3/29/2014

1
1
XT NGHIM LM SNG
PGS.TS. Nguyn Ngc Khi
BM. Dc lm sng, Khoa Dc
H Y Dc TP. H Ch Minh

Mc tiu
2
1. Nu c ngha v cch din gii kt qu ca XNLS
2. Bin lun c mt cch c bn ngha lm sng cc XN
a. Tnh trng nc-in gii
b. Chuyn ha lipid, i tho ng
c. Bnh l tuyn gip
d. Ch du nhi mu c tim
e. Chc nng gan-mt
f. Chc nng thn
3. Bin lun c mt cch c bn ngha lm sng ca cc
ch s trong XN phn tch nc tiu
4. Bin lun c mt cch c bn ngha lm sng ca cc
ch s trong XN huyt hc
3/29/2014
2
Ni dung
1. i cng
2. Xt nghim sinh ha mu
a. Cn bng nc - in gii
b. Cn bng acid-base
c. Bnh chuyn ha (lipid, glucid, protid)
d. Bnh l tuyn gip
e. Bnh nhi mu c tim
f. Chc nng gan
g. Chc nng thn
3. Tng phn tch nc tiu (sinh ha nc tiu)
4. Xt nghim huyt hc
3
A, i cng - ngha
4
B

n
h


Triu chng
lm sng
Bt thng
cn lm sng
Khm bnh Xt nghim
Chn on
iu tr
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3
A, i cng - ngha
5
n v
n v thng thng
n v SI
Nng cc cht: mol/L
(mili, micro, nano)
Nng ion: Eq/L
(mEq/L)
Hot enzym: katal
(1 mkat = 60 U)
Chuyn i n v
Khong i chng:
Ngi khe mnh
Thay i ty c s
Khc nhau ty la
tui, gii tnh

Glucose: 89 mg/dL (70 - 100)
Sinh ha mu
6
Cn bng nc - in gii Cc hormon
ADH (Vasopressin)
To ra vng di i, d tr trong
tuyn yn
Gy ti hp thu nc ng gp v
nhnh ln quai Henle
S phng thch c iu ha bi
ASTT/ mu
i tho nht: thn khng p ng
vi ADH (hoc khng sn xut c
ADH)
Lauralee Sherwood, Human Physiology: From Cells to Systems,
Seventh Edition, Brooks/Cole, 2010
3/29/2014
4
Sinh ha mu
7
Cn bng nc - in gii Cc hormon
Aldosteron
Sinh ha mu
8
Cn bng nc - in gii Cc hormon
Aldosteron
Thc y lu gi Na
+
v HCO
3
-
; bi tit K
+
v H
+
(km theo gi
nc) thn
Thc y gi Na
+
v Cl
-
t tuyn m hi
c phng thch bi angiotensin II (t s phng thch renin do
gim ti mu thn v h natri mu)
Bnh Addison: do ph hy v thng thn gy thiu ht
aldosteron v cortisol
Bnh Conn: hi chng cng aldosteron
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5
Sinh ha mu
9
Cn bng nc - in gii Cc ion
John E, Hall, Textbook of Medical Physiology
Saunders; 2005
Sinh ha mu
10
Cn bng nc - in gii Ion
Na+
K+
Ca
Mg
Cl-
HCO
3
-
4
142
5
2
103
2 (acid v c)
5 (acid hu c)
16 (protein)
27
Khng tnh
anion Gap
Khng
c o
153 mEq/L
153 mEq/L
CATION ANION
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Sinh ha mu
11
Cn bng nc - in gii Xt nghim nng ion
[Na+] =135-145 mEq/L (mmol/L)
Cn bng Na/ iu ha bi thn:
aldosteron - hormon bi niu natri
v ADH (vasopressin)- hormon
chng bi niu

Bt thng [Na]: thng phn nh
s mt cn bng nc (tnh trng
dch) ca c th
Sinh ha mu
12
Cn bng nc - in gii Xt nghim nng ion
[Na+] =135-145 mEq/L (mmol/L)
Tng [Na]/ mu
Mt nc tng i
Mt nc n thun
(bnh i tho nht)
Mt dch nhc trng
(vim d.dy-rut tr s sinh
v ngi gi)
a lng ln natri/c th
Tim truyn KS -lactam
(ticarcillin) gc mui Na
Gim [Na]/ mu
dch ngoi bo
X gan, suy tim sung huyt, suy
thn
Dng albumin, manitol
(hot tnh thm thu)
Mt natri trong c th
Gim mineralcorticoid
Bnh thn mt Na
Truyn di ngy dd ng trng
khng Na
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Sinh ha mu
13
Cn bng nc - in gii Xt nghim nng ion
[K+] : 3,55,0 mEq/L (mmol/L)
[K]/ mu:
Hng phn thn kinh v m c (tim)
Hot ng enzym
Cn bng acid-base
Chuyn ha protein v carbohydrat

S bi tit K/ thn:
Lc hon ton/ cu thn
Ti hp thu/ ng gn
Bi tit/ ng xa
Sinh ha mu
14
Cn bng nc - in gii Xt nghim nng ion
[K+] : 3,55,0 mEq/L (mmol/L)
Tng [K]/ mu
Cm gic kh chu, mt mi,
nh trng ngc
Yu c, d cm, mt phn x
Kh th nh (nhim toan)
Thay i ECG (lon nhp tim)
Gim [K]/ mu
Mt mi, yu c, au c
L m, chng mt, ln ln
Thay i ECG (lon nhp tim)
Gim K mu s lm tng c
tnh ca digitalis

