Benh Hoc Noi Khoa Tap 2

TRNG I HC Y KHOA THI NGUYN B MN NI

BNH HC NI KHOATP 2

NH XUT BN Y HC H NI - 2006

CH BIN:BS. CKII. Doanh Thim Thun THAM GIA BIN SON: 1. BS. CKII. Doanh Thim Thun 2. BS. CKI. Bi Duy Qu 3. BS. CKI. Nng Minh Chc 4. BS. CKII. Nng Th Minh Tm 5. ThS. Nguyn ng Hng 6. TS. Dng Hng Thi 7. TS. Trnh Xun Trng 8. ThS. Nguyn Vn Tha 9. ThS. Nguyn Trng Hiu 10 ThS. V Th Hi Yn 11. ThS. Nguyn Tin Dng 12. ThS. L Th Thu Hin 13. ThS. Phm Kim Lin

2

LI NI U nng cao cht lng o to sinh vin Y khoa, to iu kin cho sinh vin ang hc trong trng c ti liu hc tp v sau khi ra trng c th c li, tham kho khi cn thit. Tp th ging vin B mn Ni Trng i hc Y khoa Thi Nguyn bin son tp Bnh hc ni khoa. Ti liu ny l nhng vn c bn v ni khoa, c chia lm 2 tp. Bao gm 54 bnh ni khoa v hi sc cp cu. y l nhng bi ging v cc bnh l thng gp ti bnh vin tuyn c s v tuyn tnh. Hai tp bnh hc ni khoa ny c bin son da vo cc ti liu theo quy nh ca V Khoa hc v o to, B Y t, da trn nhng mc tiu v ni dung trong khung chng trnh c thng nht, c cp nht nhng thng tin kin thc mi, gip cho sinh vin nng cao kin thc cng nh thc hnh v t nh gi. Tuy nhin, trong qu trnh bin son, khng th trnh khi nhng thiu st. Chng ti rt mong c cc bn ng nghip v cc c gi ng gp kin ln ti bn sau ni dung cun Bnh hc ni khoa s hon chnh hn. Xin trn trng cm n! T/M BAN BIN SON TRNG B MN NI

BS. CKII. Doanh Thim Thun

3

MC LCTP 2

VIM GAN MN...............................................................................5 AN TON TRUYN MU..............................................................11 CHN ON V X TR AU NGC........................................15 CHN ON V X TR AU LNG........................................21 NHC U.......................................................................................28 SUY THN CP...............................................................................35 VIM CU THN MN.................................................................43 SUY THN MN..............................................................................47 VIM I B THN CP, MN..................................................53 VIM BNG QUANG, NIU O................................................58 SC.....................................................................................................60 CHN ON V X TR HN M.............................................66 CP CU HO RA MU..................................................................69 CHN ON V X TR TRN KH MNG PHI................75 CN AU THT NGC.................................................................82 NHI MU C TIM........................................................................87 TAI BIN MCH MU NO.........................................................93 TO BN........................................................................................104 HI CHNG RUT KCH THCH............................................107 CHN ON V IU TR THIU MU................................109 UNG TH PHI.............................................................................117 LEUCMIE CP............................................................................121 LEUCMIE KINH DNG HT...................................................125

4

VIM GAN MNM U Vim gan mn tnh (VGM) l nhng bnh gan c nhiu nguyn nhn khc nhau m trong hin tng vim v hoi t tip din t nht trong 6 thng. Trong cng ng t l vim gan mn do virus B chim mt t l kh cao trong nhng ngi mang virus, theo ti liu ca hi gan mt Vit Nam 2001 t l nay chim 7-10%. Nhng nm gn y s pht trin ca khoa hc min dch, ha t bo v cc xt nghim huyt thanh, sinh hc phn t gp phn quan trng trong chn on v tin lng bnh. 1. NH NGHA V PHN LOI VIM GAN MN nh ngha: vim gan mn tnh l bnh gan c tn thng hoi t t bo v vim c hoc khng c km theo x ha din ra trn 6 thng. V mt m bnh hc c ba tn thng ni bt - Hoi t gm nhm v hoi t bc cu khong ca - Thoi ha trong tiu thu v hoi t - Thm nhp t bo vim khong ca ch yu l cc t bo mt nhn v x ha khong ca Phn loi: c nhiu cch phn loi, trc y thng phn loi theo hnh nh gii phu bnh v c th chia vim gan mn tn ti v vim gan mn tn cng. Ngy nay a s tc gi mun phn loi theo nguyn nhn.. C th chia 4 loi nh sau: - Vim gan mn do virus - Vim gan mn do t min - Vim gan mn do thuc - Vim gan mn tim tng M bnh hc gip cho chn on, phn loi, nh gi mc hot ng vim cng nh tin lng bnh 2. CHN ON 2.1. Triu chng lm sng: thng lun khng c hiu - Ri lon tiu ha: y bng chn n, chm tiu chng hn - St nh 37- 380C - C th c gan to mt nhn, mt chc, c khi khng s thy gan, vng da v5

nim mc trong t tin trin bnh. - C th xut hin mt s triu chng ngoi gan: + au khp xng nhng khng sng v hay ti li nhiu ln nhng khng li di chng v khng bin dng khp + Da sm kh, gin mch, gin mao mch hnh sao, lng bn tay son... Ch khai thc triu chng ca mt s bnh t min khc nh vim tuyn gip, vim lot i trc trng chy mu, vim khp dng thp... Ngoi ra cn tm hiu mt s yu t nguy c gy bnh vim gan mn: tin s vim gan virus, s dng thuc chng lao, thuc h p, thuc iu tr bnh tm thn, tin s nghin ru, tip xc mt s cht c 2.2. Triu chng cn lm sng - Thm d chc nng gan + Chc nng to v d tr ng: nghim php Galactoze (+) + Chc nng chuyn ha m: nh lng albumin huyt thanh gim (bnh thng 56g 7g/l), globulin tng, nht l gam ma globulin in di min dch: c s thay i thnh phn ca IgA, IgG, IgM, IgE theo tng giai on ca bnh + Chc nng chuyn ha lipid: gim lng cholesterol este ha lm cho t l cholesterol este ha/ cholesterol ton phn gim di 50%. + Chc nng to cc yu t ng mu: t l prothrombin gim di 80%. + Chc nng chuyn ha mt: bilirubin mu tng (BT 19 mol/l) Trong t tin trin ca vim gan mn chc nng gan thng b ri lon mt vi hoc nhiu chc nng - Thm d s hu hoi t bo gan: + Men OCT (Ocnithin Cacbamyl Transferase) bnh thng 168 g/100ml + Men AST tng (Aspartate amino Transferase BT < 37U/1) + Men ALT tng (Alanine amino Transferase BT < 40U/1) - Soi bng: mt gan mt tnh cht nhn bng, nhn nheo, ln gn, c nhiu fibrin trng, co so lm. Mt gan nht mu hoc ti. B gan sc mt tng. Qua soi bng c th sinh thit gan lm xt nghim m bnh hc, qua c th chn on chnh xc vim gan mn, chn on giai on cng nh tin trin ca bnh. - Siu m gan: l hnh nh khng c hiu thng thy nhu m gan khng u. 3. CHN ON 3.1. Chn on xc nh6

Da vo triu chng lm sng. Quan trng hn l chn on nguyn nhn t mi a ra phng n iu tr thch hp. Ti cc c s vic chn on vim gan mn thng khng c iu kin lm cc xt nghim thm d phc tp nht l khng th p dng cc chn on huyt thanh hc vi cc marker min dch hin i. Vic chn on ch yu da vo triu chng lm sng v tin s mc bnh, s dng cc cht, thuc, ru c c vi gan. Cn quan nim rng cc chn on ca c s c gi tr chm sc sc khe ban u v lm cng tc sng lc trong chn on chnh xc sau ny. 3.2. Chn on nguyn nhn 3.2.1. Vim gan do virus Vim gan B: Khong 10-17% bnh nhn mang virus B chuyn thnh vim gan mn tnh. chn on xc nh vim gan B cn da vo mt s xt nghim huyt thanh hc Khng nguyn khng theo ngi vim gan BKhng nguyn HBsAg HBeAg HBcAg HBV- DNA DNA polymerase Khng th Anti HBs Anti HBe Anti HBC Huyt thanh (+) (+) (+) (+) (-) (+) (+) (+) Gan (+) (-) (+) (-) (+) (-) (+) (+)

Du n virus vim gan B giai on cp v mnDu n HBsAg AntiHBs HbeAg Anti HBe Anhti HBclgM Anti HBclgG HBV - DNA Vim gan cp (+) (-) (+) ---- (-) (-) ---- (+) (+) ---- (+) (+) ---- (+) (+) Vim gan mn (+) (-) (+) ---- (-) (+) (+) --- (-) (+) (+) ------ (-) Khi (-) (+) (-) (+) --- (-) (+) --- (-) (+) (-)

Trong vim gan virus B cp c cc biu hin nh mt mi, au m h sn phi, ri lon tiu ha cng vi men Transaninase tng ko di trn 6 thng m c7

HBsAg (+) thng chuyn sang vim gan mn tnh. Khi vim gan B mn tnh c th chia 3 giai on: GI: virus vim gan B tng ln rt nhanh, xt nghim thy HBsAg (+), HBeAg (+), HBV-DNA (+). Giai on ny gi l giai on dung np virus. G2: giai on khng c min dch, s sao chp ca virus rt thp, virus trong mu dao ng. Transaminase trong mu lun cao. Nu sinh thit gan lm xt nghim m bnh hc trong giai on ny c th chn on c vim gan mn tnh G3: Giai on nhim virus tim tng, khng c hin tng sao chp virus. HBeAg (-), Anti HBe (+), transaminase bnh thng. Sinh thit gan khng c hin tng vim gan nhng c th c x gan. Trong mt s trng hp ngi mang virus vim gan B c th c mt hoc nhiu t bin vng pres- C ca gen v vy khng c kh nng tng hp HBeAg cho s phin m ca tin cht. HBeAg b phong b nhng phin m ca HBeAg khng b thay i, v vy vn cn lm thm xt nghim HBV- DNA nh gi s nhn ln ca virus trong trng hp virus c t bin. Ngi vim gan mn do virus B cn thit c theo di cc c s y t, t 3-6 thng c kim tra 1 ln: Transaminase, HBsAg HBeAg hoc HBV- ADN, a FP v siu m gan mt theo di din bin ca bnh. Vim gan virus C L loi virus ARN c Houghton phn lp ln u tin nm 1989. Virus C thng xut hin sau truyn mu. Vim gan virus C thng khng c triu chng lm sng ch khong 20% c vng da. Hin nay ngi ta xc nh c 12 loi gen khc nhau ca virus C, kh nng gy bnh v p ng min dch ca cc genotype khc nhau. Trong giai on cp chn on da vo s pht hin ca ARN ca virus trong huyt thanh bng phng php PCR (polymerase chain reaction) ARN xut hin trong 1-2 tun u sau ly nhim. 80-90% virus C chuyn thnh mn tnh, trong khi nng khng th anh HCV vn cn rt cao trong nhiu nm. V vy tm thy khng th HCV khng cho php nh gi giai on ca bnh. Hin nay cha c k thut huyt thanh min dch cho php xc nh s hin din ca virus C trong mu. pht hin virus C ch yu vn da vo s c mt ca anh HCV v loi tr cc virus khc. Sinh thit gan thy tn thng ging hnh nh vim gan B. Vim gan virus D L loi virus RNA khng hon chnh, c pht hin nm 1976 ch c th nhn ln khi c mt virus B. V vy virus D l ng nhim hoc bi nhim. Nu ng nhim th 90% c th khi cn nu bi nhim th d chuyn sang mn tnh. Virus D ly theo ng mu. Chn on da vo s pht hin khng nguyn delta v khng th khng delta (Anti HDV).8

Khi virus D di dng bi nhim ngi nhim HBV mn tnh 80% s chuyn sang vim gan mn tnh vi s tn ti HDV trong gan lm tn thng gan nng hn, do d dn n x gan Ngoi ra cn c cc virus vim gan E ly theo ng tiu ha v virus vim gan G ly theo ng mu. S hiu bit v cc virus ny cha nhiu. 3.2.2. Vim gan t min Vim gan t min l tnh trng mt hoc gim kh nng thch ng min dch ca gan vi chnh nhng tn thng ca gan. Khng tm thy trong huyt thanh ca ngi bnh c du hiu no ca virus, nhng li thy cc yu t gi ln bnh t min. Trong huyt thanh ngi bnh thy cc t khng th nh khng th khng c trn, khng th khng DNA, khng th gama globulin, cc typ HLA tng rt cao. Nguyn nhn v c ch cha c r nhng hay gp n v iu tr bng cc thuc gim min dch c hiu qu. 3.2.3. Vim gan mn do thuc Thc cht y l mt vim gan do nhim c mn tnh ko di. Ngi bnh c tin s dng cc thuc hoc tip xc vi c cht c th gy vim gan mn. Tu theo p ng ca tng ngi, vim gan mn xut hin sm hoc mun sau khi dng thuc, c s tham gia ca c ch min dch, c th xut hin t khng th. Khi ngng thuc c th lm cho vim gan mn khi hn hoc gim nh. Mt s thuc c th gy vim gan: cc thuc chng lao, cc thuc khng gip trng, methyldopa, sulfolanid... 3. 2. 4. Vim gan tim tng T l vim gan tim tng t 10- 25% trong cc loi vim gan du hiu chnh l s thm nhim cc t bo lympho hoc tng bo, s thm nhim ny ch khong ca ch khng lan ti cc tiu thu. Cn nguyn cha bit r, pht hin nh xt nghim m bnh hc. 4. IU TR V D PHNG 4.1. iu tr * n ung, ngh ngi: khng ung ru, bia. n nhiu protid, ng v vitamin, cc thc n d tiu, hn ch m nu c vng da. Ngh ngi tuyt i trong t tin trin * Ch thuc: tu theo nguyn nhn m c thuc ph hp - iu tr vim gan virus B mn tnh: Thuc c ch s pht trin ca virus. iu tr trong giai on th hin HBsAg (+), HBeAg (+) hoc HBV-DNA (+); men transaminase tng gp 2 ln tr s bnh thng + Interferon- thuc c tc dng c ch s pht trin ca virus khng cho virus xm nhp vo cc t bo, c tc dng iu ho min dch, tng sn xut9

khng th. Liu: 3-6 triu UI/ngy hoc 5-10 triu UI/ tun, chia 3 ln, dng lin tc trong 6 thng. C khong 40 % BN p ng thuc lm mt virus, transaminase tr li bnh thng, m bnh hc c ci thin r. Ch theo di bch cu, tiu cu, transaminase... c th c mt s tc dng ph nh st gi hi chng cm... + Lamivudin: (3-thiacytidin; 3-CT) l thuc iu tr HIV nay c s dng iu tr vim gan B mn tnh. Lamivudin c ch enzym sao chp ngc ca virus. Ung vi liu 100mg/ ngy trong 12 thng lin tc c tc dng a transamiase tr v bnh thng. ADN ca virus tr nn m tnh. Hiu qu t c khong 30 - 40% cc trng hp. Ngoi ra cn mt s thuc khc cng c dng iu tr vim gan mn do virus B nh: Famcyclovir, adeflovir dipivocit, ribarvin, interleukin 2, interleukin 1, Tymosin a. Cy Ch rng ca (Phylantus Amarus, H dip chu) cng c nghin cu v thy c tc dng khng virus. Cy Ng v t (Fructus schisandrea) c tc dng lm h nhanh men transaminase BN vim gan virus, ci thin tnh trng hoi t gan. - iu tr vim gan C Gn ging vi vim gan B nhng thi gian ko di n 18 thng. Ch khi phi hp interferon vi ribarivin cn theo di tc dng ph lm tan huyt. - iu tr vim gan t min Dng thuc gim min dch iu tr tn cng lm lui bnh sau duy tr cng c kt qu iu tr prednisolon 50mg /ngy n thun hoc phi hp vi Azathioprin 50 100mg/ ngy sau gim liu v duy tr. Tuy nhin d ti pht sau iu tr 3 - 4 nm. - Cc thuc iu tr h tr t bo gan 4.2. D phng Khng c d phng chung cho tt c cc loi vim gan mn m tu tng nguyn nhn c d phng ring. i vi vim gan mn do virus B cch tt nht l gy min dch ch ng bng vacxin vim gan B. Tim cho i tng cha nhim, tt nht l tim cho tr s sinh v 99% nhim lc s sinh. i vi vim gan do thuc nn trnh cc thuc c nguy c, theo di thng xuyn chc nng gan nu bt buc iu tr. Dng thuc khi c du hiu suy gan. D phng bin chng nng ca vim gan mn nh x gan, ung th gan... cng c t ra song hin nay cha c bin php g ng k ngoi iu tr bo tn v chng hu hoi t bo gan.

