Cu 1. Hc mn Sinh l bnh gip ch g cho cng tc iu tr d phng v iu tr bnh. Cho v d chng minh?

Sinh l bnh hc hay gi l gi tt l sinh l bnh l mn khoa hc nghin cu v nhng quy lut hoi ng ca c th b bnh trong nhng trng hp c
th , ri t rt ra quy lut hot ng ca c quan b bnh ,ca cc qu trnh bnh l in hnh v cui cng tm hiu nhng quy lut hot ng ca bnh
ni chung
Sinh l bnh hc l mn khoa hc c nhiu mn khoa hc khc ca y hc nhng gi mt vai tro quan trng trong nn y hc hin i .N l mt mn y hc c
s soi sng cng tc phng v iu tr , l l lun ,trit hocjcuar y hc
Y hc hin i ly d phng l chnh ,nhng mun d phng dc bt c bnh no th cn nm dc quy lut hot ng ca chng . Sinh l bnh nghin cu v
quy lut hot ng ca bnh ,tt nhin phi ng gp quan trng trong cng tc ny .Nhng cng tc d phng ko phi ch nh vy .Ngay trong cng tc iu tr
thc d phng cng cn c
Mi ngi u bit trong iu tr c ba bin php : iu tr triu chng ,nguyn nhn v iu tr bnh sinh hay iu tr theo c ch bnh sinh.Bin php u
tin ch dc dung khi cha chun on r v khi biu hin bnh l qu mnh c th nh hng n tnh mng bnh nhn nh au qu c gy soch ,st qu cao c th
gy bin chng .nhng cng phi rt hn ch v nhiu khi c hi hn l c li.D sao d cng ch l bin php i ph
iu tr theo nguyn nhn l ng nht v tc dng ngay vo nguyn nhn gy bnh . Song nhiu bnh l hin nay cha r nguyn nhn th bin php ny ko
dung dc.Ngay nh trong nhiu bnh c ng nhn, nhng mt khi qu trnh bnh l din ra th n din ra theo mt quy lut nht nh .Khi c iu tr theo
nguyn nhn bnh vn tip tc nng i khi cn mnh hn v gy nguy him cho bnh nhn ( nh bnh hexamheimer khi dung khng sinh chng vi khun gy
bnh ).Khi ny cn s dng khi nim d phng trong diu tr tc l thong qua hiu bit v quy lut din bin ca bnh ( tc l sinh l bnh hc ca bnh) m
ra nhng bin php iu tr thch ng ngn cn hoc hn ch nhng din bin xu c hi. l iu tr sinh l bnh
V d nh: trong tnh trng da shoch ( chn thng ,chy mu ) cn cho thuc chng au ,an thn ,truyn dchhay trong vim phi nng ngoi khng sinh thch
ng cng phng tnh trng thiu oxy do tnh trng hn ch h hp.
Cu 2. Khi nim v bnh. C mt khi nim ng v bnh, gip ch g cho cng tc phng v cha bnh?
Mun tin hnh tt cng tc phng v cha bnh ,ngi thy thuc cn co mt khai nim ng v bnh
Vy bnh l j?cu hi ny dc ra t khi loi ngi c mt trn tri t.khi nim ny c xy dng dn trong qua tringf pt ca y hc v l kt qu ca cuc
u tranh lien tc ca CNDV v CNDTtrong bnh l hc.Quan nim v bnh lun lun thay ity theo s thay i,tuy theo ph ca khoa hc ni chung v ca y
hc ni ring.Di y l mt s khi nim kh khoa hc v chnh xc
gy bnh i vi t bo,t chc .Chnh tn thng t bo gy ra bnh.Bnh s xut hin khi no v ch no c tc dng ca nhn t gy tn thng. V cng
theo tc gi th khng phi ton b c th phn ng i vi nhn t gy bnh, m ch l nhng t bo , nhng c quan ring bit tham gia vo qu trnh bnh l.
+hc thuyt stress: bt c mt kch thch mnh no ca ngoi mi tc ng trn c th u c th gy ra mt trng thi cng thng (Stress), mt chui phn ng
khng c hiu kt hp vi nhau thnh hi chng thch ng chung.
+hc thuyt froi: Cn gi l thuyt phn tm, thuyt tinh thn c th. Hc thuyt ny cho rng yu t tm l l nguyn nhn ch yu gy ra cc bnh
+hc
thuyt
thn
kinh:
Trng phi Nga, vi nhng nh bc hc ni ting nh Set-s-np, Bt-kin, Pap-lp c nhiu ng gp soi sng bn cht ca bnh, v ra hc thuyt
thn kinh ca bnh. Set-s-np nu bn cht phn x ca cc qu trnh thn kinh ; Bt-kin ly hc thuyt thn kinh lm nguyn tc gii quyt bnh.nhng t tng
ny c pht trin thm mt bc trong hc thuyt hot ng thn kinh cao cp ca Pap-lp. theo hc thuyt ny, ni mi v ngoi mi l mt khi thng nht
m trong hot ng ca thn kinh cao cp chi phi kh nng thch ng ca c th i vi ngoi mi. Pap-lp bo v nguyn tc quyt nh lun trong ngun
gc gy bnh v ch r trong mi bnh c 2 qu trnh song song tn ti : qu trnh bo v sinh l v qu trnh hu hoi bnh l.
* Quan nim hin nay : Bnh l s thay i v lng v cht ca cc hot ng sng ca c th do tn thng cu trc v rlcnng do tc nhn t mt hoc bn trog
c th gy nn .
Mt cch c th hn,c 1 nh ngha hin ang c s dng rng ri:Bnh l bt k s sai lchhoc tn thng no v cu trc v chc nng ca bt k b
phn,c quan,h thng no ca c th biu hin bng 1 b triu chng c trng gip cho thy thuc c th chn on xc nh v chn on phn bit,mc d
nhiu khi ta cha r v nguyn nhn,v bnh l hc v tin lng(t in y hc Dorlands 2000).
Nh vy c rt nhiu cch hiu v bnh cho nn cn c nhng ch trong mt khi nim bnh:
+bt c bnh no cng do nguyn nhn gy ra
+bnh c tnh cht cn bng mi
+bnh l mt cht lng mi
+bnh lm hn ch kh nng lao ng
Ni tm li, mt quan nim ng hay sai v bnh s quyt nh thi ca ngi thy thuc trong cng tc hng ngy ca mnh cng tc u tranh chng li bnh
tt.
Cu 3. Ti sao trong lm sng khng c 2 ngi bnh (mc cng mt bnh) hon ton ging nhau v biu hin v din bin lm sng. Cho
v d chng minh v nu ngha thc tin ca vn ?
Trong lm sng khng c 2 ngi bnh (mc cng mt bnh) hon ton ging nhau v biu hin
v din bin lm sang v
Mi ngi lun sng v tip xc vi ngoi cnh, trong nhng iu kin sinh hot v mt ch x hi nht nh, cho nn bnh tt pht sinh rt phong ph a
dng
v
ph
thuc
vo
cc
yu
t
c
bn
sau
y:
1. Nguyn nhn v iu kin gy bnh: l nhng yu t hin nhin quyt nh s pht sinh bnh a s trng hp. Cng mt yu t bnh nguyn nhng bnh
sinh c th thay i theo cng liu lng thi gian tc dng v v tr tc dng ca bnh nguyn
-S lng, cng , c lc ca bnh nguyn: yu t gy bnh ko nhng phi c s lng,mt nht nh m pah c cng , c lc mnh ti 1 mc no
mi gy bnh v s thay i din bin bnh nu thay i cc tnh cht trn.
VD: nicotin nu a vo c th 1 lng ln qua ng h hp th s xy ra ng c cp nhng nu chia ra liu nh ,ko di th s gy VPQun mn, gim kh nng
khng c th gy ung th phi.
Mt s yu t c cng thp nhng tc dng lien tc trong thi gian di cng gy ra bnh nh ting n,ng c ru mn tnh.
-Ni xm nhp ,thi gian tc dng ca bnh nguyn: cng 1 cht c cng 1 VK s gy nn cc bnh khc nhau v mc khc nhau khi chng xm nhp vo cc
b phn khc nhau ca c th v mi c quan b phn li c chc nng v phn ng tnh khc nhau.
VD: T cu vo da gy bnh apxe, vo rut gy bnh tiu chy hay cng l 1 cng va p nhng vo s no s c bnh sinh khc hn vi vo tay chn.
Cng 1 nng bnh nguyn cng ni tip xc nu thi gian cng di th ni chung bnh cng nng
2. c im ca c th: vi mt s bnh c th, ngoi cc nguyn nhn, iu kin bnh pht sinh cn ph thuc vo nhng c im c th ca con ngi (tnh
phn ng ca c th di vi bnh tt, th tng, di truyn). Trong nhng iu kin nh nhau, bnh sinh mi c th c th khc nhau iu ny ph thuc v gii
tui v tnh phn ng ca tng c th.
- Tnh phn ng l kh nng p ng ca c th vi mi kch thch bnh thng hay bnh l. Ngoi nhng c tnh do i trc truyn li th tnh phn ng cn bao
gm nhng c tnh ca c th hnh thnh trong i sng. Do nhng c th khc nhau th tnh phn ng thng khc nhau, bnh pht sinh hay khng c im
din bin ra sao kt qu nh th no ch yu ph thuc vo tnh phn ng ca c th.C rt nhiu yu t nh hng n tnh phn ng ca c th:
-Thn kinh, tm thn: Trng thi v no hng phn hay c ch lm thay i b mt ca bnh sinh. Loi TK yu thng km chu ng 1 yu t kch thch nh cng
c th gy bnh, loi TK mnh nhng ko thng bng cng d b ri lon nng trc 1 s tc nhn gy bnh.H TK giao cm chi phi cc phn ng khng tch
cc. H TK ph giao cm c vai tr to ra trng thi trn tnh,tit kim nng lng tng chc nng tiu ho.
Yu t tm l:li ni thi ca ngi xung quanh c bit thy thuc c nh hng xu hoc tt n tm l v din bin bnh.

TK thc vt : Khi TK giao cm b HP th chuyn ho c s tng, thc bo tng, sn xut khng th c hiu b C, sn xut khng th khng c hiu tng. Ngc
li khi TK ph giao cm HP th thc bo gim sn xut khng th khng c hiu gim v sn xut khng th c hiu tng,cc hang ro bo v nh hch bch
huyt tng cng hot ng.
- Ni tit: cc HM c nh hng r rt ti bnh sinh.Cng 1 bnh nhng tnh trng ni tit khc nhau c th din bin bnh khc nhau VD ngi cng gip d st
cao khi nhim khun.
ACTH v corticoid: c tc dng chng vim, chng d ng. C tc dng gim tnh thm mao mch, gim ph n v tit dch, c ch thc bo
STH, DOC v Aldosteron : Ngc tc dng ca ACTH v Cortison lm tng qu trnh vim kch thch t chc lin kt tng sinh v chng nhim trng. STH c tc
dng chng hoi t, tng tng hp Globulin v khng th cn DOC v Aldosteron th c tc dng tng chuyn ho nc v in gii
-nh hng ca gii tnh
Mt s bnh hay gp nam gii nh lot DD-HTT, nhi mu c tim cn bnh hay gp n nh vim ti mt u v ..
-nh hng ca la tui:Mi tui c c im phn ng ring i vi bnh tt.Tnh phn ng ca c th yu khi cn nh,tng ti tui dy th v gim khi v gi.Do
cc bnh c chia thnh bnh ca tr s sinh,bnh ca tr em,bnh tui dy th v bnh ca ngi gi
V d:Vim hay st c th tr thng mnh hn ngi gi v triu chng lm sng thng in hnh, c th tr c th mau lnh bnh nhng cng c th lm vo
tnh trng phn ng qu mc cn c th ngi gi th cc biu hin c th km r rng d bin chng nguy him khi vim st
3.Yu t ngoi
-Mi trng: a l kh hu nh hng r rt ti qu trnh pht sinh pht trin ca bnh.V d: Nhit mi trng, m, kh hu u nh hng n bnh sinh
ca nhiu bnh nh bnh phi, hen Ha cht , tia x,nghin ru lm thay i kh nng phn ng ca c th
-Yu t XH: Ch XH, trnh vn ho, dn tr cng nh hng ti c cu tnh hnh bnh tt cu qun th dn c
- Ch dinh dng : Protein v vitamin nh hng r rt ti bnh sinh ca nhiu bnh, khi c th thiu ht protein lm c th d mc bnh phi v bnh nhim
khun. Vitamin c tc dng lm tng cng sc khng ca c th
Cc yu t ny thng lin quan cht ch vi nhau trong tng trng hp c th, c th yu t ny hay yu t khc ni bt ln hng u. Cng c th xp
chung l nhng nguyn nhn v iu kin gy bnh v iu kin hon cnh x hi cng nh nhng mm bnh, iu kin hon cnh ngoi mi u l cc nguyn
nhn, iu kin bn ngoi v c im c th l nhng nguyn nhn, iu kin bn trong, s xut hin bnh tt trong cc trng hp ny khng chu nh hng ca
cc nguyn nhn, iu kin bn ngoi.chnh v vy ma trong lm sang ko c hai ngi beenh hon ton ging nhau v biu hin lm sang v din bin lm sng
Cu 4. Ti sao ni bnh c tnh cht mt cn bng mi km bn vng ? cho vd minh ha ?
Bnh l bt k s sai lch hoc tn thng no v cu trc , chc nng ca bt k b phn , c quan , h thng no ca c th , biu hin bng mt b TC c
trng gip cho thy thuc c th chn on xc nh v chn on phn bit d nhiu khi ta cha r v nguyn nhn , bnh l hc v tin lng
Khi ni v tnh cht ca bnh cc nh sinh l bnh coi bnh l mt cn bng mi km bn vng . iu c chng t qua cc lun im :
-Bnh thng c th lun c s cn bng gia cc qu trnh (ng ha v d ha) , s phi hp nhp nhng ca cc c quan v chc phn v cu trc.
-Khi bnh nguyn tc ng vo c th lm thay i v cu trc hoc chc phn ca mt hay nhiu co quan no ca c th . iu ny lm mt i s cn bng sinh
l ca c th . Lc c th phn ng li bng cch to ra mt cn bng mi( ch khng phi mt cn bng) phng ng .trong cn bng ny cc b phn hot
ng khng theo quy lut sinh ly sn c
-Nhng cn bng mi ny khng bn vng v n khng th ko di , do s hot ng bt thng ca cc c quan sm hay mun cng dn n tc ng vo cc c
quan khc hoc chnh n , do cn bng ny lun c xu hng thay i theo cc hng khc nhau , c th lp li cn bng trc ( hi phc) hoc tin trin lp
nn mt cn bng bt li , khi vt qu kh nng bo v ca c th c th dn ti t vong . s ti lp cn bng mi c th rt nhanh nhng cng c th rt chm ty
theo nguyn nhn v iu kin ca bnh
Do trong iu tr phi bit u l cc qu trnh do bnh nguyn gy ra , u l phanr ng bo v ca c th tc ng ng
V d in hnh l hi chng sc mt mu: khi c th mt khong 30% lng mu bt u c shock , lc ny c th chuyn sang mt cn bng mi nhm chng li
s thay i v khi lng tun hon ( co mch ngoi vi, huy ng mu gan , lch v cc c quan ngoi vi) tp trung mu cho cc c quan sinh tn ( no
, cc trung tm sng ) . Nhng cn bng mi khng th duy tr lu , nu tc ng iu tr ng th cn c kh nng hi phc ( thit lp cn bng mi theo hng
c li ) nhng nu vn tip tc mt mu n 60% th c th mt kh nng b tr s xy ra try mch( thit lp c bng mi bt li ) rt kh diu tr
Cu 5 . Mi quan h gia nguyn nhn v iu kin gy bnh? Cho v d chng minh v nu ngha thc tin ?
Trong lch s y hc nhn loi c rt nhiu thuyt nhm gii thch ti sao dn n bnh , trong c nhng thuyt tht s sai lc nhng cng c p dng vo
thc tin nh: thuyt mt nguyn nhn ( cho rng mi bnh u do vk gy ra) , thuyt iu kin ( cho rng gy bnh phi c tp hp cc k trong nguyn nhn
cng ch l mt k ), thuyt th tng( cho rng bnh t pht khng cn nguyn nhn , nu c th do cng mt nguyn nhn , bnh nng hay nh ph thuc th tng
mi ngi)
Quan im hin i da trn nhng thnh tu khoa hc v lp trng duy vt bin chng ch ra mi quan h gia cc yu t nguyn nhn , iu kin v bnh
v mi quan h nhn qu ca bnh tt
Trong mi quan h gia nguyn nhn v iu kin th:
-Nguyn nhn l yu t quyt nh gy bnh , bnh no cng phi c nguyn nhn d tm ra hay cha , v nguyn nhn quyt nh tnh dc hiu ca bnh ,
nhnng nguyn nhn mun gy c bnh phi t c ngng v s lng , c lc , v phi c nhng iu kin h tr .
-iu kin h tr v to thun li cho nguyn nhn , NN ch gy bnh khi c nhng k nht nh c th l nhiu k nhng cng c th l rt t.Nhng phi khng
nh mt mnh k khng th gy bnh nu thiu nguyn nhn
Vd: nhim khun tit niu do Escherichia coli th chc chn phi c vk ecoli ,nhng ecoli l vk thuc h vk bt rut ch gy bnh khi c th c sc khng suy
gim, v d nhin ch suy gim khng m khng c mt ecoli th khng th nhim khun ecoli ng niu c
-Trong quan h gia nguyn nhn v k c s hon i : Nn trong trng hp bnh ny c th l k cho mt bnh khc(n thiu thn l nguyn nhn gy suy dinh
dng nhung cng c th l k cho bnh lao), ngc li k trong t/h ny c th l nguyn nhn cho bnh khc ( lnh l k cho nhim cm nhng cng l nguyn
nhn ca nhim lnh)
ngha: trc mi bnh phi c hng tm ra nguyn nhn ca n xc nh v loi tr nguyn nhn (nu cn ) , ng thi phi bit cc k thun li loi b
nhm hn ch nguyn nhn
Cu 6. Phn tch vng xon bnh l trong bnh sinh? Cho vd v nu ngha thc tin?
Bnh sinh l din bin ca mt bnh t khi bt u pht sinh n khi kt thc . bnh thng bnh sinh tun theo mt trnh t ni tip nhau , khu trc lm tin
cho khu sau n khi kt thc
Nhng khi 1 khu phia sau li lm tin d cho mt khu trc th xut hin vng xon bnh l, a s lm bnh nng hn v c kh nng t duy tr. Vng ny c
th cp din hoc trng din
+,Vng xon cp din : l vng xon nhanh chng dn n nhng hu qu nng n
vd: v thanh s
Mt mu Gim khi lng t/h Thiu oxy no Tim tng c/n Tng nhp , co mch Gim nui dng c tim Qa ti Suy tim Thiu oxy no
+,Vng xon trng din: din ra trong thi gian di
Vd: Vim rut cp Vim mn Rut d kch ng Tng nhu ng, co tht Tiu chy, au qun Km hp thu Suy mn Thc n giu m Rut
d kch ng.
NGHA: trong tin lng v iu tr bnh phi nm r c ch bnh sinh v d on cc vng xon bnh l c th xy ra, trong phng v iu tr co bin php
d phng ri vo vng xon , v khi xy ra phi tm cch ph v n bang cach ct t nhiu khu nht l khu chnh
Cu 7:Phn tch quy lut nhn qu trong bnh tt.Cho vd chng minh v nu ngha thc tin?
Bnh l s ri lon i sng bnh thng ca c th,do nh hng ca nhng tc nhn ph hoi khc nhau,s ri lon y dn ti mt cn bng mi km bn
vng,hn ch kh nng thch nghi ca c th i vi ngoi m v gim kh nng lao ng ca con ngi.
Bt c bnh no cng do nhng nguyn nhn nht nh gy nn.Nguyn nhn l nhng yu t quyt nh s pht sinh bnh tt v quyt nh c im ring tng
bnh nh trc khun lao l nguyn nhn gy bnh lao vi nhng c im ring ca bnh(tuy nhin hin nay cn 1 s bnh cha xc nh c nguyn nhn ch ko

phi ko c nguyn nhn nh bnh bch cu,1 s bnh tm thn).C rt nhiu nguyn nhn ta c th chia ra nguyn nhn bn ngoi(l nhng mm bnh,nhng
yu t ngoi m tc ng ln c th nh yu t c hc:chn thng,tai nn.yu t vt l :qu nng,qu lnh.yu t ho hc,yu t sinh hc) v nguyn nhn bn
trong nh tui tc ,th trng,di truyn.Nhng cho d nguyn nhn no i na th khi n tc ng vo c th gy ri lon hot ng bnh thng ca c th,vt qu
kh nng thch ng ca c th th u gy ra hu qu l c th b bnh.
Nhng bnh phc tp thng din bin qua nhiu khu, tip ni nhau theo mt trnh t nht nh v c lin quan mt thit vi nhau. Chnh bnh sinh hc nghin
cu v c ch bnh sinh ca cc khu cung xnh mi tng tc gia chng vi nhau. Th d lin cu khun gy vim hng, ri t c th gy vim mng trong
tim, m hu qu l h van v hp van. Nhng thay i v cu to ca tim dn ti nhng ri lon tun hon mu trong tim. Lc u c tim cn mnh, b p c,
song dn dn mt b, tim b suy, dn ti mu tnh mch m hu qu l ph v trn dch, ri lon chuyn ho v chc nng ton thn, v c th din bin lm cho
bnh
ngy
mt
nng.
Cho nn trong qu trnh bnh sinh, nguyn nhn ban u gy ra nhng hu qu nht nh, nhng thay i ny li tr thnh nguyn nhn ca nhng ri lon mi
v cc ri lon ny li c th dn ti cc hu qu khc vv... Kt qu l mt qu trnh bnh l khng ngng pht trin v bnh ngy mt nng.
c bit quan trng l trong nhiu qu trnh bnh l, nhng khu sau tc ng li khu trc lm cho bnh nng thm. Th d trong sc chn thng nng gy ri
lon thn kinh trung ng nghim trng (hng phn ri c ch) m hu qu l thiu oxy do ri lon tun hon (suy mch cp), thiu oxy li tng cng trng thi c
ch thn kinh trung ng khin ri lon tun hon v h hp thm nng, vv... C nh vy khu n tc ng ln khu kia lm cho sc din bin nng thm , to ra
vng xon bnh l lm cho sc khng hi phc.
ngha thc tin:
Nhim v ca ngi thy thuc l thy r mi quan h nhn qu gia cc hin tng bnh l, nh gi ng nhng thay i y v kp thi pht hin nhng thay i
ch yu ngha l nhng khu chnh trong qu trnh bnh sinh. iu ny rt quan trng c mt cch iu tr thch ng (iu tr bnh sinh ), kp thi ngn chn
vng xon bnh l khi xy ra v mt khi xy ra th phi kp thi ct t., ph v vng xon, tr b cc ri lon v phc hi cc chc nng . Th d trong suy
tim, trng tm iu tr l phc hi sc co bp c tim kt hp vi ch ngh ngi gim bt gnh nng i vi c tim b suy. hoc trong sc, trng tm iu tr
l phc hi lng mu lu thng bng cch truyn dch. Trong nhiu trng hp, phi tm cch tc ng ln nhiu khu cng mt lc, in hnh l trong sc, phi
tm cch tc ng ln nhiu khu : ri lon thn kinh, ri lon tun hon, ri lon h hp, ri lon chuyn ho, vv...

