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PHC IU TR NGOI KHOA 7
M CL C PH N I. CHUYN KHOA NGO I T NG H P ............................. 1
1. Vim rut th a ............................................................................................. 2 2. S i ti mt v bi n ch ng vim ti mt ..................................................... 11 3. S i ng mt ch v bi n ch ng c p tnh .................................................... 17 4. p - xe rut th a ........................................................................................ 26 5. Vim phc m c .......................................................................................... 32
6. B nhtr ....................................................................................................... 39 7. Tc rutc gi i .......................................................................................... 43 8. Vim phc m c do th ng t ng rng ........................................................... 51 9. Abcess c nh hu mn ................................................................................. 57 10. R hu mn .............................................................................................. 67 11. Chnon,i u tr tcng m ch m c treo ........................................... 76
PH N II. CHUYN KHOA NGO I TI T NI U .............................. 84
12. Viembangquang ..................................................................................... 85 13. Soith ntitni u ...................................................................................... 93 14. S i ni u qu n .......................................................................................... 102
15. Viemtuyntinli t ................................................................................ 111 16. Nang th n mc ph i ............................................................................... 115 17. S i bng quang ....................................................................................... 120
18. Ti th a bng quang .............................................................................. 125
19. Tinh hon khng xu ng ......................................................................... 128
20. Gin tnh m ch th ng tinh ..................................................................... 133 21. U c bng quang ..................................................................................... 138
22. H p ni u o .......................................................................................... 148 23. Tngs n ti n li t tuy n .......................................................................... 154 24. Baoquy u rng, h p ngh tquy u ................................................... 164 25. Trn dch mng tinh hon ...................................................................... 169 26. Thn n c do cht h p khc n i b thn ni u qu n ............................ 172 27. Rbngquangm o ........................................................................... 175
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PHC IU TR NGOI KHOA 7
28. U tuy nth ng thn ............................................................................... 177 29. Ucd ngvt ....................................................................................... 184 30. Xon tinh hon ....................................................................................... 187 31. U mo tinh hon ..................................................................................... 189
32. Ch nth ngdp nt v v tth ng c quansinhd c ngoi .............. 191 33. Ch nth ngd ngvt -v vt hang .................................................... 202 34. Ni u qu n g p khc v cht h p gy n c thn .................................. 205 35. Ch nth ngv bng quang .................................................................. 212 36. S i ni u o ............................................................................................ 216 37. Ch nth ngd ngvt-v vt hang ..................................................... 220 38. Ch nth ngvv tth ngkhngxcnh c a thn ........................... 223 39. U c t bo thn ...................................................................................... 230 40. i u tr s i thn ...................................................................................... 234 41. Ch nth ngc quansinhd c nam ....................................................... 238 42. Nhi m khun ng ti t ni ukhngxcnh v tr .............................. 244 43. H ng dn s d ng khng sinh trong b nh l ti t ni u ......................... 252
PH NIII.CHUYNKHOAUNGB U .................................... 261 44. B nh u lympho hodgkin ......................................................................... 262
45. B u nhn tuy n gip ............................................................................ 271 46. Ung th gannguynpht ....................................................................... 277 47. Ungth bngquang ............................................................................... 287 48. Ungth bu ng tr ng .............................................................................. 296 49. Ungth tuy n gip ................................................................................. 305 50. Ungth ph i khng ph i t bo nh ...................................................... 314 51. Ungth ph i t bo nh ......................................................................... 337 52. Ungth thc qu n .................................................................................. 344 53. Ungth trc trng .................................................................................. 352 54. Ungth d dy ....................................................................................... 365 55. Ungth i trng ................................................................................... 376 56. Ungth v .............................................................................................. 387
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PHC IU TR NGOI KHOA 7
PH NIV.PHC I U TR CHUYN KHOA CH NTH NG CH NH HNH B NG .......................................................................... 407
Chi trn ....................................................................................................... 408
57. Gyx ngn ....................................................................................... 408 58. V o c .................................................................................................... 409
59. Trt kh p cng vai n ....................................................................... 410 60. Kh p gi x ngn ............................................................................. 411 61. Vimx ng cnh tay ............................................................................. 412 62. Kh p gi x ngcnhtay ....................................................................... 413 63. Gy trn l i c u cnh tay ....................................................................... 414
64. Gy trt c x ngcnhtay .................................................................... 415 65. Gythnx ngcnhtayph c t p ........................................................ 416 66. Gythnx ngcnhtaycli t TK quay ............................................. 418 67. Gy h lin l i c ux ngcnhtay ....................................................... 419 68. Gy h III thnx ngcnhtay ........................................................ 420 69. Gy h II thnx ngcnhtay ......................................................... 421 70. Gy c gi i phuvx ngcnhtay ...................................................... 422 71. Gy l i c ungoix ngcnhtay ......................................................... 423 72. V o khuu .............................................................................................. 424 73. Gythnx ngcnhtay ....................................................................... 425 74. Gy lin l i c u cnh tay ........................................................................ 426
75. V tth ngbntayph c t p .................................................................. 427 76. Vim t y bn tay k c vim bao ho t dch ........................................... 428 77. V tth ngbntayt nth nggng p................................................. 429 78. V tth ngbntayt nth nggndui ............................................... 431 79. T nth nggng p vng c m (vng II) ............................................ 432 80. T nth nggng p di ngn I .............................................................. 434 81. T nth nggng p c a c tay v c ng tay .......................................... 435 82. T n th nggng p bn c tay ........................................................... 436 83. T nth nggndui di ngn I............................................................. 437 84. L ch tr csaugy ud ix ngquay ................................................ 438
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PHC IU TR NGOI KHOA 7
85. V tth ngc t ngn v t bn ngn tay .............................................. 440 86. X ng t bn ngn tay ......................................................................... 441 87. Gy trt kh p c tay ............................................................................... 442 88. Gy ph c t pmomkhuu ...................................................................... 444 89. Gy ni kh px ngkh p ngn tay ...................................................... 445 90. V tth ngc t c tay ............................................................................. 446 91. Gy h thnhaix ngc ng tay ........................................................... 447 92. Gy ud iq ngquay ...................................................................... 448 93. Gyiquay .......................................................................................... 450 94. Hi ch ng ng c tay ............................................................................. 451 95. Gy monteggia ....................................................................................... 452
96. V tth ngc t c ng tay, cnh tay .......................................................... 453 97. T nth nggng p vng I, III, IV, V ................................................... 454 98. T nth nggndui c ng v bn ngn tay ........................................... 455 99. V tth ngc t c ng tay ......................................................................... 456 100. B nh de quer vain v ngn tay c sng ............................................... 457
101. D tt dnh ngn b ngvd i 2 ngn tay ............................................ 459 102. Phc i u tr gyx ngchu .......................................................... 460 103. Gy c x ngi .............................................................................. 469 104. Gyx ngvnglinm u chuy nx ngi ...................................... 475 105. Gythnx ngi .............................................................................. 479 106. Gy u d ix ngi ...................................................................... 485 107. Cc t nth ngvngkh p hng .......................................................... 490 108. B ng ..................................................................................................... 496
109. Gyx ngbnhch ............................................................................ 500 110. T nth ngdychngcheosau ........................................................... 504 111. T nth ngdychngcheotr c ....................................................... 506 112. Phc i u tr thoi ha kh p g i ..................................................... 509 113. Gy mm chy ...................................................................................... 514
114. Chn p khoang c p tnh ...................................................................... 518
115. Gyhaix ngc ng chn ..................................................................... 521
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PHC IU TR NGOI KHOA 7
116. Gyx ngbnchnvngnchn ...................................................... 525 117. D tt bmsinhc quanvnng ....................................................... 529 118. Kh p gi ............................................................................................... 535
119. Khuy t h ng ph n m m ....................................................................... 538
120. Mng qu p ........................................................................................... 541
121. U nang bao ho t dch ........................................................................... 543 122. Phc chnonvi u tr gyx ngh ....................................... 546 123. Gyx ngvngc chn, gy hai mt c ............................................ 551
PH N V. CHUYN KHOA PH U THU T TH N KINH- C T S NG ..................................................................................................... 556
124. Ch nth ngs no n ng..................................................................... 557 125. Ch nth ngs nonguyc th p ....................................................... 569 126. Mu t d i mng c ng m n tnh ........................................................ 576 127. Mu t ngoi mng c ng ..................................................................... 582
128. Mu t trong no .................................................................................. 588
129. V tth ngs no h ........................................................................... 593 130. p-xe no ............................................................................................. 601
131. Phc i u tr no ng th y .............................................................. 609 132. Phc i u tr tngplc ni s ....................................................... 615 133. Phc i u tr khuy t s .................................................................... 621 134. D dch no t y sau ch nth ng ........................................................ 626 135. Vim mng no do vi trng sau phu thut s no& ch nth ngs no
................................................................................................................. 632
136. D d ngngtnhm ch no ................................................................ 638 137. U tuy n yn .......................................................................................... 646
138. X phu Gamma knifetrongi u tr cc u vng sn s ...................... 651 139. Phc chnonvi u tr d d ngngtnhm ch no : avm ...... 657 140. Phc i u tr cavernoma .................................................................. 663 141. Phc i u tr xu t huy td i nh n t pht do v ti phnh m ch mu
no ........................................................................................................... 668
142. U dy th n kinh VIII ............................................................................ 678
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PHC IU TR NGOI KHOA 7
143. U mng no .......................................................................................... 683
144. U sao bo .............................................................................................. 690
145. H p ng s ng tht l ng ........................................................................ 696 146. Tr t t s ng ...................................................................................... 703 147. Phc i u tr aul ng nhng b nh nhn x p t s ng b ng phu
thut t o hnh thn s ng...710 148. Tim phong b th n kinh chnonnguynnhnb nhlauCSTL
m n tnh ................................................................................................... 714
149. i u tr vim thn s nga m .......................................................... 722 150. Ch nth ngct s ng v t y s ng c .................................................. 727 151. Cc t nth ngct s ng c .................................................................. 731 152. D tt gai s ng ch i .......................................................................... 742 153. Lao ct s ng ......................................................................................... 746 154. Thot v a m c .............................................................................. 752 155. Thot v a m thtl ng ................................................................... 758 156. Phc i u tr co git n a m t ........................................................... 765 157. Phc i u tr u ct s ng, tu s ng ................................................... 769 158. Phc i u tr audyV ................................................................... 774 159. X tr t nth ngm ng th n kinh cnh tay ......................................... 779 160. Ch nth ngct s ngl ng- thtl ng ................................................ 789 161. Hi ch ng ng c tay ........................................................................... 798
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PHC IU TR NGOI KHOA 7
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PH NI.PHC I UTR
CHUYN KHOA NGO IT NGH P
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PHC IU TR NGOI KHOA 7
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VIMRU TTH A
I. IC NG 1.1Khini m
Vimrutth almtc pc ungo ikhoavth nglnguynnhngy
aub ngc p c tr emvng itr ngthnhd i50tu i.B nhth ngxu t
hi n tu it 20 n30.
Tuy ngy cng c nhi u xt nghi mm i chn on vim rut th a
nh ngtl khngchnon cvn m c15-15,3%.Tl nycaoh n n
gi i.
C kho ng 14 lo i vi khun gy vim rut th a, a ph n l Escherichia
coli v Bacteroidesyragilis.Vvy,ngoiphu thutct rut th a (m hayni
soi) l i u tr chun, s d ng khng sinh d phng lm gi m tnh tr ng
nhi mtrngv tm vapxetrong b ngv iVRTc pch acbi nch ngv
khngsinhi utrchoVRTc pcbi nch ng(ho it ,pxeRT,vimphc
m cRT)lc nthi t.
ph ncthai,nguyc sythaisaum rutth al4%.
1.2.D cht h cvsinhb nhh c Minmckho ng250.000cavimrutth a Mv itl nam: nl
1,4:1.Nguyc bvimrutth atnh t1l ntrong i nam vnl nl tl
8,6%v6,7%.Tl vimrutth aminml10/10.000.
Chnonvimrutth akhkhndolinquan nnhngc quanxung
quanhrutth ak c nam v nvccvtrkhcnhauc arutth a.
Ngu ng cc arutth alt manhtrng,cchphad ivalveh imanhtrng
kho ng3cm.Rutth aditrungbnhkho ng8-10cm,ikhidit i25cm.
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PHC IU TR NGOI KHOA 7
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Cc v tr c a rut th a: qu t ng c saumanh trng, d imanh trng,
trongti ukhung,tr ch itrng,sauh itrng...
