lam sang noi khoa

8/3/2019 Lam Sang Noi Khoa

1/47

By death_nt88 source: diendanykhoa.com 2010

Page | 1

LM SNGNI KHOA

S TAY


2/47


Page | 2

* Khm v chn on:1. St2. Ph

3. ho4. kh thcp

5. au bng cp6. nn ma7. nn mu

8. bng bng9. vng da

10. gan to

11. hch to ngoi bin12. thiu mu13. ho ra mu

14. xut huyt15. lch to

16. tiu chy17. hn m.

St1. C 3 loi st chnh: lin tc, dao ng, v c chu k.

2. Khi c st cao + ko di: ch tim mch -> phng try tim, b sung in gii (ung hoc tim), s lng nc tiu.

VIM NIU O

3. st + tiu c (m).

4. LS: st km tiu but, nu c m chxut hin u bi. Thng km vim hch 2 bn bn.

5. CLS: bch cu: tng s lng v thnh phn a nhn trung tnh -> chng t c vim nhim khun. Tim lu cu (thng gp)trong m.

VIM B THN CP

6. st: khi pht rt run sau nng, ti din trong vi ngy.

7. LS: st km au m vng thn. Sau st 1, 2 ngy nc tiu c.

8. Khm: n su h thn -> BN than au.

9. CLS: BC tng s lng v NTT. Cn lng nc tiu (cn Addis) - din tin: vi ngy u nc tiu trong, cn Addis c BCtng nhiu -> chng t nhim khun ng niu. Vi ngy sau, i th nhn nc tiu c, vi th BC tng nhiu trong nc tiu.Xt nghim vi khun: thng E.Coli hay Enterococcus. Tip theo: X quang niu (khng chun b, c cn quang) pht hin sithn hoc d dng ng niu - l nguyn nhn gy Vim b thn cp.

THP KHP CP

10. st: nh lc u, cao sau , ri ln xung tht thng.


3/47


Page | 3

11. ch yu triu chng khp: khp sng khng to, da lng, cng khp au. c bit: di chuyn khp ny ti khp kia,mi ln vy nhit ln cao.

12. Chn on: ch yu da vo LS - tnh cht di chuyn ca khp vim. CLS: fibrin mu tng nhiu, ECG ri lon nhp (nhanhxoang, chm xoang, block nhtht. c bit hay gp: PQ di 0,5 giy, ngoi tm thu).

13. Khm: vi ngy sau st: nhp tim nhanh, nhit bnh thng. Ting tim nh, thi tm thu c nng.

VIM KHP

14. St: t ngt, cao; c th km rt run.

15. au khp: sng nng au, cng hn ch. Khng di chuyn (khc vi thp khp cp). Ch1 khp au. Nu khp githy r du hiu ni.

16. Chc d khp thy cht nc c, m.

17. Hch chi phi khp vim: sng to + au.

18. Chn on: vim khp tnh cht sng nng au + CLS BC s lng v NTT tng + Chc d khp c m.

19. Xt nghim m tm vi khun, thng gp: lu cu khun, t cu khun, lin cu khun. Cn lm Khng sinh s dngkhng sinh thch hp.

AP - XE GAN

20. St: dai dng. Nhit dao ng: c lc vt cao 39 - 40o trn nn nhit bnh thng, sau vi gi tr li bnh thng. Stht thng ny khng theo chu k nht nh.

21. CLS h tr: X quang ngc kim tra y phi (P), v tr - hot ng ca c honh (P).

22. Nhng bnh ng thi cng c st nhit dao ng: nhim trng mu, ung m su (ung m thn, apxe sau tim mng,apxe di c honh - trong thng gp l apxe gan).

Ph1. Ph: l hin tng nc trong cc t chc, di da, tng. y chni n ph di da.

2. Xc nh ph: s nc di da lm cho:* nhng vng b ph: sng to, cng mng* mu da vng nht i.3. tm nguyn nhn, cn: nhn nh k tnh cht ph + pht hin triu chng km theo.

TNH CHT PH

4. mc

: nhiu, t; tin trin: nhanh, chm -> nn theo di bng cn nng.5. v tr: khu tr 1 vng, ton thn; ni xut hin u tin?

6. n lm -> ph mm; khng n lm -> ph cng.

7. c km theo biu hin vim: sng nng au?

8. lin quan thi gian: thy ph khi no? ; t th ngi bnh:ng lu ph?

9. chn nht: c lm gim ph?


4/47


Page | 4

TRIU CHNG KM THEO

10. c 3 vn chnh: 1. phn nh mc nc, 2. chim cho 1 cn tr c gii trn h thng tun hon, 3. chim cho 1vim nhim a phng.

11. phn nh mc nc: ph to -> trn dch mng (phi, bng); tiu t -> hu ht trng hp ph u c (tr ph do: 1.

vim, 2. bnh bch mch); ph cng nhiu tiu cng t. Xt nc tiu nhiu hay t da vo S lng nc tiu/ 24 gi.12. chim cho 1 cn tr c gii trn h thng tun hon:* tun hon bng h: ngc -> cn tr c gii h thng TM ch trn, h sn (P) & thng v -> cn tr c gii h thngmn - ch, bn & h v -> cn tr c gii h thng TM ch di.

* xanh tm: mi, mt -> cn tr c gii TM ch trn hoc i tun hon, cc chi tng ng vi TM c bnh.

* gan to mm, TM c ni & phn hi gan TM c, kh th.13. chim cho 1 vim nhim a phng: vim (sng nng au), sng cc hch tng ng, km theo st.

SINH L BNH

14. C cc yu t: 1. tr tun hon, 2. h t l protein huyt tng, 3. mui, 4. tn thng thnh bch mch tnh mch v5. cng aldosteron nguyn pht hay th pht.

15. tr tun hon: ph do 1. suy tim, 2. chn p hoc tc TM.

16. h t l protein huyt tng: lm thay i p sut thm thu, nc d thot ra ngoi mch mu. ph do: 1. thn nhim m(HCTH), thiu dinh dng, x gan.

17. mui: ph do vim thn.

18. tn thng cc thnh bch mch tnh mch: ph do 1. vim TM, 2. vim bch mch, 3. dng.

1. PH TON THN

19. c cc bnh: 1. Hi chng thn h, 2. Vim thn cp/ mn, 3. th phi hp vim thn + HCTH.

20. LS: ph c mt, thn, chn tay; c th trn dch thanh mc (trn dch mng phi, c trng thm thu).

21. thng gp nht: ph kiu thn (vim thn cp hoc mn, HCTH; ngoi ra: t gp hn -> suy dinh dng, cng aldosteronnguyn pht).

22. phn bit ph thn vi ph do suy dinh dng v cng aldosteron nguyn pht da vo: protein niu.

23. sau khi xc nh ph thn bng s c mt ca m niu, da vo LS v cc xt nghim th dch khc phn bit: Vimthn & HCTH.

HCTH & VCTC/M

24. Tin hnh phn bit:

* Hi chng thn h: ph trng, n lm, to & tin trin nhanh (t). Trnh t v tr ph: mi mt -> mt -> cc ni khc. Khng linquan thi gian, t th; d vy, nu BN nm lu, ph c nhiu vng lng, mt sau i bn cnh cc vng khc vn ph. Chn nht khng lm gim ph. Thng km theo trn dch mng phi v c trng nc trong hoc vng chanh thm thu. CLS:m niu cao ( 30 - 40 g/l), khng tr v HC niu, c th lng chit quang; ure mu cao, protein mu gim nhiu, lipid vcholesterol mu tng nhiu. Thm d chc nng thn thng bnh thng.

* Viu cu thn cp/ mn: ging nh HCTH, ph trng - n lm (t hoc khng) - u tin c mi mt ri mt n cc ni khc- khng lin quan thi gian, t th (nu lin quan t th, thi gian l ph do tim) - cng c trn dch mng, c trng nctrong hay vng chanh nu ph nhiu. Khc vi HCTH, y chn nht lm gim ph r rt - thng km theo Tng huytp - nc tiu t & vn c (vim cp) hoc vn trong (vim mn). V nguyn do, VCTC/M thng xut hin sau 1 nhim khun ni khc, thng nht l: 1. vim hng, 2. vim hch hnh nhn, 3. mn nht ngoi da. CLS: ging HCTH - cng c m niu,ure mu cao; khc vi HCTH vi im: m niu tng t hn (HCTH 30 - 40 g/l th y khong 10 - 15 g/l, nu HCTH khngc tr & HC niu ( thay vo c th lng chit quang) th y c -> cn lm cn Addis theo di tin trin bnh da vo s


5/47


Page | 5

lng c th ca tr, HC trong nc tiu. iu cui cng, HCTH pro, lipid & choles muu thay i (pro gim, lipid & cholestng nhiu) cn VCTC/M nhng chs ny u bnh thng. Thm d chc nng thn thy ri lon.

25. Tm li, phn bit HCTH & VCTC/M da vo cc yu t sau:1) mc ph: rt nhiu/ nhiu or t2) tc dng ca n nht: khng gim ph/ gim ph r3) HA: bnh thng/ tng or bt

4) m niu: > 30 - 40/ phc tp LS, lm sao xc nh c bnh nguynpht?

2. PH 2 CHI DI

27. c cc th: ph tim (suy tim), ph dinh dng ( K gan, apxe gan), vim tc or chn p TM ch di (lu : khc vi vimbch mch do giun ch-> ph cng).

SUY TIM (ph tim)

28. c km theo gan to, nhng khng c trng. Gan to + mm, phn x gan TM c (+)

29. lc u: ph t, kno; chc mt c chn. c bit: chxut hin vo bui chiu sau khi ngi bnh ng lu, mt i lcsng sm khi ngi bnh ng dy. V sau: ph thng xuyn + r rng.

30. gim ph khi: nghngi, n nht.

31. ph mm, n lm.

32. o p lc TM: rt cao (bt 12 cmH20 khi ngi bnh nm).

K GAN - APXE GAN

33. ph dinh dng: c th ph ton thn or ph 2 chi di. Ph trng, mm.

34. gan to: c th mm (apxe gan kinh in) or cng (K gan).

VIM TC - CHN P TM CH DI

35. ph mm, cn i 2 chn.

36. c th km theo ph b phn sinh dc.

37. c tun hon bng h loi ch di xut pht t 2 bn & trn xng mu i ngc ln trn. C th c c TM gin i, khoeo& bng chn.

38. Xc nh chn on bng CLS: o p lc TM 2 chi di thy tng nhiu; chp TM chi di vi thuc cn quang gip xc nhv tr tc or chn p.

3. PH C BIU HIN VIM NHIM A PHNG


6/47


Page | 6

39. c 2 bnh lu : 1. vim tc TM & 2. vim mch bch huyt.

VIM TC TM

40. ph thng ch 1 chi, phn nhiu chn.

41. ph mm, trng; nhng rt

au:

au t pht lm ngi bnh khng dm c

ng chn,

au t

ng ln khi s nn gn ni vimtc.

42. thng km theo mch nhanh.

43. hon cnh d gy vim tc TM: phu thut, bnh nhim khun nng - lu khi, sinh con.

44. CLS: xt nghim tm kh nng ng mu: 1. protrombin mu gim, 2. nghim php chng li heparin tng cao. Chp TM sautim thuc cn quang xc nh v tr tc.

VIM MCH BCH HUYT

45. ph cng thng ch 1 chi, phn nhiu chn.

46. ph mm, trng, n au: au t pht & tng ln khi s nn chi.

47. nhn: thy ni r ng i ca mch bch huyt thnh nhng ng , nng, au.

48. cc hch bch huyt tng ng vi mch vim: cng sng + au.

49. Chn on xc nh da vo: 1. CLS: BC tng cng vi BCDNTT, 2. pht hin ni nhim khun t nhp: vt xc, vtthng, nht lot; 3. pht hin giun ch(nguyn nhn thng gp gy vim mch bch huyt) trong mu.

4. PH CNG

50. ph cng: thng gp trong Ph chn voi, di chng ca vim bch mch do giun ch.

PH CHN VOI

51. t chc di da: dy + cng -> n khng lm. Da cng dy & cng.

52. v tr: thng gp l chn, ngoi ra cn gp : tay (bn tay, cnh tay), b phn SD (bu tinh hon nam gii, mi ln m hn gii).

53. Chn on xc nh da vo: 1. tm giun chtrong mu, nc tiu -> thng t thy v bnh giun chc th c t lu, naychcn li di chng chn voi ca 1 vim bch mch c; 2. pht hin thm nhng di chng khc ca bnh giun ch(VD: tiudng trp).

5. PH NGC

54. in hnh l ph 'kiu o khoc' trong hi chng trung tht.

HI CHNG TRUNG THT

55. chph vng ngc trn & c; nu ph nhiu: c th ph c 2 tay, mt & u.

56. ph mm, xanh nhng phn nhiu n khng lm

57. thng km theo: 1. tun hon bng h TM ch trn (chc vng ngc trn), ph to thy r; 2. cc triu chng khc ca


7/47


Page | 7

hi chng trung tht: kh th, nc, ting ni 2 ging, nut vng.

58. CLS: X quang ngc thy khi u trung tht.

59. Cc khi u trung tht gy chn p gy ph o khoc thng l: 1. u hch trung tht, 2. K ph qun & phi, 3. K mng phi.

HoSINH L BNH1. ho l phn x - do s kch thch cc vng gy ho: vng di thanh mn, ca kh qun & ca cc cung phi thy, mng phi,cc b phn tip xc vi mng phi (trung tht, vng di c honh) & thc qun.

2. phn x ny i theo dy ph v v trung tm ho hnh ty & c tr li bng s co tht nhanh - mnh ca cc c h hp,ng thi thanh mn c m ra: khng kh trong h thng h hp c tng ra nhanh - mnh -> gy nn ting ho.

TC NHN KCH THCH

3. s thay i tit dch ca nim mc kh qun, cung phi: do vim nhim.

4. tn thng cc vng gy ho & cc b phn lin quan n vng: mng phi, trung tht, cc b phn di c honh.

5. do c im ca tc nhn kch thch, ho thng gp trong cc bnh: 1. bnh hng, kh qun, cung phi, nhu m phi; 2.bnh mng phi; 3. bnh trung tht, cc b phn di c honh ( vim gan, apxe gan, apxe di c honh).