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Sinh ha mu
15
Cn bng nc - in gii Xt nghim nng ion
[K+] : 3,55,0 mEq/L (mmol/L)
Tng [K]/ mu
Gim bi tit/ thn*
Thuc: ACEI/ARB, LT gi K
Dng qu nhiu K
Tng phng thch K/ni bo:
Ph hy t bo qu mc
(huyt gii, bng, chn
thng dp nt, phu thut,
nhim trng)
Nhim acid chuyn ha
(H
+
i vo TB; K
+
, Na
+
i ra)
Gim [K]/ mu
Cng aldosterol
Nn i, tiu chy ko di
Glucose niu
Thuc:
Truyn dch di ngy (khng K)
Li tiu: manitol, LT quai hay
thiazid
Insulin v kch thch 2-
adrenergic**
Sinh ha mu
16
Cn bng nc - in gii Xt nghim nng ion
[Cl- : 95-105 mEq/L (mmol/L)
Thng thay i theo Na
t c ngha chn on (# anion gap)

H [Cl
-
]/mu:
Nn i, tiu chy, ht dch d dy, thng rut
Li tiu qu mc
(thng km nhim kim chuyn ha)

Tng [Cl
-
]/mu: nhim acid chuyn ha
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Sinh ha mu
17
Cn bng nc - in gii Xt nghim nng ion
Ca
2+
: 8,8-10,2 mg/dL (2,20-2,55 mmol/L)
Dng t do, ion ha l dng c vai tr sinh l
Kt qu/ phng XN:
gi tr [Ca] ton phn




[Ca] iu chnh= [Ca] HT + 0,8 ([alb] BT [alb] BN)
Dng phc hp 10%
Gn albumin
30%
Gn globulin 8%
Dng ion ha
t do 52%
Sinh ha mu
18
Cn bng nc - in gii Xt nghim nng ion
Ca
2+
: 8,8-10,2 mg/dL (2,20-2,55 mmol/L)
GERARD J, TORTORA, Introduction to the Human Body the essentials of anatomy and physiology, Wiley, 2010
3/29/2014
10
Sinh ha mu
19
Cn bng nc - in gii Xt nghim nng ion
Ca
2+
: 8,8-10,2 mg/dL (2,20-2,55 mmol/L)
Gunstream, Stanley E,, Anatomy and Physiology with Integrated Study Guide, McGraw-Hill, 2010
Sinh ha mu
20
Cn bng nc - in gii thm thu huyt thanh
BT: 275-298 mOsm/kg (pp nghim lnh/ nc, o trong huyt
thanh # huyt tng)
Tnh ton theo cng thc sau:
2 x [Na] (mEq/L) +
Glucose (mg/dL)
18
+
Ure-N (mg/dL)
2,8
Ngi khe mnh ([Na] = 140, glucose = 90 v BUN = 14)
= 2 (140) +
90
18
+
14
2,8
= 290 mOsm/kg
Ch yu c thc hin trong tnh trng h natri mu
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Sinh ha mu
21
Cn bng nc - in gii thm thu huyt thanh
Tng
Mt nc
Tng ng huyt, nhim acid
ceton trong T
i tho nht*
Ure mu cao
Ung ru
Ly mu c cht chng ng
hoc BN dng thuc chng ng
Gim
Tha nc
Hi chng tng tit hormon ADH
(SIADH)**
Ung nc cng bc
Sinh ha mu
22
Cn bng nc - in gii Ca lm sng 1
BN n, 61 tui nhp vin v kh th khi nm v th dc nng dn,
BN ang iu tr suy tim nhng b thuc 2 tun qua.
LS: ph chn nng (4+) v h hp nguy kch
Kt qu XN cn LS:
Na
+
123 mEq/L (BT: 135-145)
K+ 4,1 mEq/L (BT: 3,5-5,0)
Cl
-
90 mEq/L (BT: 95-105)
CO
2
28 mEq/L (BT: 22-28)
BUN 30 mg/dL (BT: 8-18)
Creatinin huyt thanh (SCr) 1,3 mg/dL (BT: 0,6-1,2)
Glucose i 100 mg/dL (BT: 70-110)
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Sinh ha mu
23
Cn bng nc - in gii Ca lm sng 2
BN nam 38 tui nhp vin v nhim c ru nng, mt tri gic, l
m, BN khng c tin s d ng thuc.

Cc xt nghim cho kt qu:
Albumin: 2,0 g/dL (BT: 4-6)
Ca: 6,8 mg/dL (BT: 8,8-10,2)
Bilirubin ton phn 10,8 mg/dL (BT: 0,1-1,0)
AST huyt thanh 280 U/L (BT: 0-35)
Alkaline phosphatase 240 U/L (BT: 30-120)
[theo n v SI : albumin, 20 g/L; Ca, 1,7 mmol/L; total bilirubin,
184,6 mol/L; AST, 4,67 kat/L; alkaline phosphatase, 4 kat/L]
Sinh ha mu
24
Xt nghim cn bng acid-base Bicarbonat,
pH mu v
kh mu ng mch
H
2
O + CO
2
H
2
CO
3
H
+
+ HCO
3
-
H hp (phi) Chuyn ha (thn)
Kim (base): HCO
3
-
(22-28 mmol/L)
Acid: dCO
2

