TRNG I HC Y KHOA THI NGUYN B MN NI

BNH HC NI KHOATp 1

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

TH K: BS. Trng Vit Trng

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 nhng vn hc 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 l 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 lng 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 c hon chnh hn. Xin trn trng cm n! T/M BAN BIN SON TRNG B MN NI

BS. Chu. Doanh Thim Thun

1

MC LCTp 11. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.TNG HUYT P............................................................................................................. 3 HP VAN HAI L ........................................................................................................... 15 H VAN HAI L............................................................................................................. 24 H VAN NG MCH CH ........................................................................................ 29 HP VAN NG MCH CH ...................................................................................... 35 IU TR SUY TIM ........................................................................................................ 40 IN TM NG DNG TRONG LM SNG ..................................................... 44 HEN PH QUN ............................................................................................................. 57 VIM PH QUN CP, MN ....................................................................................... 64 VIM PHI THY .......................................................................................................... 70 P XE PHI..................................................................................................................... 74 LOT D DY T TRNG........................................................................................... 80 XUT HUYT TIU HA CAO.................................................................................... 86 VIM KHP DNG THP ............................................................................................ 91 XUT HUYT GIM TIU CU................................................................................ 100 I THO NG...................................................................................................... 104 BASEDOW..................................................................................................................... 115 BU GIP TRNG N THUN ........................................................................... 126 CHN ON V IU TR THN H TH PHT................................................ 132 TM PH MN............................................................................................................. 138 X GAN ......................................................................................................................... 144 P XE GAN DO AMP.................................................................................................. 150 CP CU NGNG TUN HON............................................................................... 157 IN GIT .................................................................................................................... 163 NGT NC ................................................................................................................. 167 RN C CN ............................................................................................................. 171 NGUYN TC X TR NG C CP .................................................................... 174 NG C BACBITURIC ............................................................................................. 179 NG C LN HU C............................................................................................. 182 NG C THUC CHUT T TRUNG QUC ....................................................... 186

2

TNG HUYT P1. I CNG 1.1. nh ngha Theo T chc Y t Th gii, mt ngi ln b tng huyt p thc s khi huyt p tm thu trn hoc bng 160mmHg v huyt p tm trng trn hoc bng 95 mmHg. - Huyt p tng gii hn khi huyt p tm thu t 140 - 160 mmHg v huyt p tm trng 90 - 95 mmHg. nh ngha ny n gin nhng c nhc im l tr s huyt p khng hon ton n nh v huyt p thay i theo gii, tui... 1.2. Dch t hc Tng huyt p l mt triu chng ca nhiu bnh, nhiu nguyn nhn nhng c th l mt, bnh tng huyt p nu khng tm thy nguyn nhn. 1.2.1. Th gii cc nc chu u - Bc M t l tng huyt p chim 15 - 20% ngi ln. C th: Hoa K 6 - 8% Thi Lan 6,8%; Chi L 19 - 21%. 1.2.2. Vit Nam T l tng huyt p chung l 11% (B Y t Vit Nam, 1989 T l ny gia tng ng quan tm v trc nm 1975 t l ny min Bc Vit Nam ch c 1 - 3% (ng Vn Chung - 1971). 2. NGUYN NHN V CC YU T THUN LI 2.1. Tng huyt p nguyn pht Chim gn 90% trng hp tng huyt p (theo Gifford - Weiss). 2.2. Tng huyt p th pht 2.2.1. Bnh thn Vim cu thn cp, vim cu thn mn, thn a nang, vim i b thn mn do nc, m i b thn, u thn lm tit renin, hp ng 2.2.2. Bnh ni tit - Bnh v thng thn nh: hi chng Conn, hi chng Cushing. - Bnh tu thng thn: u tu thng thn (hi chng Pheochromocytone). 2.2.3. Bnh tim mch - Bnh hp eo ng mch ch, h van ng mch ch. - Vim hp ng mch ch bng ch xut pht ng mch thn. 3

2.2.4. Do thuc Cc hormon nga thai, cam tho, corticoid, ACTH, cht gy chn n, cht chng trm cm vng... 2.2.5. Cc nguyn nhn khc - Ng c thai nghn: hi chng albumin niu. - Bnh cng gip, bnh Beriberi, bnh a hng cu, hi chng carcinoid, toan h hp, tng p lc s... 2.3. Mt s yu t thun li: c lin quan n tng huyt p nguyn pht l: 2.3.1. Yu t di truyn, tnh gia inh 2.3.2. Yu t n ung n nhiu mui, ung nhiu ru, ung nc mm t Ca+, Mg+, K+, n t protid. iu ni bt c tha nhn l s lin quan gia con Nay v tn sut bnh tng huyt p. ton Na+ lm tng huyt p qua trung gian gia tng th tch mu v qua s co thi mch mu. 2.3.3. Yu t tm 1 x hi, tnh trng cng thng stress thng xuyn 3. C CH BNH SINH CA TNG HUYT P NGUYN PHT Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh lin quan n h thn kinh giao cm, thn, Renin, angiotensin v c ch huyt ng, th dch khc. 3.1. Bin i v huyt ng 3.1.1. Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch phn b li mu lu thng t ngoi vi v tim phi. Do sc cn mch mu cng tng dn. Tim c biu hin tng hot ng b tr v dn n dy tht tri, huyt p v sc cn ngoi bin ton b tng dn. Lu lng tim v lu lng tm thu gim, cui cng dn n suy tim. 3.1.2. Trong cc bin i v huyt ng, h thng ng mch thng b tn thng sm v ton b. - Ti thn, tng sc cn mch thn, gim lu lng mu ti thn. Chc nng thn suy gim. - Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh thi k c tng huyt p r. - Khi huyt p tng, sc cn ngoi vi tng th tch huyt tng c xu hng gim cho n khi thn suy, th tch dch trong mu tng c th dn n ph. 3.2. Bin i v thn kinh 4

thi k u h giao cm nh hng s tng tn s tim v tng lu lng tim. S hot ng ca h thn kinh giao cm cn biu hin lng catecholamin trong huyt tng nh: Adrenalin, No-adrenalin cc cht ny rt thay i trong bnh tng huyt p h thn kinh t ng giao cm c iu khin bi h thn kinh trung ng hnh no - tu sng v c hai h ny lin h nhau qua trung gian cc th cm p lc. Trong tng huyt p cc th cm p lc c iu chnh n mc cao nht v vi ngng nhy cm cao nht. 3.3. Bin i v th dch 3.3.1. H Renin - Angiotensin - Aldosteron (RAA) Hin nay c chng minh c vai tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ng no gy tng huyt p qua cc th th Angiotensin II. Angiotensin II c tng hp t Angiotensinogne gan v di tc dng ca Renin s to thnh Angiotensin I ri chuyn thnh angiotensin II l mt cht co mch rt mnh v lm tng tit Aldosteron. S phng thch Renin c iu khin qua 3 yu t. p lc ti mu thn - lng Na n t ng ln xa v h thn kinh giao cm. S thm d h RAA da vo s nh lng Renin trc tip huyt tng hay gin tip phn ng min dch v Angiotensin II nhng tt nht l tc dng ca cc c ch men chuyn. 3.3.2. Vasopressin (ADH) c vai tr kh r rng trong c ch bnh sinh tng huyt p c tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm thn kinh trung ng i vi phn x t xoang ng mch cnh v quai ng mch ch) tc dng ngoi vi co mch (trc tip v qua hot ha cc si adrenergic). 3.3.3. Cht Prostaglandin tc dng trung ng lm tng huyt p, tc dng ngoi vi lm gim huyt p. 3.3.4. Ngoi ra cn c vai tr ca h Kalli - Krein Kinin (K.K.K) trong bnh tng huyt p v mt s h c vai tr cha r nh: H angiotensin trong no v cc encephalin, h cng dopamin bin i hot ng th cm p lc. Mt c ch iu ho lin quan n cc th cm p lc. Mt c ch iu ho lin quan n cc th th Imidazol trung ng v ngoi bin c ghi nhn t nhng nm 80 vi s xut hin thuc huyt p tc dng ln th cm Imidazole gy gin mch. 3.3.5. C ch sinh bnh ca tng huyt p th pht: Tu thuc vo nguyn nhn gy bnh. 4. TRIU CHNG HC 4.1. Lm sng 4.1.1. C nng a s bnh nhn b tng huyt p khng c triu chng g cho ti khi pht hin ra bnh. 5