HO C TRIU CHNG CH IM TN THNG H THNG H HP DI

6. c cc hi chng:1) hi chng cung phi2) hi chng ng c3) hi chng hang4) hi chng trn dch mng phi.HI CHNG CUNG PHI

7. c cc bnh:+ vim cung phi cp: ho tng cn, i khi ho nhiu BN mt ng; lc u ho khan sau ho ra m; m lc u t sau tng dn -mu trng xanh or vng, c th ln vi tia mu. Nghe 2 vng phi thy hi chng cung phi: lc u ran rt ngy (thi k hokhan) sau ran n 2 th (thi k ho long m).

+ vim cung phi mn: ho dai dng hng nm, ti pht nhiu ln: t ti pht thng xy ra khi c k thun li nh thay ithi tit, lm vic qu sc. Ho phn nhiu u long m: m nhiu, mu trng or xanh or vng c th ln vi tia mu. St trongnhng t cp din. Hi chng cung phi biu hin bng cc ran n 2 th, ri ri 2 vng phi; c th c thm t ran rt ngy.

+ gin cung phi: tnh cht ho nh trong Vim cung phi mn (ho long m trng / xanh/ vng c th ln mu), ho thng lcsng mi ng dy, ng thi khc rt nhiu m, m rt nhiu lng trong cc thnh 4 lp; m c th hi - c m v gin cungphi thng d bi nhim. C khi BN chkhc mu. Khng st tr c bi nhim. Km theo kh th: BN th hn hn mi khi lmvic qu sc. Hi chng cung phi biu hin bng: ran n 2 th ri rc 2 vng phi or ch1 vng nu gin khu tr.

+ K cung phi: ho hng hng, khc mu nhiu ln; mi ln lng t. Xy ra ngi ln tui, khng st, t trc n nay vn

mnh khe gn y mi ho - khc mu.HI CHNG NG C

8. c cc bnh: vim phi, apxe phi.

Vim phi

9. ho nhiu, long m: m c, dnh, mu gst c th ln mu or BN khc hn ra mu.

10. lun km theo hi chng nhim trng: st cao, khi pht rt run; mt , mi kh, li d, mn gip mp.

11. Nghe: hc ng c -> thi ng, ran n 1 th; v sau ran n 2 th.


8/47


9/47


Page | 9

Vim mng phi c m

30. Tnh cht ho & cc triu chng khc ging vi Vim mng phi nc vng chanh: cng ho t hng hng tng ting - khngm; c th km theo au ngc, kh th, st. Tuy nhin trong VMP c m, BN st nhiu hn & hc nhim trng thng r rt. Ckhi ph n thnh ngc.

31. Chc d: ly

c nc mng phi

c or thnh m hn. Ch mu sc m chc ra: s c la, or vng xanh mt -> gi linquan vi 1 apxe gan amip or apxe mt qun.

32. Cn tm thm loi VK sinh m & nht l xut pht im ca vim nhim khun: c th l VMP c m hu pht sau vim phi,apxe phi or apxe di c honh (thng thng l apxe gan i vi cc VMP c m bn (P) ), c khi xut pht im xa hn:vim mng no c m, nht m, vim xoang hm mt.

33. pht hin cc tn thng nhu m phi b che lp bi lp m mng phi -> chc tho m ri bm khng kh vo mngphi t khi a n kt qu v lp m thng li trn l tng & l thnh mng phi 1 lp t mu kh dy, hn ch s kim trabng XQ lp nhu m phi di -> v vy, cn s dng n pp chp phi ct lp.

HO KHNG C TRIU CHNG CH IM TN THNG H THNG H HP DI

34. c cc bnh: ho g, vim thanh qun, vim hch hnh nhn.

Ho g

35. thng tr em. Ho rt nhiu, tng cn, ting ho rt ln nh g gy, thng vm. Sau ho km nna ra di nht, trongho mt BN bng, mi tm li. St or khng. Khm phi khng nghe ran tr khi c bin chng vim phi or ph qun ph vim.Chn on xc nh nh vo cy trc khun ho g (hemophilus pertussis) trong mi - hng.

Vim thanh qun

36. Ho: ho khan, thng xuyn or tng cn, ting ho kh rp lm cho BN thm au hng.

37. Km theo khn ting. St t or khng.

38. Khm hng: hng & mu.

39. tr em: ch vim thanh qun bch hu - hng nhng c thm mng gi trng. Ngoy hng xt nghim vi khun thytrc khun Lofle.

Vim hch hnh nhn

40. Bnh cnh ging nh Vim thanh qun: ho khan khn ting nhng khm hng ngoi thy hng cn thy hch hnh nhnto 1 bn or 2 bn sng to - .

Kh th cp1. kh th: nghti 2 trng hp:1) cn tr c gii cho s lu thng khng kh trong h thng h hp: do chng ngi vt or tn thng.

2) ri lon nhp th: nhanh, chm, khng u -> do h thn kinh chi phi.XC NH & NHN NH KH TH CP

2. t th ngi bnh: ngi bnh thng khng nm c, phi ngi dy cho d th. Hoc t th na nm na ngi: t thFowler.

3. nhp th: nhn nh da trn cng ca lng ngc or thnh bng. Nhp th bnh thng 16 - 20 ln/pht c th:1) nhanh nhng nng.


10/47


Page | 10

2) lc nhanh, lc chm; lc nng, lc su, nhp th khng u kiu Cheynes Stokes: th tng dn bin nhng nhp u rigim dn bin sau nghri li tip tc nh trn. Hoc kiu thKussmaul: th chm, ht vo, ngh, th ra, ngh, ri li tip tcnh trn.4. V mt: thng ng ngc lo s. Ty mc c xanh tm t nhiu.

NGUYN NHN

5. Kh th cp c nhiu nguyn nhn, bi v s h hp ph thuc vo nhiu yu t:1) s lnh mnh ca ton bng h hp: sut t mi qua thanh hu, kh qun, cung phi, nhu m phi & c mng phi.

2) s hot ng bnh thng ca cc c h hp: c honh, cc c lng ngc.

3) s lnh mnh ca cc trung tm thn kinh h hp: hnh ty.TNG QUAN

6. c cc nhm:1) kh th do thng tn h thng h hp:+ thanh hu: ph thanh hu, vim hng bch hu -> kh th thanh hu.

+ cung phi: hen -> hp li do hin tng co tht cung phi kt hp vi ph thng, tit nhiu cht nhy ca nim mc: kh thc hiu ca hen.

+ nhu m phi: ph nang b tn thng do vim nhim -> trng hp ph qun ph vim, lao k. Hoc c th b trn ngp bidch xut ra t mch mu tiu tun hon (do ri lon vn mch h thng) -> ph phi cp. Hoc b mu do suy tim.

+ mng phi: c th b thng & trn ngp t ngt bi khng kh lm nhu m phi b p li, cn tr cho s h hp -> trn khmng phi (mt trong nhng nguyn nhn thng thng gy kh th cp). Mng phi cng c th b trn dch -> tuy nhintrng hp ny kh th t.2) kh th do lit c h hp: thng gp trong bnh Lit tr em (P.A.A) -> c honh & cc c lng ngc b lit do tn thng ccdy thn kinh chi phi.

3) kh th do hnh ty: hot ng ca hnh ty b ri lon c th do:+ vim nhim: trong bnh P.A.A (lit tr em ) c tn thng hnh ty.

+ nhim c: trong Tng ure mu, Toan mu.VIM THANH QUN BCH HU

7. kh th thanh qun: xut hin, tin trin t t. Kh th th ht vo. Cc h trn & di xng n cng nh cc khoang linsn b lm xung khi th vo. Ting th vo nghe r thnh ting rt.

8. tnh trng nhim khun: st # 38 - 38,5oC, sng hch di hm.

9. xy ra tr em.

PH QUN PH VIM

10. hi chng nhim trng: st 39 - 40oC, mi kh, li d.

11. kh th xut hin t t, cng ngy cng tng. Nhp th nhanh - nng, km cnh mi php phng.

12. Nghe: ran n 2 th khp 2 vng phi.

13. CLS: BC tng cng vi NTT. X quang phi thy nhiu m m khng u ri rc khp 2 vng.

14. Sau khi xc nh l ph qun ph vim, bao gi cng phi tm thm trc khun Lao m & cc loi vi khun khc chn on nguyn nhn.

LAO K

15. kh th xut hin t t. Nhp th nhanh - nng.

16. hi chng nhim trng: c or khng.


11/47


Page | 11

17. triu chng chim nhu m phi: r ro ph nang gim.

18. chn on xc nh: thng nh X quang v Lao k i khi khng c triu chng chim. X quang: c nhng nt m nhnh ht k u nhau & ri rc u trn khp 2 vng phi.

19. ng thi tm thm Trc khun lao m or dch v. Ch pht hin thm tn thng lao ni khc nht l Lao mngno.

PH PHI CP

20. kh th nhanh - nng, xut hin t ngt thng xy ra vm.

21. BN khc m hng c bt -> triu chng c hiu c gi tr chn on xc nh, nhng khng ch s c mt ca n mi xcnh chn on, v khi c m hng km bt th bnh nng -> tin lng d dt.

22. Ch khm bnh pht hin triu chng thc th: nghe ran n 2 th, 2 bn phi, tng ln rt nhanh nh 'thy triu dng'.Km theo cc triu chng chim Suy tim (T): nhp nhanh, ting nga phi.

23. Nguyn nhn ph bin gy OAP:1) bnh van tim: thng nht l Hp 2 l, HM ch.

2) Tng huyt p.

3) Vim thn cp/ mn c ure mu cao, or c tng huyt p.HEN

24. Kh th: th th ra, xut hin t ngt, thng ti pht nhiu ln trong tin s. BN c khi phi t tay vo thnh ging th ra.

25. Nghe: ran rt ngy khp 2 vng phi. G: thy trong hn bnh thng.

26. Xc nh chn on da vo: tin s ti pht & tnh cht kh th; X quang -> 2 vng phi sng hn bnh thng nhng vnthy r cc nhnh cung phi; Tm t bo Charcot Leyden m khi ht cn hen.

27. V phn ln cn hen l do dng -> nn cn tm yu t sinh dng (d nguyn). Ngoi ra, BN hen lu ngy, nn lm thmcc thm d chng nng phi.

TRN KH MNG PHI

28. Kh th: th ht vo, th nhanh - nng, xut hin t ngt thng sau 1 cn au ngc d di nh dao m.

29. thng km theo chong.

30. Hi chng Trn k mng phi 1 bn ngc: na lng ngc phnh ra, km or khng di ng, g vang (nh g trng), rungthanh gim, r ro ph nang gim. C th c ting thi v km theo.

31. Xc nh chn on bng X quang phi -> 1 bn vng phi sng hn bnh thng & khng cn nhng nhnh cung phi,nhu m phi b dn p li thnh 1 cm gn rn phi.

32. Trng hp khn cp, khng th ch X quang m nghi l case TKMP: c th chc mng phi thm d ng thi o plc. Cng nhm phn bit 3 loi TKMP:1) TKMP m: p lc t: 0 -> +2, +3. Vi nghim php ng tim: pit-tong khng b di chuyn.

2) TKMP ng: p lc cng gn nh trn nhng pit-tong ca ng tim b ht vo.

3) TKMP c supap: p lc c th ln n +6, +8 & y pit-tong ca ng tim ra.tham kho thm: chc d Trn kh-trn dch mng phi - link:http://www.diendanykhoa.com/showthre...=4403#post440333. sau khi xc nh Trn kh mng phi, cn chn on thm nguyn nhn (Lao hay khng) cn c vo:1) tm trc khun Lao m hoc dch mng phi nu tr thnh Trn kh trn dch.

2) X quang: nu do Lao thng c thm tn thng bn phi khng b trn kh, hoc c nhng vng dnh mng phi bntrn kh lm cho ton b nhu m phi khng b dn p li thnh 1 cm gn rn phi m vn cn 1 vng no dnh vi l thnhmng phi. S pht hin tn thng Lao ni khc: hch, mng bng.


12/47


Page | 12

3) S tin trin ca trn kh: trong Lao, TKMP d chuyn sang trn kh trn dch; trong nguyn nhn khng Lao, TKMP dn rikhi hn nhng d ti pht.T PH TH TIM

34. Kh th: xy ra cng vi cc triu chng ngoi bin khc ca suy tim: gan hi to, ph chn, TM c ni. Phi t ran t do mu tiu tun hon. Tiu t.

35. Tim p nhanh - nh, c khi c ting thi tm thu c nng nh nhng khng bao gi c ting nga phi.

36. Km theo cc triu chng ca t ph: chn cm gic kin b, da t b, bng chn to, mt phn x gn 2 chi di.

37. CLS: o p lc TM & tc tun hon: tng nhiu -> xc nh c suy tim.

38. X quang tim: tim to, nht l tim (P) nhng vn p tt.

39. Tc dng r rt ca vitamin B1: tim liu cao (cch 3 - 4 gi li tim 100mg) vo TM -> nu ng l t ph th tim, bnh cnhs rt nhanh: BN gim kh th, tiu nhiu hn, phn x gn tr li, X quang tim nh tr li.

40. Nu c iu kin, nn nh lng acid pyruvic mu (tng) & nh lng vitamin B1 huyt tng (gim) -> c gi tr xcnh chc chn chn on.

UR MU CAO

41. Kh th: nhp nhanh - nng, v sau chuyn sang kiu Cheynes Stokes: th tng dn bin nhng nhp u ri gim dnbin sau nghri li tip tc nh trn.

42. Thng km theo: nhc u, nn ma, tiu chy, tiu t (< 300ml/24h) c khi v niu (< 100ml/24h).

43. Xy ra thng nht BN c tn thng thn: ch yu vim thn cp/ mn or si thn.

44. Xc nh chn on bng: nh lng ure/mu (ure/mu cao). Theo diiu trnh gi tin lng nh cc xt nghim: 1. slng nc tiu/ 24h, 2. nh lng ure/ NT mi ngy, 3. kim tra li ure/ mu mi ngy or 2 ngy 1 ln.

45. Nhng trc tin cn lm ngay cc xt nghim tm nguyn nhn:1) tm protein & t bo nc tiu = cn Addis: c hng chn onas Vim cu thn cp, Vim thn mn, Vim ng thn, hocVim b thn.

2) X quang thn: khng nn chp vi thuc cn quang tim TM v c ure mu cao, nhng ti thiu phi chp khng chun byn tm loi tr si niu: pht hin kp thi -> x tr ngoi khoa -> tin lng kh quan.