10

AN TON TRUYN MU1. I CNG Mu l sinh phm v cng qu gi trong iu tr bnh m cho n nay vn cha c mt vt phm no c th thay th c. Theo c tnh ca Vin huyt hc truyn mu, nc ta (nm 2001), vi dn s 76 triu ngi mi nm c tnh cn khong 1 triu lt mu, 5000 lt huyt tng. Mu chim 1/13 n 1/15 trng lng ca c th, mu rt cn cho c th v mang nhng cht nui dng cc t bo v chuyn nhng cht thi n cc b phn bi tit. Mu cn cn thit duy tr huyt p v chuyn ch cc cht. Mi thnh phn cu to ca mu c chc nng ring. - Hng cu chuyn ch oxy. - Bch cu gi vai tr bo v. - Tiu cu lm nhim v cm mu. - Cc cht protein trong huyt tng duy tr p lc thm thu gip cho vic trao i trong cc m. - Cht globulin bo v min dch. - Cc yu t ng mu trong huyt tng. Mt ngi mt 250ml mu, hemoglobin trn 35% khng nht thit phi truyn mu v c th c kh nng t hi phc d dng (c th truyn huyt thanh thay th). Truyn mu l lm cho ngi bnh c nguy c ly vim gan virus, thm ch nhim HIV nu cng tc sng lc ngi cho mu khng m bo theo quy nh. 2. CC THNH PHN CA MU LU TR Mu lu tr l mu ly xong lu tr vo t lnh dng dn. Mu ti l mu ly xong truyn ngay. Mu ton phn: Mt chai mu bnh thng khi lu tr trong t lnh phi t 3 lp. - Lp trn: l huyt tng mu vng chanh, trong sut, khng c hin tng tan mu v ng si huyt hay ln bng. - Lp gia: l lp bch cu, tiu cu rt mng, trng lp lnh, khng c cc ng v m m. - Phn di: mu thm ng nht, l lp hng cu. Khi hng cu: Khi hng cu ly t mu c chng ng ti hoc lu tr, phi iu ch theo iu kin m bo k thut quy nh. Phn khi hng cu khi ln truyn phi pha long bng dung dch NaCL 0, 9% hoc dung dch bo qun hng cu. Huyt tng giu tiu cu:11

Tiu cu ly ca mt ngi hoc tiu cu ca nhiu ngi cho cng nhm, ty t mu ti, sau khi ly xong l phi dng ngay, khng qu 2 gi. Khi tiu cu. Huyt tng ti ng lnh. Sau khi ly ra dng phi vo bnh cch thu 370c Cho tan ng v dng trong 2 gi. 3. QUY TC V CH NH TRUYN MU 3.1. Quy tc C in: truyn mu sao cho hng cu ngi cho khng b ngng kt bi huyt tng ngi nhn: S truyn mu c in: Tuy nhin, khng c truyn 1 ln qu 1 n v mu v khng c truyn 2 ln vi khong cch qu gn. Hin nay:

m bo an ton tuyt i cho ngi c nhn mu, hin nay quy nh: - Ch c php truyn mu cng nhm, hoc truyn mu t thn. - Tuyt i khng c truyn mu khc nhm d trong bt c hon cnh no. 3.2. Ch nh truyn mu Cp cu: ch nh truyn mu cp cu trong sc mt mu, sc chn thng: - Trong ngoi khoa: + Xut huyt tiu ha nng, v tnh mch thc qun, trong chn thng v gan, lch, thn. + Trong v sau khi m bi ph lng mu mt. - Trong sn khoa: t cung sau , rau tin o trung tm, v t cung, cha ngoi d con v, chy mu nng do tai bin sn khoa. Truyn mu ngoi cp cu: - Truyn mu trc m. - Cc thiu mu mn tnh: ch gii hn nhng bnh nhn thiu mu nng m nguyn nhn khng th iu tr c. + Trong thc hnh vn li, hi ca truyn mu cn c cn nhc nht l12

nhng trng hp suy tim, tan huyt cp, vim thn, cc trng thi sc khng c gim khi lng mu, nhng trng hp c truyn mu nhiu ln hoc c nhng phn ng tng t. 4. CC QUY NH TRONG TRUYN MU 4.1. i vi khoa huyt hc - Nhn giy xin lnh mu ca khoa lm sng v ng mu ca bnh nhn ( ghi r tn, tui, khoa, phng, s ging). - Xc nh li nhm mu h ABO bng 2 phng php (huyt thanh mu v hng cu mu). - Chn mu ngi cho ph hp. - Th phn ng cho. - Kim tra cht lng chai mu ngi cho. - Ghi tn, tui bnh nhn c truyn vo nhn chai mu. - Khi c bo c tai bin truyn mu, khoa huyt hc phi phi hp vi lm sng x tr tai bin theo quy nh. 4.2. i vi khoa lm sng - Khi truyn mu, bc s l ngi chu trch nhim chnh. - Bc s ch nh r rng trong bnh n v loi mu, s lng, tc truyn, ghi phiu lnh mu. - Y t bnh phng ly mu bnh nhn gi n phng tr mu. - Chun b cc phng tin truyn mu v phng tin cp cu tai bin. - Dn bnh nhn nhn n trc v sau truyn 2h, i ngoi, i tiu trc khi truyn. - Kim tra li mch, nhit , huyt p trc khi truyn. - Kim tra chai mu, phiu th mu, nhm mu: trong bnh n, chai mu, phiu th phn ng cho. - Mu lnh v khoa phi truyn ngay. - Lm phn ng tin cy trc khi truyn. - Lm phn ng sinh vt (Ochlecker): t lm. Cho truyn 10 - 15 ml vi tc XXX git/pht sau ngng li kim tra li mch, nhit , huyt p, sc mt bnh nhn v cc phn ng khc. Nu c s thay i phi ngng truyn tm nguyn nhn. - iu chnh tc truyn theo ng y lnh. - Ghi nhn xt vo phiu truyn mu ca bnh nhn v vo bnh n. - Theo di tip bnh nhn sau truyn mu phng tai bin mun. - Gi li dy, chai mu (cn 5ml). Nu sau 2h khng thy c tai bin g mi b.13

5. CHN NGI CHO MU, TIU CHUN V QUN L NGI CHO MU 5.1. Tiu chun chn ngi cho mu Vic chn ngi cho mu t tiu chun kh phc tp. - Khe mnh, c th pht trin tt. - Tui: - Cn nng: Nam t 18 - 55 tui N t 18 - 50 tui Nam 46 kg N 42kg - S lng ly mu mi ln khng qu 1 n v mu (250ml), mun cho li phi sau 3 thng. - Phi c khm lm sng, khng c mc 1 trong 24 bnh theo quy nh ca T chc Y t Th gii v phi c lm cc xt nghim theo quy nh. 5.2. Qun l ngi cho mu - Trnh tnh trng mt ngi cho mu nhiu ni, th ngn hng mu (hoc phng truyn mu) m nhn qun l h s ngi cho mu. 6. NHNG TAI BIN THNG GP KHI TRUYN MU 6.1. Tai bin tc th - Tai bin do tan mu: do khng ph hp nhm mu ABO. - St: c th do bnh nhn c truyn mu nhiu ln dn ti phn ng nhm mu ph, phn ng vi nhm bch cu ngi cho hoc c cht gy st trong cc phng tin truyn mu. - D ng: c th do mu ngi cho c d nguyn. - Phn ng do chai mu b nhim trng: st, au bng, nn, a chy. 6.2. Tai bin xy ra chm - Tai bin do min dch ng loi (xy ra 4 - 10 ngy sau truyn). - Bnh ly do truyn mu: vim gan virus, st rt, giang mai, HIV. - Xut huyt gim tiu cu sau truyn mu: do khng th khng li tiu cu - Nhim thit huyt t: do truyn mu nhiu ln dn ti tng st. 6.3. Tai bin do k thut truyn mu - Tc truyn qu nhanh: gy ph phi cp. - Vim tc tnh mch. - Do tc hi, do fibrin. 6.4. Cc tai bin khc - Ng c citrat: do truyn mu nhiu. - Ng c kali: do truyn mu tr lu ngy.14

- H thn nhit: mu khng c lm m trc khi truyn. 7. PHNG hn ch cc tai bin do truyn mu v m bo an ton truyn mu: - Phi ch nh truyn mu ng (truyn. mu tng phn). - Chai, dy ly mu, k thut ly mu, truyn mu phi ng quy nh. - Phi xc nh nhm mu ABO bng 2 phng php.- Phi lm phn ng cho, phn ng tin cy trc khi truyn mu.

- Chn ngi cho mu m bo theo ng quy nh. Phi t chc tuyn truyn cho cng ng hiu v li ch v tc hi ca vic truyn mu. Ch trng ti cng tc ng vin, khuyn khch ngi nh bnh nhn cho mu. Cn hng ng v lm tt chng trnh hin mu nhn o c nhng ti mu c cht lng, gp phn cu sng ngi bnh v phng trnh c cc tai bin do truyn mu gy ra.

CHN ON V X TR AU NGC1. I CNG au ngc l mt triu chng thng gp trong lm sng v do rt nhiu nguyn nhn. au ngc nhiu khi e da n tnh mng ngi bnh. Do vy ng trc mt bnh nhn au ngc cn hi k v triu chng c nng, khm k v thc th hng ti chn on v tin hnh cp cu ban u, c bit l cc nguyn nhn gy au ngc nguy him. 2. MT S NGUYN NHN GY AU NGC THNG GP 2.1. au ngc do tim mch - Cn au tht ngc - Nhi mu c tim cp - Vim mng ngoi tim cp - Tc ng mch phi. 2.2. Bnh phi v mng phi - Trn dch mng phi - Trn kh mng phi 3. TRIU CHNG LM SNG 3.1. Cn au tht ngc 3. 1. 1. Cn au tht ngc in hnh - Cn au thng xy ra khi i, thi tit lnh. - au vng sau xng c, au ngang ngc, lan ln vai tri, ra cnh tay nht l15

bn tri, c khi lan ln c di hm. - Thi gian ca cn au ko di vi giy n vi pht. - Ngm Nitroglyxerin th ct c cn au. - Nhng du hiu km theo: bnh nhn cm thy hi hp, lo u, kh th, v m hi nghe tim c th pht hin ting nga phi tin tm thu. 3.1.2. Cn au tht ngc khng in hnh - au v tr khc thng - Th khng au - Cn au t th nm - Cn au kiu Prinzmetal + Xy ra lc ngh ngi, khng xy ra sau gng sc mnh. + Trong cn au ST chnh ln D1 v cc chuyn o trc tim. + Chp ng mch vnh thy tn thng va x ng mch. - Cn au tht ngc tht thng. L tnh trng chuyn nng nhanh chng ca hi chng au tht ngc, c th tin ti nhi mu c tim cp. 3.2. Nhi mu c tim 3.2.1. Th in hnh - au vng trc tim, au vng sau xng c. - Thi gian cn au ko di vi chc pht, vi gi. - Ngm Nitroglyxerin khng . - Khm: + Chn tay lnh, huyt p ng mch bnh thng hoc thp. Nhng gi u thng khng st, nhng sau nhit tng ln 38-38,50C trong 2-3 ngy. + Ting tim yu, nht l T1 mm i khi nghe c ting nga phi u tm trng, c th nghe thy ting c ngoi tm mc. 3.2.2. Th khng in hnh - Tai bin mch mu no. - Ph phi cp. - T vong 3.3. Vim mng ngoi tim cp -au ngc l triu chng thng gp. V tr au thng vng trc tim. - Kh th: kh th nhanh, nng. - Mt s triu chng khc: kh nut, ho khan, nc, nhn v s khng thy mm tim p, g din tim to ton b.16

- Nghe nhp tim nhanh, ting tim m. Ting c mng ngoi tim l du hiu c trng. - Cc du hiu tr tun hon ngoi bin. + Tnh mch c ni, gan to, ph hai chi di. + p lc tnh mch ngoi bin tng + Mch nhanh nh, huyt p ng mch h v kt nu lng dch nhiu v xut hin nhanh thng thy du hiu mch nghch thng ca Kussmaul. 3.4. Nhi mu phi - au ngc t ngt d di, kh th, nhp th nhanh 60-70 ln/ pht. - Mt ti tm mi - Nhp tim nhanh c nga phi phi, gan to, tnh mch c ni, c th tru mch. - Ngy hm sau ho ra mu, mu sm. - C th tnh trng sc do tim 3.5. Trn dch mng phi - au ngc bn trn dch - Kh th, nhanh nng, ngi bnh phi ngi dy th. - Khm thc th: + Nhn lng ngc bn c trn dch nh ln, khoang lin sn gin rng v km di ng, thng c ph nh lng ngc bn trn dch. + S rung thanh gim hoc mt. + G c r rt, c th pht hin c ng cong Damoisean. + Nghe r ro ph nang gim hoc mt vng c, c th c ting c mng phi giai on u. 3.6. Trn kh mng phi - t nhin au ngc, au nh x phi, c th gy sc, ngi v m hi. - Khm thc th: + Mch nhanh nh, huyt p h + Nhn lng ngc bn trn kh bt ng, khong lin sn gin ra. + S rung thanh mt. + Nghe mt ting r ro ph nang i khi nghe c ting thi v. 4. CN LM SNG 4.1. Cn au tht ngc - in tm : ST chnh xung 2-3mm cc chuyn o ngoi bin v chuyn o trc tim. - Chp lp lnh khi gng sc vi Thellium 99 hoc chp ng mch vnh.17

4.2. Nhi mu c tim - Xt nghim mu: bch cu tng 10.000 - 20.000 tc lng mu tng. i khi ng huyt tng nht thi. - Xt nghim men: + Creatin Phosphokinase (CPK) v isoenzym c hiu ca c tim men ny tng. + Lc tat dehydrogenase (LDK) tng. + SGOT, SGPT tng sau 12-18 gi sau khi nhi mu. + Alpha hydrobutyra (AHBDH) xut hin 6-12 gi sau khi nhi mu. - in tm : bin i phc tp QRS, xut hin sng Q bnh l ST chnh ln sng vm Pardee. V tr nhi mu V1V2 nhi mu trc vch V3V4V5V6, trc bn DIII v aVF nhi mu sau di. - X quang: chp lng ngc c th pht hin du hiu xung huyt phi. C dch ng cc vch lin tiu thy, i khi pht hin c hnh nh m ca ph phi. - Siu m: thy chuyn ng bt thng ca thnh tim v vch. C th pht hin c thng vch lin tht, hot ng bt thng ca b van hai l. C th pht hin c huyt khi thnh tim. - Chp lp lnh: chp lp lnh vi albumin nh du bng Technitium phng x cho php nh gi c chc nng tht tri, kh nng tng mu. 4.3. Vim mng ngoi tim - X quang: thy tim to, p yu hoc gn nh khng p. Tim to b ra hai bn. - in tm : ri lon ti cc tht, bin i on ST v T. + Giai on I: ST chnh ln vi sng T dng + Giai on II: Sng T dt + Giai on III: ST tr li ng ng in sng T m. + Giai on IV: cc sng tr li bnh thng. - Xt nghim mu: tc lng mu tng, t l alphaglobulin v si huyt tng. - Chc d mng ngoi tim: nu ht c dch l tiu chun quan trng nht chn on xc nh. 4.4. Tc ng mch phi - in tm : + P ph DI v DIII + Trc QRS chuyn sang phi + Blc nhnh phi hon ton hay khng hon ton. + T o ngc vi V4, V5, V6.18