Stctronglngrutth alnguynnhnch y ugyvimrutth a.
Qutrnhdi nti nb nhchialm5giaio n:(1)tclngrutth agycng
lngrut,(2)gyti tT8-T10th nkinht ngdn naub ng vngth ngv
kodit 4-6gi ,(3)plctronglngruttngdn ntngplctronglng
m ch thnhrutth a a ntcngh nm chmuvthi umunuim,(4)
sthi umunuidn nph n ngvimvxm nhpvikhunvothnhrut
th a,(5)ph n ngvimvxmnhpvi trngxuynqua thnh rutgyvim
phcm cthnhvaukhutr %d iph i.
Th igiandi nraqutrnhnycth thay i.Mts nghinc uchol
th igian trungbnhdn nho i t l46-71gi .Tuynhina s ng l
80%rutth av sau48gi au.
Mts th khclvimrutth atipht,vimrutth abnc p,vim
rutth am ntnh.
1.3.Nguynnhngyb nh Tcngh n lngrutth a(60%)do:
- S iphnmnhnc acchns iny l ccs ix c a n, lgiuna,
giun kim, sn dy, l carcinoma, carcinoid.
- Cngcth lcch chb chhuy ttngs ntoln(nguynphthayth pht
t mtngu nnhi m, cbi t tr em).
- Tcngh ncndochnpt ngoi,xonv n,bgp.
Th ngt nvimcth bt ut mtchlotnimm c.
II.CH NON 2.1.Ch nonxc nh 2.1.1. Tri uch ngc nng - Tri uch ngg i:audi chuy n t th ngvhayquanh r n sng h chu
ph i,xu thi naukhu tr h chuph i,au tr c, saunn,b nhnhn
th yng im tm i,s t.
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PHC IU TR NGOI KHOA 7
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- Tri uch ngkhngg i:khngau h chuph i,cti ns autr c(k c vimrutth atiphtcngkhngnghchnonc pc uchob nhnhn.
2.1.2. Tri uch ngtonthn - S t t 37,5 - 38C.Trongtr ngh ps tcaoh n,c nph inghv tmcc
nguyn nhn khc
- Hich ngnhi mkhun:v m th chc,mikh,l ibn.
2.1.3. Tri uch ngth cth - Ph n ngthnhb ng:khmnh nhngvngh chuph ith yc thnhb ng
vngnycngh nnhngvngkhcc a b ng.Cng nsuxu ng,c mgic
coc cngtng,b nhnhnauph inhnm thay ytayth ythu cra.
+ Tri uch ng nau i mMc-Bumey,ngoiramts i mkhcnh i m Lanz,Cladolnhngd uch ngban u,saudi nti nquacph n ngdi, khngthnhb ng,coc ngthnhb ngnh vcoc ngthnhb ngddi.
+ D uhi ucothtl ngchu,d uc bt,Rovsing,tngc mgicdavngb ng. - Thmtrctrnghaythmm o ph nth ythnhph itrctrnghayb ph iticngm oau. 2.1.2. C nlmsng - Cnlmsngdngtrongchnonxcnh:
+ Cngth cmu
+ Sium:hnh nhvimrut th atrnsiuml rut th a nkhngx p
v i ngknh> 6mm.Ngoi ra lhnh nh tngm, tham nhi mm xung
quanh(d uc aph n ngvim)v apxe.
Siumllachn utintrongchnonvimrutth a.
+ CTscan:hnh nhvim rut th a l (1) tng ngknhngangc a rut
th a>6mm,(2)thnhrut th ady>2mm,(3)s iphn(30%),(4)d uph n
ngvi mxungquanh(tham nhi mm ,cokeom ctreo,dchquanhrutth a).
CT cchnhkhilmsngvsiumg pkhkhntrongchnon.
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PHC IU TR NGOI KHOA 7
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+ MRI:th ng cs d ngchocctr ngh pVRTkhchnon thai
ph hayng ich ngchnhch pCTb ng(nh yl100%v chi ul
98%).
- Xtnghi mdng trong ch non ccb nhkm theovph cv ph uthu t
+ Xt nghi m sinh ha: glucose, ure, creatinine, i n gi i , GOT, GPT,
protein, albumin
+ ngmuc b n:PT,APTT,much y,Fibrinogen
+ Xquangngcth ng
+ i ntim(trongtr ngh pcnghing b nhltimm ch)
+ Tytr ngh pc th cth cccchnhcnlmsngc th khc.
2.2.Th lmsng 2.2.3Th theol atu i 2.2.3.1Vimru tth atr em - Vimrutth a l atu inhnhi:r thi mg p,chnonth ngkhkhn,
th ng munkhivimphcm c
- Vimrutth a tr 2-5tu i:nhngtri uch ngnh s t,ach ynn,tr ntrc
qu ykhc,cochnbnph ig pvob ng,b ngch nglanhngd uhi ur t
hayg ptrongvimrutth a.Thmtrctrngmtcchnh nhngth ythnh
ph itrctrngaur tcgitrchnon.
2.2.3.2Vimru tth a ph n cthai Trong 6 thng u c a th i k thai nghn, tri u ch ng vim rut th a
kh ngcnhi ukhcbi tsov iph nbnhth ng.Trong3thngcu it cung
toymanhtrnglncaovxoayngoinni mauc arutth ab yln
caovl chrasaul ng.
2.2.3.3Vimru tth a ng igi Cctri uch ngauchnn,bu n nn,r tth ngg p ng iginh ng
t r m rh n.Ph n ng thnhb ng ng igi r tkno,hayg pch ng
b ng,nhi utr ngh pkhngcs t.
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PHC IU TR NGOI KHOA 7
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2.2.4Theoti ntri n 2.2.4.1Vimru tth ath nhi m c B nhnhns tcao39-40,m chnhanh nh ,th nng,t thuy tp, u
chitml nh.B ngch ngnh ,nnb ngaukhngr,khngrph n ng.Th
nyc n cm s m,k th pi utrkhngsinhli ucao,h is ctchcc.
2.2.4.2Vimru tth ath t cru t Hay g p ng i gi, b nh di n bi n chm, b nh nhn c d u hi u au
b ngc nkmtheos t,x-quangb ngth ycquairutgin,m cn cvh i
h chuph ihayti ukhung.
2.2.4.3Vimru tth adolao 2.2.4.4Vimru tth adoksinhtrng 2.3Ch nonphnbi t 2.3.1V iccnguynnhnkhctrong b ng - Th ng lotd dyttrng
- Vimtimtc p
- Vimt yc p
- Vimtith ameckel,vimh chm ctreovimrut tr em
- Vimph nph ,ch angoit cungv ,v nanghongth ,xonunangbu ng
tr ng ph n
- U manh trngvtcrut ng igi
2.3.2Ccb nhldoti tni u - C nauqu nthnhayvim ngti tni u
- Vimc ichubnph i
2.3.3M ts b nhln ikhoa Vimthyd iph iph i,mts tr ngh ps tviruscth gyauh
chuph i
III.I U TR 3.1i utr n ikhoa tr cm - B iph n cvi ngi is d ngccdungdch ngtr ng(Natriclorid0,9
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PHC IU TR NGOI KHOA 7
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%,Glucose5%,Ringerlactat)
- Dng khng sinh :
+ Chnkhngsinhcph khngkhuntrnvikhunGram mvkkh.
+ Cephlosporin th h 2, 3 (Cefotetan, Cefoxitin, Cefuroxim, Ceftriaxone,
Ceftazidim )
+ Cc Penicillin (ampicillin, piperacillin, ticarcillin)k th pv iccch t c
ch beta-lactamase (Clavulanat, Sulbactam, Tazobactam)cngth ng cs
d ng ntr.
+ nhngng id ngv iPenicillinthCarbapenemllachnt t.
+ Aminoglycoside s d ngtrongi u trvikhunGram (-)nh ngkhiph i
h pv iPenicillins lmtngctnhnnth ngt clachn.
+ Ph ih pkhngsinhdi tvikhuny mkhlc nthi t,nh tlkhiVRTc
bi nch ngpxehayvimphcm crutth a.
+ Trongtr ngh pn ng,phnt ngb nhnhntheoy ut nguyc chn
khngsinhthchh p.
Nhm
b nhnhn ntrli u atrli u
Ng i
tr ngthnh
Cefoxitin, Ertapenem,
Moxifloxacin, Tigecyclin
ho cTicarcillin - Clavulanic
acid
Metronidazolk th pv i
Cephazolin, Ceturoxim,
Ceftriaxon, Ceotaxim,
Ciprofloxacinho cLevoloxacin
Bnh nhn
cnhi uy u
t nguyc
knipenem-cilastatin,
Meropenem,Doripenemho c
Piperacillin-tazobactam
Metronidazolk th pv iCefepim,
Ceftazidim, Ciprofloxacinho c
Levofloxacin
- Gi mau:r th nch chnhkhicnangtheodivchnhm ch ar
rng.Khib nhnhnaunhi uvcchnhm ,dngthu cgi maucho
b nhnhntym cau(diclofenac,paracetamol,dolargan)
3.2.Ph uthu t
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PHC IU TR NGOI KHOA 7
8
- H uh tcctr ngh pk c rutth acbi nch ng ucth chnhm
nisoictrutth a,laur a b ng.Chnh tdnl utytnhtr ngb ngv
tinl ngc aphuthutvin.
* Chnhm m trongcctr ngh p
- Phuthutnisoig pkhkhnphtsinhtrongm
- S om ct ngd i b ngtinl ngdnhnhi u
- Ch ngchnhb mh i b ng:
+ B nhnhncb nhltimph in ng
+ B nhnhngiy u,suyki t
3.3.i utr saum *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ng tr ngv,dungdchkeo(c th tncc lo idung
dch).
- Ccch ti ngi i
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
*Dinhd ngsaum
- Cc dung dch nui d ng ng tnhm ch saum : ( ng, m,m ...)
trongnhngngy usaum davotontr ngb nhnhn,xtnghi mprotein,
LDH,HDH...saum
- Nhng tr ng h p vim rut th a c p, ho c vim rut th am c th cho
b nhnhn n s m saum .Nhng tr ngh pvimphcm cho ckhiphu
thutvintinl ngsaum cnguyc bi nch ng,cth cho b nhnhnn
khictrungti nho ctheoyl nhc aphuthutvin.
*S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i
b nh. Cc nhm hay dng: cefalosporin, nhm carbapenem, quinolon,
imidazon...K th pkhngsinhtrongcc tr ngh pvimphcm cho ctin
l ngb nhnhncnguyc bbi nch ngsaum .
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PHC IU TR NGOI KHOA 7
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*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c
th ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm tmu
ho cnghing ch ymu
Ccxtnghi msinhhamu,nhgich cnngganthnvtnhtr ngdinh
d ng: Glucose, Ure, Creatinin, GOT, GPT, Protein ton ph n, Albumin,
G...khinghing cd uhi ubi nlo n.
Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ngdi n
bi nhu phu.
- Ch chmscsaum :
+ T ich:thaybngv tm ,dnl u,
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnngs msaum
+ Vrung
- Ch dinhd ng
Tiuchu nravi n - Tonthn:tnhto,khngs t,huy tng n,nu ng c,
- T ich:v tm li nt t
- Ti khm sau 1 thng.
IV.BI NCH NGSAUM - Ch ymusaum
- Abcessthnhb nglbi nch ngth ngg pnh t.Tl tngd nlntheogiai
o nb nh,vi cs d ngkhngsinhdphnglmgi mtl abcessthnhb ng
- Vimphcm csaum :nguynnhnlm mrutth a,b cm mrutth at
khidotutchbucmch y ulqutrnhho it donhi mkhunt rutth a
lan sng ymanhtrng.C nph im l is mvh is ctchccsaum .
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PHC IU TR NGOI KHOA 7
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- Vimphcm ckhutr(abcesst nd trong b ng):nguynnhnldob c
g crutth aho cdolaum b ngch as ch
- R manh trng
- Tcrutsaum :cth xu thi ns msaum ho cxanhi unmsaum .Tc
ruts mth nglinquan n nhimkhuntrong b ng,tcrutxasaum
ladodych ngho cdnhruthnhthnhsaum .
- AbcessticngDouglas:Th ng g psaum vimphcm c,dolaub ngv
dnl ukhngt t.Phthi n cqungngyth 5saum :S t,auh vkm
c cc tri u ch ng kch thch trc trng ho c bng quang nh mt r n v a
nhi u l n rami nhy, i rt,...thm trc trng th y c kh i ph ng thnh
tr ctrctrngcngau,siumgipxcnhkh iabcs.X tr:Khngsinh
ton thn, th tn c mhumn,..sauvingys trchthom abces qua
ngtrctrng(trchdnl ungoiphcm c).
