NGUYEN CONG KHANH - LE NAM TRA DRC CLO ah) NHTEKHOR (TEXTBOOK OF PEDIATRICS) ngay 1000 TRE EM KHONG PHAI LA NGUOI LON THU NHO LAl,, LA MOT CO THE BANG TANG TRUONG VA PHAT TRIENSACH GIAO KHOA CHU BIEN CAC BONG CHU BIEN NHI KHOA (TEXTBOOK OF PEDIATRICS) XUAT BAN LAN THU NHAT NGUYEN CONG KHANH Gido su, Tién si, Bac sf, Nha gido Nhan dan . Chi tich Hoi Nhi koa Viet Nam Giding vién cao chp Trréng Bai hoc ¥ Ha Noi Nouyén: idm a6c Bénh vien Nhi Trung wong Phd Chi nhigm 86 mén Nhi Bai hoc ¥ Ha Noi : Truéng khoa Huyét hoc, Ung thu, Bénh vién Nhi Trung wong LE NAM TRA Gido su, Tién st khoa hoe, Bae sf, Nha gido Nhan dan Phe chi tich Hoi Nni khoa Viet Nam Giang vién Cao cp Truéng Bai hoc ¥ Ha Noi Nguyén:Phé Higu truéng Bai hoc Y Ha Noi hii nhigm 8 mon Nhi Dai hoc ¥ Ha Noi Truéng khoa Than, Bénh vign Nhi Trung wong NGUYEN THU NHAN Gido su, Tién si, Bac sf, Thay thudc Nhan dan CChiitich danh dy H6i Nhi khoa Vigt Nam Nguyén: Giém déc Bénh vién Nhi Trung wong “Trusng khoa Noi tiét- Chuyén hoa, Di truyén, Bénh vign nhi Trung Long HOANG TRONG KIM Gido su, Tién si, Bac st Nhi khoa Phe Chil ich H6i Nhi khoa Vit Nam, Chi tich Hoi Nhi khoa thanh phd Hd Chi Minh Giding vién cao c&p Trung Bai hoc Y Duge Thanh phd Hd Chi Minh Nguyén: Chil nhigm BO mén Nhi Dai hoc Y Dug Thanh phd HO Chi Minh Gidm déc Bénh vién Bai hoc Y Duge Hoang Anh. Gia Lai HOI NHI KHOA VIET NAM NHA XUAT BAN Y HOC Ha Noi - 2016Loi néi dau PHANI Chuang 1 Chuong 2 PHAN IL Chuong 3 Chuong 4 PHAN IIL Chuong 5 Chuang 6 Chuong 7 MYC LUC SACH GIAO KHOA NHI KHOA (TEXTBOOK OF PEDIATRICS) NHI KHOA DAL CUONG Dich t& hge va dy phong hi Khoa ‘© Dich t& ge site khoe tré em * Nhikhoa diy phong Phucmg phiip kim sing ni khoa ‘+ Tham khim lam sing nhi khoa © Phuong php tiép cin chin dodn va diéu tri ni khoa # Y-hoc chiing ett ép dung trong nhi khoa # Ye trong nhi Khoa TANG TRUONG VA PHAT TRIEN ‘Tang traong, © Khai nigm vé ting trang va phat trién ¢ Tang truéng thé chat 6 tre em # Réilogn ting traomg, Phat trién ‘© Banh gid sy phit eign tam ly - van dng © Chim phat trign tam tri DINH DUONG Nhu clu, dn gid dinh dutng © Nhu cau dinh duéng. ‘© Dinh gid tinh trang dinh dung Dinh dugg cho tré em + Nudi con bing sita me Dinh dung tré em theo ede lira tudi Bénh Iy dinh dudng, © Suy dinh dudng ‘+ Thita cin, béo phi © Céixuong Lé Nam Tra Nguyén Cong Khanh Naguyén Cong Khanh Nguyén Cong Khanh Pham Lé An Pham Lé An Lé Nam Tra Lé Nam Tra Cao Quée Viet Lé Bite Hinh Lé Dite Hinh Neguyén Xuan Ninh Neguyén Xuan Nink iio Thi Ngoc Dién iio Thi Ngoe Dién Dio Thi Ngoc Dién Nguyén Vin Son Newyén Van Som 25 25 48. st s7 58 58 59 82 87 87 2 99 100 100 19 125 125 130 136 136 14 146 xiCuong 18 Chuomg 19 PHAN VIL chuong 20 Churong 21 xiv © Bonk tim bam sinh tim * Nguyen ti Bénh tim mach m ‘chung diu tr bn tim bam sink c phi + Beoh thip tim © Bénh Kawasaki © Suy tim Vig ngi mae nhiém khudin Bénh ming ngoai tim Tang huyét ap * Busutim Bénh co tim * Phan logi bénh eo tim tign phat * Bénh co tim gin no tign phat © Banh co tim pi tai tign phat © Bénh co tim han ché tign phat * Bénh co tim that phai gay loan nhip * Bénh co tim that trai xép_ © Xo-chun ngi mac tim R6i loan nhip tim ‘* R6i loan nhip tim cham + Réi loan nhjp tim nhanh HE HO HAP, Phat trién hg hé hip va tiép cfin chin doan © Phat trién hé hd hap. Tip can chin doin bénh ho hip ‘© Phuong php tham dé chite nang hd hip Benh ly ho hip © Vigm thanh quan © Vigm phé quan phéi © Viém phé quan phdi tai nhiém © Viém tiéu phé quan cap © Hen Phan Hing Viet, Via Minh Phiie Phan Hing Viet Hoang Trong Kim H6 Sp Ha Nguyén Thi Thanh Lan Phan Hing Vigt Phan Hing Vigt Dé Neuyén Tin Dio Hitu Trung, Hoang Trong Kim Vo Nguyén Diém Khanh Vo Nguyén Diém Khanh Vo Nguyén Diém Khanh Va Neuyén Diém Khanh V6 Nguyén Diém Khanh Dé Nguyén Tin 6 Nguyén Tin Nguyén Thi Yén, Pham Thu Nga Nguyén Tién Ding Nguyén Thi Yén Neuyén Thi Di Nguyen Thi Di¢ Piio Minh Twin Thiy Thiy Trdn Quy Trin Quy 506 528 932 332 547 555 570 375 578 595 601 601 605 614 629 635 645 650 655 673 687 688 688PHAN VIII Chuong 22 PHAN IX Chuong 23 Chuong 24 Chuong 25 Gidin phé quin + Bénh phdi + Bénh mang phi Bénh nhiém sit phdi tién phat Dj dang dung the bam sinh ‘© Di dang phdi bam sinh TAL-MUI- HONG Bénh Iy ta mai - hong © Céich khan tai ~ mdi - hong é tré em © Viém hong cap va man + Viem tai gita © Nahe kém - Bide 6 tré em © Divat tai - mai - hong HE TIEU HOA. Si phat trién va chire ning he tiéu hoa ‘© Phoi thai hoe hé tiéu hoa Bie dim gi ph va sin yg iu tem gob ly da day - rust © Tigu chiy edp © Tigu chay kéo dai © Tio bon Hoi chimg nén # Bénh trio nguge da day - thye quan + Bau bung © Vigm loét da diy - 1a tring © Xuit huyét tiéu hoa ‘© Hoi ching kém hip thu ‘© Vigm phiie mac Bénh ly gan- mat © Chin dodin va wir tri ede bo IY gan * Vigm gan tdi cp va suy gan cép © Vigm gan man Vig gan uy mign Nguyén Thi Yén Nuyén Tién Diing Diio Minh Tun Nguyen Tidn Ding Dio Minh Tudn, ‘Neuyén Thi Mai Hoan Nhan Tring Son han Trig Som Nga Nagoe Lign Ngé Ngoc Lién han Tring Som Trang Thj Anh Tuyét Nguyén Gia Khanh Neuyén Gia Khénh Neguyén Gia Khénh ‘Nguyén Gia Khanh Neguyén Gia Khanh Neuyén Thi Viet Ha Nguyen Gia Khanh Nguyen Vin Bang Bui Quéc Thang Nguyén Thi Vigt Ha [Nguyen Thi Vige Ha Nguyén Van Bang Nguyén Van Bang Nguyén Vin Bang ‘Nguyén Van Bang BI 75 742 749 753 157 763 764 64 767 ™ 715 778 785 1786 186 196 803 803 813 817 823 832 837 843 851 864 871 876 876 883 893 897 xvong37 Benh Phinh to nigu qudn tién phat do tie Oi sa nigu quin hay gia higu quin trong tony bing quan thant nang Tons on Luding trio nguge Ms quang - nigu quan tign phat Bang quang thin kinh dao sau DIGG tiéu Ieeh thip Hep bao quy dau Di dang do t6n tai dng nigu - rén Dai dam inh due Tinh hoan khéng xudng biu Xoéin tinh hoan Gian tinh mach tinh ‘Cac bénh do tén tai éng phic tinh mac Tinh trang gidi tinh kh6ng xac dinh Hi ching bung qué man PHAN XII HE THONG NOI TIET Chuong 38 Téng quan vé ngi tiét hoc Dai curong vé ndi tiét hoc Hormon - NOi tiét t5 NGi tiét hoc lam sang ‘Chuong 39 Tuyén yén va ving dui d6i thi Giai phiu va sinh ly tuyén yén Bénh ly tuyén yén ‘Vung duréi di thi Dai théo nhat Bénh Cushing RGi loan phat trién day thi Nguyén Thanh Liém Nguyén Thanh Liém Nguyén Thanh Liém Nguyén Thanh Liém Nguyén Thanh Liém Nguyén Thanh Liém, Lé Anh Ding Nguyén Thanh Liém, Lé Anh Ding Nguyén Thanh Liém, Lé Anh Ding Lé Anh Ding Lé Anh Diing, Neguyén Thanh Liém Lé Anh Ding, Nguyén Thanh Liém Lé Anh Ding, Nguyén Thanh Liém Lé Anh Diing, ‘Neuyén Thanh Liém Nguyén Thi Hoan, Lé Anh Diing Nguyén Thanh Liém Thu Nhan Thu Nhan Nguyén Thu Nhan Nguyén Thu Nhan Nguyén Thu Nhan, Nguyén Phi Dat Nguyén Thu Nhan Nguyén Phi Dat Nguyén Thu Nhan Nguyén Phi Dat 1189 1193 1196 1202 1207 1211 1213 1215 1216 1220 1220 1225 1226 122¢ 123+ 124 1261 1271 127 128my 40 cong 41 huomg 42 PHAN XII Chuong 43 Bén Ben ih tuyén gidp va cin giép © Suy gidp trang bam sinh va thir phat © Bénh budu giip age cin gidp ih tuyén tuy * Dai thao duimg typ 1 Hon mé dai thao dung nhiém toan chuyén hoa * Ha glucose mau trong dai théo duing Dicu trj dai thio duéng khi bi 6m Bénh thugng thin Giai phdu, sinh ly tuyén thugng thin + Bénh ly tuyén thugng than © Uvo thurgng than gay chuyén gigi © U6 thugng than gay nit hoa + Ucorticosteroma - Hi ching Cushing + Utiy thugng thin * uy thugng than man va cp CHUYEN HOA Bénh chuyén héa + Réi loan chuyén héa bam sinh © Bénh Wilson © Thigu hut citrin HE THAN KINH TRUNG UONG Bénh ly 6 hg than kinh trung wong Kham thin kinh tré so sinh Dong kin Dot quy 6 tré em Chay mau trong so do thiéu vitamin K Bénh ly mach méu nao Bién chimg thin kinh ciia tang huyét 4p Céc réi loan mat myelin cua hé thin kinh trung uuomg qua trung gian mign dich Ap xe ndo Dai cuong vé khuyét tat bam sinh 6 hé thin kinh, trang wong, Nguyen Thi Hoan Nguyen Thu Nhan Nguyen Thu Nhan Neguyén Thi Hodin Neguyén Thi Hodin Neguyén Thi Hoan Nguyén Thi Hodn Nguyén Thu Nhan Nguyén Thu Nhan Neguyén Thu Nhan Neguyén Thu Nhan Nguyén Thu Nhan Nguyén Thu Nhan Nguyén Thu Nhan Nguyén Thu Nhan Hoang Lé Phive Nguyén Pham Anh Hoa Lé Bite Hink Lé Bite Hinh Neuyén Vn Thing Neuyén Vn Thing Dice Hinh Nguyén Vin Thing Tran Digp Tuan Ninh Thi Ung Lé ite Hink 1286 1286 1297 1301 1305 1305 1310 1313 1313 1315 1315 1320 1326 1326 1327 1328 1329 1333 1334 1334 1340 1350 1383 1354 1354 1358, 1371 1381 1386 1390 1391 1395 1398, xixRéi loan cm nie ng eye & te em * Réi Loan te ky © ROi loan tang déng m chit ¥ RGi loan dic higu vé ngon ngit va hoe tap * Réi loan trim cam ‘+ Tam thin phan ligt khoi phat 6 tré em * R6i loan tie va hdi ching Tourette PHAN XXII RULRO VE ‘C KHOE MOL TRUONG huong 64 Nguy co moi trang v site khoe tré em * Bién doi khi hau toan cau véi site khoe tré em * Hit thude la véi site khée tré em Pham Quinh Dip. La Thj Buc Quich Thiiy Minh, Nguyén Thi Thanh Mai La Thi Budi La Thi Budi, La Linh Nga Pham Quinh Diép. La Thi Buci Tran Nhu Minh Hang Nguyén Thi Thanh Mai, Quach Thy Minh Neguyén Cong Khanh Nguyén