3) cy mu: nu nghi ng bnh do Leptospira th khng vng da.TOAN MU

46. ging nh kh th trong ure mu cao: nhp cng nhanh - nng, nhng c th chuyn sang kiu Kussmaul: th chm, ht vo,ngh, th ra, ngh, ri li tip tc nh trn.

47. Thng km theo cc biu hin nhim c ni ti: nhc u, nn ma, tiu chy, mt mi, bing n trong my ngy trc.

48. Xy ra thng nht trong bnh cnh Tiu ng khng c iu tr.

49. CLS: xc nh chn on -> 1. tm th ceton trong nc tiu, 2. nh lng d tr kim: h nhiu, di 30 th tch CO2.

au bng cp1. au bng cp: l nhng cn au d di & xut hin t ngt bng.

NHN NH CN AU BNG CP

2. Da vo 5 c im:1) cng au2) tnh cht au


13/47


Page | 13

3) v tr au4) hng lan5) ti pht nhiu ln cha?3. cng au: da vo li khai cng t th BN trong cn au (ln ln, vt v, m ly bng, 'au chng mng'). Cc triuchng chong: au nhiu km chy mu -> chn tay lnh, mnh nhanh - yu, HA h.

4. Tnh cht au: au nh dao m, au qun, au xon bng.

5. V tr au: cn xc nh c v tr u tin ca cn au bng cch khi gi BN nh li, v iu ny chim b phn b tnthng. V sau, khi au nhiu, BN cm thy au khp bng.

6. Hng lan: c nhng hng lan kh c hiu cho mt s cn au bng:+ t h thn lan xung b phn sinh dc & i: cn au thn.

+ t h sn (P) lan ln vai: cn au gan.7. ti pht nhiu ln cha? -> Nhng cn au ti pht nhiu ln trong tin s c th l cn au d dy, cn au si thn, simt. Cn ch tnh cht cn au: nhng ln trc au nh th no? c ging ln ny khng?

NHC LI GII PHU - SINH L

8. Trong bng c nhiu ph tng: mi ph tng u c th l xut pht im ca cn au.+ thng v: d dy, t trng, ty.

+ h sn (P): gan & h thng dn mt.

+ h chu (P): rut tha, bung trng, niu qun.

+ bng di: bng quang d con.9. Mng bng bao bc phn ln cc ph tng: khi cc ph tng b vim nhim, s d lan sang mng bng. Nu mng bng bvim snh hng:+ lc u nh hng ngay c thnh bng -> co cng mng bng.

+ v sau nh hng nhu ng rut: rut b lit, hi lm cho bng cng trng.10. ng tiu ha l 1 b phn rng, c hi & c kh nng c bit l nhu ng: nhng c tnh ny lm cho bnh cnh mt strng hp bnh l ng tiu ha c nhng im c hiu gi ngay chn on.+ ng tiu ha b thng (thng d dy, thng rut): hi trong ng tiu ha s thot ra bng, chim nhng im cao di chonh -> c triu chng: g trong vng trc gan & X quang: lim hi di c honh. Tuy nhin, nu thng vo ph tng ln cn

(gan, ty) & c bt kn li: s khng c biu hin LS - XQ nh trn.

+ ng tiu ha b tc (tc rut c gii): lc u nhu ng rut s tng ln c khc phc chng ngi vt, gy ra 'du hiu rnb' thnh bng. Dn dn, rut b lit - khng co bp c na: hi li trong rut lm cho bng cng trng.11. Bn cnh cc c im ni trn, cn ch thm n cc triu chng km theo v chng c gi tr gi chn on nh:1) chim cho 1 tn thng mng bng: vim mng bng cp.+ bng khng di ng theo nhp th.

+ co cng thnh bng: cn theo di phn bit vi phn ng thnh bng.- Trong phn ng thnh bng nu tay y mt thi gian & ngi bnh khng ch n chau th thnh bng mm tr li,hoc sau mt thi gian (1/2 gi) chm & tim Atropin BN bt au th vng cng mm tr li.

- Co cng thnh bng l triu chng rt gi tr chn on Vim mng bng -> ty chnh phu thut: trc 1 BN au bngd di m cha c chn on r rt, BS cn trnh dng thuc gim au ng thi c tc dng lm bt co cng nh cc loithuc c nha phin nht l Morphin.+ thm trc trng hoc m o: ti cng Douglas rt au.2) chim cho 1 cn tr c gii ng tiu ha:+ BN nn nhiu, khng i tiu & khng trung tin c.

+ Nhn: thy du hiu rn b -> thnh bng c cc khc rut ni & di ng. C th lm xut hin cc du hiu ny bng cchbng nh nhiu ln vo thnh bng.

+ Cn tr c gii lu: bng trng hi, g vang trng.3) chim cho tai bin thng 1 b phn rng (d dy, rut) -> g thy mt ting c vng trc gan: vng tr nn g trong.

4) chim cho 1 tn thng h thng gan mt.


14/47


Page | 14

+ vng da: r rt hoc kn o.

+ ti mt to cng, hoc im ti mt (Murphy) rt au.

+ gan to v au.5) chim cho 1 bnh l tit niu.+ v niu or b tiu: biu hin bng cu bng quang.

+ tiu mu.

+ thn to.6) chim cho 1 bnh l sinh dc ph n:+ cc biu hin ca thai nghn: tt kinh, v cng c qung thm, nghn..

+ chy mu c quan sinh dc: r rt hoc kn o, phi thm m o thy mu ra tay mi bit.7) chim cho 1 hu qu ton thn.+ hin tng nhim khun cp: st cao, mch nhanh.

+ hin tng chong, thiu mu cp: ngt, nhit h nhanh, mch nhanh - yu, HA h.LOT D DY - T TRNG

1. c thau kh d di lm ngi bnh phi vt v m bng -> au qun, xon ly bng.

2. au thng v, hoc xuyn lan ln ngc hay ra sau lng, hoc sang 2 bn.

3. tin s: c nhng cn au tng t, thng xy ra vo 1 ma nht nh, phn nhiu l ma lnh (ng) & c lin quan r rtn ba n. -> lot t trng (i - lch (P) - d di xin lan - n vo du), lot d dy (no - lch (T) - m khu tr - khng xin lan).

4. bng vn mm hoc chc phn ng thnh bng thng v & vn cn vng c trc gan.

5. CLS: XQ (nt ng thuc, hnh t trng bin dng, hnh lm b cong nh...) cn chp hng lot mi c gi tr chn on.Nay c ni soi mi vic tr nn d dng hn.

6. Vn ch yu: cn xc nh xem lot chuyn sang bin chng thng cha -> da vo LS + CLS ca thng d dy.

THNG D DY

7. xy ra trn ca c tin sau lot d dy -> nghngy chn on thng, d vy cng c khi thng l bin chng mucho lot.

8. ln au ny kh d di -> BN vt v, m bng. au vng thng v, c th xuyn lan ln ngc, ra sau lng, hoc sang 2 bn.

9. Cng l cnh tng BN vt v, m bng than au vng thng v nhng Lot khc Thng ch: 1. tnh cht au nng n hn-> au nh dao m, qu tm chu ng gy shock, 2. vng thng v c co cng thnh bng (lu phn bit co cng thnhbng & phn ng thnh bng - nu trong p1), 3. c th g trong vng trc gan .

10. Xc nh chn on bng X quang: lim hi di c honh, c 2 bn hoc chbn (P). Nay c ni soi h tr v gp phn

quan trng trong chn

on xc

nh.

VIM TY CP CHY MU

11. cn au xy n t ngt trn ca mnh khe, thng l ngi bo.

12. au rt d di, thng km theo shock.

13. Thc th: au im sn lng (Mayo - Robson) -> gi chn on.


15/47


Page | 15

14. Xc nh chn on bng: nh lng amuylaz mu & NT: tng rt nhiu, soi bng tm vt nn trn mng bng, hoc phuthut thm d.

SI NIU QUN

15. Cng au d di 1 h chu, c th ti pht nhiu ln, xut hin t ngt & lan xung b phn sinh dc - i, thng xy

ra sau lao

ng hoc

i xa.

16. Thng km b tiu hoc v niu.

17. Sau cn au, BN c th tiu ra mt t nc tiu , c nhiu HC & t protein.

18. CLS: cn Addis tm HC, BC v protein trong nc tiu.

19. Chn on xc nh ch yu bng XQ bn cnh CLS. Chp thn - h niu khng chun b -> chn on v cc si titniu phn ln u cn quang.

20. Nu cn c chnh x tr ngoi khoa: chp c thuc cn quang tim TM +nh lng ure mu nh gi kh nng bi titca thn.

SI BNG QUANG

21. au vng bng di: kh d di, c th ti pht nhiu ln, t ngt, thng xy ra sau khi lao ng hoc i xa.

22. km hi chng bng quang: tiu but (au), rt (lt nht), tiu mu hoc m; c khi b tiu (bun tiu nhng khng tiuc).

23. Thm trc trng - m o: c th chm c si bng quang. Hoc thng bng quang bng ng kim loi cng c sdng nhm mc ch ny.

24. Soi bng quang: c th nhn thy si. Nu si b -> khng cn x tr ngoi khoa, c th qua ng soi a kp vo nghinnt si.

25. Chp bng quang: l phng php n gin nht, ng thi xc nh ngay chn on (v si niu phn ln u cn quang).

26. D xc nh c si bng quang, cng cn kim tra thm thn bng XQ khi b st cc si c t thn xung.

27. Sau khi chn on si niu (d thn, niu qun hay bng quang) cng nn xt nghim thm pH nc tiu -> v s thayi v pH NT thng to iu kin thun li cho vic kt si.

Nn maC CH SINH BNH

1. nn ma: l phn x - gy ra bi s kch thch bt ca im no trn ng tiu ha: ty li cho n i trng. Nhngs kch thch u a v trung tm nn ma ( hnh ty) -> ty phn x nn theo cc dy ly tm:

+ dy TK honh gy co tht c honh

+ cc dy TK chi phi c thnh bng

+ dy ph v (dy X) lm cho tm v m ra.2. s co tht c honh & cc c thnh bng song song vi s m tm va n hin tng nn.

TRNG HP HAY GP

3. Nn ma xy ra lin tc - ko di -> mt nc - ri lon in gii.


16/47


Page | 16

4. t c ch bnh sinh c th hiu c cc tnh hung c nn ma:1) bnh ng tiu ha: lot d dy, K d dy, hp mn v, vim rut tha, tc rut, lng rut, th t, nhim c thc n...

2) bnh no - mng no: tng p lc s no do u, vim no, vim mng no..

3) bnh gy ri lon hnh ty: do nhim c ni ti (ure mu cao, toan mu), do st cao (cm, vim phi, thng hn, st rt...)

4) trng hp c ri lon TK giao cm - ph v: nn nghn, say sng..5. Nn ma thng biu hin trong 4 trng hp:1) nn c nhc u - to bn: 1. tng p lc s no, 2. vim mng no.

2) nn c au bng: 1. tc rut, 2. lng rut, 3. hp mn v, 4. ngc thc n.

3) nn c tiu chy: 1. ngc thc n, 2. th t, 3. nhim c ni ti: do ure mu cao hoc toan mu.

4) nn n thun: 1. nn nghn, 2. say sng, say my bay.6. tathata chn cc mt bnh: 1. Tng p lc s no, 2. Vim mng no, 3. Ngc thc n, 4. Nhim c ni ti post lny.

TNG P LC S NO (U NO)

7. nn: rt nhiu -> nn vt: bt c thc n g cng nn, khng n cng nn - cn tr vn nui dng.

8. nhc u: rt d di -> BN ku la, khng p ng vi cc thuc an thn thng thng.

9. to bn: t lc u mt bnh. 4,5 ngy c khi 9,10 ngy mi i tiu 1 ln -> thng phi tht tho phn mi i c.

10. phn nhiu trng hp c triu chng thn kinh chim (thng l lit 1 hoc nhiu dy TK s no, n thun hoc kt hpvi ri lon vn ng cc chi) ty v tr u no.

11. CLS:+ soi y mt: c ph vng mc.

+ chc d dch no ty: thng c phn ly t bo vi albumin - s t bo khng tng hoc chtng t, khng tng xng vi slng albumin tng nhiu) & glucoz bnh thng. Lu : cn thit lm hy lm xt nghim ny, v d gy tt hnh ty xung chnvo l xng chm lm BN ngt & cht t ngt. Nu lm, BN t th nm, ly rt chm & chly mt lng nc no tyrt t, va nhn nh & lm xt nghim.

+ Xc nh chn on bng CLS: chp no sau khi tim thuc cn quang vo M no, hoc chp no tht sau khi bm hi. Ngynay c CT - Scanner.VIM MNG NO

12. tnh cht nn ma, nhc u, to bn ging nh trong u no, nhng c thm cc triu chng chim cho tn thng mng no:+ c cng

+ Kernig (+)

+ Babinski (+), 1 or 2 bn

+ cn ng kinh

+ lit dy TK vn nhn -> lc mt.13. Xc nh chn on bng chc d dch no ty: thy chy nhanh vi p lc cao. Mu sc - tnh cht cc thnh phn (t bo,albumin, glucoz) thay i ty loi vim mng no.

NG C THC N

14. c th chnn n thun, hoc nn + au bng, hoc nn + au bng + tiu chy.NHIM C NI TI

15. do ure mu cao hoc do toan mu. Nhng trng hp nng: nn km tiu chy kh nng -> BN kit nc. Thng tiu chyni bt ln trong bnh cnh so vi nn ma.


17/47


Page | 17

16. tiu chy thng km theo cc biu hin tinh thn: nhc u, mt mi, l m, c thi dn vo m sng, bn hn m ri hnm.

17. nn ma, thiu niu c khi v niu.

18. xy ra BN: ang c bnh thn, bnh do xon khun, tng huyt p.. l nguyn nhn dn n ure mu cao, hoc trn nn

i tho ng - nguyn nhn dn n toan mu.19. CLS: nh lng ure mu (i vi ure mu cao). Tm s c mt ca th ceton trong nc tiu, d tr kim trong mu h (xc nh toan mu).

Nn ra mu1. Nn mu l 1 cp cu ni khoa. Nguyn nhn ch yu l cc bnh d dy, thng nht l lot d dy - t trng. Ngoi racn c nguyn nhn khc h TM ca.

NHN NH NN MU

2. xc nh da trn:1) s xut hin sau 1 cm gic kh chu thng v ri BN nn ra.