dCO
2
= CO
2
+ H
2
CO
3
khng phn ly
dCO
2
= x PaCO
2
( = 0,0306)
PaCO
2
= p sut ring phn ca CO
2
(35-45 mmHg)
tCO
2
= CO
2
ton phn = HCO
3
- (95%) + dCO
2
(5%)
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Sinh ha mu
25
Xt nghim cn bng acid-base Bicarbonat,
pH mu v
kh mu ng mch
Phng trnh Henderson - Hasselbalch:
pH = pK'
a
+ log
[base]
[acid]
= pK'
a
+ log
[HCO
-
3
]
[H
2
CO
3
]
= 6,1 + log
[24 mmol/L]
[1,2 mmol/L]
= 6,1 + log 20 = 6,1 + 1,3 = 7,4
= pK'
a
+ log
[HCO
-
3
]
[dCO
2
]
Sinh ha mu
Xt nghim cn bng acid-base Bicarbonat,
pH mu v
kh mu ng mch
pH
(7,35-7,45)
< 7,35
Nhim acid
> 7,45
Nhim kim
CO
2
> BT
H hp
HCO
3
< BT
Chuyn ha
CO
2
< BT
H hp
HCO
3
> BT
Chuyn ha
Ri lon cn bng acid-base:
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Sinh ha mu
27
Xt nghim cn bng acid-base Bicarbonat,
pH mu v
kh mu ng mch
Ri lon Nguyn nhn
Nhim
toan
Chuyn
ha

Ngng tim do nhim acid lactic; Nhim keton-acid
trong T; tiu chy; suy thn; acid ha ng thn;
nhn i (nhim keton-acid)
H hp M/ thuc m; hen suyn; ngng tim; vim PQ mn;
suy tim sung huyt; kh ph thng; chn thng u;
c ch TK-c; bo ph; vim phi; ph phi; suy h
hp
Nhim
kim
Chuyn
ha
Li tiu; H clo, kali huyt; ung, truyn NaHCO
3
;
antacid; ht dch mi-d dy; nn i
H hp X nang; thiu mu; lo lng; ng c CO; xut huyt
no; st; suy tim; thiu oxy m; NMCT; au; mang thai
3 thng cui; huyt khi phi
Sinh ha mu
28
Xt nghim cn bng acid-base Anion Gap
Anion Gap: = [Na
+
] + [K
+
] ([HCO
3
-
]+ [Cl
-
])

BT: < 16 mEq/mL
(Nu khng tnh [K] th BT < 12 mEq/mL)

i din cho nhng acid khng c o
(lactat, phosphat, sulfat v protein)
Tng anion gap:
Nhim acid chuyn ha do tng acid lactic, acid th ceton
Ng c: salicylat, MeOH, ethylen glycol, paraldehyd
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Sinh ha mu
29
Xt nghim cn bng acid-base Ca lm sng 3
Mt BN tin s bnh b T ph thuc insulin, suy tim v thiu
mu tim cc b c nhp vin sau khi nn i. Thuc ang s
dng gm lisinopril, furosemid phi hp kali, nifedipin v isosorbid
mononitrat.
Xt nghim sinh ha mu:
K
+
5,5 mmol/L (3,5-5,0 mEq/L)
Urea 15 mmol/L (2,8-6,4 mmol/L)
Creatinin 150 mmol/L (50-110 mmol/L)
ng huyt ngu nhin 23 mmol/L
Kh mu ng mch:
pH 7,25 (7,35-7,45)
PaCO
2
2,8 kPa (4,67-6 kPa)
Bicarbonat thc 9,5 mmol/L (22-28 mmol/L)
PaO
2
12,7 kPa (10,67-13,33 kPa)
Sinh ha mu
30
XN trong bnh chuyn ha glucid ng huyt
Gunstream, Stanley E,, Anatomy and Physiology with Integrated Study Guide, McGraw-Hill, 2010
3/29/2014
16
Sinh ha mu
31
XN trong bnh chuyn ha glucid ng huyt
ng huyt i
ng huyt ngu nhin
ng huyt 2 gi sau khi dng 75 g glucose / th nghim dung
np glucose (OGTT)
Sinh ha mu
32
XN trong bnh chuyn ha glucid ng huyt
ng huyt i:
BT : 70-100 mg/dL (3,9 - 5,6 mmol/L)

100 - 126 ri lon H i (tin T)
> 126 mg/dL i tho ng
> 180 mg/dL xut hin trong nc tiu
> 300 mg/dL nguy c hn m do T
< 53 mg/dL nguy c hn m h H
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Sinh ha mu
33
XN trong bnh chuyn ha glucid ng huyt
ng huyt ngu nhin:
200mg/dl + cc triu chng tng ng huyt

ng huyt 2 gi sau khi dng 75 g glucose trong th
nghim dung np glucose (OGTT):
< 140 mg/dl: dung np bnh thng
140mg/dl v < 200 mg/dl: Ri lon dung np glucose
>200 mg/dl: i tho ng
Sinh ha mu
34
XN trong bnh chuyn ha glucid ng huyt
Tng
i tho ng,
Basedow
U no, vim mng no
Suy gan, vim thn cp
Gim
Hn m h ng huyt, nhn
i ko di
Qu liu insulin, thuc h ng
huyt ung
Suy gip, suy gan nng
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Sinh ha mu
35
XN trong bnh chuyn ha glucid HbA1c
50% gi tr HbA1c phn nh cho H 30 ngy trc
25% phn nh cho H 60 ngy trc v
25% phn nh cho H 90 trc





T l lng hemoglobin gn vi phn t glucose trn chui beta,
phn nh H trung bnh trong vng 8 -12 tun trc
Chui
Chui
Glucose
Koenig et al, N Engl J Med, (1979), Correlation of glucose regulation and HbA
1c
in diabetes mellitus,
Sinh ha mu
36
XN trong bnh chuyn ha glucid HbA1c
nh gi iu tr T lu di tt hn nhiu so vi ng huyt
i:
Ngi khng T: 4-5%
T khng kim sot tt: >8%