TILI UTHAM KH O: 1. B nhhcngo ikhoa,tr ng ihcyHNi
2. B nhhcngo ikhoasau ihc,tr ng ihcyHNi
3. C pc ungo ikhoa,tr ng ihcyHNi
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PHC IU TR NGOI KHOA 7
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S ITIM TVBI NCH NGVIMTIM T
I. IC NG: 1. Khini m
Ti mt c nhi m v l u gi mt - ch t l ng c s n xu t b i gan g m c
nhi u thnh ph n nh : cholesterol, bilirubin (sc t mt) v mu i mt Trong
ba n, ti mt co bp a dch mt vo rut non, h tr tiu ha ch t bo.
S i ti mt c hnh thnh khi c s lng ng, k t t c a cc thnh ph n
trong dch mt, c kch th c dao ng t vi mm n vi cm.
2. Nguyn nhn
S i ti mt c hnh thnh ch y u t s k t t c a cholesterol, do m t
cn b ng c a cc thnh ph n c trong dch mt. V d nh khil ng cholesterol
trong dch mtgiatngqum c,v t qu kh nnghatanc a mu i mt hay
khil ng mu i mt gi mi s dn t i hnh thnh s i cholesterol.
Ngoi ra, cn c th g p s i sc t mt hnh thnh do s k t t c a bilirubin
trong mt s b nhnh thi u mu h ng c u li m,x gan
3. D ch t
S i ti mt l b nhth ng g p n c ta, chi m t i kho ng 8 10% dn
s .Ban u, nhng tri u ch ng c a s i c th r tm h vth ng ch pht hi n
tnh c quathmkhms c kh enh k, ho c khi s igyrabi n ch ng
II. CH NON 1. Lm sng
a)C nng:
- auvngHSP, ckhikhngau chphthi nb nh tnhc khi siu m
b ng
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PHC IU TR NGOI KHOA 7
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- Cbi uhi nnhi mtrngtrongtr ngh pcvimtimtnh s t,mikh,
l ibn
- Khngcbi uhi nvngda,vngmttr tr ngh pcb nhlkmtheonh
s iOMC,vimgan,x gan,ho cs ik tc timt.
- Mts tr ngh pcth gyvimtuc pdos itimt.
b)Ton thn:
- Cth khng nhh ngt itonthnho c nhh ngrr ttrongTr ngh p
timtvim,ho it .
c)Thcth :
- Thmkhmb ngcth bnhth ng iv is itimt
- Khicvimtimts th ytimtto,auvcph n ngthnhb ngvngh
s nph i.Nghi mphpMurphy(+).Khitimtho it cth gyvimphc
m c.
2. C nlmsng:
Cc xt nghi m dng trong ch nonxc nh - Sium b ng:Th ngsium2l nc a2bcssiumkhcnhau trong
tr ngh ps i ngmtch nthu n.
- Ch pCT-Scanner:dng trong tr ngh pnghics i ngmt ch , s i trn
ganho ct nth ngkhckmtheo
Cc xt nghi mdng cho tin l ng, theo di, i u tr v ph c v ph u thu t
- XN mu: T ng phn tch t bo mu, ng mu ( prothrombin, APTT,
Fibrinogen),much y,Coc cmu,HbsAg,antiHCV,antiHIV
- Sinh ha mu: Glucose, Ure, Creatinin,GOT, GPT, Bilirubin ton ph n,
Billirubintrcti p,Proteintonph n,Albumin,G,Amylase, Lipase
- SHn cti u
- Xqtimph ith ng
- i ntm
+ Tytr ngh pc th cth cccchnhcnlmsngc th khc.
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PHC IU TR NGOI KHOA 7
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3.Ch nonphnbi t *C nauqu ngan
*C naub ngdolotd dy ttrng:Nisoid dyxcnhchnon
*Vimrutth a:Khicvimtimt ng igid chnonnh m
*Ugan:ch pCT b ngxcnhchnon
III. I UTR : 1. i utr n ikhoa Ch nh - S itimt nthu n:N ub nhnhncc nau,nkm,nnc nchothu c
gi mau,ginc vtruy ndch
- Khi c vim timt,i utrnikhoatr cm
i utr c th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ngtr ngv,dungdchkeo(Glucose5%,10%,20%;
Natriclorid 0,9 %).
- Ccch ti ngi i(Kali,Calci,Magie)
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
- i uchnhsthi uh tn cvi ngi idavoi ngi i
*S d ngkhngsinh:ph thuctnhtr ngng ib nh,dngcckhng sinh tc
d ngt t trn ngmtnh Sulperazolho ccckhngsinhCefalosporin th
h II,III,IV;nhmQuinolon,CarpapenemTr ngh pcnhi mtrngn ng,
cth ph ih p2 3lo ikhngsinh i utrchob nhnhn.
*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:diclofenac,dolacgan,nospa...)
*i utrh mengan:dngccthu ch menganchob nhnhnxu ngd i
100U/llt tnh tkhichunbm .
*Trongtr ngh pb nhnhncbi nch ngvimt y:Dngccthu cgi m
ti tnh (ccthu c cch H1,ch nknhH+,), tsonded dy.
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PHC IU TR NGOI KHOA 7
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*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
2. i utr ngo ikhoa - Ph nl ncctr ngh p cm nisoicttimt
- Chnhm m khi:
+ Cs om ct ngtrn b ng,tinl ngdnhnhi u
+ Phuthutnisoig pkhkhn
3. i utr sauph uthu t: *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ng tr ngv,dungdchkeo(c th tncc lo idung
dch).
- Ccch ti ngi i
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
*Dinhd ngsaum
- Cc dung dch nui d ng ng tnhm ch saum : ( ng, m,m ...)
trongnhngngy usaum davotontr ngb nhnhn,xtnghi mprotein,
LDH,HDH...saum .Nhngtr ngh pm nisoicttimtcth chob nh
nhnns msaum .
*S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i
b nh. Cc nhm hay dng: cefalosporin, nhm carbapenem, quinolon,
imidazon...
*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c
th ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm tmu
ho cnghing ch ymu
-
PHC IU TR NGOI KHOA 7
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Ccxtnghi msinhhamu,nhgich cnngganthnvtnhtr ngdinh
d ng: Glucose, Ure, Creatinin, GOT, GPT, Protein ton ph n, Albumin,
G...khinghing cd uhi ubi nlo n.
Chnonhnh nh:sium,Xquang, ctl pvitnhtythuctnhtr ngdi n
bi nhuphu.
- Ch chmscsaum :
+ T ich:thaybngv tm ,dnl u,
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnngs msaum
+ Vrung
- Ch dinhd ng
Tiuchu nravi n - Ton thn:tnhto,khngs t,huy tng n,nu ng c,
- T ich:v tm li nt t
- Ti khm sau 1 thng.
IV.TAIBI NVBI NCH NG 1. Cc tai bi n trong m v x tr :
- T n th ngcc thnhph n cu ng gan ( ng mt ch , ng gan ph i,ng
m ch gan...). X tr:khu ng mt; khu m ch mu; n i ng mt v i rut
- T nth ng itrngngang,ttrng,d dy:khuph ch i ngtiuhav
dnl ud igan.
2.Ccbi nch ngsaum vx tr : - Ch ymusaum :phuthutl i c mmu
- Vim phc m cdotut ngc timt:phuthutl i c mmt,laur a
b ngvdnl u b ng
- Rmt:n urt, ngmtthngthi utrnikhoas h t.N ut nth ng
ngmtl n,dchmtrnhi uph im khuho cn icht nth ngv i
ngtiu ha.
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PHC IU TR NGOI KHOA 7
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- Suyki tsaum ,nhi mkhunv tm :i utrb ngkhngsinhm nh,li ucao,
t tnh ttheokhngsinh vtruy nalbumin, m,dch,i ngi i
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PHC IU TR NGOI KHOA 7
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S I NGM TCH VBI NCH NGC PTNH
I. IC NG:
1. nhngha - S i ng mt ch l tnh tr ng c s itrong ng mt tnh t d i h pl u2
ng gan t i bng Vater khng k n ti mt.
2. Nguyn nhn:
- Nguyn nhn t o s i do tr v nhi m khun ng mt, c bi t l vai tr
c agiuna.Nghinc u c u trc s ing i ta th y li s i c xc v tr ng giun
a.
- Thnh ph n c a s i mt n c ta ch y u l mu i mt ( calcium- bilirunate),
trongkhithnhph n s i mt ccn cph ngtyhayBc M ch y u l
cholesterol.
- St s i sau m v s i mt ti pht n c ta cn r t cao do nhi u y u t nh
nhi m trng ng mt ti di n, h p ng mt, s i trong gan... v thi u p
d ngccph ngti n pht hi n s i trong lc m .
3. D ch t
- B nhth ng g p l a tu itr ngthnhvtngtheotu i, khng c s khc
nhau nhi u gia nam v n
- Vi t Nam nguyn nhn t o s i ph i k n nhi mtrng ng mt v nhi m
ksinhtrng(giuna)(linquan n v n phng b nh).
III. CH NON 1. Lm sng:
a)C nng: - Tm ch ng Charot:
+ aub ng h s n ph i
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+ S t: xu t hi nsauccc nauvigi (6-12 gi ) do nhi m khun ng
mt, v ic ns t rt run v v m hi .
+ Vng da
- Trongcc t tc mt c th th yng i b nhit,n c ti u smmunh
n c v i v ng a.
b) Th c th :
- Gantoth ng u v c 2 thy, mt m m,rungganau.
- Ti mt to c th r tr,ding theo nhp th ikhixu ng g n h chu ph i,
trong tr ng h p ti mt vim teo do vim nhi u l n lc nghi m php
Murphy (+).
- H s n ph i nau,ph n ng thnh b ng r
c) Ton thn:
- Tnh tr ng nhi m khun:h ith hi, s t 38-39 0 C
- c bi t c r i lo n ch cnngngmuc agannh ch ymud i da, c ng
m c do tc mt
2. C n lm sng
Cc xt nghi m dng trong ch nonxc nh - Sium b ng:Th ngsium2l nc a2bcssiumkhcnhautrong
tr ngh ps i ng mtch nthu n.
- Ch pCT-Scanner:dngtrongs i ngmttronggan,s imttiphtho c
trongnhngtr ngh pbi nch ngc as imtnh VFMmt,vimt yc pdo
s iOMC....
Cc xt nghi mdng cho tin l ng, theo di, i u tr v ph c v ph u thu t
- XN mu: T ng phn tch t bo mu, ng mu (prothrombin, APTT,
Fibrinogen),much y, Coc cmu,HbsAg,antiHCV,antiHIV
- Sinh ha mu: Glucose, Ure, Creatinin, GOT, GPT, Bilirubin ton ph n,
Billirubintrcti p,Proteintonph n,Albumin,G,Amylase, Lipase
- SHn cti u
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PHC IU TR NGOI KHOA 7
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- XQ timph ith ng
- i ntm
+Tytr ngh pc th cth cccchnhcnlmsngc th khc.
3. Ch nonphnbi t 3.1. V i cc b nh vng da khng t c m t:
- Thi u mu do tan mu t ng t
- Vim gan do virus
- Xon khun
3.2. V i cc b nh t c m t khc:
- U u t y
- U bng vater
- Unang ng mt
- Ungth ng mt
III. I U TR 1. i u tr n i khoa Ch nh - S i r t nh ng mt ch , khng tc mt, tinl ng c th t tri xu ng t
trng c
- S i trn gan, nh , khng c ch nh m
- i u tr tr c m i v i nhng b nh nhn c ch nh m
i u tr c th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ngtr ngvdung dchkeo(Glucose5%,10%,20%;
Natriclorid 0,9 %).
- Ccch ti ngi i(Kali,Calci,Magie)
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
- i uchnhsthi uh tn cvi ngi idavoi ngi i
-
PHC IU TR NGOI KHOA 7
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*S d ngkhngsinh:ph thuctnhtr ngng ib nh,dngcckhngsinhtc
d ngt t trn ngmtnh Sulperazolho ccckhngsinhCefalosporin th
h II,III,IV;nhmQuinolon,CarpapenemTr ngh pcnhi mtrngn ng,
cth ph ih p2 3lo ikhngsinh i utrchob nhnhn.
*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:diclofenac,dolacgan,nospa...)
*i utrh mengan:dngccthu ch menganchob nhnhnxu ngd i
100U/llt tnh tkhichunbm .