2) mu

en: c khi long pha ln vi dch v, c khi nn hn ra nhng cc mu

en. Trng hp nng c th nn ra mu

tiv mi chy mu nn ra ngay.

3) mu thng ln vi thc n.3. Cn phn bit vi ho ra mu:+ ho ra mu thng xut hin sau 1 cn ho+ mu ti, nhiu bt, khng ln thc n+ phi c ran n 2 th.4. nh gi mc nng - da vo:1) lng mu nn

2) s ln ti pht & khong cch thi gian gia cc ln ti pht.5. Tnh trng thiu mu cp: nim mc nht nht, hoa mt, chng mt, thm ch c khi ngt. Xc nh chnh xc bng: HA h;mch nhanh - nh; s lng HC & Hb gim.

C CH SINH BNH6. nn ra mu l biu hin chy mu d dy - do: v mch mu, hoc mu thm thu qua thnh mch v 1 ri lon vn mch.

NGUYN NHN

7. thng do 2 nguyn nhn:1) tn thng nim mc d dy - t trng: lot d dy - t trng, K d dy, vim d dy cp/ mn.

2) tng p h TM ca: lm cho cc TM thc qun & d dy b gin, lch to (v lch l 1 phn ca h TM ca). Thng thng,trong tng p h TM ca do nguyn nhn trong gan (in hnh l x gan): yu t tng p ca cn phi hp thm vi: 1. yu t rilon chy mu, 2. tnh trng d v ca mao qun (do tnh trng suy gan kt hp).8. 2 nguyn nhn ni trn thng d thy LS nh cc triu chng chim:1) au thng v: i vi cc tn thng d dy - t trng.

2) lch to hoc c trng: i vi tng p TM ca.9. phn loi nn ra mu theo nguyn nhn:1) nn mu km au vng thng v: c cc bnh 1. lot d dy t trng, 2. K d dy, 3. Vim d dy, 4. do s dng thuc(Aspirin, Corticoid).

2) nn mu km lch to: tng p TM ca.

3) nn mu km c trng: 1. x gan, 2. lot d dy t trng/ x gan c trng.

4) nn ra mu n c: 1. lot d dy - t trng, 2. hi chng Mallory Weiss, 3. ure mu cao.


18/47


Page | 18

LOT D DY - T TRNG

10. nn mu c th km au vng thng v, c trng hoc n thun.

Km au vng thng v

11. s lng mu nn: trung bnh hoc nhiu -> t vong ngay, hoc lng t th khng biu hin bng nn mu m chbng tiuphn en.

12. nn mu thng xy ra trong chu kau ca ngi bnh, cng c khi l triu chng khi pht ca bnh.

13. chn on da vo tin s: trc y c nhng cn au thng v c chu k thng v ma rt, cn au c lin quan viba n.

14. Cng c nhng trng hp lot d dy - t trng khi pht bng 1 chy mu tiu ha.

15. xc nh chn on bng X quang: thy hnh lot hoc bin dng d dy hay t trng, cnh trn nhiu phim. Hin nay cni soi h tr.

C trng

16. Lot ddtt thng gp BN x gan, tuy LS kn o ch yu chn on bng X quang. Cn ch n s kt hp thng cny thi x tr & thm d thch ng.

17. Trc 1 BN x gan c nn ra mu, bn cnh chn on nguyn nhn nn ra mu l do tng p TM ca, cn cp nnguyn nhn lot d dy t trng kt hp.

18. Trc khi x tr nh 1 tng p TM ca, phu thut vin nn kim tra d dy loi tr nguyn nhn .

n thun nn ra mu

19. lot ddtt khi pht bng nn mu, trng hp ny khng km au, lch to, c trng. (t gp trong thc t LS)

K D DY

20. mu nn ra: thng t, c tiu ha -> en nh b c ph.

21. thng xy ra ngi ln tui c nhng ri lon thng v trn nn khe mnh: n vo thy y hi, m ch, kh tiu, bunnn, c khi c nhng cn au ging nh lot d dy.

22. nu K xy ra trn 1 lot (lot ung th ha): tnh cht au ca lot khng ging tin s v chu k cng nh cng .

23. nu K mun: BN gy i, ni u rn - g gh thng v, c khi c c di cn sang gan hoc ln hch thng n. Tuy nhin,nu n giai on ny th khng cn kh nng iu tr.

24. XQ: thy 1 on cng b cong nh, hoc 1 hnh li -> xc nh chn on.

25. Ni soi: thy khi u nham nh rm mu trn nn nim mc d dy km hoc khng cn nhu ng. Nu l 1 lot ung thha th th b lot nham nh & rm mu b. Chc chn nht nn sinh thit. (cn sinh thit trong khi soi sinh thit cng vo u hoc ng ngay b lot).

26. Nu khng c iu kin ni soi & sinh thit, m hnh nh XQ li ging nh 1 lot d dy c thm 1 on cng b congvng , cn phi: iu trthnhlot d dy, theo di bng LS kt hp vi X quang. Sau 1 - 2 thng iu triu tr tch cc &ng phng php, nu khng thy gim bnh v LS cng nh XQ -> nn nghi K, sau xc nh chc chn bng sinh thit.


19/47


Page | 19

VIM D DY

27. mu nn ra: thng t & en.

28. BN c cm gic au vng thng v, au rt bng, ngay trong ba n & khng c chu k r rt trong nm.

29. XQ: ch yu

loi tr cc nguyn nhn khc d dy nh lot, ung th.

i khi c thy cc np nim mc ni to: vim ddy th ph i (rt him).

30. Ni soi: nim mc d dy nht mu, c th c vt xc (vim d dy th xc), nhng chm chy mu (vim d dy thchy mu), cc np nim mc c th sng to & dy (vim th ph i) nhng phn nhiu teo nh (vim d dy th teo - thnggp hn), gia cc np nim mc c th c nhiu cht nhy hoc nhy mu ng.

31. sinh thit nim mc d dy trong khi soi: c gi tr xc nh chn on ng thi phn loi vim d dy theo c th bnh hc.Tip tc vi 5 nguyn nhn cn li ca Nn ra mu:

DO S DNG THUC

32. thuc: aspirin, corticoid.

33. nn ra mu: l tai bin xy ra vi gi sau ung thuc -> s lng mu thng khng nhiu, t khi lm BN t vong. Phnnhiu, nhng loi thuc ny chl tc nhn thun li gy nn ra mu BN mang sn bnh d dy - t trng.

TNG P TNH MCH CA

34. nn mu km lch to. Lch to c th do nguyn nhn khc (nh st rt mn) d vy cng phi nghn Tng p TM ca.

35. nn mu: thng lng nhiu, c khi BN t vong do khng kp s cu.

36. lch c th to nhiu hay t, nhng mm; nht l nh bt li sau tai bin nn ra mu.

37. CLS:+ XQ d dy: loi tr nguyn nhn d dy (lot, K..).

+ ni soi: thy c TM gin (nu c).

+ o p lc lch: rt cao (bt 12cm H2O).X GAN

38. nn mu km c trng (bng bng).

39. c ch ca nn ra mu ch yu do tng p TM ca nn tnh cht mu nn ra ging nh trong tng p TM ca: nn lngnhiu.

40. Bng bng thng rt to, c tnh thm thu (phn ng Rivalta (-) & albumin < 30g/l) ti pht nhanh sau khi chc tho.Thng bao gi cng km theo tun hon bng h ca ch.

41. c th c lch to.

42. CLS: cng cn XQ,

o p lc lch nh trong T

ng p TM ca; nhng trong X gan cn lm thm:+ xt nghim thm d chc nng gan -> b ri lon nhiu: xc nh c mc suy gan.

+ soi bng: cn chc tho ht nc c trng trc khi soi soi c thun li -> xc nh chn on.HI CHNG MALLORY WEISS

43. nn ra mu trn nn nn nhiu trc , y lng mu ra thng t: vi mililit hoc mu thnh tia ln vi cht nn.-> tham kho thm: Hi chng Mallory-weiss - link: http://www.diendanykhoa.com/showthread.php?t=142

HC URE MU CAO


20/47


Page | 20

44. nn ra mu lng t, l triu chng ph trong bnh cnh thng r ca 1 ure mu cao v LS cng nhnh lng CLS.

Bng bng (c trng)1. Bng bng (c trng): l hin tng c nc trong mng bng. Nc c th do ngoi thm thu vo hoc do mngbng tit ra.

2. Trong quyn 'Chn on lm sng' ny, NXH chni n c trng t do -> thng gp nhiu nht. Khng ni n loi ctrng ngn cch - c trng bi g c bn c -> lao mng bng th b u.

XC NH BNG BNG

3. bng to: s xung khi BN ng, b sang 2 bn khi BN nm nga.

4. Rn li.

5. G c vng thp: ni BN nm nghing sang (P) ri (T) xc nh k triu chng ny. Gii hn trn ca vng c l 1 ngcong nga ln trn.

6. du hiu sng v.

7. xc nh chc chn bng chc thm d: phi lm d bng bng nhiu hay t nc. Bng bng nhiu nc - chc d gip nhnnh, bng bng t nc - chc d gip xc nh chn on.

8. Theo di bng bng bng cch: o vng bng qua rn bit mc nc nhiu hay t, mi xut hin hay ti pht nhanh -chm.

9. khi c bng bng, thng c thm hin tng nc cc b phn khc:+ di da: gy ph ton thn or chph 2 chi di.

+ cc thanh mc khc, nht l mng phi -> gy trn dch mng phi.CHN ON PHN BIT

10. cn chn on phn bit bng bng vi:1) bng bo s2) bng quang nc

3) t cung c thai vi nhiu nc i4) u nc5) thn nc gi to c trng.11. bng bo s+ cng to, cng s xung khi ng & b sang 2 bn khi nm nga.

+ tuy nhin, phn bit bng bng vi bng bo khng kh nh da vo:1) rn: bng - li, bo - khng li.

2) bo - lp m thnh bng dy, ton thn to bo.

3) g vng thp: bng - c c, bo - khng c.12. bng quang nc+ bng chto v pha di, trn xng v.

+ rn: khng li.

+ g: cng c, nhng vng c khng thay i theo t th BN & gii hn trn ca vng c l 1 ng cong p xung di.

+ cm gic ch quan ca BN - im in hnh: tc bng, mt tiu nhng tiu c.

+ kim chng thc t: thng bng quang - c nhiu nc tiu, sau thng khi u xp hn.

+ cui cng, khi xc nh c l bng quang nc, cn tm thm nguyn nhn: thm trc trng hoc m o ( kimtra tin lit tuyn hoc t cung), XQ niu.13. t cung c thai - nhiu nc i


21/47


Page | 21

+ g: cng c, nhng vng c khng thay i theo t th, gii hn trn ca vng c l 1 ng cong p xung di.

+ biu hin c thai - im in hnh: tc kinh nghn, v cng c nhiu qung thm, thm m o thy t cung to, mm; thai my..14. u nc+ thng hay nhm nht.

+ u c th ca bung trng (thng nht), ca dy chng rng hay cc b phn khc: mc treo, di tch bo thai.

+ bng: cng to, nhng to nhiu v 1 bn.

+ rn: khng li.

+ g: cng c, nhng vng c khng thay i theo t th BN, gii hn trn ca vng c l 1 ng cong p xung di.

+ 2 vng hng: g trong -> do rut by ra sau.

+ nghi ng u nc, tt nht nn chc tho bt nc (100 - 150ml) ri bm vo lng khng kh tng ng, sau em chpX quang. y l im xc nh phn bit:- nu bng bng: lng hi bm vo s t di c honh thnh 1 lim hi sng.

- nu l u nc: lng hi lng chng gia bng thnh 1 hnh hi c mc nc ngang; c trng hp u nc nhiu bcth lng hi lan ta vo cc bc lm thnh nhiu m hi trong bng, c th c m hi c mc nc ngang.

15. thn nc gi to c trng+ 1 s trng hp thn nc rt to biu hin thnh 1 u nc gi c trng.

+ bng: cng to, nhng to nhiu v 1 bn & rn khng li.

+ g: cng c, nhng vng c khng thay i theo t th, gii hn trn ca vng c l 1 ng cong p xung di.

+ nc tiu: nu c bin i vi th, hoc v xt nghim (vi th) -> cn nghn thn nc. Nhng nu nc tiu bnhthng vn khng loi c v nc tiu ra ngoi thuc bn thn lnh, thn c bnh b tc nghn khng tit nc tiu xungbng quang c.

+ nh lng ure nc chc ra (chc v nhm l c trng): m ure cao hn mu rt nhiu. Cn bng bng th ure thn hoc chbng ure mu.SINH L BNH

15. bnh thng mng bng khng c nc.

16. trong trng hp bng bng, mng bng c nc l do:1) vim nhim hoc kch thch.2) yu t th dch.3) yu t mu.17. vim nhim hoc kch thch: lm cho mng bng tit dch (trong lao mng bng, K mng bng nguyn pht or di cn).

18. yu t th dch:+ do gim protein mu lm thayi p lc keo nn huyt tng d thm thu qua thnh mch mu (trong thn nhim m, phdinh dng, cng l 1 trong nhng yu t nguy c gy c trng do x gan).

+ NaCl lm nc b gi li (trong vim thn).

+ cng Aldosteron: thng th pht, xy ra trong suy tim, x gan, hi chng thn nhim m.

19. yu t mu:+ trong tun hon TM ni chung: c trng do suy tim.

+ trong h thng TM ca: c trng do tng p lc TM ca (nht l tng p ca do x gan).PHN LOI

20. T tnh cht sinh l bnh:+ yu t vim nhim hoc kch thch bao gi cng gy ra c trng xut tit biu hin bi phn ng Rivalta (+) & c nhiuprotein.

+ yu t th dch & yu t mu bao gi cng gy ra c trng thm thu biu hin bi phn ng Rivalta (-) & t protein.


22/47


Page | 22

21. LS thng da vo mu sc nc c trng (trong, vng chanh, hoc , hng; c khi nc c hoc vng nh ngh) kthp vi nguyn nhn c trng.

22. c th:

+ nc trong: bao gi cng c tnh thm thu.1) vim thn hoc thn nhim m

2) suy dinh dng.+ nc vng chanh: c th thm thu hay xut tit.a - c trng nc vng chanh thm thu_Rivalta (-):@ khng km theo gan to:1) vim thn hoc thn nhim m2) suy dinh dng3) x gan.@ km theo gan to:1) K gan2) suy tim.b - c trng nc vng chanh xut tit_Rivalta (+):@ km theo u trong bng:1) K gan2) K d dy3) K mc treo.