- au u vng chm v hai bn thi dng. - Cc triu chng khc c th gp nh: hi hp, mt, kh th, m mt...nhng khng c hiu. - Mt s triu chng khc ca tng huyt p tu thuc vo nguyn nhn tng huyt p hoc bin chng ca tng huyt p. 4.1.2. Thc th, ton thn * o huyt p: l ng tc quan trng nht c ngha chn on xc nh. Khi o cn phi m bo mt s quy nh. - Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun trn khuu tay 2cm. Nu dng my o thu ngn phi iu chnh 6 thng 1 ln. - Khi o cn bt mch trc. t ng nghe ln ng mch cnh tay bm nhanh bao hi n mc 300 mmHg trn p lc ghi, x chm t t vi tc 2 mmHg/l giy. - Huyt p tm trng nn chn lc mt mch. - Phi o huyt p nhiu ln trong 5 ngy lin. o huyt p c chi trn v chi di, c t th nm v ng. Thng thng chn huyt p tay tri lm chun. - Cc du hiu lm sng nh: Bnh nhn c th bo ph, mt trn, c chi trn pht trin hn c chi di trong hp eo ng mch ch. Tm cc biu hin x va ng mch trn da (u vng, u m, cung gic mc...). - Khm tim phi c th pht hin sm dy tht tri hay du hiu suy tim tri. S v nghe ng mch pht hin cc trng hp nghn hay tc ng mch cnh. - Cn lu hin tng huyt p gi nhng ngi gi i ng, suy thn do x cng vch ng mch lm cho tr s huyt p o c cao hn tr s huyt p ni mch. - Khm bng c th pht hin ting thi tm thu hai bn rn trong hp ng mch thn, phng ng mch ch hoc pht hin thn to, thn a nang. - Khm thn kinh c th pht hin cc tai bin mch no c hoc nh. 4.2. Cn lm sng Cn n gin, mc ch nh gi nguy c tim mch, tn thng thn v tm nguyn nhn. 4.2.1. Nhng xt nghim ti thiu Mu: ure, creatinin, kali, cholesterol, glucose, acid uric trong mu. Nc tiu: protein, hng cu. 6

Soi y mt, in tim, xquang tim, siu m... 4.2.2. Cc xt nghim hay trc nghim c bit i vi tng huyt p th pht hay tng huyt p kh xc nh V d: bnh mch thn: chp UIV nhanh, thn , trc nghim saralasin. U tu thng thn (Hi chng pheocromocytome) th nh lng catecholamin nc tiu 24h, trc nghim Rgitin. 5. CHN ON 5.1. Chn on xc nh Cn phi chn on sm v ng n bnh tng huyt p. Ch yu bng cch o huyt p theo ng cc quy nh trn. Tuy nhin iu quan trng l nn t chc nhng t khm sc khe khm xt ton din nhm pht hin sm nhng trng hp tim tng hoc cha c triu chng. 5.2. Chn on giai on Theo OMS (1978) chia lm 3 giai on. 5.2.1. Giai on 1 Tng huyt p thc s nhng khng c tn thng thc th cc c quan. 5.2.2. Giai on 2 C t nht mt trong cc bin i c quan sau. - Dy tht tri: pht hin bng lm sng, X quang, in tim, siu m. - Hp lan to hay tng vng cc ng mch vng mc (giai on I v II y mt). - Thn: c protein niu, ure hoc creatinin mu tng nh. 5.2.3. Giai on III * C du hiu chc nng v thc th do tn thng cc c quan sau. - Tim: suy tim tri - No: xut huyt no, tiu no hoc thn no. - y mt: xut huyt vng mc c hay khng c ph gai th (giai on III v IV), cc du hiu ny l c bit ca giai on c tnh (giai on tin trin), cc biu hin khc thng gp giai on II, nhng khng c hiu lm ca tng huyt p nh: - Tim: cn au tht ngc, nhi mu c tim. - No: huyt khi ng mch trong s. - Mch mu: phng tch, bt tc ng mch. - Thn: suy thn * Tng huyt p c tnh hay tin trin nhanh l mt hi chng gm c: 7

- Huyt p ti thiu rt cao trn 130 mmHg. - Tn thng y mt giai on III v IV. - Bin chng thn, tim, no. - Bnh nhn tr di 40 tui. - Tin trin nhanh, t vong trong vng 2 - 3 nm. 5.3. Chn on th 5.3.1. Theo tnh cht - Tng huyt p thng xuyn nh tng huyt p lnh tnh v c tnh. - Tng huyt p dao ng c lc cao c lc bnh thng. 5.3.2. Theo nguyn nhn gm c: Tng huyt p nguyn pht (v cn) v tng huyt p th pht. 5.4. Chn on bin chng 5.4.1. Tim Suy tim v bnh mch vnh l hai bin chng chnh v l nguyn nhn gy t vong cao nht i vi tng huyt p. - Dy tht tri l bin chng sm do dy c tim tri i ph vi sc cn ngoi vi nn gia tng sc co bp lm cng tim tng ln v vch c tim dy ra. Dn dn suy tim tri vi cc triu chng kh th khi gng sc hen tim hoc ph phi cp sau chuyn sang suy tim ton b vi: ph, gan to, tnh mch c ni, X quang v in tim c du hiu dy tht phi. - Suy mch vnh biu hin bng cc cn au tht ngc in hnh, lon nhp tim. in tim c ST chnh xung di ng ng in cc chuyn o tim tri, khi c bin chng nhi mu s xut hin sng Q hoi t. 5.4.2. No Tai bin mch no thng gp nh: nhn no, xut huyt no, tai bin mch no thong qua vi cc triu chng thn kinh khu tr ch ko di khng qu 24 gi hoc bnh no do tng huyt p vi l ln, hn m km theo co git, nn ma, nhc u d di. 5.4.3. Thn - Va x ng mch thn sm v nhanh. - X thn gy tnh trng suy thn dn dn. - Hoi t dng t huyt tiu ng mch thn gy tng huyt p c tnh. - Giai on cui thiu mu cc b nng thn s dn n nng Renin v 8

Angiotensin II trong mu tng gy cng aldosteron th pht. 5.4.4. mch mu - Tng huyt p l yu t sinh va x ng mch, to iu kin cho s hnh thnh va x ng mch. - Phng ng mch ch, bc tch. 5.4.5. Mt Khm y mt rt quan trng v n l du hiu tt tin lng. Theo Knh Wagener - Barker c 4 giai on tn thng y mt. - Giai on 1 : tiu ng mch cng v bng. - Giai on 2: tiu ng mch hp c du hiu bt cho (gng) - Giai on 3: xut huyt v xut tit vng mc nhng cha c ph gai. - Giai on 4: ph lan to gai th. 6. IU TR 6.1. Nguyn tc: mc tiu nhm - a huyt p tr v tr s sinh l n nh. - Ngn nga cc bin chng. - Ci thin cc bin i bt thng cc ng mch ln. Do phi gii quyt 3 vn l: - iu tr nguyn nhn tng huyt p nh: ct b u tu thng thn, ct b thn teo, thng ng mch b tc... nu tm thy nguyn nhn. - iu tr triu chng tng huyt p: bng phng php ni khoa khng dng hay dng thuc hoc phu thut (ct b mt s dy thn kinh giao cm). - iu tr bin chng ca tng huyt p (nu c) Tn trng huyt p sinh l ca ngi gi. iu tr huyt p tng cn lin tc, n gin, kinh t v phi theo di cht ch. 6.2. Phng php iu tr 6.2.1. n ung v sinh hot - Hn ch Na di 5g NaCl mi ngy. - Hn ch m, cc cht bo ng vt. - Khng ung ru, ht thuc l, ung ch c. - Trnh lao ng tr c cng thng, lo lng qu , nn tp th dc nh, i b th gin, bi li. 9

6.2.2. Thuc Cn nm vng c ch tc dng, tc dng phi hp cc loi thuc iu tr tng huyt p v cc tc dng ph khi s dng trc mt v lu di. C 3 nhm thuc chnh: * Thuc tc dng ln thn kinh trung ng: C nhiu loi nhng hin nay t dng v c nhiu tc dng ph. - Alpha Methyldofa (Aldomet) H huyt p do to ra alpha methylnoadrenalin lm hot ha cc c quan th th giao cm no do c ch trng lc giao cm. Vin 250 m (500mg) liu 500 - 1500 mg/24h. Tc dng ph: h huyt p, thiu mu huyt tn, bt lc, suy gan. - Reserpin vin 0,25 m liu 2 - 6 vin/24h. Tc dng ph gy h huyt p khi ng, thiu mu huyt tn, bt lc, suy gan. - Clonidin vin 0,15mg x 3 - 6 vin/24h. Tc dng ph: trm cm, kh ming, to bn, ri lon sinh dc. - Cc thuc tc dng trung ng khc: Guafacin, Tolonidin, Hyperium... * Thuc li tiu: - Thiazid: c ch ti hp thu Na+ v Cl- trong ng ln xa. Hypothiazid vin 25mg x 2 vin/ngy. Chlorthalidon vin 50mg - 100mg x 1 ln/24h. Tc dng ph: tng acid uric, gim kim mu, tng ng mu, tng LDL cholesterol v gim HDL cholesterol. - Li tiu quai Henle Furosemid (lasix) vin 40mg x 2 vin/24h ch nh khi suy thn nng. Tc dng ph: lm h kim mu, liu cao c tnh ln tai. - Li tiu khng aldosteron gi kali. + Nhm khng aldosteron nh: Aldacton, Spirolacton vin 25 - 50mg x 4 ln/24h. Dng phi hp vi Thiazid. + Nhm c tc dng trc tip nh Amilorid, Teriam, loi ny phi phi hp v tc dng thi Na+ yu. Tc dng ph: v to, bt lc, ri lon kinh nguyt. - Li tiu phi hp: trnh c tnh trng gim kim mu. Loi ny phi hp mt 10

