tim phi trc ri v tim tri sau. Do
cc m thi xut pht t tim phi tr v bnh thng sau 1 2 nhp tim, cn
bn tri sau 7 -8 nhp tim.
Nghim php Handgrip (Isometric exercise):
Cho bnh nhn nm cht hai tay v bp mt vt cng n hi. p lc ng mch ch
tng. Kt qu:
Nu h van ng mch ch: mu v tht tri nhiu, m thi tng
Nu hp van ng mch ch: m thi khng thay i.

4.8. Khm bng v khm du hiu ph

Mc ch khm bng l pht hin gan to, du hiu phnh ng mch ch bng,
m thi ng mch thn.
S tm b gan vng h sn phi xc nh gan c to khng? Trong suy tim
thng thy c gan to di b sn phi, km theo tnh mch c ni, gan nh li
sau iu tr suy tim c gi l gan n xp.
Trong suy tim, thng km ph ngoi bin dng ph mm, n lm khm c
mt trc xng chy v vng quanh mt c.

Hnh 6.17. Du hiu ph chn

4.9. Khm cc ng mch ngoi bin

Xem thm bi Khm mch mu ngoi bin.

71
 Nn bt ng mch cnh, ng mch cnh tay, ng mch i, ng mch kheo,
ng mch mu chn v chy sau, so snh hai bn.
Quan st tm cc du hiu dn tnh mch ngoi bin chn: cc bi tnh mch,
cc thay i mu da, cc vt lot do ri lon dinh dng.
Cui cng, cn tm tt li cc triu chng pht hin c a ra bin lun v
chn on.

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam. Khm
tim. K nng y khoa c bn. Nh xut bn Y hc TPHCM, 2009.
2. Jame Thomas. Oxford Handbook of Clinical Examination And Pratical Skills. 2nd Edition,
Page 100-136.
3. James Thomas, Tanya Monaghan. Cardiovascular Examination. Oxford Handbook Of
Clinical Examination And Practical Skills, 1st Ed, 2008, Page 60.
4. Neel L Burton & Kuldip Birdi. Cardiovascular Examination. Clinical Skills For Osces 2nd
Edition. Station 18, 2006, Page 45.
5. Owen Epstein. The Heart And Cardiovascular System. Clinical Examination 3rd Edition,
2003, Page 128.

72
 BNG KIM
(Checklist)

Thc
Khng Thc
Cc bc thc hin hin
STT thc hin y
khng
hin
y
1 Ra tay
T gii thiu v nu mc ch khm
0
Chun b t th u cao 45 , bc l bnh nhn
2 Quan st tng trng
nh gi th trng bnh nhn
Bnh nhn c tnh trng kh th khng?
Bnh nhn c tnh trng hn m hoc kch thch,
vt v khng?
3 Quan st v khm bn tay
Mu sc bn tay
Hnh dng cc ngn tay, cc du hiu xut huyt
trn mng
Tay m hay lnh, c hin tng tng tit m hi
Bt mch quay
4 Quan st v khm u c
Mu sc cng mc, mu sc kt mc
Mu sc nim mc ming, li, mi
Quan st du hiu tnh mch c ni
Xung ng ca tnh mch cnh trong
c lng p lc tnh mch cnh trong
5 Quan st lng ngc
S cn i lng ngc, u cc, so m c, cc dng
c cy ghp di da nh my to nhp
Nhn mm tim: xc nh v tr
6 S v tr mm tim: v tr v tnh cht
S cc vng khc nh vng cnh c, vng y
tim, vng thng v: xc nh rung miu, p bt
thng
7 Nghe 4 van tim
8 Nghe cc v tr: c, nch, hai y phi
9 S tm b gan
S tm du hiu phnh ng mch ch bng
Nghe v tr ng mch thn: tm m thi
Khm ph hai chn
Khm cc ng mch ngoi bin
10 Cm n bnh nhn
bnh nhn tr v t th bnh thng

73
 Bi 7
KHM PHI

MC TIU
1. Xc nh c cc mc gii phu quan trng trn thnh ngc.
2. Thc hin y v chnh xc bn bc nhn, s, g, nghe trong khm phi.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 05 pht
+ Gii thiu ni dung bi ging: 30 pht
+ Ging vin khm mu 02 ln trn m hnh v sinh vin tnh nguyn: 40 pht, gm
15 pht khm mt lt v 25 pht khm c gii thch.
+ Sinh vin thc hnh: 50 pht
+ Chn 02 sinh vin khm, nhm cn li quan st v nh gi: 40 pht
+ Ging vin tng kt cui bui: 15 pht

NI DUNG
1. I CNG
H h hp gm ng h hp trn: mi, ming, hu hng, thanh qun, v ng h hp
di: kh qun v phi.
Phi c bao bc v bo v bi cc xng sn, ct sng v c honh. B mt ca
phi c bao ph bi mng phi tng v mng phi thnh. Gia hai mng ny l mt lp
dch mng, gip phi di chuyn d dng trong khi th.
Tim, kh qun, thc qun, cc mch mu ln v thn kinh nm gia hai phi v to nn
cu trc c gi l trung tht. S trao i kh xy ra trong cc mao mch phi bao quanh ph
nang. Cc ph nang v mao mch c vch rt mng v tip xc rt gn (mng mao dn), gip
cho carbon dioxide v oxy d dng khuch tn gia chng.
Phi c chia thnh nhiu thy bi cc rnh lin thy. Phi tri ch c hai thy (trn v
di); phi phi c hai rnh: rnh ngang ( trn) v rnh xin ( thp hn), chia phi phi
thnh ba thy (trn, gia v di).
Khm lm sng c quan h hp nh gi s hot ng ca c quan h hp, pht hin
cc tnh trng bnh l, nh hng lm cc xt nghim cn lm sng, gip cho chn on v
tin lng c chnh xc.
Lun phi ch khm ton trng trc khi i vo khm phi. Khm phi gm bn thao
tc nhn, s, g, nghe.

74
 Hnh 7.1. Phn chia cc thy phi (a) Mt trc, (b) Mt sau, (c) Phi phi, (d) Phi tri

2. NH KHU GII PHU HC LNG NGC

2.1. Cc tn gi mc gii phu
Xng c
Hm trn c
Gc Louis: l ch g ln tip gip gia cn v thn xng c, cch hm c khong 5
cm, ngang qua hai bn l v tr tng ng vi xng sn 2.

Hnh 7.2. Cc mc gii phu Hnh 7.3. Cc ng tng tng (mt trc)

75
 Hnh 7.4. Cc ng tng tng Hnh 7.5. Cc ng tng tng
(mt bn) (mt sau)

2.1. Cc ng tng tng

2.1.1. Mt trc ngc
ng gia xng c
ng cnh xng c bn phi, bn tri (k song song vi ng gia c)
ng trung n phi, tri: ng thng i qua im gia ca xng n, song song
vi ng gia c
2.1.2. Mt bn
ng nch gia: i qua gia hm nch
ng nch trc: t np nch trc k thng xung song song vi ng nch gia
ng nch sau: t np nch sau k thng xung song song vi ng nch gia
2.1.3. Mt sau
ng gia ct sng
ng xng vai phi v tri i qua nh thp nht ca b di xng vai, song
song vi ng gia ct sng.
ng thng ni hai u di xng vai hp vi ng xng vai phi v tri chia
mt lng thnh hai vng:
+ Vng lin ct sng ( pha trn)
+ Vng di xng vai ( pha di)

3. KHM LM SNG
3.1. Nguyn tc
Thm khm tun th cc bc: Nhn, S, G, Nghe
T th bnh nhn: cn bc l hon ton vng cn khm, i vi n nn che chn ph
hp khi cha khm mt trc ca ngc. Nu bnh nhn tnh trng n nh, v c
th ngi, nn h ngi trn mp ging hoc trn gh khi thm khm.

76
3.2. Nhn
3.2.1. Tm cc du hiu lin quan n bnh l ng h hp
Nhn c th t trnh b st triu chng: nhn tng qut, nhn bn tay, nhn vng u
mt, c, nhn lng ngc bnh nhn.
Nhn xung quanh ging bnh nhn xem c cc dng c h tr h hp nh dy th oxy,
mt n khng th li, my tr th v quan st dch tit nu c (cc cha m...).
nh gi chung v th trng
nh gi tnh trng kh th (xem bnh nhn c cc du hiu kh th lc ngh ngi),
co ko c h hp ph (l mt du hiu ca vic tng cng h hp, gp trong mt s
bnh l gy tc nghn phi). Nhng c ny bao gm c cnh mi, c c n chm,
c gian sn, cc c bng....
Quan st cch th: (xem phn Kiu th)
Biu hin nt mt: lo lng, bn chn, ng g.
Thay i mu sc da:
+ Xanh tm: mng, mi, y li (phn bit tm trung ng v ngoi bin, tm
ti trung ng l mt du hiu ca s thiu oxy mu nng)
+ bng: mi, g m, di tai
Tnh mch c ni: thng xuyn hay ch xy ra r khi bnh nhn th ra
Bn tay nng, hng l du hiu ca gi CO2.
C ngn tay di trng, tm nhun nicotin khng?

Hnh 7.6. Quan st bnh nhn Hnh 7.7. Quan st bn tay

Hnh 7.8. Ngn tay bnh Hnh 7.9. Ngn tay di trng Hnh 7.10. Ngn tay tm nhun
thng nicotin

3.2.2. Kiu th
Bnh thng: th d dng, u n
m tn s h hp, ngi ln tn s bnh thng khong 16 - 20 nhp th mi pht.
Di 12 nhp th/pht l th chm. Th nhanh l khi nhp th hn 24 ln/pht.

77
 Cc kiu th bt thng:
+ Th chm mi (th th ra)
+ Th rt: c th gy ra do s tc nghn thanh qun, kh qun (ng dn kh ngoi
lng ngc). Nguyn nhn c th l do chn p bi mt khi u, nhim trng (nh
vim np thanh mn). l mt du hiu cn x tr khn cp.

Hnh 7.11. Nhp th bnh thng

+ Kiu th bt thng c chu k

Th Kussmaul: bnh nhn ht su vo-ngng th-th ra-ngng th-thi gian
ngng th gia th ht vo v th ra khong 30 giy. Gp trong toan huyt mn,
vim mng no, u no, xut huyt no.

Hnh 7.12. Nhp th Kussmaul

Th Cheyne-Stokes: Trong chu k th c: bin ht vo tng dn n ti a

sau gim dn - tip theo l giai an ngng th - ri bt u mt chu k mi.
Gp trong u no, vim mng no, vim phi.

Hnh 7.13. Nhp th Cheyne-Stockes

+ Kiu th bt thng khng chu k

Th Biot: Nhp th khng u, lc chm lc nhanh, lc th nng lc th su, c
lc ngng th. Gp trong trng hp bnh tim c rung nh.

Hnh 7.14. Nhp th Biot

78
 Th ra gng sc: bnh nhn c th th ra ko di, gng cc c c, vai, khong
lin sn v chm mi trong th th ra. ng tc ny lm gim kh th ca
bnh nhn v gip ngn chn s xp ng dn kh trong th th ra. Gp trong
hen ph qun, vim ph qun mn, bnh phi tc nghn mn tnh (COPD).

Hnh 7.15. Th chm mi

Ht vo gng sc: bnh nhn c du hiu co ko c lin sn, trn n, khi tc

nghn ng th ln hay ng th nh.
3.2.3. Quan st khung xng lng ngc
Nhn xem bnh nhn c d dng lng ngc, c u bu khng? Bnh thng lng
ngc cn xng hai bn. Di ng u theo nhp th.
Cc bt thng ca khung xng lng ngc c th gp l: xng c b lm xung
(c hnh phu hay nh ln (c g)).

Hnh 7.16. Cc hnh dng bt thng ca lng ngc

Quan st xem cc xng di ng c i xng hay khng. Tt nht nn t tm nhn

cch ngc khong 1,5 - 1,8 m. Nu nghi ng c ng khung xng khng i xng
th yu cu bnh nhn ht su vo trong lc quan st.
C ng ca gc c sn
+ Bnh thng, c ng gc c sn m khong 90o. Khi ht su vo, gc ny m
rng ra.
+ C ng nghch thng: khi ht vo, bng lm vo. C ng ny xy ra khi c s
p c honh do tnh trng kh ph nang nhiu.
Kim tra cc cung sn sau
+ Cc cung sn sau c hp vi ng thng gia ct sng thnh 1 gc 45o khng?
+ Cc xng sn c di ng tch ri ra th ht vo hay khng (mng sn di ng)?
79
 Bnh nhn c lng ngc hnh thng hay khng?
+ So snh khong cch trc sau v khong cch bn ca lng ngc, lp t s. Bnh
thng: khong cch trc sau/khong cch bn = 1/2 n 5/7. Lng ngc hnh
thng khi t s trn l 1/1.
Khi thy bnh nhn ht vo c s co ko cc c vng c, ch tm:
+ C s co ko c c n, co tht c c hay hm c n b lm vo, co ko cc c
lin sn
+ Mt t th ngi ca bnh nhn trong lc khm bnh lm ni cc c h hp ph l
bnh nhn ngi thng, chm nh v pha trc, ngi trn gh, hai tay chng thng
ln u gi hay t ln bn khm.
3.2.4. Quan st ct sng v vng lng
Tm du hiu vo ct sng
+ Nhn pha sau lng: ng thng ni cc mu gai ct sng c thng khng. Nu
khng thy c ng ny th yu cu bnh nhn hi ci lng ra pha trc.
+ Nhn nghing: tm du hiu ct sng lng g hay lm ct sng vng tht lng.

Hnh 7.17. Vo ct sng Hnh 7.18. Ct sng bnh thng v g

+ Nhn pha trc:

Xem khong cch gia hng v khuu tay hai bn. Bn pha ct sng b vo vo
th khong cch gia khuu tay v hng ln hn bn i din.
Quan st cao thp ca hai vai. Bn vai lch thp hn bn i din: ct sng
vo vo trong bn vai lch thp.

3.3. S
3.3.1. Kh qun
Kim tra xem nm gia hay kh qun lch mt bn bng cch dng hai ngn tay s
ln kh qun xc nh.
Vic kim tra ny l kh chu cho bnh nhn, v vy cn phi nh nhng
Dch chuyn ng k ca kh qun c th gi cho bnh ca thy trn ca phi.

80
 Kh qun

Hnh 7.19. V tr gii phu ca kh qun v cch s kh qun

3.3.2. S tm rung thanh
Ting ni lm rung ng dy thanh, rung ng ny lan xung kh qun-ph qun
thnh ngc to thnh rung thanh, c nhng c im sau:
+ Ging ni trm to thnh rung thanh cao hn ging ni cao
+ Rung thanh n yu hn nam
+ Tr con thnh ngc mng nn rung thanh r ngay c khi ging ni cao
+ Ngi gy rung thanh r hn ngi bo
Cch khm
+ Nguyn tc: p st lng bn tay ln vng ngc cn nh gi rung thanh (c th
dng mt tr bn tay v mt lng cc ngn tay), yu cu bnh nhn pht m mt,
hai, ba hay ba, ba mi khi s tm rung thanh. nh gi rung thanh bng cch
p cng lc hai tay trn ngc bnh nhn.
+ V tr s tm rung thanh:
Pha trc: bt u khm t nh phi i dn xung di h n. n cn y
tuyn v sang mt bn khi cn tm rung thanh vng ngc tng ng.
Pha sau: bt u khm t nh phi, i dn xung y phi.
Ngoi ra, c th nh gi mc di chuyn ca c honh bng mt tr ca lng
bn tay, x dch bn tay xung mi 3 cm cho n khi mt rung thanh.
Rung thanh tng trong hi chng ng c phi, rung thanh gim khi c trn
dch, trn kh mng phi, kh ph thng.

Hnh 7.20. Cc v tr s rung thanh mt lng (A) v cch s rung thanh bng mt lng bn tay
(B), mt tr bn tay (C) v mt lng bn tay (D)

81
3.3.3. Kho st cc c ng ca khung sn
Nguyn tc: t bn tay st trn thnh ngc vi cc ngn tay m rng v pha bn
ca ngi bnh. Ngn tay ci nn c t ng gia hoc gn ng gia
chng c th di chuyn d dng khi ht th.
Ch : tm xem lng ngc gin n i xng hay khng i xng. Gim bin gin
n ca lng ngc v mt bn gi tn thng ca pha bn .
Bt u pha trc - vng ngc trn: ch p st hai ngn tay ci gn nhau vo
ng gia. Yu cu bnh nhn ht su v chm, cho hai bn tay di ng, ch s
di chuyn ca hai ngn tay.
Cch kho st vng gia ngc: t bn tay, ngn ci lin sn 5, cc ngn cn li
m st ra ng nch gia.
Kho st b sn: t ngn tay ci mi b sn st vo sn sn, ch s di
chuyn ca hai ngn ci khi bnh nhn ht vo.
Kho st vng y ngc: cng nh cch trn. t ngn tay khong xng sn 10.
Xem s di chuyn ca hai ngn tay ci (bnh thng 3 - 5 cm).

Hnh 7.21. S bin gin n ca lng ngc pha sau lc th ra (a) v ht vo (b)

Hnh 7.22. S bin gin n ca lng ngc pha trc

Du Hoover trn bnh nhn COPD (a,b) - Ngi bnh thng (c,d)

82
3.3.4. Khm hch
Khm hch nch, c v thng n xem hch c to khng? Hch to gp trong bnh
l c tnh ca phi v mt s bnh nhim trng...
(K thut khm: xem bi Khm ton trng)

3.4. G
3.4.1. K thut
Mt bn tay p st lng bnh nhn, chu lc g. Bn tay nhn lc g s p st ngn
gia vo thnh ngc theo khong lin sn. Khi p st, g ting g mi vang. Cc
ngn tay cn li bm nh trn b mt ca lng. Bn tay th hai s g ln bn tay ny.
Khi g, g bng ngn tay gia t thng gc xung ngn gia ca bn tay kia.
Hai bn tay nn t thng gc vi nhau.
Khi g, nn g bng tay, lc c tay, khng s dng lc c cnh tay
G theo th t t trn xung
G i xng

Hnh 7.23. Cch g phi

3.4.2. V tr g

Hnh 7.24. Cc v tr g pha trc (a) v pha sau (b)

83
 Pha mt trc: g dc theo ng gia n, theo tng khong lin sn.
mt bn: g dc theo ng nch gia
Mt sau:
+ G kho st nh phi dc ng xng b vai
+ G xung dn khi ting g c
Xc nh s di ng ca c honh da trn s mt m vang ca ting g v so snh
k ht vo ti a v k th ra ti a. Bnh thng, c honh di ng khong 4-6cm.
3.4.3. nh gi ting g
Bnh thng: g trong
Bt thng: g vang, g c nhng vng bnh thng g trong

3.5. Nghe
3.5.1. Dng c dng nghe phi v ng nghe (xem thm bi Khm tim)
Chung: nghe cc m c tn s thp nghe ting r tm trng ca hp van hai
l tt
Mng: nghe cc m c tn s cao, do , nghe m th ra ca phi tt hn
3.5.2. Mt s sai lm thng mc phi khi nghe phi
Chung
+ Chung khng n st vo da thnh ngc, nghe ting ging nh ting c mng
phi, mng tim
+ Chung n ln nhng vng da c lng, tc: nghe ting ging nh ran n
Cc m to ra bi c, dy chng, cc khp bnh nhn qu gy c th to ra tp m
gy sai lm chn on. nhng bnh nhn qu gy, nn dng chung nh, p st
chung vo thnh ngc, phn da thnh ngc s cng trn mt chung, do , chung
c tc dng ging mng.
3.5.3. Tin hnh
Nghe ting th

Hnh 7.25. Cc v tr nghe phi mt trc (a) v mt sau (b)

+ Bnh thng khi ht vo, dng kh qua mi vo ph qun to thnh m th ca kh
qun th rp, ln, nghe r kh qun.
+ m thi kh qun i vo cc ph qun: nghe r vng cn xng c, r th ht vo.

84
 + m th ph qun-ph nang: nghe r khong lin sn 1, 2, vng lin b ct sng
+ R ro ph nang: m th nh, trm, th ht vo di hn th th ra, nghe m du,
th th ra t khi nghe c.
Khi nghe mt trc phi: nghe t nh xung, i dc theo ng gia n
Mt bn: i dc theo ng nch gia
Mt sau: yu cu bnh nhn a 2 tay ra trc. Nghe vng nh trc, i dc
theo b trong xng b vai.
Cc c im m th: hhng ting th c phn bit nh v tr, cng , m sc,
tn s, th (th ra hay ht vo). Khi nghe ting th, phi da vo cc c im ny v
tr li cc cu hi sau:
+ Ting bnh thng c nghe c khng? C ting th bt thng khng?
+ C ting thm vo khng? Nu c, l ting g?
Ting th bnh thng
+ Ting th kh ph qun: nghe r nht hm trn c, do lung kh xoy trong kh
qun v ph qun ln. Nghe th, lin tc, cng ln v nghe c c 2 th.
+ R ro ph nang: do khng kh i vo cc ph nang.
S bin i ca ting th bnh thng
+ R ro ph nang mt khi c trn dch mng phi, trn kh mng phi, ng c phi.
+ R ro ph nang gim khi thnh ngc qu dy (ngi bo), lng ngc cng (kh
ph thng).
+ Khi ting th kh ph qun nghe c vng ngoi vi ca phi gi l ting thi.
Thng gp l thi ng v thi mng phi. Thi ng l mt ting mnh, m
cao, nghe r c c hai th nhng mnh hn th ht vo. Gp trong hi chng
ng c (vim phi). Thi mng phi nghe m, xa xm, nh, r th th ra.
Nghe c pha trn ni c dch mng phi th trung bnh. Nghe c ting thi
ny khi c vng ng c phi v c dch.
Ch : nghe s bin i ca m th
+ R ro ph nang/ting th kh qun
+ Bin m
+ T s thi gian ht vo/th ra
+ Cc ting th ph thm vo, ran rt, ngy, n, ting c mng phi
Ting thm vo: ting th c chia lm hai loi ty theo di hay ngn hn 250ms.
Ting lin tc l khi di hn 250 ms v ting khng lin tc l khi ngn hn 250 ms.
+ Cc ting lin tc gm ran rt v ran ngy, do hp lng kh o gy ra. Ran rt c
m sc cao, dng m nhc, tn s khong 400Hz. Ran ngy c m sc thp, tn s
khong 200Hz.
+ Cc ting khng lin tc gm ran n, ran m v c mng phi, d nghe hn khi
th chm v su.
Ran n: nghe kh, nh, m cao, r th ht vo v khng thay i khi ho.
Gp trong vim phi, ph phi cp.
Ran m: l ting lc xc do cc cht tit ph qun ln. Cc ting khng u,
mnh, nghe r hai th v thay i khi ho. Gp trong vim ph qun.
C mng phi: do hai l ca mng phi c vo nhau, nghe kh, th rp, nng,
khng thay i khi ho, r hai th.

85
Bng 7.1. Cc ting th phi
V tr nghe
Ting th Thi gian Cng m sc
bnh thng
R ro Ting th th ht vo Tng i Khp hai ph trng,
m du
ph nang ko di hn th th ra thp nghe r ngoi bin

pha trc:
Thi gian ting th th
Ph qun khong lin sn 1 v 2
ht vo v th ra bng Trung bnh Trung bnh
ph nang pha sau:
nhau
vng lin b ct sng

Thi gian m th ra ko To, Tng i

Ph qun vng cn xng c
di hn l ht vo n o cao

Thi gian ting th th Rt to, Tng i

Kh qun c, dc kh qun
ht vo v th ra bng nhau n o cao

Nghe ting ni
Khi nghe ting th c nhng vng nghi ng bt thng, c th kim tra li bng cch
nghe, tm s bin i bt thng ca ting ni vng nghi ng bnh so vi bn lnh.
Yu cu bnh nhn m mt, hai, ba, m to (khi nghe ting kh qun), m th thm
(khi nghe ting ngc thm)
+ Ting ni kh qun: vng ng c phi, ting ni s nghe c cng mnh r
rng hn so vi pha phi lnh.
+ Ting ngc thm: khi nghe vng phi ng c, ting ni th thm s nghe r
hn so vi pha phi lnh.
+ Ting d ku: yu cu bnh nhn pht m ch I, nghe vng ng c phi, m
ni nh .

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit nam. Khm phi.
K nng y khoa c bn. Nh xut bn Y hc TPHCM, 2009.
2. Khm lm sng c quan h hp. Triu chng hc ni khoa. B mn ni i Hc Y Khoa
Phm Ngc Thch.
3. Khm Ngc v Phi. Hun Luyn K Nng Y Khoa I. i Hc Y Dc Cn Th, 2011.
4. Neel L Burton & Kuldip Birdi. Respiratory System Examination. Clinical Skills For Osces
2nd edition. Station 23, 2006, Page 65.
5. Nicholas J Talley, Chapter 5: The respiratory system, Clinical Examination, A Systematic
Guide to Physical Diagnosis, Sixth edition, p256
6. Owen Epstein. Respiratory System. Clinical Examination 3rd edition, 2003, Page 96
7. Trn Vn Thi. Triu Chng C Nng V Khm Lm Sng C Quan H Hp. Bi Ging Triu
Chng Hc Ni, i Hc Y Khoa Phm Ngc Thch, 2004, tr13.
8. E lizabeth A. B urns, K enneth K orn, J ames W hyte IV, with J ames T homas T anya
M onaghan, Respiratory system, Oxford American Handbook of Clinical Examination and
Practical Skills, p181
9. Paul ONeill, Alexandra Evans, Tim Pattison, Meriel Tolhurst-Cleaver, Serena Tolhurst-
Cleaver, 3.3 Examining the breathless patient, Macleods Clinical OSCEs, p81

86
 BNG KIM

0 im: khng thc hin 1 im: khng y ( di 50%)

2 im: gn y (trn 50%) 3 im: thc hin k, y

STT NI DUNG 0 1 2 3
TRC KHI KHM
T gii thiu bn thn
1 Thu thp thng tin hnh chnh ca bnh nhn
Cho bnh nhn bit mc ch khm
ng bn phi, pha chn ging ca bnh nhn
NHN:
T th bnh nhn
2
Mu sc da nim
Tinh thn: n nh hay ht hong, lo s
NHN:
Kh th:
+ Tn s
3 + Kiu th
+ Nhp u hay khng
+ Co ko c h hp ph
+ Bin
NHN:
Tnh mch cnh
4
Hnh dng lng ngc
Ngn tay di trng
NHN: cc du hiu lin quan bnh l h hp
Th chm mi
5 Th rt
Thay i da: ti xanh (tm tm ti trung tm ca mi v li) hay
bng
S:
Tm kh qun
Tm hch
6
Tm rung thanh
Bin gin n lng ngc
n au khp sn sn
G:
nh phi
7
Phi
y phi
NGHE
Ting th thanh kh qun
8
R ro ph nang
m thanh khc

Tng cng: ../ 24 im

87
 Bi 8
KHM TUYN V

MC TIU
1. Lit k v thc hin ng cc bc trong k nng khm v.
2. Thc hin ng vic hng dn bnh nhn cch t khm v.