Cu 8 : Ti sao ni i tho ng l mt bnh c RLCB ni tit t . Hn m i tho ng ch yu do nguyn nhn no gy ra .

Bi Lm
I.T l mt ri lon v cn bng ni tit t l v:
+ Trc y ngi ta cho rng i tho ng l do tn thng tu o nhng trn thc t lm sng nhng ngi b bnh ny th khng phi bao gi cng l do
tn thng tu o
+ Mt s thng k cho thy T n thun tng i t gp m n hay i km cc ri lon ni tit khc v thng th c 1 trng hp T n thun th thy c
2 T c km theo u nng tuyn gip, 5 T c km theo u nng v thng thn, 20 T c km theo u nng tuyn yn . Khi m xc thy 25% c tn
thng tu o, 50% thy t bo beta tng tit cn 25% th tu o hon ton bnh thng .
+ Thc t bnh sinh i tho ng rt phc tp nhng ch yu do hai nguyn nhn sau gy nn :
+ Bnh pht sinh do nguyn nhn tu : do thiu nguyn liu tng hp insullin,tn thng mao mch tuyn tu , nhim trng, nhim c ,u tu , dn ti ty o
khng sn xut ra c insulin dn ti s thiu ht v s lng insulin l thiu insulin tuyt i hay cn gi l T typ I.
+ Bnh pht sinh ngoi nguyn nhn t ty l t bo beta hot ng bnh thng i khi cn tng tit insulin nhng do nhiu nguyn nhn ngoi tu gy ra
hn ch tc dng ca insulin l cho insulin b mt tc dng l thiu insulin tng i. Thiu insulin tng i c th l do tng tit hormon lm tng ng mu
ch yu l STH, ACTH v glucocorticoid(tng tng i do tc dng ca insulin b gim).Bnh ny xy ra khi tin yn hay v thng thn tng cng hot ng
hay khi gim chc nng hoc ct b tin yn th thy triu chng i tho ng gim r rt. Bnh nhn c u v thng thn hay u tu thng thn sau khi ct b u
th bnh chm dt .
+ Nhng l do trn chng t bnh i tho ng khng nhng l do thiu insulin m cn do tng tit hormon c tc dng i lp nh hoocmon tuyn tin yn,
v thng thn v c bit khi chc nng t bo beta gim sn
+ Do c th quan nim rng bnh i tho ng l mt bnh do ri lon cn bng ni tit t gia 2 loi hoocmon c tc dng ngc nhau.Mt c tc dng h
ng mu v mt nhm c tc dng tng ng mu.
+ Vi khi nim ny c th a ra phng php iu tr thch hp nht nh ct b u tin yn v hay tu thng thn , c ch chc nng ca cc tuyn ni tit
khc
+ Bnh i tho ng cn do insulin tng cng phn hu di tc dng ca enzym insulinase v khng th khng insulin c tc dng trung ho , kt hp,
phong b insulin, ngi tim insulin di ngy thi trong mu nng khng th khng insulin cao nn phi tim insulin nng cao hn so vi bnh thng
+ Tm li nguyn nhn gy bnh i tho ng rt phc tp cho nn cn quan nim i tho ng l hi chng ch khng phi l mt bnh .
II.Nguyn nhn gy hn m i tho ng
+ C rt nhiu nguyn nhn gy nn trng thi hn m trong hi chng i tho ng nhng nguyn nhn ch yu l do tng mnh th ceton trong mu .
+ Nguyn nhn tng th ceton trong mu l do thiu insulin nn enzym pyruvatkinase khng c hot ho dn ti gim tng hp acid pyruvic t PEP m acid
pyruvic l nguyn liu tng hp acid oxaloacetic , m mui ca oxaloacetic l oxaloacetat li l cht mi ca AcetylCoA trong vng Krebs , nn khi gim insulin
th AcetylCoA khng vo c vng Krebs dn ti gim s dng vng Krebs ( chuyn ho i kh ) thiu nng lng nn c th s tng chuyn ho ym kh, chuyn
ho ym kh to t nng lng nn gim tng hp glucid, protid v lipid t AcetylCoA do qu trnh tng hp cn nhiu nng lng.
+ AcetylCoA khng c s dng tng hp khng vo c vng Krebs nn chuyn sang s dng tng hp cholesterol v cc th cetonic gy nhim c t
bo v c ch thn kinh gy trng thi hn m, tng tng hp cholesterol trong mu dn ti x cng mch mu c th gy nhi mu c tim, vim thn
+ Tuy nhin trong mt s trng hp th cetonic trong mu tng nhiu song vn khng pht sinh hn m i tho ng do c nhng yu t khc cng gp
phn gy nn trng thi ny nh :
+ Thiu insulin gim s dng glucose trong t bo do hn ch nng lng gii phng lm hn ch chc nng bnh thng ca mi c quan c bit l v
no, mt khc th t bo no hp thu oxy cng vi glucose nn khi gim hp thu glucose th no thiu oxy lm gim hot ng gp phn to trng thi hn m
+ Ngoi ra th khi c th mt nc mt mui hay ri lon cn bng in gii cng l yu t ng k gy hn m trong i tho ng .

Cu 9: Ri lon chuyn ho trong bnh i tho ng , Hn m i tho ng ch yu do nguyn nhn no gy ra

Bi lm
Trong bnh i tho ng cc loi chuyn ho u pht sinh ri lon c bit l chuyn ho Glucid v Protid .
1 .Ri lon chuyn ho Glucid
+ Khi thiu insulin th tc vn chuyn glucose mu vo t bo gim. Trong t bo hot tnh enzym hexokinase gim km hm phn ng phosphoryl ho
glucose ni bo gy gim G_6P , G_6P gim lm gim qu trnh s dng glucose ni bo nh gim tng hp glycogen t glucose, lm gim s dng vng pentose
vng krebs, gim qu trnh ng phn ym kh v i kh, gim tng hp acid bo v protid
+ Gim G_6P c b p bng tng tn to glucose v glycogen t acid amin do tc dng ca glucocorticoid, khi thiu insulin th glucocorticoid tng tit hot
ho enzym Fructose_1,6DP lm tng tn to glucose v glycogen . Mt khc khi thiu insulin th Adrenalin v glucagon tng tit hot ho enzym phosphorylase
v tng glucocorticoid hot ho enzym G_6Phosphatase lm tng thoi bin glycogen .
+ Qu trnh phn ct glycogen chim u th hn so vi qu trnh tn to glycogen lm cho glucose t gan vo mu nhiu ln v khi nng glucose mu vt
qu 1,6 g/l th s pht sinh glucose niu ko theo c mt nc ( a niu thm thu ), bnh nhn mt nc nghim trng nn ung nc rt nhiu mt khc t bo
khng s dng c glucose nn lun trong tnh trng i bnh nhn n rt nhiu nhng vn khng b p c nng lng mt nn gy nhiu .
+ Ngoi ra khi thiu insulin th enzym pyruvatkinase khng c hot ho dn ti lm gim qu trnh tng hp acid pyruvic t PEP m acid pyruvic l nguyn
liu tng hp acid oxaloacetic, mui ca acid ny l cht mi ca AcetylCoA trong vng Krebs , Khi AcetylCoA khng c s dng trong vng Krebs v tng
hp acid bo th n s c s dng tng hp cholesterol v cc th cetonic
+ Glucose mu l ngun cung cp glucose duy nht cho no nn khi thiu insulin th no lun trong tnh trng thiu glucose v oxy nn v no lun trong tnh
trng b c ch su sc .
2. Ri lon chuyn ho Lipid
+ Khi thiu insulin th gim qu trnh tng hp acid bo do thiu nng lng v vng Krebs b hn ch , thiu coenzym kh NADPH 2 do vng pentose t s dng
+ Gim tng hp triglycerid do thiu acid bo v thiu _glycerophosphat .
+ Ngoi ra khi thiu insulin th tng phn ly lipid do c th tng tit cc enzym khng insulin, lm lng acid bo trong mu nhiu ln trong mu i ti t chc
thoi bin b p nng lng do thiu glucose trong t bo. Tng phn ly lipid lm cho c th gy nhiu v st cn nhanh lng acid bo t do tng trong huyt
tng s c a ti gan ti tng hp tryglycerid gy nhim m gan
+ Insulin gim s gim to acid oxaloacetic lm cho AcetylCoA khng vo c vng Krebs nn c tng s dng to cholesterol v cc th cetonic gy
nhim c t bo c ch thn kinh c th gy hn m i tho ng , nng cholesterol tng cao trong mu gy x cng thnh mch gy nhi mu c tim x
thn hay vim thn
3.Ri lon chuyn ho Protid
Gim tng hp protid do :
+ Thiu insulin acid amin t mu kh qua c mng t bo
+ Thiu nng lng do vng Krebs b hn ch km hm qu trnh tng hp protid
+ Thiu insulin khng hot ho c h thng enzym tng hp protid
+ Thiu insulin th glucocorticoid tng tit tng thoi bin protid tng tn to glycogen t acid amin
+ Ri lon chuyn ho protid trong hi chng i tho ng c ch qu trnh to hnh, tng chy mu do gim tng hp cc yu t ng mu, lu lnh vt
thng gim kh nng to khng th hn ch sc chng ca c th vi cc tc nhn gy nhim trng .
4. Nguyn nhn gy hn m i tho ng
+ C rt nhiu nguyn nhn gy nn trng thi hn m trong hi chng i tho ng nhng nguyn nhn ch yu l do tng mnh th ceton trong mu .
+ Nguyn nhn tng th ceton trong mu l do thiu insulin nn enzym pyruvatkinase khng c hot ho dn ti gim tng hp acid pyruvic t PEP m acid
pyruvic l nguyn liu tng hp acid oxaloacetic, m mui ca oxaloacetic l oxaloacetat li l cht mi ca AcetylCoA trong vng Krebs, nn khi gim insulin
th AcetylCoA khng vo c vng Krebs dn ti gim s dng vng Krebs ( chuyn ho i kh ) thiu nng lng nn c th s tng chuyn ho ym kh,
chuyn ho ym kh to t nng lng nn gim tng hp glucid, protid v lipid t AcetylCoA do qu trnh tng hp cn nhiu nng lng.
+ AcetylCoA khng c s dng tng hp khng vo c vng Krebs nn chuyn sang s dng tng hp cholesterol v cc th cetonic gy nhim c t
bo v c ch thn kinh gy trng thi hn m, tng tng hp cholesterol trong mu dn ti x cng mch mu c th gy nhi mu c tim, vim thn
+ Tuy nhin trong mt s trng hp th cetonic trong mu tng nhiu song vn khng pht sinh hn m i tho ng do c nhng yu t khc cng gp
phn gy nn trng thi ny nh :
+ Thiu insulin gim s dng glucose trong t bo do hn ch nng lng gii phng lm hn ch chc nng bnh thng ca mi c quan c bit l v
no, mt khc th t bo no hp thu oxy cng vi glucose nn khi gim hp thu glucose th no thiu oxy lm gim hot ng gp phn to trng thi hn m
+ Ngoi ra th khi c th mt nc mt mui hay ri lon cn bng in gii cng l yu t ng k gy hn m trong i tho ng .
Cu 10. Ri lon chuyn ho nc in gii b i chin u ma h cung cp nc khng . Phn tch c ch bnh sinh v nguyn tc iu tr?
Do tnh cht cng vic ca b i phi lm vic trong iu kin khc nghit nht l trong ma h di ci nng nh la cho nn vic mt nc v mui do ra m
hi l tnh trng din ra thng xuyn.Nu nh khng c b p kp thi v xy ra ko di th c th dn n try tim mch,h HA v nhim c thn kinh
Do lm vic trong mi trng c nhit cao m kh ta nhit do mc o b i dy cho nn c th phi thi nhit ra ngoi qua con ng m hi ng thi
cng c c mui cng b mt na.M hi c tnh cht nhc trng nhng nng in gii trong cng rt dao ng trong Na l 10-80mEq,Cl la5-56mEq
ty thuc vo s thch nghi,rn luyn v s b p nc cng n gin(ung )nhng nu lng nc mt qu ln(>5l)th lng mui mt i cng ng k cho nn
vn phi b p thm.Trong trng hp khng cung cp s gy ri lon chuyn ha mui nc
C ch bnh sinh l do nhit c th qu cao hn mc bnh thng cho nn c th phi thi nhit qua m hi(c ch t bo v) ng thi cng thi lun c mt
lng mui nht nh ra khi c th,nu khng b p c c mui v nc th s gy ri lon v chuyn ha mui nc trong c th.V m hi c tnh cht hi
nhc trng cho nn khi mt in gii v nc qua m hi lm cho dch c th tr thnh nhc trng v hu qu l nc t ngoi bo xm nhp vo trong t bo
gy ph t bo lm cho khi lng tun hon gim,huyt p gim c th dn n try tim mch dn n gim hoc ngng bi tit thn gy nhim c thn kinh.
V nguyn tc iu tr
1.b nc v in gii.C th cho b i ung nc c b sung mui nh dung dich omezol.
2.tng gii nhit cho c th nh mc o thong mt nht l v ma h nng nc

Cu 11. Ri lon chuyn ho nc in gii v ri lon cn bng axit baz bnh nhn nn ma v i lng ko di. Phn tch c ch bnh sinh v nguyn
tc iu tr?
Cn bng nc in gii v cn bng acid baz l nhng yu t c bit quan trng vi s sng. Nhng ri lon cn bng nc in gii v cn bng acid baz s
lm cho c th lm vo tnh trng bnh l v c th gy t vong. bnh nhn i lng v nn ma ko di nu khng c iu tr ng v kp thi s gy RLCH
nc v in gii, RLCB acid baz
C ch bnh sinh
+ bnh nhn nn ma : Khi nn ko di s gy mt dch v ko theo mt nc cng vi acid HCl dch d dy lm cho c th nhim kim, s lng dch mt i
khng nhiu nhng ko di, cc bin php n ung kh b p c nn lng nc mt nu nn ko di l rt ln khi c th s c nhng ri lon v c bit l
RLCH glucid gy ng cc sn phm trung gian lm cho c th t nhim kim tr thnh nhim toan.Nn nhiu gy mt nc,gy ri lon huyt ng hc ,khi
lng tun hon gim ,mu c, huyt p gim ,mu qua thn t ,thn km o thi cui cng dn n tnh trng nhim c, nhim toan nng nu ko kp thi c x
l.
+ bnh nhn i lng ko di :
- Dch tiu ho tit ra khong 8l mi ngy km theo nhiu cht in gii bao gm phn ln l cht in gii ng trng, nc bt (1,5l), dch d dy (2,5l), dch
mt ( 0,5l), dch tu ( 0,7l), v dch rut (3l) Dch tiu ho c hp thu ton b cng 2-3 l nc t thc n nc ung. Khi cn ng tiu ho c th hp thu v o
thi 30-40 l/ngy. Do vy khi i lng mt nc nhanh vi s lng ln .
- Mt dch tiu ho lm c th nhim toan rt nng do trong dch c rt nhiu thnh phn kim gy nn nhng hi chng suy sp tun hon nng n, HA gim
- C th RLCH nng n gy nn vng xon bnh l nghim trng.C ring s km theo:
Trong a lng nhng ri lon quan trng xut hin l
+ Ri lon huyt ng hc do mt nc nhiu lm gim khi lng tun hon dn ti huyt p gim
+ Nhim toan nng do tru tim mch lm thiu oxy cng ri lon hp thu lm RLCH , c th nhim toan
+ Tru tim mch lm mu qua gan thn gim dn ti ng sn phm c sn phm toan mt khc c th mt dch kim dch mt v dch tu lm c th nhim
toan nng thm
+ Nhim c thn kinh do thiu oxy, nhim c, nhim toan quay li c ch tun hon, h hp hnh thnh vng xon bnh l
Biu hin lm sng
+ Huyt p gim, mch nhanh, nh, kht, i t , thn nhit gim
+ Th nhanh v su , nn nhiu
+ Vt v, bun ng , hn m
Nguyn tc iu tr
+ Truyn dch ng trng trong giai on u nu nn v i lng nhiu
+ Ung nc n thun hay huyt thanh ngt cho n khi lng nc tiu tr v bnh thng nu l mt nc u trng
+ Nu nhim toan nng , dng dung dch NaHCO3 trung ho acid

Cu 12: C ch bnh sinh ca ph v trn dch

Nguyn nhn ca ph v trn dch l do nc khong gian bo. C ch bnh sinh ca ph v trn dch:
+ C ch thn
+ C ch mao qun
a, C ch thn
+ Chc nng lc cu thn gim song chc nng THT ng thn vn bnh thng : Vim cu thn, RLTH(suy tim mt b).
+ Tng ti hp thu do tng tit Aldosteron sau m, dng thuc nhm corticoid ko di
b, C ch mao qun
+ Tng p lc thu tnh : Huyt p mao mch tng, tc chy mu gim lm cho nc d thm qua thnh mch ra khong gian bo, gp trong xung huyt tnh
mch ( suy tim mt b, x gan )
+ Gim p lc keo huyt tng , khi protein huyt tng gim, c bit l albumin gy hin tng ph.gp trong thn h nhim m(pro niu nghim trng),i
n,cc bnh tiu hao,x gan
+ Tng tnh thm thnh mao mch : thnh mao mch b vim nn cho qua nhng cht c khi lng phn t ln nh protein , dch ph c cha nhiu protein lm
cho p lc thm thu keo 2 bn trit tiu nhau p lc thu tnh t do y nc ra.C ch ny tham gia trong cc loi ph nh do d ng, do cn trng t, trong
vim, trong ph phi
+ Tng p lc thm thu: gy u trng do gi nc. C quan o thi mui ch yu l thn vi s iu ho ca andosteron,bi vy loi ph ny hay gp trong
vim cu thn,suy thn, hi chng Cohn.
+ Gim sc khng ca t chc: Trong c th bnh thng mi t chc c mt sc khng nht nh, trong cc iu kin ging nhau th dch thm vo t chc
lng lo d hn t chc c do khi gim sc khng ca t chc(trng hp teo t chc,gim cht to keo ca t chc khi i n) th ph pht sinh
+ Ri lon tun hon bch huyt: Mt phn dch gian bo tr v dng mu theo ng bch huyt nn khi tc mch bch huyt th ph pht sinh.
Trong thc t lm sng th ph thng do nhiu yu t kt hp vi nhau gy ra v trong c mt yu t l ch yu.th d trong ph tim yu t bnh sinh ch yu
l do tng p lc thy tnh(do gim sc co bp c tim).
Hin nay vai tr ca aldosterol c khng nh:khi ph tng th nng aldosterol mu v nc tiu tng,khi ph gim th nng ny gim ->iu tr ph cn
hn ch mui nghim ngt hn hn ch nc.
Du hiu lm sng v cn lm sng : khi lng nc khong gian bo khng qu 1 2 lit, biu hin lm sng ca ph khng r, l trng thi trc ph , vi
nhng du hiu nh tng cn nng, khuynh hng mu long, gim nng protein huyt tng ,vv... Khi nc nhiu, ph th hin r. ng ch l khi ph
ton thn, theo di cn nng cho ta bit mc ca ph mt cch chnh xc.
Ph v trn dch nh hng khng tt ti hot ng ca t chc : dch ph chn p t chc, gy ri lon tun hon ti ch, do nh hng khng tt ti chuyn
ho ca t bo. t chc ph km dinh dng nn d b nhim trng. Ph ko di gy tng sinh t chc lin kt . Nu dch ph u trng s pht sinh mt nc t
bo (kht, st). Nu dch ph nhc trng s pht sinh nhim c nc . ri lon cn bng in gii trong ph c th gy ra ri lon cn bng axit-baz. Tu theo
v
tr,
ph
c
th
gy
nguy
him
cht
ngi.
c) iu tr ph . Ch yu l phi iu tr nguyn nhn gy ph. Ngoi ra c th kt hp mt s bin php nhm gii quyt trng thi nc, king mui, rt dch
ph, li tiu, vv...
Cu 13:nguyn nhn co ch gim protein huyt tng?
BL:
Gim pr huyt tngc th la du hiu gim pr ton phn c th v pr huyet tng phn nh tng lng pr cua c th.Gim pr ch yu l gim albumin,nguyn
nhan c th do ri lon tng hp,tng thoi bin hay co ch mt pr.:
1/ri lon tng hp pr,do:
-cung cp thiu
_ri lon tiu ha hp thu
-ri lon chc nng c quan to pr:ac bit trong vim x gan albumin.fibrinogen,prthombin giam r.
--do bnh di truyn:gim albumin mu gim fibrinogen,globulin
2/tng thoi bin pr:trong st di thao duong, nng tuyngip,nhim trng u thy gim.
3/mt pr ra ngoi:
_do chy mu,chn thung.nn tiu chy...
_protein niut rong thn h nhim m,vim xug huyt tnh mch,tng tnh thm thh mch.dc bit trong bng pr htg gim r ph thuowcj vo din bong do tang
tnh thm thanh mch
KL:
Pr htg gim phn nh trang thi suy mn ca c th.n gy ra hng loat hu qu nghim trng:
1/lgim p lc keo gy ph tuy nhin n ch xy ra khi mt s lng ln
2/gim knng kt hp,vchuyn ca pr vi nhiu cht gy nn ri lon 1 s chnng lm cth nhim c.vd:thiu vit b lm ri lon chuiyn ha Pr,L,G,gim tng hp
pr gan va cc c quan khc,gim hoat tnh xtc ca e chuyen ha to ure lm ure mu gim dn n tng NH3 gy hn m gan
3/ri lon ng mu,tng chy
4/giam sc khang do gn giam tng hp khng th.
Cu14: nh ngha , c ch pht sinh st , y nghi ca phn ng st?
BL;
1/n:St l 1 trng thi cu c th ch ng tng thn nhit do trung tam diu nhit vng di i b kthich bi cc cht gy st,lm tng sn nhit kt hp gim
thi.
Bao gm:_cht gy st ngoi sinh:cc c t vk,cc sp chuyn ha cua chng.cc tcnhn nay gy stthng qua cc cht gy st ni sinh
_chtgy st ni sinh:cc IL ch yu do di thc bo tit ra nh:IL_1,6,8,TNF_anpha.
2/c ch gy st:
Cc cht gy st ngoi sinh kch thch cc tbo bit la bi thu1cj bo tit ra ccc cht gy st ni sinh.cc cht ny s kthch sn xut pgE1,E2 nh hot ha
emzym COX.pgE2 tc ng ln trung tm iu nhit vng di i lm thay i im t nhit.lc ny nhit 370C b coi la lnh v kqu lam khi ng cc c
ch lam tang thn nhit,bao gm tng chuyn ha v gim thi.cc c ch ny dc thuc hien nho h thn kinh thuc vat.
Ngoi trung tm iu nhit vung dui i:nhom nhn gia v sau iu ha gi nhit,nhom nhn trc iu ha thi nhit.1 s yut khc cng anh hng n
png st:
a/vai tr v no:no hng phn th st cao hn v ngc li
b/yt ti:ngi gia phn ng st yu,tre nh li hay c cn st cao gay
co git.ddieuf ny lin quan dn yeu to cuong d
chuyn ha
c/ni tit:nh ng n chuyn ha.unng tuyn gip lm st cao hn trng hp bth.
3/y ngha ca phn ng st:
_st l mt phn ng bo v cua c th.
+st lm tng cng kh nng min dch :tng tng hp ccyeu to tng sinh,hoat ha bch cu lm tng kh nng thc bo,trung ha tc nhn gy bnh(tng
tng hp khang th,b th)
+tng chuyn ha to nng lng,tng kh nng chng c
Thc t:nu tim cho ngvt cht gy st ri mi cho nhim khun thi bnh nhe hoc khng b.Ngi gi b vim phi mc d st nh hoc khng nhung bnh
li nng.
_st l phn ng c hi:khi m st cao ko di,st c th suy yu km d tr th lm c th suy kit,ri lon chuyn ha,nhim c m sng co git....