Gim 1% HbA1c lm gim nguy c bin chng mch mu nh
37%, nguy c NMCT 14%
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Sinh ha mu
37
XN trong bnh chuyn ha lipid Triglycerid
BT < 150 mg/dL (10-150 mg/dL)
Ngun gc t thc n: carbohydrat, amino acid, acid bo
Tng: ung ru nhiu, bo ph, ri lon lipid huyt, i tho
ng, bnh l thn mn, stress nng
Sinh ha mu
38
XN trong bnh chuyn ha lipid Cholesterol
v cc lipoprotein
Ch yu c tng hp gan v rut
Vai tr trong chuyn ha to thnh hormon steroid, vitamin D3,
cc acid mt,
HDL: t trng cao
IDL : t trng trung bnh
LDL : t trng thp
VLDL: t trng rt thp

Cng thc Friewald:
LDL = total Cholesterol - HDL - TG/5 (nu triglycerid < 400)
non -
HDL
Cholesterol
ton phn
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Sinh ha mu
39
XN trong bnh chuyn ha lipid Cholesterol
v cc lipoprotein
LDL
Cholesterol
ton phn
HDL
< 100 Ti u < 200 Mong
mun
< 40 Thp
100-129 Gn ti u 200-239 Gii hn
cao
> 60 Cao
130-159 Gii hn 240 Cao
160-189 Cao
190 Rt cao
Sinh ha mu
40
XN trong bnh chuyn ha lipid Cholesterol
v cc lipoprotein
Cholesterol ton phn:
BT: 125 - 239 mg/dL
Tng trong vng da tc mt, RL chuyn ha lipid (bo ph, tng
cholesterol mu di truyn gia nh), T, tng huyt p, XVM
HDL:
BT: nam > 35, n > 40 mg/dL
Gim : XVM, bnh mch vnh, bo ph, ht thuc, li V
Tng : gim nguy c XVM v bnh mch vnh
LDL:
BT < 150 mg/dL
Tng : Nguy c XVM v bnh mch vnh
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Sinh ha mu
41
XN bnh l tuyn gip Cholesterol
v cc lipoprotein
Sinh ha mu
42
XN bnh l tuyn gip TSH
BT: 0,35-6,2 mU/L

Thp: cng gip
Cao: nhc gip
Nhy cm cho sng lc ban u
(thay i khng ph thuc vo cc globulin gn T4)
V thay i bt thng trc khi c du hiu/ triu chng
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Sinh ha mu
43
XN bnh l tuyn gip Cc hormon gip
T4:
BT 4-11 mcg/dL (51-142 nmol/L)
Gi tr o l T4 ton phn
Thay i trong nhiu tnh trng bnh l v khi dng thuc
T3:
BT: 75-220 ng/dL (1,2-3,4 nmol/L)
Hiu lc 4 ln mnh hn T4
FT4: 0,8-2,7 ng/dL (10-35 pmol/L)
Gi tr FT4 ng tin cy hn so vi T3 hay T4 ton phn
Dng khng nh bt thng tuyn gip khi TSH bt thng
Kh thc hin, tn thi gian, khng dng thng quy trn LS
Sinh ha mu
44
CK
(Creatin phosphokinase)
Bnh thng: 10 - 125 U/L (0 -2,5 kat/L)
Ba ng phn:
CK-MM (95-100%): a s m c vn
CK-MB (<3%): a s trong c tim
CK-BB (0-1%): No, c trn, khng c trong mu
Tng:
Tn thng c vn (TDP ca statin, corticosteroid)
Tn thng c tim (ng phn CK-MB tng cao)
XN chn on tn thng c tim
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Sinh ha mu
45
CK
(Creatin phosphokinase)
CK-MM CK-MB CK-BB
XN chn on tn thng c tim
Sinh ha mu
46
CK
(Creatin phosphokinase)
CK-MB:
BT < 16 U/L 37
o
C
L du hiu c hiu ca c tim trong huyt tng

Nhi mu c tim:
Tng trong vng 3 8 gi sau, t nh trong khong
10 - 24 gi (NMCT khng ko di)
Tr v bnh thng sau 2 - 3 ngy (NMCT khng phc tp)
XN chn on tn thng c tim
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Sinh ha mu
47
Troponin I
v Troponin T
Troponin I (BT< 0,2 ng/mL *)
v Troponin T (BT < 0,1 ng/mL *)
XN chn on tn thng c tim
Sinh ha mu
48
Myoglobin
Bnh thng < 100 g/L
C c v c tim, chuyn ch oxy vo ty lp th
Gip chn on sm trong NMCT:
Tng sau 2 gi
t nh sau khong 4 gi
Tr v bnh thng sau 8 gi
XN chn on tn thng c tim
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Sinh ha mu
49
So snh
Thi gian sau cn NMCT
Loi protein
Thi im bt
u tng (gi)
Thi im t
nh (gi)
Thi gian tr v
bnh thng (ngy)
CK 4-6 18-36 2-3
Myoglobin 2-3 6-9 1
Troponin I
& T
4-6 24-36
5-15
Ty thuc mc
tn thng
XN chn on tn thng c tim
Sinh ha mu
50
So snh XN chn on tn thng c tim
Richard A. McPherson, Matthew R. Pincus., Henrys clinical diagnosis and management by laboratory
methods.22nd ed., Elsevier, 2011
3/29/2014
26
Sinh ha mu
51
XN chn on tn thng c tim Cc XN khc
AST (Aspartate aminotransferase):
C trong gan, c tim
Trong NMCT:
Tng sau 6 - 12 gi
t nh sau 24 - 36 gi
Tr v bnh thng sau 3 - 5 ngy

