Nhng k nng lm sng

Tc gi: Chris Hatton Roger Blackwood Nh xut bn Blackwell

Din n y khoa www.diendanykhoa.com

Nhm dch Trng nhm Minmin Thnh vin Lovesnn1909 Kingkong774 Ngoalong AERISASHE Kazu1991 Tiutiu123 Hand_In_Hand Caphesang Midbeo Trungbach12hoa

9/2011

MC LC Gii thiu: Tip cn ban u Lovesnn1909 Chng 1: Khai thc bnh s Kingkong774 Chng 2: Thm khm ton thn Midbeo kingkong774 Chng 3: Thm khm h tim mch ngoalong Chng 4: Thm khm ngc AERISASHE Chng 5: Thm khm bng Kazu1991 Chng 6: Thm khm tnh trng tm thn AERISASHE Chng 7: Thm khm h thn kinh Tiutiu123 Chng 8: Thm khm ngi cao tui Lovesnn1909 Chng 9: Nguyn tc khm c bn b nh n ch n on Kazu1991 Chng 10: K nng trnh by mt ca bnh Lovesnn1909 Chng 11: Cc k thut chn on h nh nh cc phng php cn lm sng 177 Hand_In_Hand Chng 12: Vi nt c bn v in tm Trungbach12hoa Chng 14: Cn lm sng nhng gi tr b nh th ng caphesang Chng 15: X tr nhng cp cu ph bin caphesang 257 249 222 170 161 154 115 107 94 85 57 30 9 3

GII THIU CHUNG

PHNG PHP TIP CN BAN U

Nhng nguyn tc chung Nhng mc tiu tng qut. Khi sinh vin ( hoc bc s) tip cn bnh nhn, di y l 4 mc tiu ban u: o To ra mi quan h ngh nghip tt vi bnh nhn v c c s tin tng ca bnh nhn. o C c tt c cc thng tin c lin quan cho php nh gi bnh v chn on s b. o C c thng tin tng th v bnh nhn, hon cnh bnh nhn, tnh trng v cc vn x hi. c bit quan trng nu tm hiu c bnh tt nh hng n bnh nhn, gia nh, bn b, ng nghip ca bnh nhn nh th no. Vic nh gi ton th bnh nhn l rt quan trng. o Hiu c nhng suy ngh ca bnh nhn v cc vn ca h, mi quan tm ca h v h mong i g khi nhp vin, iu tr ngoi tr hay khi t vn ni chung. Hy nh rng y hc cng nhiu s phin phc ging nh bnh tt. Bt k bnh g, k c l ung th hay nhim trng ngc th s lo lng v nhng g c th xy ra l mi quan tm ch yu ca bnh nhn . Hy chm ch lng nghe. Nhng ch di y cung cp ch dn ly c thng tin cn thit. Nhng mc tiu c th

Trong ly tin s, bnh s v thm khm, c hai mc tiu b sung: o C c tt c cc thng tin cn thit v bnh nhn v bnh tt ca h. o Gii quyt vn v d nh cc chn on. Phn tch cch tip cn vn . i vi mi triu chng hay du hiu th cn phi ngh n mt chn on phn bit, v thng tin khc c lin quan( b ng tin s, thm khm v nghin cu) m mt trong s chng c th cn bc b hoc cng c thm nhng chn on c th. Khng bao gi nn tip cn bnh nhn bng nhng cu hi mang tnh hc vt. Tuy nhin, trc khi bit nhiu kin thc v y hc th ngi ta khng th bit c ngha ca cc thng tin c ch, v r rng l s thay i nhng cu hi c th cn n. Nhng ch ny cung cp thng tin c bn vic khai thc tin s v thm khm y c thc hin. iu ny cung cp mt c s cn thit tip cn v sau, pht trin cch tip cn k lng hn ging nh tng kin thc v bnh tt tip thu c. Kh nng t lp. Sinh vin phi c c tin s, bnh s bnh nhn, thm khm lm sng v vit bnh n lm sng. Sau mt thng, sinh vin ph i thnh tho trong vic ny v nhng ghi chp ca h c th tr thnh bo co cui cng ca h bnh vin khi thi c. Sinh vin cn thm mt bn tm tt v nh gi ca sinh vin i vi cc vn , chn on s b, nhng nghin cu s b. Nhng bc u ny s khng y v i khi khng chnh xc. Tuy nhin, n s gip sinh vin ghi nh phng php tip cn v lm ni bt cc vn trong cc cu hi, nghin cu hay c l cn thit. iu g l quan trng khi bn bt u?

Nn tng ca tt c cc lnh vc y hc l nng lc lm sng . Khng c kin thc, k thut s gim i. Trong vi tun u tin, iu ny l cn thit hiu c nhng kin thc c bn v y hc lm sng , bao gm nhng ghi ch di y: o Lm th no to mi quan h vi bnh nhn. o Lm th no khai thc c tin s, bnh s c hiu qu, bit nhng cu hi hi sau v trnh cc cu hi mang tnh m th. o Lm th no khm cho bnh nhn vi mt c ch hp l, trong mt thi quen c rn luy n m bn s khng b qua mt du hiu khng lng trc. Bn s ngc nhin v vic sinh vin y khoa c th khng t kt qu trong bi thi, khng ph i v h thiu kin thc m do h khng thnh th o cc k nng lm sng. Nhng ghi ch ny c vit gip bn xc nh iu g l quan trng v nhng pht hin c lin quan trong cc tnh hung lm sng ph bin. Khng c g l kh khn mc nhin v y hc lm sng. Bn s nhanh chng tr thnh mt ngi c k nng lm sng tt nu bn: o p dng i vi bn thn o Bt u hc bng cch thuc lng nhng k nng m l thch hp vi mi tnh hung. Cm nhn theo kinh nghim Cm nhn theo kinh nghim l nn tng ca y hc. o Lun nhn thc c nhu cu ca bnh nhn o Lun nh gi thng tin quan trng g l cn thit: - chn on c - c iu tr thch hp - m bo bnh nhn vn c chm sc tip theo ti nh Nhiu sai lm gy ra do b ko i chch hng v nhng kha cnh chng quan trng t no

Kin thc v k nng lm sng ca bn c th nng ln nhanh chng nh mt s t chc tt. o Hy tn dng khi gp nhiu bnh nhn bnh vin, phng khm v cng ng. iu ny l c bit hu ch khi bnh nhn ang c coi l trong tnh trng cp cu hoc phng khm trong ln u i khm. o C c mt kinh nghim rng ln v cc bnh trn lm sng, chng c qu n l nh th no. Y hc l mt mn hc lin quan thc hnh v nhng kinh nghim trc tip l v gi. Ngoi vic thc hnh trn bnh nhn, bn c th thc hin trn bn thn, iu ny c thc hin sm th bn s thnh tho v hc c nhiu hn t bnh nhn v bnh tt ca h. Xy dng kin thc. Ban u y hc dng nh l rt rng ln v nhng iu thc t bn hc c dng nh ch l mt phn ca cc thng tin. Lm th no bn c th bit nhng g l cn thit? Bn s tm thy cc phn ca thng tin c lin quan sau mt vi thng v bn c th a cc phn thng tin mi vo trong bi cnh. Cc phn s ph hp vi nhau v s t tin ca bn s tng ln. Tuy vy bn s cn phi hc nhiu hn, iu ny cng khng km phn quan trng c c quan im trong t cu hi, lp lun v bit tm kim cc thng tin b sung khi no v u. o La chn mt cun sch dy v a phi c v mi bnh bn gp trn lm sng hay mi vn m bn gp phi. Kin thc gn lin vi mi bnh nhn l mt tr gip ln trong vic tip thu v ghi nh kin thc. Thc hnh y hc m khng c sch gio khoa cng ging nh thy th m khng c h i , trong khi nghin cu

trn sch v nhiu hn l trn bnh nhn th li ging nh mt thy th m khng i bin. Hiu nhng thng tin khoa hc v bnh tt, bao gm c nhng tin b ang c thc hin v lm th no c th p dng chng vo vic ci thin chm sc. o Thng xuyn cp nht v c cc bi x lun hoc bt c bi vit no m bn quan tm trn mt tp ch y hc ni chung v d New England Journal of Medicine, Lancet or British Medical Journal. Nhng mi quan h

o to tr thnh mt bc s bao gm nhng kh khn ring bit ca vic hc: o C mi quan h t nhin, chn thnh, d tip thu v khi cn thit th c s tr gip bnh nhn v nhn vin bnh vin. o Cc phng tin c b tr tt trong lm vic vi bnh nhn v ng nghip to iu kin chm sc tt nht. Trnh by nhng pht hin ca bn v thng tin ni chung Chng 10 ch ra lm th no bn trnh by v nhng bnh nhn trong bnh phng ho c ti cuc hp . Nhng nghin cu h tr. Gii thiu thng tin v mt s nghin cu lm sng ph bin c a ra trong chng 11, km theo l mt hng dn n gin c c in tm (ECG) chng 12. iu tr bnh 7

Bn s sm thy nhng phng php iu tr ang c a ra. Chng 15 ni chi tit v cc chi tit trong nhng iu tr cp cu thng thng m bn c th gp phi. Y hc da vo bng chng, phng php phn tch thng k v gii thch cc xt nghim. Nhiu tin b y hc ang xut hin. iu ny cung cp mt kin thc nn tng gip ch trong vic nh gi nhng thng tin mi, th nghim lm sng v cc k thut. Chng 13 cung cp mt cch tng qut v gii thch cc d liu. Chc thng l bnh an Trong vic o to tr thnh mt bc s, bn c: o Quy n li trong vic pht trin mi quan h gip vi bnh nhn v nhn vin y t o C hi pht trin cc k nng thc hnh c bit o C hi hiu c s pht trin ca nhng vn hc thut m ang c thc hin Chng ti chc bn may mn trong s nghip ca bn v thnh tho trong tt c cc k nng lm sng c bn.

CHNG 1

KHAI THC BNH S

TRNH T CHUNG

TIP CN BNH NHN Tp trung vo cng vic ca bc s v gi cho bnh nhn thoi mi. Hy t tin v t ra hi thn thin. Cho bnh nhn : Goodmorning , Mr. Smith. Rung tay bnh nhn hoc t tay ca bn ln ngi anh y nu anh y b bnh. (Hnh ng ny bt u vic khm thc th ca bn. N s cung cp cho bn mt du hiu c bn tnh trng th cht ca bnh nhn. V d: nng, lnh, tot m hi, hay st...) Thng bo tn bn v rng bn l mt sinh vin y khoa gip nhn vin chm sc bnh nhn. Hy chc chn rng bnh nhn c thoi mi. Gii thch rng bn mun hi nhng cu hi v bnh nhn tm ra nhng g xy ra vi anh ta. Thng bo cho bnh nhn khong thi gian bn lm v b n mong ch iu g. V d, sau khi tho lun iu g xy ra i vi bnh nhn, bn s mun khm anh ta.

TRNH T THNG THNG CA CC S KIN

S QUAN TRNG CA BNH S N xc nh: Nhng g xy ra Tnh cch ca bnh nhn Bnh nh hng n anh y v gia nh anh y nh th no Bt k mi lo lng c bit no Mi trng vt l v x hi Thit lp mi quan h thy thuc bnh nhn N thng cung cp cho cc chn on

Tm nhng triu chng hoc triu chng chnh. Hi: - c nhng vn g? -iu g lm bn i n bc s? Trnh: -B ci g? Ci g mang ng n y? Hy bnh nhn k v bnh s ca mnh theo cch ring ca anh y nhiu nht c th. Lc u nghe v sau ghi chp vn tt nhng g anh y ni. Khi hc lm bnh s c th c mt xu hng hi qu nhiu cu hi trong 2 pht u tin. Sau khi hi cu hi u tin, bn nn cho bnh nhn ni chuyn bnh thng ,khng ngt qung n ht 2 pht. 10

ng lo lng nu cu chuyn khng hon ton r rng, hoc nu bn khng ngh rng cc thng tin c cho c ngha chn on. Nu lm gin on qu sm, bn c nguy c lt nhanh qua vic xem xt k mt triu chng hoc mi lo lng quan trng. Bn s c hc nhng iu g bnh nhn ngh l quan trng Bn c c hi xt on xem mnh s lm nh th no Cc bnh nhn khc nhau cho bnh s theo nhng cch rt khc nhau. Mt s bnh nhn s phi cn c khuyn khch m rng cc cu tr li ca h tng ng vi cu hi ca bn; vi cc bnh nhn khc , bn c th phi hi nhng cu hi c th v lm gin on trnh mt bnh s qu lan man, ri rc. Hy d tnh c cch tip cn m b n s p dng. Nu bn phi ngt li bnh nhn, hy lm th t r rng v dt khot. Hy th, nu kh thi, hy tin hnh mt cuc tr chuyn hn l thm vn, da theo chui suy ngh ca bnh nhn. Bn thng s cn phi hi cu hi tip theo da trn cc triu chng chnh c c mt s thu hiu v nhng g bnh nhn c v chui cc s kin. Thu c mt m t, din t y ca nhng li phn nn chnh ca bnh nhn. Hi thng tin v trnh t cc triu chng v s kin Hy cn thn vi chng gi bnh, v d: vim ng tiu ha- Hi xem iu g xy ra? Khng hi nhng cu hi dn ng Mc tiu trng tm trong vic ly bnh s l hiu cc triu chng ca bnh nhn t nhng quan im ring ca h. iu quan trng l khng lm m bnh s ca bnh nhn bi nhng iu mong i ca ring b n. V d, khng hi bnh nhn m bn nghi ng l nhim c gip : Bn c thy thi tit nng kh ch u?. iu ny gi cu tr li l C v sau , mt cu tr li tch cc tr thnh t c gi tr chn on. Hy hi cu hi m :Bn c bit ght thi tit nng hay th i tit lnh? Hy nhy cm vi tm trng bnh nhn v phn ng khng li V d: t do biu l cm xc.

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 Hy hiu bit, tip thu v thc t m khng qu nhiu s cm thng. Biu l v by t s ng cm nhiu hn l thng cm Him khi biu l s ngc nhin hay ch trch Lm r cc triu chng v thu c mt danh sch cc vn Khi bnh nhn hon thnh vic m t cc triu chng hay mt triu chng no : - Tm tt ngn gn cc triu chng - Hi xem liu cn c nhng vn ln no khc khng. V d, bn ni : Bn c cp n hai vn : au pha bn tri d dy ca bn v cc c ng yu trong hn 6 tun. Trc khi chng ta bn chi tit hn, C bt k nhng vn no khc m ti nn bit khng? TRNH T THNG THNG CA BNH S c tnh ca ch yu cc li phn nn. V d : au ngc, hon cnh nh ngho. Bnh s ca phn nn hin ti- Chi tit ca cn bnh hin ti iu tra cc triu chng khc ( Xem b cu hi, trang 10) Tin s bnh. Tin s gia nh Tin s c nhn v x hi Nu nh nhng cu hi u tin cho thy r rng c phn no quan trng hn bnh thng ( v d nh nhng bnh lin quan trc hay phu thut) th nhng cu hi lin quan n vn s c hi sm hn so vi trnh t hi bnh s ( v d nh s hi tin s lin quan n li phn nn ch yu ca bnh nhn) BNH S CA BNH HIN TI Bt u vn bn bnh s ca bn vi mt cu duy nht tng hp nhng iu bnh nhn phn nn. N s ging nh cc tiu biu ng ca mt t bo. V d: C/o (Certificate of origin) au ngc khong 6 thng Xc nh th i gian din bin bnh bng cch hi: -Bnh ca bn bt u nh th no v t khi no? Ho c -Bn cm thy bt c bt thng g ln u tin l lc no? Hoc -Ln cui cng bn thy hon ton khe mnh l lc no? 12

 Bt u bng cch ni r thi gian ln cui bnh nhn cm thy hon ton khe mnh. M t cc triu chng theo th t thi gian khi pht. C thi gian khi pht v khong thi gian trc khi nhp vin nn c ghi li. ng bao gi ngy cc triu chng theo cc ngy trong tun , nh th sau ny tr thnh v ngha. Thu c mt m t chi tit ca mi triu chng bng cch hi: -Cho ti bit cn au ging nh What?. Hy chc chn rng bn hi v tt c cc triu chng, cho d chng c lin quan hay khng. Vi tt c cc triu chng phi thu c cc chi tit sau y: -Thi gian ko di -Khi pht: t ngt hay t t -Nhng g xy ra t : . Lin tc hay c chu k (cn) . T n s . Tr nn t hn hay tt hn -Yu t khi pht v yu t lm gim -Triu chng i km Nu au l mt triu chng ,cng xc nh nh sau: -V tr -Hng lan -Tnh cht, V d: au m , p, nhi, dao m, m -Mc nghim trng, V d: N c lm tr ngi cng vic bn ang lm khng? Liu n c lm bn kh ng khng? -Bn c b au nh th ny trc cha? -au c lin quan n bun nn, m hi? V d: au tht ngc Trnh dng ngn ng chuyn ngnh khi m t bnh s ca bnh nhn. ng ni Bnh nhn phn nn v i phn en ( Melaena), tt hn nn ni Bnh nhn than phin i phn lng, en, i ngoi ging hc n. B SUNG BNH S Khi bnh nhn khng th a ra mt bnh s y hoc ng tin cy . Thng tin c n thit c th phi thu c t bn b ho c ngi thn. Mt bnh s t mt ngi chng kin mt s vic xy ra bt ng thng rt hu ch.

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Theo , sinh vin nn sp xp vi bc s ni tr c mt khi ngi thn ho c ngi chng kin c hi. iu ny c bit quan trng vi bnh nhn chu s au n do bnh ca h thn kinh trung ng. Ngy v ngun thng tin nn c ghi li. Khi cn thit c th sp xp mt ngi gii thch. Hy s dng K t ca bc s a khoa ( GPs letter) v lin h vi bc s a khoa (General Practitioner) nu cn thit.
B CU HI ( FUNCTIONAL ENQUIRY)

y l mt danh sch kim tra cc triu chng cha c pht hin. ng hi nhng cu hi t ra khi khai thc triu chng chnh. B cu hi ny c th pht hin nhng triu chng khc . Sa i cu hi ca bn theo tnh cht ca bnh c nghi ng, qu thi gian v tnh hung c th. Nu trong b cu hi c nhng triu chng nhn c cu tr li l dng tnh (c triu chng) ,bn phi khai thc chi tit cc triu chng ny. nh du sao (*) biu th nhng cu hi m gn nh lun lun phi c hi. CU HI TNG QUT Hi v cc im sau y: - *S thm n: Kiu thm n ca bn l sao? Bn c cm thy thch n khng? - *Cn nng : Bn c b gim hoc tng cn gn y khng? - *Tnh trng sc khe chung : Bn c cm thy c th mnh tt khng? - Mt mi: Bn cm thy mt mi nhiu hn hay t hn lc bn b trc y? - St hoc n lnh: Bn cm thy nng hay lnh? Bn c b rng mnh khng? - m hi m: Bn c nhn thy mnh m hi m hay bt k thi gian no trong ngy khng? - au. - Pht ban: B n c pht ban gn y khng? N c nga khng?

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- Cc u v chn thng H TIM MCH V H H HP Hi v cc im sau y: - *au ngc: Gn y bn c bt k au n hoc kh chu no ngc khng? Cc nguyn nhn ph bin ca au ngc l : Bnh tim thiu mu cc b: co tht nghim trng, au ngc trung tm ri lan sang c ,hm v tay tri. au tht ngc l cn au khi pht bi vn ng hay cm xc; v gim khi ngh ngi. Trong nhi mu c tim, cn au c th n lc ngh ngi , tnh trng cng lc cng t hn v ko di khong mt gi. au do vim mng phi: t ngt, au khu tr, thng mt bn, au tng ln trong th ht vo hoc ho. S hoang mang hoc lo lng: l mt nguyn nhn rt ph bin gy ra au ngc. Hi thng tin v ho n cnh dn n cn au. *Kh th: T trc n nay bn c b kh th khng? Kh th (Breathlessness) v au ngc phi c m t chnh xc. Mc vn ng dn n cc triu chng phi c ghi li (v d nh leo ln mt chuyn bay ca cu thang, hay sau khi i b 0.5km (1/4 dm)) Kh th khi nm (Orthopnoea ): Bn c th c khi nm trn ging khng? Bn s lm g sau ? Kh th gim hay tng khi m bn ang nm ri ngi thng lng dy? Bn dng bao nhiu ci gi? Liu bn c th ng m khng c gi khng? Kh th kch pht ban m: Bn c thc dy vo ban m do bt k triu chng no khng? Bn c th hn hn khng? Bn s lm g sau ? Kh th khi nm (Orthopnoea) v kh th kch pht v m (thc dy th hn hn, gim khi ngi) l cc d u hiu c trng ca suy tim tri. Ph mt c chn: Ph bin trong suy tim sung huyt (suy tim phi)

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nh trng ngc: Bn c nhn bit c nhp p ca tim khng? nh trng ngc c th l: . Ting p n (Ectopics) . Ch m hoc nhanh . u hoc khng u Hi bnh nhn khai thc triu chng ny Nhp tim nhanh kch pht (Cuc tn cng t ngt ca nh trng ngc) thng bt u v kt thc t ngt. *Ho: Bn c b ho khng? y l ho khan hay ho c m? Bn thng ho vo lc no? m (Hay m) :m c mu g? Nhiu hay t, khong bao nhiu? m mu xanh l cy thng ch ra mt nhim trng ngc cp tnh. m mi ngy u trong sut nhng thng ma ng gi vim ph qun mn tnh. m bt gi suy tim tri. *Mu trong m (Haemoptysis): Bn tng ho ra mu cha? m c mu phi c xem xt rt nghim tc. Nguyn nhn bao gm: Ung th biu m ph qun Thuyn tc phi Hp van hai l Bnh lao Gin ph qun Ngt (Syncope): Bn tng ngt hay xu cha? Bn c cm thy trong u trng rng hay cn phng quay vng khng? Bn c b mt thc khng? C d u hiu no cnh bo bn khng? Bn c th nh c nhng g xy ra khng? *Ht thuc: Bn c ht thuc khng? Bn ht bao nhiu iu thuc mt ngy?

H TIU HA Hi v cc im sau y: Vim lot ming Bun nn: Bao nhiu ln khi bn b bnh? Nn: Bn c nn khng? N th nh th no? 16

Nn b cf cho thy mu c thay i Thc n c cho thy hp mn v Mu c mu g- sm hay ti? Nut kh (Dysphagia): Bn c gp kh khn khi nut khng? Kh nut ch no? . i vi cht rn: thng tc ngn c hc . i vi dch: thng thn kinh hoc tm l. Chng kh tiu: Bn c thy kh chu d dy sau khi n khng? au bng: au u? Cn au c lin quan n ba n hay i tiu nh th no? Yu t gim au l g? *Thi quen i tiu: Thi quen i tiu ca bn c u khng? Bao nhiu ln mt ngy? Bn c thng i tiu vo ban m khng? (thng l mt du hiu ca bnh l thc s) Nu tiu chy l hng chn on, S ln i ngoi trn ngy v tnh cht ca phn (Mu? M? Cht nhy?) ph i c a vo. Phn th nh th no? ,phn c th nht nht, nhiu v ni (phn nhim m-Steatorrhoea) ho c ging hc n do mu t ng tiu ha (Melaena- thng t ng tiu ha trn) Mu ti trn b mt ca phn c th l do tr, trong khi mu trong phn c th l do ung th hoc vim rut. Vng da: Nc tiu ca bn c sm mu khng? Phn c nht mu khng? Thuc no c dng gn y? Bn c tim hay truyn dch g gn y khng? Bn c ra nc ngoi gn y khng? Bn ung bao nhiu ru? Vng da c th do: . T c nghn (nc tiu m mu, phn nh t) do: ung th biu m u ty, si mt ty. . T bo gan (nc tiu m mu, phn nht mu) do: Ru (x gan) Thuc hoc truyn mu (vim gan siu vi) Ph n ng thuc hoc nhim trng (i du lch nc ngoi, vim gan siu vi hoc amip (Amoebae)) 17

. Tn huyt (Bilirubin lin hp c lin kt vi albumin v khng c tit ra trong nc tiu) H SINH DC Hi v cc im sau y: Tiu kh: au khi i tiu, thng c cm gic nng,rt (thng l mt du hiu ca nhim trng) au hng: Bn c au n g lng khng? au trong cc phn tht lng cho thy vim i b thn. *Nc tiu: Nc tiu ca bn c bt thng g khng? Bn c tiu nhiu vo ban m khng? Bn c gp kh khn lc i tiu khng? C mu trong nc tiu khng? (Tiu ra mu). a niu v tiu m xy ra trong bnh tiu ng Tc tuyn tin lit gy ra tiu chm, yu, v lt nht vo lc gn tiu xong. Sex: Bt k vn no trong giao hp hoc lm tnh? *Kinh nguyt: Bt k vn g vi chu k kinh nguyt ca bn? Bn c chy mu nhiu khng? Bn c chy mu gia chu k khng? Chy mu m o gia chu k kinh nguyt hay sau khi mn kinh lm tng kh nng ung th t cung ho c ung th c t cung. Dch tit m o Chu k kinh nguy t: Thi k kinh nguyt cui (last menstrual period) v chy mu m o bt thng. Chy mu gia chu k. Chy mu sau mn kinh. Chy mu sau khi giao hp. au khi giao hp (Dyspareunia) v au nng bn ngoi hay au su bn trong.

H THN KINH Hi v cc im sau y:

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*Nhc u: Bn c nhc u khng? Chng u? Khi no bn b nhc u? V d: au u vo bui sng sm c th gi tng p lc ni s, khi u. au u c lin quan n n nh p nhy (m thong qua) Th gic: Mt ca bn c b m hay tng khng? Thnh gic: Hi v tai, ic, v mc nhy cm vi ting n. Chng mt: Bn c cm thy chng mt hay c lc thy mi th quay vng vng (vertigo) khng? Chng mt vi cc triu chng chong vng, khi pht t ngt, c th do tim (hi v nh trng ngc). Khi pht chm c th do Vasovagal fainting hoc xut huyt ni. Chng mt c th do bnh v tai (hi v ic, au tai hay chy m tai) hay ri lon chc nng ca thn no. Dng i khng n nh: Bt k kh khn no khi i hoc ch y? Suy yu (Weakness) T lit hoc nhy cm: Bt thng v cm gic t? Cm gic rn rn nh kin b. Ri lon chc nng c vng: Bt c s kh khn no khi nhn tiu, i tin? (mt du hiu rt quan trng ca trng lc ty sng) Ngt hay xu: Bn c bt c biu hin khc l no khng? Cc chi tit sau y cn c khai thc t bnh nhn v bt k ai quan st: . Thi gian ko di . T n s v di ca cn bnh . Thi gian xy ra. V d: ang ng v vo ban m. . Cch thc khi pht v kt thc . Thay i ca c th trc khi xy ra nh th n o? Chong vng, chng mt . Cn li, mt kim sot cc c vng, chn thng

19

Cn ng kinh ln (Grand mal epilepsy) c in gy ra cn bt tnh t ngt m khng c bt k d u hiu bo trc no v khi dy cm gic u oi, th thn trn bnh nhn vi nhc u, au li, v khng ngn li c. TRNG THI TINH THN Hi v cc im sau y: Trm cm: Tm trng ca bn nh th no? Vui hay bun? Nu chn nn th t n mc no? Bn c mt s thch th trong cng vic khng? Hay b n vn c th thch th chng? Bn cm thy th no v tng lai sp ti? iu g trong cuc sng m lm bn chn nn nh vy? Bn c cm thy ti li v vic g khng? Nu bnh nhn biu hin s chn nn, tht vng: C bao gi bn ngh n vic t t cha? Bn trong tnh trng ny bao lu ri? C chuyn g c bit khng? Bn cm thy nh th no trc khi chuyn xy ra? Thi gian hot ng: Bn c thi gian tham gia cc hot ng c bit khng? Nhy cm vi bnh trm cm c th l mt c im tnh cch. Trong trm cm lng cc (bipolar depression), hng cm tht thng (hnh ng vt gii hn, ni sng v tnh kh d kch ng) c th ti din. Hi thng tin v s thch, s tp trung , kh ch u, v kh ng. S lo lng: Bn c cm thy lo lng nhiu gn y khng? Bn c lo u khng? Trong tnh hung no? Nhng hon cnh no bn thng n trnh v bn cm thy lo lng? Bn c lo lng v sc khe ca mnh khng? C lo lng cho cng vic hay gia nh khng? Hay c bn tm g v ti chnh khng? Bn c mi hoang mang, lo s no khng? iu g xy ra? Gic ng: C b kh ng khng? Bn c gp kh khn g khi i ng khng? C thc dy sm khng?

Kh khn ca gic ng thng lin quan n trm cm hoc lo u. Mt nh gi y hn v trng thi tinh thn c b sung chng 6. 20

MT Hi v cc im sau: au mt, s nh sng hoc mt: Mt ca bn tng b , kh ch u hay au cha? . au mt , c bit l s nh sng c th nghim trng v do: Vim mng mt (vim cng khp t sng, bnh Reiter, bnh Sarcoid, b nh Behcet) Vim cng mc (vim mch h thng) Lot gic mc Bnh tng nhn p cp tnh S nh sng c th l mt du hiu ca vim mng no. . Mt khng au c th do: Episcleritis (vim cc m nm gia kt mc v cng mc) Ch tn ti tm thi v khng li hu qu Vim mch h thng . Ch mt c th do vim kt mc (thng l nhim trng) . Nga mt c th do d ng, v d: st c kh. . Sn mt c th do kh (mau kh hay h i chng Sjogren) . r nt ca th gic: Th gic ca bn c b nhe khng? M mt khi nhn gn hoc nhn xa c th do li ca s hi t, ci thin bng cch eo knh mt. Mt th lc trung tm (hoc na trn hay na di) ca mt mt c th do ri lon thn kinh vng mc hay thn kinh mt. M hon ton thong qua mt mt ko di khong vi pht-Amaurosis Fagax (m thong qua):
Cho thy s tc nghn ng mch vng mc do vt l gy nghn mch c th do nguyn nhn x va ng mch cnh (thng tin truyn ming-listen for bruit) hay c th c ngun gc t tim.

Kh khn khi nhn chm ch, kh khn khi c-c vn v giao thoa th gic, hoc ng dn truyn sau giao thoa:
Bn manh hai thi dng hon ton (Complete bitemporal hemianopia) khi u chn p trn giao thoa th. Bn manh ng danh (Homonymous hemianopia) :tn thng no sau hoc tn thng bc x quang thng l do nhi mu hoc khi u; t c phn nn v bn manh ng danh (half vision) ngo i tr c th kh khn khi c.

Chng song th: Bn bao gi nhn th y i cha?

21

Song th c th do: . T n thng cc dy thn kinh s III, IV, VI . Lit dy thn kinh s III Gy song th tt c cc hng. Thng km vi gin ng t v sa mi mt , mi mt xung di v ra ngoi. . Lit dy thn kinh s IV Gy song th khi nhn xung v gn (nh khi c) vi hnh nh c tch ra theo chiu ngang v theo chiu dc v chiu nghing (khng song song) . Lit dy thn kinh s VI Gy song th khi nhn ngang, phng v song song t hn khi nhn sang bn b nh hng. . Ri lon c. V d: Lin quan n tuyn gip (xem bn di) Chng nhc c nng (yu sau khi vn ng c, cc khng th i vi u tn thn kinh) H VN NG Hi v cc im sau y: au, t cng , hay sng khp: N bt u khi no v nh th no? Bn b chn thng khp? C v s cc nguyn nhn gy vim khp (au, sng, mm khp) v arthraegia (au khp). Bnh nhn c th khng chnh xc khi quy cho cc nguyn nhn gy ra chn thng. Vim kh p xng l mt khp hao mn, v thng khng i xng, lin quan n cc khp chu sc nng ca c th nh khp hng ho c khp gi. Tp th dc lm tnh trng khp tr n n t hn. Vim kh p dng thp l mt bnh t min c tnh tng qut v c tnh i xng hai bn. bn tay, sng dng thoi ca cc khp lin ngn c i km bi sng khp t ni xng bn tay v cc xng t ngn tay (metacarpophalangeal). Cc khp ln thng b nh hng. t cng thng din bin xu khi ngh ngi, v d: nh thc dy v din tin tt hn khi vn ng.

22

Gout thng lin quan n mt khp n, nh l khp metacarpophalangeal u tin, nhng c th dn n tay to lin quan n cc cc u acid uric khng i xng (Nt tophi) mt vi khp xng, v nh tai. Vim kh p nhim trng: y l bnh rt quan trng khng th b qua- khp au th duy nh t v nng. S bt lc chc nng (Functional disability): Bn c th i b bao xa? Bn c th i b ln cu thang? C c ng no c bit kh khn khng? Bn c th t mc qun o? Mt bao lu? Bn c th lm vic? Bn c th vit?

BNH TUYN GIP Hi v cc im sau y: Cn nng thay i? Phn ng vi thi tit: Bn khng thch thi tit nng hay lnh? Tnh d b kch thch: Bn d hay kh cu gin hn so vi mt vi nm v trc? Bnh tiu chy/to bn. nh trng ngc Da kh, tc nhn: Da ca bn c b kh hoc nhn? Tc ca bn c b kh hay nhn khng? Trm cm: Tm trng ca bn nh th no? Ni khn (Croaky voice): Bnh nhn suy gip tng cn m khng km cm gic thm n, khng thch thi tit lnh, c da kh v tc kh, mng; mt khun mt sng mp, ging ni khn, thng im tnh v c th b trm cm. Bnh nhn cng gip c th gim cn mc d n nhiu, khng thch thi tit nng, m hi qu mc, c cm gic nh trng ngc, rung, c th b xc ng v ch y nc mt. Thanh thiu nin 23

c cc triu chng khng dung np ch yu l thn kinh v sc nng, trong khi ngi gi c xu hng hin din vi cc triu chng v tim mch.
TIN S

Tt c cc bnh hoc phu thut trc y, cho d c quan trng hay khng cng phi c lit k ra. V d, tnh c cp n mt bnh cm hoc n lnh, rt run c th c c mt biu hin ca mt nhim trng b n i. Tm quan trng ca mt cn bnh trong qu kh c th thu c bng cch tm hiu thi gian bnh nhn dng bnh hoc ngh lm Cc bin chng ca bt c cn bnh no trc y nn c hi cn thn, v trong trng hp ny, cu hi dn i khi l cn thit. CU HI TNG QUT Hi v cc im sau y: - Bn tng mc cn bnh nng no cha? - Bn tng c vn v tnh cm hay lo lng cha? - Bn tng b phu thut hay nhp vin cha? - Bn bao gi: . B vng da, ng kinh, bnh lao, cao huyt p, st thp khp hay tiu ng? . i du lch nc ngoi? . Tin s d ng? - C loi thuc no tng lm cho bn kh chu, tht vng khng? p ng d ng vi thuc c th bao gm ban nga, nn i, tiu ch y hoc bnh nng km theo vng da. Nhiu bnh nhn cho rng mnh b d ng thuc nhng khng phi. Mt miu t chnh xc cc biu hin c cho l do d ng th rt quan trng. - Cc cu hi c th c hi thm: . Nu bnh nhn c cao huyt p, hi v cc bnh thn, c lin quan n cao huyt p hoc liu ng y c n cam tho-Liquorice khng. . Nu c th c mt cn au tim, hi v bnh cao huyt p, tiu ng, ch n ung, ht thuc l, tin s gia nh v bnh tim mch. . Nu bnh s bnh nhn gi suy tim, bn phi hi liu anh ta c b st thp khp khng. Bnh nhn thng c khm sc khe k cho hp ng bo him nhn th hay ngha v qun s.

24

TIN S GIA NH

Tin s gia nh cung cp cho ta cc u mi c khuynh hng nghin v chn on mt bnh no (v d: nhi mu c tim) v liu bnh nhn c th c l do cho mt mi lo lng c bit v mt bnh nht nh (v d: m cht v bnh ung th) Giy chng t v nhng hiu bit ca bnh nhn th thng khng chnh xc. Bnh nhn c th b min cng ni v bnh ca mnh hay ngi thn nu h b bnh tm th n, ng kinh hay ung th. CU HI TNG QUT Hi v cc im sau y: - Cha m bn cn sng? H cn khe mnh ch (fit and well)? Cha m bn mt l do? - Bn c anh ch em no khng? H cng cn khe mnh ch? - Bn c con cha? Chng vn khe mnh ch? - Mt vi tin s v: . Lo lng v tim mch? . Bnh i tho ng. . Bnh cao huyt p trong gia nh? Nhng cu hi ny c th c thay i ly c mt bn miu t y cc li phn nn ch yu ca bnh nhn.
BNH S C NHN V X HI

Mt trong nhng yu cu l tm ra kiu tnh cch ca bnh nhn l g, hon cnh gia nh ca anh ta v cn bnh th nh hng n anh y v gia nh anh y nh th no. Mc tiu ca bn l hiu c cn bnh ca bnh nhn trong bi cnh tnh cch v hon cnh gia nh ca anh ta. Anh y c th dng bnh mt cch thoi mi nh? V vo giai on no? Hu qu cn bnh ca anh y l g? T vn, thng tin v gip s cn thit? Mt cuc phng vn vi ngi thn hay bn b c th rt hu ch. CU HI TNG QUT Hi v cc im sau y: - Bn c mi quan h no khng?: kt hn, quan h i tc, v c con khng? - Gia nh: T t c mi th u n nh ch? C vn g trong gia nh khng?

25

C th thch hp khi hi: Mi quan h ca bn n khng? Quan h tnh dc n ch? Vn c th pht sinh t l do th cht hay tnh cm, v bnh nhn c th nhn thc c mt c hi tho lun v nhng lo lng ny. - Ch : Bn sng u? Vn n ch? - Cng vic: Cng vic ca bn l g? B n c th ni cho ti bit chnh xc nhng g bn ang lm? C thoi mi khng? Bnh ca bn s nh hng n cng vic ca bn? - S thch: Bn thng lm g trong thi gian rnh ri? Bn c mi quan h x hi no? - Ru: Bn ung khong bao nhiu ru? Ngi nghin ru thng cho rng lng ru h ung mi ngy l t. iu c th hu ch nu ch ung trong mt ngy. Nu c mt s nghi ng no v vn ung ru, bn c th hi: Bn c bao gi ung ru vo bui sng? Bn c lo lng v vic kim sot vn nghin ru? Liu n c nh hng n cuc sng, cng vic, gia nh v quan h x hi ca bn? - Ht thuc: Bn c ht thuc khng? Bn tng ht thuc? Ti sao bn khng b thuc i? Bn ht bao nhiu iu thuc, cigar, hay tu thuc l mi ngy? c bit thch hp khi hi bnh v tim mch hay lng ngc, nhng ph i lun lun c hi trong cc bnh khc. - Thuc: Bn c dng bt k loi ma ty no khng? - K toa thuc: Hin nay bn ang dng nhng loi thuc no? Bn c s dng nhng loi thuc no khc trong nhng thng gn y khng? y l mt cu hi v cng quan trng. Mt danh sch y cc loi thuc v liu lng phi c ly. Nu thch hp, hi v cc con vt nui, i du lch nc ngoi, tip xc vi bi than, aming...trong qu trnh lm vic trc y hay hin ti. KIN BNH NHN, MI QUAN TM V K VNG Hy chc chn rng bn hiu c nhng kin chnh, mi quan tm v k vng ca bnh nhn. Hoc lc , hoc sau khi khm cho bnh nhn, hi theo mu: - Bn ngh iu g l sai i vi bn? - Bn mong i iu g xy ra vi bn trong lc bn nhp vin? - Bn c mun chng ti lm g cho bn khng? - Bn c cu hi no khng? 26

Nhng iu bnh nhn quan tm c th khng l mi quan tm chnh ca bn. Bnh nhn c th c nhng mong i kh khc nhau khi nhp vin hoc ch nh iu tr ngoi tr so vi nhng gi nh ca bn. Nu bn khng gii quyt nhng mi quan tm ca bnh nhn, anh y c th s khng hi lng, dn n mi quan h gia bc s v bnh nhn kh khn v khng ng thun. CHIN LC ly bnh s, bn nn: - C mt vi kin c th chn on. - tng thc hin mt nh gi trn bnh nhn. - Bit c h c quan, c quan m bn mun tp trung vo khi khm bnh nhn. Cc cu hi thch hp c th pht sinh t cc bt thng trong qu trnh khm hoc iu tra.