Cu 15 :/n phn ng st cc giai on thai s tr cua thay thuoc voi bnh nhn st cao ko di?
BL:
1/n:St l 1 trng thi cu c th ch ng tng thn nhit do trung tam diu nhit vng di i b kthich bi cc cht gy st,lm tng sn nhit kt hp gim
thi.
Bao gm:_cht gy st ngoi sinh:cc c t vk,cc sp chuyn ha cua chng.cc tcnhn nay gy stthng qua cc cht gy st ni sinh
_chtgy st ni sinh:cc IL ch yu do di thc bo tit ra nh:IL_1,6,8,TNF_anpha.
2/cc g ca st:st thng din bin qua 3 g di ngn tuy thuc tnh chts v mc bnh:
+ Giai on st tng : C th bt u t ngt , st cao sau vi gi ( vim phi , cm ) hay tng dn sau vi ngy ( thng hn , si ) . Trong giai on ny thn
nhit thng tng cao hn so vi thi nhit ( sn nhit > thi nhit ) do cc cht gy st ngoi sinh v ni sinh kch thch trung khu iu nhit gy tng sn nhit v
gim thi nhit . Sn nhit tng nh tng cc qu trnh oxy ho v chuyn ho nng lng ch yu gan v c , tng trng lc c v xut hin rng mnh . Rng
mnh pht sinh theo c ch phn x , cc xung ng thn kinh t da ( do mao mch b co ) ti vng di i qua phn bn th li theo dy thn kinh vn ng ti
c gy co c km theo cm gic lnh run ni gai c l do cc c trn ca chn lng co li lm lp khng kh cch nhit dy ln do c ch qu trnh thi nhit cn
gim thi nhit l do co mch ngoi vi nn da nht nht c ch qu trnh bi tit m hi
+ Giai on st ng : Thn nhit duy tr mc cao do sn nhit tng ng thi thi nhit cng tng nn c mt cn bng mc nht nh nhng vn cha
thi c lng nhit tch lu trong thi gian u nn thn nhit vn duy tr c mc cao . S xut hin thi nhit biu hin bng dn mch ngoi vi do kch
thch cc si thn kinh ph giao cm nn da t trng thi nht nht chuyn thnh xung huyt nhit da tng c th ht rt run
+ Giai on st lui : Thn nhit gim xung ti mc bnh thng, sn nhit lc ny < thi nhit . Thi nhit tng mnh bng cch ra m hi , i nhiu .Thi nhit
c th gim hn hay gim t t nhng cng c trng hp gim nhanh t ngt sau vi gi tnh trng ny c th dn ti thiu nng mch cp tru tim mch do gim
trng lc cc mao mch nghim trng
Khi bnh nhn st cao ko di ( >42 0C ) th thng pht sinh cc ri lon nghim trng h thn kinh trung ng v pht sinh nhim nng. Trong qu trnh bnh l
nhim c hay nhim khun th c th pht sinh nhng bin chng nng km theo tng thn nhit qu mc lm cho bnh nhn mt thc lm vo tnh trng co git
thm ch c th t vong. Do ngi thy thuc phi c thi s ch ng n phi dng thuc h st kt hp vi iu tr c hiu vi nguyn nhn gy bnh
ng thi phi ch ti iu tr ton thn dinh dng hp l gii quyt kp thi cc ri lon chuyn ho v chc phn ngi bnh chng hi phc
Cu 16:nh ngha cc giai on ca phn ng vim.ti sao c th dng thuc chng vim chung cho cc phn ng vim,mc d nguyn nhn gy
nn vim khc nhau?
- vim l 1 phn ng c tinh quy lut do tc nhn vim gy ra,l 1 qu trnh phc hp iu ha phn ng xy ra b my lien kt v vi mch mu gy ra nhng ri
loannj ch yu v ha t chc v tnh thm mao mch dn n biu hin thot dch,bch cu xuyn mch,thm nhim tng sinh t bo v thc bo ti vim
-qu trinh vim ko phn bit nguyn nhn u din bin ging nhau qua 3 g c tnh cht quy lut,cc giai on xut hin theo 1 trnh t k tip nhau 1 cch xen k:
+giai on tn thng t chc
+giai on ri lon mch mu thot dch ri vim
+giai on tng sinh t chc
1.giai on tn thng t chc :g ny va gy ri lon tun hon,chuyn ha ti ch xm nhp,va lm tn thng t chc gy ra ri lon v trao i cht v cht
t bo
-qu trnh ny hnh thnh v gii phng cc cht c hot tnh sinh hc l cc mediators vim,cc mediators vim quyt nh tnh cht din bin ng nht ging
nhau ca cc phn ng vim,ko ph thuc vo nguyn nhn chinh l c s s dng thuc chng vim chung trong iu tr vim
-hu qu :+nhim toan,u trng ngoi bo gy ph
+ri lon trao i in gii,thiu mu v thiu oxy khu vc
+hnh thnh dch r vim do gin mch v tng tnh thm
+bch cu xuyn mch v hp dn ti vim
+EZ ni bo b hot ha gy tiu hy lm vim lan rng
2.g ri lon mch mu thot dch r vim(g xut tit)
-cc mediators vim giai on 1 tc dng ln mch mu lm:
+gin mch dn n tng tun hon,tng chuyn ha v trao i cht ti vim,sau lm gin lit cc tiu ng mch tn cng gy hin tng mu mao mch
khu vc vim,dng mu b chm li,sau cc tiu tnh mch cung b gin lm ngng chy dng mu hu qu lm tng tnh thm thnh mch
+d tc dng ca cc mediators vim ni tip gip gia cc t bo ni mc b gin cch to thnh cc khe cho protein hueets tng,cc t bo mu thot khi
long mch ra to ra dch ri vim v gy ph vim,ngoi ra cc mediators nh histamine,serotonin cn tc dng lm tng tnh thm thnh mch
+trong khi cc hng cu thot mch b ng th cc bch cu di chuyn n vim 1 cch ch ng kiu amip qua cc khe gia cc t bo ni mc,ti vim thy
c mt cc t bo lymphocyte thot mch,bch cu a nhn trung tnh,bch cu n nhn monocyte c kh nng thc bo
+dch r vim gy chn p t chc trn vo cc k t chc gy ri lon dinh dng dn n thoi ha hoi t t chc
3.giai on tng sinh t chc
-kch thch vim gim v kch thch phn bo tng dn n tng sinh t bo khp khu vc vim
-gim ri lon mch mu v bch cu vim
-i thc bo tng sinh rt nhanh xp xp li trt t ti vim cng vi nhng t bo lymphocyte,histocyte,v fibroblaste
-t bo non,mch mu tn to pht trin thay th,t chc c b hy hoi cc g trc
Cu 17c ch to dch r vim,thnh phn tc dng ca dch r vim?
*dch r vim l cc sn phm xut tit ti vim xut hin ngay t khi xung huyt ng mch bao gm nc,cc thnh phn hu hnh v thnh phn ha tan
1.c ch hnh thnh dch r vim:dch r vim c hnh thnh do 3 yu t chnh
-do tng p lc thy tnh trong cc mch mu ti vim,c vai tr ch yu giai on xung huyt ng mch ,gy ph ti vim
-do tng p lc keo:cc cht c hot tnh nh ion,NO,histamine.PG tc ng vo thnh mch lm gin cc khe gia cc t bo ni m thnh mch,lm tng thm
mch,gy thot protein.c vai tr rt ln giai on xung huyt tnh mch v lm cho dch r vim giu protein
-do tng p lc thm thu trong vim,hu wuar ca s tch li cc ion v ha cht phn t nh.c vai tr gy ph rt quan trng trong giai on mu
2. Thnh phn dch r vim
- Tu theo nguyn nhn gy vim v giai on vim m tnh cht mu sc v thnh phn dch r vim c khc nhau.Dch r vim c nng protid cao, giu cc
thnh phn hu hnh ng thi tng lng acid lactic , ceton do pH ca dch r vim gim
- Dch r vim c cc thnh phn ch yu l:
+cc thnh phn v hnh nh nc, mui, protid huyt tng :Protid thot ra ngoi theo trnh t t nh n ln qua cc giai on ca vim nh albumin, globulin
gm cc KT c tc dng trung ho tc nhn vim , fibrinogen lm ng dch r vim to hng ro bo v khu tr vim lm cho cc tc nhn vim khng lan rng
+cc thnh phn hu hnh ca mu nh BC,HC:HC ,BC, TC tu tnh cht v giai on m s lng mi loi khc nhau
+thnh phn cc cht mi c hnh thnh do ri lon chuyn ha v tn thng m:histamine,serotonin,bradykinin,cc enzim,cc acid nhn
3. Tc dng ca dch r :
+thnh phn v hnh:bch cu sau khi cht gii phng them cc enzim gy hy hoi cc m xung quanh ng thi gip tiu hy cc thnh phn hoi t dng mu
d a ra khi vim
+thnh phn hu hnh:protein gm cc khng th c tc dng cng thc bo chng li tc nhn gy vim,fibrinogen lm ng dch r vim v to hng ro bo v
vim ko lan rng
+ Cc cht c hot tnh sinh hc : Histamin, Serotonin, Acetycholin c tc dng gy co mch, lm ng mu
+ Cc kinin huyt tng nh bradykinin , heparin c tc dng gin mch gy au
+ Cc cht chit t dch r c hot tnh sinh l nh leukotaxin lm tng tnh thm thnh mch ho hng ng cho BC , leukotrien , cytokin ,IL 1,6,8 t TB
+ Cc acid nhn: lm tng tnh thm thnh , ho ng ng BC kch thch BC xuyn mch , kch thch sn xut BC ti to m , tng to KT
+ Cc enzym : Hydroxylase , hyaluronidase, lm tng tnh thm thnh mch
- Qua dch r vim c tc dng bo v , cc protein trong dch r c tc dng kt hp vi cc sn phm c trong vim trung ho , BC xuyn mch lm nhim
v thc bo , cc yu t ng mu c tc dng ngn s chy mu to hng ro bo v khu tr vim khng cho c t lan rng
- Tuy nhin nu dch r vim qu nhiu gy chn p t chc xung quanh gy au nhc hn ch hot ng ca cc c quan gy trn dch c th dn n hu qu xu

Cu 18:cc mediator vim,ngun gc,phn loi.tc dng, ngha?

1. nh ngha : Cc sn phm c hot tnh sinh vt c sn sinh trong t chc vim c gi l cc mediater tnh thm
2. c im
+ Tn ti ngn , khng tun hon trong c th
+ Sinh ra ti ch v bt hot nhanh chng ti vim
+ Gy au, st, c tc dng ho ng ng li ko BC
+ Gy dn mch, tng tnh thm thnh mch
+ Kch hot h MD kch thch phn chia t bo
3. Phn loi
a) Nhm amin hot mch
* Histamin
- Ngun gc :
+ Hnh thnh t histidin ( phn ng kh amin) di tc dng ca enzym decacboxylase, c nhiu phi, da, TK giao cm v t bo mastocyte, BC,TC . Bt hot
di tc dng ca Histidin
- Tc dng :
+ Gy dn mch nh, co t bo ni mc do lm tng tnh thm thnh mch
+ Gy co mch mu ln lm tng lu lng mu ti vim , gy xung huyt ti vim
+ Lm co c trn , tng tit HCl d dy
- ngha : Bo v c th trong vim, trong chn thng, nhim x
* Serotonin
- Ngun gc : T tryptophan c nhiu nim mc rut , t bo mastocyte , tiu cu v synap
- Tc dng : Gin mch , tng tnh thm thnh mch, co c trn , gy au
- ngha : Bo v c ch qua c ch TKTD , tng cng tc dng ca histamin
b) Nhm dn xut ca acid bo: Prostaglandin
- Ngun gc :
+ Hnh thnh nh tc ng ca tc nhn gy vim, cc men lysosom ca BC
- Tc dng :
+ Gy dn mch nh dn n tng tnh thm thnh mch
+ Co c trn ph qun
+ Ho ng ng dng tnh vi BC
+ Gy au , gy st
+ Thoi ho hong th, xy thai, non
+ Lm gim hot ng ca t bo, gim gii phng cc mediater vim t t bo mastocyte v BC
- ngha : Bo v c th
c) Nhm men lyosom ca BC
- Ngun gc : T BC N , gm cc men Protease, Catalase, Collagenase
- Tc dng :
+ Phn hu glucid, lipid v protid ca sinh vt
+ Trc tip tc dng trn ni mc v thnh huyt qun ph hu t chc ( si keo, chun , collagen )
+ Gin tip tc dng gy gii phng v to cc mediater tnh thm gy
*
Gii phng Histamin, Serotonin t t bo mast quanh huyt qun
*
Hot ho v to thnh polypeptid ca h kinin
*
Hnh thnh nhm Prostaglandin c tc dng gy tn thng t bo t chc v tng tnh thm thnh mch
- ngha : tiu dit vi khun
d) Cc cht tit ca t bo
- Ngun gc : * T Lympho bo gi l lymphokin
* T Mono bo gi l Interleukin
* T cc cht MIF v MAF
- Tc dng :
+ Ho ng ng dng tnh vi BC
+ Kch thch thc bo
+ Tng tng hp Prostagladin v Collagen
+ Ngoi ra cn c cc gc oxy t do c BC sn xut c tc dng gy tng tnh thm thnh mch lm tn thng t chc , tng hot ng ca men tiu protein
- ngha : Bo v c th
e) Nhm peptid ca kinin
- Ngun gc : l globulin ca huyt tng di dng tin men l kininogen , di tc dng ca kalicrein chuyn thnh kinin
- Tc dng :
+ Gin mch, ch yu l tiu ng mch, tiu tnh mch v mao mch gy mu
+ Lm tng tnh thm thnh mch do lm gin khe gia cc t bo ni m
+ Gy thot BC , gy au
- ngha : Dng lm thuc tng bn mng lysosom nh steroid v cortisol
Cu 19: nh ngha t chc u, c tnh c bn ca t chc u, phn bit tnh cht v hn v thot khi s kim sot ca c th ca TB u?
1)nh ngha t chc u: U l t chc pht trin vt mc gii hn ca t chc b thng thot khi s kim sot ca c th. S pht trin vn tip tc din ran
gay c khi nguyn nhn gy u ko cn na.
2) c im c bn ca TB u: 3
a) S pht trin v hn v ko chu s kim sot ca c th
/s ca 1 TB bnh thng tri qua 4 thi k: pht sinh, pht trin, tin trin v kt thc. Trong c th TB cng lun i mi nh vy v TB cht i theo 2 cch chnh
-TB cht do hoi t
- TB cht theo chu trnh
Cc TB t chc b thng pht trin ti 1 gii hn nht nh th s pht sinh s ngng li do s c ch ca ty xng. Nhng TB u ko c tnh cht ny, ko
chu s kim sot ca ty xng m pht trin v hn chng cht ln nhauddeens khi kit dinh dng ca mi trng th thi . S mt t/c ny lien quan ch yu
ti lng AMPc bn trong TB, khi lng AMPc gim s thot khi s c ch ca ty xng.Ngoi ra cng c nhiu yu t khc lien quan ti s pht trin v hn
ny nh Tb u ko p ng vi nhng nh hng c ch ca Tb xung quanh. S gim dnh gia cc TB lm TB d di chuyn v c th sng trong mi trng ko
c m . Do vy TB u pht trin ko theo quy lut ko xp lp cng nh ko theo 1 trnh t nht nh.
Ngay c trong s pht trin ca khi u, tng giai on pht trin khc nhau tc pht trin cng khc nhau. Giai oi u pht trin nhanh khi kch thc
khi u ln tc pht trin chm dn, gim lng Tb tng sinh , tng Tb u b cht b hoi t Tb bong ra gy hin tng di cn
b)C s bin i v cu trc
Tb u ging Tb t chc non , lien kt gi cc TB rt lng lo do gim lng Ca2+ ni bo, tng in tch b mt Tb tnh vn ng tng kh nng bm dnh gim
nn TB u di cn c.Ngoi ra s bm dnh ca cc khng th trn b mt Tb u cng gop[s phn tng kh nng vn ng cng vi vic gii phng cac yu t ng
mu d to ra cc mng Tb b vn li,b bong ra s theo cc dng bch huyt v mu di cn n cc t chc xa.

Mng Tb cng rt linh ng do mt 1 protein mng cng vi cc men trong Tb c bit l men tiu m tng ln rt nhiu v c gii phng ra nhiu gip khi u
xm ln ph hy t chc xung quanh.
c) Tb u c s thay i v khng nguyn
-Tb u l TB ca c th mang c nhng KN c hiu ca c th v nhng KN mi khi thnh c tnh. Cc Kn mi gm c:
+ KN ghp c hiu u: mng TB l th th tip nhn KT
+ KN T ( tumor) nm trong nhn TB kh pht hin khi hnh thnh MD, thng gp trong cc tc nhn do virus
+ KN S b mt TB
+Kn ha tan:l nhng KN c trong giai on phi thai, ngi bt c rt t cn ngi b ung th c rt nhiu

10

Cu 20: Phn bit u lnh v u c, p ng ca c th chng li Tb u

1)nh ngha t chc u: U l t chc pht trin vt mc gii hn ca t chc b thng thot khi s kim sot ca c th. S pht trin vn tip tc din ran
gay c khi nguyn nhn gy u ko cn na
- Cu trc bt ca khi u c chc, bao gm TB c bn u v t chc m xung quanh n. Trong Tb u thng c hnh thi v cu trc phn no tng t m sinh
ra n
Da vo hnh thi v cch sinh sn u th chia u lm 2 loi : u lnh v u c: t v ra s
+,Ti ch: U lnh pht trin tng i chm, p ln t chc xung quanh, pht trin c gii hn. U c th
pht trin nhanh, mc thnh mi, c chn xuyn su vo m lnh, gy chn p hy hoi t chc gy hoi t.
+,Ton thn : U lnh gy p tc nghn cc c quan. U c gy chy mu lm c th suy kit, xut hin di cn xa.
+, Ti pht: U lnh t ti pht sau khi phu thut ct b. U c d ti pht ti ch v khu vc xung quanh, c nhng ch di cn xa.
+, Di cn: U lnh khng di cn. U c di cn d lan i xa, to cc u th pht, di cn theo mu bch huyt ti cc t chc khc.
+, Biu hin tn thng TB v t chc: U lnh c ranh gii r rng xung quanh c v bc,u tng t nh Tb gc c kh nng bit ha cao,u gy chn p t chc
lm tc nghn s lu thng tun hon nhng iu tr khi t ti pht. U c xm ln cc t chc khc do c chn, r, xung quanh ko c v bc,Tb u khc TB gc, mt
hay kh nng bit ha km, u pht trin lm c th suy kit, u hay di cn xa lan rng khp c th gy t vong.
2)p ng ca c th chng li TB u
- Khi h thng kim sot MD ca c th b suy gim th cc Tb u s pht trin ko kim sot c . Thc t lm sng cho thy:
+ BN K thy suy gim HTMD qua TGTB
+ T l BN iu tr cn c ch MD th nguy c mc K cao
+T l mc u c tnh tng theo la tui, do tui cng cao HTMD cng suy gim
+ BN b K c iu tr bng cc bin php h tr nng cao MD th thi gian sng tng, t l di cn gim v ngc li
V vy MD qua TGTB l / c hiu qu chng li cc Tb u c tnh
Tb u l Tb mang KN l nn kch thch c th sinh KT v cc MD qua TGTB lm hn ch s pht trin ca khi u
Mt s KN bit nh CEA-1_glycoprotein,bnh thng ch thy trn b mt Tb biu m trong thi k bo thai
C th vt ch thng qua cc Tb nh LT gy c,cc TB, Tb NK ch tit ra IFN- c t/d hot ha cc TB, lympho
Cc TB c hot ha bi lymphokin trong giai on qu mn mun nh s hot ha ca Tb TCD4 hay bi s tc ng trc tip ca Tb TCD8 gy c
trc tip cho Tb u, mt khc s hp gia KT-BT c t/d lm mt tnh n nh v tnh thm thu ca mng TBu lm Tb u tan v v ra
Khi all cc MD cu c th ko th tiu dit hay km hm s pht trin ca Tb u th Tb u s pht trin mnh di cn xa lm c th b RL v cht