*Trongtr ngh pb nhnhncbi nch ngvimt y:Dngccthu cgi m
ti tnh (ccthu c cch H1,ch nknhH+,), tsonded dy.
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
2. i u tr ph u thu t: a) Ph u thu t nh m m cch:
+ L y h t s i pht hi n ctrong ng mt.
+ Gi i t ahontonl uthng ng mt
b) Vi c l accph ngphpph u thu t ph thu c : + Tnh tr ng chung c a bnh nhn.
+ Tnh tr ng b nh l c a s ivth ngt n c a h th ng gan mt
+ Trnh k thut v kinh nghm c a phu thut vin v gy m h i s c
* M m OMC l y s iv t ng d nl ukehr. Trong mt s tr ng h pkhi ng mtt ng i s ch, m b o l y h t s i c
th khukn ng mt khng c n t dnl ukehr(m ng mtlt ng).
- Dn l uVolker (dn l u ng mt ch qua t trng) n unh c cht h pc
oddi:
- M c tht Oddi qua t trng.
- N i ng mt v i ng tiu ha clmkhi:th ngt n ph n th p c a
-
PHC IU TR NGOI KHOA 7
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ng mt m khng gi i quy t c b ng m c thtOddinh :chth p ph n
th p OMC, b nh ng mt ph i h p(nang ng mt), s i ti pht nhi u l n
hay s i trong gan ph i h p...
- C hai lo i n i ng mt v i ng tiu ha: trc ti p v gin ti p:
+ Ki u trc ti p l n i ng mt (ti mt,OMC,hay ng mt trong gan)
v i t trng
+ Ki u n i gin ti p l n i ng mt (ti mt,OMC,hay ng mt trong
gan) v i t trng v i hng trng trn mt quai rut bi t lp ki u Omega hay
Roux en Y.
- Ct ti mt khi: vim ho i t , vim m hay vim teo, c s i, nghi ng ungth
ho c trong nhngtr ng h p ch ymu ng mt.
* M nhu m gan l y s i khi c s i trong gan k t h p v s igmch t vo ng m t v nh ng v tr khng th l yqua ng m t * C t gan:
- Nhi u s i ho c nhi u m khu tr v trnonh t l gan tri
- Ch ymu ng mtmkhutr c v tr ch y mu phnthyno
* L y s i ng m t ch qua m n i soi:
- L y s i ng mt ch qua nisoi:th ng sau ct ti mt nisoiquanong
ng c ti mt ho c m ng mt ch , s i c l y b ng k p gp s ihayb mr a
ng mt cho tri xu ng t trng.
- Ch nh khi s ickchth c nh v c n trang b cngnh thnhth o c a
kp m .Nongc vngOddilth thut c th c thc hi nkmtheo lm
tngkh nngs i tri xu ng t trng khi ti nhnhb mr a.
c) Bi n ch ng sau m v x tr:
* Ch y mu b ng. X tr: m l i c m mu
* R mt:
- N u r qua dnl uv i s l ng t c th i u tr ni khoa.
- N u r mt gy vim phc m c,pxed i honh: M l i c m mt
3. i u tr sau m :
-
PHC IU TR NGOI KHOA 7
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- Theoditontr ng:M ch,nhi t,HA,nhpth ,tnhtr ng b ngvdn
l u
-Truy n m,dch,i ngi i nuid ngkhib nhnhnch a cn
+ S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,
p lcTMTTvs l ngn cti u/gi ...
+ i uchnhsthi uh tn cvi ngi idavoi ngi i
- S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i
b nh. Cc nhm hay dng: cefalosporin, nhm carbapenem, quinolon,
imidazon...
- Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:diclofenac,paracetamol, dolacgan, nospa...)
- Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
+ Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm t
muho cnghing ch ymu
+ Ccxtnghi msinhhamu,nhgich cnnggan,thnvtnhtr ng
dinhd ng:Glucose,Ure,Creatinin,GOT,GPT,Proteintonph n,Albumin,
G...khinghing cd uhi ubi nlo n.
+ Chnonhnh nh:sium,ctl pvitnhtythuctnhtr ngdi nbi n
huphu.
- Ch chmscsau m :
+ T ich:thaybngv tm ,dnl u,chnkehr,theodil ngdchmt,tnh
ch tdchmtraquadnl uKehr
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnngs msaum
+ Vrung
- Theo di dch mt qua kehr :
+ Mu vng l bnh th ng,mu l b tth ng
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PHC IU TR NGOI KHOA 7
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+ S ml dch mtbnhth ngngy u tin kho ng 300-500ml/24h, khi c
trung ti n mt ph n dch mt xu ng t trng th dch mt qua kehr gi m xu ng
cn kho ng 200- 300ml/24h; t ngy th 5, 6 tr icn150- 200ml/24h.
+ C mu khng, c m khng, c bn mt ko, c s ibnkhng,xemn i
dnl ucb r dch ra hay khng.
+ Ch nh rt dnl ukehrt ngy th 15 -30 ho ch n.Cth rt khi dch
mt trong, khng c mu, m , bn mt, ch p th yl uthnghonton.Cth
k p th dnl uxemcs t,aukhng.Tr c khi rt c n ch p ng mt qua
ng dnl ukehr kh ngnh l n cu i khng cn st s i ng mt
- Dnl ud igan c rt sau 24 - 48 gi .
- Theo di cc bi n ch ngtrn x l kp th i
IV. CC BI N CH NG C P TNH C A S I NG M T CH
1. Vim ng m t c p - ng mt tr gin do s i gy tc khng hon ton, vi khun pht tri n trong
ng mtgyvim ng mt
- i u tr:
+ Dng khng sinh c ph tc d ng rng v i cc ch ng vi khun ng rut
c i kh ln y m kh, khng sinh c kh nngng m t tvo ng mt v c s
k t h p gia cc nhm
+ i u chnh r i lo nn cvi n gi i, c bi t l cc r i lo n ch cnnggan
v thn
+ Gi iphng ng mt t m th inh chc mt qua da hay m c tht oddi
qua ni soi
+ i u tr thc th m ng mt, l y s i, r a ng mtv t dnl ukehr
2. Vim m vabcees ng m t - Xu t hi n m trong ng mtv c bi t cc abcess nh tncc ng
mt nh tronggan.Th ngabcess ng mt l hu qu c avim ng mt
khng c i u tr
- i u tr:
-
PHC IU TR NGOI KHOA 7
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+ Khng sinh ton thn
+ H i s c t t
+ M c p c u gi i quy t tc mt: m ng mt l y s i giun, r a ng mt
3. T c m t c p (s i k t oddi)
- Ton b ng mt trong v ngoi gan k c ti mt b dn c p tnh, p lc
ng mttngcaov n c mt ng mquathnh ng mt, ti mt v m t gan
vo trong b ng
- i u tr:
+ Ph i m c p c u gi iphng ng mt n u th tr ngng i b nh cho
php, m ng mt ch l y s iv tdnl uKehrho c dnl u ng mt n
thu n
+ Trong mt s tr ng h p c th chc mtquada gi m p lc ng mt
r i m sau
4. Ch ymu ng m t - Mu ch yvo trong ng mt do s thng th ngb t th ng gia cc h
th ng m ch mu trong hay ngoi gan v i ng mtth ng l trong gan.
-Trong qu trnh tc mt c vim ng mt c bi t l c cc abcess ng
mt s thngth ngmtnhnhng m ch nh v i ng mt, mu ch y vo
trong ng mt to thnh c cmungxu ngttrngng c ln d dy khi n
ng i nn ra mu hay xu ng rutingoiphnen.
- i u tr:
+ Truy n mu h i ph c kh il ng tu nhonm t.
+ Khngsinh ng mt
+ Th t tho
+ Ph i m n u tnh tr ng ch y mu khng c m
+ M ng mt ch gi i quy t tnh tr ng tc mt
+ Ct cung gan c ngu n g c ch y mu ho c thtng m ch gan
+ t ng dnl ukehr
+ Ct ti mt trong ch ymu ng mt: n u nguyn nhn t ti mt
-
PHC IU TR NGOI KHOA 7
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5. Vim phc m c m t
- Bi u hi n bao g m hai hi ch ng : Hi ch ng vim phc m c v hi ch ng tc
mt
- i u tr: ph i m c u, x lnh mt vim phc m c, m ng mt ch l y s i
t dnl ukehr, ct ti mt n u ti mtcth ngt n v gi i quy t tnh tr ng
vimnh laur av t dnl u b ng.
6. Vim t y c p do s i ng m t - T i ph n th p c a ng mt ch c ph n chung v i ng Wirsung khi s i k t
voys t oi u ki n cho dch mt trong c vo ng t y v dch mt ho t
ha men trypsinogen thnh tripsin ngay trong lng ng t y, men ny t tiu h y
t y c p th ph n nh ngcngg p th ho i t
- i u tr: nn m s m gi i quy t tnh tr ng tc mtnh m ng mt l y s i
k t, t ng dn l ukehrhayct ti mt.
i v ith ngt n c a t y n u l vim t y c p ph n th dnl uhu cung m c
n i sau khi m bao t y, cn n u vim t y c p ch y mu th ph i l y h t ph n t y
ny t dnl u.Ph i m thng hngtrng cho b nhnhnnnhng ngy sau
m .
V. TIU CHU N RA VI N
- B nh nhn n u ng c, v t m li n t t, ch p Kehr thng t t, k p Kehr
khngau.
- Cc ch s xt nghi m trong gi i h nt ng ibnhth ng ho cbnhth ng.
- H n khm l i sau 01 thng xt rt Kehr.
-
PHC IU TR NGOI KHOA 7
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P - XERU TTH A
I. NHNGHA Kh irut th a lhuqu saucngc ath ng thnhrut th a cphn
lo it vimtay(mqunh) np-xerutth a.Kh inybaog m:rutth a,
m cn i,rutnon, itrng...
II.CH NON 2.1.CH NONXC NH 2.1.1 Tri uch ngc nng - Tri uch ngg i:audi chuy n t th ngvhayquanh r n sng h chu
ph i,xu thi naukhu tr h chuph i,au tr c, saunn,b nhnhn
th yng im tm i,s t.Tri uch ngauth ngxu thi ntr cnhi ungy
+ Tri uch ngkhngg i:khngau h chuph i,cti ns autr c
(k c vim rut th a ti pht cng khng ngh chnon c p c u chob nh
nhn.
+ B nhnhncth i utrthu ckhngsinhho c/vch ngvimtr c
2.1.2Tri uch ngtonthn - Hich ng nhi mkhun:S t t 37,5 - 38C,v m th chc,mikh, l i
bn.
2.1.3Tri uch ngth cth - Khmb ngcth th yb ngtr ng ccm ckhcnhau
- Ph nl ns th ykh ivngh chuph ichc, nau,dingh nch
- Ph n ngthnhb ngvc m ngphcm ctyt ngtr ngh p
2.1.2C nlmsng - Cnlmsngdngtrongchnonxcnh
+ Cngth cmu
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+ Sium:hnh nhvimrut th atrnsiuml rut th a nkhngx p
v i ngknh>6mm.Ngoi ra lhnh nh tngm, tham nhi mm xung
quanh(d uc aph n ngvim)v apxe.
+ CTscan:chnonchnhxctnhtr ngvimrut th av pxe, ng
th iphnbi t cv iccnguynnhnkhc
+ MRI:th ng cs d ngchocctr ngh pVRTkhchnon thai
ph hayng ich ngchnhch pCTb ng(nh yl100%v chi ul
98%).
Xt nghi m dng trong ch n on cc b nh km theo v ph c v ph uthu t
+ Xt nghi m sinh ha: glucose, ure, creatinine, i n gi i , GOT, GPT,
protein, albumin
+ ngmuc b n:PT,APTT,much y,Fibrinogen
+ Xquangngcth ng
+ i ntim(trongtr ngh pcnghing b nhltimm ch)
+ Tytr ngh pc th cth cccchnhcnlmsngc th khc.
2.2.Ch nonphnbi t 2.2.1V iccnguynnhnkhctrong b ng - Th ng lotd dyttrng
- Vimtimtc p
- Vimt yc p
- Vimtith ameckel,vimh chm ctreovimrut tr em
- Vimph nph ,ch angoit cungv ,v nanghongth ,xonunangbu ng
tr ng ph n
- Umanhtrngvtcrut ng igi
2.2.2Ccb nhldoti tni u - C nauqu nthnhayvim ngti tni u
- Vimc ichubnph i
2.2.3M ts b nhln ikhoa
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Vimthyd iph iph i,mts tr ngh ps tviruscth gyauh chu
ph i
III.I UTR 3.1.Nguynt ci utr - Ch y uli utrnikhoab ot n,vm phinctrutth asau3thng
- Chm c pc u trongcc tr ngh p pxekhngvng,nguyc v gy
vimphcm c
3.2.i utr n ikhoac th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ngtr ngv,dungdchkeo(Glucose5%,10%,20%;
Natriclorid 0,9 %).