BNH S MU

Mr John Smith 52 tui, th my, Oxford C/o au ngc d di trong khong 2 gi BNH S CA BNH HIN TI - Hon ton khe mnh cho ti khong 6 thng trc y. - au ngc m bt u ngc, i khi cm nhn c au trn hm, cn au n khi i b khong 1km (1/2 dm), t hn khi lm vic nng hoc gp thi tit lnh. Khi ngng cng vic, cn au gim i sau 2 pht. - Glyceryl trinitrate phun thuyn gim cn au nhanh chng. - Thng trc, cn au n khi ch tp th dc nh (khong 100 yards) - Hm nay lc 10 gi sng, trong khi ang ngi lm vic cn au ngc n m khng c mt tc nhn khi pht no c. l cm gic au ti t nht m ng tng tri qua trong cuc i v ng ngh rng ng s cht. - Cn au ngc, au nh b nghin nt, sit cht, lan ra tay tri v c, km theo cm gic bn nn v m hi. Bnh nhn nhanh chng c a vo bnh vin v c tim tnh mch diamorphine, cht ny nhanh chng lm thuyn gim cn au, v tim tnh mch streptokinase. in tm xc nhn nhi mu c tim v bnh nhn c nhn v o n v chm sc mch vnh (The coronary care unit). - Bnh nhn cm thy kh th khi gng sc trong khong ba thng trc, nhng khng c cc triu chng: nh trng ngc, chng mt, kh th khi nm, sng mt c hoc ho. Tuy nhin cch y 2 tun bnh nhn t nhin b nh thc

27

bi mt cn nght th v phi ngi trn mp ging, sau m ca s c th th c. iu ny khng ti pht v ng khng k li vi bc s ca mnh. B CU HI (Functional Enquiry) H h hp - Ho vo bui sng sut 3 -4 ma ng gn y vi mt lng t m trong. - Khng ho ra mu H tiu ha - Thnh thong kh tiu nhng nh. - i tiu u n - Cm gic ngon ming bnh thng - Khng c bt thng khc. H sinh dc - Khng gp kh khn khi i tiu - Cuc sng tnh d c bnh thng H thn kinh - Him khi b au u pha trn vo cui mt ngy lm vic bn rn - Ngoi ra khng c bt thng g - Khng c triu chng tm thn TIN S Y KHOA - Mi lm nm trc, ct rut tha, khng c bin chng nghim trng. - Khng c cc phu thut khc hoc bnh nghim trng - Khng c tin s b st thp khp, vim thn hay tng huyt p - Cha tng ra nc ngoi. TIN S GIA NH - Cha qua i tui 73- Nhi mu c tim - M qua i tui 71- Ung th - Hai em khe mnh 46 v 48 tui - Hai ngi con trai (tui 23, 25), c hai u khe mnh. - Gia nh khng c tin s v tiu ng v cao huyt p. TIN S C NHN V X HI 28

- Cng vic v gia nh u hnh phc. Hai con trai kt hn v sng Oxford. V lm vic nh mt nhn vin vn phng. Khng c kh khn ti chnh. Ht thuc l khong 20 iu thuc mi ngy. Ch ung 2 lon bia vo ngy th 7. Bnh nhn lun lun lm vic nh mt th my t khi ri trng, ngoi tr 2 nm Hng Kng, ni m ng khng c bnh. THUC Ngoi tr Glyceryl trinitrate phun, hin nay bnh nhn khng dng bt c thuc no khc.

29

CHNG 2: KHM TON THN

nh gi ban u v tnh trng bnh nhn c thc hin trong qu trnh ly bnh s. u tin l quan st biu hin bn ngoi ca bnh nhn v sau trt t ca qu trnh thm khm c th thay i. H c quan no c lin quan n cc triu chng ang hin din th khm trc. Nu khng th c theo trnh t khm thng thng ca mnh, khm ln lt tng phn ca c th, i ht tt c cc h c quan. V d: Biu hin bn ngoi Tnh trng t nh to, tm trng, hnh vi chung Tay v mng tay Mch quay Hch nch Hch bch huyt c Sc mt, mt, li p lc TM c Tim, v H h hp Ct sng ( khi bnh nhn ngi th ng) Bng, bao g m mch i Chn H thn kinh bao gm y mt Khm vng chu ho c trc trng Dng i D khm phn no ca c th i na th cng u nn tun theo trnh t: 30

1. Nhn 2. S 3. G 4. Nghe

Nhn tng th
Bc u tin ca qu trnh thm khm l quan st cn thn tng th bnh nhn. Cn ghi nhn: o Bnh nhn nhn c au yu khng? Khong bao nhiu tui? St, mt nc? Tnh to, bi ri hay l m? Hp tc, vui v, bun b hay bc bi? Mp, rn chc hay gy g? C au n hay suy nhc khng?

Tay
Cn ghi nhn: o Nhit Tay qu lnh - ? Do hiu sut tim thp Tay qu m - ? Do tnh trng hiu sut cao , vd: cng tuyn gip Lnh v ra m hi - ? Do lo u ho c do nhng nguyn nhn khc ca cng p ng giao cm, vd: gim glucose huyt o Tm ti ngo i bin. o Bnh Raynaud. o Nhu m mu nicotin. o Mng tay:

31

 C b cn khng? Chng mng trng - mng tay mu trng - c th c trong bnh x gan Chng mng lm - mng cong, mo m (Plate 2d) - c th c trong thiu mu do thiu st Ngn tay di trng - mt gc y mng (Plate 2a)

Ngn tay di trng xy ra trong cc bnh c th sau: Tim: Vim nhim ni mc, tm ti do bnh tim Phi: Ung th ph qun (nhim trng mn: p xe; gin ph qun, vd: u nang x ha; vim m mng phi); vim ph nang x ha (khng ph i vim ph qun mn) Gan: x gan. Bnh Crohn. Bm sinh. Vt xut huyt xy ra do vim nhim ni tm mc nhng c th c nhng ngi lao ng chn tay Nt lm Bnh vy nn Bong mng S tch mng ra kh i m n n c a mng: bnh vy nn, bnh tng nng tuyn gip Vim quanh mng Mn m 2 bn mp mng

32

o Lng bn tay: Ban - C th bnh thng, cng xy ra trong bnh gan mn , mang thai. Co cng Dupuytren (Plate 4c) S gn cht da lng bn tay vo gn c gp ngn 4. o Khp: Ph i xng do vim khp dng thp (Plate 2e) Ph bt i xng do gt (Plate 2f) v vim kh p xng mn.

Da Nhn da
S phn b ca thng tn t on cui m nn Khm k hn bng thao tc s da Ch mng nhy, lng tc v mng o Mu sc da: Da b nhum mu khc vi mu da c a chng tc hoc b rm nng kim tra nim mc m Nu xut hin vng da kim tra cng mc mt Nu xanh ti kim tra kt mc mt xc nh thiu mu o Kt cu da: bnh thng theo tu i? tr nn mng hn sau 50 tui

Mng, vd: H i ch ng Cushing, nhc gip, gim nng tuyn yn, suy dinh dng, gan ho c suy thn Dy, vd: bnh to cc chi, tha androgen Kh, vd: nhc gip Cng, vd: b nh x cng da ca ngn, km theo khi u di v o Pht ban:

33

 Trng nh th no? M t chnh xc

Nhn thng tn
Phn b ca thng tn: i xng hay bt i xng Ngoi vi hay ch yu thn ngi Ln nht nhng vng trn Hnh dng do tip xc vi cc tc nhn bit, vd: giy, gng tay, m phm S lng v kch thc thng tn Xem xt nhng thng tn xut hin gn y Ring l hay ng lot Hnh dng thng tn, vd: vch th ng, hnh khuyn, dng herpes (nh h nh con rn), d ng li C ranh gii r rng hay khng? Mu sc B mt, vd: sn si, trn lng

34

S thng tn
Phng, khng s thy vt (Plate 3c)

Ni ln Sn: trong da, c c b Mng: ln hn, vd: >0.5cm Nt: su hn h b , ko di hn 3 ngy M ay: dch ph n, thong qua, t hn 3 ngy Ti nc: cha dch (Plate 3e) Bng nc: nhng ti nc ln, vd: >0.5cm Mn m Su trong h b nt Nhit au? Ti do p lc phn ln thng tn do ban , vd: ban do thu c, dn mao mch Khng ti do p lc Ban xut huyt hay m xut huyt l nhng xut huyt nh, ring l, ng knh kho ng 1mm, , vt ban khng au Nu s c, gi vim mch (Plate 3d) Ban xut huyt lo suy cc b do nhng vt thng nh lp da mn g bn tay hay cng tay. Nhng tn thng phng, mu tm hoc nu. Cng S s ha, vd: x ha b ngn tay S thm nhim, vd: u lympho hay ung th So

Thm hi din bin ca thng tn

N xut hin c bao lu r i? N c c nh v v tr v kch thc khng? C xu t hin ri t mt i khng? Nga, nhc nhi, au hay t? 35

Kin thc v nhng chun on khc nhau s ch ra nhng cu hi khc: Vim da tay do tip xc vi ha cht hay cy c, b mn v h hng; Lot ngn chn bnh ng mch, tiu ng, bnh thn kinh ; Nhim sc t v lot phn thp gia chn Gin tnh mch.

Nhng bnh thng thng

Mn Ung th t bo y (lot gm nhm) (Plate 5e) Bng nc Vim b nhn nang lng nt sn v mn m trn mt v thn trn, mn u en (mn trng c), u nang lng. Nt bng nc vi mp gn sng v mao mch trn b mt. C th lm gia hoc lot ra. Rp da do bng, nhim trng da, d ng hoc him hn do bnh t min dch nh hng n bm dnh bn trong biu b (pemphigus) ho c ti ni giao gia biu b v h b (pemphigoid ) Nhng vt ban c nh mu nu, ring l, nhiu hnh dng v kch thc. Nu ln v nhiu th gi bnh u x thn kinh Thng ni ban, phn b i xng. C th l m ay, chm v nhiu dng khc bao gm hng ban a dng hoc hng ban nt (xem di) Vim da d ng: da kh, , tng mng, thng mt, h trc cnh tay v h khoeo, vi nhng vy sn si ln, bng nc v gi nh du triu chng ph km theo l nga . Thng lin quan n b nh suyn hay st c kh. Tin s d ng ca gia nh. Vim da tip xc: do kch thch hay d ng. , c mng sn si vi bng nc trong giai on cp tnh. i xng, vt ban/sn vim lan ta 0.5 -1 cm, thng phng ln trung tm.C th hp li vi nhau.Thng trn bn tay hoc bn chn: Phn ng thuc Nhim virus Khng r nguyn nhn Hi chng Stevens-Jonhnson vi s bong trc nim mc b phn sinh dc, ming v kt mc, km theo st. au, cc b, , ni ln lan ta, nhng nt t 2-4cm mt trc cng chn. Nguyn nhn: Nhim streptococcus, vd: st thp khp 36

Nhng mng mu caf sa Hng ban nhim sc (Plate 3c) Chm (Plate 3b)

Hng ban a dng

Hng ban nt (Plate 3f)

U si Nhim Herpes (Plate 6f) Chc l U hc t c tnh

Bnh vy nn (Plate 3a)

Gh Ung th t bo vy Chng m ay

Lang ben

Lao nguyn pht v nhng nhim trng khc Sarcoid Bnh vim rut Ph n ng thuc Khng r nguyn nhn Vng da , h nh khuyn, sn si. Khi mng tay, chng tr nn dy hn v mt i kt cu rn chc. Mn m mc thnh tng cm, ng vy cng, ti i ti li cng mt ni, vd: mi, mng. Mn m lan ta v ng vy cng mu vng do nhim staphylococcus Thng do phn b sc t khng ng u, nt sn hoc mng, nm trn b mt hoc dy vi b khng u, m rng ra vi khuynh hng chy mu Mc i xng: mn tnh, ring l, nhng mng vi vy bc. D chy mu d co nh. Thng nh hng n da u, khuu tay, u gi. Mng tay c th b lm. Do tin s gia nh v xut hin bi vim hng do streptococcus hay tn thng da. Nhim ve: nga vi nhng hang t 2-4mm trong lp biu b, vd: lp mng ca ngn tay, c tay, b phn sinh dc. Mn cm dy,cc b,c th lot. Ni m ay thong qua vi hng ban bao quanh. Ko di trong vng 24h. Thng do d ng vi thuc, vd: aspirin, hoc do tc nhn vt l, vd: chng da v ni, cm lnh. C ranh gii c nh, l nhng mng trng thiu sc t do bnh t min.

MING
o Quan st li: Tm ti, m hay kh Tm ti do gim nng oxy trong mu, >5 g/dl Hb kh oxy Tm ti trung ng (li xanh) l biu hin ca s thng t phi qua tri (mu cha bo ha xu t hin trong vng i tun hon): Bnh tim b m sinh, vd: tam chng Fallot

37

 Bnh ph i, vd: b nh tc nghn ng dn kh Tm ti ngoi bin (ngn tay xanh, li hng) l biu hin ca thiu mu tun hon ngoi bin Li kh c th do thiu mui v nc (hay cn gi l s mt nc) nhng cng xy ra khi th bng ming. o Quan st rng: Su rng (l ng rng), v sinh rng km, rng gi o Quan st nu: Chy mu, sng o Quan st: , c dch tit Amidan Hu hng: sng, , lot o Hi th bnh nhn: Mi ceton Mi cn Mi hi thi To bn, vim rut tha C mi mc trong suy gan Th ceton l hi th c mi ng do suy dinh dng hay i tho ng nng . Mi hi do gan l mi mc trong suy gan.

MT
o Quan st m t: Cng mc v vng da Vng cng mc l biu hin r rng nht ca bnh vng da (Plate 1e) Kt mc mi di v thiu mu Thiu mu : Lt mi di ln thy mu sc ca lp mng nhy. Nu thy ti th thng thng Hb < 9 g/dl. M mt: thy cht lng mu trng hay vng trong ban vng m mt (Plate 5a) 38

 Ph m mt Ph ton thn, vd: h i chng thn h Bnh mt tuyn gip (Plate 1a), cng hoc nhc Ph nim (Plate 1b) Mt Vim mng mt Vim kt mc Vim cng mc hay vim thng cng mc Tng nhn p cp

ng trng quanh gic mc, vng cung lo ha Thng thng v hi r hn ngi gi Gi tng lipid huyt bnh nhn tr tui (Plate 5b) Bnh gic mc d i bng tng canxi huyt Sarcoid U tuyn cn gip hay tng sn U t bo nh phi 39

Ung th xng th pht Hp thu tha vitamin D Tng canxi huyt c th h nh thnh 1 d i ngang qua phn gia v phn b n gic mc.

Khm y mt
Thng c thc hin nh mt phn ca khm h thn kinh khi khm cc dy TK s. N c cp n y nh nhng c trng ca vic khm tng qut. o S dng knh soi y mt Nn cho b nh nhn ngi. Bt u kim tra cch bnh nhn 1m, nh n bit ph n x v n gn cch bnh nhn 1 gc 15o. Tip cn trn cng mt phng ngang vi ng xch o ca mt bnh nhn. Nh vy c th quan st c a th gic. Sau khi quan st a th gic th kim tra ton b vng mc ngoi bin b ng cch i theo mch mu n v ra kh i 4 phn ca vng mc ngo i bin. S dng mt ph i quan st mt phi bnh nhn v mt tri quan st mt tri bnh nhn. o Nhn a th gic Bnh thng l g mu hng vi lm trng pha di b mt ca a Teo th gic a th gic ti xanh: g khng c mu hng a x cng Sau vim thn kinh th gic p lc thn kinh th gic, vd : khi u Ph gai th a th mu hng, khng c g r rng Lm bin mt Gin TM vng mc: Tng p lc no, vd: khi u Tng nhanh huyt p Vim TK th gic, giai on cp tnh Tng nhn p lm m rng, g h thp Nhng mch mu mi nhng mt mu hnh dng x i t a th; Bnh vng mc thiu mu cc b do tiu ng 40

o Nhn ng mch M hp trong tng huyt p, vi tng phn x nh sng i dc theo u mch mu Phn lo i tng huyt p 1. Hp M 2. Nipping (Hp TM do M) 3. Xut huyt dng ngn la v m si len 4. Ph gai th Tc M vng mc ti xanh Tc TM xu t huyt o Nhn vng mc Cht tit rn ( nhng m lipid bng, vng, c gii hn) Tiu ng m si len (nhng m ph, trng, mm)

m si len gy phng si thn kinh ti ch Tiu ng Tng huyt p Vim mch Virus gy suy gim min dch ngi (HIV) Nhng chm nh, Vi phnh mch s ph nh ra ca mao mch vng mc cnh ni mao mch b tc 41

Tiu ng Xut huyt Nhng vt trn xut huyt su trong vng mc Ln hn so vi vi phnh mch Tiu ng Dng ngn la: xu t huyt trn b mt dc theo si thn kinh Tng huyt p Thiu mu nng Tng nht Khuynh hng chy mu

m Roth ( Xut huyt c mu trng trung tm) Ri lon vi nghn mch Vim ni tm mc bn cp do vi khun Nhim sc t Lan ta Vim vng mc sc t Cc b Vim mng mch (s gn kt ca sc t thnh mng) c tnh thuc, vd: chloroquine

42

y mt hnh sc hay c vn: bin th bnh thng trong mng mch bn di vng mc Mch mu mi ngo i bin Bnh vng mch thiu mu cc b do tiu ng Tc nghn TM vng mc Si TK c bao myelin bin th bnh thng, vng c nhng si TK trng t a ra t th.

Khm nhng hch bch huyt s thy c

o c : Pha trn xng n (tam gic c sau) Gia vng c chm (tam gic c trc) Di hm (c th s tuyn di hm) Vng chm Nhng tuyn ny d thy nht khi bnh nhn ngi thng v khm t pha sau. C th c hch thng n tri do s di cn ca khi u v trng c tnh (hch Virchow) o nch: Cho bnh nhn giang tay ra, t tay mnh dc theo mt bn ca nch, v cho bnh nhn khp tay li, c nh th t nhng u ngn tay ti nh nch. S nh nhng. o vng mm trn rng rc: gia v trn khuu tay o hng: Trn dy ch ng b n

43

o vng bng: Thng kh cm nhn c; m t s cho l c th s th y hch M ch bng Nch thng c hch bch huyt tht, mm Hng thng c hch bch huyt nh, trn v cng Hch to ton th, n hi gi u bch huyt Hch cng cc b gi ung th Hch au gi nhim trng Nu s thy nhiu hch khm lch v tm thiu mu U bch huyt hay hay ung th bch cu?

Bu

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o Nu c bu bt thng, nhn trc r i mi s: V tr Kch thc (o bng cm) Hnh dng B mt, ra Vng xung quanh C nh hay di ng Tnh bn vng, vd: rng hay c, mm hay cng, bt nh Nh y cm vi au C nhp p Nghe Phng php chiu sng qua m Ung th thng cng, khng au, khng ng u, c nh vo cc m ln cn v c th lot da U nang c th c tnh cht: Bt nh: p lc qua nang s lm n di chuyn n ni khc Phng php soi qua m : nh sng c th nhn thy xuyn qua n (thng ch trong phng ti) o Nhn nh ng h ch b ch huyt ln cn. c th tm thy: S lan ca ung th Hch bch huyt sng ln do vim

V
Lc thch hp, sp xp mt ph n i km, c bit khi bnh nhn l ngi tr tui, e d hoc s hi.

Cch khm thng thng

o Khm v ngi n khi khm vng trc tim o Kim tra s bt i xng , nhng bu d th y, nm v lm, vng da thay i. 45

o S mi gc t ca c 2 v vi lng bn tay (kt hp ngn tay, g n nh rng khp vi lc v a phi t nhng kh p bn-ngn tay, trnh p ln nm v) o Nu c bu th tin hnh khm hon chnh hn.

Khm v hon chnh

Khi bnh nhn c triu chng hoc tm thy u bu: o Nhn Ng i thng v bo bnh nhn a tay ln Nhn s bt i xng hoc nhng bu thy r Khc vi hnh dng v kch thc ca v Nm v i xng Ban, (p xe) Gi ung th v: Bt i xng Da cht Mu da cam (ph da) Nm v lch hoc lm o S Bnh nhn nm nga, k 1 gi Khm mi v vi lng bn tay, ln lt mi gc t Khm b ng c 2 tay nu ln Khm bu nh miu t trn Bu gn vo da hay c? Khm h ch bch huyt (nch v thng n) S gan

Tuyn gip

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o Nhn: sau bo bnh nhn nut, cho ung 1 cc nc. C u bu khng? N c i ln trn khi nut khng? o S b ng 2 tay: ng pha sau bnh nhn v s vi ngn tay ca c 2 bn tay. Tuyn gip c kch thc, hnh dng v kt cu bnh thng khng? o Nu thy c bu: Tuyn gip c nhiu mu nh khng? Bu c hc khng? Tuyn gip thng mm. Nu c bu c (sng phng tuyn gip), nh gi nu s sng phng: Cc b, vd: u nang gip, u tuyn hoc u biu m Ton b , vd: vim tuyn gip t min, tng nng tuyn gip a mu Sng phng khng c ngha l tuyn ny cng hay nhc nng. Trong nhiu trng hp, bnh nhn c th c tuyn gip bnh thng. Tuyn gip hi ln hn khi mang thai. o Bo bnh nhn nut Tuyn gip c i ln bnh thng khng? o Tuyn gip c c nh khng? o C th chm n bn di bu khng? Nu khng th g ln trn phn cao ca xng c xc nh ph n ko di sau xng c o C h ch bch huy t c khng? o Nu c kh nng bnh nhn b nhim c gip (Plate 1a), tm: Tay m m hi Run ry Nhp tim nhanh, nh p xoang hay rung nh Khe nt ln, s thy c hoc mi mt ch m chp (lid lag) Ting ng gip (khi nghe) Li mt ni tit (c th i km vi cng gip): 47

 Ph kt mc: chemosis (nhn thy nh p l c nh ln m di, y n p kt mc ln khi c ph) Li mt: mt b y v pha trc (nhn mt t trn xung) Nhn ln trn v hi t km Song th Ph gai th o Nu c kh nn g bnh nhn b nhc gip (Plate 1b), tm: Tc v da kh Ban vng m mt Ph mt Ging m p Dui c nga hoc phn x gt ch m

Nhng bnh ni tit khc To cc chi (Plate 1c)

M mm bn tay, bn chn, mt to ra c tnh km, da dy v nhn, li to (v nhng c quan khc, vd: tuyn gip) Bn manh hai thi dng (do khi u nn ln giao th)

Nhc nng tuyn yn

Khng c nhim sc t da Da mng Gim lng tc th pht hoc d y th mun Vc ngi thp (v trn phim X-quang, chm ni lin u xng) Bn manh hai thi dng nu c khi u tuyn yn

Bnh Addison
Tng nhim sc t da, bao gm c vng khng phi by, vd: nhim sc t m 48

 Gim huyt p t th Nu l n, gim lng c th

Hi chng Cushing (Plate 1d)

Thn ngi bo ph, mt trn v vi chng rm lng Da mng v bm, c vn hng, tng huyt p Yu u c

Tiu ng
Bin chng tiu ng bao gm: Tn thng da Hoi t m din tin thiu mu cc b trong da, thng trn cng chn, dn n s thay th m lp h b, bao bc bi da mng. Thiu mu cc b chn (Plate 4e) Gim mch bn chn Da bng, mu xanh, trng hay en Khng c lng, mng dy Lot (Plate 4f) Bnh TK ngo i bin Khng c phn x chn Gim cm gic Da dy ln ti nhng dim chu p lc b t thng do cung bn chn b chng xung Bnh TK t ng Da kh Bnh c a 1 dy TK Si bn vng khoeo bn chn r Si III hoc IV song th

49

 Mn c bt i xng ph n trn chn Bnh vng mc (Plate 6b)

H vn ng
Thng thng ch khm vn tt khp khi ang khm nhng h c quan ln cn. Nu bnh nhn c than phin c th v nhng triu chng ca khp, t th bt thng hay khp cn lu th mi khm chi tit hn.

Th trng tng qut

o Cn ghi nhn: Bnh nhn c cao hay th p qu mc khng? o chiu cao v si tay Tt c chi, c t sng v hp s c hnh dng v kch thc bnh thng khng? Ngi bnh thng: Chiu cao = si tay nh u n xng mu = xng mu n gt Chi di: Hi chng Marfan B hon trong qu trnh trng thnh Gy ct sng Si tay > chiu cao Xng mu n gt > nh u n xng mu T th c bnh thng khng? Cong vo ct sng: Gp li: tt g Dui ra: tt n lng V 1 bn: vo ct sng Dng i c bnh thng khng? Quan st bnh nhn i l 1 phn quan trng trong qu trnh khm h vn ng v h thn kinh. Dng i au, chuyn trng tm nhanh chng khi chi b au, i nhp nh ln xung nhp i bt thng Dng i khng au bt thng c th do: Chn ngn (i nhp nh vi nhng bc di nh nhau)

50

Cng khp (nng xng chu trnh ko l chn trn mt t) Yu c chn (dng i c bc cao trnh nhng ngn chn chm t) Yu u gi (gi u gi thng trc khi t chn xung t) Yu hng (xoay sang ngang s dng c thn mnh nng xng chu ln v a chn qua) Dng i khng khp (tay vung cng bn) Hysteria hoc do nguyn nhn gi bnh Tm nhng ch mn b t thng trn giy b nh nhn

Nhn
o Nhn khp trc khi chm vo o Nhn: Da - vim So thng tn c Bm thng tn gn y M mm Mn c thng tn c Sng thng tn/vim Xng D dng so snh vi bn i din Vo vo hng vo ng gia Vo ra hng ra khi ng gia o nh gi xem ch 1 khp b nh hng hay l vim a khp. o Nu l vim a khp, ghi nh n i xng hay bt i xng o So snh nhng bt thng tm thy vi bn i din Vim khp khp b sng, nng, nh y cm vi au v au Bnh khp sng nhng khng nng v nhy cm vi au Ch ng au khp au, vd: khi vn ng, khng b sng. Sng cng c th do trn d ch, s dy ln ca cc m quanh khp, s m rng ca u xng (vd: bnh xng do phi) ho c s ph hoi hon ton t chc khp nhng khng au (khp Charcot)

S
o Trc khi s n khp phi hi bnh nhn xem c au khp khng o Cm nh n:

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 S m au Nhn mt bnh nhn xem c kh ch u khng nh v biu hin au m mm hay xng Sng hay dch chuyn Dao ng (trn dch) Mt khp b vim ni chung thng au. au cc b c th do nguyn nhn c hc,vd: rch dy chng. Trn dch khp c th xy ra trong vim kh p hay thng tn ti ch.

Vn ng
Kim tra phm vi vn ng ca khp ch ng v th ng. Phi c thc hin nh nhng. o Ch ng bnh nhn c th c ng khp bao xa trong ph m vi ca n? ng gi ly chi v di chuyn n n khi no bnh nhn phn nn. o Th ng nu ph m vi h n ch, b n c th tng thm phm vi ca vn ng khng? Dng: c ng khi trc trung tm Khp: c ng vo trc trung tm Ph m vi c ng th ng c ging vi ch ng khng? S hn ch phm vi vn ng ca khp c th do au, co tht c, co cng, vim hoc s dy ln ca bao khp hay cu trc quanh khp, trn dch vo kho ng gian khp, s pht trin qua mc ca xng hay sn hoc tnh trng au khng lin quan n khp. o Cn tr v n ng yu cu bnh nhn gp khp khi bn cn tr vn ng. C bao nhiu lc c hnh thnh? o Gi tay quanh khp khi n c ng . C th cm nhn ting rt kn kt (ting rng rc). Ting rng rc thng lin quan n vim khp xng mn tnh.

Tm tt du hiu ca cc bnh ph bin

Vim khp xng mn tnh Hao mn v h hng 1 khp c th - thng l nhng khp ln Ph bin ngi gi hoc sau chn thng v khp 52

 Thng bao g m nhng khp ca chi di v bt i xng Thng t sng tht lng hoc c au nhc sau khi vn ng, au su v nhc nhi vo ban m Hch Heberden chi xng khp gian t xa Vim khp dng thp (Plate 2e)

Theo c trng: L vim a khp i xng, vim nu hot ng Bao gm khp gian t gn v khp t bn-ngn tay trn bn tay vi cc ngn tay lch xng tr Bao gm bt c khp ln no C mn do teo c khng dng n Nt thp khp b mt c dui ca khuu C th bao gm nh ng du hiu khc, vd: lch to trong hi chng Felty

Gt (Plate 2f) Theo c trng: Bt i xng Vim u tin khp t bn-ngn chn (ngn ci) bnh gt ngn chn Bao gm bt k khp no trn bn tay, thng km ht tophy do lng ng urat cnh khp

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 Ht tophy trong tai

Bnh vy nn (Plate 3a) c bit bao g m khp gian ngn xa, hng v u gi Thng km lm mng tay do vy nn cng nh tn thng da

Vim cng khp t sng au, cng ct sng Sau c nh ti v tr b lm cong C th bao g m hng v nhng kh p khc

Khm nh hng theo h thng

Trong 1 t khm i vi bnh nhn ngoi tr, hoc nhng ca nh, thng thng c yu cu khm ch 1 h c quan. Lit k trnh t khm trong u rt quan trng, nh s khng b st bt k c im ni bt no. Mi ngi c th chn mt trnh t khc nhau

54

t nhng gi sau nu thy n hu ch cho bn thn. Hc thuc lng nhng c trng chnh ny. Ti cui mi chng khm u c bn lit k nh th ny.

Khm khun mt
o Quan st da: lot gm nhm o Ph n trn khun mt: b nh Paget, hi, bnh c, chng lit Bell o Mt: thiu mu, vng da, cng nng gip, ph nim, ban vng mi mt, chng sa mi m t, lit mt, h i ch ng Horner o Ph n di khun mt: liu php steroid, bnh to cc chi, bnh Parkinson, lit nh bn thn, khi u mang tai, phnh tuyn gip

Khm mt
o Quan st: vng da, thiu mu, vng cung gic mc, sp mi mt, h i chng Horner

Sp mi mt phi trong hi chng Horner. o Khm: Kim tra xem b nh nhn c b m khng cn th n mt gi C ng c a mt Gim th lc ho c lit Song th, git cu mt/hnh nh sai nt ca th gic Trng th gic ng t : nh sng v phn x iu tit y mt: a th, M v TM, vng mc, c bit l h th gic 55

Khm c
o Nhn t pha trc v bn Tuyn gip (b o bnh nhn nut) Hch bch huyt TM c n i Cc tuyn b ch huyt Nhng ch sng khc o Nhn t pha trc Khm TM c S M cnh Nghe ting ng tuyn gip v M cnh Kim tra kh qu n c gi a khng

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Chng 3

Khm h tim mch

Khm tng qut :

Khm: - Ngn tay di trng (clubbing of fingernails) Ngn di trng lin quan n bnh vim ni tm mc nhim khun ho c bnh tim c tm. - Bn tay lnh vi mng tay mu xanh do gim ti mu, tm ngoi vi - Li nht - Kt mc thiu mu - Cc du hiu kh th, lo lng nh gi mc kh th c th khm khi ci trn, ni chuyn, ngh ngi hoc khi nm sng soi (chng kh th khi nm). - Cc u vng: - Ban vng mt (ph bin) cc mng cholesterol lng ng di da tn ti xung quanh i mt bnh thng vi tng lipid mu . - U vng (khng ph bin): + Tng cholesterolmu lng ng ti gn (Bn tay v gn Achilles) hoc cc u vng dng nt khuu tay. + Tng triglyceride mu u vng lan trn, lng ng cc u nh mu vng mng v mt dui ca c, vi mt vng sng

57

mu .

Bt mch ng mch quay :

Bt mch quay gia xng quay, vi hai ngn tay tr. Tn s mch p : Mt trn 15 giy (ngi c kinh nghim m nhanh trong 6 giy v nhn 10 ) : - Nh p tim nhanh > 100 ln / pht - Nh p tim chm < 50 ln / pht Nhp iu : - u Bin thin bnh thng vi th th : lon nhp xoang - Thng xuyn khng u nh p i, ngoi tm thu nhp i( nhim c digoxin ) Chu k Wenckebach - Bt thng khng u ngoi tm thu a dng rung nh Nghe tim kim tra, khi mch nh khng c truyn n ng mch quay. Dng sng ca mch : - Bnh thng ( 1 ) - Tng chm v bnh nguyn gp trong hp ng mch ch nng ( 2 ) - Try mch huyt p ln hn huyt p tm trng, gp trong h van M ch , ngi gi x cng ng mch hoc bnh thiu mu nng ( 3 ) - Di i hp ng mch ch va vi thiu nng lc nng ( 4 )

58

- Mch nghch thng mch yu hoc bin mt khi ht vo, gp trong vim mng ngoi tim co tht, chn p, trng thi hen ( 5 ) Th tch nht bp : - Nh - lu lng tim gim - Ln : gp trong tr CO2 cng gip S cng ca thnh mch : - ngi ln tui, mch c th cng, p mnh, nhp nhng, bt mch quay khi cho thy c x cng ng mch, thnh mch x cng song song vi s lo ha c va x ng mch gn lin vi tng huyt p tm thu Mch nghch Khi chnh lch huyt p gia HA tm thu v tm trng di 20 mmHg cho thy c s suy gim chc nng tht tri. c xc nh bng o huyt p. khng

o huyt p - Qu n bng gn gng v cht quanh hai cnh tay. Nn bnh nhn ngi vi cnh tay cao ngang mc tim. - Nh nhng bm phng bng qun n khi khng bt c mch quay. - H p su t t t ( 3-4 mm / s ).Dng ng nghe, nghe ng mch cnh tay n khi xut hin ting mch p. Huyt p tm thu: ng vi khi bt u c ting p - Pha 1 Korotkoff Huyt p tm trng : ng vi khi ting p kt thc - Pha 5 Korotkoff Dng bng qun ln vi ngi bo ( chu vi > 30 cm ) sao cho bng qun m vng > 1/2 chu vi cnh tay . Ch cc trng hp gin on m vi ting p bin mt gia tm thu. Nu huyt p v 0 m ting p cha mt, ly pha 4 Korotkoff .

59

 ngi trng thnh, ~ > 140 / 85 l khuyn co vi bnh nhn khng b tiu ng v ~ > 130 / 80 vi bnh nhn tiu ng. Bnh nhn c th lo lng khi khm ln u v huyt p c th tng gi to. Ta phi o li vo cui bui khm.

Huyt p dong (v d nh 160 / 30 mmHg) ngh n h van M ch. Huyt p kt (v d nh 95 / 80 mmHg) ngh n hp ng mch ch. Chnh lch > 20 mmHg tm thu gia 2 tay ngh n nghn ng mch, chng hn nh phnh bc tch ng mch ho c u m. Chnh lch 10 mmHg c tm th y trong 25% i tng khe mnh. Rung nh khin huyt p kh c th o c.

Huy t p tnh mch c Quan st chiu cao p lc tnh mch c (p sut tnh mch c JVP ).

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 bnh nhn nm, ngh ngi vi t th chch khong 45 vi mt ngang vi u t trn gi, v chiu sng v mt c. Quan st tnh mch c. - Tnh mch cnh trong khng quan st trc tip : mch khuch tn, gia hay su c c n - chm - Tnh mch cnh ngoi : cnh b c c n - chm. Ch c thng tin nu mch p ( Ngh a l bnh nhn m tt mch cnh th ngm) nh gi khi ng thng vi cm trn gc cn c, khi tnh mch cnh ngoi p hoc vng c mch p khu tr c.

Tnh mch cnh ngoi thng d dng nhn th y hn nhng c th c che khut bi t chc xung quanh, v t ng tin cy

61

hn so vi xung ni b thuc c.

Tnh mch cnh trong i khi rt kh nhn bit. Nhp p ca n c th nh m ln vi ng mch cnh chung nhng n : - C nhp p phc tp - Thay i theo h hp v gim khi c p lc t ngoi tc ng vo. - Khng th bt c mch - C th b mt hon ton do p lc c s ca c Phn hi gan tnh mch c c khm do p lc vng chc ca bn ph i ln gan, ng thi theo di JVP. Tng p lc trn tnh mch gan JVP b ng 2 cm. Nu JVP ni trn gc cn c v p, ngh n suy tim phi. Tm kim du hiu kia, ngha l c ph v gan to. i khi JVP ln nhng c th b b tai lc lc(chng hiu ngha l g na ). Tnh mch c ni nhng khng p chng t khng c s cn tr ti tim (chng hn nh ung th biu m ph qun gy ra cn tr tnh mch ch trn ho c tht nt tnh mch cnh ngoi). qua, ngoi tr tay

62

Nu tng p lc tnh mch khi ht vo (n thng gim), vim mng ngoi tim co tht ho c trn dch mng ngoi tim gy ra chn p tim ph i c xem xt. Quan st c tnh ca JVP.C gng bit chc dng sng ca JVP. N s l s rung ng gp i bao gm : - Sng a : tm nh co kt thc ng thi vi ng mch cnh p gy ra nh c - Sng v : tm nh c y - khi van ba l ng lc tht co ch sau nhp p ca ng mch cnh. Sng a ln gy ra do s cn tr bt ngun tm nh phi do s cn tr khi tm tht i : Tng p ng mch phi hp ng mch phi hp l van ba l Vng mt sng a trong rung nh. Sng v ln gy ra do tro ngc mu qua im yu ca van ba l th th t thu. Dc y ng xy ra trong vim mng ngoi tim co tht. Sng i bc (sng khng l) xy ra trong block nh - tht hon ton khi tm nh phi thnh thong co mnh chng li s ng van ba l. t

ph i ph

Vng trc tim

Kim tra vng trc tim khi c nhp p bt thng. Tm tht tri ln c th d dng c thy ngc tri, i khi trong Bt nhp mm tim - im ngoi nht v di nht m s cn thy tim p Xc nh v tr 63 nch.

- Khong lin sn, m ngc t KLS hai nm bn di xng sn th hai ( i din gc cn c). - Ngang tng xng - ti - mt t ng gia. - M t mm tim so vi ng gia n, ng nch trc v ng nch gia. V tr bnh thng ca mm tim khoang gian sn V tri trn n gia n. nh gi tnh cht Hy c gng nh gi nu tim gin n l - y u ( gin ) hoc - mnh hn b nh thng ( ph i tm tht tri hay phi hoc c hai ) y lch mm tim xy ra vi qu ti khi lng : ch ng, th tch nht bp ln, chng hn nh suy van hai l hoc h van M ch, shunt tri - phi hoc bnh tim. Mm tim p lin hi xy ra vi tng p lc trong h p ng mch ch v tng huyt p nng . Th tch tng mu l bnh thng hoc gim. Mm tim p mnh (C th s thy ting tim p u tin) xy ra trong hp van hai l.

Nhp p khuch tn khng ng b vi ting p mm tim xy ra vi phnh mch tim tri mm tim lon ng. 64

Khng s c - bo ph, ngc qu cng v COPD, trn d ch mng ngoi tim. S b tri ca xng c. - S dng lng bn tay bn. Nu mm tim p mnh cho thy ph i tht phi. S vng trc tim vi lng bn tay kim tra rung miu ( ting thi r c th s c ).

N.B. Nu by gi bn tm c bt thng trong h tim mch, hy ngh n nguyn nhn c th trc khi nghe. Chng hn nh, nu tm tht tri l ch yu : -? Huyt p cao - l huyt p ( BP ) nng cao? -? Hp ng mch ch hoc thiu nng - l tnh cht mch bnh thng? Liu s c ting thi? -? H van hai l - Liu s c ting thi? -? Cng gip hoc thiu mu.

65

 Nghe tim Nghe qua bn v tr ch yu ca tim v trong mi vng tp trung nghe : - ting tim p - ting p ph - ting thi Gi th t ny khi nghe hoc m t nhng g bn nghe, nu khng bn s l ho c qun pht hin quan trng. Bn v tr ch yu l : - nh, van hai l ( v nch nu c ting thi ) - van ba l - van ng mch ch ( v c nu c ting thi ) - van ng mch phi

Nhng ny i din cho ni nghe ting tim p v ting thi lin quan n nhng van. Chng khng i din cho im xut chiu b mt ca van. Nu bn nghe nh, bnh nhn nghing sang tri, v nghe mm tim ( c bt mch khi nghe ). Mn chn (ca ng n ghe) lc ra m thanh tn s thp, cho nn chung (ca ng nghe) nn c dng trong trng hp hp van hai l. Bn s thy hu ch khi c bt chc nhng g bn ngh rng bn nghe c! 66

Ting tim bnh thng I. Ting p t ngt do dng chy qua ba l van hai l khi ng van. - anh trong hp van hai l - m trong h van hai l, hp ng mch ch, block nhnh tri - thay i trong block nh - tht hon ton v rung nh II. Ting p t ngt do dng chy qua van ng mch ch v phi v ng van thng tch ( xem pha di ) - anh trong tng huyt p - m trong hp ng mch ch hoc phi - rng b nh thng tch i block nhnh phi - rng c nh tch i khuyt tt vch lin nh

Ting tim khc III. Ting tim khi lm y tht nhanh trong u k tm trng. Thng bnh thng cho n khong 30 nm, sau c th ngh n do suy tim, x ha tm tht ho c vim mng ngoi tim co tht. IV Co tht tm nh lm y tm tht vo cui k tm trng.

67

C th l bnh thng ngi di 20 tui v vn ng vin, nhng n cho thy c s tng gnh tm nh. Khng tin lng nghim trng bng ting tim p th ba. Nhp nga phi (thng gi l phi nc i) vi mch p nhanh cho nhp sau : III: Tumtetum or Kentucky (k = Ting tim u tin)

IV: teTumte or Tennessee (n = Ting tim u tin)

M t xut - Van hai l bnh thng m ra lng l sau ting tim p th hai. - Trong hp van hai l, c ng t ngt ca van cng gy ting clic, sau ting tim p th hai (hnh3.1 ).