11

Cu 21: Cc ch tiu nh gi cht lng dng HC. ngha ca gi tr HC v ch s nhim sc

1) Cc ch tiu nh gi cht lng dng HC
S lng ( bt 3,8-4,5 tr/mm)
HST ( bt >75%)
HC li (bt 0,5- 1,5%)
GTHC=% HST/( 2 s u ca HC *2) ( bt t 0,9-1,1)
2) ngha ca gi tr HC v ch s nhim sc
Cht lng dng hng cu b bin i c th do cc yu t bnh l tc ng trc tip trn hng cu hoc do qu trnh sn xut b ri lon , c biu hin bng
cc ch tiu sau :
1.Thay i ch s nhim sc ca hng cu
Ch s nhim sc l m huyt sc t trong hng cu th hin gi tr chc nng ca hng cu v c tnh theo cng thc n gin
CSNS = % HST/( 2 s u ca HC *2)
Gii hn bnh thng ca ch s nhim sc l 0,9 1,1. Trong bnh l tu theo s thay i ca ch s nhim sc c th phn bit :
+ Thiu mu ng sc khi hng cu v huyt sc t gim tng ng ,cc
trng hp thiu mu c hu HC va phi, t hoc khng b thiu st do st c gi li ti to HC
+ Thiu mu nhc sc khi CSNS gim di 0,9 do huyt sc t gim nhiu hn so vi HC , gp bnh nhn suy nhc thiu protid, thiu st, hoc kh nng
tiu ho hp thu km kh nng tng hp protid b ri lon
+ Thiu mu u sc khi CSNS trn 1,1. y khng phi l tha d huyt cu t, s lng Hb tuyt i trong mt n v th tch mu gim tuy s lng s lng
Hb trong tng HC c tng hn bnh thng, nguyn nhn l do th tch HC tng. Bnh thng mi HC ch cha mt lng Hb nht nh khong 33% - 34%, khi
th tch HC tng th lng Hb trong HC cng tng, thiu mu u sc gp trong bnh thiu mu c tnh .
2. C kh khng u hay hin tng a c
+ Trong mu xut hin mt s HC to hn bnh thng d= 8 -10 m l nhng HC gn trng thnh v HC li ang c tng sinh thay th l biu hin tt do
mu ang c phn ng tng sinh phc hi . Nu mu c nhiu HC nh l biu hin khng tt l HC gi ci, mnh v ca HC hay l nhng HC b teo nh
di tc dng ca yu t bnh l hoc c sn xut trong tnh trng thiu nguyn liu .
3. Bin i v hnh dng hay hin tng a dng
+ Do mng HC km bn vng nn khi dn trn lam knh th HC mo m khng u to hnh dng khc nhau hay do bnh l di truyn gy bin i cu trc v
hnh dng HC, nh HC hnh bia trong bnh huyt cu t F, hnh lim trong bnh huyt cu t S.
4. Bin i v mu sc hay hin tng lon sc
+ Biu hin bng s bt mu khc nhau ca HC , HC nhn l HC khng bt mu gia do thiu huyt cu t, nhc sc. HC a sc l HC trng thnh
nhng do qu trnh chuyn ho vi vng nn vn c tnh cht i kim trong nguyn sinh cht nh t bo non, gp trong trng hp thiu mu, mt mu cp tnh
v qu mc
5. Xut hin HC bt thng trong mu ngoi vi
+ Tng Erythroblast kim, a sc, toan gp trong thiu mu nng gy phn ng mnh vi tu xng hoc trong bnh nguyn HC c tnh
+ Xut hin HC mang d tt trong trng hp thiu mu nng c ri lon chc nng tu xng . Xut hin HC c ht i kim trong thiu mu do nhim c
Cu 22. ngha ca tng s lng chung ca BC v ch s chuyn nhn
S lng chung ca BC Ca ngi btgii hn t 5000 9000/mm 3 mu. Trong trng hp bnh l BC c th thay i theo hai chiu hng l tng hay gim
S lng BC tng khi s lng tng trn 10G/ly l phn ng tch cc ca c th i vi cc nhn t gy bnh ch yu l nhn t nhim khun, BC tng cao trn
15000/mm3 v thy xut hin cc BC non gp trong cc trng hp nhim khun nng v tng cao hn na l trong cc bnh ca c quan to mu
1. ngha ca tng s lng chung ca BC
a) Trong s thay i sinh l ca c th
- tr s sinh th s lng BC 18000 20000mm3 ko di hng tun
- Trong lao ng, tiu ho, cm xc s lng BC cng tng ngoi vi do tc dng ch yu trn khu vc d tr BC trong cc xoang t/m tu xng
b) Vim v nhim khun
- L nguyn nhn hng u gy thay i s lng BC, VK Gr(+) gy kch thch tng t bo ht cn cc VK Gr(-) th ngc li, VR th nh hng ln h thng vng
ni m nn gy tng t bo BC mono
c) Nhim c
- Cc cht c l ho v sinh vt khc nhau c th lm bin i s lng BC, nh tia phng x, Asen, pyramidon, sulfamid
d) Thn kinh, ni tit
- Chn thng s no c tn thng vng di th gy tng BC
2. Ch s chuyn nhan
CSCN = % ty bo + % hu ty bo +% stab) / % neutrophil
ngha ca h s chuyn nhn
- Trong trng hp bnh l th h s chuyn nhn c th thay i theo hai chiu hng
a) Chuyn tri : L tng ch s nhn trn 0,08 l biu hin tng sinh cc t bo BC tr do tu xng b kch thch tng hot ng p ng nhu cu ca c th, tu
mc c th phn bit
+ Chuyn tri va phi : khi ch s nhn t 0,08 0,25 do cc t bo tr c tng sinh va phi thng ch tng Stab mc nhim khun khng nng lm v chc
nng tu xng hot ng tt
+ Chuyn tri mnh : Khi ch s nhn 0,25 0,5 do cc t bo tr tng sinh nhiu v mu ngoi vi xut hin nhiu Stab c th gp c hu tu bo i khi c tu bo,
thng gp bnh nhn nhim khun nng chc nng tu xng b ri lon kh nng bit ho gim st sc khng ca c th gim
+ Chuyn tri qu mnh : Ch s nhn 0,5 1 hay hn na thng l bnh ca c quan to mu kh nng bit ho ca tu xng b ri lon
b) Chuyn phi
- Khi ch s nhn gim di 0,02, rt t hay khng c BC tr Stab l biu hin ca tu xng b c ch v km theo gim s lng BC
- Chuyn phi biu hin gim t l cc t bo t nhnh v tng s lng cc t bo nhiu nhnh
Kt lun : Theo di ch s nhn ca BC c s dng trong lm sng ch yu ngoi khoa v nghin cu khoa hc nh gi tnh trng v chc nng to BC ca
tu xng
C
Cu 23. S thay i s lng ca tng loi bch cu c ngha g? Phn tch ngha ca ch s chuyn nhn?
Bch cu trng thnh lu thng trong tun hon mu v bch huyt .S lng btl 5000_7000bc/1mm3 mu (mt s ti liu m rng t 50009000bc/1mm3)
Trong N: 60-70%
E:2-4%
B:0-1%
M:4-6%
L:20-30%
Nhng bin i ca tng loi BC ( tng hoc gim s lng ) thng c ngha nht nh trong chn on theo di v iu tr bnh .
1.Bch cu trung tnh N
- Tng bc ht trung tnh gp trong trng hp thiu oxy,nhim khun,sau chy mu, ung th,trong mt s iu kin sinh l nh cm xc ,nng lnh ,sau ba n
,vn ng cowbc ht trung tnh cng c th tng.
- Gim bc ht trung tnh gp trong trng hp nhim trng huyt ,lao k,thng hn ,st rt ,nhim c (benzene, asen,thy ngn)sau chiu x ,ha cht ,nhim
virus cm ,st xut huyt
2. Bch cu toan tnh E

12

- Tng E trong bnh nhim KST ng rut , trong trng hp d ng (hen ,st) v trong cc phn ng d ng trong qu trnh nhim khun do E c kh nng hp
th histamin v cc cht tng t gii phng ra trong qu trnh din bin ca bnh ,cc bnh ngoi da,phong,sau chiu x
- Gim E thy trong giai on u ca nhim khun cp v trong Strees do E ti ch tn thng lm nhim v gii c hoc do tng ni tit tuyn thng thn tng
tit corticoid c tc dng c ch to E,suy ty,sau iu tr ACTH,corticorit
3. Bch cu lympho L
- Tng tuyt i trong mt s bnh tr em (ho g, cm, si, thng hn, nhim khun) lm nh hng n h thng gan lch (st rt, lao, giang mai) Trong nhim
khun cp th L tng mun do cn c giai on kch hp h thng MD ca c th
- Gim L tng i trong giai on u ca nhim khun cp v gim tuyt i khi tn thng h thng to lympho
4. Bch cu mono M
- Tng trong nhim khun v virt cp (thu u, si, vim hng ) tng di trong cc bnh vim mng trong tim, st rt l du hiu kch thch h thng vng
ni m . Tng M trong giai on cui ca nhim khun lm nhim v thc bo tham gia vo phn ng tng sinh m lin kt lm lnh tn thngvim
- Gim M trong bnh nhim khun, nhim c v nhim khun m lu ngy, nhim khun huyt , l du hiu h thng vng ni m b c ch v sc khng ca
c th suy yu
5. ngha h s chuyn nhn
- Ch s chuyn nhn l ch s tng quan gia BC non v BC trng thnh trong mu ngoi vi c biu hin bng cng thc sau
CSN=(T+H+ S)/(N+E+B)
Bnh thng: 0,03 0,08
- CSN chuyn tri :
L tng s nhn >0,08 y l biu hin tng sinh ca cc t bo tr do tu xng b kch thch tng hot ng p ng nhu cu ca c th
+ Chuyn tri va phi : CSN khong 0,08 0,25 , cc t bo tr tng va phi thng tng BC a mc nhim khun khng nng lm v chc nng tu xng
hot ng tt
+ Chuyn tri mnh : Khi CSN 0,25 0,5 do t bo tr tng mnh , mu ngoi vi xut hin nhiu BC a c th thy c hu tu bo v tu bo, thng l nhim
khun nng chc nng tu b ri lon kh nng bit ho ca t bo gim st sc khng c th gim
+ Chuyn tri qu mnh : CSN 0,5 1 hoc cao hn thng l bnh ca c quan to mu kh nng bit ho ca tu xng b ri lon
- CSN chuyn phi
+ Gim di 0,02 thng rt t hay khng c BC a l biu hin ca tu xng b c ch km theo gim s lng BC , tin lng xu
+ Biu hin gim t l cc t bo t nhnh tng cc t bo nhiu nhnh , c th xut hin cc t bo tng phn nhnh nh trong nhim c, nhim phng x
Ni chung theo di CSN BC c s dng trong lm sng v ch yu ngoi khoa v trong nghin cu khoa hc nh gi tnh trng chc nng to BC ca tu
xng
C
Cu 24. Khi mt mu cc phn ng b p v khi lng mu ca c th biu hin nh th no?
- Khi mt mu c th s ng vin c mt chui phn ng phc tp nhm bo v c th mt mc nht nh
1. Phn ng cm mu :y c th xem nh phn ng u tin ca c th nhm b p lg mu mt.
- qu trnh cm mu tri qua 4 giai on.Mi giai on u c ngha nht nh
+ co mch : nh phn x thn kinh sau l nh cc cht tit ra t t chc m tn thng v cui cng l tiu cu
+to nt tiu cu:tiu cu tp trung li v bm dnh nhau thnh cc nt
+to cc mu ng:l giai on quan trng nht trong cm mu (c s tham ja ca ca cc yu t ng mu nh thrombin ,prothrombin..)
T
2. Phn ng nng huyt p ( phn x tim mch )
- Do mt mu lng mu lu thng gim , huyt p ng mch gim kch thch cc TCT p lc quai ng mch ch v xoang tnh mch cnh.Ngoi ra do tnh
trng thiu oxy gy tng co bp c tim , nhp tim lm mch nhanh v mnh ln lm tng tc dng mu.
- ng thi c hin tng tng tit Adrenalin gy co mch ngoi vi v dn mch no mch vnh
- Kt qu l tim tng cng hot ng, lng mu ngoi vi gim, huy ng lng mu d tr gan lch lm tng lu lng tun hon nn huyt p ng mch
c nng ln do tm thi iu ho c hin tng mt cn bng huyt ng lc v phn phi c lng mu cung cp cho tim v no
3.Phn x tng h hp
- Do nng O2 trong mu gim v nng CO 2 trong mu tng cao kch thch trung khu h hp lm c th th nhanh v su nhm tng cng lng O 2 v o
thi CO2 m biu hin bng thng kh binh thng hay tng ln
4. Phn ng b p khi lng mu
- Lu lng mu gim gy tng tit ADH v Aldosteron c t dng tng ti hp thu nc v mui ti ng thn do gy gim lng nc tiu , ng thi c hin
tng huy ng dch giam bo vo dng mu do p lc dng mu gim.
5. Phn ng tng to cc t bo mu
- Phn ng ny xut hin mun nht sau 4 -5 ngy, pht sinh do tnh trng thiu O 2 mu kch thch tu xng tng sinh to cc t bo mu c tnh cht thch ng b
p
- Phn ng ca tu xng v tc to t bo mu ph thuc v tnh trng bn thn, mc mt mu v nguyn liu to mu
6 Tng tn dng oxy m:
Bt cc m kp ly 30%lng oxy do ng mch mang ti ( ch s s dng oxy chung l 0,3)
Khi thiu mu ch spps ny c th tng ti 0.85
Nh vy nu mt mu khng nhiu lm v iu tr gii quyt kp thi th cc phn ng b p ca c th c th n nh c tnh trng bn thn nhng nu mt
mu nng hay bnh nhn trng thi khng thun li th c th dn ti sc mt mu gy bin c nguy hi cho i sng
C
Cu 25. Thiu mu do tan mu: nguyn nhn, c ch bnh sinh, c im?
h
Thiu mu l tnh trng gim s lng hng cu ,hoc hemoglobin trong n v th tch mu .C ch chung do mt cn bng qu trnh hy v sinh hng
cu
C
C rt nhiu nguyn nhn gy thiu mu m tan mu l mt trong s (suy ty,thiu nguyn liu sx,mt mu,tan mu)
Thiu mu do tan mu l tnh trng HC b v trong lng mch sm hn i sng bnh thng do bnh ca bn thn HC hoc c cht ph hu HC trong huyt tng
a> Nguyn nhn v c ch bnh sinh
1. Tan mu nguyn nhn do bn thn HC
a) Ri lon cu to mng HC
- Bnh HC hnh cu di truyn : l loi bnh do tn thng mng HC , lm thay i t l gia b mt v th tch nn kh bin hnh khi qua mao mch v d b cc
TB bt gi tiu hy.Nguyn nhn l do khuyt thiu cht spectrin khung t bo HC
- Bnh HC hnh bu dc : him gp.C ch ch yu l spectin ca mng HCl ra dng tetramericthi nay dng dimeric
b) Do ri lon Hb bm sinh (HC cha Hb bnh l )
- Bnh thalassemia : l bnh do ri lon gen iu ho s tng hp protein ca Hb, nguyn nhn l trong chui polypeptid th HbA ( 2 , 2 ) b chuyn thnh HbF
( 2 , 2 ) loi huyt sc t thi k bo thai do gen iu ho tng tng hp chui thay cho
- Bnh do ri lon cu trc Hb : do bt thng ca gen cu trc mt aa b thay th bi mt aa khc trong mt dy polypeptid s to nn mt loi Hb bt thng
V d: bnh HC hnh lim do chui polypetid ca HbA , aa l glutamin v tr s 6 b thay th bng valin
:HbE trong glutamine v tr th 26 cu chui beta (thay bng lysine)
:HbC :glutamine v tr th 6 thay bng lysine
c) Ri lon enzym ca HC
- Nguyn nhn l do thiu ht men G_6PDH(enzym c vai tr bin t dng oxy ha (NAPD+) thnh dng kh(dng chc nng) v enzym pyruvatkinase( enzyme
c tc dng thy phn glucid thnh ATP ly nng lng cho hc trng thnh hot ng). bnh ny di truyn ln lin quan n gii tnh (NST-X) thng l nam gii
2. Tan mu do nguyn nhn bn ngoi HC
- khng th chng hc t ngoi a vo,gp trong cc trng hp

13

+tan mu do truyn nhm nhm mu ABO- mt tai bin nng

+tan mu do khc nhm ABO gia m v thai-thng nh.hay gp m c nhm mu O v thai nhi c nhm A or B.Khi hiu gi khng th chng
A,B ca m cao lm ngng kt v tan HC thai
+tan mu do truyn nhm mu O nguy him-l nhm O c hiu gi khng th chng A,B cao
+tan mu do yu t Rh:nu m l rh (-) thai l rh(+) sau ln sinh u tin s kch thch c th m sinh kt khng Rh. ln sinh th hai s to phn
ng kn-kt gy tan huyt cho thai nhi
-tan mu do c ch min dch
+tan mu do IGM :bao gm 5 tiu n v gp li l loi khng th d gn vi b th hot ha b th theo con ng c in d lam tan hng cu khi
gn vi khng nguyn b mt hc.
+tan mu do IGG:trong xoang ,lch v gan b mt TB rt c i tnh cao vi phn Fc ca IGG. Khi mang IGG hc s b cc th th trn ni trn gn
gi vo cc TB
Do cc cht c gy v hc nh : ha ch( phenol ,asen..) thuc (sulfamid..)tho mc(nm c ,,),ng vt cn( rn )
Do vi sinh vt (st rt ,), vi khun(lien cu, ph cu..)vi khun k kh
Do yu t vt l :bng nng,truyn dch nhc trng,ng mu ri rc trong long mch
b> c im ca thiu mu tan mu:
-thiu mu ng sc do st ko bi mt
-ty xng tng sinh mnh:nhiu hc li ,hc a sc v a acid.hemoglobin niu
-tng bilirubin t do trong mu
-da v nc tiu vng nh,phn rt sm mu
- tng nng st trong huyt thanh

14

Cu 26. Thiu mu do ri lon chc phn to mu?

Thiu mu l tnh trng gim s lng hng cu ,hoc hemoglobin trong n v th tch mu .C ch chung do mt cn bng qu trnh hy v sinh hng cu
Chc nng to hc ca ty xng c th ri lon do thiu nguyn liu to hc(protit ,st,sinh t B12,acid folic..)hoc do ty xng b c ch do cc nguyn nhn khc
nhau
I. Thiu mu do thiu nguyn liu to HC
1. Thiu mu do thiu protid hay thiu dinh dng
- Nguyn nhn : do cung cp khng ( i, suy dinh dng ) , do hp thu km( bnh d dy, rut ) , do gim tng hp protid ( bnh gan , RLCH ) , tng thoi bin
protid , mt protid ( st , nhim khun ,bnh thn , bng ..)
- c im : Thiu mu nhc sc ,s lng HC v huyt sc t gim ph thuc vo mc thiu mu v thiu protid , da nim mc nht nht, teo c , ph n .
Protid mu ton phn gim , Albumin gim , gamma globulin tng , BC v TC ngoi vi gim
2. Thiu mu do thiu st
- St l nguyn liu tng hp huyt cu t cn thit cho s trng thnh ca HC . St t thc n dng Fe 3+ ti d dy b kh bi HCl thnh Fe2+ sau hp thu
qu rut vo mu kt hp vi beta glubulin dng transferrin v c a v d tr gan di dng Feritin
- Nguyn nhn gy thiu st:
+ Mt mu , chy mu ra ngoi c th
+ Cung cp thiu v nhu cu cao :tr n sa b,c th ang pt..
+ Ri lon hp thu st : bnh DD , ct on DD hay rut ..
+ Ri lon chuyn ho st : Thiu nng tuyn gip, bnh l v gan ..
- c im:
+ Thiu mu c tnh cht nhc sc, s lng HC , huyt cu t ngoi vi gim , ch s nhim sc gim c nhiu HC nh v HC hnh nhn
+ Trong tu xng t l nguyn HC kim tng , t l nguyn HC a sc v toan gim
+ St huyt thanh gim
+ Thiu mu c ti sinh nhng tc v tnh trng ti sinh ph thuc vo s cung cp nguyn liu v trng thi ca bnh nhn
1.
Thiu mu do thiu B12 v acid folic
B12 v acid folic l cc yu t cn thit cho to hc theo s sau:
C cht c ngun NH2 , C (di xc tc acid folic) Purin,Pyrimidin(di xc tc vita B12) Ribose,Desoxyribose,Acid phosphoric Acid nucleic,AND, ARN.
* Thiu mu do thiu B12
- Thiu nguyn pht( cn goi l thiu mu c tnh(addison-biermer))
+ Nguyn nhn : do thiu cht GMP d dy nn khng hp thu c B12
+ c im : Thiu mu c tnh u sc, s lng HC gim rt thp , huyt cu t gim hn mc bnh thng
+ Trong mu ngoi vi thy gim s lng BC v TC , xut hin HC khng l megalo
+ Thiu mu c tnh cht c tnh, s lng HC li gim thp hoc khng xut hin
+ C RLTK nh gim tr nh , vim dy TK
- Thiu th pht :
+ Nguyn nhn : do cung cp khng y , RL hp thu ( Thiu GMP, cc bnh v DD v rut ) .
+ c im : Thiu B12 thng kt hp vi thiu protid v thiu st nn tnh cht thng l thiu mu nhc sc c c im nh thiu mu do thiu protid v
thiu st
II. Thiu mu do tu xng b c ch
Ty xng c th b c ch tm thi hoc lu di gy trng hp nhc ty hoc suy ty
- nguyn nhn
+ Do nhim khun nng, c t ca VSV tc ng mnh ln tu xng , thng ch c ch tm thi
+ Do nhim c cc ho cht nh kim loi , cht c trong bnh l ca gan , nhim x ..
+ Do lon sn tu hay tu xng b c ch, chn p trong mt s bnh c tnh : bnh BC , K cc loi , x ho tu xng
+ Do ni tit : cng lch gy thiu mu km theo gim TC , thiu erthropoietin vim thn mn , thiu nng tuyn gip , sinh dc , tuyn yn ..
- c im :
+ Thiu mu nhc sc , cht lng HC gim
+ Chc nng tu xng b c ch nn gim sn xut 3 dng t bo lm suy nhc tu
- ngha
Qua thy r gi tr v v tr ca tng loi thiu mu ring bit , nhng thc t th thiu mu thng do nhiu nguyn nhn kt hp chnh v th ngi thy thuc
phi bit phn tch tnh trng mu ngoi vi, chc nng tu xng v cc du hiu lm sng khc xc nh yu t bnh sinh ch yu th iu tr mi c kt qu
C
C u 27: Chy mu v sc chy mu thc nghim: phng php tin hnh, din bin. Phn tch nhng ri lon ch yu, nguyn tc
iu tr.
Sc mt mu l hin tng th pht xy ra sau khi mt mu nng din bin sau mt thi gian h huyt p ng mch ,do s oxy ha ko y dn n suy h
TKTW v lam ri lon nghim trongjtoanf b chc nng c th ,biu hin r nht l h tun hon.Mt mu cng nhanh mnh(chay mu ng mch ,tnh mch)cng
nhiu(25-30%)th soc mt mu co tnh cht ph bin v din bin cng nng
1. Phng php tin hnh :
- Vt th nghim : ch
- Tin hnh : gy sc bng cch ly 200 250 ml mu tnh mch i
2. Din bin
Thng theo 3 giai on
a) Giai on 1 ( Sc cng ) (ngay sau khi mt mu)
- ph thuc vo mc mt mu v trng thi ca tng c th
- Huyt p ng mch gim do gim khi lng mu tun hon, mt mu cng nhiu th HA gim cng r c th gy tru tim mch dn ti t vong do phn ng b
p khng pht huy tc dng
- Mch nhanh v mnh pht sinh theo c ch phn x, nu lng mu mt ln th th tim p yu lon nhp l c s chn on
- Tng h hp, th nhanh v su, ri lon khi mt mu nghim trng
b) Giai on 2 ( Sc tim )
- Ph thuc vo kh nng thch ng ca c th
- Nu c ch thch ng b p ca c th pht huy tc dng th tnh trng bnh nhn c xu hng hi phc :
+ Huyt p ng mch tng ln ,mch nhanh v mnh hn
+ H hp u v su hn
- Nu din bin xu i th:
+ Huyt p khng tng tip tc gim
+ Mch yu v nhanh , lon nhp
+ H hp ri lon th nhanh v nng
c) Giai on 3 ( Sc nhc )
- l giai on suy sp h thng TKTW v ton b chc nng ca c th . y l giai on mt b pht sinh do mt yu t thun li nh gy m su, chn thng ,
au n
3. Bnh sinh
- Gim khi lng mu tun hon v thiu O2 mu gy ri lon nghim trng h TKT . Cc t bo no thiu O2 nng t HP nhanh chng chuyn sang C gy RL
iu ho cc chc phn v C c ch thch ng ca c th

15

- RL trung khu h hp, huyt p ng mch gim gy RL hot ng ca c tim lng mu v O 2 n cc c quan gim gy RLCH nng n . Cht trong mt mu
pht sinh do lit trung khu h hp v ngng tim
- Do tc dng ca catecholamin nn h thng ng mch b co tht , tun hon no v mch vnh dn ra l c ch bo v nhng li lm tn thng h thng tun
hon gan thn, h thng tnh mch xp tun hon mu v tim gim nh hng ti hot ng ca tim gy nh tim. H thng mao mch dn nghim trng do RL c
tht tiu mao mch lm mu li ni tng to vng xon bnh l lm cho soc nng thm
4. Nguyn tc iu tr
- Nguyn tc ch yu l khi phc tun hon , tr li khi lng mu mt gi cn bng huyt p
- Trong s tr cn m bo cm mu tt nn cho bnh nhn nm u dc
- iu tr sm, truyn mu ngay trong hai giai on u phc hi s cn bng huyt ng hc , phng sc v ngn nga hu qu do thiu O 2 gy ra
- iu tr trong giai on ny d dng v c hiu qu v khi chuyn sang sc nhc th kh iu tr
- Sau khi thit lp c th cn bng th cn theo di v tip tc cc bin php hi phc ngn nga s th pht