I TNG A IM PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 90 pht
+ Gii thiu mc tiu bi ging: 01 pht
+ Gii thiu ni dung bi ging: 14 pht
+ Ging vin khm mu 02 ln trn m hnh: 20 pht gm 05 pht khm mt
lt v 15 pht khm c gii thch.
+ Sinh vin thc hnh trn m hnh: 30 pht
+ Chn 02 sinh vin khm, nhm cn li quan st v nh gi: 15 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. I CNG

Hnh 8.1. Gii phu hc tuyn v (Ngun: Atlas Gii phu ngi, NXB Y hc, 2013, Frank H.
Netter, MD)

Tuyn v ca n gii nm hai bn thnh ngc trc, ko di t khong gian sn

th hai n th su, t b ngoi xng c n ng nch gia. i khi m v cn ko di
v pha hm nch, gi l ui v.
V c chia lm nm phn: (1) trn trong; (2) trn ngoi; (3) di trong; (4) di
ngoi v (5) ui v.

88
 Hnh 8.2. V tr tuyn v v cch phn chia vng

Tuyn v khng xut hin nam gii trng thnh, nu v to l bnh l, gp nhiu
nht l bnh n ha tuyn v (gynecomastie) do nng estrogen trong mu cao. a s u
v n ng l ung th v. Vic khm v c kt thc bng khm vng nch v vng
trn n tm hch lympho. N gii c th c hng dn t khm cho chnh mnh,
mi thng, trong tun l u tin sau khi sch kinh. Bnh nhn thng n khm bnh v
au v, s thy u v v s b ung th v.

2. QUY TRNH KHM TUYN V

2.1. Chun b
Bnh nhn c t vn, gii thch k l do bnh nhn chp nhn, hp tc trong
vic thm khm.
Phng khm cn kn o, c nh sng, m cho bnh nhn vo ma lnh.
Bnh nhn trn t phn eo tr ln, lun c iu dng n bn cnh khi khm.

2.2. Nguyn tc
Khm v cn khm c hai v.
Khm ng k thut nhm trnh b st tn thng v hn ch tn thng gi.
Phi ch ton th lng ngc v cc vng hch nch, thng n.

2.3. Tin hnh thm khm

2.3.1. Nhn
Bnh nhn ng hoc ngi thng lng trn gh, hai tay bung thng, bn tay t
trn u gi, hai chn khng gc cho.

Hnh 8.3. Bc l vng khm

89
 Ngi khm quan st hai v so
snh: ln, s i xng, b v v
cao ca hai nm v, mt s
ph n c s chnh lch ln v
v cao ca hai nm v.
Quan st da v, qung v v nm v
c th thy tnh mch bng h hin
r hoc dn to trong lp di da. U
trong lp di da c th i ln,
thy c trn b mt da. Vng ng
hoc ph n c th tng ng vi
vim v hoc p-xe v, nhng cng
c th l tnh trng bng pht ca
ung th v. Vng da b ko chng
gi l triu chng nhu da (do khi
u xm ln m xung quanh) hoc du
hiu thay i da cam (da v cng,
sn si nh v tri cam, trnh nhm
ln l mu da v bin thnh mu
cam), cng gp trong ung th v.
Qung v c th b ko lch, nm
v b tht vo cng l triu chng
c tnh. Tuy nhin, phi hi k
loi tr kh nng c t lc mi
ln. i khi cn thy c git
dch trng c hoc git dch hng
nm v. Hnh 8.4. Quan st cc bt thng v

Yu cu bnh nhn thay i t th:

ngi ci ngi ra trc, dang tay, gi tay ln cao lm r dnh ca khi u,
mt vng ca v b nhu da, s bt i xng ca hai nm v, vng thng n v
vng c.

Hnh 8.5. Cc t th ca bnh nhn trong thm khm tuyn v (bc nhn)

2.3.2. S
Khm tt nht khi bnh nhn t th nm. T th nm l bnh nhn nm nga
hoc t th Fowler (nm u cao 45o), k gi hoc khn di vai v vng lng
cng bn v c khm. t th ny m v dn tri u ra, mng ra, d xc nh
tn thng.

90
 Hnh 8.6. T th ca bnh nhn trong thm khm tuyn v (bc s)

Bn tay ngi khm dui thng, lng bn tay phng, nh nhng m v p vo

thnh ngc, xc nh khi u trong v, khm bng cc ngn 2, 3, 4; tuyt i
khng c bp tuyn v trong lng bn tay hoc kp m v gia hai ngn tay v
nh th s to cm gic u gi. Khm bng cch xoa cc ngn tay ti ch.

Hnh 8.7. Bn tay thm khm v Hnh 8.8. Thm khm s tuyn v

Vic s nn ng cch phi c tin hnh theo trnh t t phn t ny sang phn
t khc, ng qun ui v trong hm nch. C hai cch khm: theo ng xon
c (a) v theo ng ziczac t trn xung theo tng na v (b).

V tr khi u V tr khi u

Hnh 8.9. Cch khm tuyn v: (a) theo hnh xon c, (b) theo hnh ziczac

Mc ch ca vic s nn l tm v xc nh tnh cht ca khi u v: (1) s lng,

(2) v tr my gi theo s , cch u v bao nhiu cm, (3) hnh dng, (4) kch
thc, (5) mt , (6) b mt, (7) di ng khng, (8) n au khng.
Bu v trn, c mt chc hay mm, di ng, phn bit vi m v ln cn,
thng l bu lnh.

91
2.3.3. Khm hch vng
Cc hch lympho cn khm gm 7 nhm:
1. Nhm hch nch trung tm
2. Nhm hch cnh tay
3. Nhm hch gian ngc
4. Nhm hch di vai
5. Nhm hch ngc
6. Nhm hch cnh c
7. Nhm hch trn v di n
Khm hch lympho vng nch, nu
khm nch tri ngi khm dng bn
tay phi v ngc li. Bn tay ngi
khm phi t su vo trong h nch,
cc ngn tay hi cong v vut dc
theo thnh ngc l vch trong ca Hnh 8.10. Cc nhm hch quanh v
(Ngun: Atlas Gii phu ngi, NXB Y hc, 2013,
nch, i t trn xung di v t sau Frank H. Netter, MD)
ra trc. Khm hch thng n,
ngi khm ng pha sau bnh nhn.
Nu tm c hch lympho cn xc nh cc tnh cht: (1) v tr, (2) s hch, (3)
kch thc, (4) mt , (5) di ng, (6) n au khng.

Hnh 8.11. Khm hch vng nch

3. HNG DN T KHM TUYN V

N gii t tui dy th tr i nn t khm tuyn v mi thng mt ln, trong tun u
sau khi sch kinh, nu c pht hin iu g bt thng nn gp bc s ngay. Cc bc kim
tra nh sau:
Bc 1: t th xui hai tay
+ Bnh nhn ci trn ng trc gng, hai tay xui t
nhin theo thn ngi. Nhn tht k vo ngc
quan st c im ca da, ln nh ca v, hnh
dng nm v. Nhn tht k tm nhng thay i bt
thng nh: du hiu sng n ca da ging nh v
qu cam, vng da, vng lm da, nm v b bin
dng hoc b ko lch hoc b tt vo, u v nu ln.
+ Cn nhn v so snh hai v vi nhau.
Hnh 8.12. Nhn qua gng
(t khm tuyn v)

92
 Bc 2: t th a hai tay ln u
+ Bnh nhn ng t th a cao hai tay
ln u hi gp ngi v pha trc. ng
tc ny gip cho b ngc ca bnh nhn
a ra trc v gip d nhn hn.
+ Hy nhn tht k hnh dng bn ngoi ca
hai v v lu nhng du hiu bt thng
nh bc 1.

Bc 3: t th ng chng hng
Bnh nhn t th ng tay chng hng, hi
Hnh 8.13. Nhn qua gng - tay
gng ngi mt cht. ng tc ny lm cng
gi cao (t khm tuyn v)
c ngc khin cho hnh dng bn ngoi tuyn
v ni r hn.

Bc 4: t th nm c n gi hoc khn
di vai
+ Dng 3 ngn tay xe thng xoa nh ln
tuyn v, bt u t trong qung v, va xoa
va di chuyn ra ngoi theo ng xon c,
hng tm.
+ Khi s thy mt vng no bt thng th
nn kim chng vng tng t v bn kia
xem c ging hay khng? Nu ging l iu
bnh thng, bi v tuyn v lun lun i
xng vi nhau c v hnh dng bn ngoi
Hnh 8.14. Nhn qua gng - tay
ln cu to bn trong.
chng hng (t khm tuyn v)
+ Sau , bn tip tc khm ln cao vng
nch, v tuyn v ko di n tn vng nch. S k vng nch xem c hch
khng? Sau cng dng ngn tay ci v ngn tay tr nn nh nm v xem c
chy nc vng hoc mu khng? Hy kim tra cn thn mi bn v trong cc
t th ny c th pht hin ra nhng bt thng nu c. Nu mi bt u t
khm v th c th khm nhiu ln.
+ Khi khm xong mt bn th tip tc khm v bn kia.

Hnh 8.15. S tuyn v t th nm (t khm tuyn v)

93
4. BNH THNG GP (C THM)
4.1. Vim tuyn v v p-xe v
Thng xy ra ph n ang cho con b, sa li do ng dn sa b tc. Nu b bi
nhim s lm vim m v, dn n p-xe v nu khng iu tr ng.
4.2. Bu si lnh tuyn v
Thng gp bnh nhn cn tr, bu c gii hn r, mt chc, di ng, khng
au, khng nhu da. S c r hn sau sch kinh.
4.3. Ung th v
Nu pht hin c khi s, kh phn bit vi bu si lnh trong giai on sm.
Triu chng in hnh: chy dch hng, mt cng, gii hn khng r, khng i ng,
nhu da, thay i da cam, c hch vng.
5. CC IU CN LU (C THM)
Khm lm sng phi c tin hnh c hai bn, so snh c hai tuyn v v cc
vng hch.
xc nh thay i m v l bnh l, nn khm li vo lc sch kinh. Kt qu:
+ Nu thay i khu tr ca mt vng m v nh li hoc bin mt l thay i
sinh l.
+ Nu thay i khu tr tng thm hoc khng mt i l bnh l.
Trng hp vn nghi ng th c th ch nh: siu m tuyn v, chp nh nh
(bnh nhn trn 40 tui), chc ht bng kim nh (FNA: Fine Needle Aspiration)
hay m sinh thit c kt qu gii phu bnh. i khi, c th iu tr th bng
cc liu php ni tit (thng l kch thch t nam) nhng phi chc chn l khng
lm chm tr vic chn on v iu tr ung th v.

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng Y khoa Vit Nam
(2009). Khm v. K nng y khoa c bn. Nh xut bn Y hc TPHCM, tr. 241-245.
2. James Thomas, Tanya Monaghan (2008). Breast Examination. Oxford Handbook Of
Clinical Examination And Practical Skills, 1st Edition, pp 201-208.
3. Neel L Burton & Kuldip Birdi (2008). Breast Examination. Clinical Skills for Osces,
2nd Rdition, Station 78, pp 230-236.
4. Owen Epstein (2003). Examination Of the Breast. Clinical Examination, 3rd Edition, pp
216-220.

94
 BNG KIM

0 im: khng thc hin 1 im: khng y ( di 50%)

2 im: gn y (trn 50%) 3 im: thc hin k, khm ng, y

STT NI DUNG 0 1 2 3

GIAO TIP VI BNH NHN

T gii thiu bn thn
1 Thu thp thng tin hnh chnh ca bnh nhn
Hi l do n khm
Hi tin cn u v ca bnh nhn v gia nh

GII THCH V VIC THM KHM

2 Trnh by l do khm
Thuyt phc bnh nhn ng cho khm

CHUN B PHNG KHM

3 Phng khm kn o, sng
C iu dng n ph

CHUN B BNH NHN

4
Bc l vng khm

NHN
Bnh nhn ngi.
5
Nhn 2 bn so snh
M t kt qu

S
Bnh nhn nm nga, k gi hoc khn di vai v vng
6 lng cng bn v c khm, tay gi ln u.
Bn tay ngi khm dui thng, khm bng cc ngn 2, 3, 4
M t kt qu

HNG DN BNH NHN CCH T KHM V

Gii thch l do cn khm: tm sot, theo di u
7
tui cn khm: t khi bt u dy th
Thi im khm: tun u sau khi ht kinh

8 HNG DN THC HIN 4 BC

Tng cng: ../24 im

95
 Bi 9
KHM BNG

MC TIU
1. M t cc phn khu bng v cc c quan tng ng.
2. Thc hin c bn k nng thm khm bng.
3. Thc hin c cc thao tc khm v tr cc im au vng bng.
4. Trnh by c kt qu thm khm.

I TNG - A IM - PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 01pht
+ Gii thiu ni dung bi ging: 34 pht
+ Ging vin khm mu 02 ln trn m hnh: 30 pht gm 10 pht khm mt
lt v 20 pht khm c gii thch.
+ Sinh vin thc hnh trn m hnh: 90 pht
+ Chn 02 sinh vin khm, nhm cn li quan st v nh gi da trn bng
kim: 15 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. PHN KHU BNG
bng thng thng c chia lm 4 vng hoc 9 vng, mc ch l m t v tr
cc c quan tng ng bn di, m t im au v s thay i ca cc c quan tng ng
bn di.
Cch chia l 9 vng: hai ng thng xut pht t hai ng trung n ko xung
ti np bn, ng ny tng ng vi b ngoi c thng bng. Hai ng thng
cn li vung gc vi ng thng trn, ng th nht ni vi im thp nht
ca hai mng sn, ng ngang th hai ni vi hai gai chu trc trn, chia
bng thnh 9 vng: thng v, quanh rn, h v, h sn phi, h sn tri, hng
phi, hng tri, h chu phi, h chu tri.

96
 1: thng v
2: h sn phi
3: h sn tri
4: vng rn
5: hng phi
6: hng tri
7: h v
8: h chu phi
9: h chu tri

Hnh 9.1. Phn chia vng bng theo 9 vng

Cch chia lm 4 vng: v hai ng thng tng tng qua rn, mt ng i t

mi c n khp mu; ng th hai qua rn v vung gc vi ng th nht
chia bng thnh 4 khu.

1 2

4 3

Hnh 9.2. Phn chia vng bng theo 4 vng

iu quan trng l ngi khm phi nhn bit cu trc tng ng bn trong xoang
bng ca mi vng v bit c v tr ca cc im au. Cc im au thng gp trong
cc bnh l tiu ha l:
im au thng v: l im gia on thng ni mi c n rn.
im ti mt: l giao im ca ng trung n phi v b sn phi hoc giao
im ca b ngoi c thng bng v b sn phi.
Tam gic Chauffard Rivet: l tam gic c to bi phn gic gia ng thng
i t mi c n rn v ng thng i t rn n im thp nht ca h sn
phi: l vng ty tng ng mt chnh.
im Mc Burney: l giao im gia 1/3 ngoi v 2/3 trong ca ng ni t rn
v gai chu trc trn bn phi.

97
 Hnh 9.3. V tr cc im au v tam gic Chauffard - Rivet

im niu qun trn bn phi v tri: ly t rn ra 3 khot ngn tay hoc giao
im ca ng ni ngang rn v b ngoi c thng bng.
im niu qun gia bn phi v bn tri: ly ng ni ngang gai chu trc
trn v giao im 1/3 ngoi v 2/3 trong.

Hnh 9.4. V tr cc im niu qun

im sn lng tri (Mayo Robson): giao im ca b ngoi c thng lng bn tri

v b di xng sn 12.
im sn ct sng: gc to bi xng sn th 12 v ct sng.

Hnh 9.5. V tr cc im sn ct sng

98
2. KHM BNG
Dng c khm vng bng l ng nghe
Phng khm nh sng tt
Ch : i vi khm bng thc hin cc k nng theo th t: nhn, nghe, g, s.

2.1. T th bnh nhn

Bnh nhn t th nm nga v k gi di u, vng bng c bc l hon ton
t xng c n hai np bn, hai tay xui theo hai bn, hai chn co c thnh bng
dn ti a.
Tuyt i khng k tay di u v s lm cng c thnh bng.

Hnh 9.6. T th bnh nhn

2.2. T th ngi khm

C th ngi hay ng pha bn phi bnh nhn v nhn vo mt bnh nhn. Nu
bnh nhn khai b au bng th ch au s khm sau cng.
Nu ngi khm bnh khm vng au trc, c thnh bng s co li v ngi
khm s kh khn trong n chn phn cn li.
Khi thm khm phi quan st nt mt bnh nhn bit bnh nhn c kh chu khng.
Nu khm phng lnh, bn tay ngi khm phi m (bng cch xoa hai by tay
vo nhau) v mng tay phi ct ngn.
Trong lc s nn bng, c th nh lc hng bnh nhn bng cch ni chuyn
vi bnh nhn.
Cc yu t nh hng n s nn bng: ngi khm, dy thnh bng, tnh cht
ca dch bng, tri gic bnh nhn.

2.3. Tin hnh khm

2.3.1. Nhn
Quan st ng vin hai bn bng xem bng c cn i, to b, chng cng (hnh
a) hay lm lng thuyn khng?
Xem rn c li khi bng to b hay khng? C r dch rn hay khng? (hnh b)
Xem c tun hon bng h khng? Tnh mch dn to hay va phi, thng hay
ngon ngoo, trn rn hay di rn. (hnh c)

99
 c

Hnh 9.7. Quan st thnh bng

Xem c nhng vt so m vng bng khng? Vt m ng no?

ng di b sn (P)
ng gia bng
ng cnh ng gia sn (P) ng trn xng mu
ng m rut tha
ng m thot v bn

Hnh 9.8. V tr cc so m thng gp

Bng c tham gia nhp th khng?

Hnh 9.9. Quan st thnh bng (theo chiu nm ngang)

Khi u vng bng: xut hin thng xuyn hay ch khi ho hoc rn. Yu cu bnh
nhn ho ta c th thy c khi phng ca thot v bn, thot v i hay thot v
rn. Ngoi ra, khi bnh nhn ho cn gy au cho bnh nhn v cho ta bit v tr au.
Chng hn trong vim rut tha cp th ho gy au h chu phi, vim ti mt
gy au h sn phi, thot v gy au ni thot v

100
 Hnh 9.10. Nhn khi u vng bng

Nhn mu sc da bng: da trn hay nhn, teo hay n.

Du tm bm quanh rn (du hiu Cullen) v du bm tm vng hng (du hiu
Grey- Turner): l du xut huyt sau phc mc ca vim ty cp.
Du hiu rn b: nhn tip tuyn vi thnh bng, thy cc sng nhu ng ni ln
v chy t ni ny sang ni khc cng lc vi bnh nhn than au bng. Du hiu
ny gp trong tc rut c hc.
Ti mt to: mt khi nh ln thnh bng phi, b li quay xung di v di
ng theo nhp th, gp trong tc mt do si ng mt ch hoc u u ty.
2.3.2. Nghe
Mc ch: nghe ting rut, ting ca mch mu v ting c mng bng.
+ Nghe ting rut: t phn mng ng nghe gia bng hoc vng bng di
phi nghe nhu ng rut, nghe t nht trong 2 pht, ch yu l c nhu ng
hay khng c nhu ng, m rut bnh thng nghe t 5-34 ln/pht.
+ Lu : bnh thng nhu ng rut c m sc cao va phi. Nu sau 2 pht m
khng nghe c ting nhu ng no, tnh trng mt nhu ng rut c th xy ra,
mt nhu ng rut nn hot ng rut b t lit, c th do tnh trng phc mc b
kch ng ton b. Nu tn s tng, m sc cao gp trong tc rut c hc. Tn s
tng, m sc khng cao gp trong vim d dy rut, xut huyt tiu ha trn.
+ Ting thi mch mu: ting thi vng trn rn, lch sang hai bn gp trong
hp ng mch thn. Ting thi ca ng mch ch gp trong phnh ng
mch ch bng.

Hnh 9.11. Cc v tr nghe ng mch bng

101
 Hnh 9.12. Nghe ting c mng bng Hnh 9.13. Nghe ting c mng bng
vng gan vng lch

+ Ting c mng bng: l ting ging vi la c st vo nhau, c th gp trong u

gan, nhim trng lu cu xung quanh gan hoc nhi mu lch.
+ Tm cc tng b tc: ting lc c ch (nghe lc sng khi i)
Cch 1: p ng nghe ln bng bnh nhn, dng hai tay p vo hai bn ca mng
sn bnh nhn, lc t bn ny sang bn kia.

Hnh 9.14. Nghe ting c ch

Cch 2: dng hai tay nng mng sn bnh nhn, lc t bn ny sang bn kia,
cch ny khng cn dng ng nghe.
Nu nghe c ting c ch ca nc l gp trong tnh trng d dy b dn.
2.3.3. G
Gip ngi khm nh gi s lng v s phn b ca hi trong bng, c dch
bt thng trong khoang mng bng v xc nh nhng khi u c hoc u nang.

Hnh 9.15. G bng

102
 G ton b thnh bng nh gi, g t rn ra xung quanh theo hnh nan hoa.
+ G vang gp trong tc rut, lit rut
+ G c bn c gp trong lao phc mc
+ G c vng thp: khi g c khng r rng, cho bnh nhn nm nghing sang
mt bn s thy g c bn nm nghing v g vang bn kia v ngc li.
+ G vang vng rn v thng v, ng thi g c cc vng khc gp trong
bng bng ln.

Hnh 9.16. Bng bng ln

(Tympany: vng g trong - Transition point: vng chuyn tip - Dullness: vng g c)

Xc nh chiu cao gan: t vng ngc, khong lin sn 2 g xung, g theo 3

ng: ng trung n, cnh c phi, ng nch trc, sau g t bng ln,
ranh gii pha trn v di l vng c ca gan.

Hnh 9.17. Xc nh chiu cao gan

Chiu cao gan o ng trung n bnh thng khong 10 -11 cm.

Hnh 9.18. o chiu cao gan Hnh 9.19. o chiu cao gan
gia bng ng trung n
103
2.3.4. S
L thao tc khm quan trng nht chn on cc bnh l xoang bng.
S bng c bn tay v cc ngn tay p st vo nhau, s t nng n su, nh
nhng theo nhp th ca bnh nhn, t ch khng au n ch au. Thng thng
s t h chu tri di chuyn ln hoc t h chu phi i ln.

Hnh 9.20. Cch s khm bng (a): s nng, (b) s su

+ n im au thng v: im au lch tri gp trong lot d dy v lch phi
gp trong lot t trng.
+ Tm im au ti mt: t bn tay phi, cc ngn 2, 3, 4 n nh nhng vo
im ti mt.
+ Nghim php Murphy: ch thc hin khi nghi ng vim ti mt cp, khi khng
s c ti mt to, bnh nhn au h sn phi.
Cch 1: t ngn 2, 3, 4, 5 bn tay tri m vo
mng sn phi, ngn tay ci n nh nhng vo
im ti mt, mi khi bnh nhn th ra, n su
vo n khi bnh nhn ht vo cm thy au chi
v ngng th: nghim php Murphy (+) gp
trong vim ti mt cp.
Cch 2: thc hin bng c 2 bn tay, 2 ngn ci
chm li t ngay im ti mt, 8 ngn cn li t Hnh 9.21. Nghim php Murphy
ln b sn, thao tc tng t cch 1.
+ n im au Mc Burney: au gp trong vim
rut tha cp.