Cong Khanh 1899 1907 1912 1918, 1926 1934 1940 1945 1946 1946 1953 XXiiiChong 58 PHAN XX Thuong 59 cong 60 Chuong 61 PHAN XXI Churong 62 Chuong 63 ida tri va phOng bgnh di truydn Ri lon v8 nid sie thé * Benn réilogn nhigm sie thé thudng + Bénh ri loan mhign ie thé gigi tinh © Hoi ching Fragile X UNG THU Dich t&, nguyen IY c0 ban trong ung ther * Dich t& hoc ung ther tré em * Te-bao va sinh hoe phan tir ung thu * Neguyén ly chin doan ung thu tré em Neuyén ly digu tri ung thu tré em Ung thu hé tao mau © Loxémi * Hi ching ting mo bio * Unguyén bio vang mac * Unguyén bao thin kinh © Ung ther than © Ugan nguyén phat © Ung thur xzong © Sarcoma m6 mém SUC KHOE TAM THAN Phuong phap dinh gi va ligu phdp tam ly © Phuong phip dinh gia stte khoe tam thin tré em © Tri ligu tam ly tré em ‘Tam bénh © Bénh tim the © Réilogn lo du Nguyén Thi Pucong Nguyén Thi Phuong Nguyén Thi Phhegng Nguyén Thi Phueong, Neuyén Ba Bite Neguyén Hoai Nga Neuyén Bé Dice Neuyén Cong Khanh Nguyén Céng Khanh Busi Ngoc Lan, Nguyén Céng Khanh ‘Nguyén Cong Khanh Pham Thi Vigt Hucong, Nguyén Bé ite Phitng Tuyét Lan Trin Bite Hau, Neuyén Cong Khanh Neguyén Van Bang Trin Van Cong, Nguyén Bé Bite Tran Thu Ha, Nguyén Cong Khanh La Thi Bui, La Linh Nga La Thj Buci, ‘Nguyén Thj Hang Thi, Ta Ngoe Bich La Thi Busi La Thi Budi, La Link Nga 1745 1751 1751 1762 Im 477 1778 1778 1873 1874 1874 1881 1887 1887 1892Phan I NHI KHOA DAI CUONGee Phan I. Nhi khoa dai cwong Buimg Ibi y té Vigt Nam ngay tir nhitng nm sau 1945 da lay phyong chim dy phéng la chinh. Mang luéi y té phat wién rng khip trong cé nude di mang Jai higu qua to lon vé chim séc sire khoe nhan din. TY 1g tir vong tré em dui 1 tu6i va dudi 5 tudi da gidm mot céch ding ké va déu dan trong nhimg ndm gan day va hign dang 6 mic thap trong khu vyc chiu A - Thai Binh Duong (Bang 1.9) ‘Bang 1.9. Ty tr vong té em dang gidm dn & Vigt Nam Pre | ue wm | op | MB | gnu séng | S679 1983 | 62,1 ‘54,8 | Ngan hang thé gidi va cing sy, 2001.7 1999 Téng diéu tra dan | $6, 2001:97 1888 | 68.7 | 48.0 —[ Ngan hing ib iva cOng sy, 2001:7 1999 Téng diéu tra dan sb, 2001: 97 1992 | 47,4 35,7 | Didu tra dan $5 va soc ko 2002, 2003: 78 1993 | 55,4 44,2 | Naan hang thé gici va cong sy, 2001:7_ 1997 | 39,5 23.6 Diu tra dan sé va soc Ko 2002,2003: 78. 2001 | 350 | 900 [UNICEF ame: 67 2002 | 23,8 18,2 Didu tra dan 86 va sac L fro 2000, 20037 PHAM TRU DY’ PHONG BEN TAT __ Noi dung cia phong bénh thuimg duge phan ra 3 cdp, dy phong cap mét, cap hai va cdp ba. Dy phong cép mot, hay dy phing tién phat e6 muc dich lam iim tan sudt méi mie bénh, bang céch kiém sodt nguyén nhan hay céc yéu t6 nguy co. Thi dy nhur tiém vaccin dé phéng soi hay bai ligt; diéu tri viém hong do ign cau khuan dé phéng thap tim; bo sung iod vao mudi dn dé dy phéng budu cb; b6 sung folat trrée sinh cho nguoi me cé thai dé dy phéng dj tat Ong than kinh thai nhi; sir dung bao cao su dé phing nhiém HIV. Phong bénh cap hai hay phong bénh thir phét voi mye dich kim gidm tn suat bénh luu hanh, hay phong i phat, bing cich chin dodn vi diéu tri som, dé {i khoi bénh hay gdm hau qua ning né cia benh. du nhur sing loc suy giép 6 so sinh dé diéu tri thay thé thyroxin sém va dy phong ching din dn; sing Ie thich Iue sg sinh dé cai thign bénh diée & tré em. Phong bénh cép 2 cén myc dich dé phong bénh ti phat, thi dy tiém penicilin cho tré 43 bj thip tim 4é dy phong bénh tai phat ning hon. Phong bénh cp hai en duge Sp dung, cho bign phip ngimg cé thai dé trinh sinh ra nhimg tré so sinh cé Khuyét tit nang né. Phong bénh cép ba voi myc dich tam gidm tify trién hay bién ching cia bénh, han ché hou qué cig bénh, bao gim cdc bign phép dé hyn ché tt nguyén go bénh hay thuong tich. Thi dy phong bénh cip ba ién phdp phuc hoi chic ning cho tré bai it dé te ¢4 thé hod nhdp cude s6ng, cai thign ste khoe cho tré, ‘TIEP CAN DY PHONG CAC THOI KY TUOI TRE. Vige dy phong bénh tit, ang cuong st khoe tre ‘em phai thyc hign trong sudt qué trinh tuoi tré, nyay tir khi hinh thanh, phat trién thai nhi tiép dén thé ky. sso sinh, thisi ky duc 1 tudi, thisi ky tré nhd, thési ky te Jém, tudi vj thanh nién. Méi thési ky tudi tre cb ma trong tam dy phong cin duge quan tim. Trong vai thap ky gin day, nhiéu nghién ctu 4a thira nhjn vige dy phong sm ngay ts thoi ky bao thai va tré nh la hit site quan trong. Nhiing phoi nhiém v6i mdi truémg & giai dau cita tuoi tré c6 thé lap trinh cde yéu t6 nguy 69 cao vii mpt 56 bénh xiy ra 6 giai doan musn cia d6i séng, nhur cao huyét 4p, dai thio duémg, bénh thiéu mau tim. Vi vay, cée can thigp dy phong som khong nhing chi cai thign site khoé tré em, ma cén e6 vai trd chéng mot s6 bénh & ngudsi Ién tdi Dy phong truréc khi thy thai va trong this ky that Nhiéu yéu 16 vé phia ngudi me tru6e khi thy tha 6 anh hudng 161 thai mhi sé thy thai, nhur site khoé gui me hign tg va trude 46, tu6i mgd me te qué duéi 18 tudi, hofc ln hon 35 tudi, s6 lan cé thai, khoang céch véi ky thai truéc ngin, thoi quen (nhu hat thude, udng rugu), tién sir tiém chang (nhu win vin, rubella), nghé nghigp, ting lop xa hoi, cing nh cde yéu 16 di truyén cia bO va mg, Hiéu biét, kiém soit va logi trir cée yéu t6 bat Igi trade kbi thy thai .86p phan dy phéng quan trong. Dinh dudmg cia ngudi me trong thoi ky thai anh hung lon t6i sy phat trién thai. Trong thoi ky mang thai nguéri me phai duge tang cuéng dinh dudng diy , dé tang ti 11-12 kg, bao dam thai phat trién binh thuong. Can duge bé sung di acid folic dé dé phong dj tt ong than kinh cho thai nhi, du sat dé dé phong thiéu mau; thiéu mdu trong thai ky mang thai dé c6 nguy co phat trién thai kém, sinh non. Té chite chim séc trude sinh t6t c6 the dyng sing cin d6i. véi ste khoé me va tré em. Theo khuyén céo cia nganh San - Phy & Vigt Nam, trong thé gian ‘mang thai, ngudi mg phai duge thém thai t6i thiéu ba én thai, duge tw vin cho vige bao vé thai, phat hign cc bat thuémg 6 thai, dy doin ngiy sinh, phat hign thai nguy co dé dy phong thich hgp. Cham sée trurée sinh c6 gia tri dy phong Ién cho site khoé tré em vi ngudi me. Noi dung chim s6c ‘rude sinh cén bao gém sing Igc cae bénh Iy cia ngudi me anh hudng t6i thai nhi nhu thiéu mau, viémgan B, giang mai, nhiém HIV, nhiém khudt ee nhiém HIV, nhi n don Gas, Khong 6 trig chimg, ti sin gift; etng nhit thet ed, Phat ign thai, phét hig cde cfu tre bat Sane & thai boi chimg Down cia chin dodn trsde Gy tay SH Ba me 66 cde yeu 5 guy co Abe bist thi Be ne ga inh 6 bénh ly di truyén, can phai tién = loan trude sinh, kim nhing thir nghiém ve arygen 4& te van di truyén thich gp. Nhtng nim Fy tag he tién bo ve ky thug di truyén phan ti, v8 XY thudt chan dodn trude sinh qua siéu am, chge nude oy gly mle hung mao ming dém dé phat hign bgnh iyén true sinh, xéc dinh gen bénh, Tur vn neti thai 18 bign phap dir phong thir phat ngay cing = e {ri thye tin duge ting dung 48 dye phong sinh tré 06 Kthuyét tat nang nd __Bign phap dy phong quéi thai trong giai dogn diu iia thoi ky thai la hét site quan trong, Trong 3 thang dau cua thoi ky thai can trénh phoi nhiém véi ede bénh ly nhiém do virus, han ché ding thuée va trinh tia xa. Nhiém virus trong giai doan phéi thai d& cé nguy co thai 6 di tit bim sinh, Nhing thuée, hoa chit sau diy thurimg thay ph6i hap v6i dj tat thai: diphenylhydantoin (Phenytoin),trimethadione, paramethadione, acid valproic, carbamazepin, thiourea, carbimazol, " methimazol, isotretinoin, vitamin A, etretinat, thalidomid, warfarin, methotrexat, corticosteroid, androgen, progestin, dicthylstibestrol, iodine, lithium, thuy ngin, va chlorobiphenyl. Cting can trinh Xquang ving byng. Cho dén nay chua cé chimng cit vé tic dung ¢é hai voi thai ni cia siéu am. Trong thdi ky thai eting cn te vin 48 ngudi me ngiimg hiit thuée va han ché rugu. Hit thuée c6 thé gily chim phét trién thai trong tir cung, gay mot s6 di tt bam sinh, hong thai, sinh non. Ngoai ra, hat thude trong va sau thé ky thai eén c6 nguy co bj hoi chimg, chét d6t ng6t 6 tré nho (SIDS), Cho steroid & ngudi me c6 nguy co sinh non, a2 phong bénh ming trong, gidm suy ho hip so sinh Dy phing & thai ky so sinh Théri ky so sinh, tré méi ra dé, con rat non yéu, ty Ie ti vong rat cao. Céc nghién ciru tai Vigt Nam cho thay ty 1 tir vong so_ sinh nim 2002 la 12 trén 1000 dé sng, chiém gan 50% tir vong dudi 5 tudi, va 70% tir vong dudi 1 tudi. Noi dung diy phing & ni ky so sinh nhur sau. Trude hét phai thye hign chim séc trade sinh va hi sinh t6t, bao dim sinh dé an toan, 48 phong ngat, chan thutong khi dé, dé sach, dyr phéng nhiém khuan, thyc hign t6t ce chim séc thiét yéu cho tré méi sinh, ac biét phai chim séc so sinh thiéu thing va thip can lie sinh t6t. Nguyén nhén hang dau gay tir vong so sinh van Ia tré sinh non, sinh thap cn. esse Chirong 1. Djch t8 hge va dy phong nhi khoa Chim séc, didu tr} 66 higu qué ngat so sinh, chin thugng khi sinh, ving da ting bilirubin gin tiép, nnhiém khudn so sinh, la bign phap dy phong tir vong, di chirng liu dii khé hoi phye cho tré em sau nay. Tye hign bé me s6m ngay sau sinh, bé: me hodn toan trong 6 thing dau va kéo dai d&n nm thir hai la bign php dy phong eye ky quan trong v6i tré so sinh vi tré nh. Bu me sm gidm nguy co tigu chay, viém rust hoai ti, nhiém khuin du’ng ho hap dudi, viém {ai gia va nhiém khuan ning khéc 6 tre so sinh; ngodi ra con gidm nguy ca béo phi. Nhiéu chimng cir gan diy cho thay tré thiéu stra me bj chm phat trien tri tug, do thigu mot s6 acid béo khéng no chudi dai, 1a thank phin quan trong trong sita me dé phat trién no binh thudng, Cho tré ba me thudng xuyén cdn c6 higu qua sgiém ty 1 sinh va ting khodng cach sinh con, ¢6 Igi site khoé ciia ca mg va tré. Vi thé T6 chitc Y té thé gidi va UNICEF khuyén khich xy dung Bénh vign Bon hitu dé cdi thign va hd try ngudi me nudi con bing sia me. Tai bénh vign, d& con duge nim cing vv6i me, khuyén khich ii Am cho tré bang bign phip da - ké da, cho tré ba ngay sau sinh la nhimg bién php dr phong t6. 