@ khng km theo u trong bng:1) lao mng bng th c trng2) K mng bng nguyn pht.+ nc hng hoc : phn ln l xut tit -> c trng chy mu: ging nh trng hp c trng nc vng chanh xut tit.

+ nc c: c th l dng chp hay nc m.@ dng chp: phn ln do giun ch.

@ m: do vim mng bng m.+ nc vng ngh: chc trong trng hp c trng kt hp vi vng da.1) x gan hu pht sau vim gan do virut2) x gan mt.X GAN

23. l trng hp c trng nc vng chanh - thm thu - rivalta (-): nc c trng ti pht rt nhanh, hi dnh; protein im loi tr c trng + ph do thn.+ nh lng protein mu gim.

39. tm bnh nguyn pht gy suy dinh dng: thng l cc bnh ng tiu ha mn tnh hoc cc nhim khun mn tnh

(nht l Lao) hay cc bnh c tnh (K).

Gan toXC NH GAN TO

1. nhn: gan to ni thnh 1 u dc theo h sn (P).

2. s: gan nh ra khi b sn (P), nhiu hay t, ty mc gan to & di ng ln xung theo nhp th.

3. g: bnh thng vng c ca gan 10 - 11cm theo ng trung n (P), b trn khong lin sn 5, b di st vi hsn.

4. xc nh gan to ch yu nh s + g. Ty mc , gan c th to ln trn nhng phn nhiu to xung di.

CHN ON PHN BIT

5. phn bit Gan to vi:1) gan sa2) thn (P) to3) u d dy4) u i trng, m qunh mng bng hoc khi u thnh bng.GAN SA


24/47


Page | 24

6. cng s thy + g c qu b sn.

7. tuy nhin, trong gan sa:+ chiu cao vn mc 10 - 11cm.

+ b trn thp hn lin sn 5.

+ c thy gan ln c.THN (P) TO

8. v thn sau mng bng nn khi thn to:+ khi u hng v pha sau, bao gi cng chm thn (+).

+ g pha trc, trn vng c khi u: ting g vn trong v c i trng & cc quai rut nm chn pha trc.9. thng km theo cc ri lon tit niu: tiu mu, tiu m hoc v niu; cn au qun thn hoc nc tiu c protein.

10. nu c LS ca thn to (chm thn (+), ri lon tit niu, au qun thn) th cng nghu s thy l thn to. Nhng nu khngc cng khng loi c thn to v c th thn vn to nhng b loi tr, khng bi tit c nc tiu xung bng quangna, nc tiu thot ra c l ca bn thn lnh.

11. c th cng c loi tr bng siu m bng: gan vn bnh thng, chthy 1 khi sau mng bng y cc quai rut & i trngra trc. Hoc bng XQ niu c cn quang: thy bng thn to.

U D DY

12. d nhm vi gan to (ch yu thy (T) ).

13. u thng km theo ri lon i tin: tiu chy, tiu mu en..

14. c nn sau khi n.

K I TRNG, M QUNH MNG BNG, KHI U THNH BNG

15. phn bit vi gan to ging nh vi lch to (Xem 'Lch to').

GII PHU

16. gan l c quan c lin quan vi:1) phi (P) & mng ngoi tim.

2) ng tiu ha (thng qua ng mt ch & TM ca).

3) ton thn (bng ng mu).4) tim (P) (thng qua TM trn gan) -> gan l b phn tin n ca tim (P).

NGUYN NHN

17. nhim trng t phi, ng tiu ha ko theo nhim trng gan -> gan to: trong Apxe gan.+ hu pht t vim mng phi m, vim phi or pxe phi (P), i khi t vim mng ngoi tim c m.

+ hu pht sau vim mt qun: cc vi khun ng rut nhn iu kin thun li ( mt) theo ng mt ch ln gy vim nhim mt qun -> apxe gan.

+ do amip: amip ti trng theo h TM ca v gan.

+ do nhim khun mu: nhim khun n gan bng ng mu t 1 nhim khun xa.18. lin quan tim (P) v phng din tun hon: suy tim (P) -> mu ngoi bin: nh hng sm n gan (v gan l b phn tinn ca tim (P) ) -> gan to/ suy tim =gan tim.

19. sn xut & bi tit mt qua h thng dn mt: khi h dn mt b cn tr c gii, mt khng lu thng c ht, li tronggan -> gan to/ mt = gan mt.


25/47


Page | 25

20. do tn thng khc:+ K: c th l K khi, lm cho gan to nhng vn gic mt nhn, hoc K nhiu lm gan to - ln nhn.

+ x ha ngnh kt: l x gan do nhiu nguyn nhn -> hu qu: bp cht cc nhnh h TM ca trong gan -> tng p TM ca;ng thi lm gim chc phn ca gan -> suy gan.+ cc bnh ca t chc lin kt, ch yu bnh v mu: Hodgkin, bnh bch cu... -> t chc lin kt gan bnh hng -> gan to.

PHN LOI

21. LS thng da trn tnh cht chn on nguyn nhn gan go, ch yu da trn mt gan -> chia gan to lm 2 loi,hng cho s chn on nguyn nhn:@ gan to mm:1) gan nhim khun: apxe gan2) gan mt3) gan tim.@ gan to chc/ rt cng:1) x gan (th gan to)2) K gan3) Hodgkin, bnh bch cu (triu chng chnh ca 2 bnh ny l lch hch to, hi chng chy mu).22. c th:@ gan to cng:+ mt gan g gh: K gan th nhiu u (nguyn pht, hu pht).

+ mt gan nhn:1) K gan th khi (nguyn pht)2) X gan to.@ gan to mm:+ c st, khng vng da: vim - apxe gan do amip.

+ khng st, c vng da: gan mt.

+ c st, c vng da: vim mt qun.

+ c ph 2 chi di:1) gan tim2) apxe gan - apxe mt qun mn tnh gy ph dinh dng.

X GAN TO

23. l trng hp gan to cng, mt gan nhn.

24. mt gan chc, b r - sc. Pht trin chm, dn dn: hng thng - hng nm.

25. khng st. khng triu chng biu hin y phi (P), c honh (P).

26. im lu : triu chng tng p TM ca (c trng, tun hon bng h), CLS ri lon chc nng gan -> xut hin rt sm.

27. xc nh chn on bng CLS:+ xt nghim chc nng gan: ri lon nhiu - sm.

+ soi bng:- nhiu du u anh ri rc u trn khp mt gan- nu mt gan c ch ni to, hoc u anh to - trng vng -> cnh gic x gan K ha: sinh thit gan.+ chp h ca, M thn tng -> nu chgan x to th cc nhnh ca & M gan trong gan u nh - x.

K GAN

28. c 2 th:+ th nhiu u (nguyn pht, hu pht) -> gan to cng mt gan g gh.

+ th khi (nguyn pht) -> gan to cng mt gan nhn.Th nhiu u


26/47


Page | 26

29. mt gan cng nh. Gan g gh, ln nhn nhiu u. B r. Pht trin nhanh.

30. thng km theo suy sp c th. C th st hoc khng.

31. khng c biu hin y phi (P), tr khi c di cn ln phi. C honh (P) c th by ln cao nhng vn di ng.

32. triu chng tng p TM ca + mt: thng v sau mi xut hin, khi K tin trin nhiu.

33. CLS:+ chc nng gan: lc u bnh thng, v sau ri lon.

+ soi bng: thy r u ni ln trn mt gan, mu trng vng, c nhiu mao mch (trn - xung quanh u).

Th khi

34. Ging th nhiu u, K gan th khi gan cng cng nh, b r, pht trin nhanh. Phn bit 2 th ny da vo: th nhiu umt gan g gh, ln nhn; th khi mt gan nhn.

35. Nhn chung, LS pht hin gan to tin trin nhanh - mt cng -> nghK gan. xc nh, cn soi bng. Trong th khi,khi soi thy c: khi u nh hn ln mt gan thnh 1 khi trng vng c nhiu mao mch.

36. Trng hp khi u nm trong lng ca gan -> sinh thit. D vy, nu sinh thit cha su n c K, vn khng pht

hin t bo K trong mu gan sinh thit. Lc ny cn chp h ca -> thy cc nhnh ca trong gan bt on, hoc chp Mthn tng: thy nhnh M gan trong gan b x y & c nhiu mao mch tn to vng c khi u.

GAN TIM

37. gan to, c tnh cht n gi, mt gan mm.

38. phn hi gan - TM c (+).

39. ph 2 chi di: lc u nh - kn o, xut hin khi BN ng lu hoc v chiu, mt i lc sng sm sau ng dy. V sau,ph thng xuyn & r.

40. lun km triu chng khc ca suy tim: TM c ni, kh th, xanh tm, tiu t...

41. CLS:+ o Huyt p tnh mch: rt cao.

+ o tc tun hon: rt chm.42. pht hin nguyn nhn gy suy tim: cc bnh van tim, bnh c tim, vim mng ngoi tim c nc, vim mng ngoi tim cotht, bnh tim - phi mn...

Vng da1. vng da: l biu hin ca tnh trng tng bilirubin trong mu -> c hiu chim cho bnh l gan - mt.

2. chn on vng da: cn chn on c nguyn nhn:+ do gan -> phn ln iu tr ni khoa.

+ do h thng dn mt ->

iu tr ngoi khoa.XC NH VNG DA

@ vng da r:

3. mu da: vng nhiu hay t, thng kt hp vi sm bn. Nhng ch yu vng nim mc - nht l nim mc mt, mm, li.

4. nc tiu: sm mu, vng nh ngh.

@ vng da nh:


27/47


Page | 27

5. nim mc phn pht vng -> cn pht hin di nh sng mt tri v th ny kh nhn nh di nh sng n.

6. xc nh bng CLS:+ nc tiu: c sc t mt (bt khng c).

+ nh lng bilirubin mu: cao hn bnh thng -> nh gi mc vng da.

CHN ON PHN BIT7. phn bit vng da do bnh l gan - mt vi:+ do ung Quinacrin, Santonin+ do n nhiu caroten.8. Trong cc trng hp trn chc vng da, khng vng nim mc. Nc tiu khng c sc t mt, blirubin/ mu vn bnhthng.

SINH L: S sn xut & chuyn bin sc t mt

9. sc t mt: c cu to t huyt sc t ca mu.+ Hng cu v gii phng huyt sc t tch tr lch di dng bilirubin gin tip (bilirubin tdo).

+ bilirubin gin tip theo h ca v gan, c gan ch bin thnh bilirubin trc tip (bilirubin kt hp).

+ bilirubin trc tip c thi tit theo h thng dn mt vo ng tiu ha.10. Trong qu trnh rut non, sc t mt c chuyn sang dng urobilinogen.

11. urobilinogen i theo 2 ng:1) theo ng tiu ha xung i trng: thi tit ra ngoi di dng stercobilinogen trong phn.

2) theo h TM ca tr v gan (vng rut - gan): phn ln c gan s dng ti sn xut bilirubin, phn nh theo i tunhon n thn, thi ra ngoi theo nc tiu di dng urobilinogen.

GII PHU

12. mt c gan sn xut s theo cc vi tiu qun mt trong tiu thy n cc mt qun ca khoang ca ri ra ngoi theocc ng gan, ng ti mt v d trti mtng thi c c c li.

13. Trong cc ba n, ti mt co bp tng mt tr li ng ti mt, xung ng mt ch vo t trng.

14. C 3 im cn ch :

1) cc vi tiu qun mt trong tiu thy i theo song song vi cc mao mch, chb ngn cch bi cc ct t bo gan (ctRemak).

2) dc theo cc ng gan & ng mt ch c nhng chui hch chi phi gan - d dy - ty tng.

3) on cui ng mt chi st vo mt sau hoc xuyn qua u ty tng vo on 2 ca t trng ti bng Vater chungvi ng ty.

SINH L BNH

15. khi c ri lon vic sn xut mt, hoc khi c tn thng trn h thng dn mt u c th lm cho bilirubin tng nhiu trongmu -> gy triu chng vng da.

16. cc ri lon c th l:1) sc t mt c sn xut qu nhiu2) vim nhim hoc hy hoi nhu m gan3) cn tr c gii trn h dn mt ngoi gan: si, K.17. sc t mt c sn xut qu nhiu: do hng cu b v nhiu, gii phng qu nhiu huyt sc t - tin thn ca sc t mt ->vng da do hoi mu (cn gi l vng da trc gan).

18. do vim nhim hoc hy hoi nhu m gan: lm cho cc vi tiu mt qun trong tiu thy bvim tc gymt, mt d thm


28/47


Page | 28

thu vo cc mao mch -> mt tng ln trong mu; hoc do s hy hoi t bo gan: mt cc vi tiu mt qun d thm thu vocc mao mch -> vng da do tn thng gan (cn gi l vng da trong gan).

19. do cn tr c gii trn h dn mt ngoi gan: cn tr c th l si mt (thng thng nht), K cc ng dn mt, sng cchch xung quanh ng mt ch, K u ty -> vng da do tc mt (cn gi l vng da sau gan).

PHN LOI20. Nguyn Xun Huyn phn loi vng da da trn triu chng lm sng kt hp:@ vng da khng c gan to:1) vim gan virus thin hnh2) bnh do Leptospira3) vim gan nhim c.@ vng da c gan to, ti mt to:1) tc mt do si2) vim mt qun3) vim gan th mt4) bnh Hanot5) tc mt do u.@ vng da c bng bng:+ km theo gan to:

1) x gan mt2) K gan3) bnh Hanot giai on cui.+ khng km gan to:X gan hu pht sau vim gan do virus.@ Vng da nh c thiu mu: Vng da hoi mu.X GAN

22. da vo gan to km theo c 2 th bnh:+ km gan to -> x gan mt+ khng km gan to -> x gan hu pht sau vim gan do virus.X gan mt

23. mt c th do si hoc u ri ko di gy ra x gan.

24. BN tin s c triu chng ca tc mt do si hoc vng da lu nay xut hin thm hi chng tng p TM ca (bng bng,

tun hon bng h) v hi chng suy t bo gan.

25. nc bng bng: mu vng xanh nh mt.

26. gan to, khng mm nh khi mi c mt: mt gan tr nn chc nh mi trng hp x gan khc.