Ting clic tng mu - Van ng mch ch b nh thng m ra lng l. - Trong hp ng mch ch ho c x ho, c th c ting clic sau ting tim p u tin.

Ting th hai tch i Yu cu bnh nhn ht th su. Mu c ht v ngc trong th ht vo ri vo n tht ph i. Tm thi tht phi nhiu mu hn tht tri, v tht phi cn thi gian di hn rng. Ting tch i c nghe r nht trong hai hoc ba nhp th u tin. Khng c bt bnh nhn th vo hay ra mun nghe ting tch i. Ting tch i ngc xy ra trong hp ng mch ch v block nhnh tri. c hai iu kin ny (hnh3.2 ) tht tri mt nhiu thi gian hn rng, do tr hon a2 cho n sau p2. Trong th ht vo p2 xy ra sau v m thanh n gn k nhau.

Ting th thm S dng mn chn ca ng nghe cho hu ht m cao hoc ting th thm (nh h van M ch ) v chung cho ting thi nh (nh hp van hai l ). Lu nhng iu sau y: Chn thi im tm thu hoc tm trng (bng bt mch ng mch cnh ) (Hnh3.1 ). V tr v hng lan, chng hn nh : 68

- h van hai l lan ln nch - h p ng mch ch ng mch cnh - h van M ch d c xng c

Hnh 1 : Quan h gia ting thi vi huyt p v s vn ng van 69

Hnh 2 : Ting tch i bnh thng v o nghch c tnh - anh hay m - m , chng hn nh ku cht cht hoc ku rm rm, c = mng tim hoc mng phi - trng - thi pht ngc tm thu, ton tm thu - sm tm trng, nh h van ng mch ch hoc h van ng mch ch - gia tm thu, nh hp ng mch ch hoc lung ting thi - gia tm trng, nh hp van hai l Thay i theo t th - ng v pha trc nghe r h n trong h van M ch - n m nghing bn tri nghe r h n trong hp van hai l Quan h vi nhp th - ht vo gia tng ting thi c ngun gc tim phi - th ra gia tng ting thi c ngun gc tim tri - thay i c mng ngoi tim

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 Quan h vi hot ng gng sc - gia tng ting thi ca hp van hai l

V tr ti u cho nghe ting thi (hnh3.3 ) hp van hai l- b nh nhn nm nghing bn tri, cnh tay t trn u ; nghe vi chung mm. Ting thi tng sau vn ng, chng hn nh lp li cm ng ca ngn chn t th nm gia tng lu lng ca tim. h van M ch - b nh nhn ngi v pha trc sau khi hit vo su; nghe vi mn ch n b di cnh c tri.

N. B.Ting thi n thun khng chn on. Kt hp cc triu chng khc xem xt, chng hn nh bt mch hoc nhp p tnh mch, huyt p, khm mm tim ho c ting tim p. Cng thng khng tng xng vi mc trm trng ca bnh, v trong mt hai l. vi tnh hung no di ting thi quan trng hn, chng hn nh hp van

Hon thnh : - nghe y phi : ting ran t tht suy tim tri - mch ngoi vi (bt mch v lng nghe chm ch) - s gan nhn , mm, to trong suy tim phi

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- ph ngoi vi - mt c chn / xng cng

Hnh 3. Hng lan ca nhng dng mu bt thng 72

Tm tt thi gian ca ting thi

S tng ra ting thi tm thu hp ng mch ch hoc x ho ( ting thi ging nhau, do x cng ca l van v thnh ng mch ch, vi huyt p bnh thng ) x va ng mch ch trong 50% nhng ngi trn 50 tui hp ng mch phi khuyt tt vch lin nh T chng Fallot cn tr ng ra ca tim phi

Ting thi ton th tm thu H van hai l H van ba l Khuyt tt vch lin tht Ting thi tm thu mun sa van hai l (clic m van) bnh c tim ph i hp eo ng mch ch (m rng trong tm trng n ting thi my mc ) Ting thi tm trng sm H van ng mch ch H van ng mch phi Ting thi Graham Steell trong cao p ng mch phi ( xem p. 70 ) Ting thi tm trng gia cui Hp van 2 l Hp van 3 l Ting rng Austin Flint trong h van M ch ( xem p. 69 ) u nhy nh tri ( thay i - cng c th cho ting thi khc )

Du hiu ca suy tim tri v phi Suy tim tri - Ch ng kh th. - Ting ran phi. 73

- ting T4, ho c T3 vi bnh nhn gi. bnh nhn n gi v pha trc v nghe ti nn ca phi vi mn chn ca ng nghe cho ting ran n. Ting ran n gy ra do m ph nang khi ht vo. Khi bnh nhn nm nghing trong thi gian ngn, ph nang c xp trong phi bnh thng. Khi ht th t su ting ran s c nghe nhng khng c ngha l ph phi cp. Yu cu bnh nhn ho. Nu ting ran vn cn sau ng tc, ph phi c th gp .

Suy tim phi - Tng JVP. - Gan to mm ( xem sau ). - Ph n lm. bnh nhn ngi chm v pha trc, khm ph vng xng cng. Nu c, y ngn tay ci ca bn vo ch sng v xem khi bn ri ngn tay c y li khng. Nu c, g i ph mm. Kim tra c mt c chn cho ph. Ph ( dch ) t li t cc phn ca c th. Bnh nhn hu ht ang ngi s c ph mt c trong khi bnh nhn ang ni di s c ph vng xng cng l ch yu.

Kt qu thit thc Bit c nhng bnh l c bn (nhi mu c tim, hp ng mch ch, bnh vim mng ngoi tim), lm nh gi ca kt qu thit thc. - Bnh s. Bnh nhn c th i b bao xa, v.v? - Khm. Bng chng : - b nh tim to (gin hoc dy) - suy tim - lon nhp tim - cao p ng mch phi - chng xanh tm - vim mng trong tim - iu tra. V d nh : 74

- chp X - quang ngc - in tm ( ECG ) - in tim gng sc cho thiu mu cc b - my siu m tim - sonar ' ra - a ' tim, cho c v kch thc tht, tnh phn s co c v phn s tng mu, chc nng van - ECG 24 gi cho lon nhp tim - thng tim cho cc php o p lc, s oxy ho mu v chp X - quang - phng x qut - hnh nh sng, thiu mu hoc hoi t c tim

Tm tt cn bnh thng gp

Hp van hai l - mch yu rung nh ? - JVP tng cao nu suy tim - Mm tim p mnh - T1 anh. T2 anh nu cao p M phi - clac m van 2 l - Ting thi gia tm trng ti mm ( rng tm trng ) - mc trm trng c th hin ting clac 2 l sm v ting thi ko di - tt nht nghe tim bnh nhn bn tri, th th vo vi chung, c bit sau vn ng lm ting thi ca tim r - ting thi tin tm thu ( vng mt nu rung nh v van x cng ) - m thanh ' ta ta rooofoo T ' t ting clac n ting thi tm thu

H van hai l - rung nh? - JVP ch nng cao nu suy tim - rung tm thu - T1 m. T2 anh tch i trong cao p M phi - ting thi tm thu t mm tim lan ra nch

75

Sa van hai l - clic m van gia tm thu , ting thi cui tm thu - sa l sau ting thi t mm tim lan ra nch - sa l trc ting thi t mm lan dc ng mch ch C ba giai on :

76

Hp van ng mch ch - Mch nhanh huyt p kt - JVP ch tng cao nu suy tim - thi mnh tm thu - T2 m tch i ( click tng mu ) - T1 th rp, mm v y tim, lan theo ng mch cnh - ch s khc bit ca mm tim p mnh vi mch p yu - ting thi di hn, mnh hn. ln khng i i vi mc nng ca bnh H van M ch - try mch huyt p dong. ng mch cnh p - JVP ch nng cao nu suy tim - dn cc bung tim - ( click tng mu ) - ting thi sm tm trng t y lan xung phn di xng c (ging nh ting thi ca s tng th m lung chy) - ( i khi ting thi Austin Flint - xem pha di ) - nghe r nh t vi bnh nhn chm v pha trc, trong th th ra - ting thi di hn , n ng hn hp van M ch

H van ba l - JVP ln sng V - khng c ting rng - ting thi m th tm thu ti van ba l - tng ln khi ht vo

Ting thi Austin Flint - gia ting thi tm trng (nh hp van hai l) trong h van M ch v s pht ngc dng mu ln l trc van hai l

77

Ting thi Graham Steell - ting thi u k tm trng ( h van ng mch phi c nng ) trong hp van hai l hay cc nguyn nhn ca cao p ng mch phi

Thng lin nh - JVP ch nng cao nu suy hoc h van ba l - RV + + LVo - Ting T2 tch i - ting thi tm thu phi( ting thi tm trng ba l )

Thng lin tht - RV + LV + - ting thi ton tm thu vo b xng c tri ( ln nu l thng nh ! )

Cn ng ng mch - tm thu tm trng ' my mc ' hoc ting thi lin tc di xng n tri

Van nhn to kim loi - ting lch cch inh i vi ting thi ngn - van ng mch ch tm thu - van hai l tm trng - cn chng ng

Van nhn to sinh hc - nh ln ghp d chng hoc ngi ghp cng loi - c x sau 7-10 nm, dn n hp v suy - c th khng i hi chng ng

C mng tim - lo xo, ting n nh nghe trong tm thu v tm trng - lan ra bi p lc ng nghe, v i khi thay i theo nhp th

78

Vim ni mc tim nhim khun ( ch n on bng cy mu ) - st, mt mi, thiu mu - ngn di trng - mng xu t huyt - n t Osler - ting thi tim - ph i lch - i mu

St thp khp - au khp c tnh ch t di chuyn - n t ban nt ban ri rc - mch p nhanh - ting thi - Ch ng ma git - Sydenham ( khng u, phn x git khng kim sot c ca chi, li )

Chn on bng nhn - Hi chng Down vi 3 nhim sc th 21 - thng lin th t - cn ng ng mch - cng gip - rung nh - ph nim t suy gip - bnh c tim - sm, xung huyt khun mt chn p tnh mch ch trn - m vng di mt vi v mt van hai l t hp van hai l

Chn on chung - Hi chng Turner t nhim sc th gii tnh X0 - n , tm vc thp b, c ngn - h p ng mch ch - Hi chng Marfan - b nh nhn cao vi ngn tay di,mng - h i lu ng mch ch 79

ng mch ngoi vi

Cm thy tt c mch ngoi vi (hnh3.4 ). Mch chi di thng c kim tra sau khi khm bng. Gim hoc mt mch ngh n hp hoc tc ng mch. Mch chi di cn c bit quan tm nu c tin s chng khp khing cch hi Thnh chn ng mch cnh v mch i hu ch nu c nghi ng ng ny b hp. Nu hp th ting nghe c lung thay i bt thng. Hp ng mch ch tr hon mch i sau ng mch quay. mch

Bnh mch mu ngoi vi - i mu trng hoc xanh - lot vi c m ang ln da non km v chm lnh - bng da, rng tc, mng tay dy lo n dng - mt mch - Test Buerger nh gi mc trm trng c a suy ng mch - mt s t iu chnh ca dng mu - b nh nhn nm t hot ng, nng chn ln n 45 - tch cc kim tra : xanh xao ca chn ; h thng tnh mch - treo chn bn ging : lu th i gian mao mch v tnh mch y ; huyt phn ng ; chng xanh tm tip theo sung

Tiu ng, khi c mt, cng i cng triu chng ri lon thn kinh : - da kh vi biu b dy - chai chn nhng phn gia tng p lc bt thng, chng hn nh gia chn di xng c chn , tip n ri lon thn kinh vn ng v thay i phn b trng lng - mt phn x gn gt - gim cm gic

80

Hnh 3.4 Cc v tr bt mch 81

Phnh ng mch ch - nhp p r rng ho c c th cm nhn gia bng - cn phn bit vi bnh thng, ng mch ch p r trong ng gia nhng ngi gy - phnh ng mch ch l c th pht trin sang mi bn cng nh ra trc - ting p c th nghe r - lin quan n phnh mch i v vng kheo

Gin tnh mch Gin tnh mch v thot v ( xem p. 95 ) c khm khi bnh nhn ang ng, c th vo cui cuc khm trong khi khm dng i ( xem p. 45 ). a s gn lin vi yu van tnh mch hin trong ho c ngoi . Tnh mch hin trong (di) - t tnh mch i trong n gia bn cng chn.

Tnh mch hin ngoi (ngn)- t h khoeo n sau bp chn v mt c ngoi.

Quan st : - sng ln - sc t - chm - vim - gi vim huyt khi tnh mch cho bit suy tnh mch mn tnh

Bt mch : - mm hay cng ( nghn ) - mm - vim huyt khi tnh mch - ho ny xung - hm van yu Van yu c th c xc nhn bng du hiu Trendelenburg : - Nng cao chn tnh mch rng. - vi ga - r quanh i trn. - cho bnh nhn ng ln. - Nu tnh mch y nhanh chng, iu ny cho bit c im yu bn di ga r. 82

- Nu, sau khi m ga - r, tnh mch y nhanh chng, iu ny cho bit c im yu ch ca tnh mch i nng vo i su . Nu tnh mch lp ngay lp tc khi ng th van yu i hay b p chn, test Perthes cng vy : - cng nh Trendelenburg, nhng khi ng cho mt lng mu vo tnh mch bng ch n tm thi tnh mch. - Yu cu bnh nhn i ti i lui trn ngn chn. - Tnh mch tr nn gin to nu : - ti mu c tha ng - van tnh mch su b tc hoc cn tr

Hng kim tra h thng ' Khm h tim mch ' tay - mng xu t huyt nh p p xuyn tm, nh p iu, dng sng, bin , tnh trng ng mch dng sng v bin kim tra ti cnh tay hoc ng mch cnh ' Ti thng o huyt p by gi ; bn c mun ti lm nh th? mt - thiu mu li - xanh tm trung ng JVP - chiu cao, dng sng mm tim p - v tr, tnh ch t thnh chun - mm ( vi ngn tay ci trn ng mch cnh chn thi im ) - ting tim p - ting ph - ting thi - trong c trn ng mch cnh - mi vng trc tim vi mn ch n - h ng mch ch - chm v pha trc th ra ht c vi mn ch n - h p van hai l - nm nghing bn tri v nghe mm vi chung ' By gi, ti nghe thy y phi 2 bn c ran m, khm tm gan to, ph ngoi vi v mch ngoi vi. Bn thch ti lm nh v y ch?

83

CHNG 4:KHM NGC

KHM T NG QUT Khm bnh nhn : ng cui ging quan st cc du hiu suy h h p-s dng c h hp ph,th oxy,m di. Du lng ng Nicotin trn ngn tay( ngi nghin thuc l) Chi di trng: nguyn nhn do bnh v h hp gm: ung th biu m ph qun, u trung biu m, gin ph qu n, p xe ph i, m mng phi, u x ph nang. Bng chng ca suy h hp: +Tnh trng thiu oxy : tm trung tm. +Tng CO2 huyt: bun ng, l ln, ph gai th, tay m , mch ny, cc tnh mch gin n, ting rung/p th. Tn s h h p: s nhp/pht. Kiu th: Cheyne-Stokes: + S xen k gia tng thng kh v ngng th, tng p lc ni s nghim trng, suy tht tri, sng vng cao. Bnh tc nghn ng h hp: +Th mm mi: th ra km theo h mi, tc nghn mn tnh ng h hp lm tr hon vic ng ph qun . +S dng c h hp ph:c c n chm, c bm da c, c thang. +Th kh kh. +Th rt: do tc nghn mt phn hay ton b ng dn kh. +Ting khn: do bt thng dy thanh m hoc lit thanh qun ti pht.

u tin kim tra mt trc ca ngc y , tng t kim tra mt sau ca ngc.
KHM NGC Bnh nhn nm th gin trn ging, u cao 45 .

+Tnh mch c ni, mt v tay xanh-ph, chn p trung tht nng. Kim tra hnh dng ca ng c: +Lng ngc khng i xng: xp mt bn (do xp phi, x ha) +Bin dng: kim tra ct sng ( vo,g).

84

nh: vo ct sng(scoliosis) +Ln ngc: lm xng c. Bnh t c nghn ng h h p:

nh: g ct sng(kyphosis)

+Lng ngc h nh thng: co rt mng sn vng thp khi ht su. Quan st sn thanh qu n gn hm c. Ngc khng di ng trong th ht vo.

S NN Kim tra v tr trung tht Kh qun- kim tra v tr: r b ng m t ngn tay duy nht ng gi a v xc nh s trt c a kh qun lch v m t bn.

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Cc hch bch huyt, h thng n/nch- bnh lao, lymphoma, ung th ph qu n. Mm p c th thay i (di di) do din tim ln v khng c s di lch trung tht. S chuyn ng khng cn bng ca ngc. Nhn t cui ging. Phng php s c in:

+M rng nhng ngn tay v t xa ngang xung quanh thnh ngc, hai ngn ci m rng v gp nhau ng gia. +Trong th ht vo, nh gi s di chuyn bt i xng ca hai ngn ci hai bn so vi ng gia. Thay th phng php s c in: -t mt bn tay thoi mi ln mt bn thnh ngc v s dng bn tay nh mt thc o trong vic nh gi s gim di chuyn mt bn ngc trong sut th ht vo. N.B. S gim di chuyn mt bn ng c cho ta bit ngc bn c bnh l. G -Dng ngn gia ca mt tay g vung gc vo t ngn gia ca ngn gia tay bn kia c t bng phng trn ngc, ngn tay nn g vo nhng gc bn phi. -G c hai bn ngc nghe m thanh di li,g phn trn-gia v nhng vng thp ca ngc.So snh hai bn,n u c s khc bit th c th so snh mt trc v mt sau ngc. -Nu tn ti vng c th cn g xc nh gii hn t vng g vang n vng g c. -G t trn xung di xc nh gii hn ca c honh. + Ting g vang tng c th xy ra trong trng hp: trn kh mng phi (pneumothorax), kh ph thng (emphysema). + Ting g vang gim c th xy ra trong trng hp: trn dch (ting g rt c,i khi c hon ton), phi rn (ng c phi, xp phi, p xe phi, khi u). Lun ghi nh cc d u hiu trn b mt phi khi g, thy di phi ch yu l pha sau, cn thy trn ch yu pha trc (nh 4.1).

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nh 4.1:G tm c honh t trn xung di, nhng du hiu ny xut hin u trong k th ra. Trong iu kin kim tra b nh thng, vng c ca gan m rng n sn sn th 5.

NGHE -Trc khi nghe, yu cu bnh nhn ho khc m, iu ny c th gy m thanh lm ta nhm ln khi nghe -S dng phn chung ca ng nghe nghe phn trn- gia- di hai bn ngc, sau l nch. -Yu cu bnh nhn ht th su va phi bng ming, iu ny gip vic nghe ca bn c chnh xc hn. -Vic s dng phn mng ca ng nghe s km hiu qu nu bnh nhn m, xng sn nh hay c nhiu lng ngc. - Lng nghe m thanh hi th ( r ro ph nang), so snh hai bn vi nhau.(hnh 4.2). +Ph nang: m thanh bnh thng (inspiration:ht vo; expiration: th ra):

+ Ph qun: m thanh do ph qun to ra + m thanh ca m:

. + m thanh nghe c tng t nh m thanh nghe c trn kh qun (thng l vim phi) : khi u, x ha, p xe. Nhng khng phi do xp phi, trn dch(ngoi tr trng hp him-xy ra trn b mt phi) +m thanh gim i: cho ta bit hoc khng c s chuyn ng ca khng kh(v d nh tc nghn ph qun) hoc do khng kh hay cht lng ngn s dn truyn m thanh.Gp trong: trn dch mng phi, trn kh mng phi, kh ph thng, xp phi.

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- Lng nghe m thanh i km, lu nu trong th ht o ho c th ra c: + Ting c mng phi: gy ra bi vim mng phi(do nhim trng hoc nhi mu phi), nhng phi chc chn rng m thanh ny khng phi do s ma st ca da ho c lng ln ng nghe.. + Ting ran ngy hoc ting th kh kh : do hp ng dn kh gy ra ting ran ng ( ti a trong th th ra). + Ting ran, ting lp bp hoc ran n: Nghe r: do suy tim hoc vim ph nang. Nghe va : do nhim trng. Ch thch: Stridor: ting kh kh Coarse rales: ting ran th Rhonchi: ting ran ngy Fine rales: ting ran nghe thy r

TRN DCH V d: Dch thm, dch tit, Mu

NG C V d: Vim phi thy

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XP PHI V d : Tc ph qun do nt m Ung th PQ

TRN KH MNG PHI

NH 4.2-PHN NGHE Nhng bt kh kh xc vo ph n cht dch trong ph qun ln hn,v d nh l gin ph qu n. Nu ho xong thy th nguyn nhn cho thy l do ph qun.

Khm rung thanh Ph n ny c khc so vi cch khm trong sch N i khoa Yu cu bnh nhn lp li t 99(ting Anh) trong khi nghe ngc trong cng mt khu vc thch ch n. m thanh nghe c s ln hn khi nghe vng ng c. So snh m thanh nghe c hai bn vi nhau. Ti b mt c a khu vc c trn dch, t 99(pht m theo ting Anh) s c pht m ra nghe nh ting ku be be ca con d, cn c gi l m vang (aegophony). Nu m thanh pht ra ln, ting ngc thm c th nghe c khi yu cu bnh nhn th thm 1,2,3,4.

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N.B. Rung thanh, ting th v ting m vang tt c u ph thuc vo tiu chun ging v khc nhau vi nhau. - xc nh r hn cn tip tc kim tra cc du hiu: ngc chuyn ng khng i xng, s di lch ca trung tht, ting g thnh ngc. M Kim tra m tuy kh chu nhng li rt quan trng . Tm: - S lng (tng nhiu trong gin ph qun). - S ng nht (nu tt c l dch nhy th c th l nc bt). - Mu sc (nu vng hoc xanh th c th l do nhim trng). - Mu (ung th, lao, vt lm tc mch). L tng nht l m nn c kim tra di knh hin vi:vi khun, m t bo, bch cu i toan, amiang, m nt .

CHC NNG KT QU. Lm mt nh gi chc nng kt qu :

-Tin s. Bnh nhn i b ti a c bao xa. -Kim tra: +PO2 gim: ri lon tm trung tm. + PCO2 tng: Du hiu ngoi vi: vng ngoi vi m, gin tnh mch, mch ny, v rung.Du hiu trung tm: bun ng, ph gai th , co ng t . +Kim tra kh mu ng mch. -Kim tra (thng l bnh tc nghn ng h hp): +Ti ging bnh: cho bnh nhn h hi thi khong 15 cm t ming, vi ming m rng d dng min th lu lng nh trn 80 l/pht (bnh thng l 300-500 l/pht). +Thi gian th ra: nh gi tc nghn ng h hp c th c thc hin bng cch tnh thi gian ton th th ra thng qua vic xem ming m rng sau mt hi th su.Bnh thng th nh hn 2 giy. +Ng c m rng: m rng hn 5 cm t ton th ht vo n ton th th ra. Bin n y s gim nu cng phng lng ngc qu mc do tc nghn ng h hp mn tnh. +Lu lng nh: mt bin php o lng trong tc nghn ng h hp-l tc nh ca dng khng kh ra khi phi, c o bng my.Ga tr bnh thng l 300-500 l/pht.

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TM TT CC CHNG BNH THNG THNG HEN SUYN Bnh nhn au kh, th nhanh, kh ni chuyn. Ting kh kh nghe th y r trong th th ra hoc nghe bng ng nghe. Lng ngc phnh to vi ting vang ln. Nu trung tm tm ti: bnh trm trng hoc thng kh nhn to? Mch nghch( c th l bnh thng gia cc t pht bnh). Thng l do d ng: +Kim tra khng nguyn tip xc. +Con mt trong bi nh. +Mo hay ch. BNH PHI TC NGHN MN TNH -Lng ngc h nh thng. -S dng c h hp ph. -m thanh di li ln. -Suy yu c honh- co ko b sn thp hn trong th ht vo. -m thanh hi th gim: Th tm +Tm trung tm. +C d u hiu lu gi CO2. +Khng c kh th. +Ph mt c chn: c th c hoc khng c suy tim phi. Th hng +Khng tm. +Khng lu gi CO2. +Gy +Kh th . +Khng ph. GIN PH QUN -Ngn tay di trng -m xanh/vng lin tc. -Rale th trn khu vc b nh hng.

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NH HNG KIM TRA H THNG Kim tra h thng h hp Tay: ngn tay di trng, du hiu tng CO2( tay m, mch ny, run th) Li: tm trung tm Hch thng n Kim tra: hnh dng lng ngc, tc h hp/suy, s chuyn ng ca ngc. S: dng tay s kim tra xem c s chuyn ng bt i xng ca hai bn thnh ngc hay khng. G: vng trn(LR), gia(LR), di(LR). Nghe: m thanh hi th, m thanh khc (ting lp bp, co tht ph qun, c mng phi, ting kh kh, rung thanh) Nu tc nghn ng h hp: kh o st thi gian th ra( cp pha trn).

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CHNG V : KHM BNG

I. NHN TON THN : Tm cc du hiu : - Bnh gan mn tnh :

Mng tay khum Mng trng Bn tay son Gin mao mch mt Vng da (Hnh Ie) Sao mch (Hnh If) :

Sao mch : tp hp cc mao mch cp mu bi 1 ng mch chnh. - N ha tuyn v - Lm dng ru : - Co c kiu Dupuytren - To tuyn mang tai - Teo tinh hon
-

Suy gan :
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- Du hiu chim v cnh

- Hi th nh xc cht - L ln Cc triu chng ca bnh gan mn thng r rng tuy nhin ph n mang thai vic c ti 6 sao mch c th c coi l bnh thng.

Thiu mu - Quan st kt mc, li . - Thiu st :

-

Mng tay hnh mung ( Hnh 2d) Li nht

- Vim gc ming c th bt ngun t vic dng rng gi hoc tnh trng mt rng

Thiu B12 hoc Folate :

Li nht hoc vim teo li

Nhn mi :
Ti, nht - khm kt mc tm thiu mu Nt tn nhang Hi chng Peutz Jeghers Polyp rut non c th gy chy mu, lng rut hoc tr thnh c tnh. Gin mao mch Hi chng Osler Weber Rendu gin mch mu d dy rut gy chy mu. Li kh mt nc hoc th ming Nu bnh nhn c biu hin mt nc, vo np da c. Khi b mt nc v tui gi , da vn gi np. Tm trung ng trong bnh gan mn tnh , Shunt ng-tnh mch phi. Nhim Candida li , cc mng trng vm ming Vim li Lot : - Bnh Crohn , vim lot i trng. - Mng lot trng trong bnh i trng . Rng

Nhn ming :
-

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- Hi th - mi ceton, ethanol ; hi th hi v i mu

Tm hch thng n sau khp c n tri :

Hch cng cm nhn sau khp c n tri c th l Hch Virchow v gi 1 khi ung th trong bng di cn qua ng bch huyt qua ng ngc.

II.

NHN VNG BNG :

t bnh nhn nm nga

(dng 1 gi k u) 2 tay dc thn ngi.

Bc l vng bng t b di sn ti bn

Khi thi ,vic ng t xa quan st v ng bng s gy n tng vi ngi coi thi rng bn ang nhn trc khi s bng. Nhn :
Da Cc vn, sc : mu hng trong Hi chng Cushing Lng Cc u, cc , hch So m Chng - trung tm hay 2 bn mn sn - i xng hay bt i xng. C th do : - Hi - Phn - C thai - M -Dch (c chng, u nang bung trng) - C ng : theo h hp - Nhu ng rut : c th quan st ngi gy - p - Thot v - Tun hon bng h - S lu thng dng mu tnh mch : - Vng pha trn : do chn p tnh mch ch trn - Vng pha di: do chn p tnh mch ch di - Vng xung quanh rn : do tng p lc tnh mch ca Nhng pht hin c m t trn da theo s sau :

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Hnh 5.1. Nghim php William Harvey kim tra s y tnh mch.

III. S BNG :

S vng bn

pht hin hch to (Nu bn khng thc hin ngay, bn c th qun khng lm sau ). Phn ln mi ngi c hch nh v trn, chc. a s cc hch sng to v au bt ngun t 1 nhim trng chn v bn chn. Nu hch to hy s lch 1 cch cn thn c th do ung th lympho hoc leukemia.

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 Trc khi s bng :

-

Hi : Bng bc c au ch no khng? Hy ni nu bc thy au.

Lm m 2 tay , bnh nhn nm nga.

S nng cc phn khu vng bng trc, trnh cc v tr

au v nhy cm. p c b n tay ln vng bng v cm nhn bng cc ngn tay. S nh nhng.

Quan st sc mt bnh nhn xem bnh nhn c cm thy au

khi bn s bng hay khng.

S su. Nu khng c du hiu au hy s su hn theo cch thc tng t.

au c th nng, su hoc au ny ln. Cm ng phc mc do s di chuyn ca l tng phc mc b vim so

vi l thnh. u tin g1 cch nh nhng sau g mnh dn. Nu bnh nhn khng au, n su sau rt tay ra t ngt. Phn ng thnh bng c th cm nhn c khi s bng. y l s co cng ca cc c thnh bng bo v tng b tn thng.

Co cng thnh bng C thnh bng co cng khng t ch xy ra

trong vim phc mc ton th.

IV. S CC TNG TRONG BNG : GAN :

S gan : cc ngn tay gp ti khp bn ngn, s dng b ngn tr s theo

hng song song vi gan trong khi bnh nhn th u v su. Bt u s t v tr di b sn 10 cm sau s dn ln pha xng sn.

M t v tr ca b di gan cch b di sn my cm trn

Mt B t hay sc C au hay khng ? p (trong trng hp h van 3 l ) G xc nh gii hn trn v di ca gan sau khi s xc nh li cc

ng gia n. Cm nhn b mt khi gan to cng nh b gan.

pht hin va lm. Nu khng s thy gan v g c vng h sn phi th gan c th to ti vng h v ! Do vy phi s thp hn xung pha di. Nu gan to th cn m t :

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Nu gan to lu s lch . LCH :

sn.

Tng t nh i vi gan, s t di b sn 10 cm ri s dn ln n xng

v.

Dn bnh nhn ht su y lch xung c th s c lch.

Nu khng s thy lch th g xc nh din c ca lch lch to c th ti h

Trong trng hp nghi ng lch to t c th bo bnh nhn nm nghing sang phi, tay tri nng cao v hi a ra trc v s li khm lch khi bnh nhn ht su.

Kim tra cc c im ca lch :

V tr Hnh dng ( c s thy kha hay khng ?) Khng vt qu b sn Di ng theo h hp G c

M t nh i vi gan :

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THN : S bng c 2 tay y tay tri ra trc h thn v dng tay phi cm nhn thn p ra ng

trc

Bo bnh nhn ht su y thn xung gia 2 tay

au thn xy ra khi c vim nhim. Thn to c th do c khi u thn, thn a nang hoc thn nc.

CC KHI TRONG BNG : S 1 cch cn thn tt c cc v ng ca bng.

Nu pht hin thy 1 khi trong bng cn m t :

V tr Kch thc Hnh dng chc (Phn c th b nt do p sut) C nh hay di ng Khi c di ng theo h hp khng ? C au hay khng ? C p hay khng p theo nhp ca ng mch ch hoc 1 p khc G c Quan trng trong vic xc nh khi c nm sau cc quai rut
hay khng ?

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- Khi c thay i sau khi bnh nhn i ngoi hoc i tiu khng ? NG MCH CH BNG:

S theo ng gia trn rn tm p. Nu s nh cm thy cn

nghi ng phnh ng mch ch bng v tin hnh siu m chn on vi bnh nhn nam trn 50 tui v bnh nhn n trn 60. - C th l bnh thng i vi ngi gy - H ng mch ch - Chng phnh mch

V.

G BNG : G c :
C chng Cc tng gan, lch, Khi u U nang bung trng,..

G gan, lch v thn sau khi s cc tng ny. G bt k khi no nu thy nghi ng .
Trn ng gia bng g phi vang nu khng c th l khi u d dy , mc ni nh, cu bng quang, u nang bung trng , thai. Nu bng chng u, t bnh nhn nm nghing sang 1 bn v nh du din c pha trn. y l c thay i theo t th.

VI.

NGHE BNG : Ting nhu ng rut :

Nghe bng bng phn mng ca ng nghe. - Tc rut lm tng ting nhu ng rut. - Lit rut hoc vim phc mc ton th c th gy mt hon ton ting nhu ng rut. Nghe ting thi gan i vi cc bnh nhn mc bnh gan nh: - Ung th gan nguyn pht

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Vim gan do ru Shunts ng tnh mch mc phi do sinh thit hoc chn thng

Ting thi ng mch :

Thch hp khi bnh nhn c tin s hoc khi khm (v d c tng huyt p ), nghe ting thi dc theo ng mch thn v ng mch i. Thnh thong ting thi ng mch thn nghe r nht khi nghe t ng lng.

Hp ng mch thn c th gy nn tng huyt p. Cc b nh nhn b au cch hi chi di c th c ting thi dc theo ng i ca ng mch i do hp , x va ng mch

VII.

KHM THOT V : Xc nh cc mc gii phu quan trng khp dnh mu , gai chu trc trn, ng
mch i .

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Khm bnh nhn t th ng v bo bnh nhn ho thy khi vng bn sng to ln gi khi thot v.
Thot v bn gin tip (chch ngoi) : khi thot v lm yu cu trc ca l b n trong do p lc tc ng cc thnh phn trong bao thot v v khi b nh nhn ho, khi thot v c gi bi p lc ca l bn trong. Nu rt tay ra th khi thot v thot ra pha trc gia theo l bn ngoi v c th s thy c mu. Thot v bn trc tip : khi thot v hng ra pha trc pha trn np bn gia ch ng mch i v khng c gi bi p lc ca l bn trong. Thot v i : khi thot v lm y np bn gia ch ng mch i.

VIII. KHM C QUAN SINH DC :

Hi bnh nhn 1 cch t nh trc khi bn tin hnh khm: Ti s khm tng th vng kn cho bc. Bc th y c phin iu g khng? i vi nam gii, s nn bu s tinh hon v mo tinh. Him khi vic khm dng vt l cn thit. Tinh hon sng v au c th do vim tinh hon hoc xon tinh hon. Tinh hon to, cng, khng au gi l ung th tinh hon. Tinh hon to, sng ,mm cho nh sng xuyn qua khi chiu n gi trn dch hoc 1 u nang mo tinh. Dch trn bao xung quanh tinh hon trong khi u nang mo tinh nm pha sau tinh hon. Vim quy u gi ngi khm kim tra xem bnh nhn c mc i tho ng hay khng.

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IX. KHM TRC TRNG : Khng bao gi thc hin khm trc trng bnh nhn n khi khng c s cho php ca bc s trc hoc bc s chuyn khoa hay ngi nh bnh nhn.
Ni vi bnh nhn tng thao tc bn sp thc hin. Bnh nhn nm nghing v bn tri vi gi gp v pha ngc. Ni : Ti s a 1 ngn tay vo hu mn ca bc. Khm hu mn pht hin bi tr hoc cc vt nt hu mn. Bi trn gng ri nh nhng a ngn tr vo trc trng. Cm nhn trng lc ca c tht ; kch thc v c im ca tuyn tin lit v bt k cc khi no mt bn, Nu cn thit, tin hnh soi trc trng. Kim tra phn dnh theo gng xem c mu khng .

X. KHM M O : Khng bao gi thc hin vic khm m o khi khng c ngi nh bnh nhn hoc 1 nhn vin n bn cnh. Nu c th hy tun theo ch dn ca bc s c chuyn mn.
Ni vi bnh nhn tng thao tc bn sp thc hin. Bnh nhn nm nghing v bn tri khm m o (Tuy nhin mt s bc s tin hnh khm khi bnh nhn nm t th sn khoa ). Nhn c quan sinh dc ngoi. Bi trn gng ri a 1 ngn tay vo m o v nu c khong trng c th khm b ng 2 ngn tay. S c t cung. Khm v tr cng nh kch thc ca t cung, cm gic au ca cc cu trc ph cng nh cc khi. Kim tra xem c dch dnh theo gng khng.

XI. TNG KT CC BNH THNG GP : X gan :

Mng tay nht. Mng tay khum. Bn tay son. Sao mch. Vng da. Gan chc.

Hi chng tng p lc tnh mch ca :

Lch to. C chng.

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Tun hon bng h quanh rn Du hiu chim v cnh. Ng g. Vong hnh xy dng (khng v c hnh ngi sao). C mi hi. Da kh. Xp tnh mch. Gim n hi ca da np vo da khng mt. Li kh. Mt trng. Huyt p thp c h huyt p t th. Tnh trng mt nc do nn nhiu. Bng chng . Nhn thy nhu ng rut. Khng au ( tr trng hp vim hoc 1 vi b nh l khc). G vang. Tng nhu ng rut. Chng vng b ng trn. C th c du hiu sng v. Cc triu chng khc tng t nh vi tc rut. St nh. Khm trc trng hoc n thy au vng h chu phi. Cc triu chng khc t khi pht hin c tr trng hp gy vim phc mc. Bnh nhn nm im. Bng : +) Khng di ng theo h hp. +) Phn ng thnh bng. +) Phn ng di. Mt ting nhu ng rut. au vng h sn phi ,ch yu trong th ht vo ( du hiu Murphy au do khi ht vo ti mt b y xung chm vo tay ngi khm).

Hi chng no gan :

Tnh trng mt mui,nc :

Tc rut:
-

Hp mn v :

Vim rut tha:

Vim phc mc :

Vim ti mt : Vng da v ti mt to:

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Tc khng ch do si mt m cn do ung th ty (bnh Courvoisier). Si mt thng gy x ha ti mt lm ti mt khng gin n c do p sut ngc dng v si ng mt ch. Nhim trng : nhim khun huyt hoc vim ni tm mc bn cp. Tng p lc tnh mch ca : x gan. U lympho , leukemia hoc cc bnh mu khc. Cc b nh t min : Lupus ban h thng, hi chng Felty.

Lch to:
-

XII. KHM mt cch c H THNG : Khm bng :

Tay : mng tay khum, du hiu chim v cnh, co c kiu Dupuytren. Mt : vng da, thiu mu. Li : hi th hi, nhn. C : Hch Virchow. Ngc : sao mch , v to n ng. S thy hch vng bn. Quan st s bt i xng ca bng, c ng, p, chng. Pht hin xem c au hay khng ? S tt c 4 vng ca bng pht hin cc khi : lu nhn bit cc im au, phn ng thnh b ng v co cng thnh bng. S gan, thn, lch, ti phnh ng mch ch, C chng : kim tra din c thay i theo t th. Nghe ting nhu ng rut, ting thi ng mch v ting thi gan. Khm thot v : bo bnh nhn ho. Bo bnh nhn ng dy nu c khi thot v. Khm khi cn thit : +) Khm m h / tinh hon. +) Khm trc trng.

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CHNG 6: KIM TRA TRNG THI TINH THN

GII THIU Kim tra trng thi tinh thn cho tt c bnh nhn l iu rt cn thit ch khng ch ring cho nhng bnh nhn c vn v thn kinh. Nhng hng chnh l : Cch biu hin v hnh vi. Tm trng. Tc ni- cch ni, ni dung. Suy ngh -cch suy ngh , ni dung. Nim tin bt thng- nhng tng k l v o tng. Bt thng v nh n thc- o gic, o tng. Chc nng nhn thc-tp trung, nh hng, tr nh, l lu n. iu kin hiu bit: s khc bit gi a hi c v vic kim tra khng r rng khi kim tra trng thi r i lon tm thn. Phn ln vic kim tra c thc hin bng cch theo di cn thn trong khi khai thc tiu s, sau b sung thm mt s cu hi.

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Vic kh khn trong vic c c mt tiu s r rng ho c bnh nhn cm thy au kh rt quan trng trong vic kim tra trng thi tinh thn ca bnh nhn. QUI TC CHUNG Khng phn xt. Cnh gic vi s d xt c a bnh nhn. Khng kt lun vi vng nu ch da trn nhng li bnh nhn ni. Lm r iu mun bit vi yu cu nh nhng: B n c th cho ti bit thm v iu khng? B n c th cho ti m t v d gn y khng? iu xy ra ln cui khi no? B n lm g khi gp iu ? B n c thng/bao lu bn tri qua iu ? CCH BIU HIN V HNH VI (quan st) M t n gin: Xut hin trong tnh trng nhch nhc Hoang mang, kch ng, bn chn, hung hng, nc mt, lo u: Thch hp iu chnh? Gam hot ng trong trm cm. Hot ng qu mc v hng cm. Cng thng v hay lo u. C th tr li cc cu hi. Bng chng v vic bnh nhn c p ng vi o gic. C mi ru. Bng chng ca vic lm dng thuc (v d nh c du kim chch)

TM TRNG (mt phn th quan st, mt phn th yu cu) Tm trng l mt trng thi biu l ring ca bnh nhn v l nh g ch yu thng qua vic truyn ti cm gic trong sut cuc kim tra, mc d vic kim tra cho ta thm nhiu manh mi hn. Hi: Tinh thn ca b n gn y nh th no? B n c cm th y bnh thng hay khng? y c phi l cm gic bnh thng ca b n? Trm cm-ri lo n trm cm hoc mt s iu chnh ph n ng.