Hnh 9.22. im Mc Burney

104
 + Tm phn ng di (du hiu Blumberg): phn ng di l phn ng ca s kch
thch phc mc, c th to ra bng cch n su t t trn bng, sau bung tay
ra t ngt, bnh nhn s au tng ln vng b vim cp trong vim phc mc.
+ khng thnh bng: khi tay ngi khm s ln thnh bng, c thnh bng
ca bnh nhn co cng chng li tay ngi khm ng thi bnh nhn than au
l du hiu quan trng ca vim phc mc (do hoi t ti mt, thng d dy
t trng, vim rut tha v m). khng thnh bng: c th l co cng nh
g (gp trong thng d dy nhng gi u)
+ S gan: bnh nhn nm nga, Thy thuc dng tay tri ngn 2, 3, 4, 5 t di
h tht lng v nng mng sn phi ln, ngn tay xe ra m ly vng h sn
phi pha trc, t tay phi vng 1/4 trn, pha bn c thng bng, pha di
vng c ca gan, yu cu bnh nhn ht su, tay phi n chn nh nhng.
* Ch : nu gan to, ta c th s c b ca gan. Khi s c b ca gan, phi nhn
nh xem mt mm, chc, cng, b mt ca gan nhn hay g gh, c u cc, quan st
xem bnh nhn c au hay khng?
+ Nghim php rung gan: bn tay tri t ln
mng sn phi ca bnh nhn, cc ngn
tay nm trong cc khong lin sn. Dng
b tr ca bn tay phi cht nh v gn vo
cc ngn tay tri.
+ n k sn phi: dng ngn tay 1 hoc 2
n va phi vo cc k sn, c th tm
c im au chi. im au thng Hnh 9.23. Nghim php rung gan
gp nht l lin sn 8 ng nch gia,
gp trong p-xe gan do amip.
+ S lch:
Cch 1: bnh nhn nm nga.
Ngi khm ng bn phi bnh nhn bn tay
phi trn thnh bng ngay di b sn tri.
Bn tay tri pha sau mng sn m ly vng
Hnh 9.24. S lch
lch v y lch ln trn (ra pha trc).
Bo bnh nhn ht tht su vo, nu lch to
s ng vo u ngn tay phi.
Cch 2: cho bnh nhn nm nghing
sang phi. Bn tay tri t mng sn
tri
Lch to I: di b sn 1-2 cm hay
cn gi l mp m b sn tri.
Lch to II: di b sn tri 3-7cm.
Lch to III: lch to n ngang rn.
Lch to IV: lch to qu rn.
Hnh 9.25. Phn lch to
+ S khi u: khi s c khi u phi
xc nh
V tr

105
 B khi u
Kch thc
Mt cng, chc, cng
au hay khng au
C di ng theo nhp th khng, c di ng ngang khng.
+ Du hiu Fothergill: nng na ngi trn bnh nhn khi mt ging bng bn
tay tri, tay phi s trn khi u. Bung nh tay tri lm bnh nhn phi gng c
thnh bng trc. Nu tay phi s thy khi
u r hn th khi u l ca thnh bng
trc v ngc li nu khng s thy khi
u th khi u trong xoang bng.
+ Du hiu sng v: bnh nhn nm nga,
ngi ph chn cnh tr bn tay ln nh
bng, ngi khm t mt bn tay p vo
mt bn thnh bng, tay kia v nh hoc
bng vo thnh bn i din.
Kt qu: du hiu sng v (+) s c cm gic
sng di vo lng bn tay bn i din. Hnh 9.26. Du hiu sng v

2.4. Mt s th thut khc

2.4.1. Tm du hiu c tht lng (Psoas sign)
t bn tay phi ln gi phi ca bnh nhn v yu cu bnh nhn nng i ln
chng li tay ca ngi khm.
Cch khc: cho bnh nhn nm nghing sang tri, tay tri ngi khm gi cnh
chu phi ca bnh nhn, tay phi dui chn phi ca bnh nhn ra sau.
Nu bnh nhn than au h chu phi khi lm hai th thut ny, ta ghi nhn du
hiu c tht lng (+), c ngha trong vim rut tha cp sau manh trng.

Hnh 9.27. Du hiu c tht (Psoas sign)

2.4.2. Du hiu c bt
Bnh nhn nm nga, cng chn gp vo i, i gp vo bng, ngi khm gi
u gi phi v xoay cng chn vo trong, hng ra ngoi (th thut ny lm cng
c bt). Nu bnh nhn than au vng h v phi, ta ghi nhn du hiu c bt gp
trong vim rut tha.

106
 Hnh 9.28. Du hiu c bt

3. KHM VNG BN
3.1. Nhn: ngi ln v tr ln tui, nn khm bnh nhn t th ng, quan st k
Thot v mt hay hai bn, nu mt hay hai bn bn phng to.
Thot v bn gin tip: nm st gc dng vt ( nam), gn ng gia v di
vng np gp thp nht ca vng bng di, c th xung ti bu.
Thot v bn trc tip: nm ngang hay trn np bng mu thp, t khi qua l bn
nng xung bu.
Thot v i nm di np bn, xa ng gia v y tam gic Scarpa.

Hnh 9.29. Thot v bn trc tip v gin tip

Nu quan st cha r thot v bn no, cho bnh nhn thc hin mt s ng tc

tng p lc bng (ho, rn):
+ Nu khi phng i cho theo np bn l thot v bn gin tip
+ Nu khi phng i dc xung i l thot v i
+ Nu khi phng thot v nhanh chng xp ri phng khi bnh nhn i t th
l thot v bn trc tip.

107
 B mch i

Hnh 9.30. V tr thot v bn, thot v i

3.2. S
Khm thc th bng s nn xc nh kt qu ca quan st:
+ Th thut Zieman: dng 3 ngn tay II, III v IV bn phi hay bn tri ty thuc
bn phi hay bn tri bnh nhn b thot v. Ngn II t np bng mu thp,
ngn III np bn v ngn IV y tam gic Scarpa ri bo bnh nhn ho
mnh. Nu cm gic chm ngn II l thot v trc tip, chm ngn III l thot
v gin tip, cn chm ngn IV l thot v i.
+ Thm d l bn: bnh thng ng knh l bn ngoi c u ngn tay t,
dng u ngn tay t t vo l bn v bo bnh nhn ho mnh:
Cm gic ti thot v chm u ngn tay t l thot v gin tip
Nu cm gic chm ti thot v mt lng ca ngn t l thot v trc tip.

Hnh 9.31. Thm d l bn

+ Bng s nn, ta cng c th xc nh mt phn loi tng no thot v:
Khi thot v to, khng au, khng y ln c c th l thot v mc ni
Khi y ln nghe ting lc sc nc l do rut thot v
Khi thot v to, au, khng y ln c ngh nhiu thot v bin chng nght.

108
 Thot v trc tip Thot v gin tip

Hnh 9.32. p lc y khi thot v qua l bn nng

3.3. G

G ln khi thot v, ting trong, nn c lo xo dch c th l do rut thot v.

G khi thot v ting c, nn cng chc, c th do mc ni thot v.

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam. Khm
bng. K nng y khoa c bn. Nh xut bn Y hc TPHCM, 2009, tr.124-134.
2. Hasler W.L.Nausea. Vomiting and Indigestion. Harrisons Principle of Internal Medicine.
16th, 2005, C.34, pp. 219-224.
3. The abdomen. Clinical examination, 2nd Edition. Owen Epstein, pp. 175-210.
4. The abdomen. Oxford handbook of Clinical Examination and Practical Skills, 1st edition,
pp. 222-277.
5. Trn Th Thun. iu dng c bn I. B Y T, Nh Xut bn Y hc, 2007.
6. Triu chng hc h tiu ha. Ni khoa c s tp 2. Nh xut bn y hc, 2000, tr. 171-306.

109
 BNG KIM

0 im: khng thc hin 1 im: khng y ( di 50%)

2 im: gn y (trn 50%) 3 im: thc hin k, y

STT NI DUNG 0 1 2 3
GIAO TIP VI BNH NHN
T gii thiu bn thn
1 Thu thp thng tin hnh chnh ca bnh nhn
Hi l do n khm
Hi bnh s ca bnh nhn
GII THCH BNH NHN VIC THM KHM
2 Trnh by l do khm
Thuyt phc bnh nhn ng cho khm
CHUN B PHNG KHM
Phng khm kn o, sng
3
C ging phc v cho vic khm
ng nghe
CHUN B BNH NHN
Bnh nhn nm nga, k gi di u
4 Bc l t xng c n hai np bn
Hai tay xui, hai chn co
n nh tm l bnh nhn
NGI KHM BNH
ng bn phi bnh nhn
5 Lm m bn tay khm, mng tay ct ngn
Khm t ch khng au n ch au
Quan st nt mt bnh nhn
PHN KHU BNG
Chia lm 4 vng: cch xc nh 2 ng thng
6 Xc nh tn 4 vng.
Chia lm 9 vng: cch xc nh 4 ng thng
Xc nh tn 9 vng.
V TR CC IM AU (v tr v tng tng ng)
M t im thng v
M t im ti mt
M t im Mc Burney
7
M t tam gic Chauffard Rivet
M t im niu qun trn
M t im niu qun gia
M t im sn lng tri (Mayo Robson)

110
STT NI DUNG 0 1 2 3
NG TC NHN
Nhn thng, nhn ngang
M t bng (cn i, chng, lm lng thuyn)
Tun hon bng h (v tr, hnh dng, tnh mch dn?)
8 M t nhng so m c (v tr, di, lnh so?)
Bng tham gia nhp th?
M t khi u bng
Mu sc da bng
Du rn b?
NG TC NGHE
V tr, thi gian nghe m rut
M t m rut
9 V tr nghe m thi mch mu
Nghe ting c mng bng vng gan
Nghe ting c mng bng vng lch
Nghe ting c ch cch 1, cch 2
NG TC G
Mc ch ca g
ng tc g
G vang
10
G c
M t cch xc nh chiu cao gan
G t vng ngc
G t vng bng
NG TC S
M t ng tc s
S bng nng
S bng su
S im au thng v
S im ti mt cch 1
S im ti mt cch 2
S im Mc Burney
11 M t phn ng di (Blumberg)
M t khng thnh bng
S v m t gan
Rung gan
S lch cch 1, cch 2, m t lch to (4 )
S v m t khi u
M t du hiu sng v
M t du hiu c tht lng (Psoas sign)
M t du hiu c bt

Tng im: /33 im

111
 Bi 10
KHM HU MN - TRC TRNG

MC TIU
1. Nm c cc t th khm hu mn trc trng.
2. Nm c cc thao tc khm c nng thc th.
3. Nm c cc dng bnh thng gp.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu - ni dung bi ging: 10 pht
+ Thc hin th thut mu trn m hnh: 20 pht.
+ Sinh vin thc hnh trn m hnh: 120 pht
+ Ging vin tng kt cui bui: 30 pht

NI DUNG
1. I CNG
Hu mn trc trng l on cui ca ng tiu ha. Chc nng chnh l tr phn,
cc cht cn b sau khi thc n c hp thu ht cc cht dinh dng trong qu trnh di
chuyn trong rut non, rut gi.
Vic khm hu mn trc trng l mt thm khm c bn cn phi thc hin trn
nhng bnh nhn c nhng vn v bnh tiu ha hoc i vi tt c nhng i tng
bnh nhn trn 50 tui. Thao tc thm khm hu mn trc trng tuy n gin nhng gip
cho ngi bc s c th pht hin nhng bt thng trong lng ng trc trng (bu, polyp,
tr,) hay nhng bt thng vng quanh l ngoi hu mn (r, p-xe).

Hnh 10.1. Cu trc gii phu trc trng hu mn

112
2. THM KHM
2.1. Khm c nng
Cn hi mt s du hiu c nng thng thy, lin quan n vng hu mn trc
trng nh:
+ Tnh trng i cu c bn? Rt? au?
+ Mi ln i cu c phi rn nhiu khng?
+ C thy i cu ra mu ti hay i cu phn en khng?
+ C r dch hi vng hu mn khng?
+ C thy au, nhc, sng, vng ra hu mn khng?
+ C thy hoc s c khi bt thng xut hin trong l hu mn hay cnh ra
hu mn khng?

2.2. Khm thc th

Nn c tin hnh khm thng qui cho tt c nhng ngi trn 40 tui hoc c
tnh trng bt thng ng hu mn (nga, chy dch, mu, tr,).
2.2.1. T th bnh nhn
C nhng t th c th tin hnh khm hu mn trc trng. Tuy nhin, to s
thun li cho bnh nhn v ngi khm, t th nm nghing tri vn l cch
thng dng nht trong thm khm hng ngy.

Hnh 10.2. Cc t th khm hu mn - trc trng

Trc khi tin hnh vic thm khm hu mn trc trng, ngi bnh cn
c nm mt cch thoi mi, nghing ngi qua bn tri, quay lng v
pha ngi khm. Hai chn ca bnh nhn cn c cong ln, u gi gp li
a st vo ngc.
m bo s thoi mi cho bnh nhn, ch nn bc l vng mng, hu mn cn
thm khm.

113
 Hnh 10.3. T th bnh nhn v v tr thm khm

2.2.2. Chun b ca ngi khm

Cn gii thch r cho bnh nhn v vic cn khm hu mn trc trng, cc thao
tc s thc hin v nhng kh chu m bnh nhn s tri qua trong qu trnh
khm.
trnh tnh trng nhim trng, ly cho c th xy ra trong qu trnh thm khm
hu mn trc trng cho bnh nhn, cn m bo mt s qui tc sau:
+ Cn ra tay tht k v mang gng i vi mi bnh nhn
+ Tay o cn c vn cao qua khuu, tho b cc vt mang bn tay (nhn,
vng, ng h,)
+ Mang knh bo h, tp d quanh ngi.
2.2.3. Dng c
Gng tay sch khng c cht latex
Dung dch bi trn, gel
Dng c banh hu mn
Khn sch
n chiu sng, n soi gn u
Hnh 10.4. Khm hu mn
2.2.4. Tin hnh - trc trng (nhn)

Nhn
+ Nh tt c cc thm khm khc, bc u tin ca thm khm trc trng hu
mn l nhn. Cn dng tay nng phn mng trn ca bnh nhn ln nhm bc
l r ton b hu mn v phn quanh hu mn.
+ Cn m t cc du hiu sau:
Khi nht, vim-sng- vng quanh hu mn
L r dch ngoi ra hu mn
Nga hoc try da, vng quanh hu mn hay hu mn
Mu, phn hoc cht nhy r ra t l hu mn
Vt nt hu mn

Bi tr sa ngoi hu mn

114
 Hnh 10.5. Cc tn thng vng hu mn
+ Yu cu bnh nhn rn nh i cu v quan st khi sa ra t hu mn. Khi
c th l tnh trng sa trc trng hoc tr. Nu l tr ni cn phn :
1: khng c bi tr sa
2: c bi tr sa, nhng t tt vo khi bnh nhn ngng khng rn
3: c bi tr sa, khng t tt vo khi bnh nhn ngng khng rn nhng
y vo c.
4: bi tr sa, khng y vo c
+ c th nhn thy c bn trong trc trng, cn phi kt hp dng dng c
banh hu mn. Qua dng c banh hu mn, c th quan st thy c bi tr
xut pht trn hay di ng lc (phn bit tr ni hay ngoi) hay polyp,
bu,

Hnh 10.6. Thm khm hu mn bng dng c

S
+ L thao tc tip theo cn thc hin sau khi quan st ton b ra hu mn v
hu mn.
+ Trc khi tin hnh thm khm hu mn trc trng bng ngn tay, cn thoa
cht bi trn vo u ngn tay thm khm.

115
 + Dng bn tay tri nng phn mng trn ca bnh nhn ln, bc l r l hu
mn. Ngn tay tr bn tay phi nh nhng a vo l hu mn.
+ Khi a vo l hu mn, cm gic u tin nhn c l s sit cht ca c
vng hu mn do phn x t nhin ca bnh nhn. Yu cu bnh nhn ht th
chm, nh nhng nhm lm gim dn s
co tht ca c hu mn.
+ Khi ngn tay a c hon ton vo
lng trc trng, tin hnh mit ngn tay
quanh trc trng theo c chiu thun v
ngc kim ng h nhm nh gi cc
bt thng c th c trong lng trc trng
nh polyp, u cc. M t theo cc tnh
cht sau:
V tr: qui c pha xng mu 12 gi, pha
xng cng 6 gi Hnh 10.7. Qui c theo mi gi trong
Hnh dng: trn u, dy x di thm khm hu mn trc trng
B mt: nhn, x x,
Tnh di ng khi lc, y bng u ngn tay khm
* Ch : cn phn bit gia mt khi u v cc phn rn chc

Hnh 10.8. Thao tc thm khm trc trng bng ngn tay
+ i vi nam gii, khi tin hnh khm hu mn trc trng, vic khm tin lit
tuyn l iu bt buc cn thc hin (Xem thm phn khm tin lit tuyn).
i vi tin lit tuyn bnh thng, cm nhn qua u ngn tay s lin tng
nh cc ty hoc u chm mi, mm mi nh cao su, s thy rnh gian thy,
di ng tt v khng gy au, i khi vic khm tin lit tuyn c th lm cho
bnh nhn c cm gic mc tiu.
+ Sau khi khm ton b bn trong lng trc trng, t t rt tay ra v lun phi
quan st xem c mu dnh theo gng khng hay c cht nhy hi khng?
+ Vi cc trng hp pht hin c l r r dch ra hu mn, nn tin hnh thm
khm thm vi dng c nhm nh gi ng r v v tr l r trong.

116
 Hnh 10.9. Thm ng r bng que

Theo nh lut Goodsall, tt c cc l r ngoi nm na trn hu mn (t 9 gi ti

3 gi), s c hng i thng hng tm vo lng trc trng. Vi cc l r ngoi
nm na di hu mn (t 3 gi ti 9 gi), s c hng i vng v thng qui t
l r trong ti v tr 6 gi.

Hnh 10.10. nh lut Goodsall

Trong r hu mn, ngi ta cn phn loi r theo phn Park

Hnh 10.11. Phn loi r hu mn theo Park

117
TI LIU THAM KHO
1. David C. Dugdale, III, MD. Digital rectal exam. U.S. National Library of Medicine.
Internet http://www.nlm.nih.gov/medlineplus/ency/article/007069.htm
2. Digital Rectal Exam & Anoscopy. Queens University School of Medicine. Internert
http://meds.queensu.ca/courses/assets/modules/ts-anoscopy/

BNG KIM

0 im: khng thc hin 1 im: khng y ( di 50%)

2 im: gn y (trn 50%) 3 im: thc hin k, y

STT NI DUNG 0 1 2 3

1 Cc t th trong thm khm hu mn trc trng

Nhn
- Khi nht, vim-sng- vng quanh hu mn
- L r dch ngoi ra hu mn
- Nga hoc try da, vng quanh HM hay HM
2
- Mu, phn hoc cht nhy r ra t l hu mn
- Vt nt hu mn
- Bi tr sa ngoi hu mn
- Nhn bng dng c banh hu mn

3 Phn tr

S
- Dng gel lm trn ngn tay cn thm khm
- Dng tay nng mng bc l r hu mn
- nh gi c tht hu mn
4
- Phn bit tr ni tr ngoi
- Bit cch qui c v tr theo hu mn
- Khm tin lit tuyn (nam)
- Kim tra dch ra theo gng tay sau khi thm khm

5 Thm d l r hu mn bng que thm

6 Phn loi r hu mn theo Park

Tng im: /18 im.

118
 Bi 11
KHM 12 I DY THN KINH S NO

MC TIU
1. Thc hin c cch thm khm c bn 12 i dy thn kinh s no
2. Nhn nh c p ng bnh thng v bt thng

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 90 pht
+ Gii thiu mc tiu bi ging: 02 pht
+ Gii thiu ni dung bi ging v xem video hng dn thm khm: 28 pht
+ Thc hnh k nng thm khm theo nhm: 50 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. I CNG
Cc dy thn kinh s no c chia ra:
3 i chi phi cm gic (I, II, VIII)
3 i chi phi vn ng (III, IV, VI, XI, XII)
4 i hn hp, va cm gic va vn ng (V, VII, IX, X)

2. NGUYN TC THM KHM

Cn khm tng dy v c h thng theo th t k tip nhau.
Trc khi khm, cn khai thc bnh s xem bnh nhn c than phin g khng, tai,
mt, mi bnh nhn c b bt tc, vim hay khng.

3. TIN HNH KHM

3.1. Dy thn kinh s I - Dy thn kinh khu gic
Trung tm ca khu gic nm trong thi dng. Cc si thn kinh khu gic t nim
mc mi qua sng xng bm, to thnh hnh khu gic, ri di hnh dng mt di khu
gic i vo mt di ca no. Thn kinh khu gic chi phi khu gic nim mc mi.
Dng c khm: cc loi l du nh nhiu mi khc nhau.
T th bnh nhn v ngi khm: ngi i din nhau
+ Yu cu bnh nhn ngm ming v nhm mt li
+ Ngi khm khm tng bn mi mt: bt mt bn mi v cho ngi du gi,
du thm mi va phi, khng nng nc qu, hi xem bnh nhn c cm nhn
c mi khng? Lm tng t vi bn cn li. Cn nh lc hng bnh
nhn bng thay i mi ca chai du.

119
 Kt qu:
+ Ngi bnh thng nhn din mi rt nhanh
+ Bnh nhn c th mt hay gim cm nhn mi, c th tng cm nhn mi, c
th o khu
Nguyn nhn:
+ Gim hay mt khu gic: vim mi, tn thng dy s I, u trong no chn p
hnh khu, vim mng no m, lao mng no
+ Tng: ph n c thai, hysterie
+ o khu: ng kinh thy thi dng, tm thn phn lit

3.2. Dy thn kinh s II - Dy thn kinh th gic

Cn xc nh c ba thnh phn: th lc, th trng, y mt
3.2.1. Khm th lc

Hnh 11.1. Bng o th lc

o th lc theo bng th lc: bnh nhn ngi cch bng 6m, ngi khm khm
tng bn mt mt, bo bnh nhn c tng ch n dng nh nht cn c th c
c, nh gi th lc t 1 n 10/10.
o th lc tng i: thng c thc hin trn lm sng, ngi khm a cho
bnh nhn quyn sch hay t bo, yu cu bnh nhn c; hoc a ngn tay ra v
hi bnh nhn my ngn vi khong cch khc nhau.
3.2.2. Khm th trng
Th trng l khong cch khng gian m bnh nhn thy c khi nhn vo mt
im c nh pha trc.
Th trng chnh xc: khm bng my o, c th nhn nh c v tr, kch thc,
hnh dng ca im m v cc m im bt thng. Qua cc tn thng th trng lc
khm, ta xc nh v tr no tn thng trn ng th gic.
Th trng tng i: so snh vi th trng ngi khm.
Cch khm: yu cu bnh nhn ngi i din vi ngi khm, khong cch 1 mt,
ngi khm che mt mt mnh li bng tm ba cng, yu cu bnh nhn lm
tng t vi mt bn i din. Hai ngi nhn thng vo con ngi ca nhau v
c nh nhn cu, ngi khm a u ngn tay t ngoi vo trong sang gc mi
hay thi dng, di chuyn ln xung xc nh c bn gc th trng ca mnh,

120
 u ngn tay lun gia khong cch ngi khm v bnh nhn, ngi khm yu
cu bnh nhn cho bit ngay khi thy u ngn tay. Lm tng t vi cc pha
cn li.
Bnh thng, th trng ca bnh nhn trng hp tng i vi th trng ca
ngi khm. Nu ngi khm thy m bnh nhn cha thy th bnh nhn b
thu hp th trng.
Dy thn kinh ca hai mt cho nhau ti mt giao thoa hnh ch X, pha sau tuyn
yn trc khi chy dc theo bao trong ca no n trung tm th gic trn thy
chm. Tn hiu t b phn nhn sng na trong ca vng mc chy cho qua v
phi hp vi tn hiu ca na ngoi vng mc trong mt bn kia.
Bt thng: xy ra cc trng hp sau:

Hnh 11.2. Tn thng h thng th gic

+ Mt hon ton th trng mt bn mt (m mt mt): tn thng dy th cng

bn mt do chn thng, vim th thn kinh, u chn p dy th.
+ Mt mt na th trng cng bn (bn manh ng danh): tn thng ny quan
trng v thng gp, bnh nhn khng nhn c pha thi dng bn ny v
pha mi bn kia. l do bt bnh thng trong h thn kinh sau ch giao thoa.
Nguyn nhn do tai bin mch mu no, d dng mch mu, u no, chn
thng.
+ Mt hai bn ngoi (bn manh thi dng): l do tn thng trong h thn kinh
ti vng giao thoa, thng do u tuyn yn, u mng no, u s hu.
+ Ngoi ra, cn c cc trng hp nh: m im trung tm (khng nhn thy
c gia th trng), gc manh trn ng danh, gc manh di ng danh.
3.2.3. Khm y mt
Dng n soi y mt, khm trong iu kin nh sng m v ng t gin.
Khi khm y mt, u tin i tm gai th, l ni tp trung ca cc mch mu. Quan
st mu sc gai th, sng b gai th v kch thc gai th. Quan st cc mch mu ra vo
gai th, tnh mch thng c kch thc to hn v m hn ng mch. Cc ng i ca
mch mu lin tc hay t on, c hin tng bt cho ng mch tnh mch hay khng,
c xut huyt hay xut tit khng.

121
3.3. Dy thn kinh s III - Dy thn kinh vn nhn chung
iu khin c thng trong, thng trn, thng di v c cho di, a nhn cu ln
trn, xung di v nhn vo trong.

Hnh 11.3. n soi y mt Hnh 11.4. y mt bnh thng

T th bnh nhn tt nht nn ngi i din vi ngi khm, ngi khm quan st
bnh nhn.
Xem bnh nhn c sp mi khng? Yu cu bnh nhn m mt, nu khng thc
hin c: lit dy III phn c nng mi (m mt), lm tng t vi mt cn li.
Khm vn ng nhn cu: (khm chung vi dy IV, VI)
Khm ng t:
+ Nhn di nh sng t nhin quan st hnh dng (trn u), kch thc (bnh
thng 2-3mm)
+ Phn x ng t: chiu n pin, nn a t thi dng vo, xem hai ng t c
co li hay khng, khm hai bn. Bnh thng: ng t c phn x vi nh sng
Khm hi t ca hai nhn cu v iu tit hai ng t khi nhn gn: cho bnh
nhn nhn c nh u bt hay u ngn tay ca ngi khm cch khong 2m,
ngi khm s a t t u bt v pha gia mi bnh nhn cch 6cm. Bnh
thng hai nhn cu hi t v pha mi v hai ng t co nh li hn. Bt thng:
co ng t, gin ng t, mt phn x nh sng.

3.4. Dy thn kinh s IV - Dy thn kinh rng rc

hay dy thn kinh cm ng
iu khin c cho trn v a mt nhn vo
trong v xung di.
Bnh nhn ngi i din vi ngi khm
Ngi khm yu cu bnh nhn nhn xung
v vo trong. Bnh nhn khng thc hin
c: lit dy IV.