5 3 Sing loc so sinh ngay trong tuin dau so sinh, && phat hign suy giép bam sinh, phenylketo niéu, xo hod tuy, bénh hemoglobin dé diéu tri sém la bign phép diz phong thir phat, cfp hai rt quan trong, cm thie hign & that Ky so sinh, 5 BO sung vitamin K cho tit c4 tré moi sinh, durge eée muée khuyén co dé dy phong bgnh xuat huyét ning xy ra sm 6 tré so sinh va tré nhé sau thoi ky so sinh. C6 thé tiém m6t mi vitamin KI ngay sau khi sinh hoe cho uéng nhiéu lin trong nhimg tuén 18 dau sau sinh (véi tré ba me nén cho nhiéu ln) c6 higu qua dy phong xuat huyét so sinh va tré nho 15 rét. Céc nghién ciru 6 Vigt Nam cing cho thay, tiém mt mii vitamin K1 cho tré méi sinh, higu qua gidm ty Ie xuat hhuyét ni so 6 so sinh va tré nho. Phong bénh bing tiém ching la bign php dy phang duge thyc hign ngay tir thoi ky so sinh. Céc vacein duge ching sém 6 thdi ky so sinh la vaccin BCG, viém gan B va bai ligt (xem phan tiém ching). Lay truyén doc nhiém HIV ngiy cang ¢6 nguy co nhieu tir ngudi me c6 thai nhiém HIV. Céc bign php dy phing nhiém HIV cho tré so sinh gém sing Ige nguisi me 6 thai nhi&m HIV, digu tr) thude khing retrovirus cho me va so sinh, chon gid phap sinh mo, va tranh bit sta me 6 ngudi me nhigm HIV. Dy phong cho tré duéi 1 tui va tré nho Dac diém chung cia tré 6 thoi ky nay la tré phat trién nhanh vé thé chat, tri tug va tiép xtc rong rai voi mdi trudng bén ngoai; bénh ly pho bién la cdc bénh lién quan én dinh dung, nhiém khudn va tai nan bat ngo. 7Phi 1. Nbi khoa dal curong THAM KHAMSUC KHOE DINH KY Thim Khim site khoé dinh ky li bign phip dy phong higu qua trong nhi khos. Thim Khim site khoe cho tré khoe li nén tang cia chim sée tré nh, Kon va té vi thinh nign, Bg dim bio cho té phat trién ti wu, trong chim sde nhi khoa cin cé lich tham khém sire khoé dinh ky dé danh gi dinh dugg, tiém ching, theo dai tang tram, phit tien va phat hign bénh tat sam. Theo hung din giim sat sie khoe tré em cia Bright Futures, duge H6i Nhi khoa Hoa KY chip nhan, lich thim khim va ni dung thim kham sire ikhog eho tre khoe nhur sau Bang 4.11. Lich tham khdm dinh ky cho tré em TRE DUGI1 TUS! TRE TUO! THIEU NIEN ‘Tham khém du tién - chu sinh | 5 tubi (Mai sin 6 tubi Tun dau sau sinh 8 tubi 1 thang 10 tus 2thang ‘TUOIV| THANH NiEN 4 thang 11 ud 6 thang 12 108i thang 13 tub TRE NHO 14 tub 12 thang 15 Ubi 18 thang 16 us 18 thang 17 ub 2 tubi 18 U6 3 tubi 19 tuéi 4 tubi 20 tui 21 tui (Navin: Green M, Palfrey JS (eds). Bright Futures Guidelines for Health. Supervision of Infanis, Chiiren, and Adolescents, 2nd ed rev ‘Aiington VA, National Center for Education in Maternal and CChild Health, 2002) Mue dich ciia moi lin tham khém tré khoé li —Diinh gid tng trudng va phat trién; — Phat hign bénh; Phong bénh; — Ting cung site khoé (health promotion); ‘Dé danh gid tang truéng va phat trién can danh gia inh dung xem cde chi s6 ve t nhur cn ning, chiéu cao, ving dau, vong ngyc, dénh gid phat trig tinh than - vn dng, thuong s6 tri tué, thuong s6 cam xiie, déi chiéu voi chuan binh thuéng, déng thoi sing loc giée quan nghe, nhin. : ‘Dé phat hign bénh phai str dung kY nang lim sing, him thyc the, ky thudt sing loc va kién thie bénh I 6 ce thai ky tudi tré. Ngay trong tudn dau so sinh nén lay méu g6t chan dé sing loc m@t s6 bénh bam sinh, chuyén hod, Tre tr 6 thang dén 5 tubi vi ir rén 11 ‘tudi nén xem xét thir mu dé phat hign thiéu mau, tir 11-21 tudi nén xét nghigm phan tich nude tiéu khi dén 20 ‘him khim, 6 tré lém va vj thinh nién 6 mot s6 yeu 16 ign quan t6i ben tat cin quan tim nhwe dink «lng, hoat déng the chit, hanh vi tinh due, hii thud, udng rou hay nghign thude, hinh vi d& gay tai nan, thao tie, Dé danh gid hoat dong phong bénb, méi in tham khim phai kiém tra tiém chiing, phai quan tam dén a ‘dy phong tién phat (cip 1), déng thoi ca dy phéng thir phat 6 cae tré co yéu 16 nguy ea. Voi tré o6 bénh tgt lign quan dén tinh chét gia dinh, vige tu van v6i gia dink vé phing ngiza bénh 6 tim quan trong. Huong din céc biéu hign ning cia bénh cho gia dinh, nguti chiim s6e tré, dé xir tri sém cing 66 higu qua dy phéng céc bién chimg ning, Tang curing size khoé bao gm hang logt cdc hoat dong nhim cai thign sire khoé, phoi hop céc hoat dong phing bénh véi gido duc site khoé va vin dong si ho tg cia céc t6 chire kin té - xi hoi. Dura vo két qua inh gid vé phat trién, bénh phat hign, ede bién php dur phong, cae nha nhi khoa dia ra nhimg 1bi khuyén, tur van phi. hop dé tang curomg ste Khoé. Tra Idi nhimg cau hoi cia ede bac cha me 1 diéu quan trong nhat mi lin thim khdm dinh ky cho tré khog. Phai lay ww van vé dinh dung, phing bénh, phat hign sm bigu hign bénh ning, hoat d6ng thé chat, hinh vi an toan, phong ngira tai nan la trong tim tw Van ting cuime site khoé. Dang thoi hucng dan tiép cn cdc dich vu y t&, fnrong trinh site khoé, tranh thi sy hé tro cua eée 16 chite xa hoi, kinh 18 nghé nghigp d& cai thign sic khoé. Hé trg gia dinh phat huy nhimg hoat dong tot cho site khos, han ché céc hnh vi cé hai cho site khoe 4 ting cing higu qua tham khém dinh ky. ‘THEM CHUNG ‘Tam quan trong va higu qua cita tiém ching ‘Tigm ching la mét bign php don gin, higu qua va kinh té nhit d@ phong bénh. Higu qua cia tiém ching a thanh toén duge bénh dju mia va gin thanh toin duoc bénh bai ligt trén todn cau, Tan suat hau hét ede bénh c6 thé dy phong duge bing vaccin da gidm 299% & cde nude phit trién. Tai Hoa Kj, nim 2006, tré em va tudi vi thinh nign 43 duge tiém ching thudng quy 16 bénh: bach hau, uén vin, ho gi, bei ligt, Hemophilus influenzae typ B (Hib), vigm gan A, viém gan B, sii, quai bi, Rubella, Rotavirus, thuy du, bénh do phé cau, ming nio cau, va cim. Voi tré gai 11-12 tuéi duge khuyén cio tiém vaccin Human papillomavirus (HPV), Tai Vigt Nam, Chwong trinh tiém ching mo rong 1 mot chwong trinh y té quée gia, duge bit diu tte nim 1981, tiém ching 6 loai_vaccin cho tré dudi 1 tudi dé phong 6 bénh: bach hiu, bai ligt, ho ga, 140, uuon van, soi. Tit 1995 dén nay, ty 1g tre duéi 1 tudieS dhe. sim ching 6 log vacin trén dat tn 95% ‘r 1997 chuomg tinh tigm ching mo rong b8 sung 1B, ta va thuomg hain, Nhiy chung trinh tif ty If mae va chét tré em da gidm rd ret. T mile bénh bach hiw trong 100.000 tré di gid (nim 1985) xudng didi 0.3 (1999); cde 6 Ti mg voi bénh bai ligt lt 2,7 va 04, Nam 2000, Vi Nam di chinh thie eOng bé thank ton bénh bai Ti duge TO chite Y té thé gidi céng nan, TY Ié tr vong WS dudi 1 mudi gid ti $4,8%G0 mim 1983 xudng 18,2%0 nim 2002, Trong hai thap ky qua, m6 hinh co itu mie bénh va tir vong 6 Vigt Nam da 06 thay di 18 rit, trong dé ty Ig chét do cae bénh truyén nhiém iy nén di gidm tir 53% nim 1976 xudng 15,6% nim 2001 (Bang 1.12), Bang 1.12. TY 18 co cdu tt vong theo nguyén nhan (9%) Saoiaind Nam Nauyén ahaa oR 4976 1986 1996 2001 Bénh tuyén 53,08 52,10" 33,13 15,60 rin Ben khong «44,71 41,80 43,68 68,35 truyén ahigm Tainan, chén 2.23 «6,10 23,20 18,08 thyong. ng6 abe eT, (Nouan: Nién giam thng ké y 18-2007 Mién dich voi bénh nhiém khuan dac higu c6 thé thu duge qua nhigm khuin uy nhién hay do tiém chiing. Tiém ching bao g6m tiém khang thé mign dich thy dng, hay tiém vaccin dé tao ra mign dich cha dong. Gay mign dich thy dong e6 téc dung ‘bao vé tte thi, song ngin, kha ning bao vé chi kéo di vai tun, vai thing. Song giy mién dich chi déng, khang nguyén tir vaccin kich thich hé thong mign cca ngudi duge tiém ching sin sinh Khang the va/hay mign dich qua trung gian té bio vi gay duge ky ire min dich, nén kha nang bio vé kéo dai, Muc tigu cia tiém chiing chii dng la phong bénh cho ngudi duge tigm chiing, song c6n c6 muc tiéu dé logi trit hay than toan bénh pho bién, Higu qua eda tiém ching phu thude vio dich t& cia nguén bénh, vaccin, dap img sinh hoc va xa hi cua ¢4 thé va co sir ha ting ciia dich vy tiém ching Vaccin Vaccin li mét khing nguyén c6 nguén gée tir vi Khuan hay virus, hoe giéng nhur khéng nguyén cita vi khuan hay virus, duroe sir dung dé gay mign dich chit dong. Cé nhiéu loai