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Mc cao- ri lon hng cm hoc nhim c n ng( v d nh ru, thuc, cn m sng). Lo lng r i lon lo u hoc phn ng vi ng cnh. Gin d -m sng hoc phn ng vi ng cnh. Bun nn-chn nn hoc khng c mi quan h tt v tnh cm tc l tm th n phn lit.. Bng chng ca vic chn nn, lo lng, d b xc ng, kch ng th hin bn cht v mc nghim trng ca bnh: Nu bnh nhn thy chn nn, ta hi: iu ti t nh th no? Bn tng ngh n vic t t cha? Bn nghim tc xem xt cuc sng ca bn? Cng nn yu cu y t v ngi thn nhn xt thm CCH NI CHUYN(quan st) M t cch ni chuyn ca bnh nhn bng nhng thut ng n gin v ghi li nguyn vn nhng cu tiu biu. Tc : Nhanh trong hng cm. Chm trong trm cm Hnh thc: C bt thng trong vic s dng ng php hoc din t khng tri chy?-Ghi li nhng v d v vn ny.Qa trnh ri lon suy ngh c th xy ra trong tm thn phn lit, hng cm, bnh thc th cp, mt tr nh. S xut hin ca nhng chui t ng bt thng? Ri lon v logic trong bnh tm thn phn lit-t ng ln xn. K ni lng lo vi ch ang ni-flight of idea Ni dung( quan st, chi tit ha vi yu cu): B n ni bn, hy cho ti bit thm v iu Khi bn thy bun, nhng g xut hin trong tm tr ca bn? T DUY (cch th hin v ni dung -ch yu suy ra t nhng li ni ca bnh nhn) Ghi li nhng iu bnh nhn ngh hoc mi quan tm: Tiu cc, bi quan trong trm cm-hi v nh t t ca bnh nhn. Qa khch trong hng cm. Nhng suy ngh v l trong lo u. S m nh-xm nhp vo ngh hoc lp i li nhng hnh vi m bnh nhn khng th chng li c mc d h bit rng chng khng hp l. S dai dng-s lp i lp li nhng t hay nhng cm t. C th xy ra trong lo u,trm cm, hng cm, m sng hoc mt tr nh. 108

NIM TIN BT THNG (nhng tng k l v o tng) Hi m t; khng phn xt Hi xem ti sao anh/c y li ngh nh vy-iu ny c th gip ta pht hin ra nhng suy ngh bt thng hoc o tng( Nhng o tng kin nh, nhng nim tin sai lm m khng c bng chng hp l.V d nh: Ti b AIDS/ung th)) . . N c ging nhng g m mi ngi ni v bn hay khng? B n c bao gi nhn c nhng tin nhn c bit t tivi, radio hoc tp ch? Mi ngi c thay i cch m h thng lm nhm c c bn? B n c bao gi ngh rng bn thc s quan trng theo mt cch no hoc c nng lc c bit? B n c bao gi cm thy mnh phm mt li hoc lm iu g tht khinh khng m bn thy mnh ng b trng pht. NHN THC BT THNG( o tng v o nh-thng bc l t qu kh) Hi-Gn y bn c tri qua chuyn g b t thng hay khng? Chng xy ra trong i thc hay trong u bn? Nhng o tng l nhng nh n thc sai lm m khng c kch thch( v d nh:con voi mu hng-kinh nghim thc t): +Chng c th xy ra bng bt k phng thc cm gic no + Nh ng o gic th gic c th gi bnh thc th + Ngi th ba (anh hay b) nhng o tng do thnh gic c th gi bnh tm thn phn lit. B n c bao gi nghe thy nhng iu m ngi khc khng nghe thy, v d nh ting ngi ni chuyn? Bn c bao gi nhn th y nhng h nh nh hoc nhng cnh m ngi khc khng nhn th y? B n c bao gi c nhng cm gic l trong c th hoc trn da? o nh l nhn thc sai( v d nh anh y ngh bn l mt cnh st)-chng thng xy ra nhng bnh thc th cp tnh(tm thn). CHC NNG NHN THC(quan st v b sung bng nhng yu cu c th) Gim kh nng tp trung c th xy ra do: trm cm, l ln,mt tr nh, tnh trng l ln) nh hng, qu trnh suy ngh, tr nh v logic.Nh ng kha cnh ny phi c kim tra nh mt phn trong bi kim tra trng thi tinh thn. TNH TRNG HIU BIT Bn ngh iu g xy ra vi bn? C chng bnh n o khin bn bn tm v n hay khng? Cch cha tr no bn thy ph hp nht? C b t k ph ng php cha tr no khin bn lo lng hay khng? 109

iu ny rt quan trng khi hi tt c nhng bnh nhn nhng cu hi ny.Nu bnh nhn thiu ci nhn su sc v nim tin hay hnh vi b t thng, iu ny gi cho chng ta v mt bnh tm thn BNH S V KIM TRA NI CHUNG Bnh v tm thn c th i din cho mt bnh l hoc mt bnh s y v vic kim tra th cn lm trn tt c bnh nhn. Nhng bnh l khin ta nhm vi bnh tm thn bao gm: u/nhc nng tuyn gip, tng Canxi mu; h kali,natri,magie mu; khi u no; nhng nguyn nhn gy tng p lc ni s, bnh mn tnh, nhim trng n; thuc; ri lon chuyn ha porphyrin iu gy tranh ci l tt c nhng bnh l v tm thn xut pht t s mt cn bng vt l ca chc nng vn chuyn/th th trong n o, v vic phn loi bnh da vo th cht v tinh th n l cha chnh xc.Trong bt c trng hp no, tt c bnh nhn, tt c nhng bn cht ca bnh tt nn c cha cha tr vi s tn trng v khng phn xt. NHNG VN CA BNH NHN Bnh nhn tc gin S tc gin qu mc thng l triu chng ca mt vn khc. nh gi xem s hp l ca nhng trng hp bnh nhn than th v liu n c nn c gii quyt hay khng. C bt k iu g khc lm bn kh chu hay khng? Nu bnh nhn c s phn khng chng li bn,hy yu cu bnh nhn nn gp ngi khc. BNH NHN KCH NG phng ri ro(nn c s gip gn ). Chc rng bnh nhn khng c v kh. inh hng ng vn cho d bnh nhn ang say hay ni di. Ni s hi thng khin bnh nhn thm kch ng-vy ni s l g? NC MT BNH NHN Nu bnh nhn bt u khc, hy lm cho h bnh tnh v by t thi cm thng. Khi bnh nhn bt khc, hy tm hiu nguyn nhn v sao h bun.Nu bn c th tm c nhng l do th c th gip ch cho bn trong vic to mi quan h, cch gii quyt vn tt hn. BNH NHN C T T nh gi nh c gng t t gn y(nu c). Lp k hoch v pht hin nhng vic c th xy ra. Cm nhn mc nguy him ca phng php. Ch v thi gian. nh gi nhng nh hin ti: Lm th no c gng t t? Anh/ch y mun lm g iu xy ra? iu g lm gia tng hic lm gim thiu ri ro? BNH NHN B BI RI 110

Bnh nhn khng mun ni v ni au kh ca mnh. N c th gip m bo b mt ca bnh nhn khng b tit l. Nu bn ngh l b n bit vn ca bnh nhn l g, bn c th tm hiu thm: N c phi l vn v tin/tnh cm/bn tr? Nu bnh nhn khng mun ni v mt vn , hy cp sau hoc cp n trong mt bui khc. BNH NHN NI NHIU Mt s bnh nhn i vo nhng chi tit khng thch hp, lc , nhc i nhc li nhiu v mnh. Yu cu bnh nhn ngng li v i vo vn chnh.Kim tra li nhng g bnh nhn ni v tip tc cuc kim tra. Mt cch lch s, hy niCm n,lm n gip ti vi mt vi thc mc c th , sau tin hnh hi v yu cu phi c cu tr li. TIN S V NGHA Thnh thong bn s chng tm c thng tin c ngha no ht-nh ng du hiu ca s mu thu n trong li ni ca bnh nhn, h m t nhng s vic khng th xy ra,s dai dng hay ch l s im lng, nhng t n m tit. Hy h i nhng kha cnh khc ca tin s bnh nhn, v d nh: c nhn hay tin s gia nh, hon cnh x hi. Nu nhng iu ny cng khng gip c bn, hy tin hnh qu trnh kim tra( nu kh thi). Bn c th xc nh s sa st tr tu, tm bng chng ca vic lm dng thuc, chng cung lon (hysteria) hoc nhng bnh khc c th gip gii thch nhng vn trn. Nu cn thit, c th phng vn nhng ngi cung cp thng tin khc(v d nh gi in cho ngi h hng). TM TT NHNG CHNG BNH THNG THNG Trm cm: Bun ru, khc lc(khng phi lun hin din). Thiu s quan tm v chm sc. Thiu s tp trung. T tng tiu cc. Gim lng t trng. Thc dy sm. Sc mt lo u, chn nn.. Kh nng ni v di chuyn chm chp. Gim cn. Ni dung li ni tiu cc. LO LNG Thng lo lng. Suy ngh tp trung vo nhng iu v l. Khng th ng c. 111

Nt mt cng thng, nhu lng my. M hi tay. Run ry. Tng thng kh. Nhp tim nhanh. CHN N DO TM THN m, c th t m. Lng c th pht trin. Th y mnh bo mc d ngi m. T tng b chi phi bi thc n. N V DO TM THN Cn nng bnh thng. T gy ra nn i sau khi n no. T tng b chi phi bi thc n. Mn rng do nn. RI LON TM THN CP TNH(tm thn phn lit, hng cm hoc trm cm). Tnh to v kh nng nh hng. Hot ng bnh thng b ph v. Khng th on trc c hnh vi. p ng hoc c x nhm p ng o gic. p ng vi nhng nim tin ho huyn RI LON TM THN PHN LIT. Suy ngh v l, thm ch l dng nhng t ng khng c ngha, ri rc. o gic thnh gic(ngi th ba). o tng-c bit lin quan n suy ngh .. C nhng hot ng p ng o gic v o tng RI LON TM THN Nhanh chng a ra nhng tng bay bng Hot ng qu mc, khng th duy tr lin tc. Hot ng bnh thng b ph v Qu vui v hoc cu knh. D tranh ci. TRM CM-RI LON TM THN S nh hng ca trm cm. Ni v di chuyn chm. Suy ngh tiu cc v o tng(v d nh ngh n o mnh b thi ra). Suy ngh n vic t t. TM THN PHN LIT MN TNH. Tnh to v kh nng nh hng. Khng gn gng. 112

Ni nng huyn thuyn vi nhng t ng k quc. Hnh thnh nhng o tng. Phong cch v c ch k l. Tm xem bnh nhn c b ri lon vn ng khng(c im parkinson t vic s dng ko di thuc an thn). M SNG Dao ng mc tp trung v nh hng-din bin xu hn vo ban m. o tng thong qua, thng bt ngun t vic b ngc i. Bng chng v vic b nhim c(v d nh st). NHIM C(MT KIU CA M SNG). Mi ca ru hoc keo. Du kim Bun ng v gim tnh to. Hnh nh o gic. CHNG MT TR Tnh to(tr khi cng b m sng). C th khng gn gng. Kh nng nh hng khng gian v thi gian km. Chc nng nhn thc di mc bnh thng. Tr nh ngn hn. Khng th nh v lp li mt dy s hoc mt a ch. Khng th gii thch c nhng iu n gin. Gim kh nng ni v suy ngh . B MT I NGI THN Tm trng km, khc lc khi ngh v ngi thn b mt. C th c triu chng thc th. nh gi nguy c t t ( i cng ngi thn). Nu qu nng hoc ko di(trn 6 thng) c th xe l bnh l. BNH THC TH/BNH TNG C triu chng thc th (au n, mt mi ) nhng khng c bnh trong bt k c quan, b phn no. nh gi du hiu ca trm cm.va Xc nh bnh tt, ni s hi v nim tin ca bnh nhn. Triu chng l mi quan tm chnh trong bnh thc th,s bnh tt trong bnh tng.

113

Chng 7
Thm khm h thn kinh
Gii thiu
Mc ch ca vic thm khm l tr li ba cu hi: (1) Bnh nhn c bnh thn kinh hay khng? (2) Bnh l nm u trong h thn kinh? (3) Bnh l l g? Thng thng, bnh s c tnh quyt nh. Nhng im c trng sau y trong bnh s c th cung cp nhiu thng tin: - Khi pht - t ngt cn nguyn mch mu, c hc - trong vi giy cn ng kinh - trong vi pht - au na u - trong vi gi - nhim trng, vim - trong vi ngy / tun - khi u hoc ri lon thoi ha - Thi gian - thi gian phc hi ngn, v d nh TIA ( Transient ischemic attack cn thiu mu no cc b thong qua), ng kinh, migraine, ba t tnh - thi gian phc hi di - nguyn nhn c hc, tc nghn hoc p lc - mt myelin, v d bnh a x c ng - Tn sut - M t ca ngi chng kin - c bit khi b nh nhn c giai on mt thc hoc l ln Vic thm khm thn kinh c th phi c tin hnh rt t m trong nhiu ln. Quan trng hn l bn phi c c kh nng tin hnh thm khm k lng nhng tng i nhanh chng v t tsin vi cc triu chng pht hin c. Tt nht nn pht trin h thng c bn ca ring bn trong vic thm khm v thc hnh n mt cch nht qun. iu ny s gip trnh khi cc thiu st. Thay i vic thm khm tng ng vi tnh hung. Vic thm khm hng ngy l quan trng nhng c th c thay i ph hp v i hon cnh. Khm thn kinh c tin hnh theo cc phn di y: Chc nng thn kinh cao cp. Cc dy thn kinh s no.

114

 Vn ng Phi hp. Phn x. Cm gic. Dng i v t th. Chng ta khng th thm khm h thn kinh mt cch tch bit. Cc vn lin quan khc bao gm: - c u to ca hp s v ct sng - c ng gy - mng nh trong vim tai gi a - huyt p - tim, v d: lon nhp tim, hp van hai l - ng mch cnh mch v ting thi - khi u - v, phi, bng - vng da

Chc nng thn kinh cao cp

Chc nng tm thn cao cp ch c th c nh gi thch hp bnh nhn cn lanh li, tnh to v hp tc. T bnh s chng ta thng thy r liu rng c cn thit phi khm chc nng thn kinh cao cp mt cch chi tit hay khng. Kh nng cung cp mt bnh s mch lc cho thy chc nng thn kinh bnh thng. Mt bnh nhn au thn kinh hng s lo lng nu c bt u khm bng cch yu cu gi tn cc b phn ca mt chic ng h. Tuy nhin, nu bnh nhn khng th cung cp bnh s mt cch mch lc th khi vic thm khm thc l cn thit.

Quan st chung
Dng v, v d: nhch nhc. Hnh vi, v d: hoang mang, bn chn, kch ng. Trng thi cm xc, v d: chn nn, phn khch, chng i. Quan st, v khai thc thm thng tin t y t v ngi nh bnh nhn.

Mc thc
Nu bnh nhn khng hon ton tnh to, gi bnh nhn nh nhng hoc ni to.

115

Thang im Glasgow (Glasgow Coma Scale - GCS)

Thang im Glasgow l mt phng thc nh gi mc thc nhanh chng v c s dng rng ri. Kim sot p ng vi mnh lnh bng li ni hoc l, nu khng c p ng vi kch thch au, v d: n trn mt (bng cch n ngn tay ci vo l trn mt), ch xt ln xng c (cc khp t ngn tay trn xng sn), n ging mng tay (mng tay c a ngn tay ci), vo da (nhng khng li vt bm tm). Nn ghi li phn ng ca bnh nhn c ng nh s im GCS. Tnh tng s im theo A, B, C di y. im s A p ng m mt 1 Mt lun nhm 2 M mt khi kch thch au 3 M mt khi gi 4 M mt t nhin v chp mt bnh thng B p ng li ni 1 Khng tr li 2 Tr li khng hiu c, ch rn r thnh ting 3 Tr li khng ph hp ni c t nhng khng thnh cu 4 Tr li ln xn 5 Hi thoi bnh thng C p ng vn ng 1 Khng p ng 2 p ng phn x dui v i kch thch au - vai khp v xoay trong, khuu tay dui, cng tay sp 3 p ng phn x gp vi kch thch au 4 Co rt chi li 5 nh v: c gng bo v ch au 6 C thc: p ng bnh thng vi mnh lnh

L ln
Nu bnh nhn xut hin l ln, chuyn sang nh gi trng thi thc, bao gm c s mt nh hng (trang 115). Hy chc chn rng bnh nhn khng tip nhn mt ngn ng tip nhn th nht(xem bn di).

116

Ngn ng / li ni
nh gi qua hi thoi: C kh khn trong vic pht m r rng hay khng? Nu cn thit, hy yu cu bnh nhn ni 'Hin php Anh', 'ng West Register '. - Ri lon ting ni (Dysarthria - ni ngng) - tiu no c lt hoc ngt m - neuron vn ng bc thp - lit vm m mi - cc neuron vn ng bc cao - chm, "co cng, nhn thy trong lit gi hnh no - ng c ru cp tnh C thay i ging iu ging ni? - ngoi thp (n iu v chm) - Kh ni (Dysphonia) - tn thng dy thanh m ni khn - kh ni phn ly C kh khn trong vic tm kim nhng t thch hp? - Chng cm (Dysphasia) hoc mt ngn ng hay tht ngn (aphasia), ri lon s dng cc t nh cc biu tng trong ni, vit v hiu. Gn nh lun lun do bn cu bn tri b tn thng. Ch : Thun tay phi hay tay tri? C th tn thng bn cu bn phi nu thun tay tri. - Mt ngn ng din t (Expressive dysphasia) kh khn trong vic tm t, ni chm v ngp ng ng, c th s dng li ni quanh co un khc, do tn thng trong vng Broca. Khm pht hin bng cch yu c u bnh nhn gi tn cc vt bn ch, v d nh ng h eo tay, bt, c vt. Kh nng hiu c th khng b thay i. - Mt ngn ng tip nhn (Receptive dysphasia) ni tri chy, nhng khng hiu c li ni; bnh nhn c v nh "ln ln". Khm pht hin bng cch yu cu bnh nhn lm theo mnh lnh - mt mnh lnh bao gm ba bc l mt cch khm sng lc tt (v d: "hy nht knh ln, nhng trc tin ch vo rm v sau l cnh c a "). Do tn thng trong vng Wernicke. - Mt ngn ng hn hp (Mixed dysphasia) ph bin nht; li ni t pht , t t vng, thng s dng t sai, hiu sai.Cng c nhng loi mt ngn ng khc do s gin on ca cc ng lin h gi a cc trung khu ngn ng.

117

- Cm (Mutism) hon ton khng ni c. iu ny c th do mt ngn ng, cm, bnh tm thn hoc i khi l bnh l no lan ta.

Cc khuyt tt khc xy ra khi thiu ht vn ng hoc ri lon chc nng cm gic

- Chng kh c (Dyslexia) - kh khn khng thch ng vi vic c. c c rt t dng t t bo (c chng minh l kh nng hiu v din t cn nguyn v n). - Mt kh nng vit (Dysgraphia) mt kh nng vit. - Mt kh nng tnh ton (Acalculia) - mt kh nng tnh nhm v tnh trn giy. - Mt s dng ng tc hay tht dng (Apraxia) - khng th thc hin cng vic c mc ch khi khng c vn ng hoc mt cm gic, v d: m bao dim, vy tay cho tm bit. Mt s dng ng tc mc qun o thng gp trong bnh no lan ta (diffuse brain disease). Khng c kh nng v ngi sao nm cnh gp trong tin hn m gan (hepatic pre-coma). - Mt kh nng nhn bit (Agnosia) - khng th nhn ra cc i tng (v d nh cha kha hoc ng xu t trong tay. Mt kh nng nhn bit bng xc gic (Tactile agnosia) = mt nhn thc xc gic (astereognosis)). - Tn thng thy nh (Parietal lobe lesions), c bit l bn phi, gy kh khn v khng gian; i lc nhng ni quen thuc, khng th dn bn n, v hoc lm theo mu vi cc que dim, b qua pha bn tri c a khng gian, hoc mt na c th.

Chc nng nhn thc

Hy xem xt bt k bng chng m bn c v tr thng minh, s gio dc v cc mi quan tm c a bnh nhn.

Nhn thc l mt thut ng bao gm s nh hng, qu trnh suy ngh

v t duy logic. Ngi ta cho rng nn thng xuyn s dng mt bi khm tnh trng tinh thn n gin, v d c trnh by trong phn Ph lc 3. Phn di y m t mt vi kha cnh ca vic khm nhn thc mt cch chi tit hn. nh hng Khm nhn thc v: - Thi gian: Hm nay l ngy bao nhiu?' (Thi gian, thng, nm) - Ni chn: 'Bn ang u?' - Ngi: 'Tn bn l g?' Mt nh hng cho thy tnh trng c quan cp tnh hoc sa st tr tu 118

(dementia). Bnh nhn trm cm c th khng sn sng tr li mc d h bit cu tr li. S ch v tnh ton

Cc cch khm tp trung bao gm yu cu bnh nhn tr i 7 t 100, 7 t 93,

vv, 20 tr i 3, y l mt dng n gin khc ca cch khm ny; hoc bng cch hi v cc thng ca nm trc, hoc bng cch nh vn t th gii ngc. S tp trung c th b nh hng v i nhiu bt thng ca no b c bit l m sng, trm c m v lo lng.

Tr nh Nh li ngay lp tc chiu di s Lp li cc s c ni cho mt cch chm ri. Bt u vi chui ngn n gin v sau tng s ln. Hu ht mi ngi chuyn tip qun l by ch s, nm ch s v pha sau. Tr nh ngn hn Yu cu bnh nhn ni vi bn: - ng ta n g trong ba sng - ng ta lm g vo m hm trc - ng c g trong bi bo ngy hm nay - cc mc tin tc c tnh cht thi s gn y. Cn hng ti cc mi quan tm ca bnh nhn, v d: kt qu bng nu ng ta l mt ngi hm m bng cung nhit. Bnh nhn mt tr s khng th lm iu ny. H c th tn pht (to nn nh ng cu chuyn n tng) che giu s thiu hiu bit c a h (c bit hay gp trong sa st tr tu lin quan n ru). Tr nh mi Ni tn v a ch, hy chc chn l bnh nhn c hc iu ny, v sau kim tra vic nh li sau 5 pht. Tr nh di hn Hy hi bnh nhn: - V cc s kin trc khi mc bnh, v d: nm ngoi, trong c tun trc - 'a ch ca bn l g?' Kin thc chung 119

 nh gi trong mi quan h d tnh trc vic lm t bnh s. - Tn ca N hong / Tng thng / Th tng Chnh ph l g? - Tn su th . - Cuc chin tranh cui cng xy ra vo ngy no? Trong cc tnh trng cp tnh ca c quan v chng mt tr hay sa st tr tu (dementia), tr nh gn, mi hc c, v l lun c v nh suy gim nhiu hn tr nh xa. T vng thng c lu gi tt trong sa st tr tu. i vi bnh trm cm (depression), bnh nhn c th khng mun tr li, v gn nh lon tr. - Bnh s khai thc t ngi thn hoc ngi ch l rt quan trng trong sa st tr tu sm, c bit i vi kh nng thc hin chc nng. Bnh nhn lon tr c xu hng khng th lm vic mt cch thch hp hoc li xe an ton, trong khi bnh nhn lo lng v trm cm li thng c th lm c iu ny. L lun (suy ngh tru tng) Bn s lm g nu bn tm thy tm thy mt phong b c dn tem v ghi r h, tn trn mt t?

Hp s v ct sng
Quan st v s nn hp s nu thy bt k kh nng c chn thng u no . Khm cng gy du hiu kch thch mng no (trang 147) Khm ct sng thng tin hnh khi khm lng hoc ngc. Nu nghi ng c bnh l, cho bnh nhn ng dy v khm tt c cc c ng c a ct sng.

Dy thn kinh s no
Khm cc dy thn kinh s no v chi trn khi bnh nhn ngi, tt nht l trn ging hoc trn gh.

I Khu gic
Khng phi khm thng quy. i khi c th hu ch nu c nh ng khuyt tt khc v thn kinh, bao gm ph gai th, au u cha chn on c hoc chn thng u. Du c a cy inh hng, bc h, c ph, vv - ln lt tng mi. C th l bnh thng khi khng gi tn ng cc mi, nhng phi phn bit c mi ny vi mi khc. Khng nn s dng mi hng hoc c hi nh amoniac. 120

Bt thng: - Vim mi - Chn thng u - U mng no rnh khu - ht thuc l

II Th gic
Th lc
Khm tng mt ring bit. Yu cu bnh nhn c bo in nh vi tng mt ring bit, c th s dng knh. Nu th lc km, khm chnh thc: - Th lc gn - giy in bo hoc loi Jaeger (ln lt t ng mt) (xem Ph lc 1). - Th lc xa - loi Snellen (phng php ny chnh xc hn) (xem Ph lc 2). Bnh nhn ng cch b ng Snellen 6m (ln lt tng mt). Kt qu th hin di dng t l: - 6 khong cch t ngi n th - X - khong cch m ti bnh nhn c th c loi , v d 6/6 l th lc tt, 6/60 c ngha l loi nh nht bnh nhn c th c c tc l ln c c bnh thng khong cch 60 m. Nu bnh nhn khng th c c 6/6, hy th li sau khi sa vi knh hoc l ngm. Nhn qua l ngm trong th trnh li khc x, tng t nh mt my nh c l ngm. Nu th lc vn km, nghi ng c mt nguyn nhn ti thn kinh hoc mt. Mt bng Snellen 3m c th hin trong Ph lc 2. L ngm khng hiu qu trong vic sa cha th lc gn khi c. Cc th trng Phng php nhanh khm th trng ngoi vi thi dng l bnh nhn ngi i din vi thy thuc v m c hai mt. Lun lun khm cc th trng - bnh nhn thng khng nhn thc c s mt th trng,iu n tng nht chnh l hi chng Anton (m vi s thiu nhn thc m la). - Ngi i din v yu cu bnh nhn nhn vo mi bn. - Khm ln lt t ng mt. - a ngn tay v pha trc t pha sau tai gc phn t bn trn v di c a bnh nhn v hi bnh nhn khi no c th nhn thy ngn tay.

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- Th lc bnh thng l khong 100 t trc c a mt. Cc bnh nhn phi hiu y v thao tc khm. Th trng ngoi vi ti hn c th c kim tra khi m c hai mt, v mi cn tr th lc t mt bn kia. Nu th trng ngoi vi c v b hn ch, khm li vi mt kia c che i m bo mi mt c kim tra mt cch ring bit. Phng php nhanh khm th trng ngoi vi mi l bnh nhn ngi i din vi thy thuc vi mt bn kia c che li. - Th lc bnh thng l khong 50 t mi trc ca mt. Phng php tiu chun. Vi mt l nh mu c t v tr mt phng gia bnh nhn v thy thuc. Mt kia c che kn, so snh cc th trng ca bnh nhn v i th trng c a thy thuc, s dng inh ghim a vo t th trng thi dng hoc th trng mi. Khuyt tt th trng trung tm c th c nh gi theo phng php tiu chun vi mt inh ghim nh mu c t v tr mt phng gia bnh nhn v thy thuc: - m im (scotoma) - khuy t tt trong th trng trung tm (tn thng vng mc hoc dy thn kinh th gic) - im m m rng (enlarged blind spot) hay ph gai th (papilloedema). Xc nh bng cch di chuyn bt t m im bn trong hoc im m ra ngoi cho n khi u kim mu li xut hin. y l mt cch khm th s v cc vng mt th lc nh c th cn phi c kim tra chnh thc v i mt my o th trng. Khm thiu ch cm gic khi cc th trng y khi m c hai mt. - Gi tay ca bn gia bn v bnh nhn, mi tay i din mt tai ng thi lc ngn tay tr. Hi bnh nhn tay no di chuyn. Nu khim khuyt thy nh, bnh nhn c th khng nhn thy chuyn ng ca mt bn, mc d th trng y khi khm chnh thc. Trn bnh nhn bn thc, bn manh ng danh ni chung c th c pht hin bi mt phn x chp mt khi a bn tay ca bn nhanh chng i ngang qua mt v pha tai (phn x e da). - Bn manh ng danh (Homonymous hemianopia) khuyt tt th trng (Hnh 7.1), pht sinh t tn thng pha sau

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giao thoa, cng bn vi lit na ngi nu c. - Khim khuyt gc phn t trn (Top-quadrant defect ) do ph hy thy thi dng hoc tn thng thy chm. - Khim khuyt gc phn t di (Lower-quadrant defect) do ph hy thy nh hoc tn thng thy chm. - Khim khuyt hai bn thi dng (Bitemporal defect) - do tn thng tuyn yn.

Khm y mt (xem trang 35) Cc tn thng c lin quan c bit n h thn kinh: - Teo gai th (optic atrophy)- a mu nht nht v mt myelin, v d: bnh a x

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c ng: p lc ln dy thn kinh - Ph gai th (papilloedema) - tng p lc ni s: - Khi u - Cao huyt p ni s lnh tnh - Trn dch no - Khng lu thng dch no ty (tc nghn dng chy qua no tht bn) (non-communicating) - Lu thng dch no ty (communicating) - khi hp thu dch no ty ca ty sng Mt cch khm nhy i vi rung git nhn cu l yu cu bnh nhn che mt bn kia li trong khi soi y mt. iu ny gip loi b s c nh v c th gy ra rung git nhn cu.

II v III ng t
Nhn vo ng t. Chng c trn v nm ngang nhau khng? - ng t nh v i xng: tui gi thuc phin ng t Argyll Robertson (giang mai) l ng t nh, khng u, lp d, phn ng vi s hi t nhng khng phn ng vi nh sng thuc nh mt Pilocarpine dng cho glaucoma gc hp vim mng mt - ng t i xng ln: tui tr ru cng thn kinh giao cm, lo lng cc cht ging atropine - ng t khng i xng: lit dy thn kinh III - tc ng lm ng t gin, thng km theo sp mi v song th. Hi chng Horner (tn thng thn kinh giao cm) - tc ng lm ng t co, thng km theo sp mi mt phn, lm v kh mt chn thng mng mt thuc (xem trn) Phn x nh sng. Chiu nh sng chi ca n pin ln lt vo tng ng t trong mt cn phng sng l m. ng t c co nh nhau khng? - ng t Holmes Adie: ln, phn ng chm v i nh sng. - Khuyt tt ng hng tm, m do mt hoc do dy thn kinh th gic: c hai ng t khng phn ng vi nh sng bnh nhn m mt, c hai phn ng vi nh sng ngi mt bnh thng.

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- khuyt tt ng hng tm tng i - phn ng trc tip xut hin bnh thng nhng khi nh sng di chuyn t mt bnh thng sang mt b bnh, ng t gin nghch thng. - khuyt tt ng ly tm - tn thng dy thn kinh s ba, ng t ca mt ny hay mt kia khng p ng vi nh sng. Phn x iu tit (Accommodation reflex). Yu cu bnh nhn nhn vo v t th xa, v sau nhn vo ngn tay ca bn cch mi 10-15 cm - ng t c co khng? - p ng vi iu tit nhng khng p ng v i nh sng: Argyll Robertson Holmes-Adie m mt tn thng no gia mt s tn thng dy III c hi phc

III Dy thn kinh vn nhn chung IV Dy thn kinh rng rc VI Dy thn kinh vn nhn ngoi
Chuyn ng bn ngoi ca mt Khm cc chuyn ng mt theo bn hng ch yu (sang tri, sang phi, ln trn, xung di) v khm hi t bng cch s dng ngn tay ca bn khong cch 1m. Tm chuyn ng bt thng ca mt. Yu cu: "Ni cho ti bit nu bn thy hai hnh '. Lic nhn ln v hi t thng gim nu bnh nhn khng hp tc. pht hin cc tn thng nh: - Tm hng nhn m hnh nh b tch ra nhiu nht. - Che mt mt v hi hnh nh no bin mt. Hnh nh ngoi vi c nhn thy bng mt khng di chuyn mt cch y . Hnh nh ngoi vi di chuyn theo hng

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chuyn ng ca c yu, v d: song th ti a khi lic nhn bn tri. Mt tri nhn thy hnh nh ngoi vi di chuyn sang bn. Do c thng bn tri l c yu. Song th hay nhn i (Diplopia) c th l do tn thng mt c n thun hoc tn thng dy thn kinh (lu : song th mt bn thng ngh n bnh l c a mt): - Lit lc (nheo mt) - Lit dy III: sp mi, con ngi ln v c nh, mt ch c th nhn sang bn, mt thng xung di ra ngoi - Lit dy IV: nhn i khi mt nhn xung hoc vo trong - Lit dy VI: lit chuyn ng sang bn, nhn i khi nhn v pha tn thng - Lc khng km theo lit, v d: tn thng mt tr em (childhood ocular

lesion) - gc khng i gia hai mt. Thng thng khng nhn i khi mt mt m
i (gim th lc). - lit lin hp mt - lit trn nhn nh hng nhiu ti phi hp mt hn l yu c. Khng c kh nng nhn theo hng c th, thng l nhn ln

- tn thng di nhn: hi t bnh thng nhng mt khng th nhn sang bn. nu bnh nhn nhn i tt c cc hng - c th tn thng dy thn kinh s III - bnh c do tuyn gip ( thyroid muscle disease) nng hn vo bui sng - nhc c (myasthenia gravis) nng hn vo bui ti - bnh lc

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Sp mi
Sp mi trn c th l - hon ton tn thng dy thn kinh s III - khng hon ton - tn thng dy thn kinh s III mt phn - y u c, v d nhc c ( do khng th khng th th acetylcholine ) - hi chng Horner mt phn ( bt thng nh c a con ngi vi sp mi) bnh l thn kinh t ng bnh nhn i tho ng (diabetes ) v giang mai (syphilis) - hi chng levator dysinsertion ( cc bnh nhn mc bnh mn tnh s dng knh p trng ) Rung git nhn cu y l chuyn ng khng n nh c a mt. Chuyn ng rung git c gi theo hng chuyn ng nhanh. u tin khm v tr trung gian v sau vi mt lch sang phi, sang tri v ln trn. Gi vt trong th trng hai mt v rung git nhn cu thng l bnh thng cc v tr lic mt ti a. M t nh c bn khi thc hin vi mt ngh ngi, hoc khi lic mt, VD khi c to ra bi chuyn ng ca mt. Rung git nhn cu d pht hin hn khi loi b s c nh . iu ny c th c thc hin ti ging bnh trong qu trnh soi y mt (xem trn). Hy nh rng, rung git nhn cu s xut hin hng i din. - Rung git nhn cu tiu no (Cerebellar nystagmus) - chuyn ng nhanh v pha lic mt (hoc c hai bn) - tng ln khi nhn v pha tn thng 127

- tn thng tiu no hoc thn no hoc do thuc (ethanol, phenytoin) - Rung git nhn cu tin nh ( Vestibular nystagmus) - ch chuyn ng nhanh theo mt hng ra xa tn thng - gim khi c nh nu xut pht t ngoi vi - r rt hn khi nhn sang bn lnh - bnh tai trong, tin nh hoc tn thng tiu no - rung git nhn cu m cung c th do t th - c bit trong chng mt t th lnh tnh, v c th do dui v xoay c qu mc (chuyn ng Hallpike ) sau thi gian tim tng khong vi giy s gy ra loi rung git nhn cu dc/xoay khong 10 - 15 giy, cng v i cc triu chng c a chng mt.

- Rung git nhn cu bm sinh - rung git ngang khng thay i. - Rung git nhn cu nhp nhng - tn thng l chm hoc bnh Wernicke - Rung git nhn cu co rt - tn thng no gia. - Rung git nhn cu phc tp - bnh thn no, thng l a x c ng. Chuyn ng mt nhanh y l s chuyn ng mt nhanh c s dng thay i v tr mt. Tin hnh khm cc mt phng ngang v dc, bng cch yu cu bnh nhn chuyn i c nh gia hai mc tiu (v d nh ngn tay ca thy thuc). Chuyn ng mt nhanh din ra chm c th c nhn thy trong mt lot cc ri lon bao gm cc ri lon thoi ha nh lit trn nhn tin trin.

V Dy thn kinh sinh ba

Dy V cm gic 128

 Khm cm gic xc gic nng vi c ba phn. Thng thng ch cn chm nh bng ngn tay l . Kim chm thng ch cn thit phn nh vng t b. nh 127

(Ghi ch: Nhnh mt Nhnh hm trn Nhnh hm di)

Phn x gic mc - dy V cm gic v dy VII vn ng Yu cu bnh nhn nhn ln trn v chm vo gic mc bng tm bng. C hai mt u chp. Nh l gic mc rt r rng; khng khm mng cng! Phn x gic mc c th d dng b mt chnh xc khi lm phn x 'mi mt' hoc ' e da' .

Dy V vn ng cc c hm Yu cu bnh nhn m ming chng li sc cn, v tm xem hm c b tr xung gia hay khng. Lit dy thn kinh gy lch hm bn tn thng. Rt him khi lit dy V n thun. Git hm - ch khi pht hin tn thng thn kinh khc, v d: tn thng neuron v n ng trn. Hm git ch tng ln nu c tn thng neuron dy thn kinh s nm hai bn, v d: t qu hoc lit gi hnh no hai bn (bilateral strokes or pseudobulbar 129

palsy.).
t ngn tr ca bn nh nhng trn hm bnh nhn ang m v th lng. (Anh 128)

G nh ngn tay ca bn bng mt ci ba phn x. Gii thch cch khm vi bnh nhn nu khng s khng th th lng hm c. Mt ng tc git nhanh c coi l dng tnh.

VII Dy thn kinh mt

Yu cu bnh nhn: - Nng lng my - Nhm cht mt - Nhe rng Minh ha cho bnh nhn nu cn thit. Tn thng neuron vn ng di: tt c cc c bn pha tn thng b nh hng, v d: lit Bell (Bells palsy): khe mi m rng, nhy mt yu, ming tr xung. Tn thng neuron vn ng trn: ch c cc c thp hn b nh hng, tc l ming tr xung mt bn, nng lng my bnh thng. iu ny bi v mt phn ca nhn mt kim sot na trn c a khun mt do hai bn phn b. Bt thng ny l rt ph bin trong lit nh na ngi.) nh 129

130

(Ghi ch: Tn thng neuron vn ng trn Cc c trn v di b nh hng Tn thng neuron vn ng di C trn bnh thng C di b tn thng) V gic (thng nh - chorda tympani): ch c th khm c mt cch d dng hai phn ba trc li.

VIII Dy thn kinh thnh gic

Tin nh Vic khm cnh ging khng d dng i vi dy thn kinh ny ngoi tr tm kim rung git nhn cu. Thnh gic Che mt tai bng cch n g bnh tai. m th thm cc s ngy cng ln ting cho n khi bnh nhn c th lp li chng. Mt chic ng h ku tch tc c l hu ch hn. Nghim php Rinne. t mt m thoa c m cao c lm rung ln xng chm (1 trong hnh ). Khi bnh nhn cho bit m thanh dng li, gi m thoa trc l tai (2 trong hnh). - Nu vn nghe thy: dn truyn khng kh > dn truyn xng (bnh thng hoc ic thn kinh). - Nu khng nghe ni: dn truyn khng kh < dn truyn xng (khim khuy t dn truyn tai gia).

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Nghim php Weber. t mt m thoa c lm rung gi a trn bnh nhn. Nu nghe c m thanh mt bn, ic tai gia bn hoc tai bn i din ic thn kinh.

IX Dy thn kinh thit hu

Yu cu bnh nhn ni "A" v xem chuyn ng ln trn i x ng ca li g ko lch khi bn yu hn. Chm vo mt sau ca hng vi thanh mu cam hoc ci li mt cch nh nhng. Nu bnh nhn nn e th thn kinh cn nguyn vn. Phn x nn e ny ph thuc vo cc dy thn kinh IX v X, dy IX chi phi cm gic cn dy X chi phi v n ng. Phn x ny thng khng xut hin ngi gi hoc ngi ht thuc l.

X Dy thn kinh ph v
Hi xem bnh nhn c th nut c bnh thng hay khng. Dy thn kinh ph v c qu nhiu nhnh n ni chng ta khng th chc chn c tt c cc nhnh u bnh thng. Nu dy thn kinh ph v b tn thng nghim trng, s gy kh nut, thc n nc ung c th vo phi. ng tc nut c th c nh gi bng cch yu c u bnh nhn ung mt ngm nc nh.Quan st bnh nhn. Nu bnh nhn ho khi c gng nut th c nguy c cao khi ht vo.Cui cng kim tra ging ni nu c thay i cht lng m thanh (ging t) th chng t c ng dch trn dy thanh m, 132

v mt ln na cho thy khi ht vo rt nguy hi. Khm ho c ch bnh nhn c th ho khng thnh ting hoc khng hiu qu. Khm lon vn ngn (xem trang 114).

XI Dy thn kinh ph
Yu cu bnh nhn mm c, n cm xung chng li sc cn c a tay bn. Quan st xem c hai c c n chm co bnh thng hay khng. Yu cu bnh nhn nng hai vai. Nu bnh nhn khng th thc hin c ng tc ny, c thang khng hot ng. Yu sc c thang mt bn thng lin quan vi lit na ngi (c bit l nhi mu ng mch no trc). Chn thng ct nhm dy thn kinh ph tng xy ra khi ct tuyn bch huy t lao c .