3.5. Dy thn kinh s VI - Dy thn kinh

vn nhn ngoi Hnh 11.5. Khm phn x nh sng
iu khin c thng ngoi a nhn cu
ra ngoi

122
 Bnh nhn ngi i din vi ngi khm
Yu cu bnh nhn gi c nh u, c, mt th nhn theo u bt hay ngn tay
ca ngi khm di chuyn t trong ra ngoi thi dng. Nu mt bn no khng
thc hin c, th dy VI bn b lit. Thng nu b lit bn no th nhn cu
nhn v pha mi.
Thc t trn lm sng, thng khm phi hp dy III, IV, VI. C ba i dy thn
kinh ny c chc nng phi hp trong vn ng nhn cu.
Yu cu bnh nhn nhn v trc v c nh u c. Cho bnh nhn nhn theo
ngn tay hay u bt (ch nhn theo bng nhn cu khng c xoay u v c).
V nhn cu vn ng c l nh hot ng phi hp dy II, IV, VI nn lit phn
dy no th nhn cu s khng lic nhn c v pha . Yu cu bnh nhn: nhn
sang phi v tri, nhn ln sang phi v tri, nhn xung sang phi v tri.

Hnh 11.6. S hng hot ng c mt

+ Bt thng: lit vn nhn, thng pht hin sm qua hin tng nhn i.
+ Nu mt khng a ra pha ngoi c: tn thng dy VI hay c thng ngoi.
+ Nu mt khng nhn vo trong v xung di, do tn thng dy thn kinh s
IV hoc tn thng li c cho trn.
+ Nu tn thng hon ton dy thn kinh s III hoc ti c vn nhn chung, mt
b lc ra ngoi khng a mt vo trong v ln xung, c hin tng sp mi v
gin ng t, nu ng t khng gin th tn thng dy III khng hon ton.
3.6. Dy thn kinh s V - Dy thn kinh tam thoa (sinh ba)
Thnh phn ch yu l nhnh cm gic rt to, nhnh vn ng nh i km vi nhnh
hm di.
Khm phn cm gic v vn ng
T th: bnh nhn ngi hoc ng i din vi ngi khm
Cm gic (dng kim u t, bng gn), gm 3 nhnh: V1 = mi trn, V2 = mt-
mi trn, V3 = cm

123
 Hnh 11.7. S phn b cm gic ca dy thn kinh tam thoa

+ Phn x gic mc: bnh nhn m to mt, nhn vo mt pha, dng ui bng
gn se mng nh si ch, chm vo gic mc pha ui mt cch xa ng t,
bnh nhn chp c hai mt, phn x p ng l do dy VII ph trch (vo dy
V1, ra dy VII). Nu mt phn x trn l du hiu sm nht v duy nht trong u
gc cu tiu no, ngoi ra cn c th gp trong u vng xoang tnh mch hang
hoc khe hc mt.

Hnh 11.8. Khm phn x gic mc

+ Vn ng c nhai: quan st s cn i ca hai h thi dng, hai gc hm. Yu

cu bnh nhn nhai ri cn tht cht hai hm rng li. Ngi khm quan st v
s vo vng c nhai v cm nhn c ny hn ln v co cng di tay, sau
yu cu bnh nhn h ming, nu lit bn no th hm a v pha .
+ Phn x cm: bnh nhn hi h ming, ngi khm ngn tr tri ni cm
bnh nhn, gn mi di, g nh vo ngn tay mnh, cm hi git nh ln.
Phn x ny c th khng thy ngi bnh thng. Mt phn x: tn thng
nhnh vn ng vng cu no. Tng phn x: (phn x rung git cm): lit gi
hnh no, bnh x cng ri rc.

124
 Hnh 11.9. V tr gii phu cc c nhai

Hnh 11.10. Khm phn x cm

3.7. Dy thn kinh s VII - Dy thn kinh mt

Chi phi cm gic v vn ng.
Quan st mt bnh nhn c cn i khng, c np nhn trn v rnh mi m
khng? Nhn trung b lch khng? Mt nhm c kn khng?

Hnh 11.11. Hnh nh ca ngi lit dy thn kinh VII

125
 T th: bnh nhn c th nm hoc tt nht l nn ngi i din vi ngi khm.
+ Khm cm gic v gic 2/3 trc li: mn, ngt, chua, ng. Yu cu bnh nhn
th li ra khi ming v gi yn. Ngi khm cho mui, ng tip xc vi u
li, ri hi cm nhn v gic ca bnh nhn: cn, gim hay mt v gic.
+ Khm vn ng c mt: ngi khm quan st mt bnh nhn c cn i
khng? Ch np nhn trn, rnh mi m cn r khng, nhn trung c b lch
sang bn khng? Yu cu bnh nhn:
Nhn my - Nhn trn: Bn no b lit khng thc hin c.
+ Nhm li tng mt ri c hai mt xem c kn khng? Nu ta dng tay banh mt
ra bn lit s thc hin d dng hn. Trng hp lit VII ngoi bin c du
Charles Bell (mt nhm khng kn mt bn, cn khe h, nhn thy nhn cu
a ln trn, mt phn trng en v trng trng).
Nhe rng, ci, phng m, hut so bn lit s khng thc hin c.

Hnh 11.12. Khm vn ng c mt

+ Trng hp c bit, khi bnh nhn trng thi l m hay hn m, ta dng hai
ngn ci n vo hai gc hm bnh nhn, bnh nhn au s nhn mt, bn lit s
khng nhn v c ng c (du hiu Pierre Marie v Foix).
3.8. Dy thn kinh s VIII - Dy thn kinh tin nh c tai
3.8.1. Cch khm thnh lc c bn
Bnh nhn ngi, ngi khm ng pha sau bnh nhn v dng ng h a t sau
n gn tai bnh nhn v bo khi no bnh nhn nghe ting tc tc th cho bit. So snh
vi sc nghe ca ngi bnh thng nh gi thnh lc ca bnh nhn.
Ngi khm ni chuyn bnh thng v ni th thm vi bnh nhn, bnh thng th
bnh nhn nghe r v tr li ng.
Nghim php nghe m thoa: dng dng c rung m thoa, xem thi gian dn truyn
qua khng kh v qua xng, bnh thng t l thi gian dn truyn qua khng kh/ thi
gian dn truyn qua xng l 3/1.

Hnh 11.13. Nghim php nghe m thoa

126
 Nghim php Rinne (Rinnes test): rung m thoa p vo mt bn tai, bt tai cn
li. Nu bnh nhn nghe ting rung m thoa th t m thoa vo mu xng chm
cng bn vi tai. Khi no bnh nhn khng cn nghe ting rung m thoa, li t
tr v tai. Ngi bnh thng tai vn cn nghe ting rung m thoa. Trong vim tai
gia, lc ny khng cn nghe ting rung m thoa na.

Hnh 11.14. Rinnes test

Nghim php Weber (Webers test): m thoa t ln gia nh u vng trn,
bnh nhn khng ic s nghe ting rung lan khp u v nghe c hai tai. Trong
ic do thn kinh, ch nghe c trong tai bnh thng. Trong vim tai gia mn
tnh, tai bn bnh li nghe r hn bn lnh.
3.8.2. Cch khm tin nh c bn
Du hiu Romberg: cho bnh nhn ng thng, chm st hai bn chn vo nhau,
quan st kh nng duy tr thng bng khi bnh nhn m mt v nhm mt. Trong
trng hp gim tin nh ngoi bin mt bn th khi nhm mt, bnh nhn s
chao nghing v ng v bn bnh. Nu b hi chng tin nh trung ng, th
chiu hng ng khng r rt nhng thng ng v pha sau hn.
Nghim php bc i hnh sao: cho bnh nhn nhm mt v bc i, c nm
bc tin ln th li li nm bc. Nu b gim chc nng tin nh mt bn, bnh
nhn s lch v bn b bnh khi bc ti v lch v bn bnh thng khi bc li,
bc i nh hnh ngi sao.
Ngoi ra, cn khm nghim php gi thng hai tay, rung git nhn cu, nghim
php nhit, nghim php gh quay nh gi cc ri lon tin nh.

Hnh 11.15. Webers test

127
3.9. Dy thn kinh s IX - Dy thn kinh li hu
Khm cm gic v gic 1/3 sau li (kh nh gi, bnh nhn d c phn x nn
nn kh thc hin trn lm sng)
Khm vn ng mn hu: bnh nhn ngi i din vi ngi khm, dng n pin
chiu sng, yu cu bnh nhn h ming rng, pht m A, . Bnh thng hai
bn mn hu u vn ln, bn no lit s khng vn. C th dng cy li p
vo y li, khi c phn x nn th mn hu s vn ln.

Hnh 11.16. Khm dy thn kinh s IX

3.10. Dy thn kinh s X - Dy thn kinh ph v (Thn kinh lang thang)

Dy chi phi hn hp: cm gic, vn ng, thc vt.
Phn vn ng c kt hp vi dy IX trong hot ng ca mn hu. Ngoi ra, cn c
hot ng ca dy thanh m. Nu b lit, bnh nhn s c ting ni bt thng hay khng
ni c do dy X qut ngc b chn p hay tn thng.

3.11. Dy thn kinh s XI - Dy gai ph

Vn ng c c n chm v c thang. Khi khm,
bnh nhn nn ngi.
Khm c c n chm: yu cu bnh nhn
quay u qua li, ngi khm ng sau lng,
mt tay gi vai, mt tay gi hm mt tht cht,
cng li s quay u ca bnh nhn. Bnh
thng, c c n chm bn quay s co li v
hn ln. Sau khm bn i din.
Khm c thang: Yu cu bnh nhn nng Hnh 11.17. Khm c c n chm
tng vai ln, sau nng c hai vai, bn no
khng thc hin c bn b lit.

Hnh 11.18. Khm c thang

128
3.12. Dy thn kinh s XII - Dy h thit
Ngi khm yu cu bnh nhn th li l ra ngoi, quan st li c teo bn no
khng? Sau , bnh nhn a li sang tri, sang phi. Nu b lit, li s a ra mt bn
v khng a c sang bn i din v teo li.

Hnh 11.19. Bnh nhn b lit dy XII

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam (2009).
Thm khm 12 i dy thn kinh s. K nng y khoa c bn. NXB Y hc TPHCM, trang
265-271.
2. L Vn Thnh (1992). Bnh hc ni thn kinh. i hc Y Dc TP.HCM.
3. Chris Hatton, Roger Blackwood (2011). Clinical Skills. Blackwell, 4th edition.
4. Paul O Neil (2015). Macleods Clinical OSCEs, Churchill LivingStone.

129
 BNG KIM

0 im: Khng thc hin 2 im: Gn y : trn 50%

1 im: Khng y : di 50% 3 im: Thc hin k, thao tc ng, y

STT NI DUNG 0 1 2 3
Khm dy I:
- Hi bnh nhn c bnh l g v mi khng
- Cho bnh nhn nhm mt li, khm tng bn mi
1
- Thay i cc loi mi (du gi, nc hoa), hi
bnh nhn c nhn bit c s thay i khng
- nh gi kt qu v gii thch cho bnh nhn
Khm dy II:
- Hi bnh nhn c b bnh l g v mt khng
- Khm th lc: Cho bnh nhn c sch, bng ch
v nh gi th lc tng i
- Khm th trng theo cc hng, c hng dn
2
bnh nhn trc khi thm khm bnh nhn hp
tc tt, nh gi sau khi khm xong
- Soi y mt, m t
- nh gi kt qu sau khm v gii thch cho bnh
nhn
Khm dy III:
- Hi bnh nhn c bnh l v mt khng
- Quan st xem bnh nhn c sp mi khng
- Khm phn x ng t bng n pin
3 - Khm vn ng nhn cu kt hp cc dy thn
kinh III, IV, VI; c hng dn bnh nhn trc khi
tin hnh thm khm bnh nhn hp tc tt.
- nh gi kt qu sau khm v gii thch cho bnh
nhn.
4 Khm dy IV (khm chung vi dy III v VI)

5 Khm dy VI (khm chung vi dy III v IV)

Khm dy V:
- Hi bnh s bnh nhn
- Khm cm gic ba nhnh dy thn kinh s V, khm
6 phn x gic mc
- Khm vn ng c nhai, phn x cm
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn.

130
STT NI DUNG 0 1 2 3
Khm dy VII:
- Hi bnh s bnh nhn
- Quan st nt mt bnh nhn, c cn i hay
khng, cc np nhn trn mt, nhn trung c b
lch khng
7 - Khm cm gic v gic 2/3 trc li
- Khm vn ng c mt: yu cu bnh nhn nhn
trn, nhng my, nhm mt, phng m, chu mi,
nhe rng, hut so
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn.
Khm dy VIII:
- Hi bnh nhn c bnh l v tai khng
- Khm thnh gic: cho bnh nhn nghe ting ng
8 xa gn, ting ng h, rung m thoa
- Khm thng bng.
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn
Khm dy IX:
- Hi bnh s bnh nhn
- M t khm cm gic v gic (1/3 li sau do thc
t kh thc hin trn lm sng)
9 - Khm vn ng c mn hu: cho bnh nhn ni A,
lin tc, quan st mn hu xem c nng u hai
bn khng.
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn.
Khm dy X
- Hi bnh s bnh nhn
10 - Cho bnh nhn ni chuyn xem hot ng ca
dy thanh m
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn.
Khm dy XI:
- Hi bnh s bnh nhn
- Khm vn ng c c n chm
11
- Khm vn ng c thang
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn.
Khm dy XII:
- Hi bnh s bnh nhn
- Cho bnh nhn thc hin cc ng tc vn ng
12 c li nh a li ra ngoi, bn tri, bn phi,
ln trn.
- nh gi kt qu sau khi khm v gii thch cho
bnh nhn.

Tng im:./ 36 im

131
 Bi 12
KHM CM GIC V PHN X

MC TIU
1. Bit c nguyn tc khm cm gic.
2. Bit c nguyn tc khm phn x.
3. Nhn nh c p ng bnh thng.
4. Thc hin c cch thm khm cm gic.
5. Thc hin c cch thm khm c bn phn x.

I TNG, A IM PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 90 pht
+ Gii thiu mc tiu bi ging: 02 pht
+ Gii thiu ni dung bi ging v xem video hng dn thm khm: 28 pht
+ Thc hnh k nng thm khm theo nhm: 50 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. KHM CM GIC
Khm cm gic gm hai loi
+ Cm gic th s: cm gic au, cm gic s, cm gic khp v t th, cm gic
nng lnh
+ Cm gic v no: xc nh khong cch gia hai im kch thch, nhn bit ch
vit, nhn bit vt bng phng php s
Dng c thm khm bao gm: kim gt u t, ng nc nng, ng nc lnh,
bng gn, m thoa

Hnh 12.1. Cc dng c khm phn x gn c, cm gic

132
1.1. Nguyn tc thm khm
Kt qu thm khm ph thuc vo yu t ch quan ca bnh nhn, cn phi tun th
cc c im sau:
Bnh nhn tnh to, hp tc tt
Khng khm lc bnh nhn mt mi, c th khm thnh nhiu t
Khi khm khng nn hi c, khng m hi thy g, nh th no
Khm hai bn so snh
Bnh nhn nn nhm mt trong khi thm khm cm gic.
1.2. Cm gic th s
1.2.1. Cm gic au
Dng kim chm nh trn da
Yu cu bnh nhn ni v tr, tnh cht kch thch
Cc vng khng au c nh du phn bit vi cc vng khc v so snh vi s
cm gic.

Hnh 12.2. Khm cm gic au

1.2.2. Cm gic nng lnh

Dng cc ng nghim ng nc nng, lnh xc nh nhit bng nhit k,
ln lt t trn da trong t giy.
p ng bnh thng: bnh nhn c th phn bit c.
1.2.3. Cm gic s
Dng ming bng gn qut nh trn da, yu cu bnh nhn nhm mt tr li c v
ni r v tr chnh xc mi khi cm thy s.
1.2.4. Cm gic t th khp
Bnh nhn nm nhm mt, t th thoi mi, mm c
Ngi khm cm nh tng ngn tay, tng ngn chn bnh nhn bng ngn ci,
ngn tr hai cnh, sau b gp xung hoc a ln nh nhng
Yu cu bnh nhn tr li v tr ngn no, b ln hay xung.

Hnh 12.3. Khm cm gic t th khp

133
1.2.5. Cm gic rung
t m thoa ch li ca xng nh xng
mt c, xng bnh ch
Gii thch cho bnh nhn ch thi gian
cm gic rung.
C th nh gi bng cch so snh ngng
cm th ca bnh nhn v ngi khm. Nu
thi gian ca ngi khm di hn tc l
ngng cm th ca bnh nhn gim.

1.3. Cm gic v no
1.3.1. Xc nh khong cch hai im kch thch Hnh 12.4. Dng c m thoa
Dng dng c c mi nhn hoc dng hai
ngn tay chm hai im
Yu cu bnh nhn xc nh khong cch hai im kch thch.
C th iu chnh khong cch t 2 mm n vi cm.
1.3.2. Nhn bit ch vit
Dng u ngn tay ngi khm vit cc ch ci ln cc phn c th ca bnh nhn.
Yu cu bnh nhn nhm mt c ng cc ch s. Ln lt khm hai bn so snh. V
tr thng lm lng bn tay.

Hnh 12.5. Khm cm gic nhn bit ch vit

1.3.3. Nhn bit vt qua s

t vt quen thuc vo lng bn tay cho bnh nhn s. Yu cu ni c tn vt,
hnh dng, kch thc, cht liu.

2. KHM PHN X
Dng c thm khm: ba g phn x.

2.1. Nguyn tc thm khm phn x gn c

Bnh nhn nm hay ngi, cc chi t th thoi mi
Bc l vng cn thm khm, trnh g qua lp qun o
Dng ba phn x g gn tng ci ng vo gn c, ch yu dng trng lng
ca ba g xung, khng dng sc mnh g.
G tng cp phn x i xng nhau theo trnh t nht nh trnh b st.
p ng ca phn x gn c c 5 mc nh sau:

134
 0: Mt phn x, c th l bnh ca h thn kinh
+: Phn x gim nhy, c th gp ngi bnh thng hay c bnh
++: Phn x bnh thng
+++: Phn x nhy r, c th gp ngi bnh thng qu nhy cm hay
ngi c bnh l thp
++++: Phn x rt nhy, thng c du a ng.
2.2. K thut
Cm ba bng ngn tay 1, 2, 3 khong 1/3 di cn ba, g bng lc ca ba v
lc ca c tay.

2.3. Phn x gn c (su)

2.3.1. Phn x chi trn

Hnh 12.6. Cc im khm phn x gn c chi trn

Phn x c nh u cnh tay

+ T th: bnh nhn c th nm hoc ngi, khp khuu t th gp 900, cng tay
nga ln trn.
+ Ni g: ngi khm t ngn tay ci ln gn c nh u np gp cng tay,
dng ba g ln tay ci ca ngi khm.
+ p ng: co c nh u lm gp cng tay. Cung phn x: C5-C6.
Phn x gn c tam u
+ T th: bnh nhn c th nm nga hoc ngi, cnh tay th gin, khp khuu
gp 900, bn tay ngi khm phn gia cnh tay bnh nhn.
+ Ni g: gn c tam u.
+ p ng: co c tam u lm dui cng tay. Cung phn x: C7-C8.

135


Hnh 12.7. Cch khm phn x gn c nh u

Hnh 12.8. Cc t th khm phn x gn c tam u

Phn x trm quay
+ T th: khp khuu gp nh, cng tay na sp, b xng quay hng ln trn.
+ Ni g: dng ba phn x g vo u mm trm quay.
+ p ng: co c nga di, c nh u lm cng tay gp xoay cng tay, co c
ngn ci. Cung phn x: C5-C6.

Hnh 12.9. Khm phn x trm quay

136
 Phn x trm tr
+ T th: Khp khuu bnh nhn na gp, cng tay nga nh.
+ Ni g: u di xng tr st mu trm.
+ p ng: p sp cng tay t ngt (c tay chuyn trong). Cung phn x: C8.
2.3.2. Phn x chi di
Phn x gn c t u i (di xng bnh ch)
+ T th: bnh nhn nm nga, khp gi na gp (1200), ngi khm lun bn
tay tri hay cng tay tri xung di khoeo chn bnh nhn v hi nng chn
bnh nhn ln.
+ Hoc t th ngi, hai cng chn bnh nhn bung thng xung thnh ging
thng gc vi i, hai bn chn khng c chm xung mt t.
+ Ni g: Gn c t u i ngay pha di xng bnh ch. Cung phn x:
L3-L4.
+ Nghim php Jendrassik: Bin php tng cng phn x gn c, cho bnh nhn
nm hai tay cht vo nhau, bnh nhn tp trung vo chi trn, ngi khm g
vo gn c t u i.

Hnh 12.10. Khm phn x gn c t u i

Hnh 12.11. Cch khm phn x gi t th nm

137


Hnh 12.12. Cc cch khm phn x gi t th ngi v nghim php Jendrassik

Phn x gn gt (gn Achille)

+ T th: Bnh nhn nm nga, xoay i ra ngoi, khp hng v khp gi hi co,
ngi khm cho bn chn vung gc vi cng chn, hoc bnh nhn qu
gi, hoc nm sp, cng chn thng gc vi ging.
+ Ni g: gn gt gia mt c trong v mt c ngoi.
+ p ng: c tam u cng chn co lm gp bn chn v pha gan chn. Cung
phn x: S1-S2.

Hnh 12.13. Cc cch khm phn x gn gt

2.4. Phn x da (phn x nng)

Hnh 12.14. Cc v tr khm phn x da

138
 Cung phn x
+ Da bng trn: D8-D9
+ Da bng gia: D10
+ Da bng di: D11
Phn x da bng
+ T th: bnh nhn nm nga, hai chn co da bng khng b cng.
+ Kch thch: kch thch thnh bng bng kim u t, vch nhanh t pha ngoi
bng hng vo trong.
+ p ng: c bng co git mnh, rn b ko theo lch v pha b kch thch.
Phn x i bu
+ T th: bnh nhn nm nga
+ Kch thch: dng u kim t vch nh phn trn v mt trong i theo chiu t
trn xung.
+ p ng: i co nhanh, co c bu y tinh hon ln trn. Cung phn x: L1
Phn x da gan bn chn
+ T th: bnh nhn nm nga
+ Kch thch: dng u kim t vch t b ngoi (pha ngn V) gt chn vng ln
pha ngn I, khi gn cui nhn mnh hn mt cht.
+ p ng bnh thng: ngn I v 4 ngn cn li gp v pha lng bn chn.
Cung phn x: S1-S2.
+ Bnh l: ngn ci t t dui ln, cc ngn cn li xe ra nh nan qut: du hiu
Babinski (+), ch c trong tn thng b thp.
+ p ng ba co: p ng Babinski, c thm gp lng bn chn, gp gi v gp
hng.

Hnh 12.15. Cch khm phn x da gan bn chn (tm du Babinski)

A: Cch khm B: Du Babinski m tnh C: Du Babinski dng tnh

139
TI LIU THAM KHO
1. Chris Hatton, Roger Blackwood (2011). Clinical Skills. Blackwell, 4th edition.
2. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam (2009).
Thm khm 12 i dy thn kinh s. K nng y khoa c bn. NXB Y hc TPHCM, trang
265-271.
3. L Vn Thnh (1992). Bnh hc ni thn kinh. i hc Y Dc TP.HCM.
4. Paul O Neil (2015). Macleods Clinical OSCEs, Churchiil LivingStone.

BNG KIM

0 im: Khng thc hin 2 im: Gn y : trn 50%

1 im: Khng y : di 50% 3 im: Thc hin k, thao tc ng, y

STT NI DUNG 0 1 2 3

Khm cm gic th s

- Khm cm gic nng lnh

1 - Khm cm gic s

- Khm cm gic t th khp

- Khm cm gic rung

Khm cm gic v no

2 - Khm nhn bit khong cch gia hai vt

- Nhn bit ch vit, vt bng cch s

Khm phn x chi trn

- Khm phn x gn c nh u

3 - Khm phn x gn c tam u

- Khm phn x trm quay

- Khm phn x trm tr

Khm phn x chi di

4 - Khm phn x gi

- Khm phn x gt

Khm phn x da

- Khm phn x da bng

5
- Khm phn x da bu

- Khm phn x da gan bn chn

Tng im:./45 im

140
 Bi 13
PHN TCH CC XT NGHIM THNG QUY

MC TIU
1. Nu c cc loi xt nghim thng quy.
2. Nu c gi tr bnh thng v bt thng ca cng thc mu.
3. Nu c gi tr bnh thng v bt thng ca tng phn tch nc tiu.
4. Thc hnh phn tch mt s kt qu cng thc mu v nc tiu.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 05 pht
+ Gii thiu ni dung bi ging: 45 pht
+ Thc hnh c kt qu cng thc mu v tng phn tch nc tiu: 120 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. I CNG
Xt nghim thng quy l nhng xt nghim m bnh nhn c thc hin khi n
bnh vin khm hay iu tr bnh. Nhng xt nghim ny c th gi mt vi thng tin
v s thay i sc khe ban u, t bc s s tip tc ngh mt s xt nghim chuyn
su lin quan n bnh, gip pht hin sm v ngn nga bnh tt, hn ch ti a nhng
thng tn v bin chng gy ra ca mt s bnh.
Cc xt nghim thng quy c thc hin bao gm
Cng thc mu
Tng phn tch nc tiu
ng huyt
BUN- Creatinin/mu
X-quang tim phi thng
Siu m bng tng qut
Xt nghim soi phn
in tm , bilan m: ch thc hin thng quy mt s i tng
Ngoi cc xt nghim thng quy k trn, tu theo gii tnh, tui tc, yu t nguy c
gia nh, bn thn, ngh nghip, hon cnh kinh t m c nhng xt nghim thm khc
nhau tng i tng.