27. ti mt c th bnh thng hoc to ty trng hp.

X gan hu pht sau vim gan do virus

28. bnh s l ca vim gan do virus nhng trong qu trnh din tin bnh xut hin thm hi chng tng p TM ca.

29. Bng bng c th nhiu hay t, nc mu vng xanh nh mt, phn ng Rivalta (-).

30. km theo tun hon bng h r hoc kn o.

31. din tin bnh thng chuyn bin xu: BN i vo hn m gan -> t vong, hoc cht sau bin c XHTH nng.

K GAN

32. c thm tng p TM ca hoc di cn ca K n mng bng gy bng bng, K ln ng dn mt gy thm tc mt.

33. vng da: cng ngy cng tng.

34. nc bng bng: nh trong X gan, cng mu vng xanh nh mt; nhng Rivalta (+) hay (-) ty bng bng do tng p


29/47


Page | 29

TM ca hay do di cn ca K n mng bng. Nc bng bng c th l nc mu.

35. c th km theo tun hon bng h nu do tng p TM ca.

36. gan to pht trin nhanh, mt rn, mt g gh.

VNG DA HOI MU37. BN xanh xao nhiu hn vng da -> nim mc nht nht, chhi vng, khm k di nh sng mt tri mi pht hin c.

38. bao gi cng km theo lch to: nhiu hay t.

39. phn rt vng do c nhiu stercobilinogen.

40. CLS:+ bilirubin mu cng tng nhng phn ln s bil y l bil t do (bil gin tip).

+ khng c sc t mt nc tiu.

+ phn c rt nhiu stercobilinogen.

+ hng cu gim, hnh dng HC trn, c nhiu HC li. Sc bn HC gim.41. Sau khi xc nh vng da hoi mu, cn tm nguyn nhn gy hoi mu bng LS (ch yu bng hi bnh: cc loi thuc ung trc y, cc cht ha hc tip xc..) v bng cc xt nghim (tm k sinh trng st rt mu, nghim phpCoombs trc tip & gin tip...)

Hch to ngoi binXC NH HCH TO

1. xc nh hch to ngoi bin: nh vo biu hin thnh nhng khi u to hoc nh cc v tr thng thng c hch - nch, c,bn, h thng n...

2. chn on nguyn nhn gy Hch to c chnh xc, cn nhn nh k cc tnh cht ca hch:1) v tr2) kch thc

3) mt 4) mc di ng5) c au hay khng6) cch xut hin & pht trin.V tr

3. 1 hay nhiu vng c hch, da vo hch - ty vng on bnh:+ vng na thn trn (c, nch, h thng n) -> hch lao, hch bnh bch cu.

+ vng na thn di (bn) -> hch bnh da liu: Nicolas Favre, bnh giang mai.Kch thc

4. c th to tt ngn tay n nm tay.+ hch nh: n c hoc tng chm. Thng l hch vim nhim, hch lao, hch di cn ca K.

+ hch to hn: hch Nicolas Favre, hch bnh bch cu.

+ hch rt to: hch lao th lympho, hch lympho sarcom.Mt

5. ty mt c cc th bnh:+ rn, cng -> hch K+ chc -> hch lao th lympho+ mm -> hu ht cc bnh khc c hch to. Nu mm nhn & r ra nh b u -> hch lao, c m -> cc hch nhim trng cm.


30/47


Page | 30

Mc di ng

6. di ng c, ln d dng di da v trn t chc su. Hoc dnh vo t chc su, di da hoc dnh vo nhau.

7. s mt di ng ca hch chng t qu trnh bnh l pht trin ra pha ngoi ca hch, lan sang cc t chc cnh bn ->thng gp nht: cc hch K & mt s trng hp lao.

C au hay khng8. au t nhin hay chau khi s nn hch: cc hch K thng au t nhin & kh nhiu (do s pht trin ca qu trnh bnh lsang cc t chc ln cn, chn p cc dy thn kinh). Cc hch nhim khun c thau t nhin v m nhng khi s nn thrt au.

Cch xut hin & pht trin

9. dn dn - lng l: hch lao, hch K di cn.

10. dn dn - tng t, sau mi t, hch li to thm hoc c thm cc hch khc xut hin.

11. xut hin & pht trin rt nhanh -> hch K, hch bnh bch cu.

12. Tnh cht hch gip chn on c mt s trng hp hch to nhng chn on chc chn, cn phisinh thit hch

xt nghim m hc.

SINH L

13. hch l t chc lin vng ni mc c vai tr quan trng trong:1) s to mu: ch yu trong s sinh sn Lympho.

2) s bo v c th chng vi vi khun & cc tc nhn gy bnh khc v:+ nm trn ng i ca h thng Lympho+ c kh nng sn xut ra khng th.

PHN LOI

14. cc hch thng to ra trong:1) cc bnh ca h thng vng ni mc & bnh mu: bnh bch cu..

2) cc bnh nhim khun:+ nhim cc vi khun thng thng: hch vim+ nhim virus: bnh Rubeol, bnh tng bch cu n nhn+ nhim lao.3) mt s bnh khc: hch K di cn hoc hch K nguyn pht.15. cc bnh ni trn thng biu hin di 2 trng hp lm sng:@ hch to khu tr mt vng:+ bt cvng no:1) hch vim2) hch K di cn.+ 1 vng nht nh:1) c -> lao hch th thng thng, lymphosarcome, lao hch th u.2) bn -> bnh Nicolas Favre.@ hch to pht trin nhiu ni:+ din tin cp:1) bnh Rubeol2) bnh tng bch cu n nhn do nhim khun3) bnh bch cu cp.+ din tin mn:1) bnh bu cu kinh th lympho2) bnh lao hch th nhiu vng.BCH CU CP

16. triu chng chnh - lch to: lch to qu b sn # 3 - 4 cm, xut hin - pht trin nhanh.


31/47


Page | 31

17. st rt cao - tnh cht nhim khun cp.

18. hch: to - mm - di ng, pht trin rt nhanh cng vi lch to. Xut hin khp cc vng c hch, thng nht: c, nch,h thng n.

19. hi chng chy mu di da nim ph tng: tnh cht chy mu ko di.

20. hi chng thiu mu - xut hin & pht trin nhanh: vi ngy n vi tun BN tr nn xanh nht.

21. cc tn thng lot hoi t nim mc ming - hng -> lm cho hi th BN c mi rt hi.

22. m huyt cu - lm huyt :+ HC: gim nhiu ( < 1 triu)+ TC: gim nhiu ( # 50.000)+ BC: tng nhiu ( 50.000 - 200.000, 300.000).23. trong huyt , xut hin nhiu BC nguyn thy (myeloblast), khng c t bo non trung gian, khong trng bch huyt rtc hiu ca bch cu cp.

24. vi th bch cu khng biu hin mu ngoi bin -> lm ty : trong ty t l cc bch cu nguyn thy cng tng rtnhiu.

25. sau khi xc nh Bch cu cp, cn loi tr cc trng hp 'gi bch cu' bng nh lng men phosphataza: thy menny tng.

26. tm cc nhim khun, thng nht phi -> lao k: cn chp X quang phi.

BCH CU KINH TH LYMPHO

27. hch to l triu chng chnh. Trong thi gian vi thng, hch to pht trin rt nhanh tt c cc vng c hch. Hch mm - ding.

28. lch: chhi to, qu b sn # 2 - 3 cm.

29. m huyt cu - lm huyt : HC, TC gim; BC tng.

30. vi th bnh bch cu khng biu hin mu ngoi bin -> phi lm ty .

31. huyt : c nhiu t bo non trung gian thuc loi lympho.

32. ty : t l cc t bo non trung gian loi lympho tng nhiu.

BNH TNG BCH CU N NHN DO NHIM KHUN

33. nhiu hch to, kch thc t na t ngn tay n qu to xut hin tng t nhiu vng.

34. hch chc, nhn, khng bao gi ha m.

35. au t pht, nht l khi s nn.

36. di ng d dng di da v trn t chc su.

37. sau vi ngy: st cao -> vim hng: nut au. Vim hng hoc vim hng lot.

38. thng km lch to nh ra khi b sn.


32/47


Page | 32

39. CLS: BC tng, t l BC lympho v mono tng rt nhiu (60 - 90%). Phn ng Paul - Bunnell (+).

Thiu muXC NH THIU MU

1. lm sng:+ tai, hoa mt, chng mt, ngt+ mt mi, th hn hn khi lm vic nng+ da - nim nht nht.2. xt nghim mu: c tc dng xc nh - nh gi mc thiu mu -> HC, Hct.

3. sau khi xc nh thiu mu, cn pht hin thm nh hng ca thiu mu i vi:+ ton thn: chng mt, ngt, ph dinh dng.

+ tim: t ting thi thiu mu n bnh cnh suy tim r rt c c ting nga phi.

SINH L BNH

4. mt 1 khi lng mu: thiu mu do chy mu.+ mt khi lng mu ln cng lc: thiu mu cp sau khi b chn thng huyt qun, b bng huyt hoc nn ra nhiu mu.

+ mt khi lng mu t - dai dng:1) thiu mu do chy mu rr ca lot d dy or K d dy2) bnh tr3) do giun mc.5. ri lon trong sn xut mu: v cc yu t cn thit cho vic to mu protein, cc yu t ni ti (trong dch v) v ngoi lai (B12,acid folic), Fe:+ khng c cung cp y : thc phm khng m bo yu cu.

+ khng c tiu ha - hp thu tt: dch v thiu toan, chc phn rut bt thng.

+ khng c s dng y do ri lon cc c quan to mu, ch yu ca ty xng: bnh bch huyt, bnh x ty...6. tiu hy HC thi qu bi:+ cc vi sinh vt: k sinh trng st rt.

+ tng chc phn ca lch: cng lch.

+ hng cu km bn vng bm sinh.

+ cht ha hc: ch, photpho...

PHN LOI

7. Nguyn Xun Huyn phn loi Thiu mu da vo tnh cht km theo: c or khng ri lon c quan to mu:@ C ri lon c quan to mu:+ thiu mu c lch to:1) do cng lch2) bch cu kinh th ty bo3) bnh Hodgkin th lch to.+ thiu mu c hch to:1) bch cu kinh th lympho2) bnh Hodgkin thin hnh.+ thiu mu c xut huyt:1) bch cu cp2) hi chng chy mu ko di.+ thiu mu c gim bch cu - tiu cu:1) cng lch2) x ty.@ Khng c ri lon c quan to mu:


33/47


Page | 33

1) do giun mc2) do XHTH rr ko di3) do thiu HCl & cc yu t ni ti4) do nhim trng - k sinh trng - c cht5) do chn.BCH CU CP

9. thiu mu ng sc: xut hin - tin trin nhanh. Sau 1 - 2 tun c khi chcn < 1 triu HC -> triu chng ni bt.10. hi chng xut huyt + hi chng nhim trng.

11. lch + hch to.

BCH CU KINH

Th ty bo

12. thiu mu ng sc: mc trung bnh (HC 2,5 - 3 triu). Xut hin dn dn.

Th lympho

13. thiu mu c hch to. C th hch to n thun hoc km lch to. Hch to l triu chng ch yu ni bt trong bnh cnh.

14. thiu mu ng sc: thng nh, chnng khi bnh giai on cui.

CNG LCH

15. cng lch: thiu mu km lch to & gim bch cu - tiu cu (gim 3 dng).

16. c im thiu mu: nhc sc, xut hin dn, km vng da nh do hoi mu. Thiu mu c th t hoc nhiu (c khi HCcn trn di 1 triu).

17. lch to nhiu or t, c khi khng to, mt bnh thng. Lch co li di tc dng ca Adrenalin.

18. Xc nh chn on bng CLS:+ nghim php Adrenalin: sau khi tim Adre di da, lch co li ng thi s lng HC + BC + TC tng ln.

+ m huyt cu: nu thy gim HC ng thi gim BC + TC th nghn Cng lch, lm thm Ty chn on chcchn.

+ Ty : phong ph.

THIU MU DO GIUN MC

19. thiu mu nhc sc, xut hin dn c khi rt nng hn ch hot ng ca BN hoc gy suy tim thiu mu.

20. thng km au thng v do vim t trng vi c tnh ging nhau do lot t trng (khi i - lch (P) - d di xin lan -n vo du), nhng X quang bng khng thy lot.

21. thng xy ra lin quan n ngh: cng nhn m, nng dn(tip xc nhiu vi phn bc).

THIU MU DO THIU HCl & CC YU T NI TI

22. thiu mu nhc sc. Chn on gn nh chc chn nu xy ra sau khi ct on d dy.

23. cn xc nh bng xt nghim toan ca dch v, nghim php histamin.

THIU MU DO NHIM TRNG - KST - C CHT


34/47


Page | 34

24. thiu mu khng c hiu, chl triu chng ln vo trong bnh cnh ca bnh nguyn nhn.

25. bnh nguyn nhn thng thng l:1) st rt cn2) lao3) bnh do leptospira

4) nhim c ch, photpho, quang tuyn5) nhim c cc thuc: Acsenic, khng Histamintng hp, khng gip trng tng hp.26. cng c chn on da vo hi bnh s:+ yu t bnh nguyn (st rt? lao? bnh do leptospira?)

+ ngh nghip: cng nhn (tip xc vi: Pb, P)? nhn vin y t cng tc khoa X quang?

+ ang s dng thuc: Acsenic? khng histamin? khng gip trng?

Ho ra muXC NH HO RA MU

1. xut hin sau cn ho - c mu: ti, nhiu bt; km m, khng ln thc n.

2. bo hiu bi cm gic: nng sau xng c.

3. phi: ran n 2 th, phn nhiu y (trong lc hoc vi ngy sau).

CHN ON PHN BIT

4. chn on ho ra mu vi nn ra mu:+ xut hin sau cm gic: nng sau xng c -> ho, kh chu thng v -> nn. Trong nn ra mu, thng BN trong chu kau ri nn.

+ mu: ti -> ho; en, ng thnh cc -> nn.

+ ln thc n: khng -> ho, c -> nn.

+ phi: ran n -> ho, khng ran -> nn.NH GI MC

5. da vo: 1. s lng mu khc ra, 2. s ln ti pht, 3. khong cch thi gian gia cc ln ti pht.

6. tnh trng thiu mu cp:+ ri lon thn kinh (hoa mt, chng mt, ngt)+ da nim nht nht+ huyt ng: HA h, mch nhanh - yu+ CLS: HC, Hb -> gim.