(Ghi ch: Yu c thang bn phi) Yu cu bnh nhn c ng u chng li tay ca bn. ng tc ny khm c c n chm bn i din, v c th gip chng minh chc nng vn ng bnh thng trong lit na ngi ri lon phn ly (hysterical

hemiplegia).

XII Dy thn kinh h thit

Yu cu bnh nhn a li ra ngoi. Nu li lch v bn no th l bn yu, v d: li lch v bn tri khi a ra ngoi chng t tn thng dy thn kinh h thit bn tri. Nhn xem c rung c cc b hay teo li khi m ming.

Chn tay v thn: vn ng, sc c, phi hp v phn x

Khm tng qut
Nhn vo t th ngh ngi v t th ng ca bnh nhn: - Lit na ngi - chi trn gp li, chi di dui ra - C tay r xung - lit thn kinh quay 133

 Tm c ng bt thng: - run - Parkinson - run khi ngh ngi, gim i khi vn ng - run v cn - xut hin khi c ng, nhn cnh tay dui thng - ma git (chorea) c ng t ngt, khng ch lp i lp li mt cch bn mc ch - ma v n (athetosis) c ng vn vo chm, lin tc c a chi Tm teo c. Khm s phn b: - i xng, v d: teo c Duchenne (Duchenne muscular dystrophy) - bt i x ng, v d: bi lit (poliomyelitis) - gn, v d: lon dng c gc chi ( limb-girdle muscular dystrophy) - xa, v d: bnh thn kinh ngoi vi ( peripheral neuropathy) - ton b, v d: bnh neuron vn ng (motor neuron disease) - khu tr, v d: bnh khp (joint disease)

(Ghi ch: tn thng dy thn kinh h thit bn tri) Tm rung c cc b. y l s co khng ch bt thng ca cc b si c nh. iu ny l in hnh ca ct t thn kinh, v d bnh neuron vn ng khi tn thng lan ta. Nguyn nhn do cht cc t bo sng trc ty sng. Yu cu bnh nhn gi c hai cnh tay thng pha trc vi lng bn tay nga ln v mt nhm. Quan st ch yu nhiu, t th tay v xem cnh tay c gi n nh c hay khng: - t th nhc trng (hypotonic posture) - c tay un cong v ngn tay m rng - tri dt (drift) - dn dn nng ln km theo mt cm gic,c bit l thy nh - dn dn h xung ng thi quay sp chng t c tn thng thp - h xung m khng quay sp c th thy trong ri lon phn ly hoc yu c gn - run kiu ma v n - mt cm gic (thn kinh ngoi vi) hoc bnh tiu no p nh c hai cnh tay xung di . Chng c xu hng quay v v tr c theo phn x.

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Nu cnh tay vung qu mc khi tr li v tr c, c th do yu c hoc ri lon chc nng tiu no Yu cu bnh nhn lm cc c ng ngn tay nhanh: "Chi mt on nhc nhanh trn piano", chnh bn minh ha vic ny cho bnh nhn. C ng vng v c th l mt ch im nhy cm c a mt tn thng nh ca b thp.Bn chim u th lun lun nhanh hn bn khng. Trng lc c Lun lun khm trng lc c trc khi bn nh gi sc c. y l mt phn khm kh thc hin v bnh nhn thng khng th gin. C gng nh lc hng bnh nhn bng cch ni chuyn. Yu cu bnh nhn th lng cnh tay sau bn gp dui c tay hoc khuu tay bnh nhn. C ng theo hnh vng cung rng mt cch tng i chm ri, ti nhng khong cch khng u ngn s phi hp ca bnh nhn. Yu cu bnh nhn th lng chi, nng v di chuyn khp gi (hng v c chn nu cn thit). nh gi chn l kh v bnh nhn thng khng th th gin. Rung git bn chn c th c nh gi ng thi (xem di y). Tng trng lc c (Hypertonia): - b thp: r rng hn khi gp chi trn v dui chi di. i khi gp du hiu gp dao dp, VD nh gim trng lc c trong khi c ng. - ngoi thp: cng nh ng. Nu kt hp v i run th c ng ging nh 'bnh xe rng ca'. - ri lon phn ly - tng khi tng c ng. Gim trng lc c (Hypotonia): tn thng neuron vn ng thp tn thng neuron vn ng mi tn thng tiu no mt thc Sc c 135

 i vi mc ch sng lc, khm hai c xa, mt c gp v mt c dui (v d nh ngn tay gp v dui), v hai c gn mi chi. So snh hai bn. Kim tra c nghi ng yu bng cch s nn c.

Nu bnh nhn trn ging, bt u khm bng cch yu cu: - Nng hai cnh tay - Nng mt chn ra khi ging - Nng chn kia ra khi ging Khm sc mnh khp chng li sc ca chnh bn khp vai, khu u tay,c tay. Sc c cc khp ln bnh thng khng th b thng bi l c cho php. Nu c du hiu yu hoc tn thng thn kinh khc mt chi, khm nhm c ring bit: - vai - dng, dui, gp - khuu tay gp, dui - c tay gp, dui: "Gi c tay ln, ng ti y xung" - ngn tay gp, nm, dui, khp (t mt mnh giy kp gia cc ngn tay t th dui thng v yu cu bnh nhn gi li khi bn ly n), dng (v i ngn tay dui, yu cu bnh nhn dang rng cc ngn tay chng li sc ca bn). - gp hng (yu cu bnh nhn nng chn, 'ng ti y xung ') v dui ra (yu cu bnh nhn gi chn thng trn ging, v c gng nng c chn), i khi khp v dng.

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- u gi gp, dui - c chn gp gan chn, gp mu chn, xoay ngoi, xoay trong Ch pht hin c ch yu nhiu bi v chn mnh hn so vi tay. Nu khng tm c ch y u v bnh nhn vn than phin l yu, khi cn nhng cch khm nhy cm hn, v d: i bng u ngn chn, gt chn,ng ln t v tr ngi xm, i li bng chn ny hay chn kia. i khi gp bnh nhn yu phn ly. Mt cch khm hu ch l du hiu Hoover. Du hiu ny c khm bng cch t bn tay ca bn di c chn lit ca bnh nhn. Trc tin yu cu bnh nhn dui chn lit (iu ny khng nn gy ra gng sc), v sau bng cch yu cu bnh nhn gp hng bn chn lit, kt qu l gy co c dui hng 'lit' (y l s c nh phn x m tt c chng ta u c). Khng ging nh cc cch khm khc i vi bnh khng thuc c quan, cch khm ny cho kt qu bnh thng chi lit. Sc c thng c phn loi nh sau: 0 Khng co c ch ng. 1 C th nhn thy c nh s c co c nhng khng c vn ng ch ng 2 C ng c khi loi tr trng lc, tc l theo hng ngang. 3 C ng chng li trng lc. 4 C ng chng li trng lc c thm sc cn: c th c chia thnh im t 4 ti 4 +. 5 Sc c bnh thng. Tm loi yu c - lit na ngi (hemiplegia) - y u c ton b mt bn - lit mt chi (monoplegia ) - yu c mt bn chi th - h lit (paraplegia) - yu c hai chi di - lit t chi (Tetraplegia) - yu c t chi - nhc c (myasthenia) - yu c tin trin sau co c lp i lp li thy r nht cc c nh, v d: nhy mt lin tc (xem chng sp mi trang 125) - c gn, VD bnh c - phn b r thn kinh, v d nh sa a m (disc prolapse) - phn b dy thn kinh , v d: r c tay trong lit dy thn kinh quay

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S phi hp
Yu cu bnh nhn chm vo mi ca mnh bng u ngn tay. Bnh nhn m mt, yu cu bnh nhn chm tay vo mi, sau chm vo ngn tay ca bn trc mt bnh nhn. C th thc hin lp li nhanh vi ngn tay ca bn di chuyn t v tr ny n v tr khc trc mt bnh nhn.

Ch tay qu tm v run vn ng hu trong trng hp khng c yu c cho thy ri lon chc nng tiu no. Nu bn nghi ng c bt thng tiu no, khm vn ng nhanh xen k (ri lon lin ng - dysdiadochokinesia): - quay nhanh bn tay (sp v nga) - bn tay kia v nh theo hng ngc li cng nhanh cng tt Yu cu bnh nhn gi gt chn mt bn ln v t xung c ng chn bn cn li. Khi c th thy r c s thiu phi hp. Dng i c th bc rng, v bnh nhn khng th thc hin mt dng i song song (i kiu gt chn - ngn chn ). nh 138

138

(Ghi ch: cch khm nghim php gt chn u gi) Yu cu bnh nhn dng gt chn mit dc b trc xng chy chn cn li t u gi n mu chn.

Phn x gn xng
cnh tay mt cch thoi mi sang bn vi khuu tay gp li v bn tay t ln trn bng. Ni bnh nhn th gin. Phn x c nga ngn (phn x trm quay) : g nh vo u xa ca xng quay bng ba phn x. Phn x c nh u: g nh vo ngn tr hay ngn ci ca bn trn gn c nh u. Phn x c tam u: gi cnh tay ngang ngc g nh gn c tam u. Cc phn x gi: bng cch cng tay tri pha sau c hai u gi, gi gi gp li mt phn. Yu cu bnh nhn th lng chn v g nh gn di xng bnh ch. Phn x c chn (phn x gn gt) : bng cch gp gi v dng chn. C m nh nhng vo cu bn chn,t ba c chn phi v g nh vo gn.

(Ghi ch: u gi L3 Khm phn x c t u i) Phn x gn gt thng khng xut hin ngi cao tui. (Ghi ch: Khm phn x gn gt Gn gt S1-2)

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 So snh cc bn (bn phi so vi bn tri, tay so v i chn).

(Ghi ch: c nh u c trm quay (c nga ngn) c tam a u bn tay ca bnh nhn hi gp Thy thuc g vo ngn tay ca mnh, n xung cc u ngn tay ca bnh nhn C nh u C5-6 c trm quay, c tam u C7-8 Git ngn tay C7-T1) Bnh nhn cn phi th gin v iu ny khng phi lc no cng d dng, c bit l ngi gi. Tng git - tn thng neuron vn ng trn (V d: lit na ngi - hemiparesis) Gim git - tn thng neuron vn ng di hoc tn thng neuron vn ng trn cp tnh. 140

Ch ng git rung (Clonus) - p lc ko gin mt nhm c gy co khng t ch theo nhp. Nu phn x nhanh, hy khm git rung. ng tc gp mu chn t ngt v lin tip ca bn chn bi p lc ln cu bn chn c th gy ra p bn chn lin tc trong nhiu gia y . Ch ng gia t rung khng nh tng git v gi mt tn thng neuron vn ng trn. Git i xng c th l bnh thng. Phn x da gan bn chn Hy ni vi bnh nhn nhng g bn ang lm, v vch ln cnh lng bn chn vi mt dng c gy nguy hi nhng khng lm tn thng bnh nhn. Mt que cam kh hu ch trong trng hp ny. Quan st gp dui cc ngn chn.

(Ghi ch: Kch thch p ng chn Chn L5, S1-2) p ng chn bnh thng - tt c cc ngn chn gp li. p ng dui (Babinski): ngn ci dui ra chm v cc ngn chn xe rng. Rt chn li do au hoc bun din ra nhanh v khng phi l bt thng. nhng ngi c chn nhy cm, phn x c th c gy ra bi s kch thch c hi khc bt c v tr no c a chn, g hoc xoa cnh bn ca bn chn c th rt c tc dng, hoc khm cm gic kim chm trn mt lng ca ngn chn ln.

Thn mnh
Cc phn x da bng him khi cn khm. - Vch nh mi gc phn t v i mt thanh mu cam hoc mng tay ca bn. Nh ng

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phn x ny khng xut hin hoc gim i khi c tn thng neuron vn ng cao hoc thp. Chng thng vng mt in hnh trong bnh a x cng.

(Ghi ch: T9-12 ? Cu bng quang ? Mang thai) Phn x da bu T12-L1. - Vch vo pha bn trong c a chn lm cho tinh hon co ln do c bu co. S bng quang. Bnh nhn khi c cu bng quang (distended bladder) s cm thy rt kh chu khi bn s. Nhiu tn thng thn kinh, cm gic hoc vn ng s dn n cu bng quang,lm cho bnh nhn khng gi c nc tiu v nc tiu trn ra ngoi. Khm sc c bng bng cch yu cu bnh nhn c gng ngi dy m khng cn s dng bn tay ca mnh.

Cm gic
Nu khng c cn c nghi ng c mt cm gic, c th khm cm gic mt cch nhanh chng . Khm nhanh tng chi. Thnh cng ph thuc vo vic lm cho bnh nhn hiu nh ng g bn ang lm. Tr em l ngi chng kin c m gic tt nht v thc hnh km nht. Vic khm ny mang nhiu tnh ch quan. Khi khm vn ng, cn tm xem tn thng v tr no, v d: r thn kinh (khoanh on da dermatome), dy thn kinh, mc cm gic (ty sng), gng tay / bt tt (bnh thn kinh ngoi vi), phn ly (v d au v nhit so vi rung ng v cm gic su. VD.bnh rng ty - syringomyelia).

142

(Ghi ch: khm cm gic v tr) Cm gic rung (Vibration sense) Khm cm gic rung bng cch s dng m thoa tn s 128/ s. Trc tin t m thoa trn xng c bnh nhn nh gi rung ng. Sau , t m thoa ngn chi. Thng bnh nhn cm nhn c cm gic rung lu bng ngi khm (gi s ngi khm bnh thng). Mt vi b nh nhn s cho rng c cm gic rung khi n khng c - nu iu ny ng nghi ng, hy th mt m thoa iu chnh khng rung, nu cm thy n rung ng, kt qu khm l khng ng. Cm gic rung thng gim dn theo tui tc, c th l mt phn ca bnh thn kinh lin quan n tui tc.

Cm gic v tr (proprioception)
Cho bnh nhn bit nh ng g bn ang lm. "Ti s a ngn tay / ngn chn ca bn ln hoc xung [lm nh vy]. Ti mun bn cho ti bit l a ln hay a xung trong mi ln . By gi nhm mt li. Hy gi xa khp, v lm t bn ny sang bn kia, s dng ngn tr v ngn ci ca bn, v thc hin cc c ng nh mt cch khng u, khng lun phin, trnh t, v d: ln, ln, xung, xung, ln, xung. Ngng bnh thng rt thp vn ng th ng nh nht, chm nht m bn c th to ra t cui lun lun c pht hin chnh xc.

au
Ly mt inh ghim sch hoc v trng v khng s dng cng mt inh ghim trn bnh nhn khc. Chm u nhn ca kim trn da. ng lm chy mu. Bnh nhn c th m mt. C cm thy nhi khng, ging nh kim chm? Nu bn thy mt cm gic, xc nh ranh gii vng bng cch tin hnh t ch bt thng n ch bnh thng trn da. nh 142 Nu bn khng chc chn v vic mt cm gic, (cng knh) mt phng php khc l yu cu bnh nhn nhm mt, v t u t hoc nhn ca inh ghim trn da khng u v hi bnh nhn u no l u no.

Cm gic nng
143

 Bnh nhn nhm mt. Ni "c" khi ti chm vo bng si xc gic, n vi p lc 1g, 10 g v 75 g, hoc tm bng. Chm vo cc khong thi gian khng u nhau. So snh hai bn c th. Cm gic nhit khng cn phi khm thng xuyn. Khm v i nc nng v lnh trong ng thy tinh c th khng phi l chun ha. Tm mt vng m bnh nhn gi nng l lnh hoc ngc li v rt ng dc trn da cho n khi nhn ra c ng nhit . Cm gic phn bit hai im. Ngng bnh thng trn u ngn tay l 2mm. Nu gim cm gic trong bnh ngoi vi hoc ty sng, ngng phn bit tng ln, v d: 5mm. Nu tn thng v no, khng tm thy c ngng. Nhn thc vt c khm bng cch t tin xu, cha kha, u bt, vv vo tay bnh nhn v nhm mt li, c gng xc nh bng cm gic. Thiu ch cm gic tt nht tm bng kim chm ch khng phi bng s m. Nu chm kim i xng c hai bn ng thi th ch cm thy bn bnh thng, trong khi c hai bn u c cm gic nu lm tng bn ring bit. Gp trong cc tn thng v no.

Cc khoanh on da (Dermatomes)
Hu ht cc d dng tm c bng kim chm. Khoanh vng gim cm gic. Lu tay: ngn tay gia - C7 v khoanh on da hai bn i xng n gia cnh tay. Lu chn: ranh gii bn ca bn chn v gt chn (S1), mt sau c a chn v hu mn vng c xng cng nng .

144

Dng i (xem trang 45)

Quan st bnh nhn trong khi i. Nu nghi ng mt iu ha nhng khng nhn thy khi i bnh thng, yu cu bnh nhn i kiu gt chn - ngn chn. (Chnh bn minh ha cho bnh nhn). C rt nhiu v d v dng i bt thng. Bnh Parkinson. T th ci vi hu ht cc khp gp li, bc i nh khng n nh v khng vung tay; run bn tay.

Dng i vt c (Spastic gait). Qut ngn chn mt hoc c hai bn khi i, nn c xu hng a chn vng sang ngang trnh iu .

Mt iu ha cm gic (Sensory ataxia). i bc cao, chc mi chn xung. Gp trong bnh thn kinh ngoi vi.

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Dng i tiu no (Cerebellar gait). Chn dng ra khi i.

Ri chn (Foot drop). Ngn chn v n b qut xung t mc d chn bn bnh nng cao qu mc. Dng i l bc (Shuffling gait). Nhiu bc nh - in hnh trong bnh mch mu no lan ta. Dng i hysteria. Thng lo o nhng khng ng. Nghim php Romberg thng c thc hin lc ny, nhng ch yu c p dng trong khm cm gic v tr. Yu cu bnh nhn ng thng vi hai chn chm vo nhau v nhm mt. Nu bnh nhn c bt k du hiu ng no, nghim php dng tnh. Bnh nhn cao tui c th khng thc hin c nghim php ny cn bnh nhn hysteria c th nghing ngi nhng dng li ngay trc khi h ng.Nghim php dng tnh khi mt ct sau ty sng trong bnh giang mai ty sng. Nu bnh nhn lo lng c th lc l qu mc, hy th lm mt tp trung bng cch khm cm gic nhn thc vt ng thi lc l qu mc c th mt i!

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Thng tin c bn

(Ghi ch: B thp Nhit v au Mt na cm gic xc gic (Ct lng) mt na cm gic xc gic, v tr, rung, au su) Mt cm gic ct lng - Gim cm gic v tr, rung v au su (bp gn Achilles). - Xc gic thng khng b mt, v mt na dn truyn trong c t trc. Mt cm gic v no Khuyt tt th hin bi thiu: - C m gic v tr - C m gic xc gic phn bit - Thiu ch c m gic Cc du hiu ca s kch thch mng no - C ng gy - c gng gp c li. Chng li hay l au? - Du hiu Kernig - khng nhy cm nh cng gy.

(Ghi ch: au lng) 147

Nng cao chn gi thng trong au thn kinh ta - Nng chn thng cho n khi thy au lng. Sau , hi h thp xung cho n khi ht au v sau gp bn chn v pha mu chn lm 'cng' dy thn kinh hng to cho n khi au.

Tm tt cc chng bnh thng thng

Tn thng neuron vn ng thp - teo c - rung c cc b - gim trng lc - gim sc c - mt phn x - mt c m gic - Lit T1 - yu cc c bn trong ca bn tay: dng v khp ngn tay dng ngn ci (x. lit dy thn kinh gi a v dy thn kinh tr) - mt cm gic : gia cng tay - Lit dy thn kinh gia yu c dng ngn ngn ci (cc c m ci khc c th yu) - mt cm gic : ngn tay ci, hai ngn tay u tin, b mt lng bn tay Lit thn kinh tr - xoay trong, teo c m t, yu dng v dui ngn tay; bn tay vut tr,khng th dui ngn tay (Ghi ch: au lng v h chn xung Lit dy thn kinh quay Lit dy thn kinh gia Lit dy thn kinh tr) - Mt cm gic: mt na ngn bn, b mt lng bn tay tt c cc ngn tay th nm - Lit thn kinh quay - c tay r xung - Mt cm gic: din tch nh / sn lng ca ngn tay ci - Lit L5 bn chn thng v xoay trong yu, mt cm gic gia bn chn - Lit dy thn kinh mc- bn chn thng v xoay ngoi yu; hi mt cm gic mu bn chn - Lit S1 - khng th ng trn ngn chn, mt cm gic cnh bn ca bn chn, mt phn x gn gt

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Tn thng neuron vn ng trn

- khng teo c - cnh tay dui bn tay ri xung - vung tay qu mc khi g nh - thc hin cc ng tc lun phin nhanh mt cch chm chp: 'chi n piano' vng v - tng trng lc c - chi trn co li, chi di dui ra - du hiu gp dao dp - gim sc c - tng phn x ga n xng ( ch ng gia t ga n cha n) - phn ng c dui bn chn - ri lon c vng - dng i co cng - chn dui c ng v i bn chn thng - Cnh tay khng vung c, gi t th gp Ch . Khm "mc " u tin, sau bnh l.

Ri lon chc nng tiu no

- khng teo c - gim trng lc khi vung tay; cc c ng bt thng - run hu - khng c kh nng thc hin chuyn ng lun phin nhanh mt cch trn tru (lon lin ng - dysdiadochokinesia) - dng i long chong (Ataxic) - rung git nhn cu - ni nhanh hoc ngt qung - mt phi hp khng c ci thin bng th lc (trong khi c vi khuyt tt c m gic)

Ri lon chc nng ngoi thp Bnh Parkinson

Vn ng chm, run, cng, v bt n nh t th l c im ch yu: - t th un cong ca thn mnh, c , cnh tay v chn - mt khng biu l cm xc, th , mt nhn chm chm - tay run kiu v thuc khi ngh ngi - khi u c ng chm chp - trng lc cng nh ng, c th c du hiu "bnh xe rng ca ' 149

- sc c v cm gic bnh thng - ging ni trm v n iu - dng i- bc i nh v l chn, c th bt u hoc dng li kh khn - t th khng n nh: khm bng cch cho bnh nhn ng thoi mi.ng ng sau bnh nhn v ko mnh t ngt v pha sau. Bnh thng bnh nhn s b lc nh; nu bc v pha sau, c bit nu nhiu bc, l bt thng.

a x cng
- Bng chng v tn thng khc nhau v khng gian v thi gian t bnh s v khm. Thng nh hng n cht trng ca no. Cc v tr ph bin: - teo thn kinh th gic- Vim thn kinh th gic - rung git nhn cu ng dn truyn tin nh hoc tiu no - git hm nhanh - tn thng b thp trn dy thn kinh V - du hiu tiu no cnh tay hoc dng i- ng dn truyn tiu no - du hiu neuron vn ng trn tay hoc chn - b thp, bn phi hoc bn tri (mt phn x da bng) - vim ty ngang v i mc cm gic - cho thy mc tn thng - gi nc tiu- thng ng dn truyn cm gic - mt nhn thc cm gic - ng dn truyn cm gic

Khm nh hng h thng

'Khm chc nng cao cp ca no' dng v chung mc thc tm trng ging ni nhn thc - l ln - nh hng - s ch / tnh ton - tr nh ngn hn, di hn - l lun - hiu t thng dng

'Khm cc dy thn kinh s'

I II ngi (ch khm nu c chai th mi) th lc th trng y mt

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III, IV, VI

sp m rung git nhn cu c ng mt ng t V cm gic mt phn x gic mc c hm / git VII c mt tn thng neuron vn ng trn v di (v gic nu c chai th v gic) VIII nghe Nghim php Rinne / Weber rung git nhn cu IX, X vm ming nut (v gic mt phn ba sau ca li) XI c thang XII teo c li

'Khm tay v mt thn kinh'

khm: - v tr bt thng - teo c - rung c cc b - run / chng ma vn yu cu bnh nhn dui cnh tay v pha trc, lng bn tay nga ln, gi nguyn v nhm mt, sau khm: - t th / tri xung - g nh vo pha lng c tay nh gi xem u l v tr n nh - c ng ngn tay nhanh (hnh kim t thp) - chm tay vo mi (phi hp), nghim php ngn tay ch mi - gi cc ngn tay ca ti. Ko ti ln. y ti i ' trng lc c sc c, mi nhm nu c ch nh phn x c m gic - chm nh - kim chm - rung ng - c m gic bn th

151

'Khm chn v mt thn kinh'

khm: - v tr bt thng - teo c - rung c cc b 'Nng mt chn ra khi ging " 'Nng chn kia ra khi ging " phi hp - gt chn - ngn chn trng lc c sc c - 'Nng ngn chn ln. y ngn chn xung' phn x phn x chn c m gic (nh bn tay) nghim php Romberg dng i v dng i song song( Tandem gait)

'Khm tay hoc chn'

khm: - mu sc - thay i da / mng - lot - teo c (c tay v chn c lin quan khng?) - khp s: - nhit , mch - u c c (xem trn) - khp - v n ng ch ng - c m gic lo xo, v d t tay ln u gi khi co dui khp gi) - v n ng th ng (khng lm bnh nhn b thng) - phn x - c m gic

152

CHNG 8

THM KHM NGI CAO TUI NGI T N TT LI TA iu ny l quan trng, c bit l ngi cao tui, nh gi xem bnh nhn c tn tt hay khng: - Nhng tr ngi trong cuc sng bnh thng v nhng mong mun ca bnh nhn. - Nhng iu lm bnh nhn ph thuc vo nhng ngi khc. - i hi s h tr tm thi cho nhng vn c hiu - H tr khng thng xuyn hoc thng xuyn. - Qun l tnh hnh n - iu dng ti nh vi s chm sc trong 24h iu ny l cn thit nh gi nhng vn sau mt bnh nhn: o Kh nng thc hin cc chc nng hng ngy o Kh nng v tinh thn, bao gm c s l ln v mt tr. o Tnh trng cm xc v vn ng Nhng thut ng c s dng nh ngha v phn lo i tnh trng tn tt ca t chc y t th gii: - Khim khuyt- bt c s suy gim hoc bt thng no v mt gii ph u, sinh l hoc chc nng tm l, v d mt s h thng hoc mt phn ca c th khng lm vic. - Gim kh nng- B t c s hn ch hoc thiu kh nng no (do suy yu) trong vi c thc hin mt hot ng trong phm vi b nh thng, tc l hot ng khng th thc hin. - Tn tt- tnh trng hn ch trong cng vic bnh thng do s khim khuyt hoc gim kh nng, v d h qu x hi. Do : - Mt ngi lit na ngi l mt ngi khim khuyt. - Mt ngi khng c kh nng git hoc mc qun o l mt ngi gim kh nng.

153

Mt ngi khng c kh nng lm mt ngh nghip l mt ngi tn tt. Nhng o to lm sng gii thiu nhng phn u ca cun sch ny tp trung vo nh gi nhng tnh trng khim khuyt. Gim kh nng v tn tt khng phi lc no cng c quan tm ng mc v l nhng mt thc t v x hi ca vic gii quyt bnh tt. iu ny l mt sai lm nu bc s b bn tm bi khim khuyt, v bnh nhn thng hiu gim kh nng l v n ln. Mt bn m t tm tt mt bnh nhn c th bao gm nhng iu sau: - Bnh nguyn-tng cholesterol mu c tnh gia nh. - Bnh sinh - X va ng mch - Huyt khi ng mch no gia bn phi - Khim khuyt - Lit na ngi tri - Lit tay tri, khng th dui thng tay, u gi. - Nhng du hiu thn kinh vn ng bn trn tay tri v mt - Gim kh nng-kh khn trong vic n ung. Khng th li xe. - Tn tt - khng th lm nhng vic v d nh bn hng - ngi ngng khi ha nhp x hi - Hon cnh x h i i tc c th lo c cho cuc sng ngy qua ngy, nhng khng c thu nh p t vic lm v l vn ln hin nay ca x hi

nh gi s khim khuyt
Thm khm nh k v ly tin s s gip bc l nhng khim khuyt. Cc phng php o lng chun trn lm sng c thm vo h tr vic nh lng v d: - kim tra luyn tp trn my ch y b - lu lng tc k nh - hi ng nghin cu y khoa v sc mnh c bp - lm mt ngi sao nm cnh t cc que dim ( pht hin ri lon phi hp ng tc trong bnh no gan) Bng cu hi c th cung cp mt ch s bn nh lng nhng mt quan trng ca khim khuyt v cung cp mt m t ngn gn v bnh nhn. Vai tr ca bng cu hi l mt phn ca danh sch kim tra bo m rng cc cu hi cha kha c hi. Chc nng nhn thc.

154

 ngi cao tui, s suy gim chc nng nhn thc c th c nh gi bi bng cu hi 10 im kim tra tm thn c gii thiu bi Hodkinson. Kim tra cc k nng giao tip bnh thng. Mi cu tr li ng c nh du vo b ng 10 cu hi( xem ph lc 3 ): - Tui bnh nhn - Thi gian( gi gn nht) - Cung cp a ch, cho bnh nhn lp li vo phn kt bi kim tra, v d 42 West Stress hoc 92 Columbia Road. - Nh n ra hai ngi - Nm ( nu l thng ging th nm lin trc c chp nhn) - Tn a ch, v d bnh vin hoc khu vc th trn nu nh - Ngy sinh ca bnh nhn - Nm bt u chin tranh th gii th nht - Tn th tng Anh, tng thng M - m ngc t 20 v 1( khng c php c li tr khi bnh nhn t sa cha) - (Kim tra li a ch) y l mt th nghim c bn pht hin s suy gim nhn thc, thay i trong tr nh v s nh hng. N c u im l ngn gn, s dng kin thc tng i c th v c s dng rng ri. ngi cao tui, 8-10 im l bnh thng, 7 c th l bnh thng, nh hn hoc bng 6 im l bt thng. Nhng vn c th, v d s nhm ln hoc i lang thang vo ban m khng nm trong th nghim ny, v cho thy rng y l mt th nghim hu ch nhng khng thay th cho lm sng c. Tc ng v s c gng ng lc l mt yu t quan trng tham gia vo vic thnh cng trong phc hi chc nng. S phin mun, i km vi thiu ng lc l mt nguyn nhn chnh gy ra s tn tt.

155

Hi v nhng triu chng ca trm cm( trang 16) v nhng thm khm c lin quan ( trang 102 v 115), v d: Tm trng ca bn nh th no? Bn c mt s quan tm n mi th? Thay i li sng thch hp, s gip ca ngi thn v bn b, c th l cha kha tng ng lc bnh nhn. Cc dc phm iu tr trm cm cng c th hu ch. nh gi tnh trng tn tt nh gi nhng hn ch trong cc hot ng hng ngy thng l cha kha ca thnh cng trong vic nh gi bnh nhn. o Lm mt danh sch nhng khuyt tt ring bit t cc vn khc v d chn on, cc triu chng, cc vn x hi. Danh sch ny c th c mt cc thit lp u tin, bao gm cc nghin cu ho c cc liu php c kh nng c li cho bnh nhn. Cc hot ng trong cuc sng hng ngy( ADL )

y l nhng chc nng quan trng nh hng n mc ca s t lp ngi cao tui. Mt s thang v mc khuyt tt c s dng. Trong s , ch s Barthel ca ADL, ghi li cc khuyt tt sau y c th nh hng n kh nng t chm sc v i li( xem ph lc 4): - Kh nng i tiu tin t ch. - Kh nng s dng nh v sinh. - Chi tc. - n ung 156

- Mc qun o. - Tm - Di chuyn v d t gh sang ging - i b - S dng cu thang nh gi ny ch ra trng thi hin ti v khng ph i l nguyn nhn c bn hoc ci thin kh nng. N khng bao gm cc chc nng nhn thc hoc trng thi tnh cm. Tng s im cung cp mt nh gi tng th hoc s lc v s ph thuc ca bnh nhn, nhng so snh gia cc bnh nhn l kh khn v h c th c cc khuyt tt kt hp. im s ph thuc vo tnh trng khuyt tt v kh nng c sn. Cc hot ng s dng cc cng c hng ngy( IADL)

y l nhng yu cu phc tp hn mt cht, c lin quan n kh nng sng t lp ca bnh nhn. Thng i hi nhng nh gi c bit mi trng trong nh . - Chu n b mt ba n - Lm vic nh nh - S dng phng tin i li - Qun l tin nong - Mua sm - Git - Ung thuc - S dng in thoi Trao i thng tin.

157

 ngi cao tui, kh khn trong giao tip l mt vn ph bin, v s suy gim nhng iu sau y c th cn ch n: - ic ( c cn n mt my tr thnh khng?) - Li ni( ri lon vn ngn do thiu rng?) - Ku gi s gip khi cn thit. - H tr cho vic c v d knh lp, knh eo mt. Phn tch tnh trng gim kh nng, tn tt v t ra cc mc tiu. Sau khi vit ra danh sch nhng khuyt tt, iu cn thit l to ra mt k hoch iu tr vi nhng mc tiu c th. K hoch ny cn phi thc t. Mt nhm tip cn a ng nh bao gm nhn vin x hi, vt l tr liu, y t v bc s thng l cn thit phc hi chc nng ngi cao tui. Cc mc tiu c th trong vic iu tr ngi cao tui bao gm: - chn on, nu c th, c bit l nhng bnh c th iu tr c. - bnh nhn thoi mi v gim bt cc vn v s cng thng, ngay c khi bnh khng cha c. - cung cp thm thi gian cho bnh nhn, thm ch ngay c khi khng th sng thm lu c. Nhng kha cnh c th c th cn ch n bao gm: - Gim bt cc vn x hi nu c th. - Ci thin vn si m, qun o, khu nu n, nh v sinh. - Sp xp cc dch v h tr v d gip mua sm, cung cp cc ba n, tham gia cc trung tm chm sc sc khe, vui chi ban ngy. - T chc thm hi thng xuyn t nhng ngi y t hoc cc t chc gip khc. - Chc chn rng gia nh, lng ging v bn b hiu c tnh trng bnh nhn. - iu tr trm cm. - Cung cp nhng s tr gip v d: - Nhng vt dng cm tay ln. - i li bng khung hoc nng. 158

- Giy chng trt - Tay cm nh v sinh hoc nh tm. - To iu kin thun li bnh nhn n cc trung tm tr thnh, k thut vin knh mt, bc s chuyn khoa cc bnh v chn, nha s. - m bo cc loi thuc c duy tr mc thp nht, hng dn v ng gi thch hp cho bnh nhn. Xc nh nguy n nhn gy ra khuyt tt. Nhng khuyt tt c th c th gy ra do nhng nguyn nhn c th m c th lm gim nh c. ngi cao tui, nhng vn ph bin bao gm: Nhm ln. y l mt khim khuyt. Nhng nguyn nhn thng gy ra gm: - Nhim trng - Thuc - Cc bnh khc, v d suy tim. - Mt chc nng gic quan, v d ic, m. Gi s mi s nhm ln l mt p ng cp vi mt nguyn nhn khng r. Khng km hm c - Nh v sinh xa v d trn tng - Hn ch v dng i - Nhim khun tit niu - To bn - Sa t cung - Tiu ng Off legs - Suy gim h thn kinh - Gy xng khng do chn thng - Chn nn - Nhng bnh tt khc v d nhim trng, suy tim ,suy thn, tiu ng, h kali mu, nhc gip. T ng - Th m khng vng chc - Cu thang ti - Tm nhn hn ch, v d c thy tinh th, h huyt p t th. - Lo n nhp tim - ng kinh - Thiu ht h thn kinh v d bnh Parkinson, lit nh na ngi. - Ho ho c chng ngt khi i tiu. - Nhim c

159

CHNG IX: NGUYN TC KHM C BN BNH N V NGUYN TC CHN ON.