141
2. CC THNG S CHNH CA CNG THC MU
Cng thc mu cn gi l huyt , y l mt xt nghim thng quy n gin
c s dng nhiu nht trong cc xt nghim y khoa, cung cp thng tin gi ban u
cho chng ta nhiu gi tr bnh l thng gp nh bnh nhim trng, ung th mu, thiu
mu, gim tiu cu, st xut huyt...
Cc tr s ca cng thc mu bnh thng thay i theo tnh trng sinh l, my xt
nghim, la tui, gii tnh, hot ng th cht ca c th.
Xt nghim cng thc mu l m s lng v t l tng loi t bo c trong mu.
Thng xt nghim ny c thc hin bng my m t ng, cho kt qu nhanh trong
vng mt pht. Kt qu cng thc mu gm 15 thng s chnh. Ngi ta tnh s lng
tng loi t bo nh hng cu, bch cu v tiu cu trong mt n v th tch mu.
Bng 13.1. Cc gi tr ca cng thc mu

BNH
STT THNG S TNG GIM
THNG

BCH CU Nhim trng, d Nhim trng nng,

5,2-10,8
1 (WBC = White blood cell) 9 ng, vim, bnh suy tu, AIDS, thiu
x10 /L bch cu vitamin ko di
S lng Bch cu

Bch cu a nhn trung tnh 60-66%

Nhim trng cp Nhim trng c hi
2 (NEU = Neutrophile) (1700- tnh, ung th nng, nhim c
C chc nng thc bo 7000)

Bch cu lympho 15-20% Hi chng suy gim

Nhim siu vi, ung
3 (LYM = Lymphocyte) (1000- min dch mc phi,
th mu, lao
C chc nng min dch 4000) thng hn nng

Bch cu n nhn Hi chng tng

(MONO = Monocyte) 2-2,5% n nhn nhim
4
L dng cha trng thnh (100-1000) khun, bnh mn
ca i thc bo tnh

Bch cu i toan 1-2% Nhim k sinh

5
(EOS = Eosonophile) (50) trng, d ng

Bch cu i kim
6 0,5-1% Nhim c
(BASO = Basophile)

142
 BNH
STT THNG S TNG GIM
THNG

Nam: 4,1-5,4 Thiu mu (thiu

HNG CU Mt nc, a hng st, vitamin B12,
7 N: 3,8- 4,9
(RBC = Red blood cell) 12
cu acid folic, tn
(x10 / L) huyt, suy ty)

Nam: 14- Thiu mu

Hemoglobin 18g/dL (thng km s
8 lng hng cu
(Hb) N: 12- v dung tch hng
16g/dL cu thp)

Dung tch hng cu

(Hct = Hematocrit ) Nam: 45-
52% Mt nc, a hng
9 l t l gia th tch hng Thiu mu
cu
cu so vi th tch mu N: 37-47%
ton phn

80-94 fL.
Th tch trung bnh hng Thiu mu hng
Thiu mu
cu cu nh khi
hng cu
(MCV = Mean Corpus bnh th tch Thiu mu hng cu MCV< 80fl
10 Volume) (gim sn to khi MCV >100fL
(thiu st,
Phn bit th tch hng cu xut do ung (thiu B12, acid folic) thalassemie)
nh, bnh thng hay ln) = th, suy tu,
Hct/RBC, n v femtolit, fL tn huyt,
xut huyt)

Lng Hb trung bnh trong

hng cu Thiu mu hng
27-32 pg Thiu mu hng u
(MCH = Mean Corpuscular cu nh nhc
11 Thiu mu sc (hng cu hnh
Hb) sc (thiu st,
ng sc cu, to)
= Hb/RBC, n v picogram thalassemie)
(pg)

Nng Hb trung bnh

trong hng cu 32-36 g/dL Thiu mu nhc
Thiu mu hng u
12 (MCHC = Mean corpuscular Thiu mu sc (thiu st,
sc (hnh cu)
hemoglobin concentration) ng sc thalassemie)
= Hb/Hct, n v g/dL.

Hng cu li: l hng cu Thiu mu do tng Thiu mu do

13 c phng thch t tu 0,5-1,5%. ph hy hng cu gim sn sinh ti
xng hay mt mu ty

Phn b th tch hng cu Thiu mu kch

thc hng cu
(RDW=Red cell distribution)
khng u do thiu
14 s thay i kch thc ca 11-15% mu thiu st, thiu
hng cu, s cng ln l do vitamin B12, hi
s thay i kch thc cng chng lon sinh ty,
nhiu thalassemie

150-400 Xut huyt gim

TIU CU Thiu mu, tng sinh tiu cu, lch to,
15 x 109/L.
(PLT= Platelet) tu, ct lch st xut huyt, x
(5-11 fL) gan

143
3. CC THNG S CHNH CA TNG PHN TCH NC TIU
Tng phn tch nc tiu l xt nghim n gin, khng xm ln, nhng rt c ch
trong chn on v theo di mt s tnh trng bnh l. Lu l khi ly nc tiu trnh
b ngoi nhim, nn ly vo sng sm v kho st ngay th kt qu s chnh xc hn. Nc
tiu bnh thng gn nh khng mu.

3.1. pH ( kim toan)

y l xt nghim rt c gi tr chn on cc ri lon kim toan ca c th nu
kt hp vi cc xt nghim nc tiu v huyt tng c hiu khc. Gi tr bnh thng
dao ng 4,5-7,8; trung bnh pH=6. Thng thng pH nc tiu hi acid vo bui sng v
dn tr nn kim vo bui chiu
Nu pH > 6,5 ko di: nc tiu kim tnh, gi nhim trng do cc vi trng phn
gii ur nh Proteus. Ngoi ra cn c th do nc tiu lu, n chay (nhiu rau),
dng thuc li tiu, nn i, ht dch d dy v iu tr s dng cht kim.
Nu pH < 6 ko di: nc tiu toan tnh, thng gp nht trong toan chuyn ha,
lao niu, ng c ru. Bnh thng cng c th do n nhiu tht hay vn ng
nhiu.

3.2. T trng
T trng l ch s ni ln nng cht ha tan trong nc tiu. T trng ca nc tiu
cng dao ng thng xuyn trong iu kin sinh l cng nh bnh l, thng t 1,010
n 1,025. Nu t trng ny thng xuyn gi mc c nh c th thn khng cn lm
vic tt, tn thng nhu m thn do nhiu nguyn nhn.
T trng tng nhiu, phn nh tnh trng mt nc ca c th, m niu hay do cht
cn quang.
T trng gim trong bnh i tho nht, suy thn mn, dng thuc li tiu hay do
bnh nhn ung nc qu nhiu.

3.3. Bilirubin v urobilinogen

Ch c bilirubin trc tip vo c nc tiu nn kt qu xt nghim dng tnh in
hnh gp bnh nhn b vng da do tc mt hay tn thng t bo gan. Bnh thng m
tnh. Kt qu thng m tnh bnh nhn b vng da do tn huyt nhng urobilinogen niu
bnh nhn ny thng l dng tnh.
Que th rt nhy cm vi bilirubin v pht hin c nng 0,05mg/dL.
Phn ng dng gi c th xy ra khi nc tiu b nhim phn.
Nc tiu lu v b phi ngoi nh sng c th phn ng m gi.

3.4. Glucose (ng)

Gi tr xt nghim ch nm mc pht hin bnh, bnh thng khng c ng trong
nc tiu. Khi lng ng trong mu cao vt qua ngng thn (khong 10mmol/L), s
xut hin ng trong nc tiu. Mt s bnh l tn thng ng thn gn lm gim ti hp
thu glucose nh bnh ng thn m k.

3.5. Cetone
Th cetone c th xut hin trong nc tiu bnh nhn nhn n, i ko di hoc b
nhim cetone-acid do i tho ng hoc do ru.

144
 y cng l triu chng c bit quan trng pht hin kp thi bnh nhn i tho
ng chuyn sang trng thi mt b tr (tin hn m, hn m).

3.6. Hemoglobulin v myoglobulin

Tiu mu hoc nhim mu lc hnh kinh vo nc tiu s cho phn ng dng tnh.
Cc cht c tnh oxy ha, betadine cho phn ng dng gi.
Tn huyt lm tng hemoglobin trong huyt thanh v trong nc tiu. C th chn
on tn huyt bng cch da vo bnh s, pht mu ngoi bin, mt vi xt nghim khc.
Hy c vn lm tng myoglobulin

3.7. Thnh phn Protein

Bnh thng protein niu < 150mg/24 gi (khong 100mg/L)
Protein niu l triu chng thng gp trong bnh thn nhng khng c hiu. V
vy, khi pht hin protein niu th cn c chn on phn bit tip theo.
Protein niu lnh tnh: ngi tr < 30 tui, c n 30% l do nguyn nhn sinh l
nh vn ng, t th, stress, c thai, b nng hay lnh qu.
Protein niu do cc bnh khc khng phi thn: cn au bng, nhi mu c tim, suy
tim, st cao.
Protein niu do cc bnh thn: hi chng thn h, vim tiu cu thn, vim b thn,
nang thn. nh lng m niu 24 gi l tiu chun vng chn on tiu m. Khi
m niu 20-30g/L, in di m niu gip phn bit bnh do cu thn hay ng thn. Mt s
trng hp tm microalbumin niu chn on bnh thn.
Nn ly mu lc bnh nhn mi thc dy, l ng mu khng dnh cc cht st trng.

3.8. Bch cu
L triu chng chnh trong nhiu bnh vim nhim ng tit niu di nh vim
bng quang, vim niu o.Khi thy bch cu niu, cng c th ngh n cc tn thng v
mt cu trc nh si niu. Ph n hay gp bch cu niu hn nam gii, v thng vim
ng tit niu hn, ch nn ly mu nc tiu gia dng.

3.9. Nitrite
Bnh thng m tnh.
Nitrite niu l bng chng nc tiu b nhim khun gram m, nguyn nhn do
Escherichia coli v mt s vi khun khc nh Proteus, Klebsiella, Pseudomonas
Nn ly mu nc tiu lc mi thc dy, v nc tiu phi nm trong bng quang t
nht 4 gi mi thi gian cc vi khun chuyn ha nitrat thnh nitrit. Ngoi ra trc
ngy xt nghim cn cho bnh nhn tm dng khng sinh hoc cc thuc iu tr khc.

3.10. Hng cu
Nc tiu c hng cu (mu) l triu chng ca nhiu bnh khc nhau, trong quan
trng nht l nhm bnh thn - tit niu (nh si niu, khi u, vim tiu cu thn, vim b
thn, chn thng, nang thn.) v nhm bnh tng xut huyt (do dng thuc chng
ng, bnh a chy mu, thiu yu t ng mu, bnh tiu cu). Nu xt nghim nc
tiu ph n c hng cu nn hi li tin s kinh nguyt.

145
3.11. Cc loi tr niu
Cu to bi cht nhy, t bo ca mu khi qua ng thn, ng li v mang khun ca
ng thn. S lng tr nhiu hay t trong nc tiu khng c gi tr chn on bnh nng
hay nh, v khi rt nhiu tr c hnh thnh gy bt tc ng thn l lc bnh ang tin
trin, nhng n cha bong khi ng thn th nc tiu rt t tr, nhng khi bnh lui t bo
ng thn hi phc, tr bong ra v tri theo nc tiu vi s lng nhiu li l lc bnh nh.
V vy, s lng tr trong nc tiu nhiu hay t khng c gi tr lm sng.
Cc loi tr thng gp gm:
Tr Hyaline: cn gi l tr trong, c mt trong nc tiu bnh thng, tng trong
mt nc v tiu m.
Tr hng cu: rt c gi tr chn on bnh l l cu thn, gi tr ca tr hng
cu tng ng vi soi nc tiu thy nhiu hng cu bin dng, ni ln hng
cu lt ra nc tiu l t cu thn khng phi t ng tit niu.
Tr bch cu: thng gp trong vim thn-b thn mn, rt c gi tr v ch c vim
ng-k thn th mi tng bch cu o thi trong ng thn, cn nu ch nhim khun
b thn th bch cu khng th c trong tr, v tr hnh thnh ng thn.
Tr ht: thng gp trong vim cu thn mn, nhng khng c hiu.
Tr m: do bo tng t bo thoi ha, hoc do m trong mu bi tit ra to
thnh. Cc ht m hin r trn thn tr, thng gp trong thn nhim m, hi
chng thn h v suy gip.
Tr tinh th: khng c gi tr bnh l nu l nhng cht hin din bnh thng
trong nc tiu nh mui calci, acide oxalique, acid urique hay urate. S hin
din tinh th ny khng phi l bng chng ca si niu.

4. NG HUYT
y l bnh do ri lon chuyn ho, trong giai on sm thng khng c triu
chng lm sng. Vic pht hin sm gip rt nhiu trong cng vic iu tr nhm ngn
nga cc bin chng mn tnh ca bnh. Xt nghim thng c thc hin trong khm
sc kho nh k, nht l i vi ngi > 45 tui, gia nh c ngi bnh i tho ng,
thai k, xt nghim tin phu.
Tiu chun chn on i tho ng theo khuyn co Hip hi i tho ng Hoa
K 2010 (American Diabetes Association = ADA), da vo mt trong bn tiu chun sau:
HbA1c 6,5 %
ng huyt i 126mg/dl (7,0mmol/l)
ng huyt 2 gi 200mg/dl (11,1mmol/l) khi lm test dung np glucose
Bnh nhn c triu chng c in ca tng ng huyt (n nhiu, ung nhiu,
tiu nhiu, st cn nhiu) hay tng ng huyt trm trng km theo xt nghim
ng huyt ngu nhin 200mg/dl (11,1mmol/l).
Cc tiu chun trn nn lp li hai ln hai thi im khc nhau mi chn on.
Hip hi cng a ra nhm c nguy c mc bnh i tho ng:
Ri lon ng huyt i: 100 - 125 mg/dl (5,6 - 6,9 mmol/l)
Ri lon dung np glucose: 140 199 mg/dl ( 7,8 - 11mmol/l) (sau n 2 gi)
HbA1c: 5,7 - 6,4%

146
5. CHC NNG THN
BUN: 2,5 - 7,5 mmol/L
Creatinin/mu: nam 0,8 - 1,3 mg/dL; n 0,6 - 1 mg/dL.

6. X-QUANG NGC THNG

Kho st lng ngc, tim, phi, mng phi v trung tht.
i vi X-quang ngc thng, c mt phng php nh trnh t c kh n gin:
A (Airway): xem ng dn kh c th l kh qun c cch u hai u xng
n khng?
B (Bones): xem lng ngc vi xng sn, n c b gy khng?
C (Cardiomediastinal silhouette): lin quan trung tht v tim: ch s tim, cc
cung v hng tim.
D (Diaphragm): xem xt cung vm honh: vm honh r khng? cong vm
honh? S lin tc vm honh?
E (Expanded lung): nh gi mng phi v nhu m phi.
F (Foreign object): ngoi vt c th nhn thy trn X-quang.

7. SIU M BNG TNG QUT

Siu m bng tng qut l mt trong nhng thm khm c s dng nhiu nht
hin nay khi ngi bnh vo vin. Mc ch c th l kim tra sc khe nh k hoc nh
gi nhng bnh l bit trc.
Siu m bng c th kho st mt s tng trong bng nh gan, mt, lch, ty, h
tit niu, h sinh dc, mt s bnh l ng tiu ha nh vim rut tha, cc khi u ln
ca rut v nh gi dch bng, hch bng, khoang mng phi, mng ngoi tim.

8. XT NGHIM SOI PHN

Nhm tm hng cu, bch cu, k sinh trng ng rut; mt vi trng hp c th
tm mu n trong phn.

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam (2009).
Phn tch huyt . K nng y khoa c bn. Nh xut bn Y hc TPHCM, tr 574-578.
2. Neel L Burton (2005). Urine sample testing and interpretation. Clinical Skills for OSCEs,
2nd edition.
3. Nguyn Phi Long. Bin lun cn lm sng, Nh xut bn Y hc TPHCM.
4. Trn Vn B (1999). Lm sng huyt hc. NXB Y hc TPHCM, Chng VIII, tr 397-411.

147
 BNG KIM

0 im: Khng thc hin 2 im: Gn y : trn 50%

1 im: Khng y : di 50% 3 im: Thc hin k, thao tc ng, y

STT NI DUNG 0 1 2 3

1 S lng bch cu v tnh cng thc bch cu

2 S lng hng cu v tnh cng thc hng cu

3 S lng tiu cu, ngha

4 Bin lun cc thng s nc tiu

5 Cc tiu chun chn on ng huyt

Tng im:./15 im.

148
 Bi 14
PHN TCH IN TM BNH THNG

MC TIU
1. Trnh by c trnh t phn tch mt in tm .
2. Trnh by c ngha ca cc thng s in tm .
3. Thc hin c cch o cc thng s in tm .
4. Nu c gii hn bnh thng ca cc thng s in tm .

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 05 pht
+ Trnh by ni dung bi ging: 90 pht
+ Thc hnh c ECG mu: 50 pht
+ Ging vin gii p thc mc v tng kt cui bui: 35 pht

NI DUNG
1. I CNG
My ghi in tm l mt trong nhng thit b c trang b rng ri nht ti cc
tuyn y t c s nc ta. V mc d in tm l mt trong nhng k thut lu i
nht, n gin nht nhng n li cung cp nhiu thng tin hu ch gip nh gi bnh nhn
b bnh tim nn hin ti, in tm vn cn c vai tr quan trng trn lm sng.
in tm gip ch rt nhiu trong chn on cc bnh l v ri lon nhp tim, bt
thng ca h thng dn truyn, thiu mu cc b c tim... Ngoi ra, in tm cn gip
cho vic theo di iu tr (nht l vi cc thuc chng lon nhp) v gip pht hin cc bt
thng v in gii v ri lon chuyn ha.
Khi c in tm , cn tip cn theo trnh t trnh b st nhng bt thng
quan trng.

2. GIY GHI IN TM V QUY C NH CHUN MY

Cc sng in tm c ghi trn mt giy c bit, gm nhiu hnh vung nh c
cnh l 1mm hp li. Nm hnh vung nh s hnh thnh nn hnh vung to, c cnh l 5
mm. Trc ng th hin bin sng, n v l mm (1 mV = 10 mm) v trc ngang th
hin thi gian, n v l giy. Tc ghi thng thng ca my l 25mm/1 giy. V vy,
mi cnh hnh vung nh (1 mm) c thi gian l 1/25 giy hay 0,04 giy v mt hnh
vung ln c thi gian l 0,2 giy.

149
 Hnh 14.1. Giy ghi in tm

Mt s trng hp c bit, cn iu chnh tc ghi ca my l 50mm/1 giy. Khi

, mi hnh vung nh c thi gian l 0,02 giy v mt hnh vung ln c thi gian l 0,1
giy. Lc ny, cn lu l tn s tim ch bng tn s tim ca my ghi vi tc
25mm/1 giy v tt c khong cch in tim u di gp hai ln bnh thng.
V bin sng, nh chun thng thng l 10 vung nh (tng ng 10mm
hay 2 vung ln) l 1 mV. Khi bin sng qu nh, cn nh chun li l 20mm =
1mV. Khi bin sng qu ln, cn nh chun li l 5mm = 1mV. Tc ghi ca my v
in th nh chun thng c th hin pha di ca bng in tm . Cn lu
nhn 2 khi tnh bin sng nu nh chun l 5mm = 1mV v chia 2 khi tnh bin
sng nu nh chun l 20mm = 1mV (hnh 2). tnh bin sng P, ly mc mt ng
nm ngang 16 -20 ms ngay trc sng P (thng l ng T-P). tnh bin QRS, T
v chnh ST, ly mc mt ng nm ngang 16 20 ms ngay trc phc hp QRS
(thng l on PQ hay PR)

Hnh 14.2. Cch nh chun bin

(A: nh chun chun, 10mm = 1mV; B: nh chun 5mm = 1mV; C: nh chun 20mm = 1mV)

Khi din gii kt qu in tm , cn c nh chun bin sng v thi gian

trc. Thng thng, bin 10 mm ng vi in th 1 milivolt v vi tc ghi l
25mm/1 giy th thi gian 1 vung nh l 0,04 giy. Hnh dng sng vung cho bit cht
lng my o. Nu sng khng vung m c gai nhn pha trc l my b qu
(overshoot).

150
 Hnh 14.3. Cc kiu nh chun bin
(A: nh chun ng; B: nh chun di mc; C: nh chun qu )

3. CC CHUYN O IN TM BNH THNG

in tm l mt ng cong biu din hot ng in ca tim, c ghi li bng
cc in cc b mt c th, gm 12 chuyn o c bn (6 chuyn o ngoi bin v 6
chuyn o trc ngc hay trc tim).
Chuyn o ngoi bin gm: DI, DII, DIII, aVR, aVL v aVF.
Chuyn o trc ngc gm: V1, V2, V3, V4, V5 v V6.
Trong trng hp nghi ng nhi mu c tim tht phi hoc nhi mu c tim thnh
sau, cn ghi in tm 17 chuyn o (gm 12 chuyn o c bn v thm cc chuyn
o V3R, V4R, V7, V8 v V9).
S bin thin ca cc sng cc chuyn o khc nhau ty thuc vo vc-t in tim
tc thi

Hnh 14.4. Cc chuyn o ngoi bin

Hnh 14.5. Cc chuyn o trc ngc

151
4. M T MT IN TM BNH THNG

Hnh 14.6. Cc thnh phn ca sng in tim

in tm bnh thng gm nhiu sng khc nhau, i din cho hot ng in

nhng phn khc nhau trong mi chu chuyn tim. Cc sng in tm c gi tn da
theo bng ch ci, bt u bng sng P, tip theo l phc b QRS v cui cng l phc b
ST-T-U (on ST, sng T v sng U). im J l ch ni gia phn cui ca phc b QRS
v bt u ca on ST). Cch gi tn cc sng trong phc b QRS c quy c nh sau:
Sng m u tin l sng Q
Sng dng u tin l sng R (c th khng c sng Q i trc)
Sng m i sau sng R l sng S
Cc sng i sau ty theo m hay dng m c gi l R v S
Thng thng, khi cc sng ca phc b QRS c bin < 5 mm, c k hiu bng
ch ci thng (q, r, s). Khi cc sng ca phc b QRS c bin 5 mm, c k hiu
bng ch ci in (Q, R, S).
ngha ca cc sng, tiu chun hnh dng, thi gian, bin bnh thng ca cc
sng c cp bn di.

4.1. Sng P
ngha: sng kh cc hai nh
Hnh dng: sng trn, i khi c khc, hai pha
Thi gian: 0,08 0,11 giy ( ngi Vit Nam: 0,05 0,11 giy)
Bin : < 2,5mm
Sng P lun lun dng (+) DI, DII, aVF, V3-V6; m (-) aVR; (+), (-) hoc
hai pha DIII, aVL, V1-V2
Trc sng : O 75 , 15 75 .

4.2. Khong PR
ngha: thi gian dn truyn xung t nh n tht.
Thi gian: 0,12 0,20 giy ( ngi Vit Nam: 0,11 0,20 giy).
PR ngn hn khi nhp tim nhanh.

152
4.3. Phc b QRS
ngha: thi gian kh cc hai tht
Thi gian: 0,06 0,1 giy. chuyn o chun: QRS c th m hoc dng
Thi gian kch hot tht (VAT: Ventricular Activating Time):
< 0,035 giy (V1-V2)
< 0,045 giy (V5-V6)
Bin :
+ chuyn o chi: t 5 20 mm
+ chuyn o trc ngc V1 V6:
Sng R tng dn bin t V1 n V6
Sng S gim dn bin t V1 n V6
Vng chuyn tip chuyn o c sng hai pha dng v m gn bng nhau.
Bnh thng vng chuyn tip V3, V4.

Hnh 14.7. Thay i sng R v sng S cc chuyn o trc ngc

4.4. on ST
ngha: thi gian hai tm tht hon ton b kh cc
Bt u t cui phc hp QRS n bt u sng T
Thi gian: gn bng 0,12 giy
Bnh thng on ST nm trn ng ng in. C th chnh ln 1 mm (chuyn
o chi), 2 mm (chuyn o trc ngc) hoc chnh xung 0,5 mm.

4.5. Khong QT
ngha: thi gian thu tm in c hc ca tim
Bt u t u phc hp QRS n cui sng T
Thi gian: 0,35 0,41 giy ( ngi Vit Nam: 0,36 0,40 giy), ty tn s tim.
!"
QTc = 0,42 giy (nam)
##

0,43 giy (n)

QTc l QT c iu chnh theo nhp tim.

4.6. Sng T
ngha: sng ti cc hai tm tht.
Hnh dng: sng T bnh thng cng chiu vi QRS, bt i xng (nhnh ln di
hn nhnh xung), nh trn.
Thi gian: 0,20 giy

153
 Bin : < 5mm (chuyn o chi)
< 10mm (chuyn o trc ngc)
$ $
T l T/R: - (V5 V6)
% $'
Trc sng T: 30 - 90

4.7. Sng U
ngha: ngun gc sng U khng chc chn, bnh thng khng thy trn in
tm hay ch mt sng nh sau sng T.
Bin : 1mm
Hnh dng: sng trn, r V2 V3, ln hn khi nhp tim chm, nh hn v ln
vo sng P khi nhp nhanh.