- Ccch ti ngi i(Kali,Calci,Magie)
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
- i uchnhsthi uh tn cvi ngi idavoi ngi i
*S d ngkhngsinh:ph thuc tnh tr ngng ib nh,dngcckhngsinh
Cefalosporinth h II,III,IV;nhmQuinolon,Carpapenemnnph ih p2
3lo ikhngsinh i utrchob nhnhn.
*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:diclofenac,dolacgan,nospa...)
*Dngccthu cch ngvim:alphachymotripsin,lydosinat
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
3.3.i utr ngo ikhoac th 3.3.1.M c pc u - Phuthutnisoictrutth a,laur as ch b ng,dnl u
- Chuy nm m n uphuthutnisoig pkhkhnho cphtsinhb tth ng
3.3.2.M phin - Phuthutnisoictrutth a,lms ch pxen ucn,dnl u b ng
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- Chuy nm m n uphuthutnisoig pkhkhnho cphtsinhb tth ng
3.4.i utr saum *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ng tr ngv,dungdchkeo(c th tncc lo idung
dch).
- Ccch ti ngi i
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
*Dinhd ngsaum
- Cc dung dch nui d ng ng tnhm ch saum : ( ng, m,m ...)
trongnhngngy usaum davotontr ngb nhnhn,xtnghi mprotein,
LDH,HDH...saum
- Th ii mchontytheotnhtr ngb ng,theoki nc aphuthutvin
*S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i
b nh. Cc nhm hay dng: cefalosporin, nhm carbapenem, quinolon,
imidazon...i utrk th pkhngsinh.
*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c
th ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)
*Dngccthu cch ngvim:alphachymotripsin,lydosinat
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm tmu
ho cnghing ch ymu
Ccxtnghi msinhhamu,nhgich cnngganthnvtnhtr ngdinh
d ng: Glucose, Ure, Creatinin, GOT, GPT, Protein ton ph n, Albumin,
G...khinghing cd uhi ubi nlo n.
Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ngdi n
bi nhuphu.
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PHC IU TR NGOI KHOA 7
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- Ch chmscsaum :
+ T ich:thaybngv tm ,dnl u,
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnng s msaum
+ Vrung
- Ch dinhd ng
Tiuchu nravi n - Tonthn:tnhto,khngs t,huy tng n,nu ng c,
- T ich:v tm li nt t
- Ti khm sau 1 thng.
IV.BI NCH NGSAUM - Ch ymusaum
- Abcessthnhb nglbi nch ngth ngg pnh t.Tl tngd nlntheogiai
o nb nh,vi cs d ngkhngsinhdphnglmgi mtl abcessthnhb ng
- Vimphcm csaum :nguynnhnlm mrutth a,b cm mrutth at
khidotutchbucmch y ulqutrnhho it donhi mkhunt rutth a
lan sng ymanhtrng.C nph im l is mvh is ctchccsaum .
- Vimphcm ckhutr(abcesstrong b ng):nguynnhnldob cg crut
th aho cdolaum b ngch as ch
- R manh trng
- Tcrutsaum :cth xu thi ns msaum ho cxanhi unmsaum .Tc
ruts mth nglinquan n nhimkhuntrong b ng,tcrutxasaum
ladodych ngho cdnhruthnhthnhsaum .
- Abcess ti cng Douglas: Th ng g psaum vimphcm c,dolaub ngv
dnl ukhng t t.Phthi n cqungngyth 5saum :S t,auh vkm
c cc tri u ch ng kch thch trc trng ho c bng quang nh mt r n v a
nhi u l n rami nhy, i rt,...thm trc trng th y c kh i ph ng thnh
tr ctrctrngcngau,siumgip xcnhkh iabces.
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PHC IU TR NGOI KHOA 7
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X tr:Khngsinhtonthn,th tn c mhumn,..sauvingys trchtho
m abcsqua ngtrctrng(trchdnl ungoiphcm c).
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VIMPHCM C
I. IC NG - Vim phc m c l mt hi ch ng chung do nhi u nguyn nhn gy ra.
- Nhi m khun phc m cth ng ti n tri n n ng do:
+ D ti pcnv im mb nhcs n.
+ D lanto ratonbkhoangphcm c.
- Phc m c c hai l, di n tch kho ng 1,6 - 2m2 (b ng di n tch da). L thnh c
cc s i th nkinhi t i nn d p ng v nh y c m v i kch thch, vim....l
t ng th c mth n.
- V sinh l b nh phc m c l mng thm th u, c kh nngh p thu l i nhanh
mt l ng dch avokhoangphcm c(c s choi u tr thm phn phc
m c) tuy nhin s h p thu l i khng chn lc, lm cho vim phc m c cng
n ng.
- Phc m c c kh nngch ng l i qu trnh nhi m khundo ho tng thc bo
v ph n ng vim b ng s bao vy c a cc quay rut, m c n i, m c treo...
- Khi phc m c vim l lm di chuy n1 l ng l nn c,i n gi i v Protein
vo
+ Khoangphcm c
+ T ch clink td iphcm c
+ Volngrutbdnto,nh ngkhngckh nngh pthu.
Lmchoc th m tn cvi n gi i, t o cho mt v m t chung - v m t phc
m c (Facies Feritoneal).
- S c phc m c cng do hi n t ng trn gy nn ngoi ra cn do c t vi
khunlm t nth ngc timk t h p (s cth ng PVC gi m, s c phc m c PVC
l itngcao).
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II.CH NON 2.1. Ch nonxc nh vim phc m c ni chung * Lm sng
- C nng:aub nglint ckhpb ng,cth cnn,btrung iti ndoli t
rutho c iti nphnl ng
- Tonthn:bi uhi nhich ngnhi mtrngnhi mc
- Thcth :b ngtr ng ccm ckhcnhau
C c m ng phc m c ho c nghi m php Bumbergd ngtnh
* C n lm sng
Ch y u chn onnguyn nhn, theo di, tin l ng i u tr v ph c v
phu thut
- Sium b ng:Cdch b ng,cth th yccnguynnhngyvimphc
m cnh vimrutth a,vimho it timt
- Ch pCT-Scanner:Cgitrcaotrongvi ctmnguynnhngyvimphc
m c
- T ng phn tch t bomu,ngmu ( prothrombin,APTT, Fibrinogen ),
much y,Coc cmu,HbsAg,antiHCV,antiHIV
- Sinh ha mu: Glucose, Ure, Creatinin, GOT, GPT, Bilirubin ton ph n,
Billirubintrcti p,Proteintonph n,Albumin,G,Amylase, Lipase
- SHn cti u
- Xqtimph ith ng
- i ntm
+ Tytr ngh pc th cth cccchnhcnlmsngc th khc.
2.2. Phn lo i
C nhi u cch phn lo i.
2.2.1. Theo ti ntri nchiara: + Vimphcm cc ptnhtonth
+ Vimphcm ckhutr(cc pxe)
2.2.2.Theocnnguynb nhsinhchiara: + Vimphcm cnguynpht
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PHC IU TR NGOI KHOA 7
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+ Vimphcm cth pht
2.3. Ch nonphnbi t - Tc rutc gi i c ho i t rut
- Vim t y c p
- Lao phc m c
- Vim lot d dy t trng.
- C nauqu n thn.
- C nauqu n gan.
III.I UTR 3.1. Vim phc m c tin pht
3.1.1. ci m chung * T n t nth ngt u
- Vi khunth ng ch mt lo i (2/3 l t c u khun tan mu, 1/3 l t c u trng).
- Th ng g p tr emd i 10 tu i ho c trn b nhnhnx gan
3.1.2. Nguyn t ci u tr - i u tr ni khoa l chnh
- Nh ngnghing cngph i m trnh b st vim phc m c th pht
3.1.3.i u tr c th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ngtr ngv,dungdchkeo(Glucose5%,10%,20%;
Natriclorid 0,9 %).
- Ccch ti ngi i(Kali,Calci,Magie)
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
- i uchnhsthi uh tn cvi ngi idavoi ngi i
*S d ngkhngsinh:ph thuctnhtr ngng ib nh,dngcckhngsinhtc
d ngt t trn ngmtnh Sulperazolho ccckhngsinhCefalosporin th
h II, III, IV; nhmQuinolon,Carpapenemnn ph i h p2 3 lo i khng
sinh i utrchob nhnhn.
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PHC IU TR NGOI KHOA 7
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*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:diclofenac,dolacgan,nospa...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
3.2. Vim phc m c th pht
3.2.1. ci m chung - yl lo i th ng g p lm sng, nhi m khunth ng bt u mt t ng
trong b ng r i nhi m khun khuy ch tn ra, c khi do v .
- Vi khun th ng ph i h p, hay g p l Ecoli, lin c u trng sinh m , t c u,
ph c u.....
- Gi i phu b nh l: thanh m c, ch y u phc m c t ngthnhdyln,tngsinh
m ch mu, ph n , m c treo m c n i u dy ln.
Dch phc m cth ng c, c th khng mi ho c khng th i ( c khi qua
dch phc m c m ta c th chnon c nguyn nhn).
3.2.2.Cnnguynth ng g p - Vim rut th a v
- Th ng lot d dy t trng
- Th ng ti th a
- Xon rut ho i t
- Vim ti mt
- Th m mt
- p xe gan v
- X d sau phu thut.....
3.2.3.i u tr Nguyn tc l ph ii u tr ngo i khoa k t h p v i h i s c ngo i khoa tch cc.
* H i s c ngo i khoa
- Truy ndch,i ngi i bn c,i ngi i
- i uchnhthngb ngki mtoan(Natribicacbonat).
- Khngsinhph rng,m nh,t tnh tltheokhngsinh vph ih pkhng
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PHC IU TR NGOI KHOA 7
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sinh
- mb ohh p,h nhi t...
* i u tr ngo i khoa - Nguyntc:M cngs mcngt ttrnc s h is ctchcc.Ckhiv ah i
s cv am .
- Nidungphuthut:
Gi i quy t nguyn nhn: Ct rut th a, khu l th ng ....
+ Laur a b ngs ch,chccvngth p,cch .
+ Dnl uchi uqu (vtr,kchth c,...c a ngdnl u,rts m,khng
gydnh,nhi mkhun).
- Mts ch:
+ Vc m:Gymnikhqu n.
+ ngm :vo ngtrcti pho c ngtrnggiatrnd ir n.
+ h da,ho cngda th a,ho cngb ngmt l p ton th khing
thnhb ng.
IV.CHMSCVI UTR H UPH U 1. i utr saum *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cc lo idungdch ng tr ngv,dungdchkeo(c th tncc lo idung
dch).
- Ccch ti ngi i
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
*Dinhd ngsaum
- Cc dung dch nui d ng ng tnh m ch saum : ( ng, m,m ...)
trongnhngngy usaum davotontr ngb nhnhn,xtnghi mprotein,
LDH,HDH...saum
- Chob nhnhnnkhictrungti nho ctheoyl nhc aphuthutvin.
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PHC IU TR NGOI KHOA 7
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*S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i
b nh. Cc nhm hay dng: cefalosporin, nhm carbapenem, quinolon,
imidazon...K th pkhngsinh
*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c
th ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm tmu
ho cnghing ch ymu
Ccxtnghi msinhhamu,nhgich cnngganthnvtnhtr ngdinh
d ng: Glucose, Ure, Creatinin, GOT, GPT, Protein ton ph n, Albumin,
G...khinghing cd uhi ubi nlo n.
Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ngdi n
bi nhuphu.
- Ch chmscsaum :
+ T ich:thaybngv tm ,dnl u,
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnngs msaum
+ Vrung
- Khudath2khiv tm s ch,t ch ch tmct tv inhngtr ngh pkhu
dath aho c h da
2. Tiuchu nravi n - Tonthn:tnhto,khngs t,huy tng n,nu ng c,
- T ich:v tm li nt t
- Ti khm sau 1 thng.