SINH L BNH

7. ho ra mu: l biu hin chy mu ng h hp t kh qun -> cung phi -> nhu m phi. Mu cc phn ny c th thot ra

khi

M phi, TM phi,

M cung phi, mao qun ( mch mu thuc h tiu tun hon) : dov mch or thm mch.

NGUYN NHN

8. thng do:+ tn thng nhu m phi, nim mc cung phi (d cp or mn)+ tng p lc tiu tun hon.9. nguyn nhn:1) bnh phi - cung phi:+ lao phi: thng nht+ vim phi


35/47


Page | 35

+ apxe phi+ K phi - cung phi+ vim cung phi cp/ mn+ gin cung phi.2) bnh tim mch gy tng p lc tiu tun hon:+ hp 2 l: thng nht+ tc M phi gy nhi mu phi.

9. NXH phn loi cc nguyn nhn Ho ra mu da vo triu chng st km theo:@ ho ra mu c st:1) lao phi2) vim phi3) apxe phi.@ ho ra mu khng st:1) K phi - cung phi2) gin cung phi3) nhi mu phi4) hp 2 l.LAO PHI

11. st v chiu, dai dng.

12. ho ra mu bt c lc no: s lng mu khc c tht - nhiu - rt nhiu.

13. km triu chng nhim Lao: st cn nhanh - ho nhiu - mt mi xanh xao.

14. phi:+ hi chng ng c+ hi chng hang+ ran n+ lng ngc xp.15. hon cnh thun li:: ngh nghip, iu kin sinh hot - lm vic, mi trng tip xc.

16. CLS:1) test BCG (+), phn ng vi tuberculin.

2) X quang phi: c nt thm nhim, nhng m en khng ng u hoc nhng hnh nh hang phi.

3) BK m (+) 3 mu -> xc nh chc chn.

VIM PHI

17. hi chng nhim trng: khi pht st - lnh run km au ngc.

18. ho ra mu bt c lc no: lng mu khc t ln m lm cho m c mu gst, c, dnh hoc thnh tia mu ln trongm.

19. hi chng ng c: thng rt in hnh, c cting thi ng.

20. CLS:+ CTM: BC tng cng vi BC a nhn trung tnh+ X quang phi: hnh tam gic en u, y pha ngoi chim c 1 thy or 1 phn thy.21. Cn lm BK m yn tm loi tr Lao phi.

HP 2 L

22. ho ra mu xy ra sau khi gng sc, thng km theo kh th, s lng mu thng t.

23. nghe tim: T1 vang, ting rung tm trng.

24. phi: ran n 2 th -> mu tiu tun hon.

25. CLS:


36/47


Page | 36

1) X quang tim- phim thng (chiu th sau - trc): b (T) 4 cung, or cung gia bn (T) phnh to; cung di bn (P) phnh to.

- phim nghing (sau khi cho ung Baryt): thc qun b do tm nh(T) to.2) X quang phi: rn phi m ( mu tiu tun hon).

3) ECG: P rng, 2 nh.

Xut huyt (Chy mu di da)XC NH XUT HUYT

1. xut huyt (chy mu di da) biu hin bng nhng nt thm: khi ly ngn tay ln khng bin mt.

2. ty ln nh: nh -> vt xut huyt, ln -> mng xut huyt.

3. xut huyt d ln hay nhu c c im chung:1) t pht2) ch yu da - nim3) khng bao gi trong c, xng, khp.

CHN ON PHN BIT

4. phn bit xut huyt vi ban :+ ban : nt hng or thm -> n ngn tay ln th mt+ xut huyt: nt thm -> n ngn tay khng mt.

SINH L BNH

5. 2 yu t chnh gy xut huyt:1) tiu cu: gim v s lng hoc cht lng2) thnh mch: gim sc bn vng.Chy mu do tiu cu

6. tiu cu ng vai tr ch yu trong vic thnh lp 'nt trng' do 2 tnh cht: dnh - kt t.

7. tiu cu cn c nhim v bo v trng lc ca cc mch mu: khi tiu cu thoi ha i, n phng thch ra nhng cht gy co

mch c tc dng ln c ni qun.

8. v vy, XH do gim tiu cu bao gi cng km ri lon chy mu v cc ri lon khc do tiu cu chi phi (thi gian co ccmu ko di). C th km du hiu buc tht (Lacet (+) ).

10. v ty xng sinh sn ra tiu cu, cn lch l ni tch tr v tiu hy nn s lng - cht lng tiu cu c th gim do:1) cc bnh ca ty xng: bnh x ty, bnh bch huyt.

2) cc bnh ca lch: cng lch, bnh chy mu Werlhof.Chy mu do thnh mch

11. y yu t thnh mch l ch yu, khng c ri lon tiu cu - huyt tng nn XH do thnh mch bao gi cng:+ khng km ri lon v chy mu hoc ng mu.+ km du hiu buc tht (Lacet (+) ).12. nhng yu t lm thnh mch km bn vng: vim nhim, nhim khun, dng.

PHN LOI

13. Nguyn Xun Huyn da vo tnh cht Ri lon chy mu km theo phn loi Xut huyt:

@ C km ri lon chy mu:1) bnh Werlhof (xut huyt do thiu tiu cu)2) hi chng chy mu ko di trong bnh bch cu3) hi chng chy mu ko di trong suy ty


37/47


Page | 37

4) hi chng chy mu ko di trong x gan5) bnh st chy mu.@ khng km ri lon chy mu:1) xut huyt dng thp2) xut huyt do nhim trng3) xut huyt do dng.14. cc ri lon chy mu bao gm:

+ thi gian chy mu: ko di+ thi gian co cc mu: ko di+ s lng tiu cu: gim (c khi bnh thng nhng gim v cht lng)+ Lacet (-) or (+)+ cc xt nghim vng mu: thi gian ng mu, t l Prothrombin -> bnh thng.15. Vi Lacet (+) km cc xt nghim chy mu - ng mu u bnh thng -> XH do thnh mch.

16. tathata chn ra cc mt bnh: 1. HCCMKD trong bnh bch cu, 2. HCCMKD trong suy ty, 3. HCCMKD trong x gan, 4. XHdo nhim trng tm hiu c th.

HCCMKD trong bnh bch cu

17. chy mu di da & chy mu nim mc c khi l triu chng chnh rt rm r mu cho bnh cnh (bch cu cp), c khinh - kn o: chxut hin trong nhng t tin trin ca bch cu kinh.

18. cng vi hi chng Chy mu ko di, cn c thm:1) hi chng nhim trng2) hi chng thiu mu3) hi chng lch to - hch to.19. hi chng nhim trng: rt d di (bch cu cp) hoc nh - tht thng: chst nhiu trong nhng t tin trin ca bchcu kinh.

20. hi chng thiu mu: nhiu hoc t, thng thiu mu nhiu - nhanh trong bch cu cp.

21. hi chng lch to - hch to: xut hin rt nhanh.

22. nu c thm lot hoi t, chy mu ming - hng: cng nghn Bch cu cp.

23. Cng thc bch cu: bch cu tng rt nhiu - c nhng bch cu nguyn thy hoc bch cu non cha trng thnh. Ch vai tr ca khong trng bch huyt -> c gi tr quyt nh chn on Bch cu cp.

24. Ty : t l bch cu non & trung gian: tng rt nhiu (bch cu kinh) hoc t l bch cu nguyn thy tng rt nhiu (bchcu cp).

HCCMKD trong suy ty

25. chy mu di da & nim mc c th rm r mu cho bnh cnh, c khi chxut hin vo giai on cui ca bnh.

26. cc triu chng khc ca bnh cnh c th ging nh trong bnh bch cu nhng lch - hch khng to nhiuc khi khng to.

27. triu chng ch yu l: thiu mu nng, dai dng khng hi phc c.

28. CTM: s lng huyt cu c 3 dng (HC, BC, TC) u gim nhiu, c khi ch1 dng b gim.

29. Bao gi cng phi lm thm Ty : rt ngho t bo. Tnh cht tha tht ca ty c gi tr xc nh chn on.

HCCMKD trong x gan

30. l biu hin nng trong X gan -> chng t tnh trng suy gan nng cho nn:+ chxut hin phn nhiu trong X gan giai on cui+ ngoi ra cn gp trong tt c trng hp suy gan nng khc: vim gan virus th nng, vim gan do Leptospira.


38/47


Page | 38

31. xc nh chn on bng cc CLS thm d chc nng gan.

XH do nhim trng

32. l biu hin nng, c th xy ra trong tt c cc bnh nhim khun (nht l: nhim trng huyt do No m cu - lin cu - tcu - ph cu)

33. nt chy mu c khi thnh nhng mn phng: chch ly ch mu ny xt nghim -> tm vi khun gy bnh.

34. lun km hi chng nhim trng nng c khi dn n hn m.

35. V c nhim trng: BC tng nhiu cng vi BC a nhn trung tnh.

36. CLS xc nh:+ cy mu+ xt nghim mu chch cc nt phng chy mu.-> tm thy VK gy bnh.

Lch toXC NH LCH TO1. khi to nhiu:+ lch ni hn thnh u dc theo h sn (T)+ b trong c ch lm vo+ di ng ln xung theo nhp th+ g c.2. khi to t:+ s: theo nhp th - nu lch hi to, nh lch chm vo tay BS trong th ht vo ca BN.

+ g: vng c ca lch qu b sn (T), v pha trn c th ln qu lin sn 9.3. khi sc lch to, nn li trn giy bng theo di ting trin.

CHN ON PHN BIT

4. chn on Lch to vi:1) thy (T) gan to2) thn (T) to3) u i trng4) m qunh mng bng hoc khi u thnh bng.Thy (T) gan to

5. khi thy (T) gan to, c th ln sang h sn (T), nhng khng chim vo ht vng ny v khng c lm vo nh lch.

6. phn bit chc chn bng soi bng.

Thn (T) to

7. bao gi cng chm thn (+). (Trong Lch to 4 cng c du hiu ny).

8. b trong khng sc r, khng c ch lm r nh ca lch.

9. g trong: v ci trng & cc quai rut nm ngang pha trc.

10. thng km ri lon tit niu chim: tiu mu, tiu m, tiu m, hoc v niu. Nu c cc yu t ny cng nghu l thnto, nhng nu khng c cng khng loi c thn to v c th thn vn to nhng b loi tr khng bi tit c nc tiuxung bng quang, nc tiu thi ra l ca bn thn lnh.

U i trng


39/47


Page | 39

11. hnh di hn.

12. c nhng ri lon i tin km theo: tiu ra mu, hi chng kit l hoc bn tc rut.

m qunh mng bng - khi u thnh bng

13. nng hn. Khng c ranh gii r.

14. khng di ng ln xung theo nhp th.

SINH L BNH

15. gii phu: 2 thnh phn+ nhu m lch: ch yu l nhng t chc lin vng ni mc+ mng li mao mch: c lin quan trc tip vi h TM ca.16. chc nng: lch tham gia trong:+ cc hot ng to mu - hoi mu+ s sinh sn khng th bo v c th chng li VK+ lin quan lch - ty xng trong vn to mu.

NGUYN NHN

17. nguyn nhn lch to lin quan v mt gii phu - chc nng ca lch:@ t h vng lin ni mc:+ bnh Hanot+ bnh Hodgkin.@ t h TM ca: tng p TM ca.

@ t h thng to mu:+ bch cu cp, bch cu kinh+ bnh chy mu ko di do thiu tiu cu: bnh Werlhof.@ do nhim trng - k sinh trng:+ thng hn+ st rt

+ vim mng trong tim lot si+ nhim trng mu.

PHN LOI

18. Nguyn Xun Huyn da vo triu chng km theo phn loi Lch to:

@ Lch to c st:1) Cn st rt2) Thng hn3) Vim mng trong tim lot si4) nhim trng mu5) bnh bch cu kinh th ty bo (th lch to n thun).@ Lch to c st + hch to:1) bch cu cp2) bch cu kinh th ty bo3) bch cu kinh th lympho4) bnh Hodgkin5) bnh Lymphosarcoma.@ Lch to + XHTH: Tng p TM ca (hi chng Banti).

@ Lch to + cng lch:1) hi chng tng p TM ca2) bnh chy mu ko di do thiu tiu cu (bnh Werlhof).@ Lch to n thun:


40/47


Page | 40

1) st rt cn mn tnh2) K lch.19. tathata chn ra cc mt bnh: 1. bch cu cp, 2. bch cu kinh th ty bo, 3. bch cu kinh th lympho, 4. hi chng tngp TM ca tm hiu c th.BCH CU KINH TH TY BO

Th in hnh

21. triu chng chnh:+ lch rt to - pht trin nhanh: c th xung n rn sau vi thng. Mt chc.

+ hch to nhng khng to nhiu v khng ni bt trong bnh cnh, c khi khng to.

+ hi chng st nhim khun: thng t c, v chst trong nhng t tin trin.

+ hi chng thiu mu: thng nh - kn o.

+ hi chng chy mu: chc trong nhng t tin trin.22. CTM:+ HC gim va (cn # 2 - 3 triu)+ tiu cu cng gim va hoc khng gim

+ BC: tng rt nhiu (200.000 - 300.000).23. Trong huyt , c vi bch cu nguyn thy nhng rt nhiu t bo non trung gian loi ty bo.

24. vi th bnh bch cu khng biu hin mu ngoi bin: cn lm ty -> t l cc t bo non trung gian loi ty bo tngnhiu.

Th lch to n thun

25. ging nh thin hnh, chkhc ch th ny khng c hch to.

HI CHNG TNG P TM CA (HC BANTI)

26. khi cha nn ra mu BN c lch to + cng lch.

27. khi bnh tin trin nng: lch to trn nn XHTH trn.

28. lch c th to nhiu hay t - mm - co li di tc dng Adrenalin - nh li sau mi ln XHTH.

29. chy mu ng tiu ha thng th hin di hnh thi nn ra mu, c khi rt nhiu, c th lm BN t vong.

30. c th km theo cng lch biu hin bng: gim 1 - 2 hoc c 3 dng huyt cu + tng sinh ty cu.

31. mc nng, c thm bng bng nc vng chanh thm thu & tun hon bng h ca - ch.

32. CLS xc nh: ni soi.

Tiu chy1. tiu chy: trng hp nng c th dn n t vong do ri lon nc - in gii + try tim mch + suy dinh dng do km hpthu.