vaccin, vaccin tir sinh vat séng 43 duge lam yéu di, vacein tir sinh vat 43 chét (Khir hoat tinh), li thanh phan phan lép tir sinh vat (protein thinh té bao hay polysaccharide), hay tir dc t6 da kim giam doc (bién dde t8). Chong 1. Djch hge va dy phong ahi khoa faccin sng sinh vat, di durge lim yéu di la vacein iy mi dich chi dng bing ech gay et “nin Khun he". Sinh vit de hei duge fm yéu di, thing thong bing cich ely i cy lai nh fan trong dieu kign Khdng thin lei, c& thé giy dap img khing hauyén, niumg khong gay bénh ning. Thi dy vaccin MMR dé phng soi, quat bj va Rubella. Vaccin voi Sinh vt phin img, chéo (cross-reacting organismo) Ii not dang vacein sng Khie, lim cho co thé tao ra m6t kha ning phong vé chong v 6 dy nhur yaccin Bacillus Calmette - Gu CG), Vcein chat hay vaecin Khis hogt tinh durge sin xuat tr sinh vat -dge_hi, Kim bat hoat bai nhiét, phenol, formaldehyd hay phyong phip khéc. Vacein ho gi kkinh dign la mot thi dy vé vacein toan té bao da bj dict (whole - cell killed vaccine). . ‘Vaeein thinh t8, (component vaceine) 1a vaccin sir dung mét thinh phin cia sinh vat lam khang nzuyén. ‘Thi dy vaccin thinh t6 tir protein, bao gdm vaccin ho gi moi khong té bio, vaccin Influenza, vaccin viém gan B. Vacein thinh 16 khac, tir polysaccharid, 6 vacein. phing Hemophilus influenzae typ B (Hib), vacein phong ming nio cau C, vaccin phé céu. Dap img mign dich voi vacein polysaccharid, c6 vaccin phong Hemophilus influenzae typ B (Hib), vac phing mang nio cau C, vaccin phé cau. Dap img mid dich voi vaccin polysaccharid thuimg khéng hoin ton vi khong chic chin, nhwzng ¢6 thé eai thign tinh min dich bing céch gin voi mét khing nguyén protein khic. Vi dy vaccin phdi hop gitta vaccin polysacharid Hib véi vaccin bién dc t6 uén van va bach hau, ¢6 kha nang kich thich té bio T va gay mot key tre mign dich, Vacein dc t6 durge sir dung dé bio vvé chéng véi sinh vat sinh ra dc t6 nhur bach hau va uuon van, Vacein dge t6 bach hau va uén van sin sinh +a khing thé lim bat hoat de 16 dé phong céc hu qua lm sing ning do nhigm khuan, chi khong digt durge vi kuin Vaccin sng thuimg tao ra mét dip tg mign dich sau ligu dau. Song lich tiém ching van can tiém nhc Jai dé bo sung cho céc tru’mg hop cha ¢6 higu qua. Khong c6 vaccin mio cd higu qua 100%, van co trudng hop dap img mign dich khong day da, thi dy ¢6 khodng 10% tré khong dip img sinh mién dich v mgt licu vaccin soi. Tat ed cdc vaccin chét thuomg yeu cu tiém nhiéu lan, tigp theo lan tiém dau tién de sinh, va duy tri min dich day di. Cac vaccin khéng song thuéng duge gin voi mOt_phy chat nhu hydroxid aluminium dé tang tinh mign dich va gim nguy co that bai ciia vaccin — Higu qua dy phéng bénh nhiém khuan bing tiém chiing rat rd ring. Trong twong lai nhiéu vaccin moi duge ra doi, nhiéu vaccin dap img kip thoi nhimg vy dich lon ton edu, Bé tao thuan tign va ting tink mignCE Phan 1. Nhi khos dai cwong dich, ce nghién cizw dang hum : ng huring theo te ra cic vaccin phi hep dé bio vé cing mét Ide nhieu bean vaccin ti (6 hop Khong yéu cdu pha gid hie dp lanh mgt eich net nghéo, vi vaccin tho date si vacein da ning dip img voi niu tip khing nage Lich tiém ching Khong ¢6 mot lich tiém chiing nao cé thé ap cho moi quée gia, moi cng déng trén toin thé gigi Chong trin ching quéc gia cia méi nuée cén thay 0i tuy theo dich 8 bénh nhiém khuin & tré em, sy phat trign cia vaccin mdi sin e6 sir phat igs voting, té - x4 h0i. Muc tigu co ban cia lich tiém ching li phai lam sao dén duge dai da sé tré em trong nude Lich tigm chiing phai lim cho dan gin dé cic bac cha me, nhan vign y té dé nhé, cn phai phit hop v4i chia luge cham s6e ste khoé chung, cing nhw chuvme sh site khoé chung, ciing nhur chyong trinh tng cutmg site Khoé tré em. Cac loai vaccin trong chyong trinh tiém ching, tudi phai tiém ching hu thude vio nguy eq dich t& bn, nguy cu bénh & hia tuoi, kha ning dép img voi vaccin, neuy co bién ching bénh, dic diém truyén khang thé tir me sang ‘con, gid thinh ciia vaccin va co sé ha ting ciia dich vi site khoe. ‘ _ Ngoai ra dé ty Ig bio v@ cia tig ching toan dién, coin phai quan tam dén tré di chuyén theo bé me dén ving c6 dite diém dich té dic bigt & cc khu vue trén thé gid Thai gian bit diu tiém ching thuimg quy ty thuge vio sir taréng thanh ctia hé mign dich 6 tre, vi nguy co gay nhiém khuan cia sinh vat. Tré qué nho 6 thé chua dap img day du véi mét vai vaecin, tre cén tén dir mét s6 immunoglobulin G (IgG) tir me ¥ thai, c6 kha nang bao ve ng d& vi nhiém khuan tyr nhién, do 46 c6 vaccin can tiém cham hon dé bao dim dp img mién dich Nhung 6 vaccin can tiém sém ngay sau sinh. Mite d6 bio vé bing IgG ciia me truyén cho thay doi tuy theo Joi sinh vat, thi du rat kém v6i ho gi, nhung manh hon v6i khang, thé sé Lich tiém ching 6 cée nude dang phit 1 bio dam cde tiém chiing co ban, bio vé phong diroe cae bénh ning, phd bién, phai dat trong chuong trinh chim sée site khoé ban diu. Khuyén cio cia To chire Y té thé wii, phai wu tién cho tiém ching co ban véi ty Ig bao vé trén 90% tré em, dé gidm biing phat bénh_ ré em. Tré sinh thap cn, bao gom tré sinh non, chim phat trién trong tir cung, phai duge tiém ching nhur lich tiém ching cho tré sinh di, thang. Lich tiém ching chuin cia Té chite y t8 thé gidi eting khuyén ‘cio bd sung thém cfc vaccin cho timg ving dia IY dic bigt, nhwr vaccin viém ndo Nhat Bin, vaccin sét ving, vaecin pigbel. Nhiém khuin do Hemophilus influenzae typ B cing nhu phé cau rat pho bién cae 2 nude dung phat trién, song chura di diéu kign 48 dt vito chong trinh tiem chung, mir rong @ tat © nue dang phat trién nhing nim truée day; song, nim 2002 di khuyén cio bo sung vio lich tiém ehts cho ede nuge dang phat trién, Chién dich tiém ehiy dai tra da gop phan thanh toa bai ligt trén toan cf hign nay To chic ¥ 16 thé gigi cing Khuyén co the hign chign xg loa tri so ‘Tom lai, lich tiém ching phy thude vao tinh Bi dich t8 bénh, higu qua mién dich, hoin canh kink t 14 hi, dé thu hign, duge cong dong chap nbn, p hgp véi chién luge cham séc sire khoé cua timg qu gia. Bang sau day gidi thigu 3 lich tiém ching dé « chigu, lich tém ching & Hoa Ki, theo khuyén c40 © chuong trinh tiém ching mo rong cla hire BiGi cho cc muée dang phittrign va Viet Nam. Bang 1.13. Lich tiém ching 6 Hoa Ky, cac nuoc de phat trién (Khuyén cao cla TCYTTS) va Viet Nam Hoaky | Nuée dana | viet Nar Tobi "2006; | phattién | Vi | eco | vviem gan 8 | (Pde 38.8 Ki sinhiso | i | cho vang lay fi vem gan | Toone. | Bos | ‘sinh cao | oPv (abu co odichy ‘thang — | viem gan 8 vviem gan opv ore 6 tun Viem gan 8 (Phac 46 A vaB) Hib rap pre ev 2 thang oe Hib His | Pov Viem gan opv orp, 10 tun Vor | viem gan 8 | (Phacaé'8) opv 3 thang pre Hib 14 tudn bail : orp ~——eSSG ie Hib Viem gan 8 (Phacad a { vaB) | Ter ov ~ DIP Hib Hib Pov \Vigm gan B | DTaP Pov | Vim gan 6 (6-18 thang) PV (6-18 thang) Influenza hang nam | (623 thang) | 9thang Sot S61 | Hb (12-15 | thang) MMR (12-45 thang) Pov (12-15 ‘thang Varicella (12-18 thang) Vim gan A (12-23 thang) 4 thang 6 thang 12 thang \vigm gan DTP (14-18 thang) Hip (14-18. thang) 14 thang | 15-18 bed DTaP DTaP (4-6 ) Pv (4-6 tdi) MMR (4-6 ‘ub ata ‘1-12 | Men A 6, | wissva Chi thich BCG (Bacilus Calmette - Guerin); DTP (bach hhdu, ubn van, ho ga toan té bao); DTaP (bach Nau, uén van, hho ga khéng 6 bao); dTaP (bach hau liu thép, uén van, bach hu khéng t6 bo), OPV (vaccn bai ligt ubng), IPV (Waccin ba it bat hoat), Hib (Hemophlus influenzae typ 8) PCV (vaccin lién két phé cau); Men (Vaccin én két mang no cau); MMR (séi, quai bi, rubella), Men A, C, W135, Y (vaccin 4 khang nguyén mang no cu), True tubi dén trutng Phan ding bat Igi va chong chi dinh tim ching Néi chung, hriu hét cée vacein khuyén céo trong cchurong trinh tigm ching quéc gia déu an toan cho tré em. Tuy nhién, ciing nhir céc thude, vaccin 6 thé gay ra phan img bat loi, song nguy co d6 thuéng khong dang ké so véi nguy co bi nhiém khuin néu khong duge tiém ching. Chong 1. Djeh t& hge va diy phong nhi khoa Phan ding bit Igi sau tiém ching ¢6 thé do 18i cua tigm chiing, do ban chit cia vaccin, hay do ngaw nhién, Léi tiém ching c6 thé do bio quan vaccin khong ding hay do tiém vaccin. Phin ing ngau nbién ining lip, khing lién quan truc tiép v6i tiém ching, ‘ma xay ra bat nga 6 thoi gian tiém ching. Phan dng bat Igi do bin chat cia vaccin c6 thé phan ra, phan timg tai ché hay phin img toan thé, c6 thé ludmg truce hay khéng biét trade duge. Phan ing tai ch6 thuimg thay la dau, simg, d6 tai ch6 tiém voi mite 46 khac ‘nhau, thurong chi dién bién ngan. Phan img toan thé c6 thé ludmg trude 18 sot, va noi ban, Phan img toan thé khong biét trade durge 6 thé Ii phiin vé, xuat huyét idm tiéu cau v6 can (ITP), vi nhimg dot giam trong lye - gidm dap img (hypotonic - hyporesponsive episodes: HHES). Bang 1.14. Phan Ung bat lgi thong thuong ssau tiém ching —Vacein Phan ing batloi __Thei gian DTaPIPVIFi Phin dng tai ch8, sét,__‘Trong vong ich