C-Reactive Protein (CRP):
BT<0,3 mg/dL
Ch du cho tnh trng vim, nhim (gm c au tht ngc, NMCT)
Sinh ha mu
52
XN chn on tn thng c tim Ca lm sng 4
BN n 59 tui, ang dng atorvastatin 40 mg/ngy iu tr tng
cholesterol mu. Mt tun nay, BN than phin mt mi v au c.
Khi hi bnh, bc s pht hin BN mua vin 80 mg nhng qun
khng b na vin thuc.
Kt qu XN nh sau:
AST, 51 U/L (BT, <35); ALT, 72 U/L (BT, <35);
ALP, 82 U/L (BT, 30120);
CK, 216 U/L (BT, <150);
SCr, 1,4 mg/dL (BT, 0,6-1,2)
[SI units: AST, 0,85 kat/L; ALT, 1,2 kat/L; ALP 1,37 kat/L; CK,
3,6 kat/L; SCr 123,8 mol/L]
3/29/2014
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Sinh ha mu
53
XN chc nng gan Cc enzym gan
ASAT (GOT) v ALAT (GPT):
Ch du nhy cm nht ca tn thng TB gan
C th tng m khng km tng bilirubin

Tn thng gan cp:
Mc tng cao nht ( 100 ln), tng song song vi nhau
ALT thng nhy cm hn AST
i khi ALT tng m AST khng tng:
Bnh gan nh
Giai on phc hi ca vim gan
Sinh ha mu
54
XN chc nng gan Cc enzym gan
ASAT/ GOT: 0 - 35 U/L (0 - 0,58 kat/L)
Hin din nhiu nht trong tim v gan, cn c trong c xng, thn
v ty
Hoi t gan cp (do virus hay c cht): tng cao, thng tng
song song vi ALT
X gan: AST tng cao gp 4-5 ln bnh thng (tng cao hn so
vi ALT)
3/29/2014
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Sinh ha mu
55
XN chc nng gan Cc enzym gan
ALAT/ GPT: 0 - 35 U/L (0 - 0,58 kat/L)
ALAT c hiu cho tn thng/ cc bnh gan
(mc d lng ALT trong gan t hn AST 3,5 ln)
Sinh ha mu
56
XN
chc nng
gan
Bilirubin
Sn phm
thoi ho
ca
hemoglobin
Cc yu t cn
Hormon
Kim loi
St
Vitamin B12
Acid folic
Cc vitamin khc
TB gc
Hng cu
Sng khong 120 ngy
Phn hy
h thng li ni m
Globin Ti s dng
St Ti s dng
Heme
Bilirubin
Michael Llewellyn Clark, Parveen Kumar, Michael L, Clark, Kumar and Clark's Clinical Medicine, Saunders Ltd,, 2009
3/29/2014
29
Sinh ha mu
57
XN
chc nng
gan
Bilirubin
Bilirubin
Bilirubin glucuronid
Urobilinogen
Urobilinogen
trong nc tiu
Chu trnh gan-rut
ca urobilinogen
Rut
Stercobilinogen
Vn chuyn trong huyt
tng gn vi albumin
Michael Llewellyn Clark, Parveen Kumar,
Michael L, Clark, Kumar and Clark's
Clinical Medicine, Saunders Ltd,, 2009
Sinh ha mu
58
XN chc nng gan Bilirubin
Bilirubin ton phn: 0,1-1,0 mg/dL (1,7 -17,1 mol/L)

Bilirubin lin hp (trc tip, bilirubin gan):
BT: 0 - 0,2 mg/dL (0 -3,4 mol/L)
Tan trong huyt thanh
Tch tr trong ti mt

Bilirubin cha lin hp (gin tip, t do, bilirubin trc gan):
Khng tan trong huyt thanh
Vn chuyn trong mu nh gn vi protein HT (albumin)
3/29/2014
30
Sinh ha mu
59
XN chc nng gan Bilirubin
Billirubin ton phn/ mu tng hn 43 mol/L
xut ra nim mc gy vng da, vng mt

Nguyn nhn:
Trc gan: tiu huyt
Ti gan: loi ra khi mu km hoc lin hp km
Sau gan: tc ng dn mt
Sinh ha mu
60
XN chc nng gan Ca lm sng 5
BN nam 71 tui va ung ht toa thuc 10 ngy flucloxacilin 500
mg x 3 ln/ ngy dng iu tr bnh vim m t bo. Ba tun
sau, bnh nhn phi ti gp bc s v chng ng lm, tng cm gic
bun nn. Vi ngy trc , bnh nhn thy mt hi vng v
nc tiu c mu m, trong sut 2 ngy sau bnh nhn b nga
khp ton thn v 2 cng chn gy nh hng ti gic ng.
Bnh nhn c nhp vin, Cc xt nghim cho kt qu:
Albumin 37 g/L (BT: 35-55),
Aspartat transaminase 172 U/L (BT < 35),
Alanin transaminase 211 U/L (BT < 50),
Alkalin phosphatase 1975 U/L (BT 70-290),
Bilirubin 172 mmol/L (BT 3-17),
3/29/2014
31
Sinh ha mu
61
XN chc nng thn Ure nit mu (BUN)
BT: 8-18 mg/dL (2,8-6,4 mmol/L)

Tng hp: ch yu bi TB gan t chuyn ha protein

o thi: ch yu qua thn
Lc hon ton bi cu thn,
Ti hp thu ng gn
Bi tit ng xa
Suy thn cp hoc mn: BUN tng
Sinh ha mu
62
XN chc nng thn Ure nit mu (BUN)
Khng o lng y mc ca bnh thn