V.BI NCH NGSAUM - Ch ymusaum
- Vimphcm csaum
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PHC IU TR NGOI KHOA 7
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- Vim phcm ckhu tr (abcess t nd trong b ng):nguynnhn ldo r
tiuhaho cdolaur a b ngch as ch
- Tcrutsaum :cth xu thi ns msaum ho cxanhi unmsaum .Tc
ruts mth nglinquan n nhimkhuntrong b ng,tcrutxa saum
ladodych ngho cdnhruthnhthnhsaum .
- Nhi mtrngv tm
TILI UTHAM KH O 1. B nh hc ngo ikhoasau i hc, HVQY 1993, tp 1, 2
2. Ngo i khoa sch b tcsau i hc,HYHN1984
3. Chuyn khoa ngo i NXBYH 1985
4. Tai bi n v bi n ch ng phu thut, HVQY 1988
5. B nh hc ngo i khoa, NXBYH tp 1, 2 ph n b ng 1985, 1986. Ph n t y lch
1991
6.Bchkhoath b nh hc tp1, 2, NXBYH
7. B nh hc ngo i khoa b ng,HVQYNXBQND1997
8. Maingot sAbdominal operations. T1, T2 Appleton & Lange, A. Simon&
Schuter company, Printed in the United State of America 1997
9. David Sabiton; Textbbook of Su rgery, the bilogical basis of mordem
sugical practice, T1, T2 Sauders Companny, Printed in the United State of
America 1997
10. Encclopdie Mdico Chirurgicale, Technipues chirurgicals, Appareil
digestif, T1, T2, T3, Printed in France, 75015 Pari
-
PHC IU TR NGOI KHOA 7
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B NHTR
I. IC NG 1.1. nhNgha - Trlmtb nhr tph bi n,tl mctrongcng ngkho ng35%.B nch t
c atrlhi nt ngdnc acctnhm chhumntrctrng
- Trhnhthnhdos dn qu m cmr itnhm chtr + Trnitrn ngl c
Trngo in md i ngl c
1.2. Nguyn Nhn
- Thuy tc hc:ccms ic nh igimr itnhm chchngdnd n,
ml ngl onh tlkhiplcxoangb ngtnggyrasatr.Ccnguynnhn
lmtngplctrong b ng,ccnguynnhntobn,bti u,ng inhi u, ng
nhi u,mangvcn ng
- Thuy thuy tnghc:c ch ngm ccshuntngtnhm chvng ng
humn
II.CH NON 2.1. Lm sng
B nhS - ingoiramut i
- C mgicn ngt c humn,mtr n
- Bitrsarangoi
- N ucbi nch ngthuyntc,n tk humnc mgicauddi.
Khmth cth - Thm trc trng l ng tcquan trng: tr ngh t, thuyn tc, r i lo n ch c
nngc tht
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- Soihumn
- Khmtonthn:x gangytrtri uch ng
2.2.C nLmSng Cc xt nghi m dng trong ch nonxc nh Soi i trc trng ng m m
Cc xt nghi mdng cho tin l ng, theo di, i u tr v ph c v ph u thu t
- XN mu: T ng phn tch t bo mu, ng mu ( prothrombin, APTT,
Fibrinogen),much y,Coc cmu,HbsAg,antiHCV,antiHIV
- Sinh ha mu: Glucose, Ure, Creatinin,GOT, GPT, Bilirubin ton ph n,
Billirubintrcti p,Proteintonph n,Albumin,G,Amylase, Lipase
- SHn cti u
- Xqtimph ith ng
- i ntm
- Sium b ng
- Ch pCT-Scanner:dng trong tr ngh pnghics i ngmt ch , s i trn
ganho ct nth ngkhckmtheo
+ Tytr ngh pc th cth cccchnh cnlmsngc th khc.
2.3.Ch nonphnbi t - Dath ahumn
- Polyptrctrng,polyp nghumn
- Sanimm ctrctrng
- iti nau,phnmudovim itrctrng,n tk humn
2.4. Phnlo i - Theo Milligan-Morgan:G mc3lo i
+ Trni
+ Trngo i
+ Trhnh p;trvng
- M c:Chiatrnilm4phn
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+ I:N mhontontrong nghumn
+ II:Sakhiingoi,tth to
+ III:Sakhiingoi,khngtcoln cph il ytay yvo
+ IV:Th ngxuynn mng i
III.I U TR 3.1.i uTr N i - ChnhchotrI,IIvcctr ngh p iphuthut
- Cchth c:Nghng i, thay ich n,ch ngtobn, th d cli uphp,
thu cDaflon,Ginkorfort,Proctolog.K th pngmhumn.
3.2.i uTr Ph uThu t - Ch nhchotrIIIvIV,trngo ithuyntchuy tkh i
- PhuthutMilligan-Morgan;phuthutFerguson;PTWhitehead
- PhuthutLongo:gi ml ul ngmu nbitr;treo mhumnvo ng
humn.
- K thut khu treo tr b ng tayM.Hussen, Nguy n Trung Tn (c i bin t
ph ngphpLongo):baog m ngkhutri tm chv ngkhutreotr
+ ngkhutri tm chg m12mikhuchX,trn ngl c2cm,l y
l pnimm cvd inim
+ ngkhutreotr:8mikhuchIkhutreo ngkhuth nh t,trn
ng l c 6cm, l y nimm c d i nimm c vmt ph n vo l p c trc
trng
Xuh ngi utrtrhi nnay:b ot nl p mhumn,gi mth tchbi
tr,tauS d ngvngtrn ngl c.
3.3.i utr saum Dng khng sinh ph rng v ph i h p khng sinh ph thuc vo tnh tr ng
b nhlc ang ib nh.Ccnhmhaydngnh Cefalosporinth h II,II,IV;
Penicillin
Thu cnhuntrng
Gi mautym cauc ab nhnhn(diclofenac,paracetamol,dolargan)
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Thu cctcd ngtngc ngh tnhm ch:thu cctcd ngtngc ngs c
b n m ch mu, lm gi m tnh cng gin v tr c a tnh m ch: Daflon,
Ginkofort.Cchdng:trc p,angch ymu:Daflonvin500mgli u6vin 4
ngyr i4vin 4ngyti pvgi mxu ng2vintrong 6 ngy.
ngt ich:thu cbihayvin t:Titanorein,Proctoloc,efferangan
TiuChu nXu tVi n B nhnhnkhngau,khngch ymu, iti uti nbnhth ng;
IV.BI NCH NGSAUM - Ch ymu:ch ymut di nctchnbitrho ct ngkhu iv iphu
thutLongo.Tym cch ymucth b ot nb ngngmhumnk th p
nhtmchet ichho cph im l ic mmu
- ausaum :ch y ucctr ngh pccttrd i ngl c
- R ilo n iti n
- H phumn:x trb ngcchnonghumn
- Vimtrctrng
- Bi,au udohuqu c agytt ys ng
Ti li u tham kh o:
1. Ngo ikhoac s .NXBYhcHNi
2. Tri uch nghcNgo ikhoa.NXByhcHNi
3. Gi iphuthc hnhngo ikhoa.NXByhcHNi
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T CRU TC GI I
I. IC NG - Tcrutltnhtr ngb nhlmsl uthngccch ttronglngrutbgi m
ho cm t.ylmtc pc ungo ikhoar tth ngg ptrongc pc u b ng.
- Tcrutcth xyra mil atu iTl nam,nbtcrutlngangnhau.
- Tcrutc hcc3nhm:
+ Donguynnhntronglngrut:giun,bth cn,s iphn
+ Donguynnhn thnhrut:cckh iulnhho cctnh,l ngrut,lao
rut,b nhcrohnrut,vimrutsaux tr,h pmi ngn irut,h prutsauch n
th ng
+ Do nguynnhnt ngoithnhrut:dych ngvdnhr tth ngg p,cc
thotvthnhb ng,thotvni,xonrut...
II.CH NON 2.1.Ch nonxc nh Lm sng
a)C nng - aub ngc n
- Nn
- Btrung iti n
b) Ton thn
- S m:d uhi um tn c,r i lo ni ngi ich ar
- Mun:b nhnhncth tr ngthishock,s cccd uhi uc am tn cv
r ilo nn ci ngi i,d uhi unhi mc,suythn
- Xonrut:shockcth xu thi nngaytrongnhnggi uc ab nh.
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PHC IU TR NGOI KHOA 7
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c)Th cth - B ngch ng
- D uhi urnb
- Quairutn i
- D uhi uti ngrodichuy nc ah ivdchtronglngrut
- S nn c th th y nguyn nhn gy tc rut nh kh i thot v, kh i u i
trng,kh iurutnon,bigiun
- Thmtrctrng:cth s th yutrctrng.
2.2.C nlmsng 2.2.1Ccxtnghi m ch non: - Ch pXquang b ngkhngchunb:th yccquairutgin,hnhm cn c
m ch i,khngch itdotrong b ng
- Sium b ng: th yhnh nhrutginh ivch anhi udchdotcrut,
dch b ng,cth th ynguynnhntcrutnh kh iu,kh il ng,bigiun
- Ch pCT- Scanner:chnonvtrtcrut,tnhtr ngt nth ngc athnh
rutvmts nguynnhngytc:dou,bigiun,bth cn
2.2.2 Cc xt nghi m di utr ,tinl ng,theodib nh: - XN mu: T ng phn tch t bo mu, ng mu (prothrombin, APTT,
Fibrinogen),Coc cmu,HbsAg,antiHCV,antiHIV,nhmmu,
- Sinh ha mu: Glucose, Ure, Creatinin, a Uric, GOT, GPT, Bilirubin ton
ph n,Billirubintrcti p,Proteintonph n,Albumin,Gross,Maclagan,HDL,
LDL,Cholesterol,Triglycerit,G,
- SHn cti u
- Xqtimph ith ng
- i n tim,siumtimn ub nhnhncbi uhi n,ho c ti ns b nh l tim
m ch.
2.2.Ch nonphnbi t 2.2.1.B nhn ikhoa: a)C nauqu nthn:
-
PHC IU TR NGOI KHOA 7
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b)Nh imuc tim:
c)C nauqu ngan
d)Ccb nhnikhoa tg pkhcnh :c ngtuy ncngip, r i lo nchuy n
haporphyrin,nhi mcch,gind dyc ptnh,mts thu cgyli trut,
h K+mu
2.2.2.B nhngo ikhoa a)Ccb nhngo ikhoacs tc a b ng: tnh tr ngvimphcm cgy li t
rut
b)Vimt yc p
c)Nh imum ctreorut
d)V phnhngm chch sauphcm c
e)Tcrutdoli trut
f)Hich nggi tc itrngc ptnh:b ngch nglchnh,khngaub ng,
khngnn,vncth trungti nho ctiuch y
III.NGUYNT CI UTR - T tc nhngb nhnhntcrutc gi i ucchnhphuthutc pc u-
B nhnhntcrutnn cm s m,trongvigi u,kodith igianh i
s ctr cm qulucth lmtngtl bi nch ngvt vongsaum .
- B nhnhncchnhb o t nph i c theodist, thmkhmnhi ul n
b nglmsng,ch pX- quang b ngkhngchunb.
IV.I UTR TR CM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
- Cclo idungdch ngtr ngv,dungdchkeo(natriclorid 0,9%; glucose
5%,10%,20%;ringerlactac).
- Ccch ti ngi i:Na,K,Ca,
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
- i uchnhsthi uh tn cvi ngi idavoi ngi i
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PHC IU TR NGOI KHOA 7
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*S d ngkhngsinh:ph thuc tnh tr ngng ib nh,khngsinhph rng
tonthn,dng ngtimho ctruy n,ccnhmkhngsinhth ngdungl:
th h 3,suferazon,metronidazone,imipenem,quinolon.
*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p,vnm chn ucsock,
* tsonded dy
* tsonde ti u
V.I UTR PH UTHU T 5.1.Nguynt c - ngm : ngm giatrnvd ir n,mts tr ngh p cbi tch
c n ngm nh :lmHMNTphatrnutrongtcrutdou itrng,thotv
b nngh t,thotvingh t
- Tytheotnhtr ngb ngvnguynnhngytccth phuthutnisoi
b ngho cm m .
- Thmd tmnguynnhn tc:v trvnguynnhngy tcn m ch n i
giao nrutph ngvo nx p.
- X lnguynnhntc:tytheonguynnhntcmccchx trkhcnhau.
Rutho it thcto nrutvn ingayn ulrutnon, ahai ura
ngoithnhb ngn utc itrngho cctnhtr ngvimphcm c
- Lmx prut
5.2.Ph ngphpph uthu t * iv iccnguynnhngyt c ru tnon - Do dy ch ng,dodnh:ctdych ng,g dnh
- Doxonrut:n uho it thph icto nrutvkhun ingay(khng
thoxon).N urutch aho it ththoxon,phngb xylocain,pg c m
- Thotvngh t:gi iphngthotv,x lnidungthot v(b ot n,cto n
rut),ph ch ithnhb ng.