thigh, Kémn an 4890 Mang no —-Nhu'trén, dau dau 6 tre Trong 48 gid cau lon MMR Sdi~sétnhe, ndiban 6-10 ngay Quai bi-sétnhe, sung 18-21 ngay ‘tuyén mang tai Rubella sétrnhe, ndi_ 7-21 ngay ban, dau khop 6 ngudi ten (Theo: immunization Against infectious Disease (79) Phin ing bat loi ning sau tiém ching rit hiém xy 1a, kh xée dinh duge tin suit, Song, rit 6 ring, nguy cu phan tg bat loi thap ham rat nhigu, so vi nguy oo” bign chimg ning sau nhiém Kuan tye nin (13), thi ds = Vim nao cp do sii e6 tin suit 1/1000 trang hp, so véi 1=1,000.000 truimg hop tiém ching MMR; ~ Viém mang nao trong quai bj 6 tin suat 1/10 tragmg hyp, 80 véi 1/50.000 - 1,000,000 trum hop tiém ching MMR; "= Xuét huyét giim tiga edu trong rubella ¢6 tin suit 1/3000 tragmg hyp, so véi < 1/30.000 trudng hop tiém ching MMR. Rat it chong chi inh the sur tiém chiing, hiu hét tre em can vi phai tiém ching day dit theo lich tiém ching (26). Chong chi dinh tiém ching ligu tigp theo, nnéu di chimg mink ¢6 phin img phin ve vei mot vvacein de higu hay mot thinh phin ciia vaccin ph hop trude 46. Hoan tiém ching cho tré e6 bgnh cap tinh, thi du sot, e6 bigu hign tinh trang bénh thin kink mi chua chin dodn r6 rang, hay tién Itong chura chic chin, Véi vaccin sng, eiing c6 chéng chi dinh teomg bi vi phu nit €6 thai, bénh nhan suy gam mign dich 1 ring do duomg hod tri ligu, suy gidm min dich sau hép, nhiém HIV. 2BChiron 2 PHUON >PH THAM KHAM LAM SANG NHEKHOA yin Cin ig Khanh DAT VAN DE Mae dtu e6 nh 1 Lin bd vuUgt be v8 xét nghigm chim din vy ht nh nh song yen eo brim eta thye hiinh lim sing. vlin kt kha thie bénh sir vil Khim xét thye thé. Mye dich ei thim khdm lim ing li Tig he ede yeu t6 ign quan trong tién siz, véi ‘wig ehirng phi hign duge qua thim Khim lim «dé dua ra hurdng chin dodn, xét nghigm thim d& vil chim sée, digu tri, dir phong. Do dé thim khdm 4am siing tt, 66 ¥ mgha quyét dinh vé chin dodn, digw tr) va phong benb. Khai thie bénh sit_va Khim xét thye thé trong hi how li mot nghé thu, ddi hoi phai than trong, kign wi, toin dign vi eG KY ning, CO nhieu’ thich thie trong thin kh Kim sing nbi khoa khic v6i nngurdi Kin, Tré em khOng phi fi nguri Kin thu no & duomg tang truvmg vé thé chit, duong phat t n thire va tim I hertreem eu chirng khong dic higu. Khai the bgnh str thurimg tir ngs tie ba Tré nho edn gid han vé higu bidt, k¥ nding n6i, sriao tie, Tré em thuimg khong, hop te trong thim khém vit kh6 dr dodin truce duge. Mudn thim Khim kim sing nhi khoa t6t, cin hiéu bidt day du dic diém phat trién, tim ly cde thoi ky tu ré. Mai lita tuoi 06 dite diém rigng vé sinh IY va bénh ly, edin c6 ky nding thim kham riéng. Sau sinh, tré em dhge phan thiinh ee nhim tu6i sau: Sor sinh: 28 ney 4 Tudi nha nhi: Nam dw (12 thang du sau sinh) Tre tid hoe dudmg: 1-4 tudi Tré hoe durtng: 5-18 tu Tre tuoi thanh nign: 13-18 tudi 1é thiim khdm Kim sing higu qua, edn tao ra mot indi trudng giao tiép thudin gi voi te em va ngudi i kem, Phong gino tiép, thu tign, an todn, thong thoding, sin sing dén tgp. Khée nhau; nhidu dé P LAM SAN Chung 2 Phra pip 449 don tiép an cin, niém nd, cam thong, Khong lam wre sy hai, dju dang, vudt ve, khen ugh te : Dé tré choi dd choi, hai hude, thi tham véi tre, im tré thich th ~ Hoi edu hoi dé hiéu, ngdin Tyo long tin v6i tré vA gia dinh, cm thong, chia sé ndi Jo Kiny Phai biet King nghe, kign tri : ~Phai ton trong dac diém vé gidi, van héa, dan toe, tn gido; riéng tu “Kham xét nhg nhing, tranh lam dot ngot bat ner dé cée thi thudt can thigp sau cing = Miu mye trong cach cir xit, noi nang, tao long tin rét quan trong, Phi KHALTHAC BENH SU Khai thie bénh sir c6 ¥ nghia quan trong trong thye hanh lim sing, hudng dn vigc Kham thirc the de tiep fn chin doin. Trude khi hoi dé khai thie bénh siz, can dénh gid nbanh tinh trang bénh nhi dé xée dinh c6 cain hoi site, cp cit kip thoi. NOi dung khai thée bénh sir g0m cic phan chinh sau day’ ~ Tén, tuoi, gid, ngay sinh = Ly do dén khim, bénh hign tai Tién sir trée day: chu sinh, bénh tat, tai nan — Dinh dudg, tang truég, Phat trign sir gia din, t Tién sir sir dung thude ~ TO tat va bo sung them Ly do dén khiim bénh hign t Neay khi tigp xtc, hoi ngay Iy do gi gia ré-dén kham, tré 66 biew hign bat thuong gi? Dé bi mg m6 ti bi ia con bing tir ngit theo cach rigng, Hoi dé biét bieu hign bgnh bing tricu chimg gi, bat dau tir bao gid, nhu thé ndo, da kéo dai bao lau, dién bien lién tuc hay timg con. Hign tai trigu chimng bénh da bot, hay ting len, Lite nao, lam thé nao thi trigu ching bénh giim hay tang len. Ba duge xi tri gi chura, xir tri nhw thé ndo, bang thude gi? Sau khi ding thude c6 dé khéng, dién bin ra 500? Theo gia h gi? Dua vao ly do dén kham, thay thude dat nhimg cau hoi dae higu v6i timg loai trig chimg dé lam 10 vin dé, dé tiép cn chin dodn, Bing sau day trinh biy mot s6 trigu chimng ben, la ly do tre thudng duge dua dén khim, va huréng Khai thic dé di {i chin doin. 2s_— Phin 1. Nhi khoa dat cong ‘chan an, khong dung nap loa thie an rs nut nat Noo Tao bon TTigu chy ‘Bay bung Vang da ‘thoi hay thurdma ayer inven ua thich, th bb ine v8 chb 6 an, Bb sung amin ay thie 8 kha xem do chire nding hay thye thd, boo hop tye In he fin ra ngay Khi cb ging nubt Lugng dich ubna trong nga, twong nue teu sé ugg, 36 ln, kom theo thirc an, gdng suc hay non tye innién dé dang, e6 thd mat fray mau, kém theo dau, tony thoe “Thudng xuyén, 46 Kh, dau ini dal ten, ohd 69 an Tinh chat phan, tan subt,©8 mau trong phan Vite da, i ct dau bo Gai, ting con hay thung suyén, anh hung dn they hay van dong, isn quan do Uuéng, nhu dong rust, kém ther trigu chimg iéu héa kha, dat hong, ho Ray wut hut hi phat, K6o di, tinh chat phan va ur du, KEm theo non Bau du Réiloan thi side Lei noi Nahe Not, Tu thé bat thueng, ‘dang di hay phéi hop Van dong khong ty cht Thay abi 1am trang, hanh dong hay hanh vi Vi tri, cach wut hign, mae & tid tru, tu ehirng Kem theo Cé dinh hay tiép dién, cenit hay vién thy, ma mau, hinh Tap, tu chung Kem theo Cham hay thoai trién, tinh ‘chat, khé hiéu hay khé biéu wien Kong dap ing hay khong ena y, che nang Ray thye thé, tién sir gia dinh ‘Thdi gian, kéo dai, tn s6, co cng hay rung git, ¥ thc, thé.cd sung, thay di mau da kém theo, mat do, nahet tha, chén thing kem theo ‘Tén thong trude hay thodi trién, nga hay thutong tich Tinh chat, yu t6 xam Kin, thuong tich| Lie chor hay haat ang t ha, quan tim den nay quanh hay dao choi, ‘dome md chan nn Bang 2.1. Hung dan hdi bénh theo Tie biGu hign lam sang hoa He Tew | Hoi chi tiét théng | _ ching Toan | Sétva dé | Bat du, baolau, cach do | tnd | mS noi dém | hig 38, rt un, bigu bien nde Sutcin | Mite 46, cdch aanh gia, bao 1, dinh duting, bidu hién nd | Ban Mau sie, vitri kich thud, | tinh chat cham aut hu, | ban xudt huyét, vt, sn, mun ‘ma, mun phéng, vet lost), 8 | da, gta, bid ign Kha Timtai | Mic 40, nidm mac, thong uyén hay ting dot, ngoal bien hay trung wong, két hop voi moi trang nhst Bau hi phat, tinh chit, Kéo da ‘mic 06, khu tri, khi ndo dau hay gidm, tigu chung phdihgp, dap ing dieu HO | Chay nage | Tinh eit, k6o 6 bao lau hp) mai nude ta Bau hong, | Khu tr, phbi hop sét hay bidu autal ign 6 dp kha Ho “Tinh chdt,k6o dai, y6ut6 lam ho tang, r6iloan ng, phi oP au, tiéng rit, nd, trigu chung ho hp Khe: tin chat dorm Phat The Ph6i hop véi thay dbi mau se ‘ibn (strido) | da, ngung the thin “Thé ko khé | Koi phat, yéu tb lam ting hay |_| Ki tai din, thay dBi trong nga. tru chiing ho hap kh ‘Th ngay | Thay abi tng kre, tiéng ne, (smoxing) | the bang mieng knotne | Lic gh hay gng sic, ting te nay ln tye, dém hay | ray, phbi hop ho, im ti, mae d6 Naing the | Kéo da, tung oe, oh6i hop hep hay nbiém khusn dong tne [Twin [Tete | Licnahi oan an Mgt mdi, | Chiu dung lie gng sae, métnhoe | kong choi dua Anchim | Kém theo tic tho Tang can it | Anit anh ta, tim | Tung lic hay thudng xuyén, tai kkhi khéc hay géng sic Ta | Bair gay hay dém, ns ching rigu - ru kem theo, phn ing Neu hoa sinh | painniéu | $6 lwgng nude tidy, thay abi due | tan ch dtu aikho | Dau, Kéu Khéc hi tidu tn Thay dBi | Trigu chimg tet nigu Kem mau'sée | theo, &ai mau nueetiéu | 26Tika sit bgnh trande diy ‘Clin bai thie tid sik eh sinh, He sinh va ede Big hag tree Va sat sinh, Tre sinh a ting. hay thi thang, cn mag We ih, sinh thay ph ean thigh, 68 Kho yay’ saw sin hay bj nye sa a ke hi Khun so inh Hor dé big vE tind trang site khos chung, ¢6 Doh ssi mn tinh, etvin theron hay tai ngn, Hot dd bigt we cde gah hig Klin nr sBi, ho ga thy du, bi. vim gan, Phat higm xem tre dl img di khkim, chita beh & dda, 6 pha ding thude & nha Dinh durdug, ting tring Hoi dé bid rs 66 thm an, dink duding diy dd hay Khong hop IY. Can bit sau sinh tr8 66 duege bi ngay, ba me hay an sta edn thire, phuron dim, cai sia, Tim higu xem 6 khd khan gi ve nm ddurdmg tre nur nd tr sau ki eho dn, din kém hp tha, (@8piphat) §— 160140120 400 Huy6t ap (mig) Tamthu — Huyét aptrung 80855 inh Tam tuong ing voi 605560 truong tub