loi aldosteron v mt loi Thiazid. * Thuc chn giao cm Tc dng c ch Renin, gim ng c tim, gim hot ng thn kinh giao cm trung ng. - Propranolon (Inderal) vin 40mg x 1 - 6vin/ngy. Tc dng ph: lm chm nhp tim, ri lon dn truyn nh nht, co tht ph qun, hen, hi chng Raynaud, h ng mu, ri lon tiu ha, mt ng, d ng... * Cc thuc c ch men chuyn: - c ch s to thnh Angiotensin II. - Tng cng hot ng Kali - Krine - Kinin do ngn cn s phn hu bradykinin. - Kch thch s tng hp Prostaglandin. + Ch nh: tng huyt p cc giai on. + Tc dng ph: thm n, nga, ho khan, lu khi phi hp vi li tiu gi kim, thuc chng vim. + Chng ch nh: tng huyt p c hp ng mch thn hai bn, ph n c thai. - C 3 nhm: + Catopril: vin 25 - 50mg liu 50 mg/ngy. + Enalapril (Renitec) vin 5 - 20mg liu 20mg/ngy. + Lisinopril (Prinivill) vin 5 - 20 m liu 20mg/ngy. * Thuc c ch calci. Ngn cn s i vo t bo ca con Ca++, c ch lung Ca++ chm ca knh Ca++ ph thuc in th. C 2 ni tc dng. Trn mch mu: s gim lung calci a n s gin c v lm gin mch. iu ny lm gim sc cn ngoi bin v ci thin gin n cc mch mu ln. Trn tim: lm gim nhp tim, cn bng t nhiu phn x nhp nhanh th pht v gim s co bp c tim. + Nhm 1 - 4 Dihydro pyridime: Nipedipin (Adalat) vin trung, liu 2 vin/ngy. + Diltiazem (Tildiem) 300mg LP x 1 vin/ngy. + Isotin 120 - 240 LP x 1-2 vin/ngy. - Tc dng ph (10 - 20%) cc trng hp: nhc u, ph ngoi bin, h huyt p khi ng, mt, ri lon tiu ha, bun ng, bt lc. N c th gy ri lon dn truyn nh tht, nhp chm. 11

Khng dng khi c suy tim, mc nh tht nng. * Thuc gin mch: - Minipres: tc dng c ch cm th alpha sau tip hp nn c hiu lc tt. Vin ng x 1-2 viningy tng dn 10 vin/ngy nu cn. Tc dng ph: chng mt, ri lon tiu ha, d kch ng, tiu kh, h huyt p. - Dihydralazin vin 25mg x l-4 vin/ngy. Dng khi c suy thn. Tc dng ph: nhp tim nhanh, gi mui nc, vim dy thn kinh ngoi vi. - Minoxidil: tc dng rt mnh, ch dng khi tng huyt p khng cc loi khc. 6.3. iu tr c th * iu tr bc thang p dng cho tng huyt p t nh nng gm 4 bc. - Bc l: dng mt trong hai loi li tiu (gi) chn giao cm Beta (ngi tr). - Bc 2: dng c hai loi trn - Bc 3: dng hai loi trn thm mt loi gin mch. - Bc 4: dng bn loi mt lc bng cch thm vo mt loi h huyt p mnh khc nh c ch thn kinh trung ng. - Phng php tng bc c hiu qu, d thc hin v t tn km. Gn y cc tc gi thng nht iu tr chn lc c nhn ha thch hp vi tng bnh nhn tng huyt p s dng vi mt s thuc t nht, hiu qu nht v t tc dng ph nht. * Phc iu tr c nhn ha: - iu tr khng dng thuc + Gim cn nng + Hot ng th lc + iu chnh cc yu t nguy c - iu tr dng thuc: + Mt loi thuc: - Chn giao cm Beta - Li tiu - c ch calci - c ch men chuyn 12

- Ch nh chn lc thuc theo phng php iu tr c nhn (hi tim mch hc Hoa K 1997). + Li tiu: ngi gi, da en, ph n tin mn kinh, c ri lon nhu m thn. + Chn Beta: ngi tr, da trng, nam gii, cng giao cm, hot tnh Renin cao, bnh mch vnh, au na u. + c ch men chuyn: tng huyt p nng, suy tim hay suy thn, ri lon tnh dc, tng lipid mu, i ng, tng acid uric mu. + c ch calci: ngi gi, da en, bnh mch vnh, i ng. + Bo ph, tng huyt p khng kim sot c bng chn Beta th pht sau cng aldosteron nguyn pht, bt lc, tng lipid mu v tng acid uric mu. + Khng adrenergic ngoi bin: bnh nhn tr, trm ut, hen suyn, bnh phi tc nghn, i ng, tng lipid mu. 6.4. iu tr tng huyt p cp tnh (kch pht) Cn phi dng loi h huyt p bng ng tnh mch nh: - Niprid truyn tnh mch liu 0,5 - 2mg/pht (10 mg/gi) c chn trong hu ht cn tng huyt p. Tc dng ph: ng c Thiocyanat. - Nitroglycerin (truyn tnh mch khi c suy vnh cp liu 5 - 10 mg/pht). - Alpha Methyldofa hay Clonidin (truyn tnh mch). - Cc loi c ch men chuyn - Nipedipin 10 - 20mg ngm di li. - Thng phi hp thm lasix (tnh mch). 7. PHNG BNH 7.1. D phng cp I Lu vn sinh hot hng ngy nht l cc thi quen c hi sc khe phi khm nh k pht hin tng huyt p hay cc bnh lin quan. Trong i tng ny cn ch nhng ngi c yu t nguy c mc bnh cao, cho d nhng ln u cha pht hin tng huyt p nhng cn trao i, tuyn truyn phi hp d phng cng nhn vin y t tuyn trc. 7.2. D phng cp II i vi ngi tng huyt p, cn phi cht ch hn na trong ch n ung, ngh ngi theo di huyt p u n v c k hoch iu tr ngoi tr theo di tin trin, tc dng ph ca thuc. Cn ch yu t kinh t trong iu tr v y l mt liu trnh lu di tn km. 13

8. TIN LNG Tin lng bnh nhn huyt p ph thuc vo: 8.1. Tr s huyt p: tr s cng cao th t l t vong cng ln. 8.2. Cc bin chng: l yu t tin lng gn rt quan trng nht l khi c bin chng. 8.3. Tin lng xa Cholesterol mu c v tr quan trng v a n va x ng mch vnh, nhi mu c tim sau ny. 8.4. Vn diu tr cng gi vai tr ng k, tin lng kh quan nu iu tr sm, ng cch, c theo di lu di Kt lun: Tng huyt p l mt bnh chn on xc nh d nhng vn cn phc tp v bnh nguyn, c ch. Vic iu tr c nhiu tin b nhng khng trnh khi nhng tc dng ph ng k. Bnh nh hng ln n sc khe con ngi. V vy tng huyt p l vn ln ang c nc ta v th gii quan tm.

14

HP VAN HAI L1. I CNG 1.1. nh ngha Hp van hai l l tnh trng van m ra khng ht trong thi k tm trng. N l tnh trng gim din tch ca l van do hin tng dnh mp van. 1.2. Dch t hc 1.2.1. Tn sut - Tn sut mc bnh thay i tu theo mc pht trin ca cc quc gia tc l bnh hp van hai l gp nhiu nhng nc km pht trin. Cn nhng nc pht trin th t l mc bnh gim i rt nhiu nhng vn cn gp tng lp ngho. - T l mc bnh hp van 2 l ph thuc rt nhiu vo cht lng ca chng trnh phng thp. 1.2.2. Tui, gii - Tui thiu nin d mc hn ngi ln tui. - Gii: n gii mc bnh nhiu hn nam gii (2/3), theo ng Vn Chung 1971: N gii b bnh hp van 2 l chim > 70%. 1.2.3. nc ta Thng k nm 1959 cho bit hp van 2 l chim 40% cc bnh tim ni chung. Trong 99% l hu thp. Tuy nhin c nhiu bnh nhn khng ghi nhn tin s thp khp (khong 30% trng hp v nhiu th bnh khng biu hin khp). - Bnh tim hu pht: hp van 2 l n thun 25%, hp h van 2 l 40%. 2. NGUYN NHN 2.1. Thp tim L nguyn nhn hay gp nht chim 99% trong tng s . 2.1.1. Nhng ngi c tin s thp r. sau nhiu ln b thp tin trin s li di chng hp 2 l. 2.1.2. Tin s thp khng r: khng c chn on sm v khng c iu tr do khi bnh nhn vo vin th b hp van 2 l. 2.2. Bm sinh Gp trong hi chng Lutembacher gm c hp van 2 l + thng lin nh. 2.3. Mng si trong vim ni tm mc bn cp (Osler) 15