I. NGUYN TC KHM C BN : Trong thc hnh lm sng, mt bc s khng th no c gng thu thp tng triu chng n l ca mi h c quan. Khi khm , cc triu chng c trng nn c u tin pht hin, v trong trng hp c bt c du hiu bt thng n o khc, cc triu chng km theo s c thu thp cng c thm s nghi ng ca ngi bc s. Danh sch di y l nhng nguyn tc khm c bn ca cc h c quan , n s gip bn c th thc hin vic thm khm hng ngy 1 cch y m khng qu rm r. Khm ton thn : - Th trng ton thn - Bnh nhn khe hay mt mi ? - Nhn biu theo di nhit hoc o nhit ca bnh nhn - C bt c du hiu bt thng in hnh no khng ? - Tnh trng tinh thn, cm xc v hnh vi. Khm tim mch : - Quan st xem b nh nhn c kh th, suy h hp khng ? - Kim tra huyt p - Bn tay : +) Nhit +) Mng tay : mng tay khum +) Bn tay son. - Mch : tn s, nhp, c im - Hch nch v h ch c - Mt v mt pht hin thiu mu, vng da - Li v vng h u hng pht hin tm trung ng - p lc tnh mch cnh (JVP) cao v dng ng ghi huyt p. - Mm tim v tr v c im - Vng quanh xng c ch pht hin cc p v rung miu. - Nghe tim : +) Ting tim , cc ting ph v ting thi +) Dng mt mng nghe tt c 4 van tim +) t bnh nhn nm nghing tri v dng mt chung nghe trong trng hp c hp van 2 l 160

+) Bo bnh nhn ngi dy, ci ngi ra pha trc v th ra nghe tim trong trng hp h van ng mch ch Khm h hp : - Quan st - V tr ca kh qun - Vng trc ngc : +) Di ng ca lng ngc +) G lu so snh 2 bn +) Nghe phi - Vng lng : +) Di ng ca lng ngc +) G c bit l vng y phi +) Nghe phi - Khm cht tit : m , di Khm ct sng Khm bng : - t bnh nhn nm nga - Cm nhn nhp p ca ng mch i v h ch vng b n - Khm thot v - Nhn vng bng hi bnh nhn xem c cm thy au hay kh ch u vng no khng ? - S bng 1 cch nh nhng : +) S tt c cc phn khu ca bng xem c khi no khng +) S gan sau g xc nh din c +) S lch sau g xc nh din c +) S thn +) S pht hin c chng (nu c) - Nghe bng (nu nghi ng) - Vi nam khm b phn sinh dc - Thm trc trng (ch khi c s cho php) thng thc hin sau cng - Thm m o him khi sinh vin thc hin khm m o Khm chi di : - Quan st - Mch p (khm khp nu cn thit) - Khm thn kinh : +) Khm phn x : - Gn xng bnh ch Trng lc - Gn gt C lc - Phn x gan chn Phi hp ng tc +) Khm cm gic : - Cm gic au Cm nhn v t th - Khm rung Xc gic Cm gic nng lnh Khm chi trn :

161

Quan st v t th: hai tay giang rng, mt nhm, run cc ngn tay - Phi hp tay-mi - Khm phn x : +) Gn c tam u Trng lc +) Gn c nh u C lc +) C nga - Khm cm gic : +) Cm gic au Cm gic rung Cm nhn v t th Xc gic Cm gic nng lnh Khm cc dy thn kinh s : - Dy I (dy khu gic ) : nu nghi ng - Dy II (dy TK th ) : +) Kim tra kh nng c 1 bn in cho trc +) Khm ng t - dng n pin xem s thay i kch thc ng t khi chiu n +) Soi y mt +) Th trng - Dy III, IV, VI (cc dy vn ng nhn cu) : +) Hi xem bnh nhn c mc chng nhn i khng ? +) Ch pht hin rung git nhn cu - Dy V, VII: +) Xem c ng h ming +) Nghin rng s c cn +) Cm gic xc gic +) Phn x gic mc nu nghi ng +) V gic nu nghi ng - Dy VIII (dy TK thnh gic ): +) Quan st tng bn tai +) Test Rinne, Weber nu nghi ng - Dy IX , X (dy vn ng cc c vng hu hng) : - Dy XI (dy TK ph ): khm c ng nng vai - Dy XII (dy TK h thit) : bo bnh nhn l li Quan st bnh nhn khi i li : ch dng i Khm thot v v chng gin tnh mch II. MU BNH N : H tn bnh nhn : Tui : Ngh nghip: Ni r tn bn cng nh chc v,v d : A.Bloggs SV nm II Ngy nhp vin : L do vo vin : - Ghi thnh 1 danh sch theo li k ca bnh nhn Bnh s : -

162

M t chi tit v tng triu chng (k c khi cc triu chng n y khng c mi lin quan vi nhau ) Ln bnh nhn cm thy khe gn y nh t M t theo th t thi gian t khi triu chng u tin xut hin cho n lc nhp vin (C th bao gm c thng tin t pha ngi nh bnh nhn - Trong trng hp n y, vic m t cng tng t nh trn) Hi 1 cch chi tit, t m cc cu hi khc c lin quan n cc chn on phn bit c th c functional enquiry (thm d chc nng) , kim tra cc c quan pht hin cc triu chng khc (Trnh by ngn gn trong bnh n v cn nng; cm gic ngon ming; tnh trng tiu ha, i tin, tiu tin; kinh nguyt khi cn thit)

Tin s : Cc bnh mc trc y: Sp xp theo th t thi gian. Tin s gia nh : Tin s bn thn v x hi : - Bao gm cc thng tin chi tit v hon cnh gia nh, s lng ngi ph thuc, ngh nghip ca b m - nh hng ca cc t bnh trc ti i sng v lin quan vi cc ln xut vin - Tin s ht thuc, ung ru, lm dng ma ty, dng thuc Khm ton thn : - Tnh trng ton thn, - Ghi li cc triu chng thc th 1 cch c h thng M t mt cch t m : Ph n khe mnh, c nui dng y Khng st, khng c thiu mu, vng da ho c tm Khng c h ch to Khng c mng tay khum Tuyn v v tuyn gip bnh thng H tim mch (CVS) : - Huyt p, tn s v nhp mch p - p lc tnh mch cnh khng tng - V tr mm tim - Ting T1,T2 ; khng c ting thi H h hp : - C ng lng ngc bnh thng - G khng pht hin thy iu g b t thng - Breath sounds vesicular (R ro ph nang) - Khng c ting bt thng khc Khm bng : - Li, hu b nh thng - Bng cn i, khng au - Gan, lch, thn, bng quang khng s thy - Khng cm nhn thy c khi trong bng 163

- L bn bnh thng - Khm trc trng khng pht hin thy bt thng - Khng th c hin thm m o - Tinh hon bnh thng H thn kinh trung ng (CNS) : - Alert and intelligent (tnh to v minh mn) - ng t u, phn ng vi nh sng v s tp trung tt - y mt bnh thng - C ng nhn cu bnh thng - Khm cc dy th n kinh s khc cha thy c g bt thng - C ng cc chi bnh thng Phn x gn c nh u + + Phn x gn c tam u + + Phn x c nga + + Phn x gn xng bnh ch + + Phn x gn gt + + Phn x gan chn Cm gic xc gic v rung bnh thng Ct sng v cc khp bnh thng Dng i bnh thng Cc mch (bao gm c mch mu chn v mch chy sau) u bt c TM TT BNH N Vit cc dng tm lc v : - Cc tin s cng nh triu chng dng tnh ni bt - Cc triu chng m tnh c gi tr chn on phn bit - Hon cnh gia nh - Tnh trng sc khe ca bnh nhn +) S hiu bit v bnh tt +) Cc mi quan tm c bit DANH SCH CC TRIU CHNG V CHN ON Sau khi hi bnh v thm khm, bn hy lp 1 danh sch : - Cc chn on m bn ngh c th c - Cc du hiu hoc triu chng bt thng m bn cn phn vn V d : - Cc triu chng c nng - Mi lo lng ca bnh nhn - iu kin sng thiu thn - Cc kt qu xt nghim cn lm sng - Tin s d ng thuc Tt nht l bn nn phn chia cc triu chng lm sng ca bnh nhn thc s quan trng ho c c cc triu chng tim tng i hi phi c s iu tr hoc cn theo di sau vi cc triu chng ht. V d nh : Cc triu chng ang c Thi gian Cc t ngt khng r nguyn nhn trong vng 1 tu n Cn au tht ngc t nm 1990 Tng huyt p- HA 190/100 mmHg t nm 1990 164

Suy th n mn - Creatinin huyt thanh 200 micromol/l Ga ph, khng ngh nghip, sng 1 mnh Lo lng v kh nng b thng sau 1 tai nn Tin s ht thuc l: 40 iu/ngy Cc triu chng ht Ng c gip c iu tr bng ct 1 ph n tuyn gip Ho c iu tr bng thuc c ch men chuyn

t thng 8 nm 1996

Thi gian 1976 1991

Ban u bn s thy rt kh bit cc triu chng nn c phn loi nh th no, triu chng no c th a vo 1 hi chng chn on v triu chng no ch l 1 triu chng n l. V vy, bn nn vit li cc triu chng thnh 1 danh sch trong trng hp bn c th hiu c triu chng bnh nhn c hoc 1 triu chng c ngha trong chn on. Khi bn c kinh nghim, cch ph hp nht l in cc triu chng thu thp c v 1 danh sch cc triu chng y u mi bnh n. Cc triu chng ang c Bao gm cc triu chng c nng, cc triu chng bt thng cha gii thch c, cc vn v x hi v tm l Thi gian Cc triu chng ht Bao gm tin s cc bnh, phu thut v qu mn trong qu kh. Khng bao gm cc triu chng i hi s iu tr tch cc Thi gian

T danh sch cc triu chng, bn c th a ra: Chn on phn bit , bao gm cc chn on m b n ngh nhiu kh nng c th c. Hy nh rng : - Cc bnh ph bin thng hay gp - Biu hin bt thng ca 1 bnh thng gp hay xy ra hn so vi 1 bnh him gp Khi b n nghe thy ting mng nga hy ngh n nga phi thay v nga vn - Khng nht thit phi t b bi nhng triu chng khng lin quan ( y l con g ? L 1 ngi bn ca nng dn, c 4 chn, ve vy ci ui v ku o o . l con ch, cn ting ku l ca 1 con vt khc.) Cc xt nghim cn lm sng m bn cm thy thch hp Vic theo di v liu php bn ngh c th thc hin c Tin lng cc bin chng cng nh kt qu iu tr CHN ON

165

Cc thut ng chn on m bc s s dng thng lin quan ti mc hiu bit khc nhau ca ngi bc s :

Ri lon chc nng Tn thng cu trc Bnh sinh

au cng khp Thoi ha khp Bnh nhim sc t st ca m (Haemochromatosis) Ri lon di truyn chuyn ha st t bin gen ln C282Y

Kh th Thiu mu Thiu st

au tht ngc Hp ng mch vnh Vim ng mch ch Giang mai

Bnh nguyn

Lot t trng chy mu

Cc triu chng khc nhau i hi chn on mc khc nhau, iu m c th thay i khi nhng thng tin hu ch c thu thp sau . V vy, 1 bnh nhn nhp vin c th c chn on l st khng r nguyn nhn. Sau khi chp X- quang bng khng chun b ,bnh nhn c pht hin c khi trong thn m trn phim chp CT cho thy 1 p xe quanh thn , cy mu cho kt qu dng tnh vi t cu vng. a ra ch n on xc nh , tt c cc kha cnh u phi c xc nh tuy vy iu ny thnh thong l khng th. Rt nhiu thut ng c s dng cho 1 chn on tuy nhin trong thc t chng cng bao gm c nhng hiu bit sai lch . V d : bnh tiu ng ( bt ngun do nc tiu bnh nhn c v ngt, nhng ngy nay tiu chun chn on l ng huyt cao) l 1 thut ng m t ri lon chc nng ca c th. Ung th m lin kt (Sarcoid) lin quan ti 1 lot cc triu chng v bnh sinh l do non- caseating granulomata (u dng t bo h t) trong khi cha bit bnh nguyn. BO CO THEO DI (PROGRESS NOTES) Khi bnh nhn nm vin, vic ghi chp y trong qu trnh theo di bnh nhn nn c thc hin cho bit bc tranh ton cnh v : - Chn on c a ra nh th no ? - Bnh nhn c iu tr nh th no ? - Tin trin ca bnh - C bt c bin chng no xy ra khng ? Nhng ghi chp ny cng quan trng nh gi tr ca vic thm khm ban u. Trong trng hp cp tnh, s ghi chp h ng ngy c th pht hin s thay i ca cc triu chng. Trong trng hp bnh mn tnh, cc h c quan lin quan nn c khm li t nh t 1 tun 1 ln v ghi chp li cc triu chng. Vic phn loi cc kha cnh khc nhau ca 1 bnh thc s rt hu ch : - Cc triu chng - Cc d u hiu 166

Cc xt nghim cn lm sng nh gi tnh trng ton thn : v d phn ng ca c th i vi liu php iu tr - Cc k hoch khc bao gm c vic t vn cho bnh nhn v gia nh v tnh trng bnh Cc triu chng thc th khch quan nh s thay i v cn nng, s ci thin v mu sc, mch, c im ca s h hp hoc dch a vo v thi ra c gi tr hn cm gic hon ton ch quan ca bnh nhn nh cm thy khe hn hoc ng tt hn. Trong trng hp cn thit, vic theo di huyt p hng ngy v phn tch nc tiu nn c thc hin. Li ch ca cc th thut y hc chng hn nh chc d lng ngc nn c ghi li. Cc ghi chp c bit nh : - Cc pht hin v ghi ch ca bc s iu tr hoc bc s phu thut ph trch - Kt qu hi chn - kin t cc khoa khc CC GHI CHP NH HNG NGUYN NHN Dr Larry Weed xut 1 h thng ghi chp li tin s cng nh thm khm bnh nhn c tp hp thnh 1 c s d liu.Tt c cc ghi chp sau u c t chc da vo cc nguyn nhn c nh s 1 cch c th trong danh sch nguyn nhn. Vic ghi chp nh hng nguyn nhn thc s i hi 1 h thng lu tr c bit. Do h thng y thng khng c s dng , tuy nhin danh sch nguyn nhn thc s c gi tr nh gi khi tt c cc kha cnh bnh l ca bnh nhn c ghi nhn. CC XT NGHIM CN LM SNG THNG XUYN Kt qu ca cc xt nghim cn lm sng nn c tp hp trong cng 1 bng cng 1 trang. Khi c bt c tng phn tch no c thc hin v d nh vic m s lng t bo mu, o tc lng huyt cu hoc phn tch sinh ha tng hp , kt qu c th c trnh by di dng th. BNH N PHU THUT i vi bnh nhn phu thut, vic ghi chp bnh n phu thut phi c thc hin ngay lp tc sau ca m. Khng ghi chp da vo tr nh theo thi gian ca bn bi v mt s vn tng t nhau cng c th c thc hin trong cng 1 ca m. K c trong trng hp c ca cp cu lm bn sao lng vic vit bnh n th bnh n phu thut vn phi c vit trong ngy din ra ca m. Bnh n bao gm cc bo co chi tit v cc vn sau : - Tn ca bc s tin hnh ca m v ngi ph m - Tn ca bc s gy m v loi thuc m c s dng - Tn v kch c ng m c thc hin - Tnh trng bnh l c pht hin, cng nh cc bin i gii phu - Cc th thut m c tin hnh - Phng php khu vt thng v cht liu ch khu c s dng - C t dn lu hay khng, cht liu ca ng dn lu, v c cn phi khu vt thng khng - Loi bng c s dng

167

BNH N HU PHU Vic ghi chp c thc hin trong vng 2 ngy u sau m : - Tnh trng chung ca bnh nhn - C bt c bin chng hoc triu chng bt thng no khng ? v d : au, xut huyt, nn, chng, - Phng php iu tr BO CO LC RA VIN Mt bo co y v tnh trng bnh nhn lc ra vin nn c thc hin : - Chn on cui cng - Cc vn cn tn ti - Dng thuc v cc liu php khc - K hoch iu tr - Nhng im cn theo di c bit, v d : tnh trng trm cm ko di, kim sot huyt p - Nhng iu cn lu i vi bnh nhn - Bnh nhn c chuyn i u, s gip no l c gi tr - Khi no bnh nhn s n ti khm - nh gi tin lng bnh Trong trng hp bnh nhn t vong, sinh vin phi tham d vic khm nghim t thi v hon thin bnh n bng ghi chp ngn gn v kt qu khm nghim.

168

CHNG 10: K NNG TRNH BY MT CA BNH

Trnh by vi cc bc s Y hc l mt lnh vc i hi bn phi c kh nng giao tip. Bn thc hnh nhiu hn th b n s tr nn t tin hn khi bn xut hin trc cc bc s, y t v bnh nhn. S tin tng c to ra do bc s l mt kha cnh quan trng trong iu tr v r rng l c gi tr rt ln i vi bnh nhn ca mt bc s c kh nng giao tip. Thc hnh ni chuyn vi chnh bn qua gng, trnh bt c s gin on no hoc thm t er. M mt cun sch, tm mt ch v t mnh ni chuyn v n. Thm ch nu bn khng bit bt c iu g v ch ny, bn s c th to nn mt s cu mch lc mt khi bn c kinh nghim. Trnh by khng phi l chng minh bn thu o v hi tt c cc cu hi, nhng l thi gian th hin bn thng minh khi tp hp cc yu t cn thit. Trong tt c cc bi thuy t trnh, nu ra cc pht hin tch cc ni bt v nhng tiu cc c lin quan. V d: - mt bnh nhn c tnh trng kh th tng dn, hy ni r nu bnh nhn cha tng ht thuc. - mt bnh nhn hong n, hy ni r nu bnh nhn cha tng nc ngoi, khng c bt c tim truyn hay s dng thuc gn y, khng tip xc vi bnh nhn vng da no khc. 3 dng ca thuyt trnh c th gp: trnh by mt trng hp trong bui hp, trnh by v mt trng hp mi trong khoa phng v trnh by tm tt v mt vn theo di. Trnh by mt trng hp trong cuc hp iu ny ph i c chun b k lng, bao gm c s h tr trc quan nu cn thit. Nhng chi tit quan trng, c hin th trn my chiu s gip bn nh n chng, khn gi cng d dng hn trong vic ghi nh cc chi tit trong trng hp h thy cng nh nghe chng. o Thc hnh bi trnh by ca bn t u n cui v loi tr mi yu t may ri o ng ni chuyn qua mn hnh m hy ni chuyn vi khn gi. o Khng a ct, tr khi bn cho l thch hp. o Khng bo co chung chung. o c v bnh hoc vn trc bn c th tr li bt c cu hi no. o c mt bi bo co hng dn gn y, xem li hoc nghin cu v ti ny. 169

 nhiu bnh vin vic bn trnh by vn bn gc, hp l c mong ch. Hy chun b nh ga v ph n bin bn tho. Nu cp trn ca bn khng th cung cp cho bn ti liu tham kho, tm kim trn mng, trong cc gio trnh ln, hoc hi nhn vin th vin lun gip ch cho b n. Cc nghin cu gn y thng c vai tr gio dc cho bn nhiu hn v th v hn i vi khn gi. Phn m u nn gm c: ng( b) A.B. Tui: x nm M t tm tt, v d ngh nghip. Phn nn v ( tnh trng bnh nhn) Tin s ca tnh trng hin ti - cc chi tit quan trng - cc thng tin khc c lin quan, v d yu t nguy c - cc thng tin m tnh c lin quan n chn on c th. - mc hn ch cc hot ng b nh thng do bnh hoc cc triu chng - cc triu chng khc Tin s - cp ngn gn n cc vn khng lin quan - thng tin v cc vn c lin quan vi tnh trng hin ti. - d ng, bao gm typ d ng thuc. Tin s gia nh: - M t ngn gn v cha m, ch m t chi tit khi c lin quan. Tin s x hi : - ngn gn tr khi c lin quan. - cung cp hon cnh x hi gia nh - ngh nghip v ngh nghip trc kia. - bt c vn c bit no khc - tin s ht thuc l hoc ung ru trong qu kh hoc hin ti. iu tr - ch n tn thuc v liu lng Trong thm khm M t tng th - Gii thiu th trng v d bo, trung bnh. - Cc du hiu c lin quan n bnh - Cc triu chng m tnh Hy nh cc pht hin ny nn l d kin m t hn l gii bn. Danh sch cc vn Chn on phn bit( t th t theo kh nng gim dn) iu tra - Cc pht hin m tnh 170

thch ca

Cc pht hin dng tnh Lp bng hoc th cho cc d liu lp li. Chp li in tm hoc bng nhit

Bo co tin K hoch Nhng ch thng c tho lun sau bi thuyt trnh ca bn l: - ch n on phn bit khc. - nhng im khc bit ca cc ch n on m c th c trong bn bo co ho c i hi phi nghin cu. - c ch sinh l bnh. - c ch tc dng ca thuc v cc tc dng ph c th c Sau khi th o lun lm sng, hy chu n b trnh by mt cng b v cc chi ph cn thit. Trnh by v mt trng hp mi trong bnh phng o Nhng vn bn c ghi ch tt l s h tr tuyt vi. ng c cc ghi ch ca bn hon ton m hy s dng n nh l tham kho. o nh du, nhn mnh cc chi tit bn mun tham kho, hoc vit mt tm th ring bit tham kh o. o Ni chuyn mt cch trang trng, trnh ni qu nhanh hay qu chm. Ni chuyn vi nhm ch khng ni chuyn ring vi chuyn gia t vn. o ng thng gip bn t tin hn. o Nu bn b gin on mt cuc tho lun, ch bn ang u v sn sng tip tc, hy ni li cu ni cui cng trc khi tip tc. Tin s nh dng s tng t nh trng hp thuyt trnh trn, nh n mnh n cc pht hin tch cc v tiu cc c lin quan. M t y cc triu chng ban u thng l cn thit. Khm: Sau khi tin s ca bn hon thnh, chuyn gia t vn c th hi cc du hiu lm sng c lin quan. Vn thm cc d u hiu m tnh m bn ngh l quan trng. Tm tt Hy chu n b cung cp danh sch cc vn v chn on phn bit. Nu bn ang trnh by bnh n ti ging bnh, hy m bo bnh nhn c thoi mi. Nu bnh nhn mun b sung hoc lm r iu g, y thc s l rt tt. iu ny c th lin quan v gip ch cho b n. Nu khng thch hp th bn hy lch s ni vi bnh nhn rng bn s quay tr li sau khi trnh by nhng pht hin. Khng tranh lun vi bnh nhn. M t tm tt nhng iu sau y Cho mt li gii thiu ngn gn th hin cc thng tin, v d: Mt bnh nhn nam xx tui vo vin xx ngy trc. Cc vn tn ti t lu bao gm xxx (danh sch ngn gn). Hin ti c cc triu chng xx trong giai on x. Thm khm thy cc du hiu xx.

171

Chn on s b ca xx c xc nhn/ h tr/ khng h tr bi nhng nghin cu xx. Bnh nhn c iu tr bi xx. Tin trin: - Cc triu chng - Thm khm Bt u vi cc m t khi qut v bng nhit v, nu c lin quan, cc iu tra. Nu c nhiu vn , m t ring bit, v d. - vn u tin lin quan n xxxx - vn th hai lin quan n xxxx. Nhng vn cn tn ti l xxxx. K hoch l xxxx. Bn tm tt y l danh sch cc vn c bn khi tip xc bnh nhn v bnh. Thc hin tip cn theo cu trc ny c th gip ch. Bnh s/tin s - triu chng ch yu - tin s ca tnh trng hin ti: Triu chng bt u nh th no? - trnh t - tnh trng hin ti - tin s qu kh - tin s gia nh - tin s c nhn v x hi au hoc cc triu chng khc - v tr - hng lan - c im - mc - thi gian - thng xuyn/ chu k hoc lin tc - cc yu t lm tng thm - cc yu t lm gim - cc triu chng lin quan - c khi no tt hn hoc ti t hn U cc - v tr - kch thc - b mt - hnh dng - xung quanh - mm/rn - xung quanh-c nh/di ng - au

172

Hch bch huyt ti ch Ni vi ti v bnh tt - t l mc - khu vc a l - gii /tui - bnh nguyn - bnh sinh - nhn bng mt thng - vi m - sinh l bnh - triu chng - du hiu - iu tr - tin lng Nguyn nhn gy ra bnh o Di truyn o Nhim - virus - vi khu n - nm - k sinh trng o Khi u Ung th - nguyn pht - th pht - u lympho o Mch mu - x va ng mch - tng huyt p - bnh khc, v d vim ng mch o Thm nhim - x ha - amyloid - u ht o Bnh t min o Ni tit o Thoi ha o Mi trng - ch n thng - do thy thuc-tc dng ph ca thuc - ch t c o Dinh dng - tng th - c hiu, v d thiu vitamin 173

t thi k mang thai v tc ng n giai on pht trin v sau

Chn on xc nh o Bnh nguyn, v d lao, di truyn

Bnh sinh, v d, sarcoid, amyloid

Ri lon chc nng, v d tng huyt p, i tho ng

Cc du hiu hoc triu chng v d vng da, nt trn da. Mi ngi-bao gm c bnh nhn

Mt s lng ng k nhng s phin phc, kh chu c th trnh c trong bnh vin nh truyn thng thch hp. Bc s khng phi l tt c, nhng l mt phn ca nhm gip ch cho bnh nhn. Bn phi c kh nng giao tip vi cc nhn vin iu dng, vt l tr liu, bc s chuyn khoa ngh nghip, ngi qun l v trn tt c l vi bnh nhn khc. Khi bn i thm cc phng bnh khc ln u, y l mt tng tt bn thy y t trng, vt l tr liu v tm hiu v cng vic ca h, nhng kh khn ca h v lm th no h theo di cc bnh nhn khc. Nh nhng iu sau y o Thi gian-khi bn ni chuyn vi ai , c gng khng vi v hoc h s mt tp trung v khng nghe. Mt t thi gian ni chuyn vi ai ng cch s gip bn rt nhiu. 1 pht bn ngi xung dng nh l 5 pht cho bnh nhn v ngc li 5 pht ng dng nh l 1 pht o Im lng -trong x hi hin nay khi giao tip ngi ta c xu hng trnh im lng. Trong cuc ni chuyn, ngay sau khi mt ngi tm dng ni ngi kia s ni. Khi phng vn bnh nhn, iu ny thng hu ch, nu bn mun khuyn khch bnh nhn giao tip nhiu hn, hy gi im lng lu hn mt cht bnh nhn c t nhin. Gt u khuyn khch, lp li t cui ca bnh nhn c th gip bnh nhn ni thm na. o Lng nghe-Lng nghe tch cc mt ai khng phi l iu d dng nhng l iu cn thit giao tip tt. Nhiu ngi tm dng ni nhng khng phi tt c h lng nghe. Ngi xung cnh bnh nhn l iu thun li gip bn tp trung v gip truyn thng tin n bnh nhn m bn ang sn sng lng nghe.

174

o Ti ci- n ci hoc s kch thch l cch tt nht bnh nhn tm ngng ni. Mt n ci thng s khuyn khch bnh nhn cho bn bit nhng vn ng ta s khng lm mt cch thng l. iu ny gip mi ngi th gin. o Lm yn lng bnh nhn- nu bn xut hin t tin v thoi mi iu ny s gip nhng ngi khc cng cm thy nh vy. Bnh tnh v khng vn ng c th qu nhiu c th gip bn. Hy lu lm th no mt chuyn gia t vn tt bit lm yn lng bnh nhn v cho php nhng ngi khc trong nhm th y rng h ang lm vic c hiu qu. L mt sinh vin, b n khng cng v ny tuy nhin b n c th ng gp bng cch bnh tnh v thc hin cc ho t ng c hiu qu ca bn. o Khim tn-khng c ai, c bit l vi bnh nhn.

175

Chng 11: Cc phng php chn on hnh nh v kho st lm sng

M u

Chng ny gii thiu tm tt cc nghin cu lm sng m u vi s m t chung cc phng php chnh, v theo cc chuyn khoa tim mch (tr. 199, vi ECG (tr. 235), ni h hp (tr. 209), tiu ha (tr. 214), thn ni khoa, (tr. 217), thn kinh (tr. 218), huyt hc (tr. 220), ha sinh (tr. 225), v ly mu mu (tr. 230).
Siu m

Sng siu m tn s cao (2.5-10 MHz) to ra bi hiu ng in p bn trong cc u d siu m. Cc u d ny va to ra v tip nhn sng m c di chuyn trn b mt ca da v sng m ph n chiu hnh nh ca cc cu trc c quan bn trong c th. Cc cu trc vi ch vi mt phn cch, nh cc cu trc y dch cho php sng m lan truyn qua v to ra hnh nh ti hn. Cu trc vi nhiu mt phn cch gy tr m ln v khc x sng m to ra h nh nh trng hn. Khng kh gy yu dn cc sng m, nn cc cu trc nm su bn trong khng th thy c. Siu m l mt kho st thc ti v chnh xc ph thuc vo kinh nghim ca ngi lm. Phng php c nhiu u im: an ton, pht x khng gy ion ha, c th lp li, khng au v cn chun b bnh nhn t hn.. Cng c th kho st ti ging bnh v nh gi mt lot cc c quan ch trong mt thi gian tng i ngn. Siu m c s dng trong nhiu bnh cnh, bao gm: Bng Gan: u, p xe, bnh gan lan ta, gin ng dn mt, h mch ca gan Ti mt: si mt, bnh l thnh ti mt 176

Ty: u ty, vim ty Th n: kch thc, thn nc, u, si, so Lch: kch thc, cc bt thng khu tr Bung trng: kch thc, nang, u T cung: thai, u, ni mc ng mch ch: ph nh mch Rut: vim nhim, p xe, u

No : tr em trc khi no th t trc ng Tim: xem siu m tim mch, tr. 200 Mng phi: d ch hay d y dnh mng phi Mch mu: phnh mch, cht hp, huyt khi Tuyn gip : c im nhu m

177

Bu: u, vim nhim C xng: trn d ch khp, cc khi m mm

Ni soi

Quan st trc tip cc c quan bn trong, thng vi ng ni soi mm Ni soi d dy: ng ni soi mm c lun qua ming sau tim diazepam nhn trc tip thc qun, d dy v t trng (xem tr. 214), (ERCP, tr. 215). Ni soi trc trng: Bnh nhn nm nghing, mt ng ngn c bi trn bng gel a qua hu mn. kho st: Chy mu trc trng: tr hoc carcinoma hu mn Ni soi i trng sigma: Bnh nhn nm nghing tri, ng ni soi cng hoc mm. Trc trng c bm kh. kho st: Chy mu, a chy hoc to bn: vim lot, bnh ng tiu ha nhim khun khc ho c carcinoma Vng vim nhim hoc sinh thit khi u Ni soi i trng: C th kho st to n b i trng hoc on cui hi trng sau khi lm sch i trng. kho st: Chy mu, a chy hay to bn: bnh i trng nhim khun, polyp, hay carcinoma Ni soi ph qun: Quan st ph qun gc sau tim Diazepam. kho st: Ho mu hoc nghi ng tc nghn ph qun: carcinoma ph qun, v lm sch ph qun tc nghn. Ni soi bng: C th quan st cc c quan bn trong qua ng rch nh sau khi gy m, chc ht lm t bo hoc vi khun, hoc sinh thit. Phu thut ni soi qua thnh bng bao gm trit sn, ly trng th tinh trong ng nghim v ct ti mt ni soi. Ni soi bng quang: Sau khi gy m, ng ni soi c a vo qua l niu o. kho st: i mu hoc lu lng nc tiu thp: u bng quang Ni soi niu qun ngc dng

178

Ni soi niu o: Khm xt c t cung, thng ly mu knh pht c t cung. kho st: Nhng thay i tin ung th hoc ung th. Sinh thit bng kim: Sinh thit li: Ly li nh ca m (30-1mm) nh chc kim chn on gii phu bnh. xem xt: o Gan: x gan, bnh gan do ru, vim gan hot ng mn tnh o Th n: vim cu thn, vim thn k o Phi: x, u, lao Chc ht t bo: L k thut ly t bo chn on khi u hoc chn on vi sinh. Di s hng dn ca siu m, CT, hay IMR. xem xt rt nhiu khi u cha xc nh c, v d u v hoc ty, chn on carcinoma.

X-Quang :

XQ thng thng ch thy 4 mt c bn: khng kh, kim loi, m v nc. Mt kh mu en, mt kim loi (hu ht l canxin v bari) mu trng vi ranh gii r. Nc v m ti xm. Kh xem mt cu trc 3D phim 2D. Mt nguyn tc hu ch trong vic xc nh v tr tn thng l ch mc lin k b nh thng b xa m nu c. V d : mt tn thng mt nc xa m b phi ca tim phi nm thy gia phi phi v khng thy th p hn. XQ ngc: Chp sau trc hoc chp trc sau ch thc hin khi bnh nhn nm trn ging (Hnh 11.2). Tn chnh xc cho chp ngc thng dng l chp ngc sau-trc. iu c ngha l v tr ca tim nm gn phim khi c th v hnh nh ca tim m rng ti thiu. o Theo mt tin trnh logic t trung tm ra ngoi vi ca phim- bng ca ranh gii ch nhn thy khi s cn nng lng tia X ca m lin k khc nhau. V vy b ca tim khng thy khi xp hoc ng nht vi m phi bn cnh. o Cc yu t k thut: V tr: Thy c cc nh phi, gc sn honh trn phim Ht vo: Thy c t nht 6 xng sn sau trn c honh bn phi
o xuyn thu: Nhn th y cc khoang lin t sng gia tim Xoay: Kho ng cch t mm gai n 2 u trong ca xng n b ng nhau. Lu cc catheter, ng, dy to nhp, trn kh mng phi.

179

Hnh 11.2 (a) Mt phim chp sau-trc b nh thng (PA); (b) phim chp trc sau (XQ di ng chp ti ging).

180

o Tim Kch thc: Ch s tim ngc bnh thng di 50%. ng knh tim nam < 15.5 cm, n < 15 cm. Hnh dng: Bung tim to ra? Chp trc sau (tht tri v nh phi). Chp nghing (tht phi v nh tri). Vi ha: van tim hay cc ng mch. o Mng ngoi tim Hnh cu gi trn d ch mng ngoi tim Vi ha gi lao o ng mch ch Ln trong phnh mch, nh trong thng lin nh Vi ha ni mc mch, > 6 cm trong lp o ngoi gi phnh tch ng mch o Trung tht Rng ra? Xem phim nghing xc nh v tr o Rn phi Bn phi ng ngang, bn tri cao hn 0 - 0.25 cm. Tn thng thay th gi hao ht th tch phi, v d: xp phi, x phi Rn phi to ra: Nu phn thy (mt khi hay hch lymph). Gin mch? T trng? o Mch mu phi To trong trng hp c shunt ti tim hoc ngoi vi.

181

 To trong tng p phi vi cc mch mu nh lp o th 3 - shunts, gim O2 mu, tc mch, bnh phi mn. Ph n khng c mch - nhi mu phi Nh trong suy tim sung huyt, tht phi/ hp ng mch phi o Nhu m phi m hai ph trng nh nhau (mu en) Bng ph nang - m hay hp li dy c + Phim ph qun kh: nc, m, mu, u quanh ph qun, thng thy ph qun tn, hnh vng trn gn rn phi. Nt, v d: u ht, lao Dng li - bnh phi x ha: Ch tnh thun nht, i xng, mt hay hai bn, trn hay di. Khi + Xc nh v tr, b, hnh d ng, kch thc + U, p xe, tc mch, vim o Mng phi Dch: + ng nht, m, thng li trn phim nghing. + Nu c ranh gii dch - kh: vim m mng phi hoc sau chc d thnh ngc. Trn kh mng phi + M b phi + Dch chuyn trung tht: trn phi p lc Khi + Phn thy: ngn dch hay u o Xng X ha, thnh : Di cn?, v d v, tin lit tuyn, d dy, thn, tuyn gip, lympho - x ha ty, bnh Paget Tiu xng: Di cn?, v d: phi, i trc trng, u ty Hy xng (ch pht hin trong giai on tin trin). Khng th phn bit c long xng v nhuyn xng trn phim XQ, tr vng Looser (gy xng gi) trong bnh nhuyn xng. Tm gy xng o V tr khc Thot v d dy qua c honh, gn thc qun sau tim Xp thy di tri sau tim Phi pha sau vm honh Kh di c honh trong phim chp ngc ng: thng tng rng, mi ph u thut. nh phi: C nhn thy trn xng n 182

XQ bng Hiu qu km phim ngc bi v m phn quang t hn. Kh trong rut rt hu ch nh ng c i chu. C tm ng nt cc tng khi c th. Thng chp t th nm nga (AP) Chp ng vi mc nc-hi (AFLs) + < 5 AFLs ngn l bnh thng + Nhiu: tc nghn + Cng gp trong tc rut do lit rut, bnh bng, ti tha hng trng o Ni tng Gan

+ Thn g di < 18 cm, mt di lt bi m + C kh trong ng mt trung tm? Lch to y bng kh d dy ra ng gia Th n bnh thng d i b ng 3 -3.5 t sng o Kh ng tiu ha D d y: Bnh thng l bng kh nh. Gin to trong hp mn v, tc u gn rut non. 183

 Rut non: V tr trung tm. L cc vng khuyt nh, van ngang lng rut, khng c phn. Gin > 3.5 cm u gn, > 2.5 cm u xa gi tc nghn. Rut gi: Xp dc khung i trng. Cc vng khuyt to hn. Gin > 5.5 cm gi tc nghn. > 9 cm c nguy c thng i trng. Thot v: Kh di c xng i. o Kh bt thng : Trn kh phc mc Kh trc gan Nhng di kh mnh thnh rut gi nhi mu hay vi khun sinh kh. o Vi ha bt thng 30% si mt cn quang, c th bt k v tr no trong bng Vi ha ty: theo ng xin ca ty v gi vim ty mn Si thn: thng cn quang Vi ha th n Trong si tnh mch o M mm khc ng c i chu: nh h nh bi m sau phc mc. 20% trng hp b nh thng khng thy. Mt mt bn gi u hay t mu sau phc mc C trng: Mu xm thun nht, kh ng tiu ha ni gia
Chp ct lp in ton

Phn c th c chiu tia X nhiu gc khc nhau trong khi my quay 360. Mt my tnh s tm tt d liu t cc hnh nh v to ra mt hnh nh tng hp (H.11.4). S gim chm tia X ph thuc vo m: nc ty chn bng 0, en -1000, trng +1000 UH. Cc ca s khc nhau c chn hin th cc cu trc c trng khc nhau, v d: ca s m mm, ca s phi, ca s xng. CT c th s dng : Kho st cc c quan hay cc khi bng v lng ngc Chn on cc khi u, nhi mu hay xut huyt bn cu i no Tn thng h sau kh nhn hn do xng nn s Thot v a m hay u ty sng, nhng lin k xng bn cnh. Cc loi CT: Cn quang tnh mch:

184

+ Cn quang i-t + CT cn quang mch mu + Xem r mch mu hay tng sinh mch mu Cn quang ng ung: Cn quang lng rut CT xo n c: + ng chiu tia X lin tc quay vi s di chuyn ca bnh nhn + My tnh ct thnh cc lt mng + u im: nhanh hn, chi tit hn, c th s dng mi trng cn tnh mch + La chn kho st nhi mu phi
Chp ng-tnh mch

quang

Phim c chp sau tim thuc cn quang vo tnh mch (H.11.5) Chp ng mch vnh, v d: bnh mch vnh Chp mch no, v d: phnh mch hay xut huyt di nhn

185

Chp ng mch cnh, v d: hp Chp mch phi, v d: tc mch phi hay r mch Chp mch thn, v d: hp M thn, d ng tnh mch Tnh mch chn, v d: thuyn tc TM su

Ly mu mu tnh mc ng thi c th xc nh v tr mt khi u ni tit, v d: parahormone ca u tuyn cn gip, catecholamines ca u t bo a crom, hay chn on hp ng mch thn s dng phn tch renin TM thn

Chp mch mu xa nn

Thuc cn quang c tim nhanh theo ng TM ngoi vi (chp mch xa nn TM) ho c M (chp mch xa nn M). Phim c chp khi thuc qua M lin quan. Trong cch chp ny mt my tnh s xa b nn nhn r M (H.11.6). Dng quan st hp M hay phnh mch C th s dng nh gi chc nng tht tri

186

 (Chp mch xa nn: (a) trc; (b) sau. Catheter c lun qua M i phi. Cn quang cho thy MC v hai M chu)

Y h c ht nhn

Nhng nghin cu y hc ht nhn tn dng nhng ng v phng x vi dc hc thch hp hay cc khng th n dng c thit k tm ra s khc nhau gia cc c quan hay bnh l. Cc nghin cu ny mang li hiu qu nh gi chc nng hn l hnh thi. Phng php kh nhy nhng khng c hiu.
H xng

Bt k nguyn nhn no gy tng chu chuyn xng (bone turnover) hay d ng mu ti xng, v d: u, nhim khun, chn thng, nhi mu. S dng nhiu nht pht hin di cn.

187

Phi

Chn on nhi mu phi s dng nhp nhy ti mu, khi nhi mu gy sai st m khng tng xng vi mt nc cng mt v tr trn phim ngc chp cng lc. Thng c ch nh khi c bnh ng th tc nghn mn tnh (xem Tr. 213).
H tim mch

nh gi chc nng tht, v d: phn s tng mu, v chn on tnh ton vn c tim. Thiu mu hay so gy ra vng lnh trn phim nhp nhy c tim. Nghim php thng c thc hin khi ngh ngi v sau khi gng sc (xem Tr.203).
H niu sinh dc

pht hin bt thng dng mu thn, nhu m thn chc nng v bi tit. Chp nh p nhy thn (x hnh thn) pht hin so v nh gi chc nng thn. o thanh th i Chromium-5l EDTA xc nh chnh xc mc lc cu thn. Cng c cc phng php pht hin xon tinh hon.
X hnh no

pht hin nhng bt thng lin quan ti nhng ri lon tm thn kinh. ng ch l sa st tr tu, tm thn phn lit v ng kinh.
Tuyn gip

nh gi kch thc, hnh d ng v v tr tuyn gip v pht hin cc nhn nng hay lnh do ung th biu m tuyn, cc nang, xut huyt hay bt k lin quan khc. ng thi c th nh gi s hp thu i t ca tuyn gip.
H li ni m

188

S ty xng v mch bch huyt. c bit xem gan, lch khi khng c siu m. Hn na s dng bch cu nh du phng x tm vim, nhim, ng ch l xng, nghi ng vim ng tiu ha, v sau ph u thut bng. Cng c nhng cht nh du pht hin cc khi u, ng ch l: u lymp ph, carcinoma i trng, carcinoma bung trng, u hc t. Hng cu nh du phng x c th pht hin cc v tr chy mu d dy- rut.
Cng hng t (MRI)

Cn c gi l cng hng t ht nhn (NMR). To ra cc hnh nh ct ngang (MRI) hay thng tin quang ph v cc cht ha hc trong cc m (quang ph cng hn t, MRS). Mt xe in nh a BN vo mt nam chm siu d n, nam chm ny to ra mt t trng mnh pha ngoi BN.

H trc ca ion hydro thng nm v tr bt k nhng c th nm mt gc c bit do t trng mnh (v tr a). Khi b a vo t trng sng radio th 2 gc ny b thay i (ti v tr b). Khi sng radio trn ngng, v tr a c gi bi t trng trn v mt sng radio c pht ra v c pht hin. 189

Hydrogen MRI

Hydro l thnh ph n ln nht trong c th. MRI c th pht hin s khc nhau v nng ion hydro gia cc m trong c th, ng ch l m (CH2) v nc (HOH). L phng php hon ho chn on cc bnh n o v ty sng: tm u no, cc vng mt myelin ca cht trng trong bnh a x ha (H.11.8), cc tn thng ty sng, thot v a m. U xng v m mm. MRI cho thy chi tit cc hnh nh gii phu ct ngang tng t CT m n cn cung cp cc hnh nh t mt phng ng dc v ng ngang so vi mt phng chc chun ca CT. Hnh nh thu c lm ni bt cc c im khc nhau:

Spin echo T1-weighted: +Mmu trng (sng mu) +Dchsm mu +V xngmu en

190

 Spin echo T2-weighted: +Mmu xm +Dchmu trng (sng mu) Gradient echo: +Dng mumu trng +c s dng cho MRI chp mch Cn quang tnh mch +Nn gadolini +D TM do vim +Tng sinh mch do u. Cn quang ng ung. N.B. BN mang my to nhp khng nn chp MRI. BN cy m kim loi khng c kh nng chp MRI v hi chn vi chuyn gia. MRI c vai tr ln trong y khoa cc ch nh ngy cng rng ri.
PET scanning

Chp positron ct lp (PET) l k thut hnh nh s dng ng FDG. FDG hp thu tng quan vi chuyn ha glucose. Cc khi u c tnh chuyn ha glucose mnh hn nn to ra h nh nh khi u khi s dng k thut ny. PET cn nh gi hn na nhng hu nh hu ch vi cc khi u.

Kho st tim mch

in tim(ECG)

Xem chng 12, tr.235

in tim gng sc

Gng sc c th pht hin cc ri lon khng r rng khi ngh ngi Ch yu s dng khi nghi ng bnh mch vnh. BN c ni vi 12 chuyn o ca my in tim, vi cc thit b hi sc sn c, bnh nhn chy b gng sc hay i xe p. Bruce protocol: c mi 3 pht li tng tc v dc ca my chy b. Ghi ECG mi mt pht, HA mi 3 pht. Nghim php ny nh gi: Kh nng gng sc

191

 p ng huyt ng Triu chng Thay i ECG Dng gng sc khi: Triu chng r Thay i xu trn ECG Lo n nhp tht Tt HA Thiu mu c tim gy on ST chnh xung. T l dng tnh sai khi khng c au ngc (c.20%), ph thuc vo tui v gii, t l ny cao nht vi thiu n, ngay c khi c triu chng c hiu ca au ngc. Cc bt thng lm sng quan trng: ST thng un hay dc xung (H.11.9) ST chnh xung su Thay i on ST vi triu chng au ngc c hiu. Nghim php m tnh vi lng cng gng sc cao chng t tin lng rt tt. Ch nh chp mch ch khi kh nng gng sc thp t c trc khi xy ra nhng bt thng quan trng. iu tr au ngc nu ch qua c 3 hay 4 giai on

Siu m tim mch

xem cu trc v chc nng ca tim. S dng sng m (2.5-7.5 MHz) phn nh b mt ngn cch ca tim, v d vch nh v tht, tim, van tim, mch mu ln. Tn s cao hn th phn bit tt hn nhng s m xuyn m km hn. S chm tr gia thi gian truyn v thu nhn tn hiu nh gi su.
Siu m 2D

Dng nh gi: Gii phu van tim Chc nng tht, vd: co bp yu, phn s tng mu thp, on mt vn ng, vn ng nghch thng trong phnh mch. Cc bt thng cu trc: trn dch mng ngoi tim, tng gnh tht, suy tim sung huyt.