16

Cu28:huytHC:2.8tr,Hb:40%,BC:7.200/mm3,S:1%,N:41%,E:30%,L:26%,M:2%
Trong cng tc khm v iu tr bnh vic phn tch huyt c mt ngha ht sc quan trng nhm nh gi tnh trng ca bnh nhn t c bin php iu tr
thch hp
Trong huyt trn ta nhn thy:
1>
Phn tch
a>V mt HC:
_ s lng HC: 2,8tr chng t thiu mu( bt HC:3,8tr-4,2 tr) v theo phn loi th y l mc thiu mu va
_ch s nhim sc:
CSNS=(4/(2*2,8))= 0,71<0,9
Nh vy chng t thiu mu nhc sc( bt CSCN=0,9-1,1)
b>V mt BC:
_Tng s lng BC: bnh thng
_Stab: bnh thng
_N:gim nhng khng nhiu:c th nhim khun nng,thng hn ,si ,cm..
_E tng mnh:bnh nhn b d ng or nhim k sinh trng( giun mc)
_M bnh thng
_Ch s chuyn nhn:
CSCN:1/71=0,014<0,03: BC chuyn phi
2>
Gii thch:
V BC N ko tng nhiu lm v tng lng BC gim nn y bnh nhn kh c th l b nhim khun nng c.Trong khi E li tng mnh nn c th lm gim
N( do s lng tuyt i E tng dn n s % ca E trong tng s BC phi tng lm cho ch s % ca N trong tng s BC phi gim )-bnh nhn c th ang trong
tnh trng d ng hoc nhim k sinh trng(giun mc..)
3>
Kt lun:
Bnh nhn thiu mu mc va do nhim k sinh trng( c th l giun mc..) hay d ng
Ghi ch: cn lm thm xt nghim soi ti tm trng giun sn
Khm xt lm sng v lm xt nghim xc nh d ng
Cu 29. Phn tch huyt : HC: 4.200.000/mm3, Hb 80%, BC 15.000/mm3, hu
ty bo 0.5%, S5%, N81%, E 0,5%, L11%, M 2%?
1.Dng hng cu: s lng HC 4,2 T /L nm trong gii hn bt ( 3,8-4,2) , lng hemoglobin bnh thng 80% (>75%), c th tm kt lun dng HC bt, khng c
thiu mu
2.Dng bch cu :
-S lng BC 15 G/L tng cao ( bt 5-9) , gi bnh l nhim khun , d ng hoc bnh bch huyt
-Nhng trong mu ngoi vi khng thy xut hin cc dng tb bt thng ( ty bo , hu ty bo, stab ) v s lng tuyt i ca BC E v B cng bnh thng ,
v c s tng mnh v t l Neutrophil ( 81% ) so vi gi tr bnh thng c v s lng tuyt i v t l ( bt 65%) .V th c th chn on trng hp ny c
nhim khun cp
-Nhng cng c th thy nhhieemx khun ny trong giai on sdk ca c th vn cn tt ( nhim khun cp mi) do ch s chuyn nhn = (0,5 + 5) /81 = 0,07
( chuyn nh)
-Trong huyt c s gim ca E 0,5% (bt 2-11%) c th do tng sinh BC neutrophil m c ch n, cng c s gim v t l BC lympho nhng nu tnh ra s
lng tuyt i th vn bt
Vy ta c th chn on y l huyt ca BN b nhim khun cp mi

17

Cu 30: Huyt HC: 3.800.000 /mm3, Hb: 75%, BC: 9.100/mm3 , hu ty bo:14%,S: 50% , N: 31%, E: 0%, L: 5%, M: 0%.
1.Phn tch
- y thy s lng HC v Hb trong gii hn bnh thng cho nn y khng c s thiu mu v v vy ta cng khng cn tnh CHCS(HC bnh thng 3,8 - 4,2
triu/mm3 cn Hb>75%)
- Ta thy SLBC c tng 9.100/mm3 (bnh thng l t 5.0009000/mm3
- Trong CTBC ta li thy c :
+BC trng thnh : dng M v E $= 0(bnh thng i vi M l 13%,cn
E:911%), N$ t 6070% xung cn 31%.
+ S lng BC non $cao trong mu ngoi vi( HTB= 14%, S= 50%)
=> gp trong giai on u ca nhim khun cp( N$ nhng cng b cht nhiu => N$).
- Ta c ch s chuyn nhn =(14+50)/31=2,06 => nh vy CTBC chuyn tri dng bnh BC v tin lng xu do ty xng tng sinh vi vng cc t bo cha
trng thnh (cha bit ha) ra mu ngoi vi
2. Kt lun
:NK cp nng giai on u vi tin lng bt u xu do ty xng tng sinh vi vng cc t bo cha trng thnh (cha bit ha) ra mu ngoi vi
Trong cng thc trn ta cn thy L=5% nh vy l L gim(bnh thng t 2030%) c th do c t ca VK mnh nn n gy ra c ch sn sinh ra t bo
lympho.
Cu 31. Huyt : HC: 2.500.000/mm3, Hb: 45%, BC: 3.100/mm3, S: 0%, N: 44%, E: 2%, L: 45%, M: 9%, Tiu cu: 80.000 /mm3.
Da vo cc ch s huyt v so vi cc ch s chun ta thy:
HC gim( bt l 3.8-4.2 triu/mm3) thiu mu.
Hb gim(bt >= 75%) ch s HC=45/(25*2)=0,9 thiu mu ng sc mc va.
SLBC gim(bt 5.000-9.000/mm3) :c th dng bch cu ht gim: S gim (bt 0,5-2%), N
gim(bt 62-63%), E gim(bt l 9-11%) .L tng tng i (bt l 20-30%).M tng(bt 2-3%)
SLTC(bt l 150.000-300.000/mm3) gim.Vy ta thy HC,BC ht,TC gim tu xng gim sn xut.Nhng L tng ngh n bnh mn tnh gy c ch tu
xng cn phi hp vi LS, ngh Xno tu (M,L ko gim v n c sn xut mu ngoi tu xng nh lch v h thng bch huyt).
Cu 32. Huyt : HC: 2.300.000/mm3, Hb: 50%, BC: 3.600/mm3, Nguyn tu bo: 60%, Tu bo:5%, Hu tu bo: 0%, S: 0%, N:
28%, E: 4%, L: 2%, M: 1%
Qua trinh biet ho ca dng bch cu:NTBTTBTY BOHTBSN.cc t bo bach cu a,bcu N mi c kn ra mu ngoi vi,trong do bcu a ch
chim 1 t l nh 0,5%.trn huyt ta thy:nguyn ty bao tin ty bo u c trg mu ngoi vi,c khong trng bch cu.chng t c th do bch cu tng sinh
m khng bit hoa.
+ Chn on:bnh bch cu ty cp
+ ngh:lm thm xn ty
Trong huyt s lng hng cu va cc dng limpho gim.iu ny co th gt do dng bch cu pht trin mnh c ch cc dng khc ty.

18

Cu 33:huyt :HC:2800000/mm3,Hb:52%,BC:62500/mm3,nguyn ty bo 1%,tin ty bo:4%, ty bo:16%,hu ty

bo:8%,S:13%,N:45%,E:3%,L:9%,M:1%
-HC <(3,8.106-4.2.106);Hb<75% => c HC v Hb u gim=>c th thiu mu
-s lng bch cu tng rt cao trong mu ngoi vi(bnh thng 5000-9000/mm3) xut hin nguyn ty bo(bnh thng trong mu ko c)=>gi bnh bch cu
-c cc giai on pht trin bch cu,ko c khong trng bch cu
-cc ch s cn li u gim(bnh thng N:62-63%;E:9-11%;L:20-30%;M:2-3%)
-Stab tng (bnh thng 0,5-2 %)
=>bch cu ty mn
Cu 34: Thay i khi lng mu lu thng trong sock . Phn tch c ch bnh sinh , hu qu v nguyn tc s tr
Bi lm
1.nh ngha :
- Sock mt mu l hin tng th pht xy ra ngay sau khi mt mu nng , din bin sau mt thi gian h huyt p ng mch , s oxy ho khng y dn ti
suy sp h thng TKT v ri lon nghim trng ton b chc nng ca c th biu hin r nht l h thng tun hon . Mt mu cng nhanh cng mnh th shock
mt mu pht sinh cng c tnh cht ph bin v din bin cng nng
2. Thay i khi lng mu lu thng trong sock
Trong sc c s thay i v khi lng mu c h i tun hon cng nh h vi tun hon.Trong shock th khi lng tun hon gim nn cc mch mu ngoi
vi co li tp trung mu cho cc c quan quan trng nh no ,timcho nn khi lng mu lu thng ngoi vi s gim.Mu c tp trung cc c quan trong
c th.
3. Bnh sinh
- Gim khi lng mu tun hon v thiu O 2 mu gy ri lon nghim trng h TKT . Cc t bo no thiu O 2 nng t hng phn nhanh chng chuyn sang c
ch gy RL iu ho cc chc phn v c ch c ch thch ng ca c th
- RL trung khu h hp, huyt p ng mch gim gy RL hot ng ca c tim lng mu v O 2 n cc c quan gim gy RLCH nng n . Cht trong mt mu
pht sinh do lit trung khu h hp v ngng tim
- Do tc dng ca catecholamin nn h thng ng mch b co tht , tun hon no v mch vnh dn ra l c ch bo v nhng li lm tn thng h thng tun
hon gan thn, h thng tnh mch xp tun hon mu v tim gim nh hng ti hot ng ca tim gy nh tim. H thng mao mch dn nghim trng do RL c
tht tiu mao mch lm mu li ni tng to vng xon bnh l
4. Nguyn tc iu tr
- Nguyn tc ch yu l khi phc tun hon , tr li khi lng mu mt gi cn bng huyt p bng cch truyn mu,truyn dch
- Trong s tr cn m bo cm mu tt nn cho bnh nhn nm u dc mu ln no c d dng hn
- iu tr sm, truyn mu ngay trong hai giai on u phc hi s cn bng huyt ng hc , phng sc v ngn nga hu qu do thiu O 2 gy ra.iu tr trong
giai on ny d dng v c hiu qu v khi chuyn sang sc nhc th kh iu tr hn nhiu
- Sau khi thit lp c th cn bng th cn theo di v tip tc cc bin php hi phc ngn nga
shock th pht
Cu 35: Vai tr ca thiu oxy trong bnh sinh ca shock?
C s km theo :
Trong shock th vai tr ca thiu oxi ca t chc cng l mt yu t lm nng thm shock bi n lm gim khi lng tun hon dn n shock v n cn to mt
vng xon bnh l ca shock
Khi thiu oxi t chc do nhiu nguyn nhn nh au,mt mu,thot huyt tng . lm t chc thiu oxi.Mt mt th n lm tng tnh thm thnh mch(do gii
phng cc cht TGHH nh histamin,catecholamin)gy thot huyt tng lm gim KLTH cng lm shock nng hn
Mt khc khi t chc thiu oxi n s tng chuyn ha ym kh lm cho c th nhim toan chuyn hakch thch gii phng TGHH gy gin cc c tin mao
mch nhng li gy co c sau mao mch lm mu t chc gy tng huyt p thy tnh tng thot huyt tng lm gim KLTH lm nng thm shock
Nh vy thiu oxi l yu t u tin khi pht cho vng xon bnh l ca shock.N lm cho hin tng thiu oxi ngy cng nng hn v lm cho shock nng hn
dn n shock khng phc hi bi vy trong shock cn iu tr sm bng cch tng KLTH v iu tr ct cc qu trnh ca vng xon bnh l
Cu 36:phn tch c ch bnh sinh ca thiu oxy trong 3 loi shock:chy mu ,chn thng v bng .nguyn tc iu tr?
Ni cho cng th gim khi lng tun hon mt cch t ngt m c th khng th b p c th gy nn shock
Trong chy mu:nu s lng mu mt t ngt qu ln(60%)cc c ch b tr thch nghi b tr khng kp huy ng ta s b try mch lm cho khi lng tun
hon gim dn n thiu oxi t chc gy nn RLCH(nhim toan chuyn ha )lm cho ri lon vi tun ha gy thot huyt tng v gy mu lm trm trng thm
v gim khi lng tun hon lu thng li cng lm thiu oxi t chc hn v n gy ra mt vng xon bnh l cng lm nng thm shock.C s km theo:
Trong chn thng:lm cho t chc b tn thng gy au lm hng phn thn kinh lm tng s dng oxi gy thiu oxi t chc.Mt khc trong chn thng cn
gy ra chy mu gy gim KLTH v cng gy ra thiu mu t chcthiu oxi t chc
Khi thiu oxi t chc gy nn RLCH(nhim toan chuyn ha )lm cho ri lon vi tun ha gy thot huyt tng v gy mu lm trm trng thm v gim khi
lng tun hon lu thng li cng lm thiu oxi t chc hn v n gy ra mt vng xon bnh l cng lm nng thm shock. C s km theo:
Trong shock bng:Khi b bng th c ch bnh sinh l s kt hp au n,c c mu,thot huyt tng v nhim c.Tt c chng u lm cho gim khi lng
mu lu thng ngoi vi gy thiu oxi t chc v n li to nn mt vng xon v thiu oxi. C s km theo:
Cu 37. Theo di mch, huyt p ng mch, h hp trong Shock gip ch g cho tin lng v iu tr bnh?
Shock ngoi ngha thng dng l suy sp t ngt v nng n v tinh thn ,th lc th shock trong y hc l tnh trng ri lon su sc v huyt ng hc v chuyn
ha,c trng bng suy sp chc nng tun hon khin cc c quan sinh tn khng c cp mu nui dng.Cng vi cc triu chng v huyt p th cc
triu chng v mch ,h hp cng c s thay i ty thuc vo tng giai on ca shock bi vy vic thng xuyn theo di mch, huyt p ng mch, h hp
nhng bnh nhn b Shock l v cng quan trng bi n cho chng ta bit shock ang giai on no c phng php iu tr cng nh s l thch hp
Trong giai on shock cng th HA ng mch gim nh do gim khi lng tun hon,mch nhanh v mch do c ch phn x.H hp tng,th nhanh v
su.Trong giai on shock tim th HA ng mch tng nh,mch nhanh v mnh hn,h hp u v su hn(nu c ch b p ca c th pht huy tc dng).Nu
din bin xu i th HA khng tng m tip tc gim,mch yu v nhanh,lon nhp,h hp b ri lon th nhanh v nng.Cn trong giai on cui(shock nhc)l
giai on suy sp ca h thng TKTW v ton b chc nng ca c th,tt c cc thng s trn u gim
Nh vy theo di cc ch s trn cho ta bit phn ng ca c th chng shock nh th no c tin lng v phng php iu tr thch hp nh trong trng
hp huyt p ng mch gim do thiu KLTH th ta c th truyn mu,dch nng HANu tin lng tt th iu tr s tt cn nu tin lng sai th c th dn
n nguy him cho bnh nhn.

19

Cu 38: Shock chn thng thc nghim: phng php tin hnh, din bin, phn tch cc ri lon ch yu , nguyn tc phng v iu tr shock chn
thng
Bi lm
I. Phng php tin hnh
- Vt th nghim : ch
- Tin hnh :Gy shock chn thng ch bng cch gy dp nt c nhng khng lm chy mu.Nh vy yu t ch o trong bnh sinh y l au n.Lp my
o huyt p h hp, mch, nc tiu, phn x, tc tun hon v hematocrite
II. Din bin
1. Giai on t b p
a) Trng thi t b p qu mc v tm thi ( shock cng )
- c im : tng cng hot ng ca ton b chc nng trong c th th hin trng thi HP ca TKT v h giao cm(tng HA,nhp tim,tng tc tun
hon,tng thng kh v tng chuyn ha)
b) Trng thi t b p kn o v tm thi ( shock tim )
- c im : mch nhanh nhng yu , khi lng mu lu thng gim song nh c c ch b p, huy ng lng mu d tr gan lch, co mch nh nn HA
ng mch vn gi c mc bnh thng nhng tim phi tng hot ng tng lng mu lu thng do tiu hao nng lng d tr v tin ti giai on mt
b
2. Giai on mt b ( shock nhc )
- c im : Giai on ny biu hin s suy sp ca ton b chc nng quan trng ca c th ni ln trng thi c ch ca h TKT , con vt th yu mch nhanh
nhng yu , huyt p gim, thn nhit gim, hu nh mt ton b cc phn x
III. Cc ri lon ch yu
1. Ri lon tun hon
- Xut hin ngay giai on shock cng l yu t ch yu chi phi qu trnh pht sinh, pht trin v kt thc ca shock.Khi b chn thng lm t chc b tn
thng dn n gii phng cc cht TGHH gy co mch nh cc catecholamin n gy co c tht trc v sau mao mch( tr tun hon no v vnh) gy thiu O 2
cho t chc do thiu mu v m h thng mch tt nhm dn mu cho c quan quan trng nh tim v no
- giai on shock nhc do thiu O2 nn c th nhim toan chuyn ho (chuyn ha ym kh) lm cho h thng c trc mao mch khng chu tc dng ca
Catecholamin nn m cn h thng c sau mao mch vn chu tc dng nn mu trn vo mao mch nhng kh ra c gy thiu O 2 do mu lm hoi t t chc
ni tng c bit l rut.Do mu nn p lc thu tnh trong mao mch tng,dn n thiu O 2 nn tnh thm thnh mch tng gy thot huyt tng lm gim khi
lng mu tun hon
2. Thay i huyt p
- Shock cng : Huyt p tng do hng phn h giao cm lm trung khu co mch hng phn gy tng tit Catecholamin gy co mch c tc dng nng huyt p
- Shock tim : Huyt p gim nh ch yu do gim khi lng mu lu thng ngoi ra cn do suy mch cp do trung khu vn mch b c ch
- Shock nhc : Huyt p tt mnh, mch nhanh v yu do huyt p gim kch thch TCT p lc quai ch v xoang cnh lm tim p nhanh nhng yu l do gim
khi lng mu tun hon nn tim co bp rng
3. Ri lon h hp
- Sock cng : H hp nhanh v su c tc dng b p do trung khu h hp hng phn
- Shock nhc : H hp nng, nhanh hay chm, lon nhp, c th theo chu k do trung khu h hp b c ch ( thiu O 2 v gim khi lng tun hon )
4. Thay i ca mu
- Mu long do thot protein lm gim p lc trong lng mch nn dch gian bo trn vo nhm b p lng mu mt i
- Gim s lng HC v huyt sc t
5. Ri lon tit niu
- Lng nc tiu gim do gim khi lng mu tun hon dn n mu n mao mch thn gim.
- Tng tit ADH v Aldosteron c tc dng tng ti hp thu nc ng thn
IV. Nguyn tc phng v iu tr
-u tin chng ta chng shock bng cch gim au(loi tr nguyn nhn gy ra shock): Bng b, c nh, bt ng v dng thuc gim au mnh(morphin gim
au ton thn)
- Truyn dch : nhm b p v tng khi lng tun hon trnh b try mch
- Ngn nga v loi b cc yu t ngoi lai lm shock din ra nhanh hn,mnh hn nh nng, lnh v i...
Cu 39. Thng binh b bng nng: Din bng 65% din tch c th, theo di nc tiu thy c g. Phn tch?
Thng binh b bng nng thng do nhit ca ha kh ,vi din bng 65% d l bng nng hay bng su th nguy c xy ra shock bng l rt cao. Trong shock
do bng c ch ca n bao gm c au n v gim khi lng mu lu hanh ( mt mu) do thng nng v nhanh chong chuyn sang gd sc nhc. Trong
bng ngoai da vo s bin i v tm thn kinh, tun hon, h hp, tiu ha th anh gi tin lng v hng dn cch iu tr (truyn dch) ngi ta da vo
nc tiu lm mt thng s quan trng:
a.
S
lng:
Thiu
niu
tng
t
hoc
ko
di,
s
lng
nc
tiu
did
500
ml/
24
gi
hoc
30ml/h.
Nng:
v
niu,
s
lmg
nc
tiu
<
300ml/24h
hoc
v
niu
hon
ton.
- Ri lon bi niu l triu chng sm (theo Paris 1967: gp 98%), ngay c khi nhng thay i mch, huyt p cha xut hin. N c gi tr chn on v tin lng,
l cn c tnh lng dch truyn.
* C ch ca s thay i ny thng do suy thn cp do cc nguyn nhn
Do
kch
thch
au
n
qu
mc
gy
co
tht
phn
x
cc
mch
mu
--->
thn
thiu
mu.
- Do
huyt
tng
thot
qa
nhiu
gy
chn
p
cun
mch
trong
cu
thn
(bao
Bowman
gin
rng
thm
y
huyt
tng
gy
chn
p
cun
mch).
- Do khi lng mu lu hnh gim ---> lung mu qua thn gim ---> huyt p ng mch gim thp ko di, lung mu chm 50% ---> kh nng lc cu thn
gim.
Do
tng
Hormon
thu
sau
tuyn
yn:
Aldosterol
v
vasopressin,
gy
tng
ti
hp
thu
ng
thn.
Do
tn
thng
thc
th:
hoi
t
ng
thn
cp
(hu
qu
thiu
oxy
ko
di)
--->
suy
thn
cp
thc
th.
- Nu km theo nhim toan chuyn ho s nguy him, v Hb t do khng c tng d dng khi thn m bin thnh Hematin chlorhydrat ---> tc ng thn ----> v
niu.
b.
Nc
tiu
c
th
- Nng: mu , nu sm (biu hin i Hb) :
- C th mi kht, mi sng chy.