2.4. Vi ha van hai l, vng van. 2.5. Lupus ban ri rc: vim khp dng thp. 2.6. Lng t amynoid trn van tim hu pht. 3. GII PHU 3.1. Gii phu van hai l bnh thng - Phc hp van hai l gm: hai l van, vng van, dy chng gi van, cu c, ct c - L van hai l hi hnh bu dc, gm c l trc gia ln v l sau bn. - Din tch van 2 l bnh thng 4 - 6cm2. - Hai l van dnh vo mt vng si c tnh n hi nh c vng thu nh din tch l van khi van 2 l ng li, b di 2 l van c cc dy chng dnh neo vo 2 ct tr thng. Do sut c th tm thu, cc dy chng gn cng thng, cc ct tr co cng nn cc ba van lun p st vo nhau khng b lt ngc ln trn. 3.2. Tn thng van 2 l do thp tim - L van dy do m x hay lng t cht vi (vi ha). - Cc mp van b dnh, ba van dy, cun li lm l van 2 l c hnh phu cng nm su trong lng tht tri. - Dy thng gn dnh li v co rt. - Nhng tn thng trn u tin l do thp, nhng thay i sau c th l mt qu trnh khng c hiu do dng mu b thay i khi chy qua van b bin dng trc gy chn thng l van. S vi ha 2 l gy bt ng l van, lm hp l van. - S to huyt khi v nghn ng mch c th pht sinh t chnh van b vi ha. 4. SINH L BNH L van 2 l bnh thng c din tch 4 - 6cm2. Khi van b hp khong 2cm2 (hp nh) dng mu chy t nh tri xung tht tri ch khi n c y mt p lc bt thng gia nh tri v tht tri. 4.1. Hu qu huyt ng di ch hp - Lng mu tht tri gim do tht tri bnh thng hay hi nh. - Mch ngoi vi nh, huyt p thp. - Bnh van tim tri khng nh hng n tht tri. - Bin chng tc, nghn mch c th xy ra no, gan, lch, thn. 4.2. Hu qu huyt ng trn ch hp 16

* Hp van 2 l gy tng p lc nh tri, dy gin nh tri, tng p lc tiu tun hon, nh tri gin sinh ra cc hu qu: - Lon nhp nh; huyt khi ngay ti bung tm nh tri. - Chn p cc c quan ln cn nh: + Chn p thc qun gy nut nghn + Chn p thn kinh qut ngc gy ni khn + Chn p vng cnh ct sng gy au ngc. * mu trong mao qun phi cn tr s trao i kh ti mng ph nang mao qun gy ph ph nang, ph m k, biu hin kh th, khc ra mu, bt hng. * Tng p lc ng mch phi do: - S lan truyn th ng ngc dng ca hin tng tng p lc nh tri. - Tiu ng mch phi co tht. - Tn thng thc th trong mao ng mch phi. * Tht phi dy, gin: tng p lc ng mch phi khin tht phi phi chu mt gnh nng khi bm mu vo ng mch phi nn tht phi dy, gin gy h van 3 l c nng, suy tim phi. * mu tnh mch ngoi bin nht l chi di gy huyt khi, nghn mch phi. 5. TRIU CHNG LM SNG 5.1. C nng Bnh nhn c th c pht hin bnh hoc v mt biu hin c nng hay tai bin ca bnh nh: 5.1.1. Kh th. khi gng sc, khi nm hay ph phi kt qu ca s gim tnh n hi ca phi. 5.1.2. Ho ra mu: s lng t, dnh vi m. 5.1.3. au ngc (15% trng hp) do tng p lc ng mch phi hoc nhi mu phi. 5.1.4. Hi hp nh trng ngc do ri lon nhp tim 5.1.5. Cc triu chng khc nh: nut nghn, ni khn do nh tri to chn p. 5.2. Thc th 5.2.1. Nhn - Lng ngc bin dng vng trc tim - Tm mi, ngn chi 17

5.2.2. S - Mm tim c rung mu tm trng - B tri xng c: du ny ca tht phi do tng p lc ng mch phi, tht phi ln 5.2.3. G. din c tng i ca tim to v bn phi. 5.2.4. Nghe: l triu chng quan trng nht chn on. * Mm tim: - T1 anh, gn - Rung tm trng (RTTr) - Thi tin tm thu (trm, nh) - Clc m van 2 l: nghe ti mm hay b tri xng c vng thp (khoang lin sn IV, V cnh c tri, c th lan n y tim). * y tim: - T2 vang, tch i nghe r nht van ng mch phi. - Ting Clich phun mu van ng mch phi. - Thi tm trng do h van ng mch phi c nng. * Ngoi ra c th khm thy: gan to, phn hi gan tnh mch c (+), ph chn, trn dch mng bng, mng phi. 6. TRIU CHNG CN LM SNG 6.1. X quang lng ngc 6.1.1. Phim thng - B tri 4 cung - B phi 2 cung ct nhau hoc ng tm - Bng trn m ca nh tri - Rn phi m,ng mch phi ln. 6.1.2. Phim nghing: gc kh ph qun rng, thc qun b chn p 1/3 gia v 1/3 di (ung Baryte). 6.2. in tm Nhp xoang hoc rung nh. Ph i gin nh tri: sng P > O,12s, 2 mi, Vl: p 2 pha -/+ Trc bnh thng hoc lch phi. 18

- Dy tht phi: RVI + SV5 >- tham, R/s ( Vl) 6.3. Tm thanh Xc nh cc ting tim trn lm sng. 6.4. Siu m tim: 2D - TM - Doppler. Phng php ny nhy cm v c hiu nht chn on bnh. - L trc mt hnh M, l sau di chuyn v trc, 2 l van song song th tm trng. - dc EF gim. - L trc m c dng phnh gi. - Dy l van v h dy chng di van. - o c din tch l van 2 l, kch thc cc bung tim. - o p lc mch phi th tm thu. - Pht hin huyt khi trong tm nh tri. 6.5. Thng tim - o p lc bung nh tri tng, p lc mao mch phi, ng mch phi, tht phi, nh phi tng. 7. CHN ON 7.1. Chn on xc nh 7.1.1. Lm sng: cc triu chng in hnh. - Nghe tim: T1 anh, gn, rung tm trng. V mt lm sng tuyn c s c th da vo ting rung tm trng v T1 anh. Khi c hai du hiu ny c th chn on gn nh chc chn hp van 2 l. y l triu chng ph bin, d pht hin. 7.1.2. Cn lm sng: ECG + Xquang + siu m, trong siu m l phng php chn on c gi tr nht. 7.2. Chn on phn bit 7.2.1. U nhy nh tri: lm sng ging hp van 2 l, tuy nhin ting rung tm trng thay i theo t th ngi bnh, khng c T1 anh. Chn on xc nh da vo siu m. 7.2.2. Cung gip: tng trng lc thn kinh vi nhp tim nhanh, cung lng tim tng cao c th lm gi triu chng hp 2 l. Hnh thi lm sng v siu m cho php chn on. 7.2.3. Nh tri 2 bung (nh tri ln) v thng trn nh l ln (lm gin ng mch 19

phi): ging hp van hai l trn X quang: chn on da vo siu m Doppler, thng tim, chp bung tim. 7.2.4. Ting rung Flint trong h van ng mch ch. Khng c T1 anh, nghe rung tm trng ngn hn. 7.3. Chn on mc hp Da vo: 7.3.1. Lm sng: c hay khng c hi chng gng sc. 7.3.2. Siu m: dc tm trng < 15mm/s l hp kht. - Trn siu m 2D cho php o din tch l van 2 l, nu < 1 cm2 l hp kht cn phi can thip phu thut. - Trn Doppler nh gi mc hp da vo chn p thng qua o thi gian na nh (Sm < 1 cm2 nu T1/2 > 220 m/s). - Thm d huyt ng: cho php tnh c p lc mao mch phi, ng mch phi, phn nh c kiu tng p lc ng mch phi. 7.4. Chn on th 7.4.1. Hp 2 l n thun - Th ph phi (hp 2 l kht < 1 cm2). Triu chng ni bt phi: kh th, ho ra mu. - Th hp 2 l nh (din tch > 2cm2): khng c triu chng c nng. - Th hp 2 l cm: khng c triu chng trn lm sng. Chn on bng in tm , siu m tim. 7.4.2. Hp 2 l phi hp - H van 2 l: thm vo triu chng ca hp van 2 l l nghe ting thi tm thu mm cng mnh, lan theo ng nch ra sau lng. Nu h l ch yu th ting thi tm thu nghe to, lan r ra sau lng, c du hiu gin v dy tht tri - nu h l th yu th ting thi tm thu cng nh, t hoc khng lan c T1 anh, rung tm trng ln. - H van ng mch ch: c thm ting thi tm trng ecbotkin, ngoi ra c hi chng ngoi vi. - Hp van ng mch ch: ting thi tm thu van ng mch ch lan sang phi, c rung mu tm thu. T2 m. - H van 3 l c nng: nghe ting thi tm thu sn sn VI cnh mi c hai bn, cng tng khi ht vo, gan p. - Bnh tim bm sinh: hp 2 l + thng lin nh gi l hi chng Lutembacher, c 20