192

193

 xc nh v lng chc nng van tim tt hn l dng siu m Doppler (xem tr. 204).

Siu m M-mode

S dng mt chm tia siu m, v nhn thy trn mn nh s chuyn ng ca tim, o ng knh tht trong thi k tm thu/ trng.

194

Hnh nh nuclide phng x trong tim mch \

Nuclide phng x c th c dng nh gi bnh TM trong 3 cch.

Nhp nhy ti mu c tim

Chng minh nhng bt thng dng mu trong b nh mch vnh khi gng sc. Thallium 20l c gii phng t mu t l vi dng mu. Thiu mu c tim xut hin nh mt l khuyt (cold spot) thu c ngay sau tim Thallium Nu vng trn khng b nhi mu, l khuyt c y nh s phn b ca Thallium sau 4 gi. Nghim php chn on ng tin cy hn ECG gng sc. 195

Chp tht bng ng v phng x

nh gi chc nng tht: Mu BN (thng l hng cu) c nh du bi T 99m (t1/2= 6h). Mt camera v mt my tnh s to ra hnh nh chuyn ng ca tim b ng cng my tnh vi ECG bnh nhn. Chc nng tm thu tht c o bng phn s tng mu (b nh thng 0.5 -0.7):

T l ca th tch tm trng ton b c tn i trong thi tm thu. Cc hnh nh c ly khi gng sc cng nh khi ngh ngi, nh gi nh hng ca stress ln chc nng tm thu.
Qut bng pyrophosphate

Chng minh NMCT mi, v d 1-10 ngy sa NM. T. 99m pyrophosphate c hp th bi vng nhi mu to ra im nng , ti a khi 3 ngy. Ch nh: ECG qu nhiu bt thng xc minh nhi mu (v d: block nhnh tri) BN n vin kh cc men huyt tng thay i, v d ngy th 3.
Siu m Doppler tim mch

Tc dng mu trong tim v tun hon c nh gi bi Doppler Gia tc mu qua v tr tc nghn, v d: hp van tim. Vn tc nh (peak velocity) t l vi gradient huyt ng. o ngc dng trong tro ngc van
Siu m Doppler mu

Pht hin nhanh bt thng dng mu do h van tim, hay shunt trong tim, v d: thng lin tht. Siu m Doppler nh gi chc nng b xung nh gi gii phu ca S 2D. My S tnh ton trc tip v vn tc dng, im nh bi im nh (pixel by pixel), trong mt on nh v m ha mu. N thm dng trn hnh nh 2D.
Catheter tim

196

Mt phng php nh gi xm nhp chc nng tim v bnh tim m mt ng nh c lun vo, vi an thn nh v phng phu thut: Lun ngc M ti bn tri tim v MV Lun ngc TM ti bn phi tim v M phi chn on, v d: hp van tim cp cu? au ngc do bnh mch vnh? Lp k hoch phu thut tim, c bit bc cu MV N gy ra: Liu phng x ln: Cc bin chng chnh (mt trong 2000 trng hp): + Tip cn ph nh tch ng mch (2%) + NMCT (0.1%) + Tc mch do kh hay m c th gy t qu hay NMCT + T vong (0.01%) Nguy c nhiu hn li ch m BN nhn c.

197

Phng php thng thng nht l lun ng thng qua mch mu i phi theo k thut Seldinger. Mt kim sc qua da chc thng mch mu. Kim ny c ly ra v mt catheter c lun qua dy dn m c rt ra sau . p cm mu. CC trn BN ang dng thuc chng ng, bnh mch mu ngoi vi nng, hay phnh M ch bng. Cch khc: Chc qua da vo mch cnh tay khuu tay. Khu l m M cho php s dng trn BN dng chng ng.
o p lc

Huyt ng ca tim v gradient qua cc van ring bit, v d bng cch ko catheter tr li ngang van MC, khi ghi li c p lc th tm thu.

Hp van hai l c xc nh bi p lc tm trng khc nhau gia tht tri (catheter tim ph i) v nh tri o c gin tip nh catheter tim phi v tr wedge qua MP lm tc mao mch phi v vy p lc nh phn nh p lc nh tri lan truyn qua mao mch phi (H.11.13) Cung lng tim c tnh bng nguyn l Fick hay k thut Thermodilution.
Radio-opaque contrast

L:

198

 Tim iod vo bung tim nh gi chc nng tm thu v pht hin h van, v d tim vo tht tri pht hin h van hai l. Tim vo MV pht hin bnh MV.

Ghi in tim 24 gi

ECG c mang trong 24 gi (hoc 48h) (H.11.14); ECG c lu li lin tc trong sut cc hot n g bnh thng. chn on: Trng ngc Chng mt Nng ni (light-headedness) hay thong ngt (black-outs) c th ngun gc t tim. C th ch ra bnh cnh ca: Suy tm nh Nhp nhanh nh hay nhanh tht Block hon ton

199

 Bin i on ST do au ngc hay thiu mu c tim thm lng.

Theo di huyt p 24h

Huyt p c o ngt qung cho php nh gi trong sut nhng hot ng hng ngy m khng b nh hng ca xc ng do o chong trng. THA c nh ngha l HA trung bnh trong ngy >140/>90 mmHg. Khi HA khng thp hn khng xut hin trong m gi THA th pht.

Thm d h h hp
pH v kh mu ng mch

Gii hn bnh thng:

Kim d (base excess) l lng acid cn chun pH ti 7.4. 200

Trong SHH do thng kh: P02 gim pC02 tng Trong SHH do bnh phi thng: p02 thp

pCO2 bnh thng do CO2 cao tan c v vn chuyn hiu qu trong phi. V d trong hen, CO2 tng biu hin mt mi v gim thng kh do n lc c h hp.
Toan h hp

CO2 c gi li do: Bnh HH vi shunt phi-tri Gim thng kh Bnh thn kinh c Nguyn nhn sc khe vt l 201

Tng CO2 dn ti tng bicarbonate Trong SHH mn, s b tr ca thn bng cch bi tit H+ v ti hp thu HC03- d n ti HC03- cng tng cao, ngha l duy tr pH bnh thng vi kim chuyn ha cn b.
Kim h hp

CO2 gim bi thng kh do: Hysteria Kch thch thn no (him) Trong kim HH: P02 bnh thng pC02 gim Nu mn tnh, c b tr do toan chuyn ha bi ti hp thu H+ v bi tit HC03- ca thn.
Toan chuyn ha

Tha H+ trong mu: Nhim toan ceton trong T hay nhn i Tng ure huyt gim bi tit qua thn Toan ng thn gim bi tit H+ hay NH4 Ung thuc dng acid aspirin Tch ly acid lactic shock, gim 02, gng sc, biguanide Tch ly acid formic dng methanol Mt kim -a chy Thng kim h hp b tr, v d NT Kussmaul trong hn m T (th nhanh v su): P02 bnh thng pC02 th p h tr chn on, o khong trng anion:

Nu > 16 mmol/L => c mt cc anion cha tnh c, v d: 3-OH butyrate, lactate, formate.
Kim chuyn ha

Mt H+ do: Nn ko di Mt K+ th pht do trao i K+H+ ti ng thn Ung base nghim php c iu tr NaHC03 trong lot ng tiu ha Thng toan h hp b tr vi gim thng kh: P02 gim pC02 tng 202

Lu lng nh

Thi vo mt my mnh v nhanh nht khi bn c th Ghi li mi pht ra n v lt. Hu ch cho chn on v theo di hen. Bnh thng t 300-500 l/pht.

o ph dung

Thi vo my, mnh nht c th o lu lng kh th ra gng sc phn bit bnh phi do co tht (kh ph thng, x phi) v bnh phi tc nghn (hen, bnh ng th tc nghn mn tnh)

Test d ng

Nh vi git d nguyn yu ln da, v chc lp thng b da vi mt kim chch nh qua lp cht lng trn, cy vo lp biu b. C th s dng nhng li chch nhn c bit c ph lp d nguyn ng-kh. Nt phng ti ch cho bit p ng d ng.
Yu t vn chuyn C02

Tc hp th C02 trong kh th vo quyt nh dung tch khuch tn ca phi. N gim trong bnh ca ph nang, v d x phi.
Nhp nhy thng kh/ ti mu
Nhp nhy thng kh

Bng cch hit ng v phng x chp hnh nhu m phi

Nhp nhy ti mu

Tim ng v phng x vo mu lm r tun hon phi.

Ni soi ph qun

Ni soi ng mm vi an thn nh, v d: tim diazepam TM, xt t ti ch hu, hng, thanh qun. Quan st c tc nghn 203

 Sinh thit u Chc ht mu, i khi sau khi ra nc mui, c th ly tm vi khu n hay t bo c tnh. S ph qun him khi lm thuc cn quang c tim vo cy ph qun cho thy ph qun gin ngoi vi (bnh gin ph qun).

204

Thm d h tiu ha
Ni soi ng ti u ha trn

ng ni soi mm c a vo thc qun, d d y, t trng sau khi an th n, v d diazepam TM, gy t h u hng. Quan st trc tip ng tiu ha thm d: Nut kh u thc qun hay cht hp Nn mu hay i ngoi phn en gin TM thc qun, lot d dy t trng, n mn nim mc d dy, ung th biu m. au thng v lot d dy, vim thc qun, d dy, t trng. St cn ung th biu m d dy.
Ni soi mt ty ngc dng

Nhn trc tip trn mn hnh qua ng ni soi, ng c lun qua bng Vater on m ng mt ch v a vo cht cn quang cho php nhn trn phim XQ hnh nh: ng mt, vi si, u, cht hp, khng ng nht ng ty, vi vim ty mn, gin ng ty hay bin dng do u.

205

Ni soi c th dng phu thut, bao gm ct c tht ly si mt hay a vo mt ng cng, stent qua on cht hp ca khi u dn lu mt.
Ni soi trc trng, i trng sigma, kt trng

Ung barit (nut vi thc qun, n vi d dy/ t trng) hay a trc tip vo i trng (th t tho) hoc theo mt catheter vo t trng (th t rut non). XQ c chp vi nim mc c ph barit. Khng kh a vo lm cng i trng v to ra phim cn quang i. Nhng bt thng: Cht hp, vd x ha, carcinoma Hnh khuyt, vd polyp, carcinoma Hnh lm, vd lot ti tha Nim mc khng u + Cc np nim mc xe ra do lot + Khe, rnh trong b nh Corhn hi trng v kt trng + Mt nim mc trong vim lot kt trng giai on u + Cc khi nim mc trong vim lot kt trng nng Nu bt thng trn mt phim cn xc nhn trn phim khc, v nhu ng hay phn gy nhm ln.
Chp rngen ti mt

Phng php ny hin nay him khi thc hin v siu m tt hn nhiu. Chp phim khng chun b tm si cn quang. Cht phng x cn quang BN ung c thi tr bi gan v tp trung ti mt. Si cholesterol to hnh khuyt trong ti mt C th khng thy si mt s trng hp bnh thng, si ng ti mt hay x ha sau .
Nghim php hi th hydrogen (HBT)

Th nghim th lactulose vi s tng trng qu mc ca vi khun. BN c ung lactulose, v h d tha rut non
Thm d thn
Xt nghi m nc tiu

L mt phn XN thng quy, n gin nht l s dng que th. Nhng que th vo nc tiu v so snh mu que th vi kt qu mu cc thi im c ghi r. c bit quan tm l: pH protein ketone glucose bilirubin urobilinogen 206

 blood/ hemoglobin
Soi nc tiu

C th gi nc tiu ti labo : M (microscopy): tm hng cu, bch cu, tr ht v cc tc nhn gy b nh C (culture): nui cy vi mi trng thch hp pht hin vi khun v cc tc nhn khc S (sensitivity): nhy xc nh nhy ca vi khun vi khng sing

thanh thi creatinin

o chnh xc mc lc cu thn c thc hin nh cc ng v, v d: thanh thi chromium EDTA. Thanh thi creatinin d thc hin hn, d km chnh xc hn. Ly mu lm creatinin huyt tng Lm creatinin nc tiu 24h.

Gi tr b nh thng: 80 -120 ml/pht

UIV

Phim chp khng chun b tm si thn hay niu qun. Thuc cn quang tim vo TM c tp trung v bi tit qua thn. Giai on chp XQ thn hnh thi th n: quan st v tr, hnh thi, kch thc, hnh khuyt, v d u Giai on bi tit khung chu thn: + Mt cc nh thn do vim th n-b thn mn, hoi t nh thn + Nh thn b t do thn nc + Tc nghn niu qun on xng chu khung chu ln, niu qun bnh thng Niu qun: Quan st v tr, thay i do bnh l khc?Kch thc, gin do tc nghn hay vim nhim. Khng u, c th do co tht cn xem phim tip theo.

Thm d thn kinh

in no (EEG)

207

Xp x 12 in cc c gn vo da u v tr chun v ho t ng in no c khuch i v ghi li. C nhng bin i bnh thng r v khc nhau gia lc tnh v ng. S dng chnh : ng kinh: ch yu, ng kinh ton th, ng kinh cc b Ri lon thc hay hn m: bnh no, vim no, sa st tr tu Gi tr chnh ca k thu ny l sng bt thng ph hp vi ng kinh. Bin i bnh thng ln gy kh phn tch.
Chc d tht lng

Mt kim c a vo gia cc t sng (H.11.17), qua mng cng vo khoang di nhn, v ly dch no ty chn on. Bnh thng dch no ty trong. Gi tr chn on chnh: Xut huyt di nhn: ng nht mu . Nhim hong sc: nhum vng do hemoglobin Vim mng no: m, dch c, bch cu, vi khun nui cy, ng gim v tng protein p lc tng gi c u
Ty

Tim ch t cn quang vo d ch no ty khoang di nhn xem thot v a m c hay ngc hay u ty sng
Chp ty sng tht lng

Tim thuc cn quang tm thot v a m

208

Thm d huyt hc
Tng phn tch mu v chn on hnh thi (film examination)

Mu TM dng chng ng c phn tch bi my m t ng. Hu ht cc labo lm c cc thng s sau: Hb (g/l hay g/dl): Nng hemoglobin, gi thiu mu RBC : m hng cu MCV (fl) : th tch hng cu trung bnh, xc nh nguyn nhn thiu mu, Nhc sc (<76fl), ng sc, u sc (>96fl) MCH : Huyt sc t trung b nh, <27pg l thiu mu nhc sc MCHC : Nng huyt sc t trung bnh, nhn chung khng ngha WBC : m bch cu ton b PLT : Tiu cu

209

Hu ht cc my phn tch t ng cho bit 5 loi bch cu khc nhau, v vy xc nh c phn trm v s lng tuyt i cc loi bch cu. Soi di knh hin vi cung cp thm thng tin hnh thi hc t bo mu v lun phi lm khi c thiu mu cha r nguyn nhn, bt thng ca s lng bch cu, tiu cu.
Hng cu

Thiu mu do gim nng hemoglobin nguyn nhn gm: Chy mu Tan mu (ph hy hng cu cha trng thnh: s lng hng cu li tng Bnh ty xng (gim sn xut) Thiu nguyn liu to mu (B12, folate, st) Suy th n (gim erythropoietin) Vim mn hay c thai MCV gi nguyn nhn thiu mu: Nhc sc: thiu st, thalassemia u sc: thiu B12 hay folate, gim nng gip, bnh gan, nghin ru hay bnh ty xng Bnh sc: bnh mn tnh, suy thn v mang thai. Soi mu mu c th cung cp thng tin hu ch v cn nguyn thiu mu. Hnh thi hng cu quan trng trong vic nhn ra nguyn nhn tan mu, v d : bnh tng hng cu nh, hng cu mnh, hng cu hnh lim. in di hemoglobin. in di ly hng cu s nhn thy s bin i ca hemoglobin nh HbS. Pht hin v o HbA2 rt quan trng pht hin ngi mang mm bnh Thalassemia. HbA2 >3.5% gi chn on. Enzym hng cu. Thiu G6DP v PK dn ti thiu mu do tan mu nng. Nhng ezym ny c th phn tch ti labo.
Bch cu

Cn ch khi thy s lng bch cu bt thng. Soi mu mu c th nhn ra t bo bt thng nh blast, hay n gin l s tng hay gim thnh ph n bnh thng. Bt thng hnh thi bch cu c th l ch nh sinh thit ty. Bch cu trung tnh tng: gi nhim khun Bch cu trung tnh gim: c th dn ti nhim khun nng (gram m) thng lin quan ti ha tr hay tm thi sau nhim virus 210

 Tng lympho bo: phn ng khi nhim virus nhu st tuyn, v tnh trong bnh bch cu lympho v u lympho. Gim lympho bo: thng trn bnh nhn dng corticoid, HIV, lupus ban h thng (SLE) v cc bnh min dch khc Tng bch cu a eosin: thng trong tnh trng d ng, lin quan ti dng thuc, nhim k sinh trng v u lympho.
ng mu

Mu c ly cho vo ng n ghim c citrate. Citrate lin kt c th o ngc vi Ca2+ v chng ng. Ti phng th nghim mu mu c ly tm ly huyt tng lm XN. Yu t m/ phospholipid (thromboplastin) v Ca2+ c thm vo. Thi im ti lc bt u ng vn tnh ra giy. o Prothrombin time (PT) (bnh thng 10-14s) l mt thm d nh gi ng mu ngoi sinh (yu t m/ ph thuc yu t VII). N rt nhy vi cc yu t ph thuc vitamin K (II,VII,XIX,X). PT nh y nht vi nh gi chc nng gan: ko di trong bnh gan. c dng theo di iu tr warfarin yu t ng mu ph thuc vitamin K c ch warfarin (II,VII,XIX,X). PT bnh nhn/ PT chng = PT. Nu t l PT ny c nhn vi nhy ng ca thromboplastin c s dng (ISI-ch s nhy cm quc t) = INR (ch s b nh thng ha quc t). INR ch Tnh trng lm sng iu tr thuyn tc tnh mch su (DVT) hay nhi mu 2.0 3.0 phi (PE), chng ng trong DVT hay PE ti pht, chng ng cho thay van nhn to 3.0 4.5

o Thi gian thromboplastin hot ha tng phn (APTT): thm d ng mu ni sinh. Con ng ny chm hn v yu cu c phospholipid v hot ha b mt. Huyt tng BN ly t mu c chng ng citrate cho thm phospholipid, kaolin v Ca2+. Th i gian ti lc ng vn c ghi li v (thng 30-40s). XN : Theo di heparin khi APTT gi mc khong 2.5 bnh thng. N.B. heparin trng lng phn t thp thng khng cn theo di tr suy thn khi xt nghim yu t Xa c thc hin. XN ko di khi c khng th t thn khng phospholipid Ko di trong hemophilia v b nh von Willebrand

211

o XN ng mu khc bao gm thi gian thrombin (TT) l XN nhy vi liu php heparin v mc fibrinogen nh gi trc tip nng fibrinogen trong mu. ng mu ni mch ri rc (DIC) c th gy ko di tt c cc XN trn v gim fibrinogen. o D-Dimer: hot ha h thng ly gii fibrinogen sau khi hnh thnh cc mu ng. Plasmin c hot ha v ct chui fbrin thnh cc phn t nh hn (mt vi trong s l D-Dimers). D-Dimers c th pht hin nh s dng ngng kt latex hay ELISA. S hin din ca D-Dimers gi huyt khi v hin nay c dng chn on DVT v PE. S vng mt ca D-Dimers ngha l khng c huyt khi. o Nghim php tng huyt khi (thrombophilia tests): mt s thnh phn ca mu gip ngn nga s hnh thnh huyt khi t pht. Cc yu t ny tc ng bng cch lm gin on thc ng mu. S thiu ht ny lm tng s nhy cm ca bnh nhn vi s hnh thnh huyt khi. Hu ht cc yu t ny l do di truyn nn vic khai thc bnh s ht sc quan trng. Cc yu t chnh gm: Thiu protein C Thiu protein S Thiu khng thrombin III S c mt ca cht khng ng lupus (khng th t thn khng phospholipid) Liu php oestrogen Ph u thut C thai
Ngng kt cho

Trc khi mu c th dng an ton cho bnh nhn, huyt thanh ca bnh nhn phi c sng lc khng th t thn khng hng cu c th gy phn ng truyn mu vi khng nguyn tng thch c trong hng cu ngi cho. Mt mu mu (khc nhau mi labo) ph i c gi ti labo truyn mu trc khi a vo s dng. Cn phi bit r ton b cc mu mu. Kim tra vi labo truyn mu khi ly mu cn v h thng nhn mc. Nhm mu ABO hay RhD Huyt thanh/ huyt tng nhm mu khng th t thn khng hng cu phi c xc nhn, mu mu c th a vo s dng.
Truyn mu cp cu

Him khi khng c thi gian lm ngng kt cho. Trng hp ny c th s dng nhm mu O Rh m tnh. Vi k thut sng lc khng th t thn khng hng cu nh y cao, ngng kt cho khng dng na.
Cc yu cu c bit

Mt s bnh nhn nht nh c yu cu truyn mu ring. Mt vi trng hp c lit k di y: 212

 Mu mu c chiu x, bnh nhn s mang mt tm th Cytomegalovirus (CMV): mu cn m tnh trong: + Bnh nhn ghp tng + S sinh N.B. tt c cc mu mu a vo s dng Anh u loi b bch cu.
Sinh thi t ty xng

Thng ly mo ch u (thng pha sau) v c thc hin thnh 2 ph n: Ph n ht l ty xng c ht ra t khoang ty v pht ln phin knh, nhum v soi di knh hin vi xem hnh thi t b o. Nhum ty vi xanh Prussain ca Perl s cho nhng du hiu tt nht v tnh trng st ca bnh nhn. Li ty xng c c nh bng formalin, loi b canxi v sau c ct lt m hc bnh thng, nhm pht hin thm nhim ty xng th pht sau carcinoma, x ha, bnh mu c tnh v xc nh tt nht t bo ty. K thut ny cng c th ly mng xng thm nhim s dng t ti ch hay an thn nh. Sinh thit ty xng cho bit cc thng tin sau: T bo: ngh a l khi no ty xng khng c t bo (thiu mu khng ti to), m c (bnh bch cu) hay bnh thng. T bo hc: t bo trng thnh hay b t thng h nh thi Tnh trng st:

Xt nghim ha sinh
Ure v in gii

Mui, kali, ure v creatinin. Ure hu ch trong nh gi hydrat. N ph thuc vo lng protein c th, tng khi n nhiu protein v xut huyt d dy-ru t non, gim khi suy gan. Creatinin l XN ng tin cy nht chc nng cu thn.
Khong trng anion

Khc trong tng s cation chnh (mui v kali) v anion (clo v bicarbonat) = 14-18 mmol/l. C gi tr trong thm d ri lon acid -base.
Xt nghi m chc nng gan

Albumin: Ch u trch nhim ch yu trong vic duy tr p lc keo v ch im chc nng tng hp ca gan. C th gim t ngt trong hi chng thn h v bnh l rut. AST v ALT: c gii phng khi t bo gan tn thng, nhng cng c th c trong hng cu, t bo c v tim. C th tng rt cao trong vim gan. Bilirubin: sn phm thoi ging ca hemoglobin v do vy tng trong tan mu. Cng tng cao trong bnh gan. 213

 ALP (akaline phosphatase): Mt enzym tm thy trong to ct bo (osteoblasts) v h gan mt. Tng trong bnh xng v tc mt. GGT (gamma glutamyl-transferase): Tng trong nghin ru Amylase: Enzym tiu ha ng ca tuyn ty. Tng trong vim ty.
Ch im tim/ c

AST: Enzym ni bo gan cng tm thy trong xng, c tim. Tng sm trong NMCT nhng khng c hiu. LDH: Tm th y trong nhiu t chc. Tng chm trong NMCT v c th hu ch trong ch n on hi cu NMCT. CK-MB: Tm thy trong c tim. c hiu hn AST, LDH nhng khng hon ton tuyt i Troponins (T v I): Ch s c hiu v nhy nht vi tn thng c tim, tng sm sau nhi mu. Troponin tng l mt gi hay nguy c trong au tht ngc khng n nh v phi iu tr tch cc.
Chuyn ha canxi/ xng

Hu ht cc khong cht trong c th th 99% lin kt vi xng. Nng trong huyt tng cn iu chnh i vi nng albumin trc khi phn tch. Ca c iu chnh = (40 (nng albumin g/l) 0.02 mmol/l

Cn bng Ca nh hng bi hormon cn gip (PTH) () v hot ng vitamin D. Phosphate: Nhn chung tng hu ht trong suy thn. Tng rt cao trong ly gii u. Nng huyt tng nh hng bi PTH v hot ng vitamin D PTH: Gii phng t tuyn cn gip p ng vi gim Ca dn ti tng ti hp thu ng thn v tng bi tit phosphate. Cng lm tng gii phng Ca v phosphate xng v dn ti hot ha thn ca vitamin D. Vitamin D: Ho t ha bi hydroxyl gan v thn. Kch thch tng hp thu Ca v phosphate rut v tng to xng.
Lipid

Cholesterol: Thnh ph n quan trng ca mng t bo. Ph trch tng hp steroit v acid mt. Mc tng tng quan vi nguy c bnh tim mch, c bit l nu LDL cao LDL (low density lipoprotein): Ch t mang cholesterol, gn vo receptor b mt t bo LDL cho php tip nhn. Yu t nguy c tim mch khng ph thuc. HDL (high density lipoprotein): Chc nng vn chuyn cholesterol ngc li gan chuyn ha, v vy bo v tim.

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 Triglycerides: C trong ch n m v c tng hp bi gan d tr nng lng. Yu t nguy c tim mch khng ph thuc. Tng trong bnh gan v gim nng tuyn gip.

Ni tit
Hormon thy trc tuyn yn

TSH (thyroid stimulating hormone): Kch thch sn xut thyroixine (T4) v tri-iodothyronine (T3) tuyn gip. Chn on tng hay gim nng tuyn gip ph thuc nng TSH. ACTH (adrenocorticotrophic hormone): Tng sn xut cortisol tuyn thng thn p ng vi stress, thay i hng ngy, nhim khun +Tng cortisol gi l hi chng Cushing hay bnh Cushing +Thiu ht cortisol do suy thng thn c gi l bnh Addison GH (growth factor): Kch thch s pht trin ca tr em trc touooie dy th v nh hng ln n chuyn ha ngi ln. GH c hot ha bi yu t pht trin nh insulin (insulin-like growth factor-IGF-L) gan. Tng hormon ny ngi trng thnh gy bnh khng l. Prolactin: Hormon kch thch tuyn sa tng cao khi c thai v cho con b. Tng rt cao trong vi trng hp u tuyn yn. FSH (follicle stinmulating hormon): Kch t sinh dc nui dng s pht trin nang bung trng trong na k u chu k kinh nguyt. nam gii FSH kch thch sinh tinh. Tng cao sau mn kinh. LH (lutainizing hormone): Tng cao trong na sau chu k kinh nguyt gy ra s pht trin hong th. nam gii kch thch sn xut testosteron.
Hormon thy sau tuyn yn

(antiduretic hormone): Gim s mt nc. Khng c ADH gy ra bnh i tho nht (diabetes insipidus). Tnh trng trn gy ra s bi tit ADH khng thch hp gin ti gim mui trong huyt tng. o p lc thm thu nc tiu v huyt tng.
ADH

Thm d chc nng ni tit

Test Synacthen tc dng ngn: Tim ACTH ti thi im 0 sau khi ly mu mu. Cc mu mu sau c ly thi im 30 v 60 pht. p ng sinh l lm tng cortisol ti >570 nmol/l. Gim p ng gp trong bnh Addison (suy thng thn). Test dung np glucose ng ung (OGTT): c s dng chn on T. Test dung np insulin: c s dng xc nh hot tnh bnh thng ca cortisol v hormon pht trin (c khng insulin) vi h glucose mu do insulin. Bt thng trong suy thng thn v thiu hormon pht trin. Test hi chng Cushing 215

Sng lc bnh nhn ngoi tr:

Test c ch dexamethasone qua m 1 mg: 1mg dexamethasone c s dng lc 11 gi m hay gia m, o cortisol lc 8 -9h sng. Cortisol nc tiu: Ly nc tiu 24h xc nh lng cortisol t do. Test sng lc bnh nhn ni tr: Lin quan ti test c ch dexamethasone liu thp hay cao, th cortisol lc na m v ch n on XQ tuyn yn, thng thn hay b phn lc ch lin quan khc.

Thm d h min dch

Khng th khng nhn (antinuclear antibody): C th ca bt k lp Ig no. Mu nhum lin quan vi bnh l c trng sau: ng nht Lupus Lm m Bnh m lin kt hn hp Nhum nhn X cng b Nhum NST Hi chng CREST Khng th khng c trn: Tng cao trong vim gan t min T bo thng v: Gp bnh nhn thiu mu c tnh Khng th yu t ni sinh: 70% BN thiu mu c tnh, c hiu hn Khng th ty lp th: 96% bnh nhn x gan mt tin pht Khng th khng endo-mysial v gliadin: Bnh l ca bng

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 Khng th tuyn gip: Tng cao trong vim tuyn gip t min (90%); tng khng th khng vi lp th c th gp trong bnh Grave. Yu t dng thp (RF): Khng th t thn khng IgG ngi nhng c th l bt k khng th no ca lp Ig. Dng tnh 70% bnh nhn vim khp dng thp, c bit l bnh lin quan ngoi khp. Tng rt cao trong bnh cryoglobulin mu. ANCA Cytoplasmic ANCA (cANCA): 90% trong b nh u ht Wegener; 40% bnh nhn vim vi mch Perinuclear ANCA (pANCA): 60% bnh nhn vim vi mch, c th dng tnh trong bnh m lin kt v vim mch mu.

Ly mu mu
Ly mu tnh mch

i gng khi ly mu. Thng ly np gp khuu tay, khng cn lm sch vng ly mu bng bng, gc tr khi bn. Ga r pha trn khu u tay, hay bm cuff n 50 -80 mmHg Bo BN nm tay nhiu ln Tm TM nng. Nu khng thy, s bng u ngn tay qua np khuu tm s ny ln ca TM, ranh gii tnh mch Khng c nhm vi M Xc nh v tr chc kim, pha trn gia v theo chiu di TM t ngn ci pha di v tr chc kim, ko v pha mnh lm cng da Chc kim qua da mt gc khong 20.

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Bm tim/ kim tim

Lp mt kim tng i rng vo mt bm tim thch hp t kim ln da qua gia TM, chc kim nh trn Ngay khi chc c kim vo TM, ko chm pit tng bm tim li n khi lng mu cn. Thng l chc qua TM, nu sau chc kim khng c mu, rt bm tim/ kim nh nhng cng vi ko lin tc pit tng, thy mu vo t ngt ngha l thnh cng. Nu khng c, trc khi rt kim, y tip theo mt ng khc v ht nh trn. Tho ga r trc khi rt kim, nu khng mu s chy qua v tr chc mt cch hoang ph. p mt ming gc ln v tr chc khi bn rt kim. Bo bnh nhn gi nh th trong 2 pht Dn bng bo v Nu chy mu, p lu hn v gi cao tay
H thng ng cha mu chn khng Becton-Dickinson

218

Mu tm (EDTA): m mu ton b Xanh: ng mu Xanh l cy (heparin): Ha sinh Xm: ng mu Nu (khng chng ng): XN huyt xanh nh min dch, huyt thanh vi sinh.

Nui cy mu

Lau sch np ng trc khi chc kim qua. Thay i kim gia da v ng.
Vi c hai phng php

Vt b kim v bm tim cn thn Khng garo vi mu cha canxi Nu khng ly mu c np khuu, tr cc TM mt b n c tay, hay cng tay hay ng sau u.

Thm d kh mu ng mch (ABG)

y khng phi l mt k thut d. Xem cch lm trc khi bn t lm. S dng mt bm tim 2ml v ht mt lng nh heparin, y b heparin ra, v vy s cn li lp trng heparin trong bm tim. Bm tim c chun b trc by gi c. Nu BN lo s, gim au ti ch bng lidocain. ng mch quay: tay nm ngang. Bt gia mch quay. Chc kim vo M mt gc 45. Rt t t kim ti khi mu chy t do vo bm. Ly mu v rt c bm v kim ra. p cht v tr chc v bo BN p nh th trn 5 pht. Tho kim ra v b t kn u bm tim. Mu mu phi c phn tch trong 5-10 pht.

ng mch i: Bnh nhn nm nga. Bt M i v chc kim mt gc 90. Nh rng thn kinh i n m cnh M i v TM i n m gia. Cch tin hnh nh trn. Cc im cn lu : Trnh bng kh trong mu mu Ch nng 02 bnh nhn th (khng kh, 24%, 28%,) 219

BN lo lng bn cn t ti ch. Mu M l mu ti. Rt d ht phi mu TM i mu thm, cng v vy m ngi ta thch ly mu M quay hn.

Tng v h glucose mu
Glucose mu
Phng php o mu (colorimetric methods)

Hin nay c mt vi que th mu glucose-oxydase c quyn. Que th phi c trong dng c cha kn. Chch ngn tay bng dao chch nhn v nn, p u ngn tay ly mu. t mt git mu to ln giy thm trn que th hay u d dng c o. Mt vt s khng lm. c kt qu theo hng dn, c th chnh xc trong mt pht (s dng tay ng h th hai hay ng h k thut s). Mt s phng ph p khc yu cu bn lau sch mu s dng bng hay giy. S dng mt my o mu c chnh xc hn, c bit trong h ng huyt. Phng php amperometric Mt vi my to ra dng in mt chiu t que th glucose-oxydase. Sau khi mu tip xc vi que th, c kt qu sau khong 20s.

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Chng XIII: Vi nt c bn v in tm

Gii thiu in tm (ECG) ghi li nhng hot ng in bao gm kh cc v ti kh cc ca c tim, nh vy ECG cung cp nhng thng tin trc tip v c tim v hot ng ca chng. 6 chuyn o c bn: DI, DII, DIII, aVL, aVR, aVF c ghi li qua nhng in cc mc tay, chn ( aV: augmented voltage) v quan st tim theo nhng gc nhn khc nhau.

Nhng chuyn o c bn quan st tim theo mt phng dc ngang. 221

6 chuyn o trc tim, cc chuyn o V, thu c t cc in cc dnh thnh ngc, s quan st qu tim theo mt phng nm ngang.

Tc nghn mt ng mch cp mu cho mt vng no ca tim biu hin trn ECG nhng hnh nh tng ng ca thiu mu c tim: ng mch lin tht trc: thiu mu hoc nhi mu c tim vng trc (V1-V6)

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 ng mch m: thiu mu hoc nhi mu vng bn (DI, aVL) ng mch vnh phi: thiu mu ho c nhi mu vng sau di (DII,DIII,aVF)

Trong mi bn kt qu in tm u c phn chun ha: mi 1 mV in th tng ng vi chiu cao 10 vung nh:

P = sng gy ra b i kh cc nh QRS = kh cc tht T = ti kh cc Mt bn kt qu in tm b nh thng:

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Nhng thay i bnh thng ca ECG: o Sng T c th o ngc chuyn o DIII, aVF, V1-3 o Sng T v P lun lun m aVR ( n u khng, in cc b mc sai) o nhng vn ng vin tr : o on ST c th chnh ln, c bit chuyn o V1-5 o Block nhnh ph i c th c o Du hiu dy th t tri c th c o Nhp ch m < 40 ln/pht o Sng Q sinh l o Ngo i tm thu cc tp khc nhau, him khi c triu chng. o ST chnh ln ph bin ngi chu M Caribe o Sng P V1 thng 2 pha: d chn on nhm dy nh tri(P 2 l) Sinh l in qu trnh co bp ca tim Tt c t bo c tim c xu hng kh cc dn n hng phn v co bp. Ni kh cc u tin l nt xoang (SA: sinoatrial) (di nh hng ca h giao cm v ph giao cm), dn truyn n nt nh tht sau qua b His n cc tm tht.

Nhng thay i trn ECG ghi li gi tr in th trung bnh ca tt c cc t bo c tim ti mi thi im. Chiu lan truyn ca kh cc: n gn in cc: sng dng chuyn o tng ng trn ECG Ra xa in cc: sng m trn ECG Sng P Sng kh cc truyn t SA n VA qua khi c tm nh (DI trong h nh di) D nhn nht DII v V1 Thng nh, v tm nh nh

224

Sng P bnh thng < 2,5 mm chiu cao v <2,5 mm chiu rng. Ch mi tn trong hnh, l chiu lan truyn ca dng kh cc. Phc hp QRS C mt quy c gi tn cc sng QRS:

Q: sng m u tin R: nhng sng dng, c th hoc khng bt u bng sng Q S: nhng sng m sau sng R, c th bt u hoc khng bng sng Q

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Vch lin tht kh cc t tri sang phi:

Cc tm tht ngay sau kh cc t trong ra ngoi. Do tht tri dy hn nn sng kh cc tht tri s chim u th.

Chuyn o chuyn tip, l chuyn o m sng R v S c chiu cao bng nhau, tng ng vi v tr vch lin tht. Sng S ti V6 tng ng vi kh cc vng quanh tht tri ( v tr 3 trong hnh)

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Dy tht tri ( LVH: left ventricle hypertrophy) V5 ho c V6: R> 25 mm V1 ho c V2: S su Ch s Sokolov-Lyon: chiu cao R V5 + S V2 > 35mm Ngi gy vi thnh ngc mng c th c phc hp QRS cao. Ngi bo ph c th QRS nh Ch sng R V1, chuyn o chuyn tip s chuyn sang phi trong trng hp trc tri. Sng T o ngc V5, V6 trong LVH biu hin cho s tng gnh tht tri m l ch im c a ph i tht tri. Dy tht tri vi hnh nh tng gnh tht tri

Dy tht phi (RVH) Sng kh cc ca th t tri khng cn ni tri na. V1- Sng R>S V6 Sng S su 227

Ch c: Trc in tim phi Sng P khi c dy nh Sng T o ngc V2 V3 khi c tng gnh tht phi Nhi mu c tim (MI) xuyn thnh ( tn thng ht b dy mt vng c tim) Nhi mu l thut ng ch s cht ca c tim v thiu mu. Sng Q bnh l: Rng > 0,04s ( mt nh) Su > 1/3 chiu cao sng R cng chuyn o Nhng sng Q nh hn c th l sinh l do kh cc vch lin tht Do tm th t kh c c t pha trong nn mt in cc bn trong tm tht s ghi li sng Q vi ngh a ca sng R chuyn o trc tim. Chuyn o t tng ng vi vng tim cht s ghi li kh cc ca thnh c tim i din, do to sng QS trn ECG:

Sng Q

Nhi mu c tim cp ST chnh ln Ph hy nhng cn kh nng phc hi ca c tim 228

 on ST bnh thng trong khong 0,5 mm ng ng in ST chnh ln V1,V2 c th bnh thng im J cao ST chnh ln chuyn o khc l bt thng. ng ng in bnh thng: in th n gh ca c tim khong -90 mV. Khi mt t bo b tn thng, suy chc nng mng t bo nn in th ngh ch cn -40 mV.

Nu 2 in cc ghi li hot ng in ca 2 vng c tim khc nhau, mt b nh thng v mt tn thng, in k s ghi nhn gi tr -50 mV ( chnh lch gia 90mV v -40mV). Nh vy iu n y s lm thay i ng ng in, thay i ny ch pht hin sau phc b QRS ( xem hnh di)

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Bng 12.1. Bin i in tm trong nhi mu c tim theo thi gian ( thng thng) Kho ng thi gian t lc xut hin au tht ngc Tc th th c 0-2h 2. 3-8h 3. Thay i trn ECG 1. C th bnh thng ECG c th b nh thng. C ST chnh ST chnh ln tc ng mch Tn thng m tip din Mt phn c tim cht (sng Q) Mt phn c tim b thiu mu (T Hnh nh nhi mu y : - Sng Q - ST chnh ln - Sng T o ngc 230

o)

8-24h 4. ho c hi ST tr v bnh thng Sng T o ngc vn cn Sau 1-2 ngy 5.

Tn thng c tim hoc cht phc v on

Hnh nh thiu mu bin mt Sng T tr li b nh thng Sng Q vn cn, v m c tim cht khng th hi phc

on ST chnh ln: - Tn thng thiu mu c tim cp - Vim mng ngoi tim c p - Vn ng vin - Ngi ng n Nhi mu c tim vng trc ( hnh 12.2 v 12,3) - Thay i nhng chuyn o V1-6 - Tc ng mch lin tht trc Nhi mu c tim sau di ( hnh 12.4) - Thay i chuyn o DII, DIII, aVF - Tc ng mch vnh phi Hnh 12.2. Nhi mu c tim cp ST chnh ln V2-6 gi th 3 -8

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Hnh 12.3. 10h sau nhi mu c tim vng trc cp

Hnh 12.4. Nhi mu c tim cp vng sau di: ST chnh ln DII, DIII, aVF v hnh nh chn h xung nhng chuyn o cn li.