- Chp X quang tim phi. + Tm tht v tm nh phi to + ng mch phi phng to + Phi qu sng vng ngng ti mu. + Du hiu mun: hnh m kiu vim phi, c trn dch mng phi. - Chp ng mch phi c cn quang. + Hnh ct ct mt nhnh to ca ng mch phi + Hnh phi qu sng khu tr - Chp phi nhp nhy: thy hnh nh ct ct, hnh nh gim tp trung. - Cc kh trong mu: SaO2 gim, PaCO2 gim. 4.5. Trn dch mng phi - X quang: nu dch trung bnh thy ng cong Damoiseau Nu dch nhiu thy na lng ngc b m, khoang lin sn gin rng, km i ng, tim b y sang bn i din. - Chc d: l ng tc gip chn on quyt nh, c tc ng chn on nguyn nhn, c tc dng iu tr. 4.6. Trn kh mng phi - X quang: phi qu sng bn b trn kh, khoang lin sn gin, phi b co li thnh mt cc xp xung st rn phi, c honh khng di ng v b y xung, trung tht b y sang bn lnh. - Triu chng p lc k: pht hin c ba loi trn kh mng phi; trn kh mng phi m, trn kh mng phi ng v trn kh mng phi c van. 5. CHN ON y t tuyn c s chn on xc nh i vi cn au tht ngc, nhi mu c tim, vim mng ngoi tim, tc mch phi, trn dch mng phi, trn kh mng phi ch yu da vo triu chng c nng v khm thc th. 5.1. Cn au tht ngc * Xc inh: - Da vo tnh cht cn au - Ngm Nitroglyxerin ct c cn - in tm : ST chnh xung * Phn bit: - Nhi mu c tim - Tc mch phi bn tri - Trn kh trn dch bn tri. - au do thoi khp hoc vim ct sng lng - c; vai, v cc khp sn sn.19

- Bnh tm cn. 5.2. Nhi mu c tim * Xc nh: - au vng trc tim kiu cn au tht ngc nhng ko di, ngm Nitroglyxerin khng . - Bin i sng Q v on ST chnh - Tng cc men trong huyt thanh. * Phn bit: - Cn au tht ngc: cn au ngn, p ng vi Nitrit, khng c sng Q trn in tm , men tim bnh thng. - Tc ng mch phi. - Vim tu cp, thng lot d dy t trng. 5.3. Vim mng ngoi tim cp * Xc nh: - Tim to, trn X quang thy tim ng yn. - in tim: bin i on ST v sng T. * Phn bit: - Tim to do nguyn nhn c tim: vim c tim, bnh c tim gin ta phn bit da vo: + Thng hay c ri lon nhp tim. + Ting thi tm thu do h van hai l c nng. + in tm thng c dy tht tri. + SA tim l xt nghim tin cy. 5.4. Tc mch phi * Chn on xc nh: - au ngc t ngt d di. - Ho ra mu - in tm : hnh nh P ph cp. * Phn bit: - Vim phi cp: bnh nhn c st, au ngc, bch cu tng cao. 5.5. Trn dch mng phi * Chn on xc nh: - au ngc tng dn - C hi chng 3 gim - X quang20

- Chc d * Phn bit: - Vim mng phi dy dnh: cn khai thc k v tin s trn dch mng phi do lao, chc d khng c xc nh. - X quang trung tht co ko v bn xp. 5.6. Trn kh mng phi * Chn on xc nh: - au ngc t ngt bn trn kh - Khm pht hin c tam chng Gallia * Phn bit: - Nhi mu c tim - Tc ng mch phi. 6. X TR BAN U 6.1. Cn au tht ngc - Nitroglyxerin, hoc y t c s dng papaverin. 6.2. Nhi mu c tim - Papaverin. - Nitroglyxerin, Nifedipin, an thn. 6.3. Vim mng ngoi tim - tuyn y t c s ch yu l iu tr triu chng. - Dng thuc gim au: Aspirin, an thn, chm nng ni au. 6.4. Tc mch phi - iu tr triu chng bng thuc gim au thng thng Aspirin, an thn. 6.5. Trn dch mng phi - Chc ht kh bng bm tim. 7. D PHNG - Kim tra sc khe nh k, tm cc yu t nguy c iu tr. i vi ngi trn 45 tui, c 6 thng nn i kim tra sc khe mt ln. - Dng thuc d phng huyt khi bnh nhn c nguy c.

CHN ON V X TR AU LNG1. I CNG V DCH T HC au tht lng l mt triu chng th hin bng hin tng au vng c gii hn t ngang t sng tht lngl pha trn v ngang a m t sng tht lng 5 v21

cng 1 pha di; bao gm a, t chc di da, c, xng v cc b phn su. au c th km theo bin dng, hn ch vn ng hoc khng. au vng tht lng do rt nhiu nguyn nhn gy nn i hi phi khm t m, ton din gip xc nh nguyn nhn iu tr hiu qu. au vng lng v tht lng rt hay gp trong i sng hng ngy, trong iu tra tnh hnh bnh tt au tht lng chim 12% trong nhn dn, chim 17% nhng ngi trn 60 tui (Phm Khu, 1979); 6% tng s cc bnh xng khp (Khoa C Xng khp Bnh vin Bch Mai 1988); 80% dn s c th c triu chng au lng t hoc nhiu (theo David B.Hellman), gp c nam v n, cc la tui, nht l tui lao ng, nh hng n lao ng v sinh hot. 2. TRIU CHNG LM SNG 2.1. Biu hin ti ch 2.1.1. Triu chng c nng - Triu chng au: + V tr: c gi tr gip cho nh hng chn on, c th au mt im hay mt vng. + Tnh cht: au m hay au nhc, au mi, au tng cn, au ngy hay m, lc vn ng hay ngh ngi. + Hng lan: lan ra trc, ln trn, cng chn.... + iu kin xut hin: t ngt sau lao ng hoc thay i thi tit, - Cc du hiu km theo: + D cm, cm gic kin b, t b. + Gim c lc. + Hn ch vn ng ct sng. + Ri lon c trn: khi c tn thng vng ui nga + Cc tn thng khc tu thuc nguyn nhn gy au vng tht lng: au vng thng v km chua (tn thng d dy t trng) ; i but, i c (tit niu)... 2.1.2. Triu chng thc th - S thay i hnh thi ct sng: mt ng cong sinh l tr nn thng , g vo, qu n ra trc. - Quan st phn da, t chc di da v c vng tht lng: c l r, sng so, khi u, tnh trng c cnh vng ct sng (teo hoc li ra) - Khm cc ng tc vn ng: ci nga, nghing, quay xem hn ch mc no. 2.2. Biu hin lin quan - Khm cc on ct sng khc: lng c, cng ct v khp cng chu22

- Khm thn kinh: ch cc dy thn kinh c xut pht vng tht lng nh dy thn kinh ta, dy i b... - Khm cc b phn trong bng, ch b my tiu ha, thn, sinh dc n, ng mch ch bng. - Khm ton thn v cc b phn khc... 3. TRIU CHNG CN LM SNG 3.1. Chn on nh nh 3.1.1. Ccphng php chp Chp thng thng vi 3 t th thng, nghing, chch. Chp ct lp vi tnh c th cho thy nhng tn thng rt sm ca xng, phn mm quanh ct sng. Chp cn quang pht hin cc tn thng ra m, mng no tu, ui nga v tu. C th chp bao r thn kinh, chp ngoi mng cng, chp a m. 3.1.2. C th thy mt s hnh nh bt thng nh - Nhng thay i v hnh thi ct sng tht lng: mt ng cong sinh l cc du hiu ca thoi ha (mc gai xng, x c xng), du hiu ca vim ct sng do lao (t sng hnh chm, nham nh, hnh p xe lnh), thay i hnh thi ma m (xp, dnh, ph hu), hnh nh cu xng, vim khp cng chu.... - Nhng d dng ct sng: gai i, cng ha tht lng... - Nhng thay i v thu quang ca xng: mt vi, hnh hc v khuyt (do long xng, ni tit, di cn ung th); c xng (ung th di cn...) - Thot v a m - Thay i phn mm quanh khp nh p xe lnh (lao ct sng) 3.2. Cc xt nghim khc Tu theo hng chn on nguyn nhn m lm cc xt nghim cho ph hp - Cc xt nghim v vim: cng thc mu, tc mu lng, si huyt.. - Cc xt nghim v t bo vi khun: lao.. - Huyt tu , dch no tu, phn ng Waaler Ro se, calci mu, nc tiu... 4. NGUYN NHN AU THT LNG 4.1.Cc bnh ni tng Mt s bnh ni tng trong bng hoc tiu khung c th au vng tht lng, hoc au t pha trc lan ra sau lng 4.1.1. c im chung au c mt vng khng xc nh c v tr r rt, au hai bn hoc mt bn ca ct sng. Khm khng thy thay i hnh thi ct sng, vn ng bnh thng. C cc triu chng ca bnh ni tng.23

4.1.2. Nhng bnh ni tng c th gy au vng tht lng - Tiu ha: + Lot d dy t trng, ung th d dy: cn hi tin s, cha, hi, nn, xut huyt.... kt hp soi d dy, chp X quang xc nh. + Bnh ty tng: si ty, vim ty cp v mn c th au vng tht lng, amylase mu tng... + Gan mt: vim gan mn, si gan, bnh ti mt, ng mt. - Thn tit niu: au thnh cn vng tht lng, km theo c i but, i dt, i mu... c th do si tit niu, lao thn, vim thn b thn... - Sinh dc: au bng kinh, u x t cung, bnh tuyn tin lit.. 4.2. Nguyn nhn do vim, u, chn thng, lon sn.... Thng chn on v du hiu ti ch, ton thn, iu kin pht sinh v cc du hiu X quang. 4.2.1. Chn thng 4.2.2. Vim t sng - Vim do vi khun: vim do lao (bnh Pott) hay gp, on tht lng v lng b tn thng nhiu nht so vi cc on khc, au c nh ngy cng tng, du hiu nhim lao, hnh nh X quang thy hnh chm, hnh p xe lnh, hu xng v a m. Vim do cc vi khun khc: t cu, thng hn, ph cu... chn on da vo iu kin pht bnh (mn nht, vim c...), km theo c tnh trng nhim khun, xt nghim, X quang. - Vim do bnh khp: Vim ct sng dnh khp thng au vng tht lng phi hp vim khp hng v khp gi, hnh nh X quang c vim khp cng chu, hnh cu xng cnh ct sng. Biu hin vim ct sng trong mt s bnh khp nh vim khp dng thp, vim khp vy nn, vim khp phn ng thiu nin.... 4.2.3. Nguyn nhn do u (ung th di cn, u lnh) - Ung th di cn: ung th cc tng khc di cn n, hnh nh X quang thng thy khuyt xng gn hoc xp t sng - Cc khi u lnh tnh ca xng, mng no tu - Cc bnh lon sn, ri lon chuyn ha: vim xng sn (c thot v a m vo thn t sng). - Cc bnh mu gy tn thng xng: bnh lxmi, thiu mu tan mu, a u tu xng... 4.3. Cc nguyn nhn do thay i cu trc ca t sng v a m24

4.3.1. Thoi ha Thoi ha vng ct sng tht lng xut hin sm hn cc on khc ca ct sng, l nguyn nhn thng gp ca au vng tht lng. - H khp t sng: biu hin c mc gai xng cnh thn t, hnh c xng mm sn, gp nhiu ngi trn 40 tui, phn ln khng c biu hin lm sng. - H a m ct sng: l nguyn nhn quan trng ca au tht lng cc loi. C nhiu mc khc nhau: + Mc sm khi a m c kh nng cng phng nhiu, gy nhng cn au tht lng cp sau nhng ng tc mnh t ngt v tri t th. + Mc trung bnh gy au tht lng mn tnh, trn phim X quang thy chiu cao a m gim v chp cn quang a m thy bin dng v nt. + Mc nng: xut hin ri hoc thot v a m vo ct sng. C du hiu au tht lng hng, co cng c cnh ct sng, au thn kinh ta, teo c v lon cm chi di. 4.3.2. Tnh trng mt vi ca t sng - Long xng (khi xng mt trn 30% trng lng, do long xng c tnh trng xp t sng gay au): long xng ngi gi (long xng nguyn pht), long xng th pht sau cc bnh ni tit (bnh Cushing, bnh u tuyn cn gip, i tho ng), o lm dng thuc (steroid), o nm lu, do mt trng lc ko di (du hnh v tr). - Mt cht vi ri rc to nn cc , hc, khuyt (bnh Kahler, di cn ung th)... 4.3.3. Ct sng c xng Do ng c nuorose, ung th xng th to xng. Trn phim X quang thy mt hoc nhiu t cn quang hn bnh thng. 4.3.4. Cc di dng bm sinh hay th pht vng tht lng Chng gai i, cng ha tht lng 5, thoi ha tht lng cng, trt t sng ra trc... Hu ht khng c du hiu lm sng, hoc au t. 4.4. Cc nguyn nhn khc au do t th ngh nghip: mt s ngh nghip, t th c th gy au tht lng (cng nhn bc vc, ngh s xic, lc s c t..) au do tm thn. au trong hi chng thp khp cn ung th; mt s ung th ni tng c biu hin au xng di, ct sng v khp, au rt nhiu nhng khng c tn thng thc th v du hiu di cn trn Xquang (ung th ph qun, d dy, t cung, tin lit tuyn...).25

5. CHN ON NGUYN NHN AU VNG THT LNG 5.1. au vng tht lng n thun khng c thay i v hnh thi v vn ng - au c vng, khng c im au c nh. - Khng nh hng n hnh thi ct sng v vn ng vng tht lng. - Ch khai thc cc du hiu km theo: tiu ha, tit niu, sinh dc, ton thn, iu kin lao ng... 5.2. au vng tht lng c nhng thay i v hnh thi ct sng v hn ch vn ng - Cc tn thng nt rn, ln, di lch thng do chn thng - Hin tng mc thm xng: gai xng (thoi ha), cu xng (vim ct sng dnh khp), vi ha dy chng. - Du hiu ca vim t sng do vi khun: + Hnh nh hu a m, thn t sng hnh chm, hnh p xe lnh (lao ct sng) + Hu a m v thn t (vim m) - Hnh nh tiu xng: bnh Kahler, cng cn gip, ung th xng hay di cn ung th. - Hnh nh c xng: nhim nc (c nhiu t), khi u (c mt t). - Hnh nh long xng v ln t sng km theo: long xng nguyn pht v long xng th pht. - Cc hnh nh d dng - Cc bnh v a m - Hi chng hp ng sng. 5.3. au vng tht lng m nhng du hiu lm sng v Xquang khng xc nh c nguyn nhn - H a m. - Cc nguyn nhn do ngh nghip, thi quen - Long xng v h khp ngi ln tui - Mt s bnh vim: lao, vim ct sng dnh khp - Mt s t do d dng bm sinh hoc th pht. Nh vy au vng lng v tht lng do rt nhiu nguyn nhn gy ra, cn phi hi bnh v khm bnh tht t m, nhm pht hin bnh nht l nhng ni cn thiu trang thit b h tr chn on. 6. IU TR 6.1. Nguyn tc chung - Ngh ngi v bt ng khi au nhiu.26

- Dng cc thuc gim au. - Dng thuc gin c khi c co c. - Kt hp iu tr vt l, chm cu bm huyt. - S dng mt s bin php c bit khi cn: tim ngoi mng cng, tim vo a m, ko gin ct sng... - Phu thut trong mt s trng hp - iu tr nguyn nhn. 6.2. iu tri ni khoa - Thuc gim au: ung hoc tim tu mc , dng cc thuc Aspirin, Indomethacin, Profenid, Brufen... C th dng cao dn, thuc m c Salicylat. Khng nn dng cc thuc c Steroid. - Thuc gin c: Diazepam, myocalm... khi c co c. - Cc phng php vt l: Chm nng, xoa bp Dng in: hng ngoi, sng ngn, in dn thuc... Thao tc ct sng (khng lm khi nghi c vim, ung th, long xng nng) - Y hc dn tc: chm cu bm huyt, thuc nam nh cy xu h, l lt, hy thim... - Cc phng php c bit: Ko gin ct sng bng dng c, ch nh cho thot v a m Tim ngoi mng cng vi Novocain v vitamin Bi2 trong au tht lng hng. C nh bng ai, np, ym khi c nguy c ln v di lch ct sng (lao, ung th..) Th dc liu php v bi trong vim ct sng dnh khp, h khp. 6.3. Phu thut Ch nh trong cc trng hp: - Cc bnh di lch chn p vo tu, ui nga (lao, chn thng, u) - Phu thut lm cng, c nh khi c nguy c ln t sng, g vo nhiu... - Phu thut iu tr thot v a m: m ly nhn thot v, m ct cung sau. Tm li: rt nhiu nguyn nhn dn n au vng lng v tht lng, chn on nhiu khi d nhng nhiu khi kh chn on, nn cn phi khm bnh t m chnh xc, trong iu tr cn chn la v phi hp phng php ph hp iu kin v kinh t ca ngi bnh iu tr c hiu qu.