Mu
sc:
vng
trong :
do
tan
huyt
lm
tng
bilirubin
Do huyt tn, Hb t do trong mu tng ---> nc tiu s c HC, khun tr hnh Hb

Nu anh gi cc thng s cn lm sang c th thy :-protein niu , hng cu niu , Hb niu , tr hnh , tr ht , t trng tng, urobilinogen tng,
Cu 40. Ph bnh nhn suy tim do nhng yu t g gy ra. Hng iu tr ch yu l g?
Suy tim xy ra khi tim mt 1 phn hay ton b kh nng co bp y ra khi tim mt lng
mu thch hp vi i hi c th.Khi suy tim tri th kh nng ht mu v tim gim trong khi
mu vn tip tc c a n phi nhng ko c gii phng nn mu b gi li phi,cn trong
suy tim phi th ch yu tnh mch ngoi vi thay i cc yu t nh p lc thu tnh long

20

mch, p lc keo huyt tng, p lc thm thu gian bo, tnh thm thnh mch, (l nhng yu
t gy ph) Ph.
Vy ph bnh nhn suy tim l do nhng yu t :
Trong bnh nhn suy tim tri: l ph phi mu phi gy tng p lc thu tnh trong mao
mch phi khin nc thot vo ph nang gy ph phi mn tnh. i khi c th pht sinh ph
phi cp , y l bin chng nguy him nht ca suy tim tri thng do tim phi vn cn kho
bt cht tng ln hot ng(do gng sc chng hn) y mt lng mu qu nhiu ln phi m
tim tri ht yu nn mu b li phi lm tng p lc thu tnh trong long mao mch phi,mt
khc do mu b li phi lm cho qu trnh nui dng ca thnh mao mch ko tt mao
mch phi gin ra v tng tnh thm thnh mch, ng thi lm gim p lc keo huyt tng v
khi tnh thm thnh mch tng t th ch c nc v cc ion thot ra ngoi cn c tip tc tng s
ko theo cc phn t ln thot ra ngoi nh albuminmu s t vo ph nang gy ph phi
cp.Lm cho bn trng thi ngt ti cp din, ng bnh giy da lo s lm cho tnh trng nng
them v cng lm tim phi tng cng co bp cng lm mu dn ln phi c th cht nu ko c
iu tr kp thi.Hng iu tr l lm garo chi(hoc trch mu tnh mch) lm gim gnh
nng i vi phi,dng thuc tr tim phc hi sc co bp tim tri b suy,dung thuc li
tiu,kt hp vi tim mocphin bnh nhn yn tnh.
Trong bnh nhn suy tim phi :ph do nhiu yu t kt hp li:Huyt p tnh mch tng lm
chon nc thot ra khi mch nhiu, ng thi cn tr s ti hp thu nc t gian bo vo long
mch(y l yu t ch yu).Gim p lc keo trong long mch do gim protein huyt tng(hu
qu ca ri lon chc nng gan.do mu gan thiu oxy do tun hon km). ng nc v
mui do gim lc cu thn(do lu lng mu qua thn gim, ng thi mu tnh mch thn
gy gim p lc lc cu thn).Hng iu tr l phi gii quyt cc yu t gy ph nh gim p
lc tnh mch(dung thuc tr tim phc hi sc co bp tim phi mu v tim ko li
mch),dung thuc li tiu,dung thuc tr gan.
Trong uy tim ton b :ph do nhng biu hin ca suy tim tri v phi kt hp li vi nhau.

Cu 41. Phn tch c ch nhng biu hin ca suy tim tri?

Suy tim xy ra khi tim mt mt phn hay ton b kh nng co bp y ra khi tim mt lng
mu thch hp vi i hi ca c th.
Trong suy tim thng thy gim lu lng tim v tng huyt p tnh mch, do nh hng su
sc ti v nhiu chc nng sinh l. Song tu theo suy tim tri hay phi m biu hin cng nh
c ch khc nhau.
.
Nhng biu hin chnh ca suy tim trai:
:
a) Kh th: y l biu hin thng gp v quan trng nht. Ngi bnh thng th nng v nhanh, c cm giac ngt, nht l sau khi gng sc(lao ng ,ln cu
thang ).Kh th trong suy tim tri l do tim tri co bp yu, khng y ht mu ,dn dn pht sinh mu phi.Mu phi lm cho t t chc phi bt co gin
ng thi cc mao mch phi cng mu gy chn p cc ph nang,kt qu l hn ch lng khng kh, gy kh th. Ngi bnh thng hay kh th khi nm l do
t th ny gy mu phi nng nht,cho nn ngi bnh thng ngi th d th hn. Kh th khi nm l mt triu chng thng thy khi c suy tim tri, n khi
c suy tim phi th triu chng ny gim c mu tnh mch ngoi vi nn v phi t i ngi suy tim tri c nhng cn kh th xy ra ban m, ging nh cn
hen (thng gi la hen tim) do dy X tng cng hot ng trong gic ng, gy xung huyt phi v co tht c trn ph qun
.
b) Ph phi: mu phi gy tng p lc thu tnh trong mao mch phi khin nc thot vo ph nang gy ph phi ma tnh nghe phi thy ting rn t c hai
th c bit r nn phi i khi, c th pht sinh ph phi cp . y l bin chng nguy him nht ca suy tim tri , thng do tim phi vn cn kho bt cht tng
hot ng(do gng sc chng hn) y mt s mu qu nhiu ln phi, ng thi trng thi thiu oxy trong t chc lm cho thnh mao mch tng thm, kt qu
l mu s o t vo ph nang gy ph phi cp , lm cho bnh nhn cht trong trng thi ngt ti cp din nu khng kp thi iu tr. Ngi bnh giy da, lo s
lm cho tnh trng nng thm v tim phi tng co bp li cng dn mu ln phi. Cho nn trong iu tr ngi ta lm garo chi(hoc chch mu tnh mch)d gim
gnh nng i vi phi, dung thuc tr tim phc hi co bp ca tim tri b suy, kt hp vi mocphin ngi bnh yn tnh
.
c) Ph dung sinh hot gim:tnh trng mu phi lm gim tnh co gin ca t chc phi , hn ch thng kh phi, dn ti gim ph dung sinh hot. Suy tim tri
ko di c th dn ti x phi
Cu 42. Phn tch c ch nhng biu hin ca suy tim phi?
Suy tim xy ra khi tim mt mt phn hay ton b kh nng co bp y ra khi tim mt lng
mu thch hp vi i hi ca c th.
Trong suy tim thng thy gim lu lng tim v tng huyt p tnh mch, do nh hng su
sc ti v nhiu chc nng sinh l. Song tu theo suy tim tri hay phi m biu hin cng nh
c ch khc nhau.
Nhng biu hin chinh ca suy tim phi
:
Nu nhng biu hin ca suy tim tri phn ln thuc v triu chng phi th nhng biu hin
ca suy tim phi ch yu thuc v khu vc tnh mch ngoi vi
a) Ph: trong suy tim phi do nhiu yu t kt hp li:
- huyt p tnh mch tng lm cho nc thot ra khi mch nhiu, ng thi cn tr s ti hp
thu nc t gian bo vo lng mch. y l yu t ch yu
- gim p lc keo trong lng mch do gim protein huyt tng (hu qu ca ri lon chc nng
gan
- ng nc v mui do gim lc cu thn
b) Gim bi tit nc tiu, do lu lng mu qua thn gim, ng thi mu tnh mch thn gy
gim p lc lc cu thn, gim lng nc tiu, dn ti mui v nc, gy ra ph
c) Ri lon chc nng gan: trong suy tim phi, mu gan lng mu gan c th tng gp
i(t 400 ln 800 ml).Th tch gan to ra , b di c th xung ti ng rn. iu tr tt, tim
phc hi kh nng co bp mu lu thng d dng, gan s nh li ri li to ra khi tim suy tr
li. Do , m gan khi to khi nh tu theo kh nng co bp ca tim(gan n xp). Dn dn v
sau, tnh trng thiu oxy do tun hon km ko di gy thoi ho m, ri qu trnh x ho pht
trin t khong xung quanh tnh mch gan,lu ngy dn ti x gan gy tng huyt p gnh v
trn dch mng bng(c trng, bng nc)
)
d )Xanh tm: triu chng ny hay gp ngi suy tim nng, thy r mi , mng tay c th
c th l:
:
-do khi lng mu lu thng gim nn huyt sc t khng c bo ho vi oxy hemoglobin
kh tng.
.

21

- cc mao mch, tnh mch b dn v mu

Cu 43:Phn tch bnh n suy tim ton b do hp van 2 l :gan to 4cm di b sn,s hi
cng,kh th r nht l khi nm, c ting ran t lc c 2 bn nn phi,pro mu 4,8g%?
C ch bnh sinh:c s km theo:
Suy tim phi lu ngy suy tim tri suy tim ton b.
Vy trong bnh n trn ta c gan to di b sn 4cm s hi cng l do mu gan,lu ngy
dn n x gan(x gan tim) s chc,phn hi TM ca (-).Tng p lc tnh mch ca lch to,c
trng,suy gim chc nng gan.Kh th y l do suy tim mu phi thot dch vo
PN lm din tch trao i kh gim,khi nm cao p ng mch phi ln hn thot dch nng l
hn kh th hn.C ting ran t lc c 2 nn phi l do thot dch vo PN,nng c th ph
phi cp.Protein 4,8g% gim(bt 6,8-7,2g%),nguyn nhn y l do x gan c/n gan gim
kh nng tng hp protein gim pro huyt tng gim.

22

Cu 44. Nguyn nhn, c ch bnh sinh, nguyn tc iu tr ngt?

1. nh ngha : Ngt l hin tng tc nghn hon ton ng lu thng kh o gy thiu O 2 v ng CO2 trong mu dn ti suy sp chc nng ton b c th
v cht nu khng kp thi c bin php cp cu hp l
Bnh thng thnh phn kh bao gm : + O2 : 20,96%
+ CO2 : 0,04%
+ N2 : 79%
2. Nguyn nhn : Do 3 nhn t chnh
+ Do c ch trung tm h hp : Thuc m
+ Lit v co cng c h hp
+ Do tc nghn hon ton ng lu thng kh o : tc d vt, ph n thanh qun
+ Do trn dch ph nang: cht ui, ph phi cp
3. C ch bnh sinh
Ngt thng din bin theo 3 giai on :
+ Giai on kch thch: ng lu thng kh o b tc, lit c h hp, thay i thnh phn khng kh th tt c cc nguyn nhn trn u gy nn trng thi
thiu O2 v tha CO2 trong mu, khi CO2 trong mu tng th gy kch thch cc phn x c ch trung tm h hp v qu trnh vn mch, biu hin ban u l h hp
nhanh v su, th th vo ko di mch nhanh v mnh, huyt p ng mch tng cao, tng trng lc c c tc dng b p
+ Giai on suy sp: Sau khi c mt lot cc p ng b p nhng c th vn thiu O2 v tha CO2 trong mu qu nhiu gy c ch h hp, h hp chm li, huyt
p h tim p chm dn, thn kinh lm vo tnh trng c ch su xut hin co git ton thn, thn kinh chi phi c trn hu mn v bng quang t lit nn mt kh
nng kim sot tiu i tin
+ Giai on suy sp: V no v trung tm h hp b c ch su sc, c th mt ton b cc phn x, ng t gin mt hon ton h hp, tim p chm dn, huyt p
tt nhanh v tim ngng p
4. iu tr
Nh vy cht do ngt l do thiu oxy trm trng v ng qu nhiu CO 2 trong mu gy c ch trung tm h hp v h thn kinh trung ng. Phn p CO 2 trong
mu tng rt cao nh vy nn nguyn tc iu tr trong ngt alf phi h hp nhn to loi b CO 2 , tr b cc nguyn nhn cn tr ng h hp cung cp oxy
cho bnh nhn nhng khng c dng oxy nguyn cht v s lm mt phn x th b p vi trng thi thiu oxy .
Cu 45,Phn tch cc ri lon thong kh v ri lon khuych tn trong cc bnh hen,vim phi?
Thng kh phi l qu trnh lun phin lien tc gia ht vo v th ra nhm duy tr 1 phn p O2 nht nh trong ph bo v mu l 100-104mmHg v phn p CO2
mu nht nh 40-42mmHg.C cc hnh thi ri lon thong kh l tng thong kh, gim thong kh,thong kh khng u.
Kh nng khuch tn ca phi l lng cht kh c chuyn qua mng ph bo mao mch phi trong 1 pht vi chnh lch phn p 2 bn mng l 1mmHg.L kh
nng chuyn cc cht kh t vng c p lc cao n vng c p lc cht kh thp hn.Kh nng khuch tn ph thuc nhiu yu t:din khuch tn,mng khuch
tn,h s khuch tn.Ri lon khuch tn khi cc yu t ny thay i.
Hen
ph
qun:
L mt bnh d ng do khng th loi reagin, gy co tht h thng ph qun m biu hin lm sng ch yu l cc cn kh th, c bit l th th ra.
Nguyn
nhn
v
bnh
sinh:
- Do cc d nguyn c trong hon cnh sinh hot v lao ng bnh thng nh bi nh, phn hoa, cy c, kh hu, cht t
- Do d ng sau nhim khun, thng gp sau cc bnh nhim khun ng h hp , tai-mi- hng, c bit sau vim xoang( 60,4%)
V bnh sinh ca hen, cn ch cc yu t di truyn( c ti 51,8% con ci mc bnh do di truyn t b hoc m), v yu t thn kinh ( hen c th pht sinh theo c
ch phn x c iu kin v thng xut hin ban m khi trung khu v no b c ch khng kim ch c cc trung khu thc vt di v no ).
Cc
ri
lon
h
hp
trong
hen:
- Cn hen thng pht sinh do tc dng ca d nguyn gy kt hp khng nguyn khng th gii phng cc cht ha hc trung gian nh histamin, bradikinin,
prostaglandinkch thch cc si ly tm ca thn kinh ph v gy co tht h c trn v ph qun, tng tit nim dch, ph n v vim cc nim mc ph qun dn ti
cc cn kh th ra, bnh nhn rt kh th nh lng ngc b p, thng phi ngi dy c th, mt xanh tm, tit nhiu m ri, thng kh t bo gim, dung
tch sng gim, VEMS v h s Tiffeneau gim, lng cn tng. Tn s cc cn hen, thi gian ko dica cc cn ph thuc vo tnh cht ca bnh, thng nng v
cn
ko
di

ngi
trng
thnh
(hnh
6).
- Hen lu ngy c th lm gim tnh n hi ca t chc phi gy tnh trng trng ph nang, nim mc ph qu ph i gy trng thi phi b c khi bnh thng.
Ph bo cng, lun p vo mao qun, lm tr ngi tun hon phi, gy tng huyt p ng mch phi, tm tht phi tng cng hot ng lu di c th dn ti
suy tim phi c gi l tm ph mn. Cn hen c tnh l do tc ton b cc ph qun nh c th gy suy h hp, rt nguy him nu khng cp cu kp thi.
Vim
phi.
L mt trng thi bnh l ph bin trong nhn dn cng nh rong qun i, chim 49,3% trong tng s bnh h hp, 17% trong tng s cc bnh ni khoa.
a)Nguyn
nhn
v
bnh
sinh:
- Do nhim khun: ph cu, lin cu v mt s virut thng c sn trong ng h hp, di tc dng ca cc yu t thun li (lnh, mt mi) lm gim sc
khng
ca
c
th
to
iu
kin
cho
bnh
pht
sinh.
- Do nguyn nhn min dch: thiu gamma- globulin loi IgA lm gim kh nng thc bo chng nhim khun ng h hp.
- Do cc nguyn nhn thi chin: bng, hi c chin tranh, chn thng gy mu phi, gy tc mch do nhi mu hay t chc thi nt t vt thng a ti,
hoc cng c th do phn x t cc b phn khc gy mu v ri lon tun hon phi (vt thng s no. vt thng bng)
b)
Ri
lon
h
hp
trong
vim
phi
:
- Kh th, th nng v nhanh do t chc phi b vim, tng tit dch di phng trong ph bo gy tng hng phn cc cm th ph bo c ch lm th th vo sm b
c ch ng thi din h hp v khuch tn kh cng gim. Hu qu l thng kh ph bo gim, dung tch sng cng gim gy tnh trng thiu oxy.
- Mu qua vng phi b vim khng c bo ha y oxy nn bo ha oxy ca mu gim r rt (c khi ch cn 70%). Thnh ph nang b ph n dy nn
cng
nh
hng
n
kh
nng
khuch
tn
ca
phi.
- Do cc khu vc lm tng thng kh b p nn thng khng c u thn. Thiu oxy, xanh tm v u thn r ch gp cc trng hp c km vim ph qun (ph
qun - ph vim) cc ph qun nh b vim, ph n, bt kn cc dch nhy hoc co tht cc ph qun nh.
Cu 46: M t bnh ln cao thc nghim (thiu oxy do gim phn p) Phn tch kt qu
Bi Lm
Cc du hiu bnh l xh ph thuc vo cao v sc chu ng ca c.Thiu O2 l 1 qu trnh bnh l phc tp do cc c quan m bo ko cung cp c O2 y
v 1 l do no ko sd c O2.Trong c th k n TH thiu do gim p.
- NN ca thiu O2 ny l do khi ln cao trn mc ca mt bin, p lc KQ gim do p lc O2 trong kk cng gim gy gim pO2 torng ph bo v trong mao mch
v thiu O2.
+ c th tnh theo cng thc sau:pO2 =[O2 kk](Pk.quyn-47)
- pO2 kk: p lc O2 trong kh th (mmHg)
- [O2 kk] mc bt= 0,21
- P k.quyn : p lc kh quyn =760 mmHg
Bnh thng pO2 kk= 0,21.(760-47)= 150 mmHg
Khi ln cao 3000m: pO2 kk= 0.21.(550-47) 80 mmHg do gy thiu O2
1.bnh ln cao:
a/ dnghia:+ L htng thiu O 2 cp khi ln cao t ngt trn 3000m hoc bay cai trn mc gii hn m ko c or hng bnh O2. cao 4000-5000m c coi l gii
hn ko cn thm O2 ,dh sm nht l cc RL thn kinh,RL ng quan: mt mi bt thng, nhc u,gim tr nh,fx chm chp, bun nn,RL th gic,thnh gic...
u l dh ng.him nht l /vi phi cng chin u. Do c th b p bt lc gy tng o thi CO2 nn l loi thiu O2 km nhc thn v nhim kim hi. Tim
p nhanh,yu c th lon nhp.Nu ko x l kp thi h TK b c ch su sc dn ti co git, hn m v cht.Bin php ch yeu l cung cp oxi nguyn cht.
b/+thc nghim bnh ln cao dc tin hnh vi chui trong phng th nghim d chng minh cho iu ny.tao kin tng t bng cch cho chut vo trong phng
kn.dng my hut chn khng ht khong khicho dn khi t p sut tng ng cao trong thc t.kqua:n ngng chu ng con vt bt u cogit v
cht.ngng ny thp hn con vt b hng phn bng cch tim cafein va cao nht con chut b c ch thn kinh bng bacbiturat.

23

c/phn tch:
khi hng phn con vt tng s dng nang lng tng nhu cu oxi nen mc nhy cam vi thiu oxi s cao hn.
khi ln cao trn 8000m: pO2 kk= 0,21. (270-47)= 47 mmHg
+ Cung cp O2 gnuyn cht: 1.(270-47)=223 mmHg
+ Ln cao trn 1000m th d cho O2 nguyn cht cng ko m phi c bung p lc mi trnh c tnh trng thiu O2 v v trng lng.
Vi cc vn ngvien leo ni,xy ra hin tng thiu O2 cp khi leo ln cao trn 6000m( cc nh thm him).Nguy him ca thiu O2 cng f thuc vo
cao v mt s yu t ph thm nh: mt mi th cht, lnh,t/d ca tia cc tm,tia v tr...Khi ln cao trn 3000m cc dh thiu O2 bt u xh: h.f TK,trthi
kthch,khoan khoi,hay ci ni.Ln cao trn 4000m dh r rt nh:nhc u, bun nn,mt mi tht thng,km tr nh,kh th,tm ti,h hp chu k... cao
6000m l gh cui cng con ngi c ht chu ng c m ko cn c thm O2.
+ Cht trong bnh cao v ni cao l do t lit tr.tm h hp v c ch h TKTW v cc tr.khu TK, bnh leo ni cn c trt nhim toan chuyn ho do cc c fi
lm vic trong hon cnh thiu O2, sn sinh nhiu acid lactic v nhiu acid khc.
+ vi nhng dn tc sng trn ni cao th ttr thiu O2 mn c c th thch nghi b p g/q n nh cn bng ni mi,HC c th tng t 7-8 triu O2/mm 3 mu,
nhim kim hi c b p bng thi tr bicacbonat ca thn do s cung cp v sd O2 ca TB c m bo v nhng ngi ny co th sng v lao ng sx bt.
Cu 47: Ph phi cp thc nghim, Phng php tin hnh, din bin, phn tch nhng ri lon ch yu, bin php iu tr ( nu l ph phi cp
trong bnh tim )
Bi Lm
Ph phi cp l hin tng cc ph nang b ngp nc do huyt tng trn ra lng mch.
1. P2 tin hnh
- V th nghim lch kho mnh
- Dng AgNO3 0.03% tim vo M i ch khong 20-30ml$truyn dch cho n khi xut hin cn PPC .
2. Din bin
- Do mao mch phi thnh mng va k/n v/c chm cho nn t.g AgNO 3 tip xc vi mao mch phi lu hn $lm ph hu mao mach phi $trn dch vo PN (htg +
hcu)$gy ra Ph phi cp .
- Ton thn:g u H2 tng,HA tng ,mch nhanh ,con vt trong trng thi kch thch$sau H2 $,HA $,mch chm nng ,con vt trong trng thi c ch l .
- Ti phi: thy ran m t y phi dng ln ,c bt kh mu hng trn ra KQ ,bp t chc phi thy lo xo.
- Khi ch chtt m thy vt m khng c mu, tim mu sm mu phi vng y thm tm cn trn hng nht(ct 1 phn dy tha nc th chm)
3/phan tch nhng ri lon ch yu:
_do mmch phi tn thng ph nang cha dy dchmng khuech tn dy ln ,din ktn gim.,h s ktn gim.kt qu lm thiu oxi kthch tktk HH v TH
lmtang h hp,tim p nhanh,huet p tngcng lm thiu oxic ch hhp gim tim p chm.
_ ngoi ra dch trn y ph nang lm gim khi lng tun hon tt huyt p dn ddeens truy tim mch.
_dich pnang la huet tng c nht nn khi h hp s to ting ran ng thi kkhi b xo trn vi huyt tg to nn bt kh mu hng.bp phi thy lo xo.
_do KLTH gim nen mu co ve trung tam nen vt m khong co mu.tim nhiu mu c th tam tht phi hay trai tuy thuc vo tim ngung p thi nao hay ki
thut vin kp ki nao.
4/bin php iu tri ppc do suy tim
Ppc do suy tim l do tm tht tri suyht mu v tht tri km gy ma git li.tht phi cn khe s tng co bp lm tng t ngt p lc mmpppc.do ta
phi :
1.hn ch mu v tht phi bang cach garo chi luan phien,trich mu tinh mch,li niu.
2.trnh ong mu phi bngcch tr tim tri,
3.dung an than tranh xuc ddng kch thch.
Cu 48. Ngt thc nghim: phng php tin hnh, cc giai on, c ch bnh sinh, nguyn tc x tr?
nh ngha: ngt l tnh trng bnh l do thiu O2 v tng CO2 trong thnh phn khng kh th.
Bnh thng oxy 21%, CO2 0.04%, N2 72%
1/phng php tin hnh gy ngt thc nghim:
a/chun b:+ch cc nh trn bn.
+tin hnh m kh qun ch.
t canuyn,
Dung km koche kp ly canuyn.ngn con vt h hp vi kh tri.quan sat din bin h hp v tun hon ca ch trn bng giy.qua thc nghim thy ngt din
bin qua 3 gdoan:
2/cc giai don va c ch:
- Giai on I: ng lu thng kh o b tc nghn nn thiu O2 ng CO2 gy kthch phx, hng phn cc trung tm h hp v vn mch,
_Biu hin h hp nhanh v su, th th vo ko di, nhanh v mnh, huyt p ng mch tng rt cao c tc dng b p.
- Giai on II:( b p bt lc)
_c ch:thiu O2 v ng CO2 nhiu gy c ch trung tm h hp,
_biu hin:th chm li, nng, ri nh ch, huyt p ng mch cng gim dn, tim o chm do thn kinh ph b kch thch v h thn kinh trung ng cng b ri
lon, mt thc, c th xut hin co git ton thn, v vi a, i do h c trn b co tht bt thng.
- Giai on III: c ch su sc v kit qu cc trung tm thn kinh cc phn x mt, ng t gin, h hp hon ton nh ch, tim p chm, yu dn, huyt p tt
nhanh, tim ngng p.
Nh vy cht do ngt l hu qu ca thiu O2 trm trng v ng CO2 mu gy chn p cc trung tm thn kinh
3/s tr:
Trong trng hp ny paCO 2 c th tng ti 80mmHg cho nn trong cp cu ngt ch yu l phi lm h hp nhn to hoc thi ngt loi thi CO 2 tr b cc
nguyn nhn gy chng ngi ng h hp, cung cp O2 nhng khng nn dng O2 nguyn cht ngay v s lm mt phn x th b p vi trng thi thiu O2.
Cu 49. Thiu oxy do nhng loi nguyn nhn no gy ra. Phn tch?
Thiu oxy l mt qu trnh bnh l phc tp do cc c quan bo m khng cung cp c oxy y cho nhu cu chuyn ho bnh thng ca t bo hoc do t
bo t chc v mt l do no khng s dng c oxy.
Thiu oxi c th do suy h hp hay thiu nng h hp:
1/suy h hp

nh ngha: Suy h hp l tnh trng b my h hp ngoi khng m bo c chc nng cung cp O2 v thi CO2 trong iu kin bnh thng v bt
thng ca c th