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PHC IU TR NGOI KHOA 7
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- V ithotvni:chcth chnontrongm ,gi iphngngh t.
- L ngrutc p:
+ Tr cnb:chnhthol ngb ngh i,th tbarytho cth tn c, ttrn
90%.
+ M c pc ukhi nmun,b ngch ng nhi u,thol ngkhngck tqu .
M thol ngn urutcnt t,cto nrutkhirutho it .
+ ng i l n: tg pvth ngdou i trngvth bnc p:m c pc u
n utcrutvx trnh tcdou itrng.
- Tcdodvt:
+ Do giun m rutl ygiunvkhul irut.
+ Dobth cn:ph iki mtratonbt d d yt igch imanhtrng
trnhb st,cth m rutho cbpntbth cnyxu ng itrng.
- Dourutnon:cto nrutcuvn ingay.
- Tc rut saum :i u trnikhoa tr c,m c pc ukhicd uhi ungh t
ho ci utrnikhoath tb .
* iv iccnguynnhngyt c itrng: - Tc itrngph i:u itrng,xon itrngph i ct itrngph i,n i
ngayn utnhtr ngtonthnvtnhtr ng b ngchophp
- Tcdou itrngtri:ct itrngcu,lmhumnnhnt o,n irut th
sau.
- Tcrut tr ctrng:cto nrutcuvlmHMNT.
- Xon itrngsigma:
S m:t ngsondehumnthoxon.
Thoxonth tb iho ct imun,rutho it thct itrnglmHMNT,
n irut thhai.
VI.I UTR VCHMSCSAUM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan
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+ Cc lo i dung dch ng tr ng v, dung dch keo (natriclorid 0,9%;
glucose5%,10%,20%;ringerlactac,albumin).Ph thuctnhtr nglmsng
vxtnghi mc ab nhnhn.
+ Ccch ti ngi i:Na,K,Ca,
+ S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,
plcTMTTvs l ngn cti u/gi ...
*Dinhd ngsaum
- Ccdungdchnuid ng ngtnhm chsaum :( ng, m,m ...)trong
nhng ngy u sau m da vo ton tr ng b nh nhn, xt nghi m protein,
LDH,HDH...saum
* S d ng khng sinh: theo khng sinh (n u c). Cc nhm hay dng:
cefalosporin, nhm carbapenem, quinolon, imidazon...
*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c
th ngdng: diclofenac, paracetamol, morphin, dolacgan, nospa...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
+ Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm t
muho cnghing ch ymu
+ Ccxtnghi msinhhamu,nhgich cnngganthnv tnhtr ng
dinhd ng:Glucose,Ure,Creatinin,GOT,GPT,Proteintonph n,Albumin,
G...khinghing cd uhi ubi nlo n.
+ Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ng
di nbi nhuphu.
- Ch chmscsaum :
+ T ich:thaybngv tm ,dnl u,
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnngs msaum
+ Vrung
-
PHC IU TR NGOI KHOA 7
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- Ch dinhd ng
VII.CCBI NCH NGSAUM VH NGX TR Ch y mu sau m (ch y mu trong b ng, ch y mu v t m ): phu thut l i
c m mu, khu l i v t m .
VPM sau m do b c, x mi ng n i ng khu: phu thut l i, x l nguyn
nhn.
pxe t nd :i u tr khng sinh m nh, ph i h p, truy n dchvi n gi i
Tc rut s m sau m :th ng ph i phu thut l i gi i quy t nguyn nhn
* R tiu ha:
- N ukhngcvimphcm cthi utrnikhoab ng tsonde b nght
r alint c.
- Chokhngsinhm nhph ih p.
- Nuid nghontonb ng ngtnhm ch:truy nalbumin, m,m ,i n
gi i nkhirtiuhali n.
*Nhi mtrngv tm :tchv tm ,chi un,s d ngkhngsinhtheokhng
sinh .
* B c v t m : khu l i v t m , dinh d ng ng tnh m ch b ng truy n
albumin, m,m .
*Xuy thuy ttiuhasaum cth xyra,hayg p b nhnhntr c,trong
vsaum cshock.
*Vimph i,vim ngni u,lottdon mlu...
VIII.TIUCHU NRAVI N - Tonthn:tnhto,khngs t,huy tng n,nu ng c.
- T ich:v tm li nt t
- Ti khm sau 1 thng.
TILI UTHAM KH O 1.PGS.TS.HVnQuy t(2006),Tcrut,B nhhcngo idnhchosau i
hc,trang188- 198,Nhxu tb nYhc2006.
-
PHC IU TR NGOI KHOA 7
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2.LHng,i utrtcrut,Bigi ngi utrhcngo ikhoa,trang336 -
365,Nhxu tb nYhcChinhnhThnhph H ChMinh2007.
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PHC IU TR NGOI KHOA 7
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VIMPHCM CDOTH NGT NGR NG
I. IC NG - Th ng t ng rng: th ng rut do th ng hn, vim ti th aMeckel ho i t ,
vimtith a itrngho it (tg pth ngm ram ichnon c).Hay
g pth ng lotd dyttrng,i utrk tqu t tn u cphthi ns mv
x trkpth i.
- Chnond vas cctri uch ngi nhnhvrr t
- Theoth ngknam gi inhi uh nngi i
II.GI IPH UB NHL * Lth ng:
- Th ngchmtlth ng,r ttkhith yhaihaynhi ulth ng.
- Lth ngcth mtlotnonhayb chaic ngdoqutrnhti ntri nlu
di
- Vtrlth ngth ng m ttr cttrnghayd dy.
- Tnhtr ng b ng: b ngs chhaybnkhcnhautytheob nhnhn ns m
haymun,th ngxahayg nban,lth ngtohaynh
III.CH NON: 1. Lm sng:
* Ton thn:
- ns m:
+ Tnhtr ngtonthnch athay inhi u
- nmun:tnhtr ngnhi mtrng,nhi mcn ng
*C nng:
- auth ngvtngtddi
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PHC IU TR NGOI KHOA 7
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- Bu nnnho cnn
- Btrung iti n
*Thcth :
- Nhn:b ngc ngkhngdingtheonhpth ckhib ngh ich ng
- S nnth yb ngc ngnh g
- G:vng ctr cganm t,g cvngth p
- Khmtrctrng:auticngDouglas
2.C nlmsng: 2.1Ccxtnghi m ch non: - XQ b ngkhngchunb:hnh nhli mh id ivmhonh2bn(kho ng
80%).
- Cc tr ngh pkhph i ch pCT b ng: ckh tdo trong b ng,ho c
chnonphnbi tv ib nhlkhcnh :tcrut,vimt yc p,
2.2Ccxtnghi m i utr ,tinl ngvtheodib nh - XN mu: T ngphntcht bomu:b chc utng,ngmu: prothrombin,
APTT,Fibrinogen,coc cmu,HbsAg,antiHCV,antiHIV,nhmmu,
- Sinh ha mu: Glucose, Ure, Creatinin, a Uric, GOT, GPT, Bilirubin ton
ph n,Billirubintrcti p,Proteintonph n,Albumin,Gross,Maclagan,HDL,
LDL, Cholesterol, Triglycerit,G,ment y,
- SHn cti u
- Xqtimph ith ng
- i n tim,siumtimn ub nhnhncbi uhi n,ho c ti ns b nh l tim
m ch.
- Sium b ng:cdchtdotrong b ng.
3.Ch nonxc nh: - Ti ns :i utrvimlotd dyt trng
- autngtddivngth ngv
- B ngc ngnh g
- Gm tvng ctr cgan
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PHC IU TR NGOI KHOA 7
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- XQ b ng:chnh nhli mh id ic honh.
- Ch pctl p b ngm c as kh:ckhtdotrong b ng.
4.Ch nonphnbi t - Vimt yc p:Amylase mu, ni utngcao
- Vimphcm crutth a
- Vimphcm cmt
- Tcrut
IV.I UTR TR CM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan:
- Cclo idungdch ngtr ng,dungdchkeo,ccch ti ngi i.
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
- i uchnhsthi uh tn cvi ngi idavoi ngi i .
*S d ngkhngsinh:khngsinhph rng ton thn,dung ng timho c
truy n, cc nhm khng sinh th ng dung l: th h 3, suferazon,
metronidazone,imipenem,quinolon.
*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc
lo ithu cth ngdng:paracetamol, morphin, dolacgan, ...)
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,vn
m chn ucsock,
* tsonded dy.
* tsondeti u.
V.I UTR PH UTHU T *Khulth ngd dy- ttrngb ngphuthutm ho cphuthutnisoi,
laur a b ngvdnl u.
*Khulth ng- n ivtrng.
*Cto nd dytrongtr ngh p:
- lotx chai,khkhu,khud b c
- lotcnhi ul nch ymuho cch pmnv
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PHC IU TR NGOI KHOA 7
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- lotnghingh ungth ha
- Tontr ngb nhnhnchophp,trnhkinhnghi mphuthutvin
*Th ng itrng:lm HMNT
*Th ngrutnon:khulth ng,cto nrutn iho cdnl u.
VI.I UTR VCHMSCSAUM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan:
- Cclo idungdch ngtr ngv,dungdchkeo(natriclorid0,9%,glucose
5%, 10%, 20%...).
- Ccch ti ngi i:kali,calci,
- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p
lcTMTTvs l ngn cti u/gi ...
*Dinhd ngsaum
- Ccdungdchnuid ng ngtnhm chsaum :( ng, m,m ...) trong
nhngngy usaum davotontr ngb nhnhn,xtnghi mprotein...sau
m .
*S d ngkhngsinh:theokhngsinh (n uc),ph thuctnhtr ngng i
b nh.Ccnhmhaydng:cefalosporin,nhmcarbapenem,quinolon,imidazon,
metronidazone...
*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c
th ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)
*Thu cgi mti t:omeprazone,esomeprazone
*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h
p...
- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:
+ Ccxtnghi mhuy thc:cngth cmu, ngmutrongtr ngh pm t
muho cnghing ch ymu.
+ Ccxtnghi msinhhamu,nhgich cnngganthnv tnhtr ng
dinhd ng:Glucose,Ure,Creatinin,GOT,GPT,Proteintonph n,Albumin,
G...khinghing cd uhi ubi nlo n.
-
PHC IU TR NGOI KHOA 7
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+ Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ng
di nbi nhuphu.
- Ch chmscsaum :
+ T ich:thaybngv tm ,dnl u,
+ Tonthn:v sinhcnhn,ngvinan ing ib nh...
+ Vnngs msaum
+ Vrung
- Ch dinhd ng:
VII.CCBI NCH NGSAUM VH NGX TR *Ch ymusaum (ch ymutrong b ng, ch ymuv tm ):phuthutl i
c mmu,khul iv tm .
*VPMsaum dob c,xmi ngn i ngkhu:phuthutl i,x lnguyn
nhn.Tr ngh pnyn ngn ,tl t vongcao.
*pxe t nd :da theokhngsinh ho c:i u trkhngsinhph rng v
ph ih pkhngsinh,truy ndchvi ngi i.
*Tcruts msaum :th ngph iphuthutl i gi iquy tnguynnhn
* R tiu ha:
- N ukhngcvimphcm cthi utrnikhoab ng tsonde b ng ht
r alint c.
- Chokhngsinhm nh ph ih p.
- Nuid nghontonb ng ngtnhm ch:truy nalbumin, m,m ,i n
gi i nkhirtiuhali n.
*Nhi mtrngv tm :tchv tm ,chi un,s d ngkhngsinhtheokhng
sinh .
* B c v t m : khu l i v t m , dinh d ng ng tnh m ch b ng truy n
albumin, m,m .
*Xuy thuy ttiuhasaum cth xyra,hayg p b nhnhntr c,trong
vsaum cshock.
*Vimph i,vim ngni u,lottdon mlu...
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VIII.TIUCHU NRAVI N - Tonthn:tnhto,khngs t,huy tng n,nu ng c.
- T ich:v tm li nt t.
- Ti khm sau 1 thng.
- Dngthu cgi mti ti utrli n lottrongkho ng04- 06tu n.
- Khml isau01thng,mts tr ngh pc nnisoil id dy quy tnh
i utrnikhoati phayphuthutctd dy.