27

NHC U1. I CNG 1.1. c im dch t hc nhc u Thut ng nhc u hay au u bao hm tt c cc loi au u, nhng thng thng ta dng t nhc u ch ni ti nhng cm gic kh chu vng vm s. Nhc u l mt trong nhng cm gic kh chu thng gp nht ca con ngi, l mt triu chng thng gp do nhiu nguyn nhn khc nhau, xut hin trong rt nhiu bnh. Nhc u c th l du hiu u tin, duy nht trong mt thi gian di ca mt bnh thn kinh thc th. Nhc u cng hay gp trong cc bnh ni tng, bnh ton thn hoc bnh tai mi hng, mt, rng. Nhc u c xp vo 10 l do hng u khin bnh nhn ti thy thuc khm bnh. Cc cuc iu tra cng ng cho thy c 65 - 80% ph n v 57 - 75% nam gii b nhc u mi thng. S hin tng mc nhc u gim xung theo tui, trong khi tn s ti bc s khm bnh v nhc u li tng. Nhc u l nguyn nhn lm mt nhiu ngy cng lao ng. Phn ln nhc u thng l lnh tnh, nhng i khi c nhng vn rt nghim trng c th cng c mt vi nhc u. iu tr nhc u khng phi ch l iu tr triu chng m cn bn l iu tr nguyn nhn, iu tr bnh. 1.2. C ch nhc u Mt tc ng vo thnh phn c cm gic ca cc t chc trong s u gy nhc u theo nhiu c ch. * C ch thn kinh: - Tc nhn kch thch: + Tn thng ti ch: vim mng no, vt thng s no nh hng ti mng cng, xm nhp ca khi u. + Kch thch c hc: p, co ko mng no v cc mch mu no trong tng p lc ni s, u no, p xe no, hoc ri lon tun hon mu v dch no tu. - B phn kch thch: Mng cng, thnh mch mu trong s c nhiu c quan nhn cm, c nhiu tn cng thn kinh cm gic. - ng dn truyn kch thch: Khi cc th th b kch thch, xut hin cc xung ng thn kinh. Cc xung28

ng c truyn ln no bng dy V, dy IX, dy X v dy c I, II, III. ng dn truyn ny i qua hai chng quan trng l qua i th v qua cht li. * C ch phn x: Do r cm gic ca dy V nm trong vng cu - hnh no, bn cnh nhng y thc vt. C l v vy nhiu bnh ca c quan ni tng gy au u * C ch thn kinh thdich: Do kch thch cc th th ha hc thnh mch mu, mng no trong nhim c nhim khun ton thn, ri lon chuyn ha, ri lon ni tit. * Tng tnh hng phn ca t bo v no: Trong suy nhc thn kinh, v no trng thi m ngng chu kch thch ca v no b h thp. V no tip thu c nhng kch thch nh, thng xuyn t cc c quan ni tng truyn ti, do bnh nhn hay cm thy nhc u. * c im tm thn: C ngi chu au tt, c ngi chu au km. 2. NH GI BNH NHN V XC NH CC TRIU CHNG I KM VI NHC U 2.1. Hi bnh - Khai thc bnh s: bnh s bnh nhn l phn quan trng nht ca vic nh gi nhc u, cn khai thc k v s khi pht, tn s, thi lng, tnh cht, cng , v tr, cc yu t tng gim, cc triu chng phi hp, cc biu hin thn kinh, vic dng thuc trong qu kh v hin nay. Cc d ng v chn thng cn c xc nh. - Lch s gia nh: nhc u Migren c khuynh hng di truyn. Nguyn nhn dn ti nhc u th pht c th pht hin t s hiu bit v tin s bnh trong gia nh nh tng huyt p, nhim khun, i tho ng, ung th. - Cc tress x hi v c nhn: cn tm hiu cng vic, gic ng, n ung, thi gian hot ng. Xc nh s tiu th ru, nc ung c c ph, ht thuc l, thuc lo v tin s dng cc thuc khc. 2.2. Khm thc th Mc ch xc nh v loi tr nhng nguyn nhn th pht ca nhc u. - Khm v u, c, thn kinh: xc nh tng nhy cm au, s khng u v hnh dng, cc ting bt thng trn hc mt, cc ng mch cnh, thi dng v ng mch chm. - nh gi cm gic au khi ming m v ng, cc khp cn lch v s nhy cm au ca khp thi dng - hm. G trn xoang trn v xoang hm tm nhy cm au. - Trong nhc u vng chm nn nh gi t sng c, nh gi ng tc nga29

gp v quay. Bnh t sng c c th dn n nhc u gy ra do co c hoc bnh d thn kinh chm. Cn c bit ch ti cc dy thn kinh s no, thn kinh th gic. - nh gi v tm l: s dng cc test chun v tm l. - Khm cc chuyn khoa: khm mt, khm th lc, th trng. - Khm rng hm mt: pht hin rng su, rng mc lch. - Khm tai mi hng: pht hin vim tai gia, vim tai xng chm, vim xoang, vim hng v amydal... 2.3. Cc xt nghim - Cc nghin cu phng th nghim cn c ch dn bng cc kt qu v tin s bnh v thm khm thc th. - Xt nghim dch no tu, m s lng hng cu - bch cu, cy mu v dch no tu. - Tc mu lng: tng trong nhc u do vim ng mch thi dng. - in git . - ng huyt lc i chn on i tho ng hoc h ng huyt. - Chp ct lp vi tnh trong nhng trng hp nghi u no, chn thng s no. - Cng hng t ht nhn. - o nhn p chn on glaucome. 3. NGUYN NHN NHC U 3.1. Nguyn nhn mch mu * Nhc u vn mch: l th thng thng nht, do mt ri lon vn mch trong no, thng gp trong cc bnh nhim trng, st, cc trng thi thiu oxy no, i, nhim c ru v thuc l mn tnh. * au na u (Migren thng thng): - c im c bn ca Migren l au na u tng cn, ti din c chu k, km theo bun nn, nn. Trc khi au thng c tin triu. Ngoi cn hon ton bnh thng n b bnh nhiu hn nam. Gp nhiu la tui 15 - 30. - Yu t khi pht cn thng l yu t tm l, lo lng, xc cm. Migren tng ln trong thi k kinh nguyt, tin mn kinh v dng thuc trnh th thai. Yu t mi trng, nh sng, ting ng, bnh tng huyt p, mt s thuc cng lm tng tnh trng nng ca bnh. - V tr au thng mt bn u, tu tng cn, au u c th lun phin bn phi, bn tri. - Tnh cht au: cm gic nng u rt kh chu, ny theo mch p ng thi vi nhp tim. - Cng au: au va n d i. Trn cng mt bnh nhn cng au 30

mi cn c th khc nhau. au tng khi ln cu thang, khi vn ng, hoc bi nh sng, ting ng, mi thuc (thuc l, thuc cha bnh). Do , bnh nhn phi tm ch yn tnh, bung ti, khng mun tip xc vi mi ngi. - Hng lan: xut pht t vng trn - thi dng, au c th lan ln nh u, ra vng chm, xung hm di hoc ra hc mt cng bn. 84% au ch lan ra na u. - Thi gian ca cn: xy ra thnh tng cn lu 4 - 24 gi, giai on au nht t 30 pht n 2 gi. - au u gim sau khi nn hoc gim dn trong ngy, thng ng c mi ht cn, gic ng cng su cng nhanh ht. - Khm trong cn thy ng mch thi ng cng, ni ngon ngoo, ny, p mnh bn au. * Tng huyt p: - Ngoi nhc u, bnh tng huyt p cn c nhng triu chng khc nh: chng mt, nh trng ngc, chy mu cam, tai, mt ng, i i m... - Tnh cht nhc u trong tng huyt p thng gp trong tng huyt p nng, hay nhc vng chm, xy ra bui sng v gim dn trong ngy. * Gin mch na u: au mt bn v nhy cm vi histamin. * Vim ng mch thi dng (bnh Horton): - L mt bnh vim h thng ng mch, ch yu l ng mch thi dng. N b nhiu hn nam, hu ht l trn 60 tui, c yu t di truyn. Thng au mt bn thi dng, au thng xuyn, tng ln khi kch thch nh (chi u, eo knh...). - Trong cn kch pht: nhc u d i. - C th au but theo mch p. - au nhc vng thi dng lan ra vng trn v hc mt cng bn. - Khi khm pht hin thy mt on thng ng mch thi dng cng mu tm, n au. S thy ng mch c ch to nh khng u, mch p yu hoc khng p. - C th pht hin tn thng khu tr mt s ng mch khc. - Ton thn bnh nhn c st, mt mi, chn n, gy st. - C th c biu hin m mt t ngt, do nghn hon ton ng mch mt, mt s trng hp biu hin thiu mu no, vim ng mch ngoi s v vim ng mch cc chi. 3.2. Nguyn nhn ni s * Tng p lc ni s: thng nhc u vo bui sng, lc gng sc, i khi thng xuyn.31

* U no: - Lc u, nhc u xut hin thnh nhng cn ngn, ri sau ko di v tr thnh thng xuyn, i khi khng chu ni. - au c th xut hin tng ln v mt i theo s thay i t th ca u: khi bnh nhn c t th bt buc, nm nghing sang bn hoc nm nga, u ci ra trc, ra sau. Nguyn nhn gy nn cc t th bt buc ca u l do: + Kch thch cc d thn kinh cm gic. + Kch thch tai trong. + Nhng thay i ca tun hon dch no tu. - Nhc u xut hin hoc au tng ln khi: + p ng mch cnh hoc truyn cc trung dch u trng. + au khu tr di ln khi g vo u. - V tr nhc u xut hin u tin c lin quan n v tr khi u, 1/3 s bnh nhn u no c v tr nhc u trng vi v tr khi u. Nhc u ch c v tr nh khu khi khng c tng p lc ni s. * p xe no: km theo st, tng p lc ni s. * Vim mng no v chy mu di mng nhn: bnh thng mng nui v mng nhn khng nhy cm au. Nhng trong vim mng no v chy mu di mng nhn th bnh nhn li nhc u d di l do: - Nhng cu trc (bnh thng c sn tnh nhy cm vi au) chy qua hoc p st vo mng nui b kch thch nh: nhng ng mch ln ca nn s v cc nhnh ca n, nhng xoang tnh mch ln. - Cc dy thn kinh s no b kch thch: + Cc dy thn kinh gic quan b kch thch s pht sinh s nh sng, s ni to. + Cc dy thn kinh cm gic b kch thch s gy tng cm gic au. + Cc dy thn kinh vn ng b kch thch gy nn co cng mng no, co cng au gy, co cng hm. - i khi m ri mng mch b kch thch gy tng p lc dch no tu. 3.3. Cc nguyn nhn s - Thng gp trong bnh Kahler, cc u xng di cn vo hp s, pht hin bng chp Xquang s. - Tn thng cc dy thn kinh cm gic: au c theo cc y thn kinh b tn thng, n vo au c th l zna. 3.4. Cc nguyn nhn ngoi s - Nhc u do bnh mt: + Cc tt chit quang, vim mng mt th mi, nhc u nhiu khi trn, tng ln khi gng nhn.32

+ Glaucome: au u d di, nhc trong h mt, nhn vo n thy c qung xanh nh cu vng, n nhn cu thy cng cng, tng nhn p. + Ngoi ra cn gp nhc u sau khi lm vic bng mt, c sch, xem v tuyn. - Nhc u do bnh tai mi hng: + Vim tai gia, vim xng chm, nhc u thng thi dng, mt bn v cch hi, nn vo xng chm gy au. + Vo vch ngn mi, ph i xng cun mi. + Vim xoang trn, xoang mi hoc xoang sng: nhc u ch yu vo bui sng v tng ln khi lnh. - Nhc u do bnh rng: Cc bnh su rng, p xe chn rng, rng khn mc lch thng au ti ch, nhng c th au ln thi dng, nh u, khi cn vt cng au tng ln. 3.5. Nguyn nhn khc * Nhim c: ru, nhim c ch, asen, ht nhiu thuc l: thng nhc ton b u. * Nhc u sau chn thng: - au u xut hin vi ngy sau chn ng no hay ng gip no, thng khu tr ch b thng, tng ln do cc trng thi xc cm v thay i t th. - Mt thi gian sau chn ng no hoc ng gip no, au u xut hin ngy mt tng, ng thi li xut hin nhng triu chng thn kinh thc th th phi ngh ti kh nng c bc mu t di mng cng mn tnh. * Nhc u sau chc tu. sng: - Xy ra vi gi sau chc d tu sng v ko di 1 - 2 ngy. au c tnh cht cng ko, i khi nh mch p, au tng t th ng hoc ng, hoc sau cc c ng mnh ca u, ho, gng sc. - Chc ng tht lng bng kim c ln, gy nhc u nhiu v ko di hn dng kim nh. - p lc dch no tu gim lm thay i cn bng thu tnh ca no v tc ng p ti cc cu trc nhy cm au. - S cng thng ni tm v lo lng s hi sau chc d tu sng l yu t thun li gy nhc u. * St: st cao gy gin mch gy nn nhc u. au nhiu vng trn, chm hoc ton b u. * Thiu mu: xut hin trong trng hp thiu mu nng, hoc nhng ngi bnh thng cao. Nhc u do thay i p lc tai, xoang mt. Lm ng tc nhai, nut hay33

nghim php Valsalva th s chnh lch p lc s c thng bng nhanh chng. * Vim x cc c c. xc nh im au ch bm cc c c. 4. IU TR Bc quan trng nht trong iu tr au u l cc bin php pht hin v loi b cc bnh chnh hoc cc ri lon chc nng. - i vi au u hng ngy thng thng do mt mi, sang chn tm l hoc dng qu nhiu ru, thuc l, tng stress, Aspirm 0,6g hay Acetamiophen 0,6 g, 6 - 8 gi 1 ln. - au na u (Migren): + Cho ti nay cha c phng php iu tr trit , cn phi phi hp phng php iu tr nhm lm gim tn s cn, cng cn, thi gian ca mi cn v triu chng km theo. + Trnh yu t gy au, trnh cc ung c ru, nht l ru vang + iu tr cn au u: dng thuc no l tu thuc vo mc nng, nh ca bnh, vo kinh nghim ca thy thuc cng nh p ng ca mi ngi bnh. + Th nh ch cn Analgin (500mg - ung sau ba n). + Cn au nng hn cn dng mt trong s cc thuc nh: Ergotamin leng, ung hoc t di li, ngay t bt u cn, sau 30 pht (nu khng ) th ung thm 1 vin, khng dng qu 3 vin/ ngy. Khng dng qu 10 vim tun. Khng dng gia cc cn au. Ch phm ny thn trng khi dng cho ph n c thai hoc nhng ngi b bnh mch mu. Paracetamol, Tamik. Thuc chng vim khng steroid: Voltaren, Indomethacin. Cc thuc an thn: Seduxen, gacdenan nhng cng khng nn lm dng. + iu tr d phng cc cn au, ch p dng vi th nng: Avlocardyl, tamik, laroxyl hoc Sibelium. + Cn phi iu tr cc yu t lm tng bnh nh ri lon ni tit, tiu ha, gan mt v liu php tm l, trnh cc ung c ru. - au u do tng huyt p: + Nhc u thuyn gim ng thi vi con s huyt p h. + Tc dng iu tr c hiu qu tt nht l dng thuc h huyt p kt hp vi thuc an thn. + Trong qu trnh iu tr cn theo di huyt p v mc nhc u.34