thal Nhip thé; 40:60 30.50 20- 15. {ohipipht) 40 206 tré em, ri fon nip xoang ki nip va thé teh ange thay 40i theo nhip thd. The tich meh nbd khi ed try tun hoi va hep dng mach chi thé tich mach tng khi 6 ting higu suit tim nur Khi e6 thigu mu, ng thong dng mach vd Khi ed st, Saw phdu thug Blalock - Taussig, thé tich mgeh giim hoje mit rmgeh dai, mach di mit hay no nghi i. Diu higu tinh mach Kho dnh gid 6 tre nho, nhung khi thiy ip c6 the thiy khi c6 miu don nguge if nw hi tity e6 nhip nhur song dai bic (cannon waves) trong trudng hgp ¢6 bloc tim. So ving trade tim, vi tri mom tim dap thuemg & Khoang ign suri 4 hay 5, trén during gitta dn ta C6 the st thay ving canh ie dip do xung dng tht hay tigng rung do c6 tiéng thoi: manh & tim. Khi eim nha c6 rung & viing trén ire phi kiém tra xem e6 hep ong mach chi Dong thei dé lich to, va dnh gi xem c6 phi chi phi chi 1a daw higu mudn eta suy tim, Nehe hit hign e6 gan, Nghe ving mém tim dé xde dinh tiéng tim. Tiéng thir nhat li tiéng don dc, tiéng thir hai tich 401 thay 44i theo nhip thé, ting khi hit vio. Tiéng tim thir ba & mom tim thudng gap 6 tré dui nh. Nehe phat hign céc tiéng thoi 6 cae vi ti ngye (Hinh 2.4). va tre mot tu Hinh 2.4. Vj tri nghe tim ‘mdm tim; 2 mai re dus ta, $e Ue tr td, 4d dn trai; 5-bd de tén pha, 6b re dugi pha, 7-dusng rach gia phai; 8-canh cb phai; 9-canh o& trai, 10-phia sau ‘ngye (Theo Laing va Mcintosh) anh gid vi. m6 ta tiéng thoi nhue sau: “Thi: tam thy, tam trong, lign tue Giai doan: dau, gia, sau sing mhi khoa ‘Churong 2. Phuong phiip Kéo di: ng, sudt tim tha Am sie: D6 1-2: rit hg Dg 2: nhe 1g 3: dé nghe, khOng rung 6 4-6: vang v6i rung GS: nghe thy khi nhc ng nghe khdi lng neue 1D9 6: nghe khong cin dng nghe Vitek mani : Lan trayén th dt Kn 06 trong hep dng mach chis sau img trong hep €0 dng mach chiv/hep dng mach tdi nich pha trong khOng c6 vach nh " Luu yj, khi nghe tim & tr€ em c6 thé thy mot tiéng thdi nhe, nein, gia tim thu, khu tri, thay d6i theo tr thé va ho hip, thuimg @ mai tre trai dui, khong Ian truyén; tiéng thoi ny Khong phi tiéng thoi bénb 19, khong ¢6 diu higu khie cia bénh tim. Cing 6 the nnghe tiéng vang cia dong miu chiy & eée tinh mach ton 6 phia phai trén cia long nguc, thay di theo vi tr, r3 hom khi ngoi diy va mat di khi an vio ving 6; 1g vang nily cing khéng c6 y nghia bénb ly. sm theo rung (thril), 6 thi tam trong Judn Tus la tid, thdi bent I. Bang 2.12. Dc diém cia ting thdi bénh ly Ting thdi sudt thi tam thu hay tm truong Nghe dB nto bo uc tra tren Tho rap Tiéng tim the hai bat thudng ng clic 6 dau hay gid tam thu + Do huyét dp Tigu chuan vang dé do huyét 4p 1a phuong phap theo dai séng ndi mach lién tue (invasive continuous intra - arterial waveform monitoring), day li phrong phip xm lin, Nhigu phyong php do huyét 4p khong xim lin duge ép dung l& phuomg php nghe, phuwong phip do dao dong tur déng (automatic oscillometric) va phurong phip Doppler. Phuong phaip do huyét ap tam thu dang séng oxy ké (pulse oximetry waveform systolic blood pressure measurement) la phirong phap chinh xc hon phyong phip do dao dng ty dng cho tré so sinh, sau phau thugt, va bénh nha van chuyén, Huyét dp trung binh cia tré so sinh twong dong ‘v6i s6 tuan tudi thai, Huyét ap binh thudmg 6 tré em £6 thé tham Kho theo bing 11 6 trén, C6 thé use lugng gid trj huyét ap tré em nhur sau: Huyét ap = -100mmHg le 6 tudi; sau 6 tim thu tudi mdi tudi ting thém khong 2,SmmHg Huyét ap = 60+ 6 tuoi tim trong, Mac dau con han ché vé diém cat sé tuyét déi cia huyét ap tré em, song goi la cao huyét ap khi huyét ap 3Phin 1 Nbi khow dai cum : im trong > 95 ntile) theo tudi va gidi cua bang tré binh thuding, durge do it nhit 3 lan, Kj thudt do huyét dp bang éng aghe (Phuong phi Korotkott): Gidi thich cho tré biét trude khi bit dau. Tré pha 6 tw thé thodi mai, khéng khée, khong ving vay Tré ngoi, bd tay do, bée 19 enh tay phai, dé ngang v6i mat phing cua tim, Chon bang huyét ap thich hop tuéi, véng bang huyét ap di rong, khodng 75% cinh tay, tir vai dén Khuyu tay. Cée phwong phip Doppler, may do dao déng hay may sigu am sé do huyet dp ty déng. Bom hoi cang bing huyét dp, trén diém mat mach quay khoang 20mmlg, xi hoi tir tr khong 3mmHg/gidy, nghe huyét ap 6 dong mach dnb tay. Huyét ap tam thu la diém nghe thiy dap dau tién, huyét ap tam truong la diém khong nghe thay tiéng dap hoic diém thay tiéng dip nghe Kh6ng rd, Huyét ap duge do bing mmHg (milimét thiy ngan), Bing sau day ting hop mot thé phat hign khi khim tim mach va cée nguy 6 thé Bang 2.13. Dau higu thyc thé & tim - mach va nguyén nhan —Nauyén nhs Van dng, dau, gdm thé tich, nhiém khudn, nhiém 6c gidp, tim thu trang binh va / hay huyét dp trigu ching thye han Dau higu Tim 8p nhanh suy tim, phan v6, u 16 bao ua crém, thube Tim dp cham Thiéu nang ip, bloc tim, ting 4p lc n6i 0, ha than nig, suy tim, thude Cao huyét ap Lo léng, bgnh than, u té bao ua ‘8m, 60 dng mach chi, tang ap le n6i 80, noi chung Cushing va Conn, lupus ban 46 he thong thube Ha huyét ap Suy tim, gidm thé tich mau, s6¢ ‘hig khudn hay tim, phan ve, bbenh Addison, mat thang bang ign gi, thidu nang giép, thube Rung nh Hoi ching Wolf - Parkison - White, nhiém dc giap, bénh van do thép Mach kép ‘S61, nhiém d6c glp, tidy mau, (bounding pulse) tang carbon dioxt huyét Mach truy (Chay nguoe len dng mach chi, cn. éng dng mach, bloc tim nhiém “doc gidp, twain hoan cudng lve Mach phéing Hep déng mac chi, hep €0 (plateau) «dong mach chi Mach nghich Hen ning, tran dich (paradoxus) mang tim, vidm mang ti Nhip ngva phi ‘Suy that tral, gian co tim, viem uM mang ngoai tim co thit aag nO tim thu Sin PS van Pal Tes Soa Pee ‘ing nian tha Sih cin bp Tieng «ong mach, hep déng mach pha hhop dong mach cho, ting es 18h al dn ating veep niguge van hal 1s, chy ty van bala, bénh oo tim. "YE Tiéng_vang tinh mach, hi van «ong mach chi, nep van hal i chay ‘nguoe dng’ mach en, chay ngurgre ding mach phd, Nop ven bal Tibng thi cb thé sb auge Vigm mang ngodi tim, s6 thdp, vim mang ph ism phd Tiéng tnd tam tevong Tiéng rung (thrill) Tiéng co mang tim Tiéng dong tim ‘Hep dong mach chi, oj dang (eruits) «00g - tinh mach Tiéng ddyidén Phi dai that trai - mém tim, phi (iheustineave) {ai that phai - mai trai du Kham hé hap + Nhin Quan sat va nghe dé phat hién cdc biéu hién cia bénh ho hap: ~ Xem kiéu thé va dém nhip ther ~ Tim tii (o SaOs néu cin) = Tho rit thi hit vao ~ Tho Kho Khé thi the ra ~ The loc xoe (grunting) = Dap cinh mii ~ Ho - nhu ché sia trong viém thanh quan (croup), hho uit vi kho khé trong viém tiéu phé quan Co that khi quan ~ Co rit ling ngye: dui sun, khoang lién st {rn xuong din, trén ire, dud tee ~ Sir dung eo phy dé the: eo lién sun, eo te - dé ~ chim ~ Thay déi tiéng khée, tiéng ho ~ Khé néi, khé an ~ Chay nude mii, khyt khit, xudt tie dung thi tren, Ng6n hinh chiy - thudng théy trong bgnh phéi rman tinh, bénh Him mii man tinh nhur bénh xo his nang ~ Mite 46 va tu thé hoat dng = Xét nghigm dom, Quan sat lng ngve xem téng ngye 6 can déi khéng, seo long ngye, hinh ding ling ngye. Léng rngye hinh thing khi bi hen, enh Harrison do co kéo eg hon, bénh phoi man tinh & tré sinh non Xem van dong hé hap, van dong ho hip dio nguge, long neye ving ie lm vio tong khi bun pong ra 6 thi the vio va nguge lai 6 thi thd ra.Doi voi tré trén S$ tudi 6 thé ' DS we thé lm thir nghigm do at pans 28 bp, do thé tich khi thér ra. ta da, a int ha a tai bi ba vaaie ge dita tri hen, Thé tich Dinh thdng theo uo gis PME 8° WOE 86. a3 hin v Kh quin & hom é ; i gui & hom ie ttn, dng tie sy hie civ comes nen thay ig sph BA Sea ee i, ng sh ’ ven xg te, ban ay dt wong sal Ing nave, bo te tho sta. Ge bin tak dg gn ci dn ining Se ye a © 88 pat quan rane hig ng due kc wan dich mang pwn van bo i chi mang phéi, khi phé thing. Phai thye hign ca Dla te his on ue i 3 sn he bx 8 hei ing hn. el vor a dog te Ving d6ng_/ mach oni ‘Ving aye tim Mém tim 68 \Vang van hai la ve ‘Thuy trén phdi pha Thuy gjite phdi phai Vang aye gan Churong 2. Phurong phap Him sing ahi Khoa Dang thoi edn nin bung dé phat hign trigu ching ‘gan to hay gan sa thip xudng. + Nghe phéi Ding éng nghe c6 ming, nghe phia trrée, phia sau, ving niich, dn gi. luéng khi the vio, thera hal bn phdi. Lu ¥ anh gid chat luong tiéng the, c6 thé €m di, thd rip, im sic cao. Tiéng th tho rap thudme & duimg trén ho hip. Tiéng tho phé quin am sic cao hon tigng the 6 phé nang ci thi ther vao va ra, suét chigu dat dung tho. Nghe phat hign viing mit ri rio phé nang, Khi c6 ving trin dich. Nghe phat hign cfc tiéng the bat thugng nw ran nd, ran rit, ran ney, ting eo ming phi, Ran rit am sic eao & thi the ra the hin e6 co thi dung thé, xa. Ran Am khong lién tue Tien quan véi déng mé tiéu phé quan. Cling nén nhor ‘mt $6 bénh phi tré nh c6 thé khéng phat hign duzoe trigu chimg khi nghe phdi. Thuy tren phi tra Thuy dugi pho tr ‘Vang vang da day Vang dye tach Hinh 2.5. Cac méc trén ling ngye tré em (a) Trr6e, (b) Sau, (c) Ben