Biu hin
- Ri lon h hp ngoi: thng kh khuych tn gim du hiu u tin l kh th.
+Giai on tim tng kh th xut hin khi gng sc.
Khi nng lao ng nh, ngh ngi vn kh th
-Thay i TP kh mu: pO2 < 92 mmHg, Pco2 > 44 mmHg;
bo ho oxy SaO2 < 94% suy h hp r rt.
Suy h hp nng pO2 < 50 mmHg, bo ho oxy < 79%.
Suy h hp cp Pco2 > 80 mmHg, mu nhim toan, CO2.
2/Thiu nng h hp
H hp bao gm cung cp, hp thu v s dng oxy, thiu nng giai on no cng dn n thiu oxy. C 4 nhm chnh thiu oxy.
2.1 Thiu oxy do cung cp

c im: pO2 ng mch gim

Nguyn nhn:

24

+ pO2 khng kh gim (ln cao, kk ngho oxy)

+ Thng kh gim (tc hp ng dn kh, lit c h hp, d dng lng ngc) tng sc cn ng dn kh v t chc phi (hen, kh ph) trn kh ph
mc, th nng (do au trong vim phi), trung khu h hp b c ch.
+Khuych tn gim: gim s lng ph nang thng kh (chng, xp ph nang x ho vch ph nang v mao mch phi)
+Mt cn bng gia thng kh/ Phn phi mu phi. Cc ph nang khng thng kh tng (kh ph)
2.2.Thiu oxy do thiu mu

c im: pO2 mu ng mch bnh thng nhng lng HbO2 gim, s lng cht lng mu gim
2.3.
Thiu oxy do tr

c im pO2 bnh thng, HbO2 bnh thng, mu n cc m gim (ga r, u chn p, suy tim phi mu ngoi vi)
2.4. Thiu oxy do tn thung t chc m

Qu trnh oxy ho t bo gim do cht c c ch qu trnh ny

nh gi thiu nng h hp bng cc nghim php thm d chc nng h hp: V.lt, V.hv, V.tr, V cn, dung tch sng, VEMS, Tiffeneau, pO2, pCO2
Ngoi ra khi Hb khng bo ho oxy tng cao ti mao mch v biu hin mt mu xanh tm mi, di tai, chi.(dau hiu xanh tm) cung la 1 nguyn nhn dn n
thiu oxi t chc.
Bnh thng mu ng mch c bo ho gn ht vi oxy 95 - 97%, tnh mch c khong 70% Hb c bo ho, mao mch 17.5 % khng bo ho
oxy. Xanh tm xut hin khi Hb kh oxy mao mch tng ln 30 - 50 %.Gp trong cc trng hp sau:
+Do tr tun hon: suy tim, sc Hb kh tang cao tnh mch.
+Do tng HC: HC tng, Hb tng, nn khi qua phi khng c oxy ho ht do lng Hb kh cao
+Do ng c: Hb b c v MetHb mu sm hn bnh thng.
Cu 50: Phn ng b p ca c th khi thiu oxy?
Blam:
Thiu oxy l mt qu trnh bnh l phc tp do cc c quan bo m khng cung cp c oxy y cho nhu cu chuyn ho bnh thng ca t bo hoc do t
bo t chc v mt l do no khng s dng c oxy.
Khi thieu oxi c th c cc phn ng b p sau:

H hp tng do kch thch trung khu h hp (O2 gim, CO2 tng)

Tun hon tng: O2 gim, CO2 tng kch thch th th thnh mch, no do tim p nhanh, mnh, HA tng. Mt khc do tng h hp lm tng sc
ht lng ngc mu v tim nhiu V. tun hon tng th tch mu tun hon tng.

Phn phi li mu: mu c dn ti no, tim, mu d tr c a ra s dng. S kt hp v phn ly HbO2 d dng hn t chc s dng oxy d
dng.

Ty xng tng sn xut HC.

T chc m: enzym tng hot ng, tng chuyn ho theo ng ym kh, tng tn dng oxy t chc.
Hot ng thch nghi ny nhanh chng hay ko di, nhiu hay t l ty thuc mc thiu oxy v thu oxy cp din hay trng din.
Cu 51. Nguyn nhn, c ch bnh sinh, hu qu v nguyn tc iu tr ca i lng?
i lng l i i tin nhanh nhiu ln, trong phn c nhiu nc do rut tng co bp ,tng tit
dch bao gm tiu chy cp v mn :
Tiu chy cp : mt rt nhiu nc , i tin nhanh nhiu ln lin tip
Tiu chy mn : phn nho v ko di trong nhiu tun , thng, gy hu qu nng v dinh dng do gim hp thu
1 .Nguyn nhn : chia thnh 3 nhm chnh
-Tn thng thc th nim mc rut do
+Vim: nhim k sinh trng , vi khun v c t ca chng , ri lon thng bng vi khun
i trng
+c tnh hoc d ng ti rut
-Thiu dch v enzyme tiu ha: thiu acid trong v toan dch d dy, thiu dich ty, thiu
mui mt, thiu dch rut , thiu bam sinh mot so enzyme tieu hoa
-Cc nguyn nhan khac lm tng nhu ng rut: u rut , vim phc mc, vim rut tha ,
ung th i trng , ung th dng carcinoid
2.C ch bnh sinh
- C ch tng tit dch : l c chhay gp trong vim rut , , nc c tit ra t nim mc
rut tng gp nhiu ln binh thng
- C ch tng co bp: lm thc n qua rut nhanh m li khng kp tiu ha , thc n dng
th lm tng p lc thm thu rut lm nc c gi li trong long rut
-C ch gim hp thu: khin lng nc thi theo phn tng ln
3. Hu qu
- Tiu chy cp:
+ Ri lon huyt ng hc : do mt nc v in gii, mu b c c , khi lng tun
hon gim, , huyt p gim v gy nng gnh cho tim, dn n suy tun hon , v niu
+Nhim c v nhim acid do mt nhng mui kim ca dch tuy , dich rut v dch mt ,
hn na do ri laonj huyt ng dn n ri laonj chuyn ha (ym kh) cng lm
nhim acid nng them , gin mach , v niu cng lm tng them tnh trang nhim c
v nhim acid
+Mt nc , mt mui v nhim c li lm tng ri lon huyt ng hc v hnh thnh
vng xon bnh l t duy tr nu khng c iu tr sm.C s km theo:
-Tiu chy mn : do RLTH ko di dn n gim kh nng tiu ha v hp thu rut
dn n thiu protein, vitamin, st, calci.m hu qu cui cng l thiu mu , suy dinh
dng , ci xng
4. Nguyn tc iu tr
-Cp: ngoi iu tr ngun nhn phi chng nhim khun, c ch n thch hp phc
hi nc v in gii , chng try tim mch( truyn dch)
-Mn : iu tr nguyn nhn v chng suy dinh dng , ci xng bng cc dch v ch
n

25

Cu 52. C ch bnh sinh ca bnh lot d dy t trng, nguyn tc iu tr?

1.Ri lon tit dch trong bnh sinh lot d dy t trng
Lot dd-tt l hu qu ca s mt cn bng gia yu t tn cng ( acid v pepsinogen)
v bo v(cht nhy, HCO3-, s ti to nim mc ). trong yu t tn cng chim u th
1.1Yu t tn cng
-Pepsin: thc nghim chng t va tr gy lot ca pepsin, ng vt thc nghim thng khng b lot khi ch c tng tit acid , lot s tng nu tng acid phi
hp voi tng pepsin
-Acid HCl : Schwann nu khng c acid khng c lot , thc t cho thy khng bao g gp lot bnh nhn v toan, v bng chng thuyt phc nht l vai
tr ca acid tng hi chng Zollinger th 97% c lot v lot thp
1.2Yu t bo v
-Cht nhy c vai tr ngn cn acid v pepsin tip xc vi b mt nim mc , ion hydrocarbonat c vai tr trung ha lng acid thm qua lp nhy v kh nng ti
to nim mc ( 2 yu t ny ph thuc vo kh nng ti mu ), bng chng l: khi b bng rng mc d tit t acid nhung van loet th pht cao , lot th phat trong
soc chy mu , loet do s dng lu cc corticoid, . Thng hay gy lot cao khi yu t bo v suy gim
2.Cc yu t nguy c : lm tng tit acid v gim kh nng bo v
2.1.Yu t th tng: nhm mu O b lot cao hn , nhm HLA B5, DQ-A1 cng vy , mt s ngi bm sinh c s tb thnh cao, nhy cm bm sinh vi cc nguy
c t ngoi cnh , nhy cm vi thuc khng vim , helicobacter
2.2.Yu t ni tit: tit nhiu hoc s dng nhiu ACTH , cortisol gy suy gim hng ro bo v , glucose mu gim cng lm tng tit acid
2.3.Yu t thn kinh: cng ph giao cm gy tng co bp v tiet dch ,ri lon vn mch lm gim bo v nim mc , tm l cng c vai tro nht nh
2.4.Thuc khng vim NSAIDs: gy trn thng trc tip nim mc , hoc do cc sn phm chuyn ha thi tr qua mt , lm suy gim hnagf ro phng ng do
tng hp PG va NO , ngn cn qua trnh tai sa cha
2.5.Thuc l , ru, stress
2.6.Vi kun : xon khun hecolibacter pylori: enzyme urease ca HP to ra amniac gip vi khun to ra mi trng trung tnh quanh n ng thi lm tn thng
nim mc, HP cn lm tng tit acid, , cc enzyme protease , VaC ca n cng c vtro quan trng
3. Nguyn tc iu tr
Theo c ch bnh sinh,hn ch nguyn nhn v loi b cc yeu t nguy c to iu kin lin vt thng, dit khun pylori, trung ha acid , bo v niem mc
Cu 53. Nguyn nhn, c ch bnh sinh, nguyn tc iu tr ca tc rut?
Tc rut l tnh trang mt on rut khng lu thng khin pha trn n b cng gin
do tr cht tiu ha
1.Nguyn nhn : chia lm 2 nhm chnh
-Nguyn nhn c hc: xon , thot v ,bt ( bi giun, u , so )
-Nguyn nhn chc nng( tc rut c nng ): lit rut , cng ph giao cm( co tht)
2.C ch bnh sinh
Ban u on rut trn ch tc tng co bp (du hiu rn b, au qun d di ) trong khi on di gim co bp , sau rut chng hi do nut kh ( chng bng
trn lm sng , chp XQ c hnh nh mc nc mc kh ) v s ln men ca cc vi khun lm thc n khng tiu ha m thi ra sinh nhiu cht c , cui cng l
lit rut (sau co bop ko di) v sc (hu qu ca au n , mt nc v nhim c)
Ty theo v tr tc m c cc hu qu. Nu tc cao th ni bt l mt nc do nn, nhim kim , nu t trng gy nn dch rut lm mt nc km nhim acid, tc
thp biu hin nhim c sm v nng hn mt nc
3.Nguyn tc iu tr: gi quyt nguyn nhn tc( phu thut cp cu nu tc c hc) , b nc in gii, chng cng , au (ht nc v hi ch tc)
Cu 54. Ri lon chc phn chuyn ha v chng c bnh nhn suy chc nng gan?
Gan l c quan ln nht trong c th ,m nhn nhiu chc nng quan trong. v phc
tp , cc chc nng c mi lien quan cht ch vi nhau ,ri loan chc nng ny thng dn ti ri lon chc nng khc lm qu trnh bnh l thm phc tp . Khi
gan b suy cc chc phn chuyn ha , chng c , tit mt tun hon , to mu u b suy gim
1.Ri lon chuyn ha
-Ri lon chuyn ha protid : gim kh nng tng hp protid, gim sn xut cc yu t ng mu (II, VII, I X, X), fibrinogen, prothrombin, gim kh nang ging
ha protid lm cc diamin, polypeptide hp thu t ng tiu ha vo thng mu( gy d ng hoc hi chng mng no )
-Ri lon chuy ha lipid: thiu mui mt khin y bng , hkos tiu khi n m, gim hp thu m , gy thiu vitamin K ,E,A,D m m b huy ng dn cn kit,
cholesterol gim ,
-Ri lon chuyn ha glucid: gim kh nng d tr glucose khin trong v sau ba n gan chm hp thu glucose lm tng ng mu ko di v khi xa ba n th
li gim ng mu do gan km kh nng duy tr nng cht ny.Tng cc sn phm chuyn ha trung gian ca glucid nh lactate, pyruvat do khng s dng
c vit B1 a vo vng Krebs
-Ri lon chuyn ha mui nc:do gim tng hp albumin dn n gm p lc keo, lm nc thot ra ngoi gy ph, x gan lm trn dch mng bng do tng p
lc tm ca , gim kh nng hy cc hormone c tc dng gi nc v mui (ADH) , aldosterol tham gia gy ph
1.Ri lon chc nng chng c
Bnh thng gan chng c qua 2 c ch :c nh v thi tr do cc tb nhu m v cc tb lin vng m nhim, khi gan b suy dn n :
-Gim phn hy mt s hormone: kch t sinh dc (lm teo tinh hon, gin mch, mt kch dc tnh), kch t v thng thn (lm mui v nc ) , hormone
chng li niu ( gy ph )
-Gim kh nng c nh cht mu: , gim kh nng c nh vi khun b suy
-Gim kh nng chuyn cht c thnh cht khng c hoc km c bng cc phn ng ha hc : phenylbutazol, hexobarbital, chloramphenicol, sulfonamide, mt
kh nng lin hp bilirubin , ammoniac, acid benzoic. lm nhim c cc cht ny
Cu 55. Thay i phn, nc tiu trong 3 loi vng da: do tan mu, do tn thng gan v do tc mt?
Vng da l hin tng bilirubin trong mu cao hn mc bnh thng v ngm vo da v nim mc (thng bilirubin ton phn trong mu >= 40UI th bt u c
vng da trn lm sng), tuy vy nc tiu v phn ca bnh nhn cng c nhng bin i c trng( ch bilirubin dng kt hp tan trong nc mi co trong nc
tiu ). Theo c ch bnh sinh vng da c xp vo 3 loi
1.Vng da trc gan (vng da do tan mu)
-Do dung huyt nn tng hy hemoglobin lm tng bilirubin qu nhiu ( st rt, huyt tn tr s sinh, nhim khun , nhim c , truyn nhm nhm mu). Dng
bilirubin t do trong mu tng cao nhung do dng ny khngtan trong nc nn khng c trong nc tieu , do vy nc tiu bt, chc nang gan bnh thng nn kh
nng kt hp cn , do lm tng urobilinogen v stecobilinogen lm phn sm mu
2Vng da do tn thng gan
-Do ri lon cc khu khc nhau ca qu trnh chuyn ha bilirubin
+Ri lon vn chuyn bilirubin t do qua mng tb nhu m gan : lm phn bc mu nhng nc tiu bt
+Ri lon qu trnh chuyn bilirubin t do thnh dng kt hp : vd bnh Crigler Najjara lm bilirubin t do tng cao trong mu (ging trng hp 1) hoc bnh
Dubin Jonhson li lm bilirubin kt hp tng qu cao trong mu lm nc tiu vng
+Do tn thng tb nhu m gan v ri lon tit mt nn trong mu tng c bili t do v kt hp nn nc tiu vng nhng phn bc mu
3.Vng da sau gan(tc mt)
-Lm mt khng xung c rut vo mu gy vng da , phn bc mu nc tiu vng (do bilirubin lien hp trn ngc vo mu )
Cu 56. bnh nhn x gan thy ni bt ln cc du hiu bnh l g, phn tch?
X gan l bnh l ca gan m trong tb gan bnh thng c thay th bng m x. C rt nhiu nguyn nhn dn ti x gan ( siu vi B,C,D; do ru , do chuyn
ha ; bnh ng mt ko di; nghn tm gan ; do min dch , do cc c cht ). Mc d nguyn nhn th c nhiu nhng nhng biu hin li thng ging nhau.

26

 gai on u do kh nng b tr ca gan cn tt nn hu nh c t TC , thng biu hin cc TC ko c hiu : chn n , mt mi , suy nhc ,vng da nh,
nga ,ni mn . Nhng n gd ton pht v giai on cui th c 2 biu hin ni bt l : Suy chc nng tb gan( biu hin r gd ton pht) v HC tng p lc tm
ca( r gd cui) . tin lng v iu tr ngi ta da ch yu vo 2 yu t ny
1.Suy chc nng tb gan
-Biu hin qua ri lon chuyn ha cc cht( glucid, lipid, protid, mui nc ) gy ra mt mi , suy nhc ri lon iu ha ng mu , RL iu ha cholesterol
mu , ph (do ri lon hp thu mui nc, v do gim sx protein dn n gim p lc keo ), chn n ( do gim sx mt ) , gim hp thu cc vitamin (A,D,E,K cc
vitamin tan trong du) nh hng chc nng to mu( thiu mu ), ri loan ng mu ( do gim sx cc yu t ng mu II, VII, I X, X), lm d b bm tm .
-Gim kh nang chng c : gy vng da , nga do ng bilirubin, nhim c ammoniac do khng chuyn c thnh ure c th dn ti ri lon tm thn ,run,
hn m, nhim c cc thuc , gim kh nng phn hy mt s hormone : kch t dc( gy teo tinh hon ) ,kch t v thng thn ( ph , bng ), suy thn km theo(
hi chng gan thn)
2. Tng p lc tm ca
S x ha gan lm thay i cu trc ca xoang mch v tiu thy gan lm lu lng tun hon qua gan b thay i , tr lm p lc mu trong tm ca tng cao gy
ra nhiu biu hin
2.1Tun hon ngoi gan gy ra cc biu hin
- Nn ra mu : do tng p lc vng ni thc qun gia tm vnh v ca h thng tm n ca h thng ch v tm ch trn . khi p lc tng cao gy v vng ni ny
lm bn nn ra mu ti t
- Tr : do tng p lc cua vng ni quanh hu mn
- Tun hon bng h : do tng p lc ca vng ni quanh rn , to nhng vng mch ngon ngho di da bng
Tuy vy tun hon ngoi gan khng c ngha lm thay i s tng cao p lc tm ca m n li chnh l nguyn nhn lm gin mch vng ni gy cc hu qu
trn
2.2.Tch t dch c th : biu hin ch yu TC bng bng, ph chn
Bng bng c hnh thnh do nhiu c ch:
-Tng p lc thy tnh ca h thng tm ca
- Tng tnh thm thnh mch do tnh trng thiu oxy v nhim c mn tnh
-Do gim p lc keo huyt tng ( gim sx protein)
-Do gan khng phn hy c mt s hormone gi mui (aldosterol) v hormone gi nc ( ADH)
C s km theo:
Cu 57. Nhng yu t tham gia c ch hn m gan. Hn m gan cht ch yu do yu t g?
1.hn m gan
Gan l c quan c chc phn rt quan trng ca c th chnh v vy khi gan b tn thng s gy ra nhng ri lon ca ton c th.c bit khi gan bi suy n ko thc
hin c chc nng cu mnh v c th dn ti hn m gan
+hn m gan do suy gan bt u t tnh trng RLTK nh chn tay run ry , phn x tng ,tr nh gim co git v hn m . C ch kh phc tp ch yu do cc
RLCH gy ra :
+ Ni bt hng u l nhim c amoniac m nng trong mu rt cao,NH3 tng t 2 ngun:NH3 ni sinh(do chuyn ha)t qu trinh kh cc acid amin v NH3
ngoi sinh(do vi khn ng rut gy ra). Tuy nhin c nhiu trng hp c RLTK m nng NH 3 trong mu khng tng hoc khng c s song hnh gia hai
yu t trn cho nn NH3 cha hn l nguyn nhn chnh gy hn m gan
+ Cc sn phm c t ng tiu ho trn vo trong khi gan suy mt kh nng gii c , phn ln cc sn phm ny l do qu trnh kh cacboxyl ca cc acid
amin
+ Glucose mu gim do gan suy mt kh nng tng hp Glycogen v iu ho ng mu
+ Ph t chc, c bit l ph no do RLCH nc v in gii
+ Ngoi ra cn cc yu t tng cc cht dn truyn TK gi : Trong hn m gan nhn thy c gim dopamin v noradrenalin trong t chc no v tng cc dn xut
bt thng ca t chc thn kinh . Trong rut ca bnh nhn suy gan thy tch rt nhiu cht dn truyn thn kinh gi l dn xut chuyn ho ca phenylalanin v
tyrosin , bnh thng chng b gan o thi nhng khi gan suy chng vo mu ri tch li t chc thn kinh v b hydroxy ho thay th cho cc cht dn truyn
thn kinh . Cc cht ny nu tch lu t chc no th lm pht sinh hi chng tm thn cn nu tch lu t chc thn kinh ngoi vi th cc cht ny thay th cho
adrrenalin gy gim trng lc mao mch nh, m cc mch tt ngoi vi lm gim lng mu v ni tng to hi chng suy thn bnh nhn suy gan
- Hn m gan l tnh trng cui cng , trong cc c quan u b ri lon nghim trng , ngoi nhng nguyn nhn trn cn c rt nhiu yu t ph khc lm cho
trng thi hn m d pht sinh
-c ch chuyn ha hnh thnh cc chat dn truyn thn kinh gi
Cu 58. Phn tch bnh n x gan: nga, ni mn, bng cng chng, c tun hon bng h, khng s thy gan, protein mu ton phn gim,
albumin gim, ng mu gim, SGOT v SGPT gim?
-nga ni mn :do gan gim kh nng chng c bilirubin t do ko c lin hp ti gan s tch t di da gy da b nga v ni mn -chng bng c hnh thnh
do nhiu c ch:
+Tng p lc thy tnh ca h thng tm ca
+Tng tnh thm thnh mch do tnh trng thiu oxy v nhim c mn tnh
+Do gim p lc keo huyt tng ( gim sx protein)
+Do gan khng phn hy c mt s hormone gi mui (aldosterol) v hormone gi nc ( ADH
+ngoi ra do ri lon tiu ha thiu mt dn n gim co bp v tit dch ca rut gy chng hi,y bng
-chng bng c hnh thnh do nhiu c ch:
+Tng p lc thy tnh ca h thng tm ca
+Tng tnh thm thnh mch do tnh trng thiu oxy v nhim c mn tnh
+Do gim p lc keo huyt tng ( gim sx protein)
+Do gan khng phn hy c mt s hormone gi mui (aldosterol) v hormone gi nc ( ADH
+ngoi ra do ri lon tiu ha thiu mt dn n gim co bp v tit dch ca rut gy chng hi,y bng
-Tun hon bng h do: x gan s gy xung huyt th ng tnh mch ca,t c nhng biu hin xung huyt ca ng tiu ha v tng p lc ca vng ni
quanh rn , to nhng vng mch ngon ngho di da bng rt d v
-khng s thy gan do :a s cc trng hp gan b teo nh,nh hn gan thng do t bo gan b cht dn v teo nh,ng thi b m x co ko,b cht.thng gan
tri b teo nng hn gan phi do nhn mu ca tnh mch mc treo trng di nn km dinh dng hn gan phi
-protein mu ton phn gim v albumin gim do gan l ni tng hp protein quan trng cua c th c bit 95% albumin c gan tng hp.khi gan b x thi kh
nng ny b gim do dn n protein mu v albumin gim
-ng mu gim do gan l ni d tr glycogen quan trng nn gan c vai tr quan trng trong i ha ng mu ca c th khi gan b x kh nng ny ko
cn.c th ko co glycogen chuyn thnh glucose a vo mu dn n ng mu gim
-SGOT,SGPT gim do 2 enzim ny c nhiu t chc nhu m gan c bit l GPT nn khi x gan cc t bo gan b x ha ko cn kh nng a 2 enzim ny vo
mu na nn chng s b gim i
Cu 59. Thay i s lng nc tiu trong cc bnh v thn. Phn tch c ch bnh sinh?
S lng nc tiu 24h ca ngi bnh thng dao ng t 0.5-2L n ph thuc vo rt nhiu yu t,ty s lng nc tiu bi tit trong 24h m ngi ta chia
ra :a niu,thiu niu ,v niu
*a niu :lng nc tiu >2l/24h
-c ch chung gy a niu l do tng p lc lc cu thn hoc do gim kh nng ti hp thu ca ng thn.vd khi ung nhiu,dng thuc li niugm c a niu
do bnh l ca thn v a niu do cc bnh l ngoi thn