- au u do cng c: xoa bp, th gin, kt hp vi cc thuc trm cm Amitriptylin, an thn Seduxen, cc thuc gim au Analgin, kt hp tm l liu php. - au u sau chn thng: tm l liu php, chm nng, xoa bp, cc thuc Indomethacin hoc Phenylbutazon. - Vim ng mch: Prednisolon 40 - 60 mg/ngy, dng t nht 1 thng sau gim dn liu cho n khi triu chng lm sng, xt nghim v bnh thng. C th kt hp vi thuc chng vim khng Steroid trong giai on cng c. - Do u no: tt nht l chuyn tuyn trn iu tr phu thut ct b hon ton khi u. - Nhc u do st: iu tr theo cn nguyn v dng bin php h nhit bng chm lnh, hoc dng cc thuc h st nh Paracetamol, Analgin kt hp vi thuc an thn. Trong khi iu tr au u cn phi ht sc ch , trnh lm dng cc thuc gim au nh Analgin, Aspirin, Indomethacin, Seda... nht l nhng bnh nhn c tin s lot d dy hnh t trng, v c th gy bin chng chy mu ng tiu ha rt nguy him. Nu ch nh dng thuc gim au khng Steroid phi khuyn bnh nhn ung sau ba n, sau phi c gng tm nguyn nhn iu tr. 5. PHNG BNH - Tm quan trng ca cng tc v sinh chung, mt ch n y , ngh ngi ph hp, lao ng hp l, xc nh v loi b nhng yu t lo u hng ngy l gip cho vic phng nhc u c hiu qu. - Thay i tp qun sinh hot, trnh cc tc nhn gy cn, tm l liu php, tp luyn dng sinh, cc bin php ny cn c coi trng trong phng nga nhc u Migren. - Cn chuyn tuyn trn kp thi chn on v iu tr i vi nhng trng hp iu tr bng nhng bin php thng thng khng thy kt qu, kh xc nh nguyn nhn.

SUY THN CP1. I CNG 1.1. nh ngha Suy thn cp l mt hi chng xut hin khi chc nng thn b suy sp nhanh chng do nhiu nguyn nhn cp tnh dn n. Mc lc cu thn gim v c th b gim st hon ton, bnh nhn s i t v niu, Nitphiprotein tng dn, cng tng nhanh th cng nng. Ri lon nc in gii, thng bng kim toan ca mu l khng trnh khi. bnh nhn s cht do kim mu tng, do ph phi cp, do hi chng m mu35

cao hoc do bnh chnh. Cho n nay mc d c nhng phng tin hi sc tch cc nh lc mu ngoi thn nhng t l t vong cn rt cao. Tuy nhin nu c x l kp thi v chnh xc th nhiu trng hp c th chc nng thn hi phc hon ton hoc gn hon ton, ngi bnh c th tr li cuc sng bnh thng. 1.2. c im dch t Suy thn cp c coi nh mt s suy gim nhanh chng, tc lc mu ca cu thn v ng trong mu nhng sn phm ca chuyn ha no, hi chng ny xy ra trong 5% tng s cc ca nhp vin v c th chim ti 30% cc ca iu tr tch cc (theo thng k ca PGS. Trn Vn Cht v BS. Trn Th Thnh 1991 - 1995). Suy thn cp l mt bnh cp cu ni khoa t l mc bnh khng lin quan g n gii v a d. Vic chn on iu tr kp thi v chnh xc nht l trong cng ng c chn on sm th rt nhiu trng hp chc nng thn c khi hon ton hoc gn hon ton trnh c cc bin chng t vong. 2. NGUYN NHN 2.1. Nguyn nhn trc thn L nhm nguyn nhn gy bnh suy thn cp chc nng. - Sc gim th tch. - Sc tim. - Sc nhim khun. - Sc phn v. - Cc nguyn nhn gy gim khi lng tun hon khc nh: hi chng thn h, x gan, thiu dng gy gim protid mu. 2.2. Nguyn nhn ti thn - Bnh l cu thn cp: chim 3 - 12% bnh nhn suy thn cp + Bnh cu thn nguyn pht. Suy thn cp c th l bin chng ca vim cu thn cp sau nhim lin cu + Bnh cu thn th pht: Vim cu thn Lupus trong t tin trin cp tnh. Hi chng Good pasture Schoenlein Henoch c tn thng thn... - Cc bnh ng thn k cp tnh chim 58 - 65% bnh nhn suy thn cp + Ng c: ng c mt c trm, thuc nam... + Ng c thuc: thuc khng sinh, thuc chng ung th, thuc gim vim, gim au. + Tan mu cp tnh: Truyn nhm nhm mu.36

St rt c tnh. Dng thuc gy tan mu: Quanh. RifamDVcin... + Tiu c vn cp tnh: Chn thng c Thiu mu c. Hn m ko di, co git. Nghin heroin, lm dng thuc chng ng knh... + Cc tnh trng sc lc u l suy thn cp chc nng, sau c th dn n hoi t ng thn cp. + Nguyn nhn nhim trng: Nhim trng mu, nhim xon khun gy hi chng gan thn cp... Hoc theo con ng ngc dng: vim thn b thn cp + Nguyn nhn thng qua c ch min dch d ng: khng sinh, thuc chng co git. + Nguyn nhn gy ri lon chuyn ha: nh tng acid uric mu. + Cc nguyn nhn khc: Myelome... - Chn thng thn. - Tc mch thn - Cc nguyn nhn khc 2.3. Nguyn nhn sau thn L cc nguyn nhn gy tc nghn ng bi niu - Si b thn, niu qun - U chn p tc ng bi niu - Nguyn nhn do vim x cht hp: lao thn, giang mai... - X ha sau phc mc. 2.4. Cc nguyn nhn khc cha r 3. TRIU CHNG LM SNG V CN LM SNG Cc triu chng lm sng v cn lm sng tu thuc vo tng giai on ca bnh. 3.1. Giai on khi u L giai on tn cng ca tc nhn gy bnh. Din bin tu theo tng nguyn nhn. Bnh nhn ng c th din bin nhanh c th dn n v niu ngay, bnh nhn sc th din bin nhanh hay chm tu theo nguyn nhn gy sc v k thut hi sc ban u. 3.2. Giai on i t, v niu37

V niu c th din bin t t, bnh nhn c th i t ri dn n v niu, nhng v niu cng c th xy ra t ngt. i t, v niu c th ko di 1 n 2 ngy, c khi 3 n 4 tun, trung bnh l 7 - 12 ngy v c cc triu chng sau: - Lng nc tiu gim (21/24h. 3.4. Giai on hi phc - Khi lng nc tiu dn tr v bnh thng - Cc ri lon v sinh ha dn tr v bnh thng Tuy nhin kh nng c c nc tiu ca ng thn c khi hng nm mi hi phc hon ton, mc lc cu thn hi phc nhanh hn. S hi phc nhanh hay chm tu thuc vo tng nguyn nhn, vo tnh trng ban u, ch iu tr v cng tc h l i vi bnh nhn. 4. CHN ON 4.1. Chn on xc nh: da vo - C nguyn nhn cp tnh: ung mt c trm, ng c kim loi nng, a chy mt nc, vim cu thn cp... - Xut hin: + Thiu niu, v niu + Ur mu, creatinin mu tng dn + K+ mu tng dn + Toan chuyn ha + Din bin qua 4 giai on (nh trn) 4.2. Chn on phn bit - Phn bit vi t cp ca suy thn mn: suy thn mn: + Tin s c bnh thn, tit niu + Thiu mu tng ng vi mc suy thn + Cao huyt p, suy tim + Siu m c th thy hai thn teo nh. - Phn bit gia suy thn chc nng v suy thn cp thc tn. + Suy thn cp chc nng l do gim th tch tun hon, tt huyt p: mt mu cp, a chy, suy tim... Huyt p tt, mch nhanh nh, kim niu cao hn nan niu, t trng nc tiu cao. Nu khng iu tr kp thi s chuyn thnh suy thn thc tn (sau 72h) + Suy thn cp thc tn: thn b tn thng thc th do hoi t ng thn (ng c, sc) hoc vim cu thn cp, nhi mu thn... Da vo: Lm sng c tt huyt p, mt nc, mt mui, ging ha nhiu th ngh n suy thn cp chc nng.39

Thi gian v niu cng ko di cng chc chn c hoi t ng thn, thng sau 72h v niu th gn nh chc chn l bt u c tn thng thc th. Da vo kt qu xt nghim ta c th phn bit suy thn cp chc nng v suy thn cp thc tn nh sau:Ch s - Natri nc tiu - Na/K nc tiu - Ur nc tiu/ur mu - Ur mu/creatinin mu Suy thn cp chc nng Suy thn cp thc tn < 20mEq/1 > 40mEq/1 >1 > 10 > 30 600 mos/kg - T trng nc tiu >1,018

35 mmol/1 Khi cretinin mu >600 mol/l41

Khi c biu hin toan mu 5.2.3. Giai on i tr li - Tip tc hn ch protid trong thc n, ch cho n tng protid khi m mu tr v bnh thng. - Ch cho n qu chn khi khng c tng kali mu. - Nu cn th phi tip tc lc mu. - Truyn dch hoc trong chng mt nc v in gii. + Trong trng hp i nhiu va phi ch cn cho ung Oresol (2-2,5l/ 24h) + Khi nc tiu >31/24h th phi b bng ng truyn tnh mch, lng truyn tu thuc vo lng nc tiu. - Cn theo di st in gii mu c bit l Na+ v K+ mu. - Bnh nhn i nhiu c 2 n 3 ngy th m niu, creatinin niu tng dn, ur mu, cretinin mu gim dn, bnh nhn s chuyn sang giai on hi phc. Cn tng dn lng protid trong ch dinh dng. 5. 2. 4 Giai on h i phc s c khe - Sc khe bnh nhn dn c hi phc khi m mu tr v bnh thng th cn tng proti trong khu phn n m bo cm v vitamin. - Ch n cng tc iu dng ngay t u chng lot, chng bi nhim do nm lu - Tip tc iu tr nguyn nhn nu c: nguyn nhn tc nghn, bnh l ton th. 6. PHNG BNH - Theo di nh k hng thng i vi cc bnh l c th tr thnh mn tnh nh bnh cu thn, bnh l k thn do thuc hay do nhim trng, cn khm nh k cho bnh nhn lu di. - iu tr nguyn nhn (nu c) - Gio dc tuyn truyn trong cng ng, phng mt s nguyn nhn hay gy suy thn cp thng gp: mt nc, mt mui, ng c mt c trm, mt cc... Kt lun: suy thn cp l mt hi chng nng nhng c th hi phc chn on ch yu da vo triu chng: i t, v niu, m mu tng, kim mu tng cao dn. Theo di phi o lng nc tiu 24h. Phi tnh m niu o thi 24h, ur mu phi xt nghim hng ngy. X tr phi theo tng giai on, phi kin tr tp trung sc lc v phng tin v bnh nhn c th c cu sng hon ton. Nhng trng hp m, kim mu khng tng nhanh iu tr ni khoa bo tn cng . Nu ur, kali mu tng qu nhanh th phi lc mu ngoi thn.

42

VIM CU THN MN1. I CNG Vim cu thn mn l mt bnh c tn thng tiu cu thn tin trin dn n suy thn mn, c nhiu nguyn nhn dn n v c kh nng xy ra nhiu bin chng nguy him. Nu c pht hin sm v iu t ng th c th hn ch c qu trnh tin trin ca bnh v hn ch c nhng bin chng c th xy ra. 1.1. nh ngha Vim cu thn mn l mt bnh c tn thng tiu cu thn tin trin t t ko di nhiu nm c biu hin lm sng c th c tin s ph, protein niu, hng cu niu, cao huyt p nhng cng c th ch c hng cu niu, Protein niu n c. Cui cng dn n suy thn mn vi cc triu chng: - C s bt thng trong nc tiu ko di (hng cu niu v tr niu) - Suy gim chc nng thn t t 1.2. c im dch t - Vim cu thn mn l mt bnh gp tng i ph bin cng ng. Theo thng k ca PGS Trn Vn Cht v BS. Trn Th Thnh (1991 - 1995) ti khoa Tit niu Bnh vin Bch Mai th bnh vim cu thn mn chim 31,5% trong la tui hay gp l 16-44 tui chim 88,32%. Nh vy bnh gp nhiu la tui lao ng nn nh hng sc lao ng cng ng. Cng theo 2 tc gi trn th bnh khng c s lin quan n gii v vng a d. iu tr ch yu l bo tn, cn c k hoch pht hin sm cc trng hp vim cu thn mn trong cng ng, c gng trnh cc yu t gy giai on cp c bit l nhim trng ko di tui th cho bnh nhn. 2. NGUYN NHN GY BNH - Do vim cu thn cp (10- 20%) - Do vim cu thn c hi chng thn h - Do cc bnh ton th nh Lupus, bnh h thng nh ban dng thp... Bnh chuyn ha: i tho ng... - Bnh cu thn di truyn. - Khng r nguyn nhn. Ngoi tr bnh cu thn nguyn pht vi tn thng ti thiu hu ht cc bnh cu thn u dn n vim cu thn mn. Do vic pht hin sm v phng nga cc nguyn nhn gy vim cu thn cp, ci thin mi trng v sc khe cng ng v gii quyt tt cc bnh nhim trng c ngha rt quan trng trong vic phng bnh v lm chm s tin trin ca vim cu thn mn, ko di tui th cho bnh nhn.43