TILI UTHAM KH O 1.PGS.TS.HVnQuy t(2006),"Th ng lotd dy - t trng,B nhhc
ngo idngchosau ihc,Tp1,trang98- 110,Nhxu tb nYhcHNi
2006.
2.LHng,Th ng lot d dy - ttrng,Bigi ngi u tr hc ngo i khoa,
Nh xu t b n Y hc Chi nhnh Thnh ph H Ch Minh 2007.
-
PHC IU TR NGOI KHOA 7
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ABCESSC NHH UMN
I. IC NG 1.1Khini m Abcess c nh hu mn l b nh thuc nhm b nh v hu mn v trc trng.
L hi nt ng hnh thnh cc m m m nh b s ngquanhvnghu mn, trc
trng. Cc m m m c th ch a m , sau mt th i gian c th b v ra,gyau
n, kh chu thm ch pht s t, shock nhi m khun cho b nh nhn. B nh c n
c pht hi nvi u tr kp th i.
1.2 Nguyn nhn gy nn b nh p xe c nh h u mn
B nh do nhi unguynnhngyra,nh ngch y u vn l mt trong s nhng
nguyn nhn sau:
- Do vim nhi m: vng humnth ng xuyn g p ph i cc b nhnh b nh
tr,n t k humnkhiccctri u ch ng b nh,ph n da vng hu mn r t
d b vim nhi m, t dn n p xe hu mn.
- Do dng thu c: nhng thu cdng i u tr cc b nh v humnth ng c
tnh kch thch cao nn d dn n ho i t cc m v p xe hu mn
- Sau phu thut: nhngng i lm phu thut cc b nh vng hu mn r t d b
vim nhi m n unh khngv sinh s ch s .
- Ngoi ra, v i nhngng i c s c khng y u,c th suynh c, thi u dinh
d ng, d cnguyc b p xe hu mn.
- Do vim nhi m: nhngng it ng b tr,n t k hu mn, polyp hu mn,
vim lot itrnglnhngng i d b vim nhi m. Khi vi khun t n cng
vo nhng vng b hu mn hu mn t oc hi hnh thnh nn apxe hu mn.
- Nhngng i thi u ch tdinhd ng,c th b suynh c, s c khng km
cngkhi n vi khun xm nhp gy nn apxe hu mn.
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PHC IU TR NGOI KHOA 7
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- Cc thu cdngtrongi u tr trc trng c tnh kch ng cao, c th lm ho i
t dn n p xe hu mn.
- B nh nhn v vim nhi m sau cc ti u phu vng hu mn.
- Do vi khun l, khun lao, lin c u, t c u hnh thnh.
1.3 D ch t
Lo i khun gy b nh c a p xe hu mn l cc vi khun ng rutnh
Escherichia ColiCng c th l cc vi khun th ng g p trong cc nhi m
trngthngth ngkhcnh t c u khun, lin c u khun
Theo Danis v Puy - Montbrun (1991), nhng nhi mtrngm ngm c a hu
mn vng chung quanh, lin quan t i ng humnl76%,linquan n vng
trn ng hu mn l 2%, khng lin quan t i hu mn trc trng l 22%.
1.4. Cc lo i p xe h u mn
Lc u th ng t n l tnh tr ng nhi m trng cc ng tuy n Hermann-
Desfosser. Ti p theo l tnh tr ng nung m . Cc nhi m trng ny m vo cc
h c c a ngl c. M theo cc tuy n pht tri n d n ra pha nng r i cu i cng
m ra da vng chung quanh l hu mn, g n hay xa l hu mn.
Ty theo v tr c a m ,ng i ta chia p xe hu mn lm nhi u lo i.
pxed i da m n m r t nng v r t g n l hu mn.
pxed i nim m c m c a p xe n mngayd i nim m c, d i th pn i ng hu mn hay
trncaon ibngtrc trng. Nguyn nhn c apxed i nim m cth ng l
hu qu c ath ngt n n t hu mn b nhi mtrnghaytrtc m ch b nhi m
trng. V ti n tri n,pxed i nim m c khng pht tri n ra pha ngoi vo l p
c mcxuh ng v vo trong lng ng hu mn.
p xe gi accc th t m c a lo i p xe ny n m giac thttrongvc tht ngoi. m n m
l p th p hay l p cao. Khi th p n st vo b d ic tht ngoi v v ra
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PHC IU TR NGOI KHOA 7
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ngoi g n ng hu mn. Khi cao, n v ra pha ngoi vo h ng i-trc trng
hay vo pha trong, bng trc trng.
p xe h ng i - tr c trng
th ny, m n m trong h ng i-trc trng, nng hay su: Thnh trn c a h
ng i - trctrnglc nnghumn,thnhd i l da v m t bod i da.
p xe v tr ny pht tri n nhanh chngraphatr c, ra sau v sng bn i
di n. Khi pht tri n sng bn i di n, n t o thnh p xe hnh mng nga.
pxetrnc th t m n m m td ic nnghumnhaytrnccc tht.
p xe khoang ch u hng - tr c trng
m c a lo i p xe lo i ny n mtrnc nnghu mn. Nguyn nhn c a th
p xe ny c th l nhng p xe c a h ng i - trc trng ph v c nnghu
mn lan t d i ln.Cngc th pht sinh t nhng nhi m trng c a cc
t ng n m trong b ng, lo i ny t g p.
II.CH NON 2.1 Lm sng:
2.1.1 Tri u ch ng ton thn
Ton thn c cc tri u ch ng c a mt nhi m trng c p tnh. B nh nhn c
th c s t, nhi t c th tngcaotrongmtvingy u r i h d n.Ng i
m t m i, b t r t,mkhngng .Khngdmnvs ph ii i ti n.
2.1.2 Tri u ch ng c nng - auhu mn l tri u ch ng g p u tin c a b nh.Ng i b nhth ng th y
aunh c nh tlkhiil i,i i ti nhay ng ln ng i xu ng. C nhngng i
b aut i m c khng dm ng i xu ng.
- Ban u,ng i b nh th y hu mn b s ng,vcc mgicnng, , ton
thn th y m t m i,au u, c th b s t.
- Sau, hu mn s xu t hi n n ts ngph ng, cch l hu mn vi cm, c ng,
ch m vo r tau, gia hnh thnh ch m trng nh lm . lu, cc n t
s ch y m mu vng, c mi hi.
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- Hu mn b ng a do s kch thch c a dch nh y trong hu mn v dich m
bn ngoi nn lun lm cho hu mn b m t, kch ng v ng a.
- Pht hi n xung quanh hu mn c m n l cc kh i m m ho ch ic ng, c th
ch a m .
- B nh nhn c m th yaubu t, ng a gy kh chu, ng ng i khng yn.
- C th c tri u ch ng s t.
- i ti n ra mu, c dch nh y m theo phn ra ngoi.
- V tth ngch y m kh li n, d ti pht, d gy r hu mn.
- Haycngth ng, khng tp trung, p lckhiiti u ti nv i ti n
Hu mn b sng ty
Tri u ch ngchnhlau.au vng humn,lanrachungquanh.au
nh c nh i v lin t c.autngkhiil i, khi ng i, khi ho, khi r n i ti n. V i
cc lo i p xe nng, b nh nhn khng dm ng i b ng c hai mng, khng dm
ng i trn yn xe.
2.1.3 Tri u ch ng th c th
- Nhn
+ pxed inimm c
Lc m i bt u, nhn khng th y g, khi p xe v , th y mt vi git m trng
long t trong hu mn ch y ra.
- p xe h ng i - trc trng
Lc u, th y mt ch dabngs ngph ng, khng c gi i h n r r t, cch l
hu mn vi centimet. Vi ngy sau, ch t y ny c gi i h n r r t v i mt
ch m trng gia, m hnhthnh.Trongas cctr ng h p p xe ch c
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mt bn, bn ph ihaybntri.Cngckhi p xe h ng i - trc trng c c
hai bn lm cho p xe c hnh mng nga.
- p xe giaccc tht
Lc u nhn khng th y g.
- p xe khoang chu hng - trc trng
Cngnh pxegia cc c tht, lc unhn cngkhng th y g. Lo i ny
th ng c chnonlpxeh ng i - trc trng. Khi r ch dnl uth y m
t trn cao ch y xu ng. B ng mtkmdi thm th th y p xe ln kh cao,
th ng s khng ch m cypxe, lcm i bi t l p xe khoang chu
hng-trc trng.
Thmh u mn tr c trng B nh nhn n m ng a,haichnco,haiid ng. Ming tc c a th y thu c
ph i r t nh nhng, t t , v n u khng lm b nh nhn r tau,khngchoti p
t c khm. N uaunhi u, nhnnh cc tri u ch ng s khng chnh xc.
Ngntaythmhu mn trctrnglun cbitr n d avotrong ng
hu mn.
- pxed i nim mac Ngn tay s c mt ch ph ng nh , n m b t c v tr no c a chu vi ng
hu mn. Nim m c ch s ngph ngnytr nlng, n nh vo r tau.
- p xe giaccc tht v p xe h ng i-trc trng
C mgic c kh is ngt ngoi l i vi trong lng ng hu mn, n r t
au.Thmkhmhu mn trc trng lm b nh nhn r tau.Vvy nn h n ch
thmkhmhu mn trc trng b ng tay v b ng d ng c .Th ng th b nh nhn
t ch i,khngchothmkhml n th hai.
2.2 C n lm sng
2.2.1 Cc xt nghi m ch non: Th ng th p xe hu mn trc trng c cc tri u ch ngr chnon.Tuy
nhin cc xt nghi m chnoanl:
+ Siumph nm m:th yc pxec nhhumn.
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+ Siumnisoi:trongnhngtr ngh pkhphnbi tv icckh iuhay
khixcnhrvtr,l nvtnhch tc ath ngt n,cth dngsium
nisoi.
2.2.2 Cc xt nghi m i u tr ,tinl ng v theo di b nh - XN mu: T ng phn tch t bo mu: b ch c utng,ngmu: prothrombin,
APTT, Fibrinogen, co c cmu,HbsAg,antiHCV,antiHIV,nhmmu,
- Sinh ha mu: Glucose, Ure, Creatinin, a Uric, GOT, GPT, Bilirubin ton
ph n, Billirubin trc ti p, Protein ton ph n, Albumin, Gross, Maclagan, HDL,
LDL, Cholesterol, Triglycerit,G,
- SHn c ti u
- Xq tim ph i th ng
- i n tim, siu m tim n u b nh nhn c bi u hi n, ho c ti n s b nh l tim
m ch.
III.BI NCH NGABCESSH UMN pxehumnban uth ngchgyau nchong ib nhnh ngn u
khngi utrkp th i,b nhs gyranhi ubi nch ngnguyh inh : - Nhi m trng ch y m : b nh n ukhng ci u tr ngay, m s ch y nhi u,
dn n nhi m trng, v b nhcnglanrng ra nhng vng xung quanh, khi n
choi u tr tr nn ph c t ph n.
- R hu mn: lc u, cc p xe hu mn r t c ng, n unh i u tr nh ngl i
khng tri t s khi n cho kh i p xe pht tri n l nh n,dn n v ra v ch y
m , cng ko di s gy ra r hu mn, gy nguy h ichong i b nh.
- i ti n kh: cc p xe hu mn khi n cho ng i b nh lun c m th y b p lc
khii i ti n v ti u ti n, gy nn tnh tr ng to bn, dn n b b nhtr.
IV.NGUYNT CI UTR i u tr p xe hu mn trc trng l dng khng sinh ton thn v r ch dn
l um .
V.I UTR TR CM Khipxeang hnh thnh
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- H nch nhi mtrng:
S d ng khng sinh: khng sinh ph rng ton thn, dung ng tim ho c
truy n,ccnhmkhngsinhth ng dung l: Ampicilin + Sulbactal; th h 2, 3;
suferazon; metronidazone; imipenem;Khng sinh ch h n ch nhi m trng
ch th ngkhngngnch n c qu trnh lm m ,khngngnch n c p
xe hnh thnh.
- Gi mau
Ban ngy, dng thu c gi mau.T i,tr ckhiing , nn u ng t thu c ng
c th ng c.
Ngm humntrongn c m: ngy nhi u l n ng i vo chun c m lm b nh
nhn au,c m th y d chuvcng p xe hnh thnh nhanh h n.
- nu ng
i ti n lm b nhnhnau,nh t l khi to bn, bt b nh nhn ph i r n. V vy
nnnnh , d tiu, nhun trng. N u c to bn nn dng t thu c nhun trng.
VI. I UTR PH UTHU T - Khipxehnhthnh
+ i utr
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