XC NH TIU CHY

2. xc nh d dng nh 2 yu t:


41/47


Page | 41

+ tiu nhiu ln trong ngy+ tnh cht phn: phn st v c nhiu nc, hoc lng ton nc; nc c thc hoc trong, c th km th tht, cht mcha tiu hoc mu.3. ngay sau khi xc nh tiu chy, cn pht hin:1) cc biu hin kit nc - in gii:+ kht nc, tiu t+ mi kh - li kh

+ da nhn nheo, mt tnh cht n hi (vn gi np nhn sau khi vo)+ ure mu c th tng (ure mu cao ngoi thn).2) cc biu hin try tim mch:+ chn tay lnh, tot m hi+ ch yu: mch nhanh - yu - kh bt+ HA h+ tim p nhanh - yu, c th c ting nga phi.4. cc biu hin kit nc - in gii v try tim mch thng xy ra trong cc trng hp tiu chy cp din nng; tri li tiuchy mn (ko di > 1,5 - 2 thng) cn pht hin cc biu hin suy dinh dng do km hp thu:

@ lm sng:+ st cn, gy t+ xanh xao - thiu mu+ ph nh 2 chi di, c th ph ton thn+ c th c nhng cn co git kiu tetanie.@ cn lm sng:+ CTM:- HC: gim- Hb: gim.+ SHM:- protein mu: gim- cholesterol & ng mu: gim- canxi mu: gim -> ph hp biu hin tetanie lm sng.

SINH L BNH

5. 3 yu t chi phi hin tng tiu chy:1) yu t nim mc2) yu t thi gian3) yu t men tiu ha.6. yu t nim mc:- bnh thng nim mc rut c nhim vtit cht nhy & ht li nc c c phn.

- khi b tn thng, or b kch thch: nim mc rut khng lm trn c nhim v -> tit qu nhiu cht nhy & khng ht linc li c na lm cho phn tr nn lng.7. yu t thi gian:

- cc thc n qua ng tiu ha, nht l qua rut: c tc nht nh - nh nhu ng rut. Cc nhu ng ny chu chi phi ca hthn kinh, c th ca dy giao cm & dy ph v -> 2 dy ny cn chi phi c s dch ca nim mc.+ dy ph v: kch thch nhu ng & bi tit.

+ dy giao cm: km hm nhu ng & bi tit.- khi mt cn bng gia dy ph v & dy giao cm: thc n c thi qua ng tiu ha nhanh hn, khng thi gian nimmc rut ht li nc, trong khi nim mc li tit qu nhiu cht nhy.

8. yu t men tiu ha:

- cc men: pepsin, HCl, dch ty - mt... rt cn thit tiu ha thc n, m bo cho phn c bnh thng.

- ngoi ra, s c mt ca vi khun thng tr rut cng rt cn sinh ra mt s men gip cho vic hon thnh s tiu hathc n.

9. Ngoi 3 yu t sinh l bnh nu, cn lu : rut cn l mt ng thi tit cht c.

NGUYN NHN


42/47


Page | 42

10. c 4 nhm nguyn nhn:1) c tn thng nim mc tiu - i trng2) thiu men tiu ha3) tc thc n qua rut qu nhanh4) c hin tng nhim c.11. c tn thng nim mc tiu - i trng:

+ c tnh cht lot hoi t: th t, thng hn, kit l amip, l trc khun, lao rut, K rut...+ hoc chc tnh cht mu bnh thng nh trong tiu chy do dng.12. thiu men tiu ha:+ sau ct on d dy+ x gan, suy ty tng+ ang s dng khng sinh (nht l cc thuc: Chloramphenicol, Oreomycin...).13. tc thc n qua rut qu nhanh: do ri lon dy giao cm & dy ph v nh trong tiu chy khi b xc ng.

14. c hin tng nhim c:+ ngoi lai: nhim c thc n, thy ngn, Acsenic..+ ni ti: ure mu cao, toan mu, cn cng gip trng kch pht..

PHN LOI

15. Nguyn Xun Huyn phn loi Tiu chy da vo tnh cht cp din hay mn tnh; c hay khng cc triu chng km theo:st, suy dinh dng:

@ Tiu chy cp:- c st:1) th t2) l trc khun3) thng hn.- khng st:1) ngc thc n2) do dng, xc cm hoc thuc khng sinh3) do cng tuyn gip trng4) l amip th tiu chy5) ure mu cao, toan mu.@ Tiu chy mn:- c suy dinh dng:1) lao rut2) vim rut non khng c hiu3) vim i trng amip mn tnh4) K i trng5) vim ty mn6) sau ct on d dy hoc ct dy ph v.- khng suy dinh dng: Ri lon c nng i trng.TIU CHY DO DNG - XC CM - KHNG SINH

17. dng khc xy ra cng lc tiu chy: cn ht hi, ni mn, cn hen, ph Quynck)..

18. cc chn thng tinh thn, tnh cm hoc s hi xy ra trc vi gi.

19. trong khi s dng khng sinh: Oreomycin, Biomycin, Chloramphenicol.. xy ra tiu chy, v dt bnh sau khi ngng s dng.

TIU CHY DO URE MU CAO - TOAN MU

20. thng km theo cc biu hin tinh thn: nhc u, mt mi, l m; c thi dn vo m sng, bn hn m ri hn m.

21. nn ma, tiu t; c khi v niu.

22. xy ra BN ang c nhng bnh c tha n ure mu cao: bnh v thn, bnh do xon khun, tng huyt p..; hoc an toan mu: i tho ng..


43/47


Page | 43

23. nh lng ure mu: thy ure mu cao (nu l trng hp do ure mu cao).

24. tm thy th ceton trong nc tiu + d tr kim mu h (nu l trng hp do toan mu).

TIU CHY DO CNG TUYN GIP TRNG

25. thng xy ra trong nhng cn kch pht c km st hoc khng.26. nghn khi c triu chng ca Cng gip: gy nhiu - nhp nhanh - mt li - tay run - bu c.

27. chn on chc chn da vo: tc dng nhanh chng i vi chng tiu chy khi iu tr thn thun bng cc thuckhng gip trng.

TIU CHY DO VIM TY MN

28. Tiu chy ko di hng thng, c th nhiu ln trong ngy: nc nhiu hn phn, nht l nc long m trong phn - c ththy cc th tht cha tiu ha nu bnh tin trin nng.

29. au m vng thng v khng c chu k r rt, trn nn au ny c th c nhng ln au tri: th hin mt t tin trin cpca bnh.

30. khm bng: thng khng thy g c bit, mt s trng hp c th km hi chng vng da tc mt.

31. xt nghim phn: nhiu tinh bt, th tht cha tiu, ht m -> xc nh chn on ng thi chng t bnh tin trin nng.

32. XQ vng ty tng: c hnh si hoc vt vi ho.

33. nh lng Amylaza mu v nc tiu: chtng trong nhng t cp ca bnh.

TIU CHY SAU CT ON D DY - DY PH V

34. thng d nghngay n chn on ny khi:+ BN c tin s phu thut ct on d dy or dy ph v+ tiu chy ko di xy ra sau phu thut.

RI LON C NNG I TRNG

35. l trng hp tiu chy mn khng c suy dinh dng.

36. tnh cht: tiu chy tht thng, xen ln nhng t phn bnh thng hoc to bn, kit l.

37. th trng BN bnh thng.

38. tc lng hng cu (VS): khng cao.

39. xc nh chn on: cn loi tr tt c nguyn nhn khc c th gy tiu chy mn - khm k lm sng (khm ton thnni chung & ng tiu ha ni ring, lu nh thm trc trng) - CLS ( xt nghim phn nhiu ln loi tr nguyn nhn vi

khun or KST, nht l amip). Nu c phng tin, nn soi trc trng; nht l chp i trng c baryt.

Hn m1. Hn m - chn on nguyn nhn thng kh nhng xc nh bao gi cng d. C nhng loi thuc khi dng ng lc - ngnguyn nhn cng hiu rt r:+ Dng Quinin i vi hn m do St rt cn c tnh+ Dng khng sinh i vi hn m do Vim mng no+ Dng Insulin i vi hn m do i tho ng+ Dng dung dch ngt u trng i vi hn m do Hng huyt.


44/47


Page | 44

XC NH HN M

2. hn m l trng thi bnh l trong BN mt hn lin h vi ngoi gii nhng s sng dinh dng vn tn ti.

3. xc nh hn m da trn:@ 3 yu t mt or gim:1) mt vn ng t ch

2) mt tr tu3) mt cm gic.@ 3 yu t cn:1) phi vn cn th2) tim mch vn cn p3) bi tit vn cn.CHN ON PHN BIT

4. Phn bit Hn m vi Ngt. Trong Ngt:+ lin h vi ngoi gii cng mt+ mt ci sng dinh dng+ nhng cc ri lon ny chtrong thi gian ngn ( 5 - 10 pht).PHN HN M

5. ty theo biu hin lin h vi ngoi gii mt hoc gim t hay nhiu:@ hn m nh: BN l m. Gi c th bit nhng khng tr li c chnh xc nhng cu hi, bu vo cn bit au, cn cngc chn tay.

@ hn m va: BN mt hn tr tu, gi khng bit nhng vn cn phn x nut, phn x gic mc, c th cn cm gic au, cncng c tay chn t nhiu.

@ hn m su: BN cng mt hn tr tu, gi khng bit nhng vn cn phn x nut, phn x gic mc; mt hn cm gic &thng khng cng chn tay na.6. Hin nay s dng thang im Glassgow nh gi phn Hn m.

PHN LOI

7. Nguyn Xun Huyn da vo triu chng thn kinh chim & St phn loi Hn m:

@ Hn m c triu chng thn kinh chim:- c lit na thn:1) xut huyt no2) tc M no.- c hi chng mng no:1) xut huyt mng no2) vim mng no.- c co git, ng kinh, st:1) vim mng no2) vim no3) st rt cn c lit.@ Hn m c triu chng thn kinh chim nhng khng c st:- c co git ng kinh, khng st:1) ng kinh2) hn m do hng huyt3) sn git4) ph no.@ Hn m c st nhng khng c triu chng thn kinh chim: st rt cn c lit.

@ Hn m khng c st, khng c triu chng thn kinh chim:1) hn m do i tho ng2) hn m do ure mu cao3) hn m gan4) hn m do thuc ng.8. chn ra cc mt bnh: 1. xut huyt no, 2. tc M no, 3. XH mng no, 4. hn m do hng huyt, 5. hn m do DTD, 6.hn m do ure mu cao, 7. hn m gan, 8. hn m do thuc ng tm hiu c th.


45/47


Page | 45

XUT HUYT NO

9. hn m xut hin t ngt, thng xy ra sau nhng ba n thnh son, sau tic ru hoc do thay i kh hu t ngt.

10. phn ln trng hp, hn m tin trin cng ngy cng su; phn t may mn sau thi gian ngn BN c th hi tnh.

11. bao gi cng km lit na ngi: lit cng bn vi lit mt - lit hon ton.

12. xy ra ngi ln tui c HA cao hoc x cng M.

13. Bnh cnh in hnh ni trn thng nghn hn m do Xut huyt no nht l khi xy ra mt ngi ln tui c HAcao hoc x cng M. Nu xy ra ngi tr tui, nn nghn d dng bm sinh ca M no (phng M, u mu).

TC M NO

14. bnh cnh ging nh XH no nhng:- khi pht khng t ngt bng XH no- hn m khng su cng khng lu bng, chvi ba gi hoc vi ba ngy sau BN c th hi tnh.

15. xy ra mt ngi c sn bnh d gy tc

ng mch nh: hp van 2 l - nht l khi c lon nhp tim hon ton, cc bnhvan tim c bin chng Osler.

16. bnh cnh xy ra, nu c y cc yu t ni trn - nht l pht hin c nguyn nhn gy tc -> thng chnon tc M no.

XUT HUYT MNG NO

17. tnh cht ca hn m (xut hin - mc - tin trin) ging nh trong XH no & cng thng xy ra ngi ln tui c HAcao hoc x va M, nhng km theo c cng & du hiu Kernig, khng c lit na ngi nh trong XH no.

18. chc d dch no tu: nc mu hng hoc nh mu, khi lu ngoi khng kh nc mu khng ng li.

19. protein: tng, c nhiu HC (do chy mu), cn Glucose & BC vn bnh thng.

20. Cng ging nh XH no & Tc M no, khi xy ra BN tr cn nghn:- d dng bm sinh ca M mng no- hp van 2 l c lon nhp tim hon ton. Hoc tc M mng no do Osler nu BN c sn bnh van tim.

HN M DO HNG HUYT

21. hn m xy ra t ngt, bo hiu bi cm gic bn rn tay chn, mt mi, cn co trong bng.

22. bao gi cng km nhng cn co git ging nh co git trong ng kinh.

23. Sau cn co git hoc khi tnh li, BN ra m hi rt nhiu.

24. tc dng rt nhanh chng ca iu tr th: tim TM dung dch Glucose u trng hoc cho BN ung nc ng.

25. tt nht: nh lng Glucose mu -> h nhiu.

26. cn ch : ly mu th khi BN cn ang hn m & trc khi iu tr th.

27. Sau khi xc nh, cn tm nguyn nhn gy hng huyt:@ nu xy ra BN i tho ng:- c th nghngay n Hng huyt do Insulin nu hn m xy ra khi BN mi c tim Insulin cch y vi gi (c th quliu Insulin).

- hoc do chn: nu BN ang theo mt chn qu hn ch Gluxit.@ nu xy ra BN khng c i tho ng, cn nghn:


46/47


Page | 46

1) K gan: BN c th ra khi hn m nh truyn dung dch Glucose nhng tr li hn m rt nhanh sau khi ngng truyn. Chnon chc chn nu lm sng s thy gan to & cng km soi bng thy r nt K trn gan.

2) Xgan hoc Vim gan cp din nng: din bin cng ging nh trong K gan, thng chn on nguyn nhn ny d v Xgan or Vim gan cp din gy HH phn nhiu u c bnh cnh lm sng kh r.

3) U ty: nghn nguyn nhn ny nu hn m xy ra nhiu ln trong bnh s, nht l xy ra vo lc i (thng v khuya

hoc 4 - 5 gi sng) hoc sau khi lao ng qu sc.Ngoi ra: c th do Suy thng thn, Suy thy trc tuyn yn..

HN M DO I THO NG

28. hn m xy n dn dn sau mt thi

lam sang noi khoa

Documents