3. TRIU CHNG LM SNG V CN LM SNG 3.1. Protein niu T 2 - 3g/24h trong giai on vim cu thn mn tim tng th c th t hn. Nu tng trn 3,5g/24h l biu hin c hi chng thn h. 3.2. Ph Ph trng, mm, n lm, c khi ch nng m mt, giai on tim tng ph khng r rt. Nu c hi chng thn h th ph to ton thn c th trn dch cc mng. i t lng nc tiu thay i tu tng bnh nhn v tng giai on ca bnh. 3.3. Cao huyt p giai on cha c suy thn hoc suy thn nh t l bnh nhn cao huyt p thp. Khi suy thn giai on III, IV th t l trn 80% c cao huyt p 3.4. Hng cu niu Thng c, t khi c i mu i th 3.5. Tr niu, tr hng cu, tr trong, tr ht, khi c suy thn thng c tr to 3.6. Thiu mu Thng gp khi c suy thn cng nng th thiu mu cng nng. Hng cu, huyt sc t gim khi c suy thn, thiu mu ng sc hoc nhc sc rt kh hi phc. 3.7. Cc triu chng biu hin hi chng m mu cao: (Khi c suy thn r) Nn, ri lon tiu ha, xut huyt, c biu hin tim mch, thn kinh cc biu hin ca lm sng toan mu: (Th su, ri lon kiu th) v nng nht l hn m do m mu tng cao. 3.8. X quang Bng thn teo nh u hai bn giai on c suy thn. Khi cha c suy thn nu chp UIV th thy hnh nh i b thn bnh thng. 3.9. Siu m thn Kch thc thn bnh thng khi cha c suy thn. Thn teo nh u hai bn khi c suy thn. Mc teo nh tu thuc vo giai on tin trin ca suy thn v tu vo nguyn nhn khi u. 3.10. Sinh thit thn Trong giai on cha c suy thn hoc suy thn nh 1,2 c th tin hnh sinh thit thn. Qua sinh thit thn s cho bit loi tn thng m bnh hc. 4. CHN ON 4.1. Chn on xc nh Da vo: - Ph.44

- Protein niu. - Hng cu niu. - Tr niu. - Cao huyt p. - Ur mu. - Creatinin mu tng. - Hnh nh X quang chp thn. - Tuy nhin trong giai on tim tng chn on xc nh phi sinh thit thn 4.2. Chn on phn bit - Vim thn b thn mn tnh. Trong vim thn b thn mn bnh nhn thng c tin s vim nhim tit niu, si thn - tit niu nhng khng c ph, Protein niu thp, t khi qu lg/24h, bch cu niu nhiu, c vi khun niu. Nu c tr th l tr bch cu. Hai thn to nh khng u, b thn thng g gh, i thn b thn c th gin rng (chp UIV). - X mch thn lnh tnh (tc l bnh cao huyt p) trong vim cu thn mn, Protein niu thng xut hin trc khi c cao huyt p hoc cng mt lc. Trong bnh cao huyt p protein niu nu c th xut hin mun v s lng t. - X mch thn c tnh (cao huyt p c tnh) trong vim cu thn mn ko di, hai thn thng teo nh v c thiu mu, trong cao huyt p c tnh hai thn khng teo nh, bnh thng tin trin nhanh, suy thn nng nhng khng c thiu mu nng. - Protein niu lnh tnh trng hp ny protein niu thng ch c tng lc, khng thng xuyn, khng bao gi dn n suy thn nh vim cu thn mn. - Vim cu thn cp: bnh nhn c tin s nhim khun hng v da, sau xut hin ph, i t, i mu, cao huyt p. Chn on xc nh bng siu m hoc chp thn nu hai thn nh hn bnh thng l vim cu thn mn. - Vim cu thn cp tin trin nhanh: bnh nhn c tin s nhim khun hng v da, sau xut hin ph, i t, i mu, cao huyt p, ur mu v creatnin mu tng. Chn on xc nh bng chp thn hoc siu m thn, thy thn nh hn bnh thng l vim cu thn mn. 4.3. Chn on th - Th tim tng: Da vo bnh nhn c tin s bnh cu thn, xt nghim c hng cu niu, tr niu ko di. Chn on chc chn da vo sinh thit thn. - t cp ca vim cu thn mn: Bnh nhn c tin s vim cu thn mn v c cc yu t thun li nh: + Cao huyt p c tnh45

+ C cc t nhim khun + C thai... Vim cu thn mn l mt bnh mn tnh do cc bnh ti cu thn tin trin, ko di hng thng, n hng nm. Vic pht hin ra sm da vo bnh nhn b bnh cu thn nhng c hng cu niu v protein niu ko di v xut hin thm cc triu chng: ph, cao huyt p, thiu mu nn rt d pht hin sm cng ng. 5. IU TR 5.1. iu tr triu chng v bin chng - Ngh ngi, n nht v dng li tiu khi c ph v cao huyt p. - Khi huyt p cao th: + n nht, hn ch nc a vo. Khi c suy thn cn hn ch protid trong khu phn thc n. + Li tiu: Lasix 40mg x 1 vin/24h. C th cho liu cao hn nu vn cn ph. + Thuc h p cc nhm thuc u dng c. Khi c suy tim th khng dng thuc chn giao cm. Niphedipin 20mg x l - 2 vin/24h Coversyl 40mg x 1-2 vin/24.... Nu bnh nhn p ng tt vi nhm c ch men chuyn c th gip bo v nhu m thn lu di - Cho khng sinh khi c t vim nhim: Cn cho dng cc khng sinh thch hp, trnh cc khng sinh c cho thn, dng ko di t 7 - 14 ngy. i vi vim hng th tt nht l Penicilhn hoc Ampicihn 5.2. iu tr bnh chnh nh Bnh ton th, h thng, chuyn ha: Lupus ban h thng hoc i tho ng... 5.3. iu tr bnh phi hp nh Hi chng thn h (nu c). 6. PHNG BNH 6.1. Phng bnh vim cu thn cp Phng vim hng v chng cc nhim trng da. 6.2. Pht hin sm bnh bng cch xt nghim nh k nc tiu nhng bnh nhn b vim cu thn 6.3. Phng v iu tr cc yu t gy vim cu thn mn nng thm - iu tr cao huyt p nu c - iu tr cc nhim khun nu c46

- Hn ch khng nn c thai nhng bnh nhn vim cu thn mn - Hn ch m khi bnh nhn c biu hin suy thn - Khng dng thuc c vi thn Vim cu thn mn l bnh hay gp, vic iu tr vim cu thn mn mc ch chnh l iu tr bo tn, phng cc yu t nguy c dn n s tin trin nhanh ca bnh l vn ht sc quan trng trong qu trnh ko di cuc sng ca ngi bnh.

SUY THN MN1. I CNG 1.1. nh ngha Suy thn mn l hu qu cc bnh mn tnh ca thn gy gim st t t s lng Nephron chc nng lm gim dn mc lc cu thn. Khi mc lc cu thn gim xung di 50% (60ml/pht) th c gi l suy thn mn. Suy thn mn l mt hi chng lm sng v sinh ha tin trin mn tnh qua nhiu thng, nm, hu qu ca s x ha cc Nephron chc nng gy gim st t t mc lc cu thn dn n tnh trng tng nitphiprotein mu. c trng ca suy thn mn l: - C tin s bnh thn tit niu ko di. - Mc lc cu thn gim - Nitphiprotein mu tng cao dn. - Kt thc trong hi chng m mu cao. 1.2. c im dch t Suy thn mn l mt bnh tng i ph bin v hay gp trong cc bnh thn tit niu. Theo thng k ca PGS Trn Vn Cht v Trn Th Thnh (1991 - 1995) ti Khoa Tit niu Bnh vin Bch Mai th suy thn mn chim 40,4% v khng thy c s khc bit gia nam v n. Ring tui 16 - 24 th thy nam nhiu hn n. Khng thy c s khc bit gia cc vng, a d, la tui hay gp l la tui lao ng t 16 54 tui nn nh hng rt nhiu ti sc khe ca cng ng. 1.3. Nhng yu t lm bnh nng thm Suy thn mn l mt bnh ko di hng thng, hng nm c nhng yu t lm thc y qu trnh suy thn: - Cao huyt p - Nhim khun, xut huyt tiu ha, mt nc - Tc ng dn niu - n qu nhiu protid - Dng thuc c vi thn - Ri lon nc in gii: a chy mt nc, dng Lasix qu nhiu...47

Nn vic lm gim cc yu t nguy c trn s c ngha ko di qu trnh suy thn lm ko di tui th cho bnh nhn. 2. NGUYN NHN GY BNH Hu ht cc bnh mn tnh khi pht l bnh cu thn, bnh ng k thn hay bnh mch thn u c th dn n suy thn mn. 2.1. Bnh vim cu thn mn: thng hay gp nht chim t l 40% - Do vim cu thn cp dn n - Do vim cu thn nhng bnh nhn c bnh chuyn ha, h thng - Do bnh cu thn c hi chng thn h 2.2. Bnh vim thn, b thn mn Chim t l khong 30% 2.3. Bnh vim thn k Thng do dng thuc gim au lu di, hoc do tng acid uric, tng calci mu 2.4. Bnh mch thn - X mch thn lnh tnh hoc c tnh - Huyt khi vi mch thn - Vim nt quanh ng mch - Tc tnh mch thn 2.5. Bnh thn bm sinh (di truyn hoc khng di truyn) - Thn a nang - Lon sn thn - Hi chng Alport - Bnh thn chuyn ha Qua trn thy nguyn nhn hay gp l bnh vim cu thn mn v vim thn, b thn mnh do vic khai thc tin s ca bnh nhn v pht hin hai nguyn nhn ni trn iu tr sm c ngha rt quan trng trong vic gim t l ca bnh suy thn mn. 3. TRIU CHNG LM SNG V CN LM SNG CA SUY THN MN Mc du tn thng khi pht cu thn, h mch thn hay t chc k thn th cc Nephron b thng tn nng cng s b loi khi vai tr chc nng sinh l. Chc nng ca thn ch c m bo nguyn vn bi cc Nephron nguyn vn cn li. Khi khi lng Nephron chc nng b tn thng qu nhiu, s cn li khng cn duy tr s hng nh ca ni mi th bt u xut hin cc bin lon v nc in gii, v tun hon, v h hp, v tiu ha, v thn kinh to nn hi chng suy thn mn. 3.1. Triu chng lm sng 3.1.1. Ph48

- Suy thn mn do vim thn, b thn thng khng c ph. Bnh nhn thng i nhiu do tn thng nng k thn, giai on cui c th c ph do c km cao huyt p v suy dinh dng, suy tim. - bnh nhn suy thn mn do vim cu thn mn thng l c ph (tr giai on i nhiu). Ph y c th do hu qu ca hi chng thn h, do suy tim kt hp v do cc yu t ni tit khc gy gi mui v gi nc. 3.1.2. Thiu mu - Thng gp, nng nh tuy theo giai on, suy thn cng nng th thiu mu cng tng. y l mt du hiu qu trn lm sng chn on phn bit vi nhng trng hp m mu cao do cc nguyn nhn cp tnh. - Thiu mu a s l bnh sc hnh th kch thc bnh thng c khi c hng cu to nh khng u. Nhiu bnh nhn c chn on khi n khm v thiu mu. - Thiu mu rt kh hi phc do thn khng sn xut Erythropoietin l yu t cn thit c ha tin hng cu. 3.1.3. Tng huyt p - Tng huyt p thng gp chim khong 80% bnh nhn c tng huyt p C bit c bnh nhn c t tng huyt p c tnh lm chc nng thn suy sp nhanh chng dn n t vong. 3.1.4. Suy tim - Khi xut hin thng mun v thng do gi mui, nc v tng huyt p lu ngy ca qu trnh suy thn mn. 3.1.5. Vim ngoi tm mc - Ting c mng tim l mt biu hin giai on cui cng ca suy thn mn v l du hiu bo hiu t vong t 1 - 4 ngy nu khng c lc mu hoc iu tr tch cc. 3.1.6. Nn, a chy - Triu chng tiu ha ca suy thn mn giai on u thng l chn n, giai on III tr i th c bun nn, a chy. C khi c xut huyt tiu ha, c lot hoc khng lot. 3.1.7. Xut huyt - Chy mu mi, chy mu chn rng, chy mu di da l thng gp. C trng hp tiu cu gim rt kh cm mu. Xut huyt tiu ha nu c th me mu s tng ln rt nhanh. 3.1.8. Nga L mt biu hin ngoi da thng gp do lng ng calci trong da. y l triu chng gi ca cng cn gip trng th pht.49

3.1.9. Chut rt - Thng xut hin ban m c th l do gim nghi v calci mu. 3.1.10. Vim thn kinh ngoi vi - Tc dn truyn thn kinh gim. Bnh nhn c cm gic rt bng chn, kin b. Cc triu chng ny rt kh iu tr k c lc mu ngoi thn. 3.1. 11. Hn m - Hn m do m mu tng cao l biu hin lm sng cui cng ca suy thn mn. giai on tin hn m bnh nhn c th c co git, c ri lon tm thn. Nhng triu chng lm sng rt hay gp l: ph, thiu mu, tng huyt p, do da vo cc triu chng chnh ny ti tuyn c s c th chn on c bnh suy thn mn. 3.2. Biu hin cn lm sng 3.2.1. Mc lc cu thn gim - Cng gim nhiu suy thn cng nng 3.2.2. Nitphiprotein tng cao - Ur mu trn 50mg% l bt u tng - Creatinin mu l, 5mg% l tng r - Acid c cng tng - Ur mu ph thuc vo ch n v qu trnh ging ha ca c th (nhim khun, xut huyt, mt mu thng tng nhanh). - U r mu v creatinin mu tng song song l biu hin ca suy thn n thun. - U r mu tng nhiu v creatinin mu tng t l biu hin tng m ngoi thn 3.2.3. Natri mu thng gim Kali mu bnh thng hoc gim. Khi kali mu cao c biu hin t cp c km theo thiu niu hoc v niu. 3.2.4. pH mu gim Suy thn giai on III - IV, pH mu s gim, d tr kim gim. 3.2.5. Calci mu gim Phospho mu tng C kh nng cng cn gip trng th pht. 3.2.6. Protein niu suy thn mn giai on III-IV bao gi cng c nhng khng cao. Nu l vim thn b thn th ch di lg/24h, nu l vim cu thn mn th khong 2 n 3g/24h. 3.2.7. Hng cu niu Nu c i mu th phi ngh n si tit niu trong vim cu thn mn cng c hng cu trong nc tiu.50

3.2.8. Bch cu niu v vi khun niu Trng hp suy thn do vim thn b thn mn c khi c i m. 3.2.9. Tr niu C tr ht hoc tr trong l du hiu ca suy thn mn. 3.2.10. Ur niu Suy thn cng nng m niu cng thp, giai on cui ch o thi c 64g/24h. 3.2. 11. Th tch nc tiu Giai on u nc tiu nhiu 2-3 lt/24h, i nhiu v m l du hiu ca suy thn mn, suy thn mn nng nc tiu vn c 500-800ml/24h. C i t, v niu l c t cp, hoc l suy thn mn giai on cui. 4. CHN ON 4.1. Chn on xc nh Suy thn mn do bnh cu thn: + C tin s ph + Ph - cao huyt p - thiu mu + U r mu, creatinin mu cao, mc lc cu thn gim. + Protein niu 2 - 3g/24h. - Suy thn mn do bnh vim thn b thn mn: + C tin s nhim khun tit niu + Cao huyt p - thiu mu. + U r mu, creatinin mu cao, mc lc cu thn gim. + Protein niu c nhng t khng qu lg/24h. + Bch cu niu bao gi cng c, vi khun niu c th c hoc khng. tuyn c s c th da vo cc triu chng trn ngh n bnh nhn b suy thn mn v nu c iu kin th lm cc xt nghim m mu, creatinin mu chn on xc nh. 4.2. Chn on phn bit - t cp ca suy thn mn da vo: + Tin s + T l ur mu / creatinin mu >40 + Mc thiu mu tng xng mc suy thn 4.3 Chn on giai onGiai on Suy thn mn Mc lc cu thn (ml/pht) Creatinin mu mol/1 mg/dl 51 Lm sng