Cc yu t nh hng ln tr s BUN:
Tnh trng protein trong mu:
Lng protein n vo
S d ha protein ni sinh
Xut huyt ng tiu ha trn
Lng dch c th
3/29/2014
32
Sinh ha mu
63
XN chc nng thn Ure nit mu (BUN)
Ba n
Lng protein n vo
mi ngy (g/kg cn nng)
BUN trung bnh
(mg/dL)
t protein 0,5 ~5
protein BT 1 ~12
Giu protein 2 ~22
Sinh ha mu
64
XN chc nng thn Ure nit mu (BUN)
Tng
Vim cu thn cp
Hi chng thn h
Suy thn
T
Ng c thy ngn
Suy tim sung huyt
Tiu chy, mt nc nng
Xut huyt tiu ha trn
Shock, nhim trng nng
Tc nghn ng niu
n nhiu protid
Gim
Vim gan, suy gan, nghin ru
Suy dinh dng, ba n ngho
protid
dch, mang thai, hi chng
tng ADH
3/29/2014
33
Sinh ha mu
65
XN chc nng thn Creatinin huyt tng
BT: 0,6-1,2 mg/dL (50-110 mol/L)
To ra t creatin v phosphocreatin (c)
Tc to thnh khng i, quyt nh ch yu bi khi lng c
(trng lng nc ca c th)
o thi ch yu bi thn
Lc hon ton qua cu thn
Khng c ti hp thu, c bi tit mt lng nh vo ng thn
Lng bi tit hng ngy:
Thng khng i
t ph thuc V nc tiu, chc nng gan hay lng protein n vo
Sinh ha mu
66
XN chc nng thn Creatinin huyt tng
Tng
Vim cu thn, vim thn, vim
b thn
Suy thn
a u ty, vim khp dng thp
T, Gout
Suy tim sung huyt
Mt nc
Shock, nhim trng ni tm mc
Tc nghn ng niu
Gim
Teo c
Mang thai
3/29/2014
34
Sinh ha mu
67
XN chc nng thn
CockcroftGault
(140 tui) Cn nng

Ccr: mL/pht

Lu : nu > cn nng 30% AjBW (kg)
Nam: IBW = 50 kg + 2,3 kg x (chiu cao (inch) 60)
N: IBW = 45,5 kg + 2,3 kg x (chiu cao (inch) 60)
AjBW = IBW + 0,3( ABW - IBW)

MDRD
GFR = 186 (Scr)
1.154
(Tui)
0.203
0.742 (n)
1.212 (da en)

Schwartz (tr em)

CrCl (ml/min/1,73m
2
) = [chiu cao (cm) x k] / Scr
k = 0,55 i vi tr em tui t 1-13
(72 Scr )
GFR =
x 0.85 (n)
eGFR
Tng phn tch nc tiu
68
ngha
Gip pht hin sm cc hi chng trong ri lon chuyn ha:
i tho ng:
T trng
Glucose, keton
Bnh thn v ng tit niu:
Mu sc, t trng
Bch cu, nitrit, pH, glucose, protein, mu (hng cu/
hemoglobin)
Bnh gan c lin quan vng da:
Mu sc
Urobilinogen, bilirubin
3/29/2014
35
Tng phn tch nc tiu
69
Ch tiu
Mu sc:
Nc tiu trong (c nh)
C mu vng nht n h phch
T trng:
BT 1,003 - 1,040
Gim: i tho nht
Tng: c protein, glucose, keton trong nc tiu
Glucose:
BT m tnh
Keton:
BT m tnh
Tng phn tch nc tiu
70
pH nc tiu:
BT: 5 - 6
Thc t: dao ng trong khong 4,5 - 8, ty ch n, bnh l v
dng thuc

Protein:
BT: < 10 mg/ dL
Protein (b l albumin) trong nc tiu l ch du h hi thn do
bnh tiu cu thn, bnh i tho ng v THA
Ch tiu
3/29/2014
36
Tng phn tch nc tiu
71
Nitrit:
BT: m tnh
Nitrit to ra t phn ng kh nitrat bi cc vi khun: E. coli,
Proteus, Klebsiella, Aerobacter, Citrobacter v Salmonella
Du hiu ca nhim trng ng tiu (gram m)

Bch cu:
BT: khng c
Du hiu ca nhim khun ng niu
Ch tiu
Tng phn tch nc tiu
72
Mu:
BT: khng c hoc gii hn < 3 HC/quang trng
Bnh l khi > 5 HC/ quang trng:
Do si, khi u, bnh l cu thn, b thn

Cn lng:
Xem cc tinh th calci oxalat, urat, struvit, cystin phn bit
bnh l tn thng thn v ng tit niu

Tr niu (cast)
Ch tiu
3/29/2014
37
73
BN nam 33 tui chn on T type 1 cch y 10 nm, cho n
hin ti bnh c kim sot tt vi phc insulin. BN nhp vin
v tin s 3 ngy st, n lnh, kh tiu, kh chu v hi ln ln, BN
cng bun nn v nn i, gim v gic. V BN khng th n trong
vng 48 gi qua nn khng dng insulin.
Test nhanh glucose mu l 545 mg/dL,
Phn tch nc tiu gia dng cho thy :
pH 5,2; c; t trng1,033; protein 3+;
glucose 4+; th ceton dng tnh;
VK 4+; WBC: nhiu khng m c;
mt vi TB vy biu m/ vng m; nitrit dng tnh
Ca lm sng 6
Tng phn tch nc tiu
Xt nghim huyt hc
74
RBC: s lng hng cu
Hgb (hemoglobin) huyt sc t
Hct (hematocrit) t s huyt cu trn th tch mu