thm ting thi tm thu lin sn II bn tri. 7.5. Chn on giai on hp 7.5.1. Theo phn loi ca M da vo triu chng c nng - Giai on I: khng c kh th - Giai on II: kh th khi gng sc - Giai on III: kh th khi lm vic nh - Giai on IV: kh th khi ngh ngi 7.5.2. Phn loi theo Lin X (c) phn lm 5 giai on da vo c cn lm sng - Giai on I: khng kh th, tim khng to, ECG bnh thng - Giai on II: kh th khi gng sc, ho khc mu, nh tri to, phi m, ECG c dy nh tri. - Giai on III: kh th nhiu hn, ho khc ra mu, gan to, nh tri tht phi to, ECG c dy tht phi. - Giai on IV: suy tim r hn, ph, gan to, tnh mch c ni r, iu tr cn hi phc. - Giai on V: suy tim khng hi phc 7.6. Chn on bin chng 7.6.1. Ri lon nhp nh nh Rung nh, cung ng nh, ngoi tm thu nh. S xut hin ca rung nh gy hu qu xu d hnh thnh cc mu ng trong tim. 7.6.2. Suy tim phi - Hay xy ra cn hen tim, ph phi cp hp van 2 l kht. - Hi chng suy tim phi tin trin khng th trnh khi. 7.6.3. Tc mch - Cc mu ng c hnh thnh nh tri lm tc mch no, thn, chi. - Cc mu ng hnh thnh tnh mch ch di gy tc mch phi. 7.6.4. Nhim trng - Vim ph qun - phi do vi trng, vim phi, p xe phi. - Vim ni tm mc bn cp (Osler). 7.6.5. Mt s th lm sng c bit - Thai sn: ngi bnh hp van hai l c thai s lm nng thm tnh trng huyt ng do tng cung lng tim v th tch mu khi mang thai. Do ngi bnh c 21

nguy c cao b ph phi cp. - Ti hp van: sau khi m tch van hai l kn. Nguyn nhn c th l do dai dng qu trnh thp tim hoc l ti b thp tim. Thng thng km theo h hai l (do phu thut). 8. IU TR 8.1. Ni khoa Trnh lao ng nng, tm ngh thch hp khng i hi hot ng th lc nhiu. 8.1.1. Khi c hi chng gng sc th phi chuyn bnh nhn ln tuyn trn, c th can thip ngoi khoa cho ngi bnh trong lc ch i, tuyn c s c th cho bnh nhn dng li tiu nh: Furosemid 40mg x l-2vin/ngy. Thuc gin mch Nitrat nh Risordan 10 80 mg/ngy. Thuc tr tim hay c dng khi bnh nhn c rung nh vi tn s tht nhanh. 8.1.2. Phng nga thp tim v u tr bin chng nn c Ni chung l trng hp hp khng kht, bnh nhn dung np c, tuy nhin khng loi tr c th xy ra bin chng ri lon nhp. 8.2. Ngoi khoa 8.2.1. Tch van 2 l: m tim kn hoc tch van bng bng. Vit Nam cn thng dng ch nh m kn tch van: tui 20 - 60, hp < l,5cm2, giai on 2 hoc 3, hp n thun hoc kt hp h hai l, h ch nh. - Chng ch nh khi h hai l, h ch nng, hp ng mch ch, t chc di van h bin, van vi ha. - Chng ch nh tng i: khi ang c t thp tin trin, vim ni tm mc hoc tc mch mi xy ra. 8.2.2. Thay van 2 l: bng van sinh hc hoc van c hc trong trng hp h bin t chc di van v calci ha nng. Trong trng hp tn thng phi hp c th phi sa hoc thay c hai van. 9. TIN LNG - Tu thuc mc hp v s hin din hay khng ca cc tn thng phi hp - Tin lng khng tt khi tui tr, c thai, lao ng nng. Vi s tin b ca k thut phu thut cng nh cc phng tin iu tr mi ca y hc tin lng cho bnh nhn b hp van 2 l ngy cng kh quan. 10. PHNG BNH - Hp van 2 l l bnh van tim rt thng gp nc ta, nguyn nhn ch yu l do thp tim. Bnh c th sinh nhiu bin chng nng, do vn chm sc sc khe 22

ban u rt quan trng. - Cn phi gio dc rng ri v y t trong cng ng phng nga vim hng tr em. Khi mc bnh cn c iu tr y . - T chc khm sc khe nh k cc trng hc, v hc sinh l tui d mc bnh thp khp cp. - Khi pht hin bnh thp khp cp, cn c ch iu tr cht ch, ch qun l theo di bnh nhn pht hin di chng van tim ng thi theo di ch khng sinh phng nga n ht thi gian quy nh. - Cn pht hin sm nhng trng hp hp van hai l c k hoch c th, trnh bin chng c th xy ra.

23

H VAN HAI L1. I CNG 1.1. nh ngha H van hai l xy ra khi van 2 l ng khng kn trong th tm thu, cho php dng mu chy ngc t tht tri ln nh tri. 1.2. Dch t hc 1.2.1. Tn sut Mc bnh tu thuc theo mc pht trin ca cc quc gia tc l bnh h van 2 l gp nhiu nhng nc km pht trin. Bnh xy ra vng nng thn, ngoi thnh c kinh t, vn ha thp. - H van hai l hay gp phi hp vi hp van hai l (t l 40% trong tng s bnh tim mc phi) v h van ng mch ch. - T l h van 2 l ph thuc rt nhiu vo cht lng ca chng trnh phng thp. 1.2.2. Tui, gii - Tui thiu nin d mc hn ngi ln tui. - N gii mc bnh nhiu hn nam gii (2/3). 1.2.3. nc ta - Hp, h van 2 l chim 40% bnh tim hu pht. - 99% l do thp tim (ng Vn Chung - 1971). - Bnh gp nhiu nng thn, ngoi thnh. 2. NGUYN NHN 2.1. Thp tim - Chim 1/3 cc trng hp h van 2 l n thun, hay gp nam gii. - Tui 20 - 35. - Lc bnh nhn b thp tim n khi biu hin h van 2 l r khong 20 nm (Braun Wald). 2.2. Cc nguyn nhn khc - Vim ni tm mc c lot v si do vi khun gy thng van hai l. - Nhi mu c tim: tn thng n vch, nh hng n cu - c, ct c. - Bm sinh: x chun ni mc, van 2 l nhy d. 24

- Bnh c tim ph i. - Sa van hai l. - Vi ho vng van 2 l. - Lupus ban ri rc, vim ct sng dnh khp. - Hi chng Marfan: ri lon di truyn m lin kt. - H van hai l c nng do bt k nguyn nhn no lm gin tht tri. 3. GII PHU BNH 3.1. H van 2 l do thp tim mn Gy cng, bin dng, co rt ba van. 3.2. Vim ni tm mc nhim khun Gy thng van, t dy chng, co rt l van. 3.3. Nhi mu c tim Gy t c nh, gin tht tri, phnh vch tht vng y c nh. 3.4. Vi ha vng van 2 l Do l sau dnh vo khi calci gy bt ng l van. 3.5. Sa van hai l L di chng ca thp tim trong bnh c tim, thiu mu c tim. Sa van 2 l lm t dy chng v gin vng van lm h van. 4. SINH L BNH H van 2 l c th l kt qu ca mt qu trnh bnh dn dn gim st chc nng van. Mt dng mu pht ngc vo nh tri, gnh nng v s e da nhm vo, tun hon tnh mch phi v phi dn dn tht tri suy, cung lng tim ti gim giai on mt b. 5. TRIU CHNG LM SNG 5.1. Triu chng c nng - Kh th khi gng sc, dn dn kh th theo t th, c cn kh th v ban m. - Ho ra mu. - au ngc nht l khi c bnh ng mch vnh kt hp. 5.2. Triu chng thc th 5.2.1. Nhn: lng ngc hi g bn tri. 5.2.2. S 25

- Mm tim p mnh, lch xung di. - C rung mu tm thu mm. 5.2.3. Nghe: nghe tim l triu chng chnh chn on. Ta c th nghe c ting thi tm thu mm tim. - Cng rt to 4/6. - m sc th rp ging ting pht hi nc. - Lan ra nch tri hay ra sau lng. - Khng thay i theo t th ngi bnh. - y tim: nghe ting T2 vang, tch i. 6. TRIU CHNG CN LM SNG 6.1. Triu chng X quang - Tht tri to ra. - Bng nh tri ln v gin n nhiu. - Chp nghing: ung Baryte nh tri to s chn p vo thc qun. - Vt ng vi vng van 2 l. 6.2. in tm - Nhp xoang u hay rung nh. - Dy nh tri: P DII 0,12sec. P 2 pha -/+ V1 - Dy tht tri: Sokolow - lyon: RV5 + SV1 35mm. 6.3. Siu m tim: siu m 2D - TM - Doppler. - Xc nh h van 2 l: c dng mu pht ngc. - Xc nh nguyn nhn gy h van. - o kch thc bung tim (nh tri, tht tri). 6.4. Tm thanh Xc nh s xut hin ca ting thi v ting tim. 6.5. Thng tim tri - o p lc bung tht tri, p lc mao mch phi. - Thy c dng cht cn quang pht ngc vo nh tri. - nh gi chc nng tht tri, phn sut phun mu. 26