Bnh thng I II IIIa IIIb IV

120 60-41 40-21 20-11 10-05 900 > 10

Da vo triu chng lm sng: thiu mu v cm gic n tuyn c s c th chn on sm c giai on ca suy thn mn ra quyt nh iu tr sm. 5. IU TR 5.1. iu tr bo tn 5.1.1. Chng cc yu t gy nng bnh - Cao huyt p - Nhim khun (khng dng cc thuc khng sinh c vi thn) - iu chnh nc v in gii - Khng dng thuc c cho thn 5.1.2. Trnh cc sai st thng mc phi - Dng li tiu khng ng: Dng Lasix gy mt nc, Hypothiazid gy gim mc lc cu thn.- n nht qu mc ko di khng cn thit gy gim natri mu

- Dng thuc c cho thn gy gim mc lc cu thn: Gentamycin, Kanamycin... - Dng thuc qu liu so vi chc nng thn: V d: Digitoxin d gy lon nhp tim nhng bnh nhn suy thn, mc d liu khng cao so vi ngi bnh thng. 5.1.3. iu tr theo giai on - Suy thn giai on 1 v 2 +n t m hn bnh thng. + iu chnh huyt p: Aldomet 250mg x 2-4vin/24h, c th dng Propranolol, Nifedipin... + n nht nu c ph v cao huyt p + Li tiu nu c ph v tng huyt p - Suy thn giai on III: + Ch n l bin php ch o hn ch m mu tng, protid = 0, 5kg/24h, m bo vitamin, tng cm bng bt t m. m bo cc acid quan52

bng trng, sa trong thc n. cui giai on 3 ch nn cho vi mt ngi sng: 20g protid m bo 1800 - 2000 calo/24h. + Mui: n nht khi c ph, cao huyt p. + Nc: ch ung bng lng nc tiu 24h + Kali: giai on u thng khng tng kim mu, cui giai on 3 c th tng kim mu nn hn ch cc rau qu v thc n c nhiu khu. + Calci: cho vitamin D v calci khi c calci mu gim + Kim: cho khi c toan mu + Tr tim: khng dng ko di, gim liu lng khi c suy thn nng + Chng thiu mu: c th truyn mu, khi hng cu cho vin st, Erythropoietin - Suy thn giai on IV + Lc mu ngoi c th l ch nh bt buc, c iu kin th ghp thn 5.2. Lc mu ngoi thn - Ch nh bt buc: giai on IV - Ch nh sm: giai on IIIb - Suy thn mn l mt hi chng din bin qua nhiu giai on v ko di nhiu nm. iu tr rt phc tp v t kt qu, c nhiu bin chng nng n nn cn phi sm pht hin v iu tr sm cc bnh tit niu phng dn n suy thn mn

VIM I B THN CP, MN1. I CNG 1.1. nh ngha Vim i b thn l nhim khun t chc k ca thn nguyn nhn do vi khun. giai on cp ca bnh c th cha khi hon ton nu c loi b nguy c v nguyn nhn gy bnh. Nu b ti pht nhiu ln s chuyn thnh mn, v hu qu cui cng s dn n suy thn mn. Bnh nhn c th t vong do bin chng suy thn mn, do nu c pht hin sm, iu tr ng v trit bnh nhn phc hi hon ton. 1.2. c im dch t Vim i b thn cp v mn l mt bnh gp nhiu n, gp mi la tui nht l la tui lao ng v hot ng sinh dc nhiu. N gii c s lin quan vi tnh trng c thai. Theo J.Conte khi nghin cu cng ng bnh chim t l 10% dn s. Ti khoa Thn Bnh vin Bch Mai (1997- 2000) c 17% bnh nhn b suy thn l nguyn nhn do vim i b thn mn (PGS. Trn Vn Cht). Trong nhm nguyn nhn do si chim 27% v nhiu thng k cho thy vim i b thn mn l nguyn nhn ng53

hng th hai dn n suy thn. Qua trn ta thy vim i b thn mn l bnh hay gp c nguy c dn n suy thn do vic tuyn truyn gio dc cho cng ng nhng nguy c gy bnh s gim bt t l mc bnh. 2. NGUYN NHN GY BNH V C CH BNH SINH 2.1. Nguyn nhn 2.1.1. Nguyn nhn do vi khun - Vi khun Gram (-) chim khong 90% cc trng hp: + E. Coli: 60-70% + Klebsiella: 20% (15-20%) + Proteus mirabilis: 15% (l0-15%) + Enterobacter: 5- 10% + V mt s vi khun Gram (-) khc. - Vi khun Gram (+) chim < 10% + Enterocoque: 2% + Staphylocoque: 1% + Cc vi khun khc: 3-4%. 2.1.2. Nguyn nhn thun li L nguyn nhn gy tc nghn ng bi xut nc tiu, gy tr dng nc tiu, to iu kin cho nhim trng v khi c nhim trng th duy tr nhim trng. V vy vim i b thn xy ra trn mt bnh nhn c tc nghn dng nc tiu thng rt dai dng v nng. - Cc nguyn nhn thng gp l: + Si thn tit niu + U thn tit niu + U bn ngoi p vo niu qun + U tuyn tin ht + D dng thn, niu qun - Cc nguyn nhn khc: + Thn a nang + Thai nghn + i tho ng Cn khm ton din, chp thn khng chun b, UIV, siu m thn, UPR pht hin cc nguyn nhn thun li iu tr trit trnh tin trin bnh nng thm. 2.2. C ch bnh sinh Ch yu l ng ngc dng c th l nhim khun ngu nhin. n t l54

thng cao hn, nam t l thng t gp hn do ng niu o di, hp hn, xa l hu mn hn. Cht tit ca tuyn tin lit cng c kh nng st khun. - Vi khun c th n gy vim i b thn qua ng mu v ng bch tuyt nhng him gp hn. 3. TRIU CHNG LM. SNG V CN LM SNG CA VIM I B THN CP V MN 3.1. Vim i b thn cp - Hi chng bng quang: i trut, i dt, i mu, i m cui bi. Tuy nhin hi chng bng quang c th xut hin trc khi c vim i b thn cp. Khi c triu chng vim i b thn cp th triu chng vim bng quang nn d b qua chn on. - au vng tht lng + Thng au mt bn, nhng cng c khi au c hai bn + au m thnh thong tri thnh tng cn. + V hng lng (+) l triu chng rt c gi tr, nht l trong trng hp ch c au mt bn - Khm c th thy thn to v au. - Triu chng ton thn - Bnh nhn c hi chng nhim trng: st cao, rt run, mi kh, lu. bn, c th thy du hiu mt nc do st. -Nc tiu c c th c i m i th, bch cu niu dng tnh, vi khun niu dng tnh, Protein niu c nhng 38,50C c th dng tnh. - Siu m thn: + Thn hi to hn bnh thng + i b thn gin + C th thy nguyn nhn thun li nh si, thn a nang... - X quang: + Chp bng khng chun b nu nghi ng c si. + C th thy nguyn nhn thun li gy tc nghn ng bi niu. 3.2. Vim i b thn mn 3.2.1. Vim i b thn mn giai on sm - Tin s nhim khun tit niu, vim i b thn cp nhiu ln hoc c tin s55

c bnh gy tc nghn ng bi tit nc tiu. - au vng tht lng - Tiu tin v m tng t nht mt hoc nhiu ln trong mt m gi chc nng c c ca thn gim. - C th c cao huyt p. - Thiu mu nh hoc khng. - Protein niu thng xuyn nhng thng < lg/24h - Bch cu niu nhiu, bch cu a nhn thoi ha dng tnh s bch cu a nhn tng khi c t cp. - Vi khun niu dng tnh khi c t cp. - Kh nng c c nc tiu gim: + Lm nghim php c c, t trng ti a khng vt qu 1,025. + Lc ny mc lc cu thn cn bnh thng gi l c s phn ly chc nng cu thn, ng thn. y l mt xt nghim c gi tr trong chn on vim thn mn trong giai on sm. - Siu m thn c th thy b thn g gh, thn teo nh t, i b thn gin t. - Chp thn (UIV) thy tn thng i b thn mc khc nhau. 3.2.2. Vim i b thn mn giai on mun Ngoi nhng triu chng trn xut hin thm: - Suy thn (Suy chc nng lc): + Mc suy thn t nh n nng, khi suy thn mc nng c th c cc triu chng ca hi chng m mu cao trn lm sng v c th c ph. + Ur mu tng creatinin mu tng: bnh nhn y triu chng ca hi chng tng nh mu biu hin cc c quan: tiu ha, thn kinh, tun hon, h hp, c th c xut huyt... + Mc lc cu thn gim. - Thiu mu r: mc nng nh ca thiu mu i i vi giai on ca suy thn mn. - Da xanh, nim mc nht, s lng hng cu hemoglchin v hematocrit mu gim - Tng huyt p: (>80%) c th tng va hoc tng rt cao. - Siu m v X quang thn: hai thn teo nh nhng khng u, x ha c th thy nguyn nhn thun li: si, d dng ng niu... 4. CHN ON 4.1. Chn on xc nh - Vim i b thn cp:56

Da vo tam chng c in: + Bnh nhn c hi chng nhim trng: st cao, rt run. + au mi vng tht lng + i but, i dt, i mu, i m, nc tiu c bch cu, t bo m v vi khun. - Vim i b thn mn: Da vo cc triu chng sau: + C tin s vim i b thn cp ti pht nhiu ln + Suy thn: hi chng tng m mu, tng huyt p, ph, thiu mu. + Siu m thn hoc chp X quang thn thy thn teo nh khng u. 4.2. Chn on phn bit 4.2.1. Vim i b thn cp phn bit vi t cp ca vim i b thn mn Vim i b thn mn t cp c cc triu chng ca vim i b thn cp ngoi ra c thm triu chng suy thn, siu m thn v X quang thn thy thn teo nh khng u. 4.1.2. Vim i b thn mn - Giai on tim tng phn bit vi cc bnh gy i nhiu nh: i tho ng, i nht... Ch yu phn bit da vo triu chng ca cc bnh trn - Vim thn k do ung qu nhiu thuc gim au, chng vim: da vo tin s - Vim thn b thn k do tng acid c mu, tng calci mu: da vo in gii v khng c triu chng nhim khun. - Thn teo mt bn bm sinh: thn teo nh mt bn nhng khng c triu chng nhim khun, da vo X quang v siu m thn chn on xc nh. Nh vy tuyn c s c th da vo bnh nhn c hi chng nhim trng, hi chng bng quang v au mi vng tht lng ngh ti vim i b thn cp. Nu bnh nhn c tin s nhim trng ng tit niu ti pht nhiu ln, c hi chng bng quang v i tiu nhiu v m l c th ngh n vim i b thn mn. 5. IU TR 5.1. iu tr vim i b thn cp Dng khng sinh chng nhim khun: - Tt nht l cy nc tiu tm vi khun gy bnh v lm khng sinh , da vo kt qu khng sinh dng khng sinh cho thch hp. Trong khi ch kt qu cy vi khun v khng sinh cn cho khng sinh ngay. Nu vi ba ngy iu tr, triu chng lm sng khng bt s iu chnh khng sinh theo kt qu khng sinh . - Cc khng sinh thng dng hin nay cho vim i b thn cp l:57

+ Nhm Quinolon: Peflacin, Nonoxacine... + Cephalosporin: Zinnat, Fortum... + Nhm Aminosid: Amikacin, Gentamycin... + Nhm lactamin: Ampicillin, Unasyn... - Dng liu cao v phi hp khng sinh, thi gian dng khng sinh t nht l 2 tun l. Trong trng hp c bit nh trc khun m xanh hoc t cu vng hoc khi vim t tuyn tin lit, khng sinh c th dng ko di 1 thng. - Khi ngng khng sinh 5 ngy cy li nc tiu tm vi khun niu (m tnh), UIV khng c tn thng coi nh khi hn. 5.2. iu tr vim i b thn mn - Khng sinh chng nhim khun dng khng sinh khi c t cp ca vim i b thn mn. Cn lu la chn khng sinh khng c vi thn, khng lm gim mc lc ca cu thn v lu chnh liu khng sinh theo mc suy thn - iu tr triu chng: + iu tr tng huyt p + iu tr thiu mu + iu tr suy thn bng iu tr bo tn ni khoa hoc iu tr thay th thn suy tu tng giai on ca suy thn. 5.3. iu tr chung cho vim i b thn cp v mn - Ung nhiu nc m bo nc tiu >l,5l/24h. - Loi b c cc nguyn nhn thun li: m ly si, iu tr u tuyn tin lit... 6. PHNG BNH - m bo v sinh trnh vim thn ngc dng - Trnh cc th thut khng cn thit: thng i... - Loi b cc yu t nguy c. - Khi c suy thn: + m bo ch n + Dng khng sinh khng c vi thn + iu tr tng huyt p, ph, thiu mu (nu c)

VIM BNG QUANG, NIU O1. I CNG 1.1. nh ngha L tnh trng nhim trng cp tnh hay mn tnh bng quang, niu o.58

1.2. c im dch t Vim bng quang, niu o l mt bnh l rt thng gp vi cc triu chng i dt, kh i v i m, bnh khng dn n t vong nhng gy kh chu nh hng n sc khe ca ngi bnh, nu bnh khng c chn on v iu tr sm th s dn n vim thn ngc dng v hu qu cui cng dn n suy thn mn. Nu c chn on v iu tr sm th trnh c nguy c suy thn ng tic xy ra... Theo J. Con te nghin cu cng ng thy vim bng quang, nim o chim 10% dn s, bnh gp nhiu n gii, t l n/nam - 9/1. tui gi th 2 gii bng nhau. Bnh khng lin quan n ni sng, gp rt nhiu la tui lao ng v hot ng sinh dc nhiu. 2. NGUYN NHN GY BNH 2.1. Nguyn nhn vi khun - E.coli: 60 - 70% - Lin cu - T cu - Trc khun m xanh - Lao - Cc vi khun khc 2.2. Yu t thun li - L nguyn nhn tc nghn bi sut nc tiu gy tr dng nc tiu to iu kin cho nhim trng v khi c nhim trng th duy tr nhim trng v vy vim bng quang, niu o xy ra trn bnh nhn c tc nghn ng tit niu thng rt dai dng v nng - Cc nguyn nhn thng gp l: + Si bng quang, niu o. + U tuyn tin lit + Ung th b phn sinh dc ngoi + Ung th c bng quang + B i ko di - Cc nguyn nhn khc: + Hp niu o bm sinh + L thng bng quang trc trng + Thng i 3. TRIU CHNG LM SNG V CN LM SNG 3.1. Triu chng lm sng Ba triu chng quan trng l:59

- i dt (hay i tiu) - Kh i (au trc, trong v sau i tiu) Cm gic but mt lc cui, nhiu khi au d di, chut rt lan ti quy u n hai bn v hu mn - i m: nc tiu c ton b nhng ch yu l u bi v cui bi cn vn c kh c c khi ln i mu nu c vim bng quang xut huyt. - Triu chng ton thn: bnh nhn c th c hi chng nhim trng cp tnh. 3.2. Triu chng cn lm sng - Xt nghim nc tiu thy t bo biu m, t bo m. - Cy nc tiu c th tm thy vi khun gy bnh. - Soi bng quang thy nim mc xung huyt c nhng gi mc v c nhiu vt lot. 4. CHN ON 4.1. Chn on xc nh - Da vo i m phi hp vi i kh v i dt - Cy nc tiu tm vi khun gy bnh v lm khng sinh 4.2. Chn on phn bit Vi cc bnh ly qua ng tnh dc: - Bnh nhn c tin s tip xc vi ngun ly - Xt nghim m chn on xc nh 5. IU TR - Loi tr nguyn nhn gy cn tr ng bi niu (nu c th) - Dng khng sinh theo khng sinh - Gim au, an thn, chng co tht - Ngm mng vo nc m Giai on mn tnh cc th thuc khng sinh thng khng c hiu qu thng i tho sch nc tiu cn li trong bng quang ri bm cc thuc st trng (Nitrat bc 0,05% hoc 0,l%). 6. PHNG BNH - iu tr trit t cp. - iu tr cc nguyn nhn gy cn tr ng bi niu - V sinh c nhn.