5. PHN TCH MT IN TM BNH THNG

5.1. Nhp tim
* Nhp tim u hay khng u?
Nu: (RR) di nht (RR) ngn nht < 4 nh th c th ni mt nhp u (mt
nh: 0,04 giy)
* Tn s
Trng hp nhp u ta tnh tn s nh sau:
Nhp tim/1 pht = 60/(khong cch RR, tnh bng giy)
Trng hp nhp khng u ta m cc nhp trong thi gian 3 giy, ri suy ra nhp
tim/1 pht.
Cch tnh nhanh nhp tim:
+ Vn tc giy o 25mm/giy; do : mi nh = 1mm x 1/25 giy = 0,04 giy,
+ Mi ln = 5mm x 1/25 giy = 0,20 giy
+ o s ln gia cc phc hp QRS:
1 nhp/1 ln = 300 nhp/pht
1 nhp/2 ln = 150 nhp/pht
1 nhp/3 ln = 100 nhp/pht
1 nhp/4 ln = 75 nhp/pht
1 nhp/5 ln = 60 nhp/pht
1 nhp/6 ln = 50 nhp/pht

154
 Tn s tim = 300/(s vung ln gia RR)

Hnh 14.8. Cch tnh nhp tim

* C phi nhp xoang hay khng?

Nhp tim bnh thng l nhp xoang, c to ra bi xung ng in hnh thnh
trong nt xoang nh v c trng bi:
+ Sng P ng dng, u, tn s t 60 n 100 ln/pht
+ Sng P dng DII, aVF v m aVR
+ Mi sng P i km vi mt phc b QRS
Cc cu hi v tnh u nhp
+ Nhp nhanh hay chm? (Tn s tim bnh thng 60 100 ln/pht)
+ QRS u hay khng u
+ QRS hp hay rng
+ Sng P c lun i trc mi QRS khng?
+ Khong PR c hng nh khng?

5.2. Trc QRS, trc T v gc QRS-T

Trc QRS
+ Bin ca QRS bt c chuyn o no cho bit lc in hc ca vc t
kh cc tim trong hng .
+ Trc l cch xc nh tim c c kh cc trong hng bnh thng khng?
(hng xung di v sang tri)
+ Trc QRS l tng cc vc- t in tim tc thi trong sut thi gian tm tht
kh cc. xc nh c trc in trung bnh ca tm tht, ta tnh tng i s
bin ca QRS DI, DII, DIII. V trc in trung bnh ca tht trn tam gic
Einthoven hay trn h thng ba trc ca Baley.
+ Trc in trung bnh ca tht bnh thng: - 30 + 110 (ngi Vit
Nam : +26 + 100 ngha l hi lch sang phi so vi ngi u).
+ Phng php xc nh nhanh trc QRS:
Ghi nh trc ca DI = 0 .
Ghi nh trc ca aVF = 90 .
Nu QRS dng DI v aVF l trc bnh thng.

155
 Trc t - 30 n - 90: lch tri bt thng.
Trc t +110 n +180 : lch phi bt thng.
Trc T: thng song song vi trc QRS. Gc QRS T: thng < 60

Hnh 14.9. Cch tnh trc QRS

5.3. Phn tch cc sng v cc khong cch trn chuyn o DII

Sng P
Khong PR (PQ)
Phc hp QRS
on ST
Sng T
Khong QT.
5.4. Mt s ch s chn on ph i tht
Tiu ch in th Cornell chn on ph i tht tri: ( nhy 22%, chuyn
bit 95%)
SV3 + RaVL > 24mm (nam)
SV3 + RaVL > 20mm (n)
Tiu ch in th khc chn on ph i tht tri:
+ Chuyn o chi
R aVL > 11mm. Nu c trc lch tri, R aVL > 13mm + SDIII > 15mm
R DI + S DIII > 25mm
+ Chuyn o trc ngc
Ch s Sokolow Lyon: tnh tng ca gi tr tuyt i ca SV1 + RV5 (hay
V6) > 35mm
Tiu ch in th chn on ph i tht phi:
+ Chuyn o trc ngc
RV1 + SV5 (V6) > 10mm
T l R/S V5 hoc V6 < 1

156
 RV5 (hoc V6) < 5mm
SV5 (hoc V6) > 7mm

5.5. Kt lun
So snh cc tr s o c vi tr s bnh thng v kt lun in tm c bnh
thng hay khng.

TI LIU THAM KHO

1. Ferry D.R. Basic Electrocardiography in ten days, 2001.
2. Frank G. Yanowitz, MD, Professor of Medicine, University of Utah School.
3. Goldman M.S Principle of Clinical Electrocardiography, 1986.
4. Trn Trinh, Trn Vn ng: Hng dn c in tim, Nh xut bn Y hc, H Ni, 2002.
5. Wagner G.S Marriots Practical Electrocardiography 10th ed, 2001.

157
 BNG KIM PHN TCH IN TM BNH THNG

Khng nhn Nhn nh Nhn nh

STT Ni dung nh khng chnh xc chnh xc
0 im 1 im 2 im

Nhn xt v nhp tim

Tn s tim
1
Nhp u hay khng

Nhp xoang hay khng

c chuyn o DII

Thi gian sng P

Bin sng P

2 Thi gian QRS

Bin QRS

Thi gian sng T

Bin sng T

Tnh khong cch

3 Khong PR ( DII)

Khong QT ( V5)

Nhn xt on ST DII, V1-

4
V6

V trc in trung bnh ca tht

Tnh bin QRS DI, DII,

5
DIII

V trc QRS

6 Tnh ch s Sokolow- Lyon

7 Kt lun

158
 Bi 15
K THUT S DNG
CC THUC NG KH DUNG

MC TIU
1. Hiu c u im ca vic s dng thuc qua ng h hp.
2. Lit k c ba k thut s dng cc thuc ng kh dung thng gp.
3. Thc hin ng ba k thut s dng kh dung ny.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 5 pht
+ Gii thiu ni dung bi ging, xem video clip: 25 pht
+ Ging vin thao din cc thao tc ca tng k thut phun kh dung, lm mu 02
ln trn m hnh v sinh vin tnh nguyn: 40 pht (gm 15 pht lm mt lt
v 25 pht lm c gii thch).
+ Sinh vin chia thnh nhm, mi nhm hai em, mt sinh vin thao tc, mt em
khc quan st v ghi nhn trn bng kim, sinh vin lm tng k thut, khi no
thnh tho s i sang k thut khc: 60 pht
+ Chn 02 sinh vin biu din cc k thut phun kh dung, nhm cn li quan st
v nh gi: 40 pht
+ Ging vin tng kt cui bui: 10 pht

NI DUNG
1. I CNG
Thuc ng kh dung c vai tr rt quan trng trong iu tr nhiu bnh l h hp.
u im ca vic dng thuc ng kh dung l c th a thuc trc tip n v tr cn
gy tc dng, l cc ph qun v ph nang. Nh , thuc s c tc dng rt nhanh
trong vng 5 pht k t khi bt u ht v rt hu ch khi dng cp cu ct cn suyn.
Trong khi dng thuc bng ng tim phi mt t 15-30 pht v ng ung t 30-60
pht mi c tc dng.
Dng thuc bng ng kh dung cn c u im l hn ch c nhng tc dng
ph ton thn ca thuc, nht l vi cc thuc c ngun gc corticoide. Nh ta bit, s
dng corticoide di ngy bng ng tim hoc ung s em li rt nhiu tc dng ph
nguy him nh lot d dy, long xng, mp ph, rn da, lm nng thm cc bnh i tho
ng, tng huyt p... Ngc li, dng corticoide bng ng ht c chng minh l
rt an ton, hon ton khng gy cc tc dng ph k trn. Cc thuc gin ph qun bng
ng ht cng lm gim bt phn no nhng tc dng ph thng c khi ung hoc tim
thuc nh run tay, hi hp, nhp tim nhanh...

159
 Khi s dng cc thuc corticoide ng kh dung, c th gp mt s tc dng ph ti
ch nh ho, khn ging, nhim nm vng hu hng, kch thch nim mc hu hng hoc
kch thch da mt nu s dng mt n. Hu ht cc tc dng ph ny u c th trnh c
bng cch sc ming v ra mt sch sau khi dng thuc.
K thut s dng tng loi kh dung l khc nhau v vic s dng ng s quyt nh
lng thuc lng ng hu hng v hiu qu ca iu tr. Ba loi kh dung chnh c
dng hin nay l bnh ht nh liu, bnh ht bt kh v my phun kh dung. My phun kh
dung c kch thc ln hn bnh ht nh liu v bnh ht bt kh nn bt tin khi phi vn
chuyn xa. Cc tin li v bt tin ca tng loi kh dung c th hin bng 1. Nhiu
bng chng cho thy hiu qu tng ng gia cc loi kh dung nu c s dng ng
cch. V vy, vic chn la loi kh dung no thng ty thuc vo a thch, iu kin
kinh t ca ngi bnh v s c sn ca thuc.

Bng 15.1. Tin li v bt tin ca tng loi kh dung

Loi kh dung Tin li Bt tin

Chi ph thng t hn
Tn nhiu thi gian hn
Khng cn s hp tc ca
My kh dung D nhim trng hn
ngi bnh
Cn chun b my v dng c trc
khi iu tr
Gn, d em theo
Bnh ht nh liu Chi ph thp hn my kh dung
Cn c s hp tc ca ngi bnh
(Metered Dose Inhaler: Khng cn chun b my v
Lng ng thuc vng hu hng
MDI) dng c trc khi iu tr
t gy nhim trng hn
t cn s hp tc ca ngi
Bnh ht nh liu km bnh hn Chi ph cao hn khi dng bnh xt
bung m (Spacer) t lng ng vng hu hng nh liu khng km bung m
hn
t cn s hp tc ca ngi Cn lu lng dng kh ht vo
Bnh ht bt kh bnh hn trung bnh n cao
(Dry Powder Inhaler: Tin li C th lng ng nhiu hu hng
DPI) Khng cn dng cht y thuc Khng th s dng ngi bnh
Khi ng thuc bng cch ht t ni kh qun hoc m kh qun

2. K THUT S DNG MY PHUN KH DUNG

2.1. My phun kh dung l g?
My phun kh dung l dng c c s dng rng ri trong iu tr bnh hen (suyn),
bnh phi tc nghn mn tnh. y l dng c khng th thiu ti cc phng cp cu, cc
khoa iu tr bnh h hp. Ngoi ra, my cng c dng kh ph bin ti cc gia nh.

160
 Hnh 15.1. My phun kh dung

My phun kh dung l my gip a thuc vo c th di dng nhng ht sng

nh li ti. Cc ht ny s theo hi th ht thng vo phi v to tc dng ti y. My phun
kh dung to ra cc ht sng c kch thc khc nhau: Nhng ht sng c kch thc ln
khong 8 m ch ng li vng hu hng, cn cc ht sng nh khong 3-5 m s vo
su trong cc ph qun nh v c th n tn cc ph nang, y chnh l v tr thuc pht
huy tc dng tt nht. Nhng ht qu nh, c kch thc t 0,3-0,5 m s c bnh nhn
th ra ngoi. V vy, khi chn mua my phun kh dung, chng ta cn lu : ch cc loi
my phun kh dung to ht sng c kch thc 3-5 m mi c s dng trong iu tr
suyn, cn cc my kh dung to ht ln hn thng c s dng trong cc bnh l tai -
mi - hng.

2.2. Nguyn tc
To thnh nhng ht nc nh c ng knh 3-6 m (dng sng m) vo ng h
hp v cho tc dng ti ch. Ty theo v tr sng ri m ta c tc dng mong mun.
Trc khi tin hnh cc k thut phun kh dung u phi gii thch cho ngi nh
(nu tr nh) hay cho tr (nu tr ln).

2.3. Phun kh dung vi oxy hoc my phun

Phun kh dung vi oxy hoc my phun c khuyt im l cng knh v gi thnh
cao, to ting n v cn ngun in vn hnh. Tuy nhin, d s dng v d t hiu qu
iu tr hn so vi bnh ht nh liu. V vy, my phun kh dung thng c s dng
trong cc phng cp cu cho tr em, ngi cao tui v nhng bnh nhn khng s dng
c bnh ht nh liu.
2.3.1. Ch nh
Vim thanh qun cp v ph thanh qun sau t ni kh qun: phun vi
epinephrine 10/00 (Adrenaline), Racemic Epinephrine 2,25%.
Suyn, vim tiu ph qun: phun thuc dn ph qun salbutamol (Ventolin),
terbutalime (Bricanyl), ipratropium bromide (Atrovent).
Long m: phun vi Natri chloride 0,9%.
2.3.2. Dng c
Bnh oxy hay h thng oxy trung tm hoc my phun kh dung
Dng c phun: bu kh dung (Nebulizer), mt n (mask) cc c, dy oxy

161
 Dng c ly thuc: ng tim v kim tim
Thuc: tu theo ch nh ta c cc thuc nh k trn
Natri chloride 0,9% pha thuc khi phun
Mm ng dng c, cn v bng gn, bn ht u
Bp b cc c lm bnh nhi.
2.3.3. K thut
Xc nh chn on v thuc cn dng
Tnh liu lng thuc nh sau:
+ Adrenline 10/00: 0,1 mg/kg/ ln (ti a 3mg)
+ Ventoline: 0,15 mg/kg/ln (ti a 5mg, ti thiu 2mg)
+ Bricanyl: 0,2mg/ kg/ ln (ti a 5 mg, ti thiu 2 mg)
+ Atrovent:
Tr < 12 thng: 125 g/ln
Tr > 12 thng: 250 g/ln
+ Natrichloride 0,9%.
Ly thuc vo ng tim theo liu tnh
Ly thm dung dch nc mui sinh l va 3ml (thuc + nc mui sinh l)
M np bu phun v bm thuc vo
y np bu phun li
Ni bu phun vi dy oxy
Dng dy oxy ni bu kh dung v ngun oxy
Chun b bnh nhn: bnh nhn t th thoi mi (thng l ngi)
T t p st mt n vo mi ming bnh nhn, bo bnh nhn th ming (nu c
th) t hiu qu ti u
iu chnh liu oxy (s lt): ty theo v tr tc dng, ta cho lng oxy khc nhau:
+ 4 lt/pht: tc dng ti thanh qun
+ 6 8 lt/pht: tc dng ti ph qun v tiu ph qun
Nu dng my phun, tc dng thng ph qun v tiu ph qun: ch cn
m my
Thi gian phun thng khong 10 15 pht c tc dng tt nht v t tc dng
ph. ngi ln hoc tr ln c kh nng hp tc, ta bo bnh nhn ht vo chm
v su trong 5- 6 giy, ngng th khong 5- 10 giy, sau th ra.
Nn g nh vo thnh bu phun m bo thuc bm trn thnh bu phun ri
xung ht trc khi chm dt phun.
Sau khi phun xong phi tt oxy (hoc tt my), g dy, bu phun v mt n.
2.3.4. Nhng vn cn lu khi s dng my kh dung
Mi my phun kh dung u c km theo mt n hoc ng ngm. Ty theo thi
quen, ta c th dng mt trong hai loi dng c trn, nhng cn bit rng dng
ng ngm th lng thuc n phi s nhiu hn khi dng mt n. Tuy nhin, vic
s dng ng ngm i hi phi c s hp tc tt ca ngi bnh, do , khng
nn dng cho tr em di 5 tui.

162
 Khi s dng mt n, thuc c th ng li trn mt hoc thot ra ngoi nu mt n
khng p st vo mt, do lm gim lng thuc vo phi.
Vic bo qun cc dng c sau khi s dng cng l iu rt cn thit, nhm trnh
h hng cho dng c v hn ch c vn nhim vi khun vo phi do my
mc, dng c km v sinh. V vy, sau khi dng xong, cn v sinh my nh sau:
+ Tho mt n hay ng th ming v cc ng thuc ra khi ng dn nha. Ra
mt n hay ng th ming, cc ng thuc, ng nh git hay ng tim di vi
nc ri t ln khn sch cho kh. Lp tr li vo ng dn ri m cng tc
cho my chy khong 10-20 giy lm kh pha trong.
+ Ch :
Khng c t my nn kh vo nc
Khng c ra ng dn bng nha
Mi tun: ra mt n hay ng th ming, cc ng thuc, ng nh git hay
ng tim bng nc m vi x bng, sau ra li bng nc sch. Lm kh
pha ngoi v pha trong nh trn. Thnh thong lau mt ngoi my nn kh
bng khn m.

3. PHUN KH DUNG VI LIU NH CHUN HAY BNH XT NH LIU

(MDI: Metered Dose Inhalers)
3.1. Bnh xt nh liu l g?
Bnh xt nh liu c cu to gm mt bnh kim loi, mt van nh liu v mt u
ng ngm ming. Bnh kim loi cha mt hn dch gm thuc, cht y, surfactan, cht
bo qun, cht to mi v cht gip pht tn thuc. Cht y thng chim khong 80%
thnh phn ca hn dch. Trc y, cht y thng c s dng l chlorofluorocarbon
(CFC) nhng hin nay c thay bng hydrofluoroalkane (HFA) do tc ng xu n
tng ozone ca CFC.

Hnh 15.2. Cu to bnh xt nh liu

Phun kh dung vi liu nh chun c u im l nh, gn, d mang theo bn mnh
nhng phi bit s dng ng cch th lng thuc ht vo mi t yu cu. Ngi s dng
bnh ht nh liu phi bit cch phi hp nhun nhuyn ng tc bm thuc v ng tc
ht su a thuc vo phi. Ngi cao tui, tr em, ngi l ln hay ri lon tm thn,

163
ngi c khim khuyt khi thc hin cc ng tc bng tay... rt kh s dng tt bnh ht
nh liu. Vi nhng bnh nhn ri vo cn suyn nng, suyn c tnh... khng cn sc
ht su, vic s dng bnh ht nh liu cng t em li hiu qu.
Lu l khi s dng bnh xt nh liu ln u, phi lc k l thuc trong 5 giy v
xt b 4 nht u tin. Trng hp l thuc khng c dng trn 2 tun, khi s dng li,
phi xt b 4 nht.

3.2. Cch s dng bnh xt nh liu

3.2.1. Ch nh
Dng iu tr suyn (thuc dn ph qun) ti nh: Ventoline, Bricanyl.
Dng phng nga cn suyn (Corticoides): Bcotide, Pulmicort, Fluticasone,
Seretide (Salmeterol + Fluticasone).
3.2.2. Dng c
Chai thuc phun
Dng c phun
Dng c ht bt kh v thuc
Bung m cc la tui: nh nhi, tr 1- 5 tui, tr trn 5 tui
Mt n cc c
Khn lau sch.
3.2.3. K thut
K thut phun khng c bung m: p dng cho tr t 8 tui tr ln.
+ Lc k chai thuc trc khi phun trong 5 giy
+ M np bnh xt nh liu
+ Cm dng c phun vi bn ngn tay sau cho phn y chai thuc hng ln v
ngn tr (hoc ngn ci) trn y chai thuc
+ Bnh nhn th ra ht
+ u bnh nhn hi nga ra sau.

Hnh 15.3. Dng c phun khng bung m

+ t phn ming ca dng c phun vo ming gia hai mi hoc cch ming
2,5 - 5 cm, va n vo chai thuc va ht t t vo bng ming (thi gian ht
vo khong 6 giy).
+ Nn th t nht 10 giy ri th ra

164
 + Nu mun phun tip ln hai, hy i 1 pht v lp li cc trnh t nh trn: bt
u l lc chai thuc v kt thc bng ng tc th ra.

Hnh 15.4. Hnh K thut phun khng bung m

+ Sau khi phun xong phi lau kh vng ming ca dng c phun v y np li
+ Nu phun vi corticoides, bnh nhn phi xc ming sau khi phun xong
trnh nhim nm Candida.
K thut phun vi bung m khng mt n: p dng tr t 4-8 tui.

Hnh 15.5. K thut phun c bung m khng mt n

Bung m (spacer) l mt ng hoc ti vi th tch ln, gip kh dung t bnh xt
nh liu c lu li lu hn, thi gian cho ngi bnh ht thuc vo phi. Bung m
c xem l cng c h tr, gip a thuc ng kh dung vo trong c th ngi bnh.
Th tch bung m vo khong 100 - 700 ml v chiu di t 10 - 13 cm. Mt s bung
m c gn thm van mt chiu gia bung m v ng ngm ming nhm ngn chn tnh
trng kh th ra i vo trong bung m.
Cc bung m thng dng l Babyhaler, Volumatic, Asthma Kit, Aero Chamber.
Kt hp bnh ht bt kh vi bnh xt nh liu gip lm gim lng thuc lng ng
vng hu hng, tng lng thuc n phi v t cn s phi hp gia ng tc bm thuc
v ng tc ht su. Cch s dng nh sau:
+ Trc tin phi kim tra lng thuc trong chai thuc
+ Kim tra dng c phun

165
 + Gn chai thuc vo dng c phun
+ Lc k chai thuc trc khi phun
+ Gn dng c phun vo bung m
+ Cho phn ming ca bung m vo gia hai mi ca tr
+ Tay tr (hoc tay ca ngi tr gip) cm chai thuc nh trn vi ngn tr
(hoc ngn ci) ln y chai thuc
+ n vo y chai thuc v thuc s vo trong bung m
+ Tr ht chm bng ming trong t nht 6 giy
+ Sau tr nn th tu theo kh nng tr hoc t nht trn 10 giy v th ra
bung m
+ i 1 pht sau lp li ln hai.
K thut phun vi bung m c mt n: p dng tr t 5 thng - 4 tui.

Hnh 15.6. K thut phun c bung m c mt n

+ Trc tin, phi kim tra lng thuc trong chai thuc
+ Kim tra dng c phun
+ Gn chai thuc vo dng c phun
+ Lc k chai thuc trc khi phun
+ Gn dng c phun vo bung m
+ Gn mt n vo bung m
+ Chun b t th tr: tr ngi da vo ngi ba m, c hi nga ra sau, mt
hng v pha trc
+ Gii thch cho tr bit trc khi cho mt n vo mt tr (nu c th)
+ p mt n vo mi ming tr
+ Tay tr (hoc tay ca ngi tr gip) cm chai thuc nh trn vi ngn tr
(hoc ngn ci) ln y chai thuc
+ n vo y chai thuc v thuc s vo trong bung m
+ K thut th: c hai cch:
n chai thuc bn nht lin tip v cho bnh nhn th vi mt n t nht 30 giy.
n chai thuc mt nht v cho bnh nhn ht th bn ln (hoc 10 giy), sau
n tip nht th hai.

166
3.3. Nhn bit ht thuc

Hnh 15.7. Cch nhn bit lng thuc cn li trong bnh bng cch th vo nc

Hnh 15.8. Bnh xt nh liu km thit b m liu

Mt vn quan trng khc l lm th no bit c thuc trong bnh xt nh

liu ht? Trc y, cc nh sn xut khuyn co kim tra lng thuc cn li trong
bnh bng cch tho l thuc kim loi ra v cho vo nc nhng hin ti, cch ny
khng cn c khuyn dng.
Phn ln bnh xt nh liu ngy nay u c gn thm b phn m liu thuc.
Mt cch khc bit c khi no ht thuc l ngi bnh cn ghi li s liu s dng
v b l thuc i khi tng s liu s dng bng vi tng s liu ca l thuc.

4. PHUN KH DUNG VI BNH HT BT KH (DRY POWDER INHALER)

4.1. Bnh ht bt kh l g?

Hnh 15.9. Cc loi bnh ht bt kh

Bnh ht bt kh l nhng thit b gip to ra thuc ng kh dung v khi ng
bng hi th. Tc lu lng ht vo cn thit ngi bnh c th s dng bnh ht bt
kh l t 30 - 60 lt/pht. Bnh ht bt kh to ra kh dung bng cch rt kh ca bt thuc.

167
C hai loi l bnh ht bt kh tng liu ring r v bnh ht bt kh a liu. Khi s dng
bnh ht bt kh tng liu ring r, cn cho thuc vo bnh trc khi ht, trong khi bnh ht
bt kh a liu thng cha lng thuc dng trong 2 - 4 tun. m cao trong khng
kh thng gy ra vn cc thuc v lm gim hiu qu iu tr khi dng bnh ht bt kh a
liu. Trong khi , bnh ht bt kh n liu gip thuc khng b nh hng bi m.

4.2. Cch s dng bnh ht bt kh

S dng cho tr 6 tui v hp tc
Kim tra xem lc ht vo c lc khng trc khi s dng phng php ny
bng mt dng c c bit. Khi tr ngm dng c ny vo ming v ht tht mnh
vo, nu lc ta s nghe ting ku nh ting ci.
Nu tr lc ht vo, ta bt u tin hnh k thut ny:
+ M np y dng c
+ Xoay np iu chnh qua ht bn phi sau xoay ngc qua tri cho n khi
nghe ting clic: thuc vo ng v tr (v d: Symbicort)
+ Gii thch v hng dn cch th cho tr
+ Chun b t th tr: tr ngi, c hi nga ra sau, mt hng v pha trc
+ t phn ng ngm ca dng c phun vo gia hai mi tr
+ Tr ht chm v su vi thi gian t nht l 6 giy
+ Sau nn th 10 giy v th ra
+ ng np y dng c li.

TI LIU THAM KHO

1. Bch Vn Cam v cng s, 1999. Phun kh dung, th thut cp cu nhi - bnh vin Nhi
ng 1, tr 25-26.
2. European Respiratory Society Guidelines on the use of nebulizers. Eur Respir J 2001; 18:
228242
3. Laberge S., M. Gauthier, G.Lapierre, G.R.Girouard, 1994, Etat de malasthmatique,
Urgences et Soins intensifs pediatriques, Les Presses de IUniversit de Montreal, pp 427-
446.
4. Lenoir G., 1996, Pharmacologie pendiatrique, Prcis de pediatrie, Payot Lausanne, pp
1479 -1505.
5. Salomon M.E., 1977, Use of Metered Dose Inhalers, Spacers and Nebulizers, Textbook of
Pediatric Emergency Procedures, Williams & Wilkins, pp 847 862.