7. CHN ON 7.1. Chn on xc nh - Nghe ting thi tm thu thc tn mm tim. - T2 tch i y tim. - Cn lm sng 7.2. Chn on nguyn nhn - Thp tim: da vo lm sng - tin s. - Vim ni tm mc nhim khun: cy mu (+) - Nhi mu c tim. - Sa van 2 l. 7.3. Chn on bin chng - Ri lon nhp tim - Suy tim tri - suy tim phi - suy tim ton b. - Ph phi cp. - Tc mch no. - Thp tim tin trin. - Vim ni tm mc. 7.4. Chn on th 7.4.1. Th n thun 7.4.2. Th phi hp - Vi hp van 2 l - (hp h van 2 l). - Vi h van ng mch ch. 8. IU TR 8.1. Ni khoa - V ni khoa khng c thuc cha h thc tn. - tuyn c s: ch yu iu tr bin chng do h van 2 l gy nn nh: 8.1.1. iu tr ri lon nhp tim bng cc thuc chng lon nhp, c bit l rung nh. 8.1.2. iu tr suy tim bng tr tim Digoxin, li tiu Trofurit, an thn seduxen, kali gluconat... 8.1.3. Nu c cn ph phi cp th phi iu tr cn ph phi cp. 8.1.4. iu tr thp tim tin trin bng khng sinh, corticoid. 27

8.2. Ngoi khoa Phu thut lm nh l h hoc thay van 2 l. 9. PHNG BNH - cng ng vic quan trng nht l pht hin ra h van 2 l c phng php phng thp tim kp thi hu hiu. Thy thuc pht hin v x tr ng lc vim hng do lin cu tim Pemcillin chm 1 thng 2.400.000 n v. - Ci thin mi trng sng, vn ha, kinh t. - Sau khi tn thng van, pht hin sm phng bin chng, ko di sc lao ng v tui th.

28

H VAN NG MCH CH1. I CNG 1.1. nh ngha H van ng mch ch l s ng khng kn van sigma ng mch ch trong thi k tm trng gy tro ngc mu t ng mch vo trong tht tri. 1.2. Dch t hc H van ng mch ch chim 15% trong s cc bnh tim. - L bnh van tim mc phi ng th 2 sau hp van 2 l. - Hai nguyn nhn thng gp nht l thp tim (gp cc nc km pht trin) v lon dng va x ng mch (cc nc pht trin). 2. NGUYN NHN 2.1. H van ng mch ch mn tnh 2.1.1. Thp tim: gp ngi tr, tn thng do thp tim gy dy v co rt cc l van gi l bnh corigan. 2.1.2. Bnh lon dng ng mch ch: gy h hi l van hoc vng van (va x ng mch, gi l bnh Hodgson). 2.1.3. Cc nguyn nhn khc him gp - Giang mai giai on III (gome giang mai). - Vim ct sng dnh khp (bnh Becherew). - Vim khp dng thp. - Lupus ban ri rc, bnh Takayasu. 2.2. H van ng mch ch cp tnh 2.2.1. Vim ni tm mc nhim trng (Osler) 2.2.2. H van ng mch ch sau chn thng 2.2.3. Phnh tch ng mch ch (kiu I hoc II) Cc nguyn nhn ni trn c th gy tn thng h thng van ng mch, ch yu mt ni tm mc (thp tim), mt ni mch mc (va x ng mch, giang mai III) hay vng l van (hi chng Marfan). 3. SINH L BNH 3.1. Tht tri Do b h van ng mch ch nn tht tri phi bp mnh hn tng ht lng 29

mu tro ngc trong thi k tm trng. C ch b tr ny bo m cung lng tim bnh thng trong nhiu nm. Sau phn s tng mu gim, lc u l sau gng sc v sau c lc ngh ngi v ph i ri cui cng dn n suy tim tri. 3.2. Huyt ng S tro ngc mu lm cho ng mch rng, xp, huyt p ti thiu gim thp, th tch mu cui tm trng tht tri tng ln, km theo tht tri bp mnh lm cho ng mch ny mnh, huyt p ti a tng trong k tm thu, hiu p tng gy ra cc triu chng lm sng ngoi vi. 3.2.1. Lng mu pht ngc tht tri tu thuc vo 3 yu t. - ln ca b mt h. - chnh p tm trng gia ng mch ch v tht tri. - di ca k tm trng. 3.2.2. Hin tng suy vnh trong h van ng mch ch nng l do: - Gim p lc ng mch tm trng (ti mu vnh thc hin k tm trng). - Tng p lc cui tm trng ca tht tri. - Tng khi lng c tim. 3.2.3. Trong trng hp h ch cp tnh thi cc du hiu suy tim xut hin sm do cc c ch thch nghi ca tht tri khng c th gian pht ng 4. TRIU CHNG 4.1. Lm sng 4.1.1. Triu chng c nng - Khng c triu chng c nng trong mt thi gian di mt s trng hp h van ng mch ch. - Khi h van ng mch ch nng bnh nhn c cm gic kh chu, tim p mnh c hi hp nh trng ngc hoc c au tht ngc do suy vnh c nng. Triu chng au ngc s ht rt nhanh khi s dng - Khi c suy tim tri th trn lm sng c du hiu tng p lc tiu tun hon: kh th, ho khc ra m ln mu. 4.1.2. Triu trng thc th 4.1.2.1. Ti tim (trung tm) - Nhn mm tim lch sang tri, din p mm tim rng, p mnh. - S: mm tim di mnh vo lng bn tay. - G: din c tng i ca tim to v bn tri. 30

- Nghe: van ng mch ch hay ecbtkin nghe c ting thi tm trng, m sc m du, cng nh, lan xung mi c hoc mm tim. y l triu chng c bn nht chn on h van ng mch ch. - Ngoi ra cn nghe c ting thi tm thu km theo van ng mch ch. - Ting rung Flint mm tim. - y tim: ting T2 vang, ting cch m van sigma. 4.1.2.2. ngoi vi - Mch ny mnh chm su (mch corigan) - Huyt p ti a tng, huyt p ti thiu gim, lm cho hiu s huyt p ti a v huyt p ti thiu tng ln. - C du hiu nhp nhy mng tay. - ng mch i: nghe ting thi i Dieusier. - ng mch p qu mnh gy u gt theo nhp tim (du hiu Musset). - ng mch li g lc hng, lc ti. 4.2. Cn lm sng 4.2.1. in tim - Trc tim lch tri, dy tht tri kiu tng gnh tm trng. 4.2.2. X quang tim Tht tri, quai ng mch ch p mnh cung di tri gin, ng mch ch gin v di ra, c du hiu tr tiu tun hon. - o ch s tim ngc gredel > 50%. 4.2.3. Siu m - Siu m - Doppler c th chn on h van ng mch ch nhy >93%, trong khi lm sng v tm thanh ch c 82%. - Siu m TM v 2D cho thy du hiu gin tip ca h van (l trc van 2 l rung k tm trng) v tnh trng van ng mch ch (si trong vim ni tm mc). - Siu m Doppler c th ghi c dng mu pht ngc t quai ng mch ch tr v tht tri, kch thc bung tht tri gin to. 5. CHN ON 5.1. Chn on xc nh 5.1.1. tuyn c s. chn on tng i d vi th n thun trong ch yu da vo nghe ting thi tm trng v du hiu ngoi vi: huyt p ti a tng cao, huyt p 31

ti thiu gim thp. 5.1.2. Tuyn trn: trong nhng trng hp kh th ta phi da vo siu m Doppler hoc thng tim chp mch. 5.2. Chn on phn bit 5.2.1. H van ng mch phi Nghe khoang lin sn II bn tri xng c c ting thi tm trng Graham Steel km theo c du hiu tng p lc ng mch phi nghe T2 vang mnh tch i, khng bao gi c du hiu ng mch ngoi vi. 5.2.2. Vi hp van hai l phi hp Phi phn bit rung Flint v rung tm trng. 5.3. Chn on nguyn nhn 5.3.1. Da vo tui - S sinh: bm sinh - Tr tui: 7 - 14 tui: do thp tim - Trung nin: do giang mai III - Gi: do x va ng mch 5.3.2. Da vo xt nghim - Cy mu (+) nguyn nhn do Osler - BW (+): nguyn nhn do giang mai III - Yu t thp (+) nguyn nhn do cc bnh t min Becherew, vim a khp dng thp. 5.3.3. Da vo c ch bnh sinh - Nu h van ng mch ch + Hp van 2 l nguyn nhn chc chn do thp tim. - Nu h van ng mch ch + nt phng ng mch - nguyn nhn do giang mai giai on III. - Nu h van ng mch ch + cholesterol mu tng cao nguyn nhn do x va ng mch. 5.4. Chn on th 5.4.1. Th n thun - H van ng mch ch c tnh: t gp, tin trin nhanh trong vi thng suy tim ton b, t vong. - H van ng mch ch do thp tim. 32