SC60

M U Danh t sc c dng trong lm sng ch cc trng hp tt huyt p, tru tim mch hoc suy tun hon cp. Thc ra trong sc ngoi vn tru tim mch cn c cc biu hin khc ca mt tnh trng ti mu cc t chc b suy sp. y chnh l cn nguyn ca cc biu hin trong sc. Nh vy sc ch l mt biu hin nng do nhiu nguyn nhn gy nn. Vic x tr sc i hi phi khn trng, chnh xc v cn tm nguyn nhn iu tr tn gc. 1. NH NGHA Sc l tnh trng thiu oxy t chc do nguyn nhn tun hon, thc cht l thiu ti mu t chc, biu hin trn lm sng bng cc du hiu: - Mt ti, tm cc u chi, mng tm trn da, khi n vo cc chi th nht i v chm tr li - Da lnh, mi, cc u chi lnh, tot m hi - Mch nhanh, huyt p h, HA dao ng v kt - Nhp th nhanh - V niu (Di 50ml trong gi u - ng thng) - in tm c ri lon ti cc 2. CC BIU HIN LM SNG, CN LM SNG 2.1. Lm sng - H huyt p: khng c con s cng nhc cho huyt p. Nu bit c s huyt p lc bnh thng th rt tt. Trong tru mch HA tt nhanh t ngt m khng dao ng, cn trong sc HA thng dao ng trc khi try mch. Trong sc HA thng kt - khong cch HA ti a v ti thiu nh do c tr tun hon. Thng o p lc tnh mch trung tm trong sc nhm gip chn on v theo di sc. Thng t 0-5cm nc. Nu p lc gim thng sc do gim th tch, nu tng thng do suy tim hoc p tim cp - Nhp tim thng nhanh hoc rt nhanh, nhng trong ng c gacdenal hoc meprobamat thng chm hoc sc nhi mu c tim mch li bnh thng... - thc: bnh nhn thng tnh hoc c lo s ht hong, cng c khi l kh tip xc c khi hn m, nu hn m phi ngh n nguyn nhn ng c, chn thng s no - Da: da thng lnh, tot m hi, c mng tm. i khi da li nng do gin mch, l trng hp sc nng him gp hn (sc nhim khun) - Nc tiu: nn theo di bng ng thng. Thng trong sc lng nc tiu gim hoc v niu, khi nc tiu tng chng t tin trin tt. - Thn nhit: thng tng trong sc nhim khun, lc u rt run sau nhit 61

c th v bnh thng. Ch cy mu cho bnh nhn khi st - Nhp th: khi c sc nng nhp th nhanh v su do tng thng kh tin pht. Ch tm cc tn thng ng h hp - Cc biu hin khc: khm ton thn tm nhng tn thng, tm nguyn nhn: thm m o, trc trng cn thn. Ch tm du hiu xut huyt ni, du hiu thng tng rng, du hiu vim tu.... 2.2. Cn lm sng - in tm : thng c ri lon ti cc T (-) v ST (-). Nu sc do nhi mu c tim s c Q v QS l c hiu. Cng c th thy cn nhp nhanh hoc tc nh tht hoc blc nh tht - Natri mu thay i, c th thy nam niu gim, kim mu tng - Ur huyt tng, m niu tng hoc gim. Ur niu cao chng t c suy thn chc nng nhng nu gim c th do tn thng thn khi truyn dch nht l dch c nghi phi cn nhc k. - ng huyt thng tng lc u - Thng bng kim toan: thng khng c ri lon ng k v thng bng kim toan trong sc nu sc nng c th thy tng lactat mu. - Men: CK, AST, ALT tng trong sc do nhi mu c tim, c th tng trong mt s sc khc. Amylase tng trong vim tu cp - ng mu: sc nng c th dn n ng mu trong mao mch xt nghim c Fibrrin gim, Prothrombin gim, tiu cu gim... ng mu ni mch l hu qu ca sc ch khng phi l nguyn nhn gy sc 3. CHN ON Trn lm sng khi c bnh nhn tru mch, tt huyt p ngi ta thng ngh n sc. chn on sc cn phi i chiu cc biu hin nh mch, huyt p, nhp th, thn nhit, da mt... nh nu nh ngha. Cn thm khm cc c quan, lm cc xt nghim tm cc du hiu lm sng v cn lm sng ca sc. Khi iu kin khng cho php khng th lm c cc xt nghim ngi ta cn c vo cc du hiu lm sng nht l huyt p, tnh trng tun hon, h hp chn on sc. Trn thc t ngi ta phn ra cc loi sc theo nguyn nhn v mi loi sc c c im ring c th nhn thy v x tr kp thi 4. PHN LOI V NGUYN NHN GY SC Phn loi sc thng da vo c ch bnh sinh v nguyn nhn gy sc l ng n v d hiu nht. Tuy nhin cng c nhng phn loi da trn tnh cht ca sc: sc tin pht gm cc nguyn nhn thn kinh v d ng, thng xut hin nhanh, khi nhanh hoc cht. Sc chm thng xut hin mun tin trin chm, iu tr phc tp Phn loi theo nguyn nhn bao gm cc sc sau y:62

* Sc do tim: Thng do nhi mu c tim, nhi mu phi gy tnh trng tm ph cp. Ngoi ra cn c cc nguyn nhn khc nh nhim c nc cc, quinidin, nhim khun thng hn, bch hu. C khi do cc nguyn nhn ri lon nhp qu nhanh hoc qu chm, ngay sau m tim, p tim do trn mu, trn dch mng ngoi tim cp... Thng sc nng trn bnh nhn c bnh tim t trc, x tr rt kh khn * Sc gim th tch Thng do mt mu trong chy mu tiu ha, cha ngoi t cung v, v lch, phu thut. Do mt huyt tng trong bng, vim phc mc, vim tuy Mt nc, mt mui do nn ma, a chy cp nhim khun, tc rut, hn m tng p lc thm thu, suy thng thn cp * Sc nguyn nhn thn kinh, ng c, d ng lm gim tun hon ngoi vi: in hnh l sc phn v. Thng xy ra sau khi tim hoc ung mt cht c tnh khng nguyn nh khng sinh, cc peptid l hoc mt s thc n. Biu hin rm r bng ph n ton thn, ph n ng h hp, tru tim mch, tnh trng nng c th t vong. X tr khn trng v ng phc c th cu c bnh nhn * Sc nhim khun: Xy ra trn bnh nhn c nhim khun nng t trc li c mt mu mt nc, mt mui hoc c bnh tim phi hp. Cng c khi xy ra sau truyn mu, truyn dch b nhim khun. Thng l sc ni c t nhng cng c khi do cc vi khun c ngoi c t nh t cu, lin cu, trc khun m xanh... * Sc chn thng: Xy ra sau cc chn thng nng, a chn thng. Cc sc chn thng c nhiu c ch gy nn: mt mu, mt huyt tng, au n, nhim c sn phm chuyn ha ca cc t chc p nt... iu tr kh khn o tn thng thng ln v nghim trng. 5. NGUYN TC X TR SC NI CHUNG Tu theo nguyn nhn c cch x tr ring bit. y l 10 ng tc c bn khi x tr sc - S cu chy mu nu c - m bo thng kh: oxy, ht m di, ni kh qun hoc h hp nhn to khi cn - o huyt p, ly mch - t catheter tnh mch trung tm, qua o p lc tnh mch trung tm, ly mu lm xt nghim, truyn dch qua catheter thng thng hoc dch cao phn t hoc truyn mu nu cn - Ghi in tim, in no, t my monitor theo di tim mch - t ng thng bng quang ly nc tiu xt nghim, theo di lng nc tiu63

tng gi. + Ly nhit , nu st phi cy mu. + Chp phi ti ging + Theo di tnh cht, khi lng phn, nu c a chy ly phn soi ti tm a mp, vi khun, cy phn Tm v x tr nguyn nhn gy sc Ti tuyn c s khng phi lc no cng c iu kin lm c mi bc x tr sc, thng ch thc hin c ba bc u sau truyn dch v nu c th duy tr huyt p bng Dopamin, Noradrenalin ri tm phng tin vn chuyn ln tuyn trn. Ch trong khi vn chuyn vn cn x tr tip tc. 6. CC LOI DCH TRUYN - Trong sc do gim th tch mu: dch truyn c s dng rt rng ri. Ngay sau khi t polyten TMTT truyn ngay dung dch nam clorrua 0,9%, glucose 5%, huyt tng, dextran, cc dung dch cao phn t nh hemacel, heasteril 6%, plasma... ni chung c th truyn bt c loi dch truyn no c trong tay trong khi ch mu truyn (ch khng truyn glucose 30%). Trong sc do mt nc mt mui: natriclorua 0,9%. Glucose 5%, bicarbonat 0,14%, c th cho thm khu vo dch truyn nhng cn nh gi kali mu - Tc v lng dch truyn ph thuc p lc TMTT, tnh trng sc v mc gim th tch mu - i vi sc nhim khun, sc chn thng: vic truyn mu ht sc cn thit v thng trong sc nhim khun c tan mu v xut huyt. Sc chn thng thng c chy mu nhiu khi chy mu v mt huyt tng nng. Khi khng c mu hoc huyt tng mi dng cc dch truyn nh nu trn. - Truyn dch trong sc cn ch phng ph phi cp bng cch theo di mch, huyt p, p lc tnh mch trung tm, nc tiu, th tch gan, tnh mch c, nghe tim, nghe phi. Khi c bt thng nn thn trng. Tm li cn tm tng quan gia chc nng tim tri v phi, gia khi lng nc tiu v p lc tnh mch trung tm. - Trong sc tim v sc phn v: vn truyn dch khng phi l c bn. Dch truyn ch va duy tr ng tnh mch cho php truyn cc loi thuc vn mch, tr tim... 7. CC THUC TRONG IU TR SC * Cc thuc co mch: Noradrenalin, Adrenalin, Dopamin: c tc dng co mch, nng huyt p. Cn c tc dng trong mt s nguyn nhn thn kinh nhim c, d ng, nhng khng nn lm dng khi dng qu 6 gi khng thy hiu qu phi ngng Noradrenalin 4mg trong 500ml glucose 5% nh git TM. Adrenalin ung tim bp trng bm tim TM c tc dng trong sc phn v, sc d ng. Dopamin: ng 5064

m pha long truyn tnh mch. Bt u liu 2-5g/kg/ pht sau tng dn ln 7lo~g/kg/ pht, c th tng liu ln n 20g/kg/ pht. Khng pha vo cc dung dch kim. * Cc thuc kch thch th thbeta - Isoproterenol (isupren, novodrrin) c tc dng lm gin c trn trc v sau mao mch. Dng sau khi hi phc th tch mu m huyt p khng ln, hiu qu trong cc sc khng c gim th tch mu nh sc nhim khun, sc do tim - Cch dng: Isupren 1-2mg trong 500ml glucose 5% bc kn l thuc bng giy en truyn trong 6h. Khi mch nhanh >120 ln/ pht cn gim truyn hoc ngng hn * Corticoid: c th s dng hydrocortison hemisucinat (Solu-cortef), depersolon hoc Metylprednisolon (Solu-medrol) truyn nh git tnh mch hoc tim tnh mch chm * Tr tim: - Digitan ch dng khi c sc do tim da ph phi cp. Chng ch nh khi c sc do ng c digitan. Liu 0, 5mg Digoxin tim TM hoc truyn TM - Glucagon: 5-15mg tim hoc truyn TM c tc dng trong cc loi sc k c sc do ng c digitan * Chng toan mu: (ch s dng khi pH mu III, mt chc b c rng ca t c bnh no lch to n nh vy (95%) . - Da xanh, nim mc nht biu hin thiu mu nh (75%) . - St thng l st nh tng t khng r nguyn nhn (74%) . - Gan to thng l to t l-2cm di b sn, mt mm b sc (62%) . - Gy st thng gy st t nht l trong thi k c st, triu chng ny khng c hiu nhng hay gp (61%) . - Nghe tim c ting thi tm thu do thiu mu (90%) . - Hch to: thng l nhng vng c hch to sn nh vng trc c, bn ch to t, mt chc di ng d (36%) . - Xut huyt di da: giai on mn th khng c xut huyt di da, ch xut hin giai on chuyn dng cp. - Tc mch: do bch cu tng qu cao trong mu c th tc mch chi di gy au v ph tm, tc mch dng vt gy du hiu Priapison hoc tc mch no gy lit na ngi. 2.2. Xt nghim - Tng sinh dng bch cu ht trong mu ngoi vi thng l trn 80.000 bch cu/1mm3 c khi ti vi trm nghn bch cu, ngi ta thy t c loi bnh no gy tng bch cu n nh vy. - Cng thc bch cu ngi ta khng thy khong trng bch cu giai on mn tnh. Khi chuyn dng cp mi xut hin khong trng bch cu. - Hm lng vitamin B12 trong mu tng cao (bnh thng t 4.500 - 8.500 lt) - Men Phosphatase kim bch cu gim nng (bnh thng t 30 - 80%) . - Hm lng acid c tng cao (bnh thng t 4-5 mg%) - Tm c nhim sc th Philladelphy trong mu. - Tng s lng t bo tu trong tu m ch yu l ca dng bch cu, t non126

n trng thnh. - Thiu mu ng sc hng cu bnh thng. Trn y l nhng triu chng lm sng v xt nghim m chng ti sp xp theo th t da theo s thng gp v tnh cht quan trng ca n gip cho chn on. 3. CHN ON 3.1. Chn on phn bit Ni chung bnh Leucose kinh dng ht nm trong hi chng tng sinh tu c tnh. Ta ch cn phn bit vi mt bnh cng c lch to v bch cu cng tng cao l bnh lch to sinh tu. Trong bnh lch to sinh tu lch thng khng to bng Leucose kinh dng tu. Bch cu cng tng nhng t khi qu 50.000 bch cu trong mt ml trong : - Ch yu l tn cu cn bch cu ht ch cn chim 20% tu xng b x cng (Xc nh c khi ta chc tu lm tu ) v men Phosphatase kim bch cu bnh thng, vitamin B12 trong mu bnh thng, acid c mu bnh thng. + Chn on xc nh: da vo lm sng triu chng ch yu l lch to. Xt nghim: s lng bch cu tng cao khng c khong trng bch cu C nhim sc th Philladelphy trong mu. 3.2. Chn on giai on - Giai on mn tnh: bnh c chn on giai on ny d dng da vo lm sng l lch to, xt nghim bch cu tng cao, giai on ny iu tr thng p ng rt tt c th lch nh li, cng thc mu bch cu v bnh thng, men Phosphatase kim bch cu dn c tng ln. Trn lm sng khng cn triu chng ngi bnh c th sinh hot v lm vic bnh thng thi gian lui bnh c the ko di t 30 40 thng nu iu tr v theo di cn thn c th di hn. Cuc sng ngi bnh ch kt thc khi bnh chuyn dng cp. - Giai on chuyn dng cp: y l giai on cui cng ca bnh Leucose kinh dng tu n c nhng c im sau: - Mt s nhy cm vi iu tr. - Tnh trng lm sng nng ln: lch to nhiu xut hin thm st cao, xut huyt di da. . . - Mt kh nng bit ha t bo tu. Thi gian ny c th ko di 2 thng k t lc pht hin chuyn dng cp n khi t vong. Tuy nhin c bit cng c bnh nhn p ng vi iu tr (tt nh

Documents

Benh Hoc Noi Khoa Tap 2