pha, (d) Ben trai 35Phin L. Nhi koa a Bang 2.14. Dau higu thyc thé v8 ho hdp va nguyén nhan bias —— = dng nave hinh KAT phE thang, hen al Nave (pecs Han, con, lt ong carinatum) nhiém sac thé hay ‘chuyén héa ‘Nguc hinh phéu Hen, obi xzong, bat thudng (pectu: ) nhiém sc thé hay chuyén hoa ea ‘Chudi hat suon Codi xvong (thoracic rosary) Ho nhuché sda Viém te thanh quain (croup) Ho ramau Cdn song dung tho, hal lvl, aide khul, dang bg mach, tng it het Viém te than quin,viém np {anh qn shop than quan, nhiém ting bach ebu don than bach hu, «mach hay ken duct thanh men Thi ko Khe——— Hen, vem ph quan The phéquén Binh thudng 8 tre nd, vem nui Ran im tho \Viem tidy pb quan, gin pd can Ran dm nhé hat Viém pi, ph phi ep phi Comang phd Vim mang ph, wm pi, ryt kph , ng thong ksi Loting, dau, s6t, tan chuyén Tie fea, nibm thud, tid 09), thode hot chung Ret Gaim thong ko ‘Tang 4p lye nd so, thube, benh phéi Khim he tigu héa + Nhin a Dat tré nim ngira, véi tré nho ABt tré nim trén edn y bo ogc me 1 ° Sindh i nh trang dinh dudmg, Nhin mit dé phit hign ving da hay thiéu miu, Xem migng dé phat hhign co viém migng, viém Iudi, loét hay chiy miu nniém mgc migng. Kiem tra xem c6 ngén hinh chiy, e6 thé c6 do viem nhiém rust man tin, Nhin bung xem bung chudng hay bung lép, 66 thin quai rugt hay o6 khOi u, bung 06 vigm né hay e6 seo 6 bung, Néu thy phan nio 6 bung phéng to, luu vi tri va kich thug. Bung to toain thé c6 thé la bung & ‘ré béo, c6 dich 6 bung, bung tr phan hay chung hai ‘Truimg, hop bung cd trusng to kém theo c6 dau higu rin 1. Bung to Khu tri o6 thé do mot bo phan trong bung to, hode quai ru6t gidn to, Khdi uw trong 6 bung, hhode thodt vi. Thodt vi rén, hoge khe he thinh bung cing o6 thé phit hign thay Ki nhin 6 bung, Traeng hop tie rut, 66 thé nhin thay nhu déng rudt. Déng ‘thoi edn xem phan va nude tiéu, 36 + Sor nn buns : i Dé so, nin fl chinh xdc can dé tré 6 tu thé thodi ri, gdm co Nom ay true Ki in bung tr Tee 8 phan i ‘ dé Kam tré bét cha §, dé phan img khi si, nin bung, ue bat wrong hi Khim bung héi tré mot sO digu vé trong hoc hoae tro choi ma tré thich. Dé tu thé dau géi gap de pian ‘co thanh bung. Néu tré khée, nan bung i tre thy vo ge dé a ki tema. Nan cn thin eb 4 dc thinh bung, xem bung mém hay cing, ¢6 pt {mg thinh bung, c6 diém dau, vita quan sat bO mot tre 4 phit hign diem dau. Déinh gid ce bO phan, Khoi u, mit d6 trong 6 bung, Hinh 2.6. S nan: (a) Gan, (b) Lach, (¢) Than So gan: binh thuimg c6 thé s& thiy ba duéi gan, Khong 1-2cm dudi bd son phai trén duong gitta xuong din @ tré dudi 3 tudi. Truémg hop bénh ly, gan to xuong dui ving hé chu phai, di déng theo nhip thd. Do 6 phai sé gan tir ho chau phai, ding dau cic ngén tay s@ dan lén dé phat hign bo durdi gan. Luru §, trong bénh phéi gan c6 thé bj diy xudng dudi, dé kim 1a gan to, Do do, ludn ludn phai go ba trén gan, do kich tude gan bang centimet. Sér lich: 46i khi c6 thé si thay Lich & duréi bo surém trai 6 tré mhé, nat la khi c6 nhigm virus. Lach to tit ‘bo sui tri sang phii, di khi rat to ti hé chau t Xoay tré sang bén phai dé dé so thiy lich hon, Cin phan bigt lich to véi thin tri to, dua vio dic diém bo lich, & phia trén va. g@ duc ving thin. Do lich bing centimet du6i be stn, So thin, bang quang: déng théi khi khim bung, iém tra than va bing quang. G tré so sinh co thé so thay thin, song binh thugmg khong siy thy than @ tre ahd va ln, Truong hop than to nhigu 6 thé si thay & su biing mt tay, song dé thdy hon nén sé than bang, mot tay phia bung, mot tay & pha sau, than dé thay khi thé, bé than ti; hé thin phia sau cam ide diy, tay sau day lén va tay trén bung dé s& thy thin, Trudg hgp bing quang day, ¢6 thé so thy cu bing quang. So, niin phat hign vin dé khéc 6 bung: ngodi si niin cée co quan trong 6 bung, sé nan bung co thé phat hign thay c6 trudmg 6 bung, Trrdng hop 6 trudng nhiéu, c6 truéng ty do, go s& cém thay 6 rung cia dich, c6 trigu ching song v6. Truong hop c6 truéng it g6 sé thay duc ving thap, cho bénh nhan nghiéng vé phia d6i dign, g0 lai ving due thiy mat, Kiém tra xem c6 khdi u ving bung, Déng thoi kiém tra ving ben dé phit hign thodt vi, hach to ving bénh. Khi 6 bigu hign nghi ng, can kiém tra ving, hau mén, thim trye tring + Nghe 6 bung Cé thé nghe thy tiéng ru6t van chuyén hi ting hu déng trong tie rut hay tiéu chay cap, mat tiéng tnhu dng khi c6 viém phic mac hay ligt rust Bang 2.15. Du higu thyc thé 6 tiéu hoa va nguyén nhan Dau higu Nguyén nhan Bung phinh Tc rut it rub, im phic mac, to chung, khbiu, BS phn to ‘Bung hinh Todt i hoanin Bim sinh tuyén Kn6iu bung To b® phn, u, cb dich, thoat vi, nang, ap x0, 06 thai Todt v Tré cue non thigu nang gidp, hoi ching Beckwith - Wiedeman, mucopolysacctaridose ‘Thoat vjr6n VB cn, hoi chung Beckwith Wideman, noi chimg Patau, hol chung Edward Ganto ‘uy im sung huyét,viém gan, benh chuyén héa hay tr dong, cO thai Lach to “Tang dan nhan ahiém tring, ibm no tam mac, tang ap lve ira, loxémi, w Iympho, thibu mau tan mau, s6t rt Bung cling Vig phic mac Byng.g8 dye Cb truéng cchuyén ché Déurigz Cd trubng song vb soibung Te rub, vidm rupt nhi&m dO Phan bec —_Suyty, the dng mat mau Phan mau Chay mau iu hoa tn, did tr st Phan xann —-Ru6t chuyn nhanh, 46 au ngay Khong hgu HU qua thoi trién phn dui rust mon Chuong 2. Phuong phap lam sing nhi khoa Kham tiét nigu - sinh dye ‘Néu can kham tiét nigu - sinh dye, yéu cu ¢6 mat td me hay ba di kém va ghi chép day di. Truémg hop nnghi tré bi hinh ha tinh dye, nén dé chuyén gia bao ve tré dah gid. # Tré trai Kham dirong vat vé kich thuéc, xem 15 nigu dao cO @ div duong vit khong, Truimg hop 15 nigu dao thap (hypospadias) 18 nigu dao & phia bung durong vat (phia dau, thin, day chau), trudmg hyp 16 nigu dao m6 trén (cpispadias) 16 niga dao 6 phan lung duong vat. Hep bao quy dau rat phé bién 6 tré dudi 4 tudi, song phan lim khi tré lon phin da phi s& tr co Iai khong can cit bao quy dau. j Khim biu, phai si duge ci hai tinh hodn, néu chi sé thiy mét tinh hodn, can xé¢ dinh xem ¢6 phai tinh hoan khdng xudng biu hay chi do co lai, bang cach bao tré ngdi xém va khim lai, Néu phai do kich thuoe tinh hodn, sir dyng b6 do tinh hodn (orchidometer) Trin dich tinh mae rat phd bien & tré em; Khi thay biu to, ding dén pin ehigu sing s® phit hign duge tran ddich tinh mac. Khdi thodt vj ben xuéng biu sé khong phit sang, khic vi tran dich tinh mac. Thoat vi ben cing pho bién 6 tré em, cn quan tam kham xét + Tré ga Nhin xem kich thuge am vat, méi kin, méi bé, vi tri dm dao va céc chat xuat tié am dao. Phan biét khuyét 16m v6i rach ming trinh khiinghi ng& tré bj hanh ha tinh due. « Su trudng thanh vé sinh duc 16i phat trién tinh sinh duc thir yéu thay déi lon. 1 6 tré gai sm. hom tré trai dau sém tir 8 tudi, trong khi phat trién tinh hoain & tré trai bat dau hic 9-10 tuoi. Day thi phat trién nhanb lic 12 tuOi v6i tré gi va 14 tudi véi tré trai, Phin giai dogn day thi véi tré gai dya vio phit trién vi va long ‘mu, véi tré trai dya vio phat trién long mu, dong vat, tinh hodn va biu theo Tanner 1962. _ ebleilrd Pyl deity ls 37Phin I. Nhi khoa dai cong Tré gai - Phét trién vai Giai doan 1: nhur tré nho 2muva 3: vil va qudng vai to lén . 4: quing vi va nim vi nhé lén khdi via tolén 5: vi truémg thanh Tré trai - Phat trién sinh dye Giai dogn 1: tinh hoan, biu va duromg vat nhur tré iho 2: tinh hodn, biu to hon. 3: duong vat dai len 4: duong vat to, dai hon, va phit trién tuyén 5: sinh duc nhur ngugi én Gai va trai - Phat trién long mu Giai doan 1: khng 6 léng mu 2: long mu thua thot & mdi bén géc duong vat hay moi. 3: Jong thé den hom tp trung trén khp ma 4: Jong nhwr ngudi Kin, khong lan rong toi mat gilta di 5: nhur ngucsi kin, lan rong t6i mit gita di Hinh 2.7. Giai doan phat trién day thi (Theo Laing & Mcintosh, dugc phép cia Balliére Tindall) Bang 2.16. D4u higu thyc thé & oo quan sinh san va aguyén nhan Dau higu Nguyén nan To va dan ng Dy th, Béo phi, nhiBm Bbc gia, bbéah sinh dye thugng thn -tuyén yen, bénh gan, tube ibe nbibs stra Binh thuting & mit 6 90 sinh, u than - ie mie Emtec ae 5 (2a san thug than bm sinh, Merb soem th cg Pra“ WH, bt tnudrng nen s8c the ke “Tinh hon nsbng chibm, nguyen fewenice an me Ds gon tan Keb toh poss Trin dich tinh mac, thoat v, vie tinh haan Kbim than kinh Noi dung khém thin kinh bao gom: — Danks gi tinh trang ¥ thse va tisn than — Quan sét hinh dang, kich thude dau; hinh anh ‘bién dang: ton thuong than kinb - da — Tien cau bles mang niso - nlas ob tris chimg gyi §. — Kbéen bé van ding -truome lye, lye co, phan x9 ~ Diaoh gi cian gike - nies cb trig ching goi ¥ — Dich pit chire ning tibu no - dang di, thing bing va phbi bop ~ Khim thin kinh 50 10. + Nhin, so Nhin dinh gid tinh trang ¥ thite va tim thin Quan sat tur thé tré xem c6 mit 4di xitng, tr thé chi bat thudng (nhur chin bitt chéo, ligt mira ngudi, chin bbudng thong), hay c6 dng tée khdng ty chi Nhin xem e6 vét tn thuong thin kin ~ da, nhur vec cc phé sita, ming vi xanh mo, ndt mit