168
 BNG KIM

0 im: Khng thc hin 2 im: Gn y : trn 50%

1 im: Khng y : di 50% 3 im: Thc hin k, thao tc ng, y

K NNG PHUN KH DUNG VI OXY

STT CC BC TIN HNH 0 1 2 3

1 Gii thch cho b m/bnh nhn trc khi phun

2 Dng ng tim ly thuc ng liu

3 Pha thm lng nc mui sinh l va .

4 Bm thuc vo bu phun.

5 Gn mt n ng c vo bu phun.

6 Ni dy vi bu phun v ngun oxy

7 Chun b ng t th cho bnh nhn.

Gii thch v hng dn cch th trc khi p mt n
8
vo mi ming bnh nhn.
9 iu chnh ng liu oxy cn dng.
G nh vo thnh bu phun m bo thuc trn
10
thnh ri xung ht.
Tng im

K NNG PHUN KH DUNG VI MY PHUN

STT CC BC TIN HNH 0 1 2 3

1 Gii thch cho b m/bnh nhn trc khi phun.

2 Dng ng tim ly thuc ng liu

3 Pha thm lng nc mui sinh l va .

4 Bm thuc vo bu phun.

5 Gn mt n ng c bnh nhn vo bu phun.

6 Ni dy vi bu phun v my phun.

7 Chun b ng t th cho bnh nhn.

Gii thch v hng dn cch th trc khi p mt n
8
vo mi ming bnh nhn.
9 M my phun
G nh vo thnh bu phun m bo thuc trn
10
thnh ri xung ht.
Tng im

169
K NNG PHUN KH DUNG VI LIU NH CHUN KHNG BUNG M

STT CC BC TIN HNH 0 1 2 3

1 Gii thch cho b m (hoc bnh nhn)

2 Kim tra dng c phun

3 Gn chai thuc vo dng c phun

4 Cm dng c phun ng t th

5 Lc k chai thuc trc khi phun

6 Hng dn t th v cch th cho bnh nhn

7 t phn ming ca dng c phun vo ng v tr

Xt thuc vo ming v yu cu bnh nhn ht vo
8
bng ming
9 Yu cu bnh nhn nhn th trong 10 giy

10 Bnh nhn ht th bnh thng tr li

11 Lau kh phn ming ca dng c phun v y np li

10 Nu phun vi Corticoides, bo bnh nhn sc ming

Tng im

K THUT PHUN KH DUNG VI LIU NH CHUN C BUNG M (C

H TR CA THN NHN)

STT CC BC TIN HNH 0 1 2 3

1 Gii thch cho b m hoc cho tr trc khi phun

2 Kim tra dng c phun

3 Gn chai thuc vo dng c phun

4 Lc k chai thuc trc khi phun

5 Gn dng c phun vo bung m

6 Hng dn cch th cho tr

7 t phn ming ca bung m vo ng v tr

8 Xt thuc vo bung m

9 V sinh phn ming ca bung m

10 Nu phun vi Corticoides, bo bnh nhn sc ming

Tng im

170
K NNG PHUN KH DUNG VI LIU NH CHUN C BUNG M V
MT N (C H TR CA THN NHN)

STT CC BC TIN HNH 0 1 2 3

1 Gii thch cho b m trc khi phun.

2 Kim tra dng c phun

3 Gn chai thuc vo dng c phun

4 Lc k chai thuc trc khi phun

5 Gn dng c phun vo bung m

6 Hng dn b m b tr ng t th

7 Gii thch v hng dn b m cch xt thuc

8 V sinh mt n v ming tr

Tng im

K NNG PHUN KH DUNG VI DNG C HT BT KH

STT CC BC TIN HNH 0 1 2 3

1 Kim tra lc ht ca bnh nhn bng dng c c bit

2 M np y dng c

3 Xoay np iu chnh thuc vo ng v tr

4 Gii thch v hng dn cch th cho bnh nhn

5 Chun b ng t th cho bnh nhn

Hng dn cch t ng ngm ca dng c phun
6
vo ming bnh nhn
7 Quan st bnh nhn ht thuc bng ming

8 V sinh phn ngm ca dng c phun

9 Nu phun vi Corticoides, bo bnh nhn sc ming

Tng im

171
 Bi 16
PHN TCH PHIM X-QUANG NGC THNG

MC TIU
1. Bit c qui trnh c bn chun b bnh nhn khi chp X-quang ngc thng.
2. Nm r tiu chun phim X-quang ngc thng.
3. Nm r cc qui c mu v qui tc xc nh bn.
4. Nm r qui tc c phim X-quang ngc thng
5. Nhn din c mt s du hiu bt thng trong phim X-quang ngc thng.

I TNG, A IM, PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht
+ Gii thiu mc tiu bi ging: 05 pht
+ Trnh by ni dung bi ging: 90 pht
+ Thc hnh c X-quang ngc thng mu: 50 pht
+ Ging vin gii p thc mc v tng kt cui bui: 35 pht

NI DUNG
1. I CNG
Chp X-quang ngc thng l mt k thut chn on
hnh nh khng xm ln c s dng kh ph bin ngy nay
ti cc c s y t nhm kho st mt s hnh nh ca lng
ngc v cc c quan nm bn trong lng ngc. Bng cch
chiu mt chm tia X i xuyn qua thnh ngc trong 1 khong
thi gian rt ngn v thu nhn li tnh hiu pht ra sau khi i
qua c th vo mt tm cassette hoc di hnh thc chp k
thut s ti to li nhng cu trc ca lng ngc.

1.1. Qui trnh chun b bnh nhn khi chp X-quang

ngc thng
c c hnh nh chp X-quang ngc t tiu chun,
ngi bnh c hng dn b ht ton b nhng trang sc Hnh 16.1. T th chp
ang eo trn ngi (dy chuyn, bng tai,), khng em sau trc - PA
theo cc vt dng khc (mt knh, in thoi, cha kha, hp qut, ) v s c yu cu
thay o ang bn bng o khoc khng cc trnh nhng hnh nh khng mong mun c
trn o nh hng n cht lng hnh.
Bnh nhn c hng dn ng p ngc vo bng phim, hai tay chng hng, p vai
st nhm mc ch tch ri hnh nh hai xng b vai ra khi hai ph trng trn phim.
u n chp X-quang s c t sau lng bnh nhn vi khong cnh 6 feet (# 1m8) v
pht chm tia nh v khung hnh nhm mc ch ly hnh nh ca lng ngc (t th

172
sau trc - PA). Trung tm tia c xc nh b trn t sng ngc th 4 trong trng
hp chp phi hoc b trn t sng ngc th 6 trong trng hp chp tim v ng mch
ch. Tia trung tm lun thng gc vi mt phim.
Bnh nhn c yu cu ht vo tht su v nn th trong vi giy k thut vin
X-quang tin hnh pht tia X nhm thu li hnh nh. Cn nh du ngay v tr tri/phi
gc phim tng ng vi bn ca bnh nhn trnh tnh trng ln bn khi ra.
Trong mt s trng hp bnh nhn khng th ti phng chp X-quang nh khng
th ng c, chn thng, hn m, th my; c th chp phim X-quang ngc ti ging
vi bng phim c t sau lng (t th trc sau - AP). T th bnh nhn nm nga, 2
khuu tay c gp li v t trn hai hng vi lng bn tay xoay ra ngoi, on k cao 2
khuu tay y xng b vai ra khi lng ngc trn phim. Tia trung tm xuyn qua gc
c v thng gc vi mt phim khi chp phi hoc ngay gia xng c khi chp tim. Nu
c c th quay u ging ln cao (t th semi Fowler) vi mc ch lm cho c honh
h thp xung.

Hnh 16.2. T th chp trc sau - AP

Vi cc bnh nhn ang mang thai, cn thng bo cho nhn vin y t trc khi bc
vo phng chp X-quang. Nu vic chp X-quang l cn thit, ngi bnh s c khot
o c lp ch phn bng - chu hn ch ti a s nh hng ca tia X ti thai.

1.2. Ch nh chp X-quang ngc thng

Nhng du hiu v h hp: ho, kh th, chn thng ngc
Nhng du hiu v tim: au ngc, au thnh ngc
Khc: st, xc nh cc thit b, dng c xm ln c t vo ngi (my to
nhp, khung nng thnh ngc, van tim, sau t CVP,...)
nh gi trc phu thut

2. TIU CHUN PHIM X-QUANG NGC THNG

Kim tra xoay (Rotation): 2 xng n phi xo i xng nhau qua ng
thng gia xng c, 2 khp c n phi ngang bng nhau

173
 Phim c chp th ht vo ti a (Inspiration). nh vm honh (P) mc lin
sn 10 pha sau hoc lin sn 5 7 pha trc.
xuyn thu (Penetration) (cht lng tia): thy c hnh nh ct sng ngc
t mc D4 tr ln v cc mch mu sau tim. Nu phim khng thy c ct sng
ngc l do tia cha cng (tia mm) s lm m hnh nh, y phi hai bn
khng r. Nu ct sng ngc thy qua mc D4 tr xung l do tia c cng
qu mnh (tia cng) s lm tng sng ca phi v mch mu d gy c nhm.
Gc chp phim (angulation): v tr xng n khng c vt qu cung sau ca
xng sn s 3.

Hnh 16.3. S khc nhau gia mc ht vo khi chp X-quang ngc thng

3. QUI C MU TRONG PHIM X-QUANG

Ty theo tng c quan, b phn trong c th hp th khc nhau vi tia X, nn trn
phim X-quang sau khi chp s biu hin theo gam mu xm (thay i t trng sng ti en
hon ton).

Hnh 16.4. Qui c mu trong phim X-quang

4. CC BC C PHIM X-QUANG NGC THNG

ng trc mt tnh hung phi c phim X-quang ngc thng, lc no chng ta
cng gp phi vn l nn c ci g v ci g nn c trc. to thun li trong qui
tc c v d nh, cn tun th theo nguyn tc bng ch ci A, B, C, D, E, F, G, H, I.
Mt nguyn tc cn phi nh l phim X-quang ngc thng l hnh nh hai chiu (2D)
c ghi li t hnh nh thc ba chiu (3D) nn khi nim trc sau s khng c gi tr
trn phim X-quang. t phim ln bng c phim sao cho bn phi (P) ca ngi c l bn
tri (T) ca phim, tng ng vi bn tri (T) ca bnh nhn.

174
 Khi c X-quang ngc thng, chng ta cn tun th 14 bc nh sau:

A=Airway (ng th)

B=Bone (xng)
C=Cardiac silhouette (bng tim)
D=Diaphragm (c honh)
E=Edge of the heart (vin quanh tim)
F=Field of lung (vng phi)
G=Gastric bubble (bng hi d dy)
H=Hilum of lung (rn phi)

Hnh 16.5. Cc vng trn phim X-quang ngc thng

4.1. Bc 1: Lun kim tra thng tin ngi bnh trn phim X-quang
Tn
Tui
Gii tnh
Nu nh trong trng hp hai phim c cng ba thng s trng nh trn, nn kim tra
thm thng s nh danh (ID) hoc m s h s bnh n (nu c ghi nhn trn phim X-
quang). Nu vn khng c cc thng tin nh vy, cn qua bc th 2.
4.2. Bc 2: Xc nh ngy chp phim X-quang
Nu bnh nhn c chp nhiu phim X-quang ngc thng vo nhng thi im khc
nhau trong mt t iu tr bnh, khi c phim cn phi so sch s khc nhau (nh gi din
tin) theo thi gian nhm gip tin lng v a ra hng iu tr thch hp tip theo.

4.3. Bc 3: Xc nh phim c chp t th sau trc (PA) hay trc sau (AP).
Phim (PA) thng c thc hin ti phng chp X-quang t th bnh nhn ng.
Phim (AP) thng c thc hin ti ging (phng bnh, phng cp cu, phng ICU) khi
bnh nhn khng th ng m phi chp t th nm, hay tr nh. Cc du hiu gip nhn
din phim AP hay PA. (bng ). Tuy nhin, khng phi lc no phim X-quang cng m bo
cc du hiu gip cho vic xc nh kiu chp, c th hi thm bnh nhn v ln chp .

Bng 16.1. Du chng phn bit t th AP hay PA

Du hiu T th chp sau - trc (PA) T th chp trc sau (AP)
Xng b vai Thng tch ra khi 2 ph trng Thng t tch ra khi 2 ph trng
Bng hi d dy Thng c Thng khng c
Khe gian t sng c Thng to hnh du ^ Thng to hnh du hay -

4.4. Bc 4: Xc nh pha, bn ca bnh nhn trn phim X-quang ngc thng

Thng thng, khi chp phim X-quang ngc thng, KTV s phi ghi k hiu trn
phim (du chng ch quan) nhm trnh sai st (c s thay i khi chp AP v PA). P,
F, R l cc k hiu ghi nhn bn phi; T, L l cc k hiu ghi nhn bn tri.

175
 i khi trong mt s trng hp trn phim X-quang ngc thng khng c cc du
chng ch quan nh trn, chng ta cn phi da vo mt s du chng khch quan nh:

Bng 16.2. Du chng phn bit bn T hay P

Du hiu Bn phi (P) Bn tri (T)
Mm tim lch Khng C
Bng hi d dy Khng C
Vm honh Cao hn Thp hn

Tuy nhin, trong mt s bnh l nhng du chng khch quan trn c th s b sai
lch hoc khng c. Nu trong trng hp khng th xc nh chnh xc pha, bn trn
phim X-quang ngc thng, tt nht nn tin hnh chp li phim khc.

4.5. Bc 5: nh gi cht lng phim X-quang ngc thng da vo ba thng s (R.I.P):

xoay ca hnh trn phim X-quang (Rotation)
Mc ht (Inspiration)
Lng tia pht (Penetration)
Nh vy, nm bc u tin l qui tc cn v quyt nh xem phim X-quang
ngc ny c c c khng? Nu mt trong nm bc trn khng m bo, nn yu cu
c chp li phim khc.

4.6. Bc 6: ng th (A: Airway)

ng th bao gm: kh qun, gc Carina v hai nhnh ph qun (P) v (T)
Kh qun: nm gia, thng v thnh song song. Nu ghi nhn kh qun b lch qua
1 bn, khng thng hoc mt tnh song song cn tm kim nguyn nhn:
+ y: tuyn gip to, tuyn c to, trn kh mng phi p lc, trn dch mng
phi,
+ Ko: xp phi, so co rt,
Gc Carina: bnh thng 60 -100
+ Tng: ln nh (T), ph i hch trung tht (hch gc Carina),
+ Gim: Xp thy trn phi (T),
Hai nhnh ph qun: thng bn (P) s di hn (T), (P) s dc hn (T).

Hnh 16.6. Hnh nh ng th trn phim X-quang ngc thng

176
4.7. Bc 7: Xng (B: Bone)
Bao gm: xng sn, xng n, xng b vai, xng c (s khng thy c trn
phim X-quang ngc thng), xng ct sng (KHNG C). Kim tra xem c tnh trng
nt, gy, di lnh, chng xng, Khi nim nt, gy xng l khi hnh nh xng mt
tnh lin tc trn phim X-quang (ch phn bit vi cc khp ni gia 2 u xng). Nhn
tng th xem khung xng lng ngc c cn xng khng? Hnh dng xng b vai? Vin
xng cn lin tc? Mt xng? (long xng thng mt khong s gim, vin
xng mng)? Vi ha xng? (cc im sng trn xng)? Khe khp?

4.8. Bc 8: Bng tim (C: Cardiac silhouette)

T l bng tim / lng ngc
+ ng knh tim ln nht: khong cch
c tnh t ni xa nht ca bng tim v
hai pha
+ ng knh lng ngc ln nht: khong
cch c tnh t ni xa nht ca lng
ngc v hai pha (ly theo mng phi
thnh)
+ Nu t l < 0,5: bng tim bnh thng
+ Nu t l 0,5: bng tim to (ch xc
Hnh 16.7. T l bng tim/lng ngc
nh khi phim c chp t th PA)
Hnh dng bng tim
+ Hnh chai nc (water bottle): trong bnh l c tim ph i hoc trn dch
mng tim

Hnh 16.8. Bng tim hnh chai nc (Water bottle)

+ Shmoo hay hnh ln tht (T)
+ Hnh git nc hay dui thng (straightening) bnh thp tim, hp van 2 l.

Hnh 16.9. Bng tim hnh git nc

177
 Cc vin bng tim

1. Thn ng mch cnh tay

u phi
2 - 4. Tnh mch ch trn
3. Tnh mch n Azygous
5. Nh phi
6. Tnh mch ch di
7. ng mch di n tri
8. Cung ng mch ch
9. ng mch phi chnh
10. Tiu nh tri
11. Tht tri
12. M quanh tim

Hnh 16.10. Cc vin bng tim

4.9. Bc 9: C honh (D: Diaphragms)

nh gi xem c honh phng cao hay dt. Thng c honh dt trong kh ph
thng, phng cao trong vim phi, lm kh phn nh c thy di ca phi vi vng
bng. Kim tra gc sn honh (gc to bi chn c honh vi thnh ngc) coi cn nhn
khng? Nu bt u mt nhn v cao dn ti nh vm honh (kh nng trn dch mng
phi t 300 500ml) gi l du hiu Meniscus (meniscus sign).

Hnh 16.11. Meniscus sign (trong trn dch mng phi)

4.10. Bc 10: Vin quanh tim v m mm xung quanh (E: Edges of heart; External soft
tissues)
nh ngha: Mt bng m trong lng ngc c m dch, tip xc v mt gii phu
vi b ca cc cu trc c m dch trong lng ngc (tim, ng mch ch, vm honh)
s xa b tip xc vi nhau. Ngc li, nu khng tip xc v mt gii phu th b ca cc
cu trc vn hin r trn phim cho d c chng lp ln nhau.
Khi c hin tng xa b ta gi l Silhouette sign (+)
Khi khng xa b ta gi l Silhouette sign (-)
y l du hiu c bn v quan trng nht trong X-quang lng ngc qui c.

178
 Hnh 16.12. (A) Du Silhouette sign (-); (B) Silhouette sign (+)

Ch vin bng tim xem c lp kh vin quanh, nu c th y l du chng ca trn

kh trung tht. Hoc vng m mm quanh thnh ngc v vng c xem c lp kh xen ln
trong m mm khng? Nu c l du chng ca trn kh di da.

Hnh 16.13. Trn kh di da vng c (mi tn en); trn kh trung tht (mi tn trng)

4.11. Bc 11: Nhu m phi (F: Fields of the lungs)

Kim tra mng phi pht hin cc trng hp dy dnh mng phi, trn kh
mng phi.
Khi nim: dy mng phi hay trn kh mng phi l tnh trng tch 2 l mng phi
ra vi nhau to thnh khoang mng phi thc s.
Nu dy mng phi, mng phi tng tch ri mng phi thnh, gia hai lp mng
phi l lp dch dy dnh (mu, m, dch vim) s c hnh nh trng, s khng
thy vin en ca phi (mng phi tng) p st vo thnh ngc (mng phi thnh).

179
 Hnh 16.14. Dy dnh mng phi
- Nu trn kh mng phi, gia hai lp mng phi s l lp kh v c hnh nh
en ng nht. Vin ranh gii gia mu en ng nht (kh t do) vi en c
nhng di x xm (nhu m phi, mch mu trong phi) chnh l mng phi
tng. Ty theo lng kh trong khoang mng phi m s phn loi trn kh
mng phi lng t nhiu.

Hnh 16.15. Trn kh mng phi (P) (c s thay i thang mu hai bn ng k)

Kim tra nhu m phi, ch phi kim tra i xng hai bn phi, cc mch mu
trong nhu m phi (bnh thng t phn b ra ti 1/3 ngoi ca ph trng), s hin din
ca cc khi chong ch (khi u, khi p-xe, bng kh,).

*
* * *
* *
* +*
+

Hnh 16.16. Bng kh nh phi Hnh 16.17. Khi p-xe phi vi mc nc

(+) hi (*)

180
 *

Hnh 16.18. Khi u cnh rn phi (T)

4.12. Bc 12: Bng hi d dy (G: Gastric bubble)

Thng xut hin di vm honh (T), t th chp PA, do hi trong d dy tp trung
phn cao (tm v). Trong trng hp chng d dy c th thy c bng hi d dy
trong t th chp nm (AP) hoc nu d dy xp, c t sonde d dy s khng c hnh nh
bng hi d dy ngay c t th chp ng (PA).
Cn phn bit gia bng hi d dy v cc bng hi khc (hi i trng, hi t do
trong bng).
Bng hi i trng s c hnh nh hnh ng theo cu trc lng i trng nm
ngang hoc cu trc gp gc (i trng gc lch).
Hi t do trong bng (lim hi di honh) s thy ch yu di vm honh
(P). Lp kh ny s mng, tri di theo vm honh v nm st vo vm honh (to
nn hnh nh li lim). Khi c hi t do trong bng cn ngh ti cc nguyn
nhn sau: (1) thng ng tiu ha (thng d dy, thng rut non, thng i trng);
(2) vt thng thu bng (thng da) lm khng kh t mi trng ngoi trn vo
bng (do thng, do phu thut vng bng); (3) vim nhim phn ph (khng
kh thng thng vo bng thng qua tai vi vi trng t cung m o).

* *
*
* *
*

Hnh 16.19. Lim hi di honh (*)

4.13. Bc 13: Rn phi (H: Hila)

Kim tra c hch hoc khi chong ch vng rn phi khng? Thng vng rn phi
(T) cao hn (P) l mt m trng (mch mu) vng ra bng tim hai bn trn cc ra ca
cc bung tim. Nu thy khi trng (c calci ha) rn phi cn ngh ti hch lympho ph
i thng thy trong lao phi c hay hch ung th.

181
 Hnh 16.20. Hch rn phi (T) ph i

4.14. Bc 14: Cc cu trc bt thng (I: Instrumentations) ngoi c th: ng ni kh

qun, sonde d dy, dy in cc in cc, ng dn lu, dng c t vo c th (ch thp,
van tim, stent ng mch, khung nng ngc, my to nhp tim,).

Hnh 16.21. Cc cu trc bt thng ngoi c th

182
 Bi 17
K NNG PHNG M C BN

MC TIU BI GING
1. Nu ng cc thi im phi ra tay.
2. Thc hin ng quy trnh ra tay thng quy.
3. Thc hin ng quy trnh ra tay phu thut.
4. Thc hin ng quy trnh mc o phu thut.
5. Thc hin ng quy trnh mang gng phu thut.

I TNG - A IM - PHN B THI GIAN

i tng: sinh vin Y2 YLT2
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 90 pht
+ Gii thiu mc tiu bi ging: 01 pht
+ Gii thiu ni dung bi ging: 20 pht
+ Ging vin hng dn trn m hnh, clip: 20 pht
+ Sinh vin thc hnh: 30 pht
+ Chn 02 sinh vin thc hnh, nhm cn li quan st v nh gi: 15 pht
+ Ging vin tng kt cui bui: 4 pht

NI DUNG
1. RA TAY
1.1. Ra tay thng quy
Theo T chc Y t th gii, ra tay c coi l liu vaccine t ch, rt n gin, d
thc hin, hiu qu v chi ph cng nh c th cu sng hng triu ngi. Theo nhiu bo
co ca cc chuyn gia kim sot nhim khun trong v ngoi nc th cc bnh truyn
nhim v ang din ra trong cng ng hon ton c th phng nga c bng cch
gi gn v sinh, trong c ra tay bng x phng. Theo , ch mt ng tc ra tay sch
lm gim ti 35% kh nng ly truyn vi khun gy bnh tiu chy lm t vong hng
triu ngi mi nm trn th gii.
Trong qu trnh chm sc v iu tr, i bn tay ca nhn vin y t rt d b nhim
bn vi cc tc nhn gy bnh. Mc nhim ph thuc vo loi thao tc v thi gian
thc hin thao tc trn ngi bnh. V d: sau cc thao tc nh xoay tr ngi bnh, bt
mch, o huyt p, ly nhit c th, ng chm vo vai, bn ngi bnh th trn i tay
s c 100 1.000 khun lc Klebsiella spp. Sau cc hot ng nh tim, truyn tnh mch,
chm sc ng th, sau khi tip xc vi cc cht bi tit ca ngi bnh, trn i tay s
c 300 n v khun lc.

183
 Trn da tay c c hai loi vi khun: vi khun thng tr v vi khun vng lai. Cc vi
khun thng tr c c tnh thp, t khi gy nhim trng qua cc tip xc thng thng,
song chng c th gy c tnh qua cc th thut xm ln vo ngi bnh. Cc vi khun
vng lai l nhng tc nhn gy nhim trng bnh vin ph bin, thng tn ti trn da
khng qu 28 ting. Chng khng c kh nng nhn ln trn da v d b loi b bng ra
tay vi nc v x phng.

Hnh 17.1. Cc thi im ra tay (Ngun: T chc Y T th gii - 2006)

1.2. Quy trnh ra tay thng quy vi nc v x phng

Hnh 17.2. Cc bc ra tay thng quy (Ngun: B Y t - 2010)

184
 Trong trng hp khng c nc v x phng, chng ta c th ra tay thng quy
bng cn 70 hoc dung dch ra tay nhanh, cc bc thc hin tng t nh ra tay vi
nc v x phng, cui bc 6 tay t kh hoc tip tc ch n khi tay kh, khng dng
khn lau tay. Ch : khng p dng phng php ny trong trng hp bit chc chn
hoc nhn thy vt bn trn tay nh: tay dnh mu, dch tit,...

1.3. Ra tay ngoi khoa

Ra tay, mc o chong v mang gng (gant) v khun l ba cng vic bt buc m
nhn vin trong phng m (bc s gy m, phu thut vin, iu dng dng c) phi thc
hin trc khi lm cc th thut gy m hi sc (t ty sng, t ngoi mng cng, t
catheter), cc th thut, phu thut ngoi khoa.
1.3.1. Mc ch ra tay ngoi khoa
Vic chi ra khng lm cho tay tr nn v trng, nhng n lm gim s lng vi
khun trn da tay n mc ti thiu, gip hn ch nguy c nhim trng cho th thut,
phu thut.
1.3.2. Chun b dng c - phng tin
H thng nc sch (tt nht l nc un chn hoc nc c kh khun),
m (v ma ng), mt (v ma h), c vi dn nc n ni c thc hin
vic ra tay.
Nc x phng chn (nn trong hp c vi dn x phng ra) hoc dung dch
ra tay tit khun.