- Du hiu ngoi vi r, thng phi hp vi hp van 2 l. - H van ng mch ch do giang mai. Tui kh ln (> 30) do vim ng mch ch gy tc l M vnh hay lm au tht ngc. Xquang ng mch ch gin nhiu, ngon ngoo, phn ng huyt thanh giang mai BW (+); tin trin xu. - H van ng mch ch do Osler: Do vi khun, van b si, tin trin nhanh, nng. - H van ng mch ch c nng: do tng huyt p hoc va x ng mch (Hodgson): ln tui, gin van ng mch ch gin rng mch ch ph i tht tri. Nghe thi tm trng v tng huyt p nh hn, du hiu calci ha ng mch ch hay gp, dung np tt hn. - Do phnh tch ng mch ch: tin s au ngc ging nhi mu c tim nhng khng c du hiu in tim ca nhi mu, au ngc cp d di, d t vong. 5.4.2. Th phi hp: thng gp - Vi hp van hai l: trn in tm dy c 2 tht 4/6 van ng mch ch km theo rung mu tm thu. - Vi h van hai l thc th hay c nng. 5.5. Chn on bin chng Bnh c biu hin triu chng nh trong thi gian kh di nhng mt b t ngt. - Gy vim ni tm mc bn cp Osler. - Thp tim ti pht sau vim hng cp. - Tc mch: no, thn, chi, lch - Suy tim tri biu hin cn hen tim hoc OAP. 6. IU TR 6.1. Ni khoa: c th thc hin tuyn c s. 6.6.1. Th nh: ch c hot ng th lc nh, lm ngh t tn sc, c th dng an thn. 6.1.2. Th va v nng c suy tim: iu tr suy tim nu au tht ngc c th chn thuc gin vnh nh Trinitrin, iu tr suy tim bng thuc tr tim Digoxin, li tiu (Thiazid, Furosemid...) l rt r tin thc hin d dng tuyn c s ngay c thuc gin mch. 6.1.3. Phng bnh vim ni tm mc nhim khun bng iu tr tt mi nhim khun c bit nhim khun ng h hp. 33

6.1.4. iu tr nguyn nhn: thp tim, giang mai, x va ng mch... 6.2. Ngoi khoa 6.2.1. Thay van nhn to: ch c th thc hin trung tm tim mch chyn su. Nu c iu kin nn gi bnh nhn ln tuyn trn khi ngi bnh c triu chng c nng. - Ch nh: + H van ng mch ch cp tnh + H van ng mch ch mn tnh Triu chng c nng 3, siu m c FR (Phn s co hi) < 25% ng knh cui tm trng tht tri > 70mm, ng knh cui tm thu tht tri > 55mm. + Chp bung tim c FE (Phn s tng mu), < 50% X quang c t l tim/1ng ngc >60%. T l t vong 3 - 5%. 7. TIN LNG H van ng mch ch khi c suy tim t l t vong 25% trong 5 nm. Nu suy tim tin trin nng th t vong trc 2 nm. 8. PHNG BNH - Tng t 6 thng phi iu tr d phng Osler k c bnh nhn h ch nh, va v nng. - Phi gim hot ng th lc ngay t khi chn on h van sigma ng mch ch d bnh nhn cha c biu hin cc triu chng c nng trn lm sng. - Phi hn ch mui v cho bnh nhn dng li tiu thi mui. - Dng thuc tr tim Digoxin sm ngay c khi cha c cc triu chng suy tim. - Thuc gin mch dng nhm Nitrat thng xuyn c tc dng chm v ko di nht l khi bnh nhn hay c triu chng au ngc. - Phi iu tr tch cc nguyn nhn gy ra h van ng mch ch v phi phng Osler v rt d xy ra trn mt ngi h ch. - Phi phng thp tim nu nguyn nhn gy h van ng mch ch l do thp.

34

HP VAN NG MCH CH1. I CNG 1.1. nh ngha Hp van ng mch ch l tnh trng van ng mch ch m ra khng ht nn cn tr dng mu t tht tri ra ngoi vi trong thi k tm thu. 1.2. T l mc bnh L mt bnh t gp hn cc bnh van tim khc nh hp van 2 l hoc h van ng mch ch. Thng gp ngi tr tui do thp tim. T l mc bnh nc ta cng nh cc nc khc thp (ng Vn Chung 1971). 2. NGUYN NHN GY BNH 2.1. Thp tim Gp ngi tr tui. Tn thng van mt ni tm mc, cc van dnh vi nhau gy hp van. 2.2. X va ng mch ch Gp ngi gi, tn thng van t pha ni mch mc ca van. 2.3. Hp van ng mch ch c van calci ha cha r nguyn nhn. 2.4. Bnh bm sinh Khng c 3 l van r rt m ch c mt mng c l nh gia. 3. GII PHU BNH - Bnh thng l van sgma ng mch ch khong 3cm2, 3 l van ring bit nhau v mng. - Khi hp van ng mch ch: + L van nh hn li, khng cho lt c ngn tay. + Cc van sigma b dy, cng, mp van dnh vo nhau ch h gia mt l trn nh: v van b x cng khng c ng c nn l khng th to ra c. Trong thi k tm trng, van cng khng khp cht c nn bao gi cng c h km theo. + Hp van ng mch ch n thun rt t, phn nhiu u phi hp vi h nhng hp l ch yu. + Nu nguyn nhn do thp tim: cc mp van dnh vi nhau. 35

+ Nu do x va ng mch: tn thng t vch ng mch ch lan dn n van lm van phng ra khng khp li c v gy ra tn thng nhim vi rt cng. + Cc tn thng ni trn cng lan n xung quanh l ng mch vnh v lm hp cc l y. 4. SINH L BNH - V hp van ng mch ch nn tht tri phi tng cng sc bp m bo lu lng mu cho c th. Do dy v to. ra. Khi bnh nhn gng sc lu lng mu khng na nn bnh nhn thng b ngt khi gng sc do thiu mu no. - V l ng mch vnh b hp nn mu vo ng mch vnh t hn nn cn au tim xut hin. - p lc tm thu trong tht tri tng cao nhng p lc tm trng trong ng mch ti thp. S chnh lch cng cao nu hp cng kht.

5. TRIU CHNG 5.1. C nng - Ngt khi gng sc (15-20%) hoc thip i rt nhanh trong vi giy ri tnh ngay. - Cn au tim (50%) lc gng sc. - Kh th. 5.2. Thc th * S: khoang lin sn II bn phi xng c ( van ng mch ch) c rung mu tm thu (86%). * Nghe: - Ting thi tm thu van ng mch ch. + Cng 5/6 - 6/6. + Chim ht thi k tm thu. + Lan ln xng n phi, ln vai phi. - Ting thi tm trng: nh hn (l/6) c trong 50% trng hp. - Ting T2 m hoc khng nghe thy (57%). - Nhp tim u, mch nghe yu. - Huyt p: tr s ti a thp hoc bnh thng. - Tr s ti thiu h (nu c h km theo) 36

5.3. Xquang - Tht tri to - ng mch ch to - C th thy van b calci ha khi chp. 5.4. in tm - Ph i tht tri, tng gnh tm thu. - Trc tri, dy tht tri. Ch s RV5 + SV5 35mm R rt cao V5, V6, T m V5, V6 5.5. Tm thanh Ta ghi c ting thi tm thu kiu pht v hnh qu trm. 6. CHN ON 6.1. Chn on phn bit 6.1.1. H van ng mch ch: c t ra khi c km theo ting thi tm trng - Ting thi tm thu nh. - Khng c rung mu. - Huyt p ti a tng cao. 6.1.2. Vim ng mch ch km theo h ng mch ch - C ting thi tm thu nhng khng c rung mu. - Ting T2 vang. 6.1.3. Hp van ng mch phi - Nghe thy ting thi tm thu khoang lin sn III, IV bn tri lan ln trn hoc sang tri. - Huyt p ngoi vi khng thay i. 6.2. Chn on xc nh - Ting thi tm thu rt to khoang lin sn II bn phi xng c lan ln xng n phi. - Rung mu tm thu. - Ting T2 nh hoc mt. - Mch yu, huyt p ti a v ti thiu h. - Thng tim tri c s chnh lch gia p lc tht tri v ng mch ch. 37

6.3. Chn on nguyn nhn 6.3.1. Da vo tui - Tr tui: thp tim - Gi: x va ng mch ch 6.3.2. Nu hp van ng mch ch kt hp vi hp van hai l hoc h van 2 l th chc chn do thp tim 6.3.3. Nu van b nhim vi - 50% cho rng n l mt bnh ring bit khng r nguyn nhn g. - 50% cho rng nhim vi l mt qu trnh khng c g c hiu. 7. IU TR 7.1. iu tr ni khoa Ch iu tr triu chng hoc cha suy tim khi bnh mt b. - tuyn c s vic pht hin sm bnh hp van ng mch ch iu tr sm ngn chn cc bin chng xy ra hoc chuyn bnh nhn ln tuyn trn c iu kin phu thut cho bnh nhn. - iu tr triu chng. + Dng thuc gin mch nhm Nht hoc Lenitral ngy 2V (2,5mg). Nu cn au tim xut hin. + Kt hp vi an thn v thuc chng lon nhp. - iu tr bin chng: + iu tr suy tim tri bng tr tim, li tiu, an thn, kim. + iu tr lon nhp tim bng thuc chng lon nhp. 7.2. iu tr ngoi khoa - M l b hp bng: + ng tht tri. + ng ng mch ch. - Thay van nhn to (Starr). * Ch nh phu thut - Bnh nhn tr di 50 tui. - Hp ng mch ch n thun hoc hp l ch yu. - Hp kht: da vo triu chng c nng nh ngt, au tim, s thay i ca mch v iu tr. 38

* Chng ch nh: - Bnh nhn ln tui > 50 tui. - Cha c ri lon c nng. - Phi hp vi h van ng mch ch r. - Suy tim - Tc ng mch vnh. * Cc trng hp: - Phi hp vi hp van 2 l. - Nhim vi cc van khng phi l nhng trng hp chng ch nh. 8. PHNG BNH - tuyn c s vic quan trng nht t ra l pht hin bnh sm c hng iu tr. - Phng thp tim: c bit ngi tr tui c tin s thp r. Dng Penicillin chm 2.400.000 UI/1 thng. - iu tr trit vim hng lin cu. - Phi c ch n ung, sinh hot, theo di rt st phng cc bin chng nh suy tim tri, Osler...