Nhi mu c tim vng bn Thay i DI, aVL Tc ng mch m Nhi mu c tim trc vch Thay i V2-V3 Tc nhnh vch lin tht ca ng mch lin th t trc Nhi mu c tim vng sau 232

 Thay i V1 ( sng R, ST chnh xung) Tc nhnh ng mch vnh phi Thiu mu c tim mn tnh Gim cung cp oxy cho c tim: ST chnh xung Sng T o ngc Sng T cao nhn Nhng thay i ny c th xut hin khi tin hnh nghim php gng sc lm tnh trng thiu mu tng ln:

Trc QRS Trc in tim rt hu ch trong chn on Mt ch im ca ph i tht phi hay th t tri Tm trong nhng chuyn o c bn ( ngoi vi) phc hp QRS cn i nh t ( R=S). Trc in tim gn vi phng chuyn o vung gc vi chuyn o trn, tng ng vi phng chuyn o o c sng R dng nht.

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Nhn dng trc in tim Trc tri

Trc phi

Phc b QRS Bnh thng nu rng < 0.12s ( 3 nh) Nu > 0.12s block nhnh Mt QRS c v rng, < 0.12s block nhnh ho c gim d n truyn lin tht Block nhnh tri( LBBB) thng i km vi mt bnh tim khc

234

 RBBB c th bnh thng, c bit l nhng vn ng vin. Nu RBBB xut hin ngay sau mt nhi mu c tim, l mt du hiu nng. Block nhnh tri Hnh dng ch M V6 Trong su t ECG, ST nm ngang v sng T o ngc V6: o Kh cc ca vch lin th t t nhnh phi cho hnh nh sng dng o Kh cc tht phi cho hnh nh sng m o Kh cc tht tri cho hnh nh sng dng

Trc tri: dng kh cc t th t phi sang tht tri C th xy ra nu ch c b trc c a nhnh tri b block o Block nhnh tri trc Block nhnh phi Hnh nh M V1 Chuyn o V1 o Kh cc vch t nhnh tri cho hnh nh sng dng o Kh cc tht tri cho hnh nh sng m o Kh cc tht phi cho hnh nh sng dng

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Ri lon nhp Ri lo n nhp xoang Ngo i tm thu Nhp nhanh Nhp ch m Ri lon nhp xoang Thay i sinh l theo h hp: tng tn s trong th ht vo.

Ngoi tm thu Ngoi tm thu nh pht nhp ngoi tm thu tm nh. Kh cc qua tm nh n nt AV nh nhp p bnh thng: Sng P thay i hnh dng Phc b QRS bnh thng Xut hin sm Theo sau bi nhp ngh b - ch i xung kh cc tip theo t SA

236

Ngoi tm thu b ni Ngo i tm thu ti nt nh tht, khng c sng P, QRS b nh thng

237

Ngoi tm thu tht pht nhp ngoi tm thu u trong tm tht. Kh cc xut pht t tm tht v truyn sang tht cn li: Khng c sng P QRS rng Hnh nh block nhnh o pht nh p tht tri: RBBB o pht nh p tht ph i: LBBB Ngo i tm thu nh v b ni thng lnh tnh nu c pht hin tnh c. Phn ln ngoi tm thu th t lnh tnh, ngoi tr khi n xut hin sau nhi mu c tim. Ngoi tm thu tht pht hin qua monitor thng quy ngi khe mnh t l vi tui.

238

Nhp nhanh Phn lo i nhp nhanh o Nhp nhanh c chia lm cc th: o Phc b QRS hp-u QRS khong 0.08s ( 2 vung nh) Nhp nhanh xoang

Nh p nhanh trn tht, nhp nhanh nh, cung nh

239

o Phc hp QRS hp khng u Nhp nhanh nh vi block thay i, rung nh o QRS r ng QRS khong 0.12s 3 vung nh Lo n nh p tht, nhp nhanh trn tht c ch m dn truyn o Phn bit gia nhp nhanh do nh hay tht khng ddng. Di y l mt vi im mu cht: o Nhp nhanh c QRS hp thng t nh v nu QRS rng thng t tht, nhng khng h n th o Trong bnh cnh thiu mu c tim cp, nhp nhanh thng t tht, nu khng c thiu mu c tim, nhp nhanh thng t nh, nh ng khng h n th o Nu c du hiu nh hot ng c lp ( sng P xut hin ngu nhin), nh p nhanh l t tht. o Xem nhng ECG trc ca bnh nhn. Nu nhp nhanh ging nhng nh p ngoi tm thu trc, l s typ ca nhp nhanh ny ( xem li Ngo i tm thu) o Nghim php cng ph giao cm thng ch c tc dng vi nhp nhanh nh . o Nhp u hay khng u khng hu ch phn bit r i lon nhp t tht hay nh. Rung nh Nhng xung kh cc c dn truyn khng theo mt ng nh bnh thng m theo v s ng khc nhau trong tm nh: o Hnh nh ch su run ry o Nhng sng nh khng u trn ECG - r nh t V1

Digoxin vn l thuc c la chn n lm gim dn truyn cc xung in xung b His. 240

Cung nh Nh co bp cc nhanh, 200 -250 ln/pht, cho h nh nh rng ca, nhng tht ch p ng vi mi 2-3-4 xung ng t nh (block 2:1, 3:1,4:1 )

Cung nh 2:1 iu tr bng Digoxin, bnh thng dn n rung nh. Nhp nhanh trn tht (SVT) o pht nh p gn nt nh tht, 170 ln/pht hoc hn, u o QRS bnh thng hoc rng nu c block nhnh o Ph bin bnh nhn tr ( 20-30 tui) o Him khi km bnh l tim khc o Xut hin t ngt v ht cng t ngt o T mt vi pht n vi gi o C th mt mi, khng tho i mi o nhng bnh nhn cao tui hn, SVT thng km theo bnh l tim khc

Cc nghim php cng ph giao cm ( xoa xoang cnh) c th ct cn SVT Vo li l c ch ph bin nht ca nhp nhanh. Gi thit c 2 ng dn truyn xung kh cc xung tm tht. nhp tim bnh thng, xung kh cc theo 2 ng vi thi gian nh nhau.

241

Vn xy ra khi mt con ng chm hn so vi con ng cn li. Khi , xung kh cc ch xung tht theo mt con ng, xung kh cc t con ng chm vo li tht sau khi xung nhanh gy hng phn cc t bo c tim xong ( th ti kh cc) do to th kh cc mi nhp nhanh. Hi chng Wolf-Parkinson-White y l typ lon nhp theo c ch vo li kinh in. C 2 con ng ring r dn xung kh cc t nh n tht. Trn ECG lc ngh , ng vo sm bng con ng dn truyn bt thng i tt xung b His, to sng delta.

Hnh 12.5. C ch vng vo li ca nhp nhanh

242

Nhp nhanh tht o Lo i nhp nhanh ny tim n s nguy him khi c th chuyn thnh rung tht o Nhanh nhng khng nhanh nh SVT ( thng < 170 ln/pht) o Thng hi khng u o Bnh nhn thng ngt o QRS lun lun rng o LBBB nu pht nhp th t phi o RBBB nu pht nhp tht tri iu tr vi lignocaine 100mg tim tnh mch mt ln v chuyn bnh nhn n bnh vin.

Nhp chm Nhp tim < 60 ln/pht Xoang Sng P bnh thng v QRS bnh thng.

243

Nhp chm xoang o Nguyn nhn: o Vn ng vin o Thuc chn Bta o Suy gip o Tng p lc ni s o au vi p ng ph giao cm au rng Tng nhn p Cn au qun mt

Ngng xoang do kch thch ph giao cm Block nh tht I o on PR(u sng P n u QRS) > 0.22s (5,5 vung nh) o Kh cc chm nt nh tht

244

Block nh tht WENKEBACH Mt chu k gm 3-4 nhp p, on PR di dn ra n khi sng P xut hin n c m khng theo sau bi QRS. Chu k li c lp li.

Block 2:1 QRS ch p ng vi ch mt s sng P, s khc khng c QRS theo sau

Block nh tht hon ton o Khng cn lin h gia sng P v QRS o Nhp tht kho ng 40 ln/pht o QRS bt thng v pht nh p tm tht

245

My to nhp o Khi dn truyn khng to nhp hay nhp rt chm, my to nhp c th kch thch c tm nh v tm tht tr li nhp hot ng To nhp tht n thun y l typ ph bin nht ca my to nhp (80%). Nu nh tm tht khng th kh cc ( to sng QRS), my to nhp s gip to sng kh c c vi tn s khong 60 -70 ln/ pht, n ngng tc dng khi tht to c nhp bnh thng.

To nhp nh n thun Trong hi chng suy nt xoang, SA khng to c sng P nhng dn truyn qua AV v b His bnh thng. To nhp lin tc

c mt in tm ? c theo mt trnh t logic: o Nhp 246

o Nhp xoang +/- ngo i tm thu, tr r i lon nhp xoang o u Block nh tht hon ton chm Nhp ch m xoang Nhp nhanh xoang Nhp nhanh trn tht Nhp nhanh tht Cung nh u o Khng u Rung nh Nhp nhanh nh vi block thay i o Tn s: m s vung nh gi a 2 sng R lin tip, ly 300 chia cho s V d: 300/5 nh = 60 ln/pht

Cng thc ny khng ng trong trng hp nhp khng u, m s sng QRS trong 6 giy v nhn vi 10 o Phc bP QRS hng d n nhanh: o Sng P: Ngo i tmthu nh?, P hai l, P ph 0.1-0.22 s ( 2.5 n 5.5 ) on PR: ko di? >0.22s: block nh tht I < 0.1s: h i chng WPW o Phc b QRS Sng Q r ng: nhi mu xuyn thnh? QRS rng> 0.12s: block nhnh Sng R ln: dy tht o on ST: chnh ln hay chnh xung- thiu mu hay nguyn nhn khc o Sng T: n u o ngc - thiu mu hay nguyn nhn khc Tm li, ch tm du hiu: o Nhp bt thng o Tn s bt thng o QRS bt thng - c bit thiu mu c tim, nhi mu hay dy c tim. 247

Chng 14:
GI TR BNH THNG CA CC XT NGHIM

Gii thiu

o Cc gi tr bnh thng thng c biu th bi kho ng gi tr ( cn di- cn trn) o Cc kt qu xt nghim cn lm sng ng gp quan trng trong chn on v iu tr o V d mt s trng hp c th: o S gia tng gp 2 ln so vi gi tr bnh thng ca enzim creatinie kinase (CK) trong huyt tng c gi tr ch n on bnh lon dng c Duchene o Hoc Khi gi tr ca cholesterol mu cao hn so vi gii h n bnh thng (>6.5mmol/l) c th ph i c quyt nh iu tr o Tiu chun kim sot ng mu ca nhng bnh nhn i tho ng o Do c s khc nhau v phng php v trnh gia cc phng th nghim,v ty theo gii tnh,tui tc ca cc ti liu tham kh o ph bin v sc khoe.Nn cc kt qu di y c s dng ngi ln v c th khng ng vi kt qu phng th ngim ca b n
o HUYT HC

NAM

248

Hb(hemoglobin): PCV (th tch hng cu c) MCV (th tch trung bnh hng cu) MCH (lng trung bnh hemoglobin) MCHC (Nng ca Hb trong t bo) Hng cu li Bch cu(WBC) Tiu cu(PLT) Thi gian prothrombin

13,5-18 g/dl

11.5-16 g/dl

40-54%

37-47%

76-100fl

27-32 pg

32-36g/dl 0.8-2% 4-11*10 9/l 150-450*10 9/l 10-14s 30-40s

Thi gian hot ha thromboplastin tng phn Gi tr chun ha quc t INR Tc lng mu bng phng php Westregent 1 ting (0-10mm)

2-3

(0-15mm)

(Tc mu lng c th cao nhng bnh nhn cao tui)

o DCH NO TY o o o o o T bo: ng: p lc: m: 0-5 bch cu. Khng c hng cu 2.8-4.2 mmol/l 78-180 mm H20 0.15-0.45 g/l

SINH HA (N V SI)

o Huyt thanh ho c huyt tng o ACE (men chuyn angiotensin-) Acid phosphatase (ton phn) 249 20-54U / l 1 -5iu / l

Acid phosphatase (tuyn tin lit) ACTH (Hormon thy trc tuyn tng) Albumin Aldosterone, nm (tng gp i sau 30 pht trong t th th ng ng) Alkaline phosphatase (ngi ln) Alpha-1antitrypsin Amylase Anion gap Aspartate aminotransferase (AST) o Bicarbonate Bilirubin (tng cng) Bilirubin tr s sinh (gi tr c) Bilirubin (lin hp) C-peptide (gii thich cho gi tr glucose) 0,2-0.8 C-reactive protein (CRP) Caeruloplasmin Calcitonin Canxi (khi albumin mu bnh thng) Carbon monoxide ( ngi khng ht thuc) Carbon monoxide ( ngi ht thuc) o embryonic khng nguyn o catecholamine - Noradrenalin e - Adrenaline Chloride Cholesterol (ch s ph bin) ng nmol / l

0-1iu / l <80mg / l 35-50g / l

100- 500pmol / l 80-250 iu / l 107-209mg/dl 25-180 n v 7-16 mmol / l

15-42 iu / l 24-30mmol / l 3-17 Mmol / l > 300 Mmol / l 0- 5 Mmol / l

<10

mg / l

16-60 mg/dl <0.08 Mg / l 2,12 -2.65mmol / l

0-2% trn 5%

(CEA) 0-9mmol / l

<5.7 Mmol / l <2.1Mmol / l 95-105mmol / l 3,9-7.8mmol / l 12-26 Mmol / l

250

Cortisol Cortisol (na m) Creatine kinase (ph n) Creatine kinase (nam) Creatinine 11-Deoxycortiso DHEAS (dehydroepiandrosterone sulphate) (ph n ) DHEAS (nam) Ferritin (ph n) Ferritin (nam) Alpha fetoprotein (AFP) Folate (huyt thanh) Folate (hng cu) Hormone kch thch nang (ph n cha mn kinh) Hormone kch thch nang (ph n sau mn kinh) o Hormone kch thch nang (nam) Gastrin (lc i) Gastro-inhibitory peptide (lc i) Glucagon (nh n i) Glucose (huyt tng lc i) g-glutamyl transpeptidase (ph n ) g-glutamyl transpeptidase (nam) HbA1C o HDL (lipoprotein t trng cao) cholesterol Hormon nhau thai ngi (HCG) 17a-Hydroxyprogesterone Immunoglobulin (globulin min dch) A Immunoglobulin E 251

(0900h) 280-700nmol / l 80-280nmol / l 24 195iu / l 24-170iu / l 70-150 Mmol / l l 7-16 nmol / l

4,9-9.4 mol / l 2.3-12.0 mol / l 15-140 Mg / l 17-230 Mg / l 0-14 kU / l 2.1-18 Mg / l 160-640 Mg / l 2-8 U / l

> 30 U / l 0.5-5.0 U / l <40 pmol / l <300 pmol / l <50 pmol / l 3.8-5.5 mmol / l 7-40 iu / l 11-51 iu / l 4.5-6.2%

0.8-2.0 mmol / l 0 5 iu / l <20 nmol / l 0.8-3.0 g / l <80 kU / l

Immunoglobulin G Immunoglobulin M Insulin (lc i tng thch vi nng glucose ) St (ph n) St (nam) Iron-binding capacity Lactate (lc i) Lactate dehydrogenase Ch (mu) <0.7 Mmol / l Hormon hong lc th (LH)(n cha mn kinh) Hormon hong lc th ( ph n sau mn kinh)

6.0-13.0 g / l 0.4-2,5 g / l

2-13 mU / l 11-30 Mmol / l 14-31 Mmol / l 45-70 Mmol / l 0.6-2.0 mmol / l 110-250 iu / l

3-6 U / l

> 30U / l LH (nam) Magie 17b-estradiol (n cha mn kinh) 17b-estradiol (nam) (p lc th m th u huyt tng) Hormone tuyn cn gip (PTH) Phosphate Potassium Progesterone (n cha mn kinh) o Progesterone (n ng) Prolactin (ph n ) Prolactin (nam gii) Khng nguyn c hiu tuyn tin lit (PSA) Protein (ton phn) Pyruvate Renin (nam) Renin (t th ng) Natri mu 3-8U / l 0.75-1.05mmol / l 180 -1100 pmol / l <220 pmol / l 278-305 mosmol/kg 0,9-5.4pmol / l 0.8-1.45mmol / l 3.5-5.0mmol / l 16-77nmol / l 0-6 nmol / l <450 mU / l < 400 mU / l <4 Mg / l 60-80 g / l 41-67 Mmol / 1.1-2.7pmol/ml/h 2.8-4.5 pmol/ml/h 134-145mmol / l

252

Testosterone (ph n ) Testosterone (nam) Transaminase (GOT, AST) Transaminase (GPT, ALT) Triglyceride (i ) Thyroxine Thyroxine (t do) Triiodothyronine (T3 ) Triiodothyronine T3 (t do) TSH (hormone kch thch tuyn gip) Urat (ph n) Urat (nam) Urea VIP vitamin B12 : Vitamin D : Vitamin E: Km (Zn) o Nc tiu 24 h Aldosterone d-Amino laevulinic acid : Calcium(Ca): Chloride(Cl): ng (Cu) Coproporphyrin: Cortisol : o thanh th i creatinin (ph n) : thanh th i creatinin (nam) : 5-HIAA (5-OH indoleacetic acid): Homovanillic axit (HVA) Metadrenaline 253

1.0-2.5nmol / l 9 -42 nmol / l 5-35 iu / l 5-45 iu / l 0.6-1.9 mmol / l 70-140 nmol / l 9 -25 pmol / l 1.0-3.0 nmol / l 3.4-7.2 pmol / l 0.5 6.0 mU / l 150-390 Mmol / l 210-480 Mmol / l 2.5-6.7mmol / l <30pmol / l 150-750 Mg / l 7-50 Mg / l 11.5-35.0 Mmol / l 6-25mmol / l

10-50 nmol/day 9.5-53.4 Mmol/ngy 2.5-7.5 mmol/ngy 110-250 mmol/ngy 0.2-1.0 Mmol/ngy 51-350 nmol/ngy 28-280 nmol/day 85-125 ml/pht 95-140 ml/pht 10.4-41.6 Mmol/ngy <82 Mmol/ngy <2 Mmol/ngy

Normetadrenaline OH methylmandelic acid (HMMA) Osmolalityp sut thm thu nc tiu) Osmolality (sau khi hn ch ung 12h) pH : Phosphate Porphobilinogen Potassium Protein Natri : Ur :
o o o NNG THUC TRONG HUYT TNG

<3 Mmol/ngy 10-35 Mmol/ngy 50-1400 mOsmol/kg > 850mOsmol/kg 5.5-8.0 12.9-42 mmol/day 0-10 Mmol/day 40-120 mmol/day 50-80 mg/day 60-280 mmol/day 164-600 mmol/day

c a ra y l cc gi tr thng thng lin quan n thi gian iu tr Thi gian ung mt s loi thuc c khi rt quan trng.Chng hn nh nng paracetamol huyt tng >1mmol/l c kh nng gy thng tn gan nhng khong thi gian nh hng nng thuc trong huyt tng s quyt nh tr liu thng gim dn theo thi gian

o Amiodarone trc khi ung thuc Carbamazepine trc khi ung Carbamazepine (tr em) Carbon monoxide khng ht thuc Carbon monoxide Ht Thuc Clonazepam trc khi ung Digoxin t nht 6 gi sau liu cui cng ca Disopyramide trc khi ung Epanutin trc khi ung Ethosuximide trc ung Lithium Phenobarbitone trc khi ung Phenytoin trc khi ung

0.6-2.0mg / l 34-51 Mmol / l 17-35 Mmol / l 0-2% 0-5% 25-85 Mg / l 1.0-2.0 nmol / l 2.0-5.0 mg/dl 40-80 Mmol / l 40-80 mg / l 0,5-1.5mmol / l 65-170 Mmol / l 40-80 Mmol / l

254

o Salicylate theophylline -Trc khi dng valproate -Trc khi dng o NNG GY NG C Barbiturat, c kh nng gy t vong - Tc dng ngn - Tc dng v a -Tc dng ko di Ethanol (sinh l <0.2 nmol / l) - Gii hn php l cho cc li xe paracetamol Nguy c tn thng gan - Lc 4 gi - 15 gi Salicylate o MT S XT NGHIM KHC Cht bo trong phn Clorua trong m hi Phc hp khng th_khng nhn trong cc bnh h thng: Anti-RoSLE, bnh lupus Anti-LaSLE, bnh Sjogren Anti-SmSLE (c th) Anti-RNPSLE, hn h p lin kt m bnh Anti-SCL-70 Bnh x cng b ri rc Anti-Jo 1 Vim a c

0.4-2.5 mmol / l 55-110 Mol / l 0,3-0.7 mmol / l

35 Mmol / l 105 Mmol / l 215 Mmol / l

<17.4 nmol / l

> 1.32mmol / l <0.2mmol / l > 2.5mmol / l

<18mmol/day 6-40mmol / l

255

CHNG 15:CC IU TR CP CU PH BIN

GII THIU:
Bn s thy cc bnh nhn c iu tr.Cc ghi chp sau y hng dn v cc phng php tr liu c s dng.Trong mi ca u cn c mt chn on.Cc phng php iu tr c p dng cho nhiu trng hp khc nhau .Ty tng nguyn nhn c th c thm phng php iu tr b sung khc.Cc phng php iu tr di y c cho l thch hp ti thi im ny (thng 5 nm 2002).Tuy nhin cng vi thi gian c th s c nhng phng php tr liu thch hp hn

TIM MCH
NHI MU C TIM (Kinh in :cn au tht vng tim ,lan ra cnh tay, xanh xao,ra m hi,kch thch vt v ,thay i trn ECG)

+Th oxy 100% +Nhai mt vin aspirin 300mg +Cho diarmorphine tnh mch liu 2.5 -5 mg ho c morphine tnh mach liu 5-10 mg (chng nn nu thy cn thit) +ECG theo di

256

+Nu ST chnh ln >= 2mm t nht 2 trong s cc chuyn o trc tim, hoc =1mm cc chuyn o ngoi bin hoc c block nhnh tri hon ton trong bi cnh lm sng ni trn _S dng tan huyt vi streptokinase v d :s dng ng tnh mch 1500000 ui trng vng mt gi.Hoc cc cht hot ha plasminogen nu khng c chng ch nh (tnh trng xut huyt,vim lot d dy t trng,xut huyt no,tai bin mch no thong qua,phnh tch ng mch ch) _Hydrocotisone 100mg tnh mch nu bnh nhn d ng vi streptokinase _Nu huyt p bnh thng, khng c suy tim,c ng truyn tnh mch (tay m) ,s dng chn beta v d : atenolols5mg tim tnh mch _Nu huyt p tm thu <= 90 mmHg ,chn tay lnh,theo di p lc tnh mch trung tm (CVP).C th cho 200ml NaCl 0.9g/dl hoc s dng andrenaline/dobutamine ng tnh mch _iu tr cc lon nhp (lu :khng s dng lignocaine) _Nu c suy tht tri (Rale n ,bng chng trn XQ, ting nga phi T3) s dng furosemide 40 mg ng tnh mch ,c th xem xt ti nhm c ch men chuyn -Nu nc tiu< 30ml/pht, iu suy thn cp (xem phn iu tr STC) _Sau khi s dng streptokinase c th xem xt heparin tnh mch _Nu sau 24h m huyt p tm thu >100 mmHg,khng c suy chc nng tim: +S dng chn beta ng ung +Xem xt s dng c ch men chuyn ng ung khi nhi mu c tim trc vch,hoi t rng c tim trc ,hoc c bng chng suy tim _HMG Co A reductase inhibitor (Yu t c ch coenzymA???) _ Xem xt cc yu t gy tng m mu

CN AU THT NGC KHNG N NH: (Cn au tht ngc m khng c bng chng nhi mu c tim)

_TH oxy 100% _Aspirin nhai 300mg, buccal GTN (Nitroglyxerin ngm di li) _S dng heparin v d:tnh mch 5000 ui, truyn 1000ui/h.Theo di thi gian hot ha thromboplastin tng phn.Hoc s dng heparin trng lng thp 257

_Diarmorphine+ chng nn _Xem xt GTN truyn tnh mch bt u 1mg/h tng ln 10 mg/h gi huyt p ti a > 100 mmHg _CHn Beta ng ung khi khng c bng chng suy tim trn lm sng _Ch n canxi ng ung,amlodipine khi chc nng tht tri km, hoc digitazem nu chc nng tht tri tt _Xem xt kh nng can thip mch vnh: nong hoc bc cu ni nu cn au vn tip din (85% cn au thuyn gim khi iu tr bng thuc) _Xem xt vic iu tr tng m mu SUY TIM TRI CP (Kh th,nhp tim nhanh,nhp ba,rale n) _Cho bnh nhn ngi _TH oxy 100% _Theo di ECG ch lon nhp _Tim tnh mach frusemide 40 -120 mg hoc bumetanide 1 -2 mg _Tim tnh mch diarmophine 2.5-5mg hoc morphine 5 -10mg tnh mch(Chng nn:tnh mch cyclizine 50mg hoc prochloperazine 12.5 mg tnh mch) _Nu suy tht tri vn cn xem xt c ch men chuyn hoc nitrat truyn tnh mch _Nu khng ci thin,cn kh th c th cho th my p lc dng lin tc CC RI LON NHP: +Nhp tim chm< 40 ln /pht hn m,ngt xu,kch thch vt v Xem xt s dng atropine 0.6mg tnh mch (nhc li liu ti a 3mg) hoc isoprenaline tim tnh mch,trong khi ch t my to nhp +Nh p tim nhanh > 140 ln/pht nhng bnh nhn b tn thng nh suy tim,h huyt p,tin s bnh tim mch _Cc loi hp van tim: Bnh nhn b shock:xem xt s dng my kh rung Adenosine tnh mch liu 3mg,sau tip liu 6mg nu cn thit,tip tc v liu 12 mg nu cn,sau nu cn dng amiodarone 300mg tnh mch tim trong 30 pht Verapamil ng tnh mch c th dng lm thuc thay th (nhng khng phi cng vi chn Beta) _Cc li h van tim: 258

C shock :dng my kh rung Bnh nhn thy kh chu:lignocaine:10mg truyn tnh mch vi tc 4mg/pht gim liu theo khuyn co +Rung tht :xem hng dn ph rung (298)

CN TNG HUYT P NNG: (V d:huyt p > 220/120 mmHg au u,ph gai th) _Kim tra lai huyt p ,v mch,t monitor theo di n u c iu kin _Mc tiu h huyt p tron g 24h (Trnh h huyt p qu nhanh c th gy nhi mu no) _S dng cc thuc chn beta,chn canxi,c ch men chuyn (khng s dng nefedipine ngm di li) _S dng nitropruside tnh mch, monitor theo di _iu tr cc bin chng nh :Suy tht tri ,bnh no do tng huyt p c bit nu i km vi cc triu chng nh

H hp
Cn hen ph qun cp tnh (Kh th,th kh kh,tnh trng nguy kch h hp) _Th oxy 100% ngoi tr trng hp c tin s bnh l h hp mn tnh _Ventolin phun linn tc (khng ht) 5ml pha vi 2ml nc _Hydrocortisone 100mg tnh mch hoc prednisolone 30 -50 mg ng ung _Aminophiline 5mg/kg tnh mch chm trong 10-15 pht .Nhng khng s dng nu bnh nhn dng theophiline trc _Lm kh mu: P02 NH Va Nng Nguy kch <10 8-10 <8 <7 pc02 <4 <4 4-6 (xem xt cn thn) >6 xem xt th my

259

_Theo di tnh trng ton thn ,xem xt th my nu bnh nhn tr nn kit sc

T CP BNH PHI TC NGHN MN TNH

(Kh th thng xuyn, ho,kh c m,rale n,rale rt ngy) _Th oxy 24% v tng ln nu PC02 khng tng _P02 gim,pc02 gim ,hng ho (pink puffer) :tng nng oxy _P02 gim,pc02 tng, xanh tm (Blue bloatters): thn trng khi tng nng oxy.Lm li kh mu .Khi loi b tnh trng thiu oxy c th khin gim th tch v tn s th.iu chnh li p02 xem xt s dng doxapram.My th c th c ch nh khi c tin lng tt _Vt l tr liu tnh trng ho khc m _Cy m,XQ, xem xt khng sinh

TIU HA

XUT HUYT TIU HA CP TNH (Ton trng suy sp t ngt, nn ra mu (haematemasis) ,i cu phn c mu ho c en st, huyt p <100 mmHg,mch >100 ln /pht) _nh gi xem c: x gan/ tng p ca,lot d dy t trng _Lu ng truyn tnh mch,lm cc xt nghim cng thc mu,sinh ha mu ,phn loi nhm mu (crossmatching) _Nu huyt p< 90 mmHg ,500 ml NaCl 0.9g/dl truyn tnh mch hoc dung dch cao phn t,trong vng 30 pht _Nu huyt p khng o c xem xt truyn mu :nhm O ,RH _Nu khng bt c mch,tin hnh hi s tun hon _Theo di CVP _Truyn mu theo nhu cu nhm tng huyt p v CVP _Sonde tiu nu mt mu nng _Hi chn ngoi v chun b ni soi cp cu SUY GAN CP

260

(vng da, hi th c mi hi, gan teo (liver flap),l ln) _Nu huyt p tm thu <90 mmHg, tnh mch 500ml glucose 5%,hoc dung dch keo,trong vng 30 pht _Theo di CVP p lc tnh mch trung tm _Theo di ng mu nu < 4mmol/l truyn tnh mch glucose 10% ,v lm li ng mu
_

Xem xt cc thuc dung trc bao gm c paracetamol khi dng qu liu

_Tm cc nhim trng t ng mu,ngc,ng niu ,bng _Tm kim tnh trng xut huyt tim n,tng ure mu _Xem xt s dng huyt tng ti ng lnh nhm ci thin tnh trng ng mu _Bt u s dng lactulose ng ung xem xt s dng c neomycin _Trnh lot ng tiu ha vi khng H2 hoc c ch bm proton _Vitamin B,K ng tnh mch _Hn ch mui, nc _Theo di:thuc,in gii ,chc nng gan,chc nng ng mu,PH

THN KINH
CN NG KINH (Co cng,co git ,cn vng thc) _Th oxy _Diazepam 5-10mg tnh mch trong vng 2 pht. Sau tim tnh mch 2mg/pht trong vng 20 pht cho n khi ct cn.nh gi tnh trng suy h hp _Kim tra glucose mu gin bit vi h ng huyt _Nn cho bnh nhn ti phng hi sc tch cc (Prone recovery position )tr khi ng th c bo v bi ni kh qun _Khm xt tnh trng: chn thng u,cng c,thiu ht cc chc nng thn kinh _Hi thm thng tin: i tho ng,s dng thuc insulin,hoc thuc ung khc ,k c kh nng t t _Ngn chn cn ng kinh,co git (xem trn) _Nu tn s th <10 nhp /pht s dng naloxone tim tnh mch _Lm glucose mu

261

_Nu huyt p tm thu <90 mmHg truyn tnh mch 500ml dung dch NaCl 0.9g/dl ,hoc dung dch keo _Lm kh mu _Ly mu ,nc tiu lm xt nghim tm cc loi thuc dng (k c ma ty) _nh gi mc hn m bng thang im Glasgow VIM MNG NO (St cao,au u,nn ma,s nh sang,cng c) _Trong vim mng no n u c ban xut huyt th ngay lp tc cho khng sinh ng tnh mch_ ceftriaxone 2g _Sau khi ly mu cy vi khun _Kim tra xem c cc du hiu ca tng p lc ni s khng,v d:ph gai th _Chc dch no ty nu khng c cc du hiu ca tng p lc ni s +Ch p lc dch no ty +Lm xt nghim dich no ty:nui cy, soi t bo vi trng,sinh ha,PCR tm virus _DNT m(Bch cu tng):s dng khng sinh tnh mch liu nhc li,sau khi cy mu _Nu dch c mu:c th do chm mch tc l c mu nhng git u tin sau trong ho c do tnh trng xut huyt di nhn (cng c khi dch mu vng do s thoi ha ca hng cu)

CC C QUAN KHC
SUY THN CP: (Gia tng nhanh chng creatine trong huyt tng, lng nc tiu <30ml/h) _Xem xt cc nguyn nhn trc thn:(bnh nhn mt nc_li kh ,np vo da mt ch m, tnh mch xp,CVP thp ,huyt p tt).Cung cp dch cho n khi p lc tnh mch cnh trn 2-3 cm the manubriosternal junction. _Xem xt cc nguyn nhn sau thn:(chng hn nh ph i tuyn tin lit,si niu qu n 2 bn,tc nghn ca thn hoc niu qun on chu _pelviureteric obstruction).Nu tuyn tin lit qu ln,hoc cu bng quang_ xem xt t sonde tiu _Nu khng tm nguyn nhn r rng suy thn.Siu m bng thy hnh nh gin niu qu n,gin i b thn_ dilated renal pelves, Ho c kch thc thn nh ,cho thy kh nng suy thn mn tnh

262

_Xt nghim kim tra :kali mu,natri,ure,creatinie( Nu K.>6mmol/l v c thay i trn ECG.Cung cp tnh mch glucose/insulin ,canxi gluconate ,hoc cht trao i ion qua ng trc trng _Kim tra Na niu v p sut thm thu nc tiu: +Trong suy thn trc thn:p sut thm thu nc tiu>400 mosmol/kg v nng Na<30mmol/l +Trong suy thn ti thn:<400mosmol/kg v >30 mmol/l _Soi nc tiu tm:hng cu,bch cu,tr niu v vi khun _Kim tra PH ng mch _Nu l hoi t ng thn cp :cho frusemide 80 -500mg tnh mch _Khi c hin tng nc,hn ch lng nc nhp vo=500ml+ lng nc mt mi ngy _Ch n giu nng lng v gim protein _Kim sot nhim trng _ Xem xt lc mu nhn to khi :creatinine>400Mmol/l,Kali vn >6mmol/l,Tha dch,nhim toan,vim mng ngoi tim NHIM TOAN CETON NGI I THO NG: (Thng xut hin nhng bnh nhn T m b :nhim trng,nn ma,hoc khng tim insulin .Bnh nhn: l m,ng g,mt nc,hi th mi ceton) _Kim tra glucose mu,in gii ,PH mu ng mch,CRP,troponin,cy mu v nc tiu,ECG,XQ phi _Tm th ceton trong nc tiu ,nh lng nu c th.C th s dng nng ceton mu.Nu khng tm thy ceton,phi ngh ti kh nng hn m do tng p lc thm thu,hoc cc hn m khng tng ceton khc _Truyn dch thay th ban u thng s dng NaCl ng trng thng 11 trong vng 30 pht ,11 trong vng 2h, 11 trong vng 4h ,11 trong vng 6h sau mi 8h .Nu nh nng glucose mu <11 mmol/l i dch truyn Glucose 5% (Lu :lng dch truyn ny c th thay i khi c cc bnh l khc i km v d nh:suy tim xung huyt) _ng truyn tnh mch trung tm o cvp nh gi khi lng dch chuyn _Liu khi u insulin 10 n v actrapid tim di da

263

_Truyn insulin (Thng pha 50 n v actrapid trong 50 ml dung dch mui NaCL truyn tnh mch ).Nhm mc ich a glucose mu v 6mmol/l _ >20 17-20 14-17 11-14 7-10 Glucose mu(mmol/l) insulin (U/l) 6 5 4 3 2

4-7 <4

1 0.5

_Theo di nng ceton v glucose mu theo gi v iu ch nh liu insulin cho ph hp _Nu bnh nhn l m nn t sonde d dy trnh t phi cht nn _Kali thay th_khng t ra nu K+<5.5 mmo/l.Nu khng th thm Kali 20-40 mmol trong 1 lt nc mui truyn tnh mch

H NG HUYT

(Triu chng: l m/bt tnh, m hi,nhp tim nhanh,mch ny nhanh,thng xut hin nhng bnh nhn i tho ng ang iu tr insulin qun ba n nh, hoc tng ch luyn tp.NB nhiu bnh nhn i tho ng khng c triu chng ca h ng huyt) _Kim tra ng mu _(Khng nn ch i kt qu xt nghim nn iu tr ngay lp tc) _Gi thng thong ng th _Nu khng c ng truyn tnh mch lp tc tim bp glucagon 1mg trong 5 -10 pht (Khng s dng trong h ng huyt do u o ty) _Trong cp cu :S dng glucose trng 50ml(50g/dl) truyn tnh mch cng vi 50ml NaCL 0.9g/dl trnh s x cng (If emergency,e.g.fitting,50ml 50g/dl i.v.glucose followed by 50ml of 0.9g/dl saline to wash sclerosant,hypertonic glucose out of vein.) 264

NHIM TRNG HUYT (St>39 0,lnh run) _Th oxy 100% _Tm tiu im nhim trng _Nu huyt p tm thu< 90 mmHg ,truyn tnh mch 500 ml dung dch NaCl hoc dung dch keo trong vng 30 pht _Theo di p lc tnh mch trung tm _Khng sinh tnh mch sau khi tin hnh cy mu,cy nc tiu ,d ch hu hng hoc m _Nu huyt p tip tc gim,Ph mu gim,tri gic tr tr chuyn bnh nhn ti phng iu tr tch cc NG C V NG CTHUC _Th oxy 100% ,ngoi tr trng hp ng c thuc dit c _o nng paracetamol v aspirin tt c cc bnh nhn _S dng naloxone khi nhp th <10 ln/pht.Lm kh mu v xem xt s dng my th _Nu huyt p tm thu <90 mmHg truyn tnh mch 500 ml NaCl trong 30 pht _Xem xt kh nng ra d dy_ t sonde d dy nu bnh nhn hn m _Nu qu liu paracetamol_S dng acetylcystein da theo nng paracetamol trong mu _Qu liu Aspirin : +Ra d dy ti 12h +Theo di PH +Xem xt li tiu cng bc tnh kim _Ng c amphetamine +Ch ti kh nng ph n ti kh qun, nn phi c thit b t ni kh qun ,thuc gm:adrenaline,chlopheniramine, hydrocortisone _Xem xt kh nng s dng than hot tnh qua ng ung hoc sonde d dy _Nu l c kh nng l cht c khng thng gp nn c t vn bi cc chuyn gia ti trung tm chng c

265

Biu hin d ng _Th oxy 100% _Chlopheniramine 10mg tim tnh mch trong vng 1 pht _Hydrocortisone 100mg tnh mch _Nu trm trng :adrenaline 0.5-1 mg tim tnh mch chm trong 1-2 pht _Nu huyt p <90mmHg th m 500 ml NC truyn tnh mch hoc dung dch keo T VONG: Chn on mt trng hp t vong khng phi l yu cu tr liu cp cu nhng l mt vn rt quan trng ca y hc _Nu bnh nhn t ngt mt thc-cn hi sc tim phi_Xem phn cp cu ngng tun hon _Ti nht,khng bt c mch,ngng th_nghe ming,quan st ngc _Khng nghe tin tim_ nghe vi ng nghe _Bt ng ng t _u v mt di chuyn cng vi nhau khi u di chuyn tc l khng c ph n x xoay mt hay phn x mt bp b _Khng phn ng gic mc _Khng phn ng bt k kch thch no khc Nu ton thn lnh <350C,hoc qu liu mt loi thuc no chng hn nh barbiturate. Bnh nhn dng nh t vong.Nhng nu nghi ng th soi vng mc bng knh soi y mt ,thy ngng tr tun ho n trong cc tnh mch TIU CHUN CHT NO _Nu bnh nhn ang th my v ngng th,cn c kim tra bi 2 chuyn gia c lp nu c th +Ti thiu 6h sau khi bt u hn m +Ti thiu l 24h sau hi sc tun hon thnh cng _Cho d bnh nhn c nguy c c nhng tn thng no khng hi phc c _Khng c phn x n o k c co git _Khng c h than nhit >350C _Khng phi l ng c thuc- kt thc iu tr trong 48h c bit l cc thuc chng trm cm hoc c ch dn truyn thn kinh c _Khng h ng huyt,nhim toan hay ri lon in gii 266

_Mt tt c cc phn x thn n o_c khng nh bi 2 nh lm sng +ng t khng cn ph n x vi nh sang _Khng cn ph n x gic mc _Khng cn ph n x tin nh mt(phn x cu no): +a vo mng nh +20ml nc lnh mi tai +Khng c phn ng nh trng mt _Khng cn ph n x hnh ty: +Khng phn x hu hng:nn,nut +Khng phn x ho,phn x co tht ph qun +Khng t th khi ngng my th:PC02 trn 6,7 kpa _Tng kim ta li t nht sau 2h ,thng l sau 24h _Ln kim tra th 2 c gi tr php l trong chn on cht no CH : Ph n x ty sng v in no khng lien quan. Cnh bo cho gia nh cn c mt s phn x vng chn vn tn ti d chc nng cung no khng cn.

267

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