Cc ch s hng cu:
MCV (mean corpuscular volume): th tch trung bnh hng cu
MCH (mean corpuscular hemoglobin)
MCHC (mean corpuscular hemoglobin concentration)
RDW (red cell distribution width): phn b kch thc v hnh
dng hng cu, BT: 11-14%
Retic (reticulocyte) lng hng cu non hay hng cu li
3/29/2014
38
Xt nghim huyt hc
75
Lauralee Sherwood, Human Physiology: From Cells to Systems, 7e, 2010, Figure 11,9, p, 404
Cc thnh phn
Xt nghim huyt hc
76
Rhoades, Rodney, Medical physiology : principles for clinical medicine, Lippincott Williams & Wilkins, 2013
Cc thnh phn
3/29/2014
39
Xt nghim huyt hc
77
Cc thnh phn
Hng cu D: 15 ngy
LS: 100-120 ngy
T/g pht trin (D)
v i sng (LS)
Loi Minh ha
4-6 triu
SL (mm
3
)
Vn chuyn
O
2
v CO
2
Chc nng
Bch cu
Neutrophil D: 14 ngy
LS: 6 g- vi ngy
3000-7000 Thc bo VK

7-8 m
Eosinophil D: 14 ngy
LS: 5 ngy
100-400 Dit KST
Ph phc hp
k. nguyn k. th

10-12 m
10-14 m
Basophil D: 1-7 ngy
LS: vi gi -vi ngy
20-50
Phng thch histamin
Cc cht trung gian
gy vim,
cha heparin

10-14 m
Bch cu ht (granulocytes)
Xt nghim huyt hc
78
Cc thnh phn
T/g pht trin (D)
v i sng (LS)
Elaine Nicpon Marieb, Katja Hoehn, Human Anatomy And Physiology, Benjamin-
Cummings, 2006
Loi Minh ha SL (mm
3
) Chc nng
Bch cu
Lymphocyte D: vi ngy/tun
LS: vi gi/nm
1500-3000 Cho p ng m. dch
bng cch tn cng
trc tip t bo hay
thng qua khng th

Monocyte D: 2-3 ngy
LS: thng
100-700 Thc bo, pht trin
thnh i thc bo
m

5-17 m
14-24 m
Bch cu khng ht (Agranulocytes)
Tiu cu D: 4-5 ngy
LS: 5-10 ngy
150.000-
400.000
ng mu,
lm lnh vt thng

2-4 m 78
3/29/2014
40
Xt nghim huyt hc
79
Thiu mu
S lng hng cu:
BT : 4 5 triu/ mL (nam > n)

Huyt sc t (Hemoglobin):
BT : 13 -15 g/dL (nam > n)

Rubin, Emanuel, Rubins pathology : clinicopathologic foundations
of medicine, Lippincott Williams & Wilkins, 2012
Xt nghim huyt hc
80
Elaine Nicpon Marieb, Katja Hoehn, Human Anatomy And Physiology, Benjamin-Cummings, 2006
Hng cu Hemoglobin
Hemoglobin = protein globin + heme
2 alpha + 2 beta 4
Heme
Thiu mu
3/29/2014
41
1, LY MU 2, LY TM
Huyt
tng
(55%)
BC v TC
(<1%)
Hng cu
(45%)
Xt nghim huyt hc
81

T l % gia th tch huyt cu v mu ton phn
BT: 38 - 50% (nam > n)
Gim trong thiu mu v chy mu tiu huyt
Tng trong mt nc do tiu chy, nn ma, st ko di
B nh hng bi nhiu yu t v iu kin bo qun mu mu
Hematocrit
Elaine Nicpon Marieb, Katja Hoehn, Human Anatomy And Physiology, Benjamin-Cummings, 2006
Thiu mu
Xt nghim huyt hc
82
Hematocrit
Donald C, Rizzo, Delmars Fundamental of Anatomy & Physiology, Thomson, 2001
Thiu mu
3/29/2014
42
Xt nghim huyt hc
83
MCV: th tch trung bnh ca hng cu xc nh kch thc
hng cu
BT: 80 -100 femtolit (fl)
MCV < 80 : Thiu mu hng cu nh
MCV >100 : Thiu mu hng cu to (thiu vit. B12, acid folic)
Ch s hng cu
MCV =
Hematocrit
S lng hng cu
Thiu mu
Xt nghim huyt hc
84
MCH: Lng Hb trung bnh ca hng cu
BT: 30-32 pg

MCHC: Nng Hb trung bnh ca hng cu
BT: 320 340 g/L
nh gi tnh cht ng sc, u sc hoc nhc sc
Ch s hng cu
Huyt sc t
S lng hng cu
MCH =
Huyt sc t
Hematocrit
MCHC =
Thiu mu
3/29/2014
43
Xt nghim huyt hc
85
HC li (Retic): BT 0,5- 1,5% lng hng cu
Hng cu non mi ra ngoi mu, sau 24 - 48 gi tr thnh hng
cu trng thnh,
Tng cao (30 40%) sau chy mu hoc tiu huyt