27

+a niu do cc bnh l ca thn hay gp trong x thn :do t chc x pht trin xung quanh ng thn lm hp cc mch mu,v th ng thn gim kh nng ti hp
thu.thng gp ngi cao tui,vim thn mn tnh,thn gim kh nng ti hp thu,a niu cng gp giai on u ca vim thn cp do xung huyt cu thn lm
tng p lc lc
+a niu do cc bnh ly ngoi thn :a niu thm thu :p lc thm thu trong lng ng thn tng cao,chng li lc ti hp thu(a niu trong bnh tiu ng,khi
truyn nhiu dung dch manitol,mt s thuc li tiu c tc dng tng p lc thm thu trong ng thn),trong bnh i tho nht th trung tm(tuyn yn gim tit
ADH)
-thiu niu :khi lng nc tiu bi tit di 0,5l/24h.v d khi ung t nc,ra nhiu m hi,v bnh l cng c thiu niu do thn v ngoi thn
+thiu niu do bnh l ti thn :tn thng thc th ti thn lm gim kh nng lc ca cu thn trong khi ng thn vn ti hp thu bnh thng.gp khi vim cu
thn,si thn,vi ha thn,vim ng thn
+thiu niu do bnh l ngoi thn :tt c cc trng hp lm c th mt nc mt mu,lu lng mu gim hoc cung cp ko nc,lu lng mu qua thn gim
khin p lc lc gim u dn n thiu niu
-v niu :khi ko c nc tiu xung bng quang(trong lm sng lng nc tiu <0.3l/24 c coi l v niu)
+c ch gn ging vi thiu niu nhng mc nng hn ngoi ra cn c v niu do phn x :au n qa mc gy co mch vo cu thn ng thi tng tit
ADH v aldosteron gy gim lc cu thn ng thi tng ti hp thu ng thn
+v niu gy nn nhng hu qu rt nghim trng :nh tng nito mu v ri lon cn bng nc in gii,kim toan v vy cn phi cp cu v x l kp thi
Cu 60. Thay i cht lng nc tiu trong cc bnh v thn. Phn tch c ch bnh sinh?
* Nc tiu bnh thng mu vng nht, mi hi khai t trng l 1,018 cha clorua, phosphat, sulfat, ure, acid uric creatinin v 1 s t bo lt ca ng tit niu.
Khi c ri lon tit niu th ko nhng dn n nhng thay i thnh phn v t l m cn xut hin cc cht bt thng nh protein niu,huyt niu,tr niu
-protein niu : ngi bnh thng c khong 50-100mg/24h v c coi gn nh ko c trong nc tiu khi c trn 150mg/24h c coi l c protein niu
+protein niu sinh l :c th gp ngi tr khi ng lu, phu n c thai do gan ln tnh mch thn tri lm cho tun hon ti thn km i. ngi lao ng
nng do co tht mch thn lm cho thn bt cht thiu mu
+protein niu do bnh l ti thn :vim cu thn,hi chng thn h :bnh thng cu thn ch nhng protein phn t lng di 70000 i qua do mng lc cu
thn b tn thng ,cc l lc rng ra lt protein qua,trong a s l albumin,khi tn thng cu thn cng nng th t l globulin cng tng theo
+do ng thn :khi chc nng ti hp thu protein km,lng protein mt theo nc tiu tng ln
+protein niu c th gp trong nhiu bnh l khc :vim ng tit niu di,ri lon tng hp protein :nh xut hin protein bences jones c trng lng phn t
nh nn qua c mng lc cu thn
-hng cu niu :bnh thng hu nh nh ko c hng cu trong nc tiu
+hng cu niu xut hin trong 1 s bnh l ca thn nh :vim cu thn vim ng thn,vim thn k .nephron khi b tn thng c th gy chy mu vo lng ng
thn,trong vim m thn th hng cu niu bao gi cng i km vi bch cu
+cc trng hp tn thng ng tit niu :chn thng lm v cc mch mu ca ng tit niu,vim bng quangnc tiu bnh nhn c nhiu hng
cu,dng nghim php 3 cc c th xc nh c v tr ca xut huyt
-tr niu :c hnh thnh do cht tit,protein,lipid ca ng thn vn li theo khun ca lng ng thn.tr niu xut hin khi nng protein nc tiu
cao,lng nc tiu tng i thp v chy chm trong ng thn,c nhng thay i v l ha nc tiu lm protein d ng vn.
Globulin d b kt ta hn albumin cho nn khi c globulin niu th bao gi cng c tr.cn c vo thnh phn bm trn chia ra :
+tr trong :do protein v lipid to nn gp trong thn nhim m,a u ty xng
+tr ht gp khi vim cu thn
+Tr lin bo :c cc t bo ng thn bm trn tr trong
Cu 61 Phn bit suy thn cp v suy thn mn ?phn tch v nguyn nhn hu qu v cch x tr ?
-Suy thn l hu qu ca nhiu bnh thn khc nhau,trong thn ko thc hin c y chc nng ca n,trc ht l chc nng o thi,biu hin bng s
ng trong c th cc chtcn b v cc cht tha khc,ty theo qu trnh din bin chia lm suy thn cp v suy thn mn.
So snh theo s :t v ra s .
+, c im: Suy thn cp l hi chng suy gim hay mt chc nng nhanh chng ca thn lm ngng hay suy gim nhanh chng mc lc cu thn dn ti thiu
niu hay v niu ure tng trong mu, gy RLCB in gii, RLCB kim toan, khi nguyn nhn gy tn thng b loi tr th chc nng thn hi phc. Suy thn mn
l hu qu cui cng ca cc bnh thn-tit niu mn tnh, lm gim chc nng, gim s lng cc nephron ca ng thn v mt kh nng hi phc.khi triu chng
suy thn biu l trn lm sng v xt nghim th c ti 70% s cu thn b x ha v hon ton ko cn hot ng chc nng.
+, Nguyn nhn: Suy thn cp c cc nguyn nhn sau :
- Nguyn nhn trc thn
+ Gim th tch mu : Mt mu, mt nc nng n, cc c ch b p c huy ng ti a nu vn khng m bo c lu lng mu qua thn s dn n suy
thn cp
+ Gim cung lng tim
+ Do tt HA ko d i: Sock, tru tim mch, co tht t ngt mch thn
+ Do cc bnh h thng : tiu ng, cao huyt p...
- Nguyn nhn ti thn
+ Do mch ln thn : huyt khi /m thn, t/m thn, vim mch thn, x va, hi chng ure cao.
+ Do cu thn : vim cu thn cp do nhim LC v NK lm ri lon vi tun hon ti mch thn v sau l ng thn gy gim GFR
+ Do ng thn : vim ng thn cp do thiu mu ti thn, ho cht, thuc, do tan huyt, dp nt c din rng, c ch ~
+ Do vim thn k cp tnh : Do d ng, thuc,vim thn m v do u di cn ...
- Nguyn nhn sau thn
+ Rt him:gp trong si, u gy chn p ng tit niu gy tc t ngt c 2 bn
Suy thn mn do cc nguyn nhn sau :
- Vim cu thn tin pht
- Vim cu thn th pht
+ Luput ban h thng, vim a c
+ Vim cc mao mch nh : vim mch mu d ng, vim vi mch, u ht, i ng ...
- Bnh k thn
- Bnh mch mu thn
- Bnh thn bm sinh
+,Hu qu: Suy thn cp c cc hu qu:
- T bo tn thng v thoi ho gy hu qu
+ T bo phng to lm cht hp hay tc ng thn dn ti thiu niu hay v niu
+ T bo hoi t, bong ra lm lp ng thn lm nc tiu chy trc tip vo mu em theo cht thi
+ S tr cp din nhiu s/p c : H+, hp cht nit gy hi chng ure huyt cp din
+ Cc cht c hot tnh ca vim c gii phng vo mu
Suy thn mn c cc hu qa:
- Ph ton thn do gi mui v nc
- Nhim acid
- tch ng ngy cng tng cc sn phm chuyn ha cha nito:creatinin,ure
- Tng nng cao cc cht o thi khc nh phenol, sulfat, phosphat, kali... to thnh phc h c t ure-huyt gy ra 1 s triu chng thn kinh:nhc u,bun
nn,run c
-thiu mu,cao huyt p
-thi k cui c nhng biu hin nh suy thn cp:thiu niu v niu,ure mu tng cao
+, Cch s tr: Suy thn cp:

28

-iu tr cho bnh nhn bnh chnh,v cc bin chng nh bi nhim suy tim
-iu chnh th dch
-iu chnh ch dinh dng hn ch ure va creatinin mu
-lc mu nu cn thit
Suy thn mn: -lc mu ngoi thn chu k,ghp thn.
Cu 62: Cc nguyn nhn gy ri lon bi tit nc tiu ti thn
1. Vim ng thn cp

Cc nguyn nhn nhim c:

+ Ho hc v thuc: thu ngn, ch, asen, bismuth, sulfamid, cyanua, tetrachloruacacbon ...
+ Cc cht hu hoi m do phu thut, chn thng, bng, truyn mu khc loi...
+ Cc cht t vi khun nh Bacillus perfringens.
+ Mt ng vt nh mt c trm, nm c...

Cc NN gy thiu oxy t bo ng thn nh thiu mu do: mt nc nng, suy tim, suy h hp, tc mch, tan mu
2. Vim cu thn cp
Do cc phn ng min dch lin quan n nhim trng.
Bnh thng l th pht sau cc trng hp vim nhim ko di hng, da, phi.(vim hng,vim hnh nhn 54%, vim da v cc b phn khc sau
nhim khun huyt 25%..) tr em , VCTC thng xy ra sau 15-25 ngy vim hng do lien cu khun tan mu nhm A vi bnh cnh lm sng l: ph tiu tin
t
3. Vim cu thn mn
Nguyn nhn gy VCTM rt phc tp, c 1 s TH do vim cu thn cp chuyn thnh, cn a s TH l vim cu thn mn ngay t u v dn n suy thn. Nguyn
nhn cn cha r nhng c th do Va c vai tr ca phn ng MD KN+KT Va c vim
4. Vim thn k(Vim thn ngc dng, vim b thn - thn)
-Nguyn nhn: vim m t ng tit niu ngoi vo b thn v k thn, sau vim m l t chc x pht trin gy teo thn.
-Gp 80% n.
5. Hi chng thn h
Nguyn nhn:a dng.
Nguyn pht: nguyn nhn thng khng xc nh.
Th pht: sau nghn tnh mch thn, nhim c ton thn, VCT, bnh huyt thanh.
6. X cng mch thn
Nguyn nhn RL chuyn ho, v x ng mch
-Th lnh tnh: ngi gi c v x chung
-Th c tnh: ngi tr v x ch yu mch thn.
Theo Clearance: Chc nng ng thn b gim nhiu hn cu thn.
Cu 63: Bnh vim cu thn cp : nguyn nhn, c ch bnh sinh, triu chng lm sng v nguyn tc iu tr
Nguyn nhn Do cc phn ng min dch lin quan n nhim trng.
Bnh thng l th pht sau cc trng hp vim nhim ko di hng, da, phi.(vim hng,vim hnh nhn 54%, vim da v cc b phn khc sau
nhim khun huyt 25%..). tr em , VCTC thng xy ra sau 15-25 ngy vim hng do lien cu khun tan mu nhm A vi bnh cnh lm sng l: ph tiu tin
t
C ch bnh sinh:
+ (GI) Phc hp khng nguyn - khng th lng ng cu thn => hot ho b th, thm nhim bch cu - gy phn ng tiu, vim, hot ho h ng mu,
kinin, protease, hydrolase ... => tn thng cu thn
+ (GII) phc hp KN-KT v khng nguyn (VK) lin kt vi mng nn cu thn = phc hp KN mi

c th to khng th khng li KN mi (cha mng nn cu thn).

Kt qu to ra qu trnh t min dch i vi cu thn

Phc hp KN-KT lng ng trn ni mc cu thn c tc dng gy ra thm nhim cc bch cu, t chc lin kt => tn thng tng sinh ni mc cu thn
Triu chng lm sng v hu qu
+ Gy gim kh nng lc ca cu thn, Natri

thay i chc nng ng thn => thiu niu, v niu, Na+ => gi nc gy ph. Nc tiu mu , c, t trng cao, c protein, HC, BC, tr htMu
:toan mu, nhiu sn phm CH a n h/c tng ure huyttng p lc thm thu gy ph , suy thn , hn m thn
+ Mao mch tn thng -> tng tnh thm thnh mch => lt protein (albumin) v t bo ra nc tiu
- Tng huyt p : do hot ho h thng RAA
- Suy tim, kh th, th nhanh v nng nhp tim nhanh, huyt p gim
- St nh, c th c cn au qun thn, bun nn , i lng
- Protein niu , hng cu niu
4. Nguyn tc iu tr
- Ngh ngi, khng lm vic nng, trnh nhim lnh, nhim khun
- Khng sinh : Penicillin, Rovamycin hoc Erthromycin
- iu tr ph : dng thuc li tiu
- iu tr tng huyt p : dng thuc h huyt p
- iu tr suy thn cp : truyn dung dch glucose 30%, Nabica 1,25% , tim lasix tnh mch , cn cn bng lng nc vo v ra trnh ng c nc
- iu tr d phng : Chng nhim khun mn tnh hng, nt m ngoi da
Dng khng sinh , khng lao ng qu sc, trnh nhim lnh .
Cu 64. Phn tch bnh n vim cu thn cp: ph ton thn, nc tiu 200ml/24h c mu c, protein niu 6g/l, huyt p tng?
1. ph ton thn l do:
S xung t KN-KT tc ng nn ton b h thng mch mu ngoi vi v mao mch cu thn gy vim cu thn t dn n:
-Tng tnh thm mao mch gy dch khong gian bo
-Mc lc cu thn gim gy mui v nc, mt khc mui v nc cn do tc dng ca s tng tit Aldosteron v ADH. Hu qu ca mui v nc l ph
2.nc tiu 200ml/24h c mu c: (bt dung lng nt trong 24h l 1,5l.Khi nt t 300- 700ml/24hthiu niu ,v niu khi nt 24h< 300ml)
S xung t KN-KT tc ng ln mao mch cu thn Vim mao mch cu thn Tng sinh, ph n lm gim dng mu n thn Mc lc cu thn gim gy
thiu niu hay v niu, tng ur mu, tng creatinin km theo ri lon nc in gii v cn bng acid baz
3.protein niu 6g/l: (bt nc tiu ko c or c rt t protein) v niu khi VCTC nng
S xung t KN-KT tc ng ln mao mch cu thn Vim mao mch cu thn Tng tnh thm mao mch cu thn. Protein vt qua mng nn vo khoang
Bowman lm xut hin protein niu .
4.Huyt p tng
S xung t KN-KT tc ng ln mao mch cu thn Co mch mu v tng sc cn ngoi vitng HA
Mt khc S xung t KN-KT tc ng ln mao mch cu thn Vim mao mch cu thn Tng sinh, ph n lm gim dng mu n thn S xung t KNKT tc ng ln mao mch cu thn Vim mao mch cu thn Tng sinh, ph n lm gim dng mu n thn dn n tng tit renin hot ho h RAA gy
tng huyt p. C th gy tng huyt p kch pht gy co git, hn m v suy tim cp tnh, hen tim v ph phi cp
Cu 65: Nguyn tc cc th nghim chn on u nng tuyn ni tit ?

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- chn on u nng tuyn ngoi cc triu chng lm sng cn c th s dng cc nghim php thm d chc nng hot ng ca tuyn, thng hay s dng l
nhng th nghim tnh v ng
a) Th nghim tnh
- Th nghim tnh nh gi trc tip hay gin tip lng hormon, nhng cht chuyn ho ca chng trong mu hay trong nc tiu
V d: u nng thng thn th t chc thng thn sn xut rt nhiu corticoid c th nh lng c trong huyt tng hay qua nh lng cc sn phm
chuyn ho ca chng trong nc tiu (17-CS). Trong u nng cn gip, Ca mu tng , phosphat mu gim, Ca niu gim, phosphat niu tng. u nng tu th
glucose mu tng
b) Th nghim ng
- Nhng th nghim tnh khng cho bit c ngun gc ca u nng do ta phi s dng thm th nghim ng chn on nguyn nhn xy ra ti tuyn hay
ngoi tuyn
- Nguyn l chung ca th nghim l km hm tuyn nh thm d bng cch gim kch t ca tuyn v quan st hot ng ca n
+ Nu l u nng ti tuyn thy hormon vn duy tr mc cao (-), chng t hot ng ca tuyn khng cn chu s iu ho bnh thng
+ Nu tuyn tng cng hot ng do kch thch t bn ngoi, dng th nghim km hm thy lng hormon gim (+) chng t u nng ngoi tuyn
- Trng hp cc tuyn ph thuc tuyn yn th khi cho vo trong c th mt lng ln hormon th theo c ch tc dng c ch ngc th hormon s c ch
tuyn yn gim tit kch t v tuyn trc thuc s khng b kch thch t trn xung s gim tit hormon, l nguyn nhn ngoi tuyn
V d : Bnh thng khi tim vo trong c th cht triiodthronin ( hormon tuyn gip ) th thy hormon trong mu gim t nht 25% sau 24h, nu u nng ti tuyn
th m hormon trong mu khng gim m vn cao, hoc khi a vo trong c th mt corticoid tng hp thy trong nc tiu gim cht 17-OCS l mt sn
phm chuyn ho ca cortison nu u nng ti tuyn thng thn th cht vn cao
- Trng hp cc tuyn khng ph thuc tuyn yn (tu , cn gip ...), th ch cn lm thay i tng i tnh cht l ho ca ni mi l c th nh gi c hot
ng ca tuyn yn
V d : Bnh thng nu gy tng Ca mu bng cch tim vo trong c th mt lng ln Ca th ngay lp tc tuyn cn gip s gim tit v biu hin l Ca mu
gim v phosphat mu tng ng thi Ca niu tng v phosphat niu gim, song nu c u nng ti tuyn th nghim km hm ny (-) tc l hormon cn gip trong
mu vn cao, hay bnh thng khi n mn, tim huyt thanh mn u trng, tim DOCA hoc tng th tch mu thy v thng thn gim tit Aldosteron song nu
c u nng ti tuyn Aldosteron trong mu vn cao
- Tm lai: Nu tuyn tng hot ng do b kch thch thfi th nghim km hm s lm cho tuyn tr li hot ng bnh thng, cn nu nh u nng do tuyn th th
nghim m tnh hay khng r rt
Cu 66: Nguyn tc cc th nghim chn on nhc nng tuyn ni tit ?
- chn on phn bit gia thiu nng ti tuyn hay ngoi tuyn ngi ta dng th nghim ng ch, yu l th nghim kch thch m nguyn l l dng nhng
kch thch bnh thng vi tuyn v quan st thay i ca tuyn
- Nu l nguyn nhn ti tuyn : Ngha l nhu m tuyn c vn , th th nghim kch thch (-) tc l nng hormon vn thp nh c, tri li khi tuyn ch b c
ch do mt nguyn nhn bn ngoi th khi b kch thch tuyn s tng cng hot ng ( th nghim kch thch + )
- Trong thiu nng tuyn ni chung th th nghim tnh cho nhng kt qu hot ng ca tuyn thp hn bnh thng
+ Thiu nng tu th glucose mu tng
+ Thiu nng thng thn Lng corticoid trong mu v sn phm chuyn ho ca chng trong nc tiu gim
- i vi cc tuyn trc thuc tuyn yn th thng dng hormon tuyn yn tng ng
V d : thiu nng tuyn gip th khi kch thch trc tip tuyn gip bng hormon tuyn gip, nu hormon tuyn gip vn thp (-) th nguyn nhn l ngay tuyn
gip v ngc li nu hormon tuyn gip tng (+) th nguyn nhn l ngoi tuyn, c hai trng hp c th xy ra hoc l tn thng tuyn yn hoc l tn
thng vng di th
+ Kch thch trc tip tuyn yn bng TRF ( yu t kch thch gii phng hormon tuyn gip ) nu hormon tuyn gip khng tng th nguyn nhn vng di th
hay kch thch gin tip vng di th bng cch gim tit hormon tuyn gip, nu hormon tuyn gip khng tng th nguyn nhn vng di th
- Nu l mt tuyn khng trc thuc tuyn yn ( tuyn tu , cn gip...) th s kch thch bng cch thay i tnh cht ca ni mi.
+ Bnh thng khi tng p lc thm thu huyt tng ( hn ch nc hay tim huyt thanh mn u trng ) thy ADH tng tit gy thiu niu.
+ Nu lng nc tiu khng gim ( th nghim - ) c 2 trng hp c th xy ra l gim tit ADH hoc do ng thn gim THT, tri li nu lng nc tiu gim
l do gim tit ADH nguyn nhn c th l do tn thng vng di th ( nhn trn th v cnh tht tit ADH ) hoc l do tn thng ng vn chuyn ADH
hoc tn thng thu sau tuyn yn
V d : Trong thiu nng tuyn cn gip nu gy gim oxy mu ( bng EDTA, estradiol benzoat ) thy Ca mu gim r rt v sau khng tr li bnh thng v
tuyn gip khng cn kh nng tit hormon tng chuyn ho Ca

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