sie (6 bay ‘mao mach 6 mit ‘ ‘Quan sat hin ding, kich thude dy, hoe nét mit it thuimg, c6 hign twemg co ctmg ea, dc bit & Ndi Nhin tré viin dong, xem e6 vin dng yéu hay vin dong it, thiing bing va trong lye toan thé. ‘Voi tré so sinh, tré dudi | tubi edn s& thop va Kho s9, xem edn he ay di déng kin, Binh thang thép trade khodng 0,5-2,5em dung kin lic sinh, ding kin le 18 thing tudi. Th6p sau khong 0,5em, dng kin sau mt thei gian ngin sau sinh, Khép s9 66 thé chong khdp lic sinh do tu thé sinh qua khung chau, Khép 9 6 thé dinh sém 6 tré sinh non, hay gifin rong do t nurdc niio that hay tang ap lye ndi so. New nghi nee 6 4j dang déng - tinh mach nao, c6 thé nghe thay tiéng 9 mio khi nghe qua xtramg so. ++ Désu higu mang no ming nio ¢ tré em khée biéu hign déu nao nhu 4 cing, dau dau, tho bén 6 ngudi Win. Cac dau higu cb dién vé ming nio nhu cig gly, sq anh sang va thop phing & tré nbd thé hhign mun ciia viém mang nao. Trigu chimg sém cia viém mang nao nhiém khuan 6 tré em la dau cing chain, Janh ngoai bién va ndi van 6 da, bénh nhan bo ba, nén vi ch thich. Khi nghi ngiy viém mang nio tim diu u cig gay. Tré 6 biéu hign cig gay thuong khong cir dng cé, nim & tu thé dudi, Bao tré gip c6 an cm vio long ngye hose xoay sang hai vai, hoe nhin nguge len phia tren, tré thye hign khé khan vi dau, Nh nhang gap ¢6 tré, dong thai nhin mat tré thay tré dau va cudng lai. V6i tré nim ngita, gip cling chin tré vio chau hong vi du g6i, im du higu Kernig, kéo thing cng chan tis dau goi, tré s@ dau c6 va phin tng. ‘Tim dau higu sy anh sng bing céch quan sat tré dap (mg kbi dura tré vio phong sang hay chiéu thing én sng vio mét tré. Voi tré cOn thép tim déw higu thop phong, hay thép trude cing; nhé ring khi tre hoe hay viing viy thi thop trude cing c6 thé phong. + Dinh gid truong le co Dinh gid truong lye co bing céch nhin tu thé tré, ___ Tré gdm truong lye co toan bé nim tu thé nhu "con éch’, khi nhac thing tre, tré 6 tur the budng thong. ‘Tré tang truong lye nim & tw thé dudi, ¢6 vem, ban tay nim chat Dinh pid trang lye eo cia than bing eéch kéo tré ngbi diy hay git tré 6 tur thé ndim shp v6i tré nbd vA 491 tré ngbi v6i tré in,trang co cimg, gidt rung hay budng thing cg. Tang trugmg live eo chi dui, Khi nbd thing tré len thay hai chan vat chéo: véi tré dang di thiy got chan cham dat Tang truomg Ive co cé thé din dén co cimg khap. lai giam truong lye co kim khép ling leo, tham chi trat khap. + Dinh gid lue co Lue ca duge danh gia bing sire manh cia nhom co, duce phan 46 nh sau: 1G 0- khong vin dng duve Bo I- c6 van ding t6i thiew 1B} 2-08 van ding song khng chiu due tong hag ‘DO 3 - van dong khang trong lye ty chit Do 4 - van dong khang duge sie can DO S- sire manh binh thong , Can anh gia xem van dng c6 déu hai bén, khéi ca (phan bigt gia phi dai co Duchenne). Voi tré nh chwa biét di, sit dung nghigm phap chire ning vin ong Ion, nghigm php 180 d6: ~ Véi tré nh nim ngita, quan sit vin dng khang Ic, c6 thé lat sp due khong. Chuong 2. Phuong phap kim sing nhi khoa = Kéo tay tré lén tu thé ngdi, xem dau 6 bj ngira ra sau ~ Xem tré c6 thé ngdi khong edn d6 khéng? Tré c6 sidt duge dau? Co phan xa bio ve khOng ~ thudng c6 tir 5-6 thang, Tré ¢6 quing tay sang phai khi xoay ngudi vé phia ben. — Xée niich dat té diimg trén mat phing, tré c6 chju duge trong lye khong? " — Nhic tré In, xem tring lye va tur thé chan, ~ Quan sit plain xa "tha di, thuimg c6 tir 6-9 thang, Ii dat te nim sap, tré s® dudi tay dé tu bio v8 'D§t tré nim sp, xem tré c6 nhac dau lén, ty d& ig cach dudi cénh tay, nhac long ngye lén khoi mit giuong. J. — Xemn tré c6 lt tir thé nim sip sang niim ngir. Voi tré Ion 4a biét di, dinh gid cde van dng lon hu chay, nhay, ngdi xém, leo tréo. Lye van dong nhd anh gid bing dong tée khéo léo. Bang 2.17. Cac tréc nghiém than kinh va van dong Trae ghia wow Nguyen nhan 66 thé Diu Babine Vach Goan gan Ban Giant g6CGEN naan Gy Gadi Blah tarda 6 é nh, tn thong ReUTON gon ca van dong én Barow Motta ot 8 cnn chay Nong tay Ka gang hang Hang knéng 08 inh {16, ding ngon cai Bn adm tran trong dura phia S20, pha ngoal xem hang oO 3 Kho hay King 0 Ginh Braga Gépmu ban chan sounding thing cng chén gy dau _Lién quan & thd Knh hing . cng eran va ving tre Diu Brudzinsti Gap abu lim chan colin ich thich mang nao Du Chvostek GO nhe than kinh mat gay giat co mat Ha calci mau Llamaong ide Tre dmg ln Bing cing tay vo chan Len dudng co Duchenne Gower Du Kemig Voi hang duBi, nang thing gb lam gan hé Khoeo va Kich thich mang no co that lung co cig Lachman Budi hoantoan du 6, rong chty chuydn vb Gin hay dit dy ching cho tute phia Idi cau xuvong dui MeMuray Gap dng va au gi 90 3. Mottay nim gt chan, Chuyn sun Kho oft nee cea gh Dusgosur big en” uensnaten dng 99k chan, trong th sb nin dong Kho, lam sarong chay xoay ra ngoai va vao trong, thay tiéng Gong chug t8 dl chuyen sun Ortolani_ Mot tay gidr ob inh chau hdng, giang hang, ding ‘Trat khép hang bam sinh ‘ngon giva én mau chuyén lon, cam thay téeg dong 7 trugt phia trude khap do tr&t khop hang Dau Romberg Nném mat khi dling gBy du dura hay nga Suy tin ginh hay cm thy ban than, t8n thuong cot sau nhém de ‘Simmond ‘Bénh nhan nm sép, van bap céng chan, Khong gp But gan Achilles duge mu ban chan Thomas 'Bénh nhan ndm ngira, dat mgt ban tay gitra cét_——_—Bién dang gdp hi sng that lung va ai ving, Gap hang Bish thurong ea iene 8 bot cang cbt séng tht lung, Chan ai cién sé nde Kd vang néu o8 bien dang gép 08 inh Trendelenburg Trang kn ing, chau néng aghing v8 bén chan Trt kop hdng bm sin, loan dung oo nang len. Phia 46 dién tén thong Du Trousseau chan (carpopedal spasm) Ep vong chi gy co tht khop mong ban tay - ban Ha calci mau, nhiém kiém, hi chang Bartter 39 wwa, NOM NAM Ano tg many » Kido pa ve geen nite wee NO 4800 940 gah PAN NG Nh} ly oot Lee oy gd Wa AME gl AN, Go pata Nig ct ga tay ed Rt tag fwd = AW 6 AS tHE He HANA. CHAE Fay Seuiks QC ct oh ANE lh Caer ne SONS ae git camel inh ia che Bi « HHO WHE VA LED ahd LRU Kn, phe tap, wl tHe kid hg S ngs hap te, Bay kh phi 48 Kb xéethurdmg guy, NG 6 tigu ching nghi Ngo, eat pit cam aide tA cd Khe bt (etmatome). ‘Dts i tién han tham dd eam give, gid thich 9 rng ohe ee ve ping hw the no. Minh, ‘hoa edioh thin, 8 cam te € tre nhin thay, Sau dé khi tidy huh dah gt bio tre him mit. Dah gi dip tg oi en eva = Khi kich thick dau, kieb thich ba as a lanh, kich thich bing rung dong va eam Hinh 2.8. Phan doan than kinh da (Theo Geigy) + Kham than kinh so ndo Kham than kinh so nao tré em doi hi thye hanh, kién tri va khéo Iéo. Bang céch theo, d6i biéu hign trén nét mat, vin dng mit, nhin tré in, nghe tré néi c6 thé cho nhiéu th6ng tin, Danh gid chi tict thin kinh so no c6 thé tién hanh bing cde nghiém phap khém xét sau day véi sv hgp téc cia bénh nha Nhiéu nighiém phap kh thue hign duge & tré nhd. anh gid khiru gidc va vi gidc khong phai la nghigm phap thing qui 6 tré em. Bang 2.18. Kham xét than kinh so ndo ~Thin kinh Nghiém phap thy hign sono T. Than kink “Trode khi thy, kibm ta xem 6 mal (66 thong. Thir cdm giéc mui timg 16 ‘midi. Thurong ding cc thir c6 mii ‘nhu ca phé, chocolat, vé cam, Khu gidc A Tada Nal Mic ‘i int yt (eA 8 wit ined adn), tong ban BANA Fay ae wn 1 4 8 A Daa ay st 7 NANNY UC TRAN IIH "Tk nat vy ng Hd, hot Yarn ganar ce dag oR Wikinty WAN nv dng KNOG WAN. wage ty ana HN roive roe vr fag 10, RA NGA AN Voda a gh i a vg avena Tanta at can vor an 880 rnin 8 4d \" Tra yen, UY 0 gle Yuen ea Nan Wee ha a bang midng bong Way NaOA lay. ‘Thi cd gid PNA truree HO bang motmau eam. S xh phan x@ giao mae, 00 Thu boeg Trchem yao goo Der uot mat trona kh ted hin Hon pv tran, wom chop mat ‘Bao tr8 on chat va Ind KNOL CO" ‘on, Tho? gia cg ham bang eaeh gO Nhe ‘ao cam bang boa phan x9, {ng ni migng mo Wy do. Vil Tan Kn Th co mat bang each bao tre mat hién eau kinh, vul va, ngge nhieA, ‘he rang, (hdl bong, huyt sao, xem Linh dt xdng, phat hide Wet, THO vf flag phan tro heOl Bang ducing, ud, urge chan UIC TAAA Wah Ther thintrgiae va thang bang. Thor {idn dinh= Ge, thinh glde bang thor nghiém lang tt tal 1x. Thain kin wai pits au UR DAN lug shu dung, mudi, nude chanh Ther eam glac hong chi thye hign cho tré Kho ‘nudt. Duing mot mau cam thir cfm ka _ gid hal ban, ae X Thin kinh” "Bako trd phat im Ung “aa’, “ova phd vi 'g', quan sat von dong vom migng, “into on bu 6d KN nuh XI, Than kinh | Nhin va 907 khdl ao tre = dn = chm poy va 9 thang, ‘GI chm mot phia, bho tr quay dau phia.chéng ial, thir lyre co tro» don = ‘cham phia di didn, ‘Thi? lye cor thang bing cach bio tro rnin va kh ob gg lm gid XI THAR Kinh” BAO rd thé IU vai dua lui te Bén u6ilue! \ndy Bang bén khidc, Quan wat 46 ch va co cng cyc bd. Bao tré dy lyBi vao mat trong ma, danh gia lye dy cia ub. wat + Dainh gid chite nding tiéu ndo Dinh gid chite nang tiéu no chi thye hign dug diy du Gtré Kin, gdm n6i dung sau; 1. Xem déng di cua tre, 2. Nghe tré ndi - noi chdm va lip li mot die didn cia bénh tiéu nao,