Mi bc thc hin 5 ln
Tng thi gian ti thiu 30 giy

Bc 1: Lm t hai lng bn tay bng nc. Ly x phng v ch hai lng bn tay vo nhau.
Bc 2: Ch lng bn tay ny ln mu v k ngoi cc ngn tay ca bn tay kia v
ngc li.
Bc 3: Ch hai lng bn tay vo nhau, mit mnh cc k trong ngn tay.
Bc 4: Ch mt ngoi cc ngn tay ca bn tay ny vo lng bn tay kia.
Bc 5: Dng bn tay ny xoay ngn ci ca bn tay kia v ngc li.
Bc 6: Xoay cc u ngn tay ny vo lng bn tay kia v ngc li.
Ra sch tay n c tay di vi nc chy v lau kh tay.

Bn chi lng mm c hp kh trng ch tay

Hp ng khn tay v khun.
1.3.3. K thut ra tay v khun
Chi ra tay phi ng k thut. Hin nay da vo nguyn tc v qui nh chung v
ra tay ngoi khoa, tt c cc bnh vin u thit lp c quy trnh chi ra tay ring ca
mi bnh vin. Tt c cc quy trnh u ging nhau mt im: chi ra tay ti thiu 5
pht trc ca phu thut u tin v 3 pht cho cc ca phu thut tip theo.

185
 Chun b trc khi ra tay
+ Ci b trang sc trn tay (nhn, ng h, vng eo tay)
+ Ci b trang phc i ngoi, mc qun o git hp kh trng ca phng m
+ i m (tc khng th khi m), eo khu trang (che kn ming v hai l mi)
+ Vn tay o ln qu np khuu tay 10-15cm bc l r vng tay nh ra
+ Kim tra cc mng tay: ct mng tay nu mng di. Mng tay di l ngun ly
nhim, ng thi c th lm rch gng khi mang gng v tin hnh phu thut.
+ Kim tra cc tn thng da tay (cc vt xc, try xt hay nhim trng ngoi
da). Ngi c tn thng tay khng nn tin hnh cuc phu thut.
Tin hnh ra tay
+ Kim tra nc: m cn gt nc bng khuu tay hoc bng chn. Tuyt i
khng dng i bn tay m vi nc trong qu trnh ra. Nu cha kim tra
nhit ca nc trc th phi iu chnh nhit ca nc thch hp (tt
nht l c h thng iu chnh nng lnh).
+ Thc hin k thut ra tay: 2 bc
+ Bc 1: ra tay thng quy n qua khuu tay nhng khng lau kh tay.
+ Bc 2: ly x phng chn hoc dung dch tit khun b vo bn chi ch
ra tay. Thao tc thc hin ti thiu 5 pht.

- K thut ch tay: theo dng xon c, lun phi tin hnh song song 2 bn theo
trnh t sau:
+ Ch mng tay, k mng tay.
+ Ch k gia cc ngn tay.
+ Ch lng bn tay.
+ Ch mu bn tay.
+ Ch mt trong cng tay v ln pha trn khuu tay 5-10cm.
+ Ch mt ngoi cng tay v ln pha trn khuu tay 5-10cm.
- B bn chi s dng vo khay ng bn chi bn.
- X nc ra ht x phng v cht bn trn tay.
- Lu : hai bn tay lun hng ln trn, gi cao hn tm ngc nc chy theo
chiu t pha trn ngn tay xung pha di khuu tay.

Sau khi ra tay hai ln xong th dng khuu tay hoc chn ng vi nc. Ngy
nay, hu ht cc phng m u trang b h thng cm ng nn chng ta khng
phi tt vi nc.

186
 Hnh 17.3. Cc thao tc ca ra tay v khun

Dng khn v khun lau kh tay theo th t:

+ u cc ngn tay
+ Cc k ngn tay
+ Lng bn tay
+ Mu tay
+ C tay
+ Cng khuu tay
B khn lau tay vo khay ng khn bn.
1.3.4. K thut chi ra tay c mt s iu cn lu
Chi ra tay ti thiu 5 pht
Sau khi thoa x phng, chi ra tt c cc mt ca ngn tay cng nh ca bn tay,
cng tay v khuu tay, theo hng t ngn tay ln khuu tay
Ra tay di vi nc ang chy, dng cnh tay ln sao cho dng nc chy
xung khuu tay
Kho vi nc bng khuu tay
Lau kh tay vi khn v khun
Hai bn tay lun hng ln trn, gi cao hn tm ngc.

2. MC O CHONG V KHUN
2.1. Mc ch ca mc o v khun
Ngn nga vi khun t nhn vin ly vo vng th thut, phu thut v ngc li.
2.2. Chun b dng c phng tin
o chong v khun c gp ng quy cch: mt ngoi vo trong, mt trong ra
ngoi, ng trong hp v khun c hp.
Kp kocher c mu v khun (Kim tip liu).
2.3. K thut mc o chong v khun
Ngi ph m hp o hp (theo nguyn tc v khun)
Kp kocher v khun ly o t trong hp a cho ngi mc
Ngi mc n ly o chong bng cch cm ly b vai pha trong (mt tri) ca
o bung nh xung. (Khu vc ngi mt ng phi c mt khong trng khi
bung o v mc th o khng b va qut vo cc vt xung quanh).

187
 Hai tay lun vo hai tay o v a thng ra pha trc.
Ngi ph ng sau (cch nhn vin 0,5m) lun tay vo mt trong ca o ko dy
c o ln v buc li. Lu : trong qu trnh ph mc o, ngi ph khng c
chm vo tay ngi mc cng nh mt ngoi ca o.
Ngi mc cm hai u dy khu trang (khu trang lin o) ln ngang tai v ra
ngang (hai tay a ngang b vai, khng a tay ra qu pha sau lng hoc tay cn
pha trc ngi). Ngi ph n ly on dy pha trong vng ln pha trn tai
nhn vin v buc li pha sau u.
Ngi mc cm ly hai u dy lng o v a ra ngang. Ngi ph n ly on
dy pha trong, vng qua ngi nhn vin v buc li pha sau lng.

Hnh 17.4. Cc thao tc mc o chong v khun

2.4. K thut ci o chong

c thc hin sau khi ci
gng tay.
Ngi ph tho nt buc o
pha sau lng.
Ngi mc ci o: tay phi nm
ly vai o bn tri ko o ra.
Tng t tay tri nm ly vai
o bn phi ko o ra.
Cun o mt ngoi vo trong.
B o vo ng ni quy nh.

Hnh 17.5. Cc thao tc ci o chong

188
3. MANG GNG
C hai loi gng l gng thng (gng sch) v gng v khun. Mang gng thng
trong nhng trng hp phng trnh tip xc trc tip vi cc cht d, cht ly nhim nh
mu, dch tit, dng c y t s dng Trong phm vi bi ny s cp n vic mang
gng v khun.

3.1. Mc ch mang gng v khun

trnh a vi khun vo c th ngi bnh v ngc li thng qua i bn tay ca
nhn vin khi lm th thut, phu thut.

3.2. Chun b dng c phng tin

Gng tay v khun
Kp kocher khng mu v khun (kim tip liu).

3.3. K thut mang gng: c hai cch mang gng v khun

Cch 1: c ngi ph
+ Ngi ph sau khi ra tay, mc o, i gng v khun th ly gng t hp ng
+ Dng hai tay m rng c gng (khng c chm vo mt tri gng)
+ Nhn vin a tay vo gng theo ng chiu ca gng
+ Sau khi mang c hai gng th t chnh gng (khng c chm vo mt
tri ca gng).

Hnh 17.6. Thao tc mc o chong, mang gng v khun c ngi ph

Cch 2: t mang gng

+ Ngi ph dng kp kocher v khun ly gng th nht a cho nhn vin.
+ Nhn vin n gng bng cch cm pha trn np gp ca gng (ch mt tri
gng) 1 tay gi np gp ca gng v m rng c gng. Cho tay kia vo trong
gng theo ng chiu ca gng.
+ Ngi ph a tip chic gng th hai.
+ Nhn vin n gng bng tay cha i gng. Dng 4 ngn tay (tr ngn ci) ca
tay i gng lun xung pha di np gp ( mt ngoi ca gng) m
rng c gng. Cho tay cn li theo ng chiu.

189
 + Chnh li gng (khng c chm vo mt tri ca gng) v dng gc v khun
lau sch bt tan mt ngoi gng.

Ly 1 gng bng Cho tay vo gng

ngn ci v ngn tr

Dng tay mang gng Cho tay cn li

lun vo c gng cn li vo gng

Chnh li c gng sao cho

Qu trnh hon thnh
trm ht c tay o

Hnh 17.7. Thao tc t mang gng v khun

3.4. K thut tho gng

Tho gng th nht: dng tay kia cm ly mt ngoi c gng ln nh ra ngoi.
Tho gng th hai: dng tay tho gng cm ly mt trong c gng ln nh ra ngoi.

190
 Hnh 17.8. Thao tc tho gng

TI LIU THAM KHO

1. Alfred Cuschieri (2003). Clinical Surgery, 2nd Edition, pp.34-35.
2. Gyrgy Wber (2008). Basic Surgical Techniques, pp.15-16.
3. L Hng (2009). Ngoi khoa thc hnh. Trng i Hc Y Khoa Phm Ngc Thch,
tr 10-15.
4. Nguyn Tn Cng (2008). iu dng ngoi 1. i hc Y Dc Tp.HCM, tr 15-17.

191
 BNG KIM

0 im: Khng thc hin 2 im: Gn y : trn 50%

1 im: Khng y : di 50% 3 im: Thc hin k, thao tc ng, y

STT NI DUNG 0 1 2 3

1 TRNH BY 5 THI IM RA TAY

THC HIN QUY TRNH RA TAY THNG QUY: 6

2
BC

CHUN B TRC RA TAY PHU THUT

Ci b trang sc.
Mc qun o git hp kh trng ca phng m.
3
i m, eo khu trang, vn tay o ln qu np khuu tay.
Ct ngn mng tay.
Kim tra cc tn thng da tay.

THC HIN RA TAY PHU THUT

4 Bc 1: ra tay thng quy, khng lau tay
Bc 2: 5 pht

5 THC HIN LAU TAY SAU RA TAY PHU THUT

6 THC HIN MC O CHONG PHU THUT

7 THC HIN MANG GNG PHU THUT

Tng cng: / 21 im

192
 Bi 18
CC MI KHU - CT CH PHU THUT C BN

MC TIU
1. Nm vng cc loi ch phu thut.
2. Nm vng cc loi kim phu thut.
3. Thc hin c k thut khu c bn.
4. Thc hin c cc ng tc ct ch c bn.

I TNG - A IM - PHN B THI GIAN

i tng: sinh vin Y2 YLT2.
a im: Trung tm hun luyn k nng lm sng Bnh vin m phng
Phn b thi gian: 180 pht.
+ Gii thiu mc tiu bi ging: 10 pht.
+ Gii thiu ni dung bi ging: 25 pht.
+ Ging vin khu mu 02 ln trn m hnh: 40 pht
+ Sinh vin thc hnh: 50 pht.
+ Chn 02 sinh vin khu, nhm cn li quan st v nh gi: 40 pht.
+ Ging vin tng kt cui bui: 15 pht.

NI DUNG
1. CH PHU THUT
1.1. nh ngha
Ch phu thut l vt liu dng khu ni vt m v buc tht mch mu trong
ngoi khoa

1.2. Phn loi

1.2.1. Phn loi theo tch cht tan - khng tan
Bng 18.1. Phn loi ch phu thut theo tnh tan
Phn loi Thnh phn Tn thng mi
Chromic catgut
T nhin Collagen tinh khit t thanh mc b, cu Chromic gut
CH TAN

Plain gut
Coated vicryl
Polyglacitin 910
Monocryl
Tng hp Polyglecaprone 25
Safil
Polydioxone
Monosyn
Merk silk
CH KHNG TAN

T nhin T si thin nhin Silk

Silk black
Prolen
Polyester
Prolen mesh
Polyamide
Tng hp Dafilon
Polypropylene
Premilene
Thp khng r
Nylon

193
1.2.2. Phn loi theo cu trc si ch

Hnh 18.1. Cu trc si ch

Ch n si (Monofilament): thnh ch trn lng, d dng khi i qua m, khng
gy xc - ct m
Ch a si (Multifilament): gm nhiu si bn vo nhau, c bn hn, n
hi tt hn, gip cc nt kha ch chc, trnh tt. Tuy nhin, d to rnh cho cc
vi trng bm vo si ch, d gy tn thng m

1.3. Thi gian tan v lc gi cc vt m ca cc loi ch tan

y l hai yu t quyt nh cht lng ca mt loi ch tan
Tan trung bnh: 60 90 ngy
Tan nhanh: 40 50 ngy
Tan chm: 120 ngy

Bng 18.2. Thi gian tan v lc gi m ca cc loi ch

LOI CH LC GI M TAN SI CH

75% (14 ngy)

56 - 70 ngy
VICRYL* PLUS 50% (21 ngy)
(trung bnh 63 ngy)
25% (28 ngy)

Chromic 21-28 ngy 90 ngy

Plain 7-10 ngy 70 ngy

70% (2 tun)
PDS 50% (4 tun) 180 - 210 ngy
25% (6 tun)

194
 Hnh 18.2. Thi gian tan si ch

1.4. n v o kch thc ca mt si ch

Tiu chun USP l tiu chun ca Hip hi Dc M (United States Pharmacopedia)
nm 1937, k hiu kch thc si ch, v d: 4-0 hoc 4/0 hoc 0000. S trc s 0 cng
ln, si ch cng nh, lc ko cng yu (si 5/0 s nh v yu hn si 4/0)
Bng 18.3. ln ca si ch gim dn

7 6 5 4 3 2 1 0 1/0 2/0 3/0 4/0 5/0 6/0 7/0 8/0 9/0 10/0 11/0

1.5. Ch nh cho tng loi ch phu thut

i t ngoi vo trong, ch phu thut c s dng nh sau:
+ Lp da: Khng tan
+ Lp di da: Ch tan
+ Lp cn c: Bt buc phi dng ch tan, kch thc ty theo vng
+ C quan, tng: Ch tan, kch thc ty vo c quan; i vi mch mu: th
thut tht ct th dng ch khng tan.
Cng nh bng keo, mi loi ch phu thut c sn xut nhm p ng cho mi
mc ch c th no cho tng mc tiu
+ Ch khu da: Silk, Nylon
+ Ch khu mch mu: Prolene
+ Ch thp (ch chu lc): dng trong phu thut chnh hnh xng.
2. KIM PHU THUT
2.1. Khi nim
Kim phu thut thng c lm bng thp khng r, chc, khng bng. Kim phi
cng khng b cong nhng cng phi c do khng b gy. Mi kim phi sc
nhn, c kch thc ph hp vi ch c th d dng a ch xuyn qua t chc v t gy
tn thng m.

195
2.2. Cu to kim
Cu to kim gm 3 phn: ui kim, thn kim, mi kim. Da vo cu to ca kim c
th c cc cch phn loi khc nhau.

Hnh 18.3. Cu to kim phu thut

2.2.1. ui kim
Trc y ui kim c 1 l nh hnh bu dc lun si ch qua, sau ngi ta ci
tin thnh dng kiu cht ci ging nm c (kim bt) thao tc lun kim d dng hn.
Hin nay c nhiu loi kim lin ch, ui kim c cu to hnh ng bp cht ly ch nn
khng cn thao tc xu ch. Hn na, loi kim lin ch khi xuyn qua t chc t gy tn
thng m hn do kch thc kim v ch l gn bng nhau. Kim dng 1 ln nn sc
nhn v bn cng hn cc loi kim c.

Hnh 18.4. Cu to ui kim

2.2.2. Thn kim

Ty tnh cht, v tr ca t chc cn khu m c th la chn kim c thn kim vi chiu
di, cong v ng knh ph hp.

Hnh 18.5. Hnh dng thn kim

196
2.2.3. Mi kim

Hnh 18.6. Cu to mi kim

Loi kim mi trn (dng khu cc t chc mm) v loi kim mi tam gic (dng
khu da) l hai loi thng c s dng nht. Ngoi ra, ngi ta cn ch to ra nhiu loi
mi kim c hnh dng v tit din ph hp vi cc mc ch c bit (vd: mi kim t
khu cc tng c, mi kim hnh thang trong phu thut mt )

Hnh 18.7. Cc hnh dng kim phu thut

3. BAO CH PHU THUT

Cc si ch c tit trng v ng sn trong gi, khi dng ch x ra. tit kim,
ngi ta thng ng trong 2 ln bao, nu x bao ngoi sn trn bn dng c, nu
khng dng th ln sau s dng

Hnh 18.8. Thng tin bao ch phu thut

197
4. K THUT KHU C BN TRONG NGOI KHOA
4.1. Khi nim
C nhiu phng php khu vt thng. Vic la chn phng php khu vt
thng ty vo cc yu t sau y:
Hnh dng ca vt thng
V tr gii phu ca vt thng
dy ca vt thng
Mc cng hai mp ca vt thng
Yu cu v thm m ca vt thng
Mc d c nhiu thay i trong k thut khu v cht liu ch khu, vic khu vt
thng cn t c cc yu cu sau:
ng kn cc khong cht
H tr vt thng cho n khi lnh vt thng chu mt lc cng c xu
hng lm h hai mp vt thng
Hai mp vt thng bng mt v p st nhau
Cm c mu v ngn c hin tng nhim trng

4.2. Phn loi vt thng

4.2.1. Phn loi theo m hc v gii phu
Vt thng nng: da b tn thng c th km theo mt phn m m di da
Vt thng su: da, m di da b tn thng, c th gp cc tn thng i km
nh: c, cn, gn, mch mu, thn kinh...
4.2.2. Phn loi vt thng d - sch
Vt thng sch: xy ra trong mi trng sch, c can thip ngoi khoa < 6 gi
Vt thng d: xy ra trong mi trng d, hoc nhng vt thng xy ra trong
mi trng sch nhng qu 6 gi cha c can thip ngoi khoa.
Vt thng nhim: khi vt thng c m, m hoi t...
4.2.3. Phn loi theo tn thng ti ch
Vt thng sc
Vt thng ng dp
Vt thng xuyn thu
Vt thng ha kh...

4.3. Cc mi khu c bn
Cc phng php khu vt thng chnh bao gm: khu mi n, khu mi Blair -
Dorati, khu mi ch U, khu mi ch V, khu trong da, khu di da, mi khu ln mp,
mi khu chu lc v mi khu vng.
4.3.1. Khu da
Mi n

198


Hnh 18.9. Mi n khu da

Mi Blair - Donati
L s chn la khi c s cng gia hai mp vt thng. Vi mi khu ny, hai mp
da bng mt hn. Tuy nhin mi khu ny tn nhiu thi gian hn cc mi khu khc.
Trnh t nh khu mi n; k thut nh hnh v, tin hnh theo chiu mi tn.
Mi ch U

Hnh 18.10. Mi Blair - Donati khu da

Mi khu ch U to lc h tr phn b u trn vt thng hn. Tuy nhin vi mi
khu m nm ngang, hai mp vt thng khng c xu hng p st nhau.

Hnh 18.11. Mi ch U khu da

ng dng duy nht ca mi khu ch U l dng khu vt thng gan. Mi khu
ch U c tc dng cm mu mt ct gan, khng x rch nhu m gan, ng thi m vt
thng ra b mt, trnh nguy c t dch trong nhu m gan sau m.

199
 Mi khu lin tc
+ Mi khu lin tc n gin: l mi khu khng b gin on, ch c 1 mi kha
khi u v 1 mi kha cui mi khu. Mi khu nhanh, to lc cng u dc
theo ng khu, nhng yu, d bung ng m khi t ch bt c v tr no.
Mi khu cn c ct ch sau 7 - 10 ngy.

Hnh 18.12. Mi khu lin tc n gin (Simple Continuous Sutures)

+ Mi khu lin tc c kha: l mi khu khng b gin on, ch c 1 mi kha
khi u v 1 mi kha cui mi khu, c mi nt tht h tr ti mi mi qua
da. Mi khu nhanh, cm mu mp da tt, gim c tnh trng bung ng
m khi b t ch bt c v tr no. Mi khu cn c ct ch sau 7 - 10 ngy.

Hnh 18.13. Mi khu lin tc c kha (Continuous Lock Sutures)

+ Mi khu lin tc m ngang

Hnh 18.14. Mi khu lin tc m ngang (Continuous Horizontal Mattress Sutures)

+ Mi khu cho lin tc: l mi khu khng b gin on, ch c 1 mi kha
khi u v 1 mi kha cui mi khu. Thng khu cho cc trng hp da
qu dy m mi lin tc thng thng kh chu lc tt. Lt khu u su,
khng sit cht, rng tng ng chiu dy da. Lt khu sau gn mp da vi
mc ch chnh mp da c u.

200
 Hnh 18.15. Mi khu cho lin tc (Cross Sutures)

Hnh 18.16. Mi khu lin tc di da

4.3.2. Mi khu di da
Mi khu ln mp v mi khu vng
+ c s dng nhiu trong khu ni ng tiu ha
+ Vi mi khu ny, thanh mc ng tiu ha c ln vo trong, trnh c
nguy c dnh rut sau m.

Hnh 18.17. Mi khu n di da

201
 Hnh 18.18. Mi khu ln mp Hnh 18.19. Mi khu vng

Mi khu chu lc
+ Ch dng khu mi chu lc tt nht l ch nylon hay ch thp.
+ Dng s dng khu ng cc thnh bng kh. l trng hp thnh bng
kh cng sau khi ng (BN bo ph, BN b vim ph qun mn hay hen suyn,
tnh trng tng p lc trong xoang bng) hay thnh bng kh c kh nng
lnh nhanh (BN ln tui, suy kit, suy gim min dch)
+ Mi khu ly ht c b dy ca thnh bng. Sau khi khu, khng xit cht cc
mi ch, tip tc khu ng thnh bng theo cch thc thng thng. Sau khi
kt thc khu ng lp da mi xit cc mi ch ca mi khu chu lc. Cc
u ch ca mi khu chu lc s lun qua mt ng ngn lm bng nha hay
cao su trc khi xit cht.
+ Mi khu chu lc c ct ch sau 2 4 tun.

Hnh 18.20. Mi khu chu lc

4.4. Thi im ct ch ca mi khu ty thuc vo hai yu t chnh

Kh nng chu lc ni ti ca vt thng, trung bnh mt vt thng s t 80%
chu lc sau 1 2 tun
Lc cng hai mp ca vt thng
Thi gian ct ch trung bnh ca vt thng vng mt l 5 7 ngy, vng c l
7 ngy, da du l 10 ngy, vng thn v chi trn l 8 10 ngy, chi di l 10 14 ngy.
Ct ch mun c th dn n nhim trng vt thng, hin tng biu m ha quanh
si ch lm cho so c hnh xng c.

202
5. CT CH
5.1. Ct ch bng dng c

1 2

Hnh 18.21. Ct ch bng dng c

5.2. Ct ch bng tay

Hnh 18.22. Ct ch bng tay (cch 1)

203


Hnh 18.23. Ct ch bng tay (cch 2

5.3. Mt s nguyn tc ch khi ct ch

Cc mi ct ch phi chc, trnh sit cng si ch qu mc khi ct c th lm
t ch
Cc mi ct ch phi gn, trnh to cc ln ch d tan, khng to phn ng m.
ui ch cha cng ngn cng tt
Trnh tnh trng ma st hay cn gi cn ch khi ct (thng do thao tc buc
ch sai, cho si ch khi buc)
Trnh lm xc si ch khi ct bng dng c (kim tra dng c gi ch, trnh sc
c th lm t hoc xc si ch)
Khng nn sit mi ch qu cht v c th lm thiu mu nui m.

TI LIU THAM KHO

1. D n y mnh hun luyn k nng tin lm sng ti 8 trng khoa Y Vit Nam. K nng
y khoa c bn. Nh xut bn Y hc TPHCM, 2009
2. Ti liu Hun luyn k nng dnh cho sinh vin. B mn Hun luyn k nng i hc Y
Dc Cn Th, 2011.
3. Ti liu Hun luyn k nng y khoa. B mn Hun luyn k nng i hc Y Dc TP. H
Ch Minh, 2005.

204
 BNG KIM

0 im: Khng thc hin. 2 im: Gn y : trn 50%.

1 im: Khng y : di 50%. 3 im: Thc hin k, thao tc ng, y .

STT NI DUNG 0 1 2 3

Mi khu c bn

1 ng kn cc khong cht

2 H tr vt thng cho n khi lnh vt thng

3 Hai mp vt thng bng mt v p st nhau

4 Cm c mu v ngn c hin tng nhim trng

Tng cng: / 12 im.

205


NH XUT BN Y HC
CHI NHNH THNH PH H CH MINH
a ch: 699 Trn Hng o P.1 Q.5 TP. H Ch Minh
in thoi: 08.39235648 Fax: 08.39230562
Email: cnxuatbanyhoc@gmail.com

TI LIU
HUN LUYN K NNG LM SNG

Chu trch nhim xut bn:

Tng Gim c
CHU HNG CNG
Chu trch nhim ni dung
Ph Tng bin tp
BSCKI. NGUYN TIN DNG

Bin tp:..
Sa bn in:..
Trnh by ba:.
Kt vi tnh:

In.. cun kh A4 ti Cng ty TNHH MTV in Kinh t, 279 Nguyn Tri Phng, P.5,
Q.10, TP. H Ch Minh. S xc nhn ng k xut bn:
Quyt nh xut bn s: .. ngy .
thng . Nm 2015. In xong v np lu chiu qu IV/2015. M ISBN: .

206