RDW (red cell distribution width): phn b kch thc v hnh
dng hng cu, gip chn on phn bit thiu mu hng cu nh
l do thiu st hay do thalassemia
BT: 11-14%
Nu MCV gim, RDW bnh thng l thalassemia, nu RDW tng
l do thiu st
Ch s hng cu Thiu mu
Xt nghim huyt hc
86
Ch s hng cu
Theo kch thc hng cu Theo huyt sc t
Thiu mu hng cu nh Thiu mu nhc sc
Thiu mu hng cu to Thiu mu u sc
Thiu mu hng cu bnh thng Thiu mu ng sc
Thiu mu
3/29/2014
44
Xt nghim huyt hc
87
Bnh nhn nam 50 tui phng khm bnh vin b nhp tim nhanh
v tt huyt p. Tin s dng thuc gn y gm hydroclorothiazid
v aspirin di ngy.
Kt qu xt nghim mu nh sau,
Xt nghim huyt hc:
Hb 8,8 g/dL
RBC 4,7 x 10
12
/L
Tiu cu 570 x 10
9
/L
MCV, MCH v cc XN huyt hc khc u bnh thng
Sinh ha lm sng: Urea 11,6 mmol/L (2,5 - 7,5 mmol/L)
Creatinin bnh thng v cc nng Na
+
, K
+
u bnh thng,
Ca lm sng 7
Xt nghim huyt hc
88
Cng thc bch cu
Bch cu
BC ht
BC khng ht:
cc lymphocyte
BC a nhn BC n nhn
BC Trung tnh BC a kim BC a acid
3/29/2014
45
Xt nghim huyt hc
89
Bch cu khng ht (Agranulocytes)
Bch cu ht (Granulocytes)
Bch cu
(WBC: 4,800-10,800)
Tiu cu
Bch cu
Hng cu
Elaine Nicpon Marieb, Katja Hoehn, Human Anatomy And Physiology, Benjamin-Cummings, 2006
Cng thc bch cu
Xt nghim huyt hc
90
WBC: 3,2 -9,8 10
3
/mm
3
(3,2 -9,8 10
9
/L)
Granulocyte: bch cu ht
Neutrophils hay PMN: bch cu trung tnh
Eosinophil: bch cu a acid
Basophil: bch cu a kim
Band: bch cu non

Lymphocyte: bch cu lympho
Natural killer, t bo B, t bo T
Monocyte: BC n nhn, khi vo m s bin thnh i thc bo
Cng thc bch cu
3/29/2014
46
Xt nghim huyt hc
91
Bch cu khng ht (Agranulocytes)
Bch cu ht (Granulocytes)
Neutrophil Eosinophil Basophil
Lymphocyte Monocyte
Elaine Nicpon Marieb, Katja Hoehn, Human Anatomy And Physiology, Benjamin-Cummings, 2006
Cng thc bch cu
Xt nghim huyt hc
92
Bch cu trung tnh (Neutrophil) 50 - 70%
Bch cu a base (Basophil) 0 - 1%
Bch cu acid (Eosinophil) 1 - 4%
Bch cu lympho (Lymphocyt) 20 - 35%
Bch cu mono (Monocyt) 5 - 10%
Cng thc bch cu
3/29/2014
47
Xt nghim huyt hc
93
BT: 1500- 3000 /mm
3

2 loi BC lympho:
Lympho B: min dch th dch, sn xut khng th
Lympho T: min dch t bo
Thay i trong mt s bnh nhim virus v nhim khun
Gim nhiu: suy gim min dch (ho cht iu tr ung th, thuc
c ch min dch dng trong ghp m, nhim x, nhim HIV)
Cng thc bch cu
Xt nghim huyt hc
94
Loi BC Tng Gim
BC trung tnh Nhim khun cp tnh
Thng hn, cm, si,
HIV, st rt,
Thuc: phenothiazin,
phenytoin, khng sinh,
sulfamid, thuc tr ung
th
Sc, HC Cushing, tn
thng hon ton ty
xng
iu tr corticoid
BC a acid
D ng, hen, eczema,
cc bnh giun, sn
BC a base
Trng thi tng mn
cm (d ng), thiu
nng gip
BC n nhn
Lao, cm, thng hn,
nm, vim gan, ung
th
Cng thc bch cu
3/29/2014
48
Xt nghim huyt hc
95
Tiu cu
BT: 150.000- 300.000/ mm
3
Tham gia vo qu trnh ng mu, cm mu

Gim : < 100.000 /mm
3
Suy ty, do ung th, nhim c arsen, benzen, nhim khun v
virus
Thuc: quinidin, heparin, thuc chng ung th
Aspirin, clopidogrel: c ch kt tp tiu cu
Xt nghim huyt hc
96
Tc lng mu (VS)
Tc lng hng cu (ESR)
o tc lng ca HC

BT: < 10 mm/h
(ngi trng thnh)
XN khng c hiu, ch yu dng
theo di tnh trng vim trong
c th: VS (ESR) s tng cao
Vim khp dng thp, vim rut,
khi u v nhim trng
Rhoades, Rodney, Medical physiology :
principles for clinical medicine, Lippincott
Williams & Wilkins, 2013
3/29/2014
49
Xt nghim huyt hc
97
BN nam 45 tui nhp vin v nghi ng nhi mu c tim. BN khng
c bnh s g ng ch , ngai tr trc y b nga vi
amoxicillin/ clavulanat

Kt qu xt nghim:
Na 137 (136-144); K 3,8 (3,7-5,2); Cl
-
101 (101-111);
bicarbonat 25 mEq/L;
BUN 17 mg/dL; Cr huyt thanh 0,6 mg/dL (0,8-1,4)
WBC 18,6 x 10
3
/mm
3
, PMN 85%, band 10%
Hgb 12,3 g/dL (13-17), HCT 37,0% (38%-48%);
Tiu cu 170 x 10
3
/mm

(150-400)
Ca lm sng 9
Ti liu tham kho
98
Frances Fischbach, A Manual of Laboratory and Diagnostic Tests,
Lippincott Williams & Wilkins; Seventh Edition edition (2004)

Mary A, Williamson, L, Michael Snyder, Interpretation of Diagnostic
Tests, Lippincott Williams & Wilkins; Ninth edition (June 29, 2011)