39

IU TR SUY TIM1. NHC LI PHN CHN ON Mun chn on c mt bnh nhn suy tim thng thng ngi ta da vo: lm sng - Xquang - in tm - Siu m v mt s thm d ph tr khc, nhng thng thng tuyn c s ch yu da vo lm sng. d dng nh li chng ti nhc li nhng triu chng lm sng v cn lm sng chnh theo cch phn loi m ni phn trc. - Suy tim phi: + Triu chng c nng u tin l kh th vi tnh cht kh th t t tng dn khng c nhng cn kch pht, tu theo giai on m kh th c th nhiu hoc t. + Triu chng c nng tip theo l ph vi tnh cht ph tim ngha l ph chn trc, ph tm n lm, ph bui chiu nhiu hn bui sng, n nht c bt ph. + Triu chng thc th ti tim: din c tng i ca tim to v bn phi, c du hiu Harzer, nghe thy ting thi tm thu do h van ba l c nng. + Triu chng ngoi vi: huyt p ti a bnh thng huyt p ti thiu tng. Gan to vi tnh cht gan tim: b t, mt nhn, phn hi gan - tnh mch c (+). + Triu chng XQ: tim phi to y mm tim ln cao v sang tri, phi huyt. + in tm : trc in tim lch phi, dy tht phi. - Suy tim tri: + Triu chng c nng cng l kh th nhng thng l kh th tng cn xut hin sau gng sc hoc na m v sng. + Triu chng th hai l ho v ho ra mu trong cn hen tim v ph phi cp. + Triu chng thc th ti tim: tim to v bn tri, c th c ting nga phi tri, nghe thy ting thi tm thu do h van hai l c nng. + Ngoi vi: huyt p ti a gim, huyt p ti thiu bnh thng. + Xquang: tim to ch yu bn tri y mm tim chc xung, phi huyt ch yu l vng rn phi. + in tm : trc in tim lch tri - dy tht tri. - Suy tim ton b: c th ni y l bn bnh n tng hp ca c suy tim phi v suy tim tri nhng d nh chng ti tp hp thnh nm triu chng chnh. + Mt l: kh th thng xuyn vi tnh cht kh th ca suy tim. Mc kh th ph thuc vo mc suy tim. 40

+ Hai l: tim to ton b trn c lm sng v X quang. + Ba l: gan to vi tnh cht gan to do mu, mc cng ph thuc vo mc suy tim. + Bn l: ph vi tnh cht ca ph tim. + Nm l: tr tiu tun hon th hin trn lm sng l ran m phi v X quang l phi huyt. Trn y chng ti nhc li nhng triu chng chnh trn lm sng.v cn lm sng gip ch cho chn on iu tr c hiu qu. 2. PHN GII ON SUY TIM THEO NYHA Cho n nay c rt nhiu cch phn giai on suy tim nhng theo chng ti phn loi NYHA l cch n gin d nh d sp xp t s thng nht gip cho cng tc iu tra qun l v iu tr tt hn. NYHA phn suy tim lm 4 giai on. - Giai on 1 l giai on suy tim tim tng ngha l khng r rt, triu chng ch xut hin khi gng sc m triu chng hay c k n nht l kh th, ngha l kh th ch xut hin khi bnh nhn gng sc cho d l suy tim phi hay suy tim tri. - Giai on 2 l giai on suy tim r rt nhng khng ton b, ngha l tc nhn nh vo tim no trc th biu hin ca suy tim r rt cn tm tht kia bnh thng, v d hp van hai l mi ch biu hin suy tim phi. - Giai on 3 l giai on suy tim ton b cho d ch c tc nhn nh vo mt tm tht, v d hp van hai l c suy tim ton b nhng khi iu tr suy tim ng th suy tim hi phc. - Giai on 4: l giai on suy tim ton b iu tr khng hi phc. Vi cch phn giai on nh trn chng ta thy khi ni n giai on no ca suy tim th ta lin hiu ngay ngi bnh ang trong tnh trng nh th no v c thi x tr ng mc. 3. IU TR SUY TIM 3.1. Nhng nguyn tc chung Lm tng cung lng tim bng thuc tr tim hoc nhng thuc c tc dng lm tng cung lng tim. Lm gim tr tun hon bng n nht, li tiu, kim sot lng nc a vo c th. 3.2. Nhng bin php chung L nhng bin php c th p dng cho suy tim do bt c nguyn nhn no, bt c giai on no, c chng khc nhau mc can thip. 41

- Ch n v ung: ni chung ch n ca ngi b suy tim u cn hn ch Na nhng ty tng giai on suy tim m chng ta c th hn ch Na+ nhiu hoc t. Cn lng nc ung th khoa hc nht l da vo lng nc tiu 24 gi ca ngy hm trc + 200 - 300ml nc mt theo ng khc, ng nhin phi cng c lng nc trong thc n. Thng th ch hn ch nc ch p dng cho nhng ngi bnh suy tim giai on 3 tr i.+

- Ch lm vic v ngh ngi: y ta khng t vn l ch lm vic trong x hi v vn ny khng ph thuc hon ton vo cn b y t. Chng ta ch t vn ngh ngi hp l trong tng giai on ca bnh. Bnh giai on cui th cn ngh ngi tuyt i ti thng v nhng vic lm khi khng suy tim th l nhng cng vic nh nhng nhng khi suy tim nng th li l cng vic cn gng sc. - Thuc li tiu: l thuc rt cn thit nhm lm gim tr tun hon v lm gim tin gnh trong suy tim, thuc li tiu thng c chn l Furocemid nhng tu nguyn nhn gy suy tim m ta c th thay i, v d suy tim trong tm ph mn ta nn chn thuc li tiu c ch men AC hoc suy tim trong tng huyt p ta li chn li tiu thi mui. Tuy nhin da vo lm sng ta iu chnh liu v thi gian dng cho thch hp. - Thuc tr tim: l thuc rt cn thit cho tt c cc loi suy tim nhng cn nm vng tc dng, tc dng ph cng nh chng ch nh ca tng nhm thuc. Suy tim c nhp nhanh khng c ngoi tm thu th tt nht l Digoxin thuc nhm Digitalis liu dng thng bt u bng 1-2 vin 0,25 m ri tu tc dng, thng l da vo nhp tim v tnh trng lm sng m gim dn liu, khng nn qu 10 ngy cho mt t iu tr. Nhng trng hp suy tim cp cn tc dng nhanh hoc suy tim khng c nhp nhanh ta dng nhm Strophantus bit dc hay dng l Ouabain ng 0,25mg tim tnh mch, ngy dng 1-2 ng ty trng hp c th, t iu tr t 5-10 ngy. - Thuc gin mch: l thuc mi c a vo nhm lm gim tin gnh hoc hu gnh nhm ci thin tnh trng huyt ng trong suy tim. Cc thuc gin mch thng khng c ch nh trong nhng trng hp suy tim c huyt p tm thu 1mm RV1 7mm; V1 dng R/s 5.2.3. Tng gnh hai tht Nguyn nhn: bnh hai l - ng mch ch, tm ph mn, tng huyt p. Triu chng: tng gnh hai tht gm triu chng ca dy tht phi v dy tht tri phi hp. - R cao v STT m c V1 ln V5 V6 - Hoc R cao v STT m V5 V6 nhng li c trc phi mnh > + 100o - Hoc c dng hai pha RS vi bin cao V3 V4 6.3. Block nhnh: l ri lon dn truyn trong tht. 6.3.1. Block nhnh tri khng hon ton V5 V6: sng R gin rng c mc nh, c th c sng Q nh hay khng, nhnh ni in (0,04 - 0,055s), STT c th dng. V1 V2: dng rS c mc i khi l dng QS l hnh nh gin tip. 6.3.2. Block nhnh tri hon ton Triu chng quan trng nht khng th thiu l QRS, gin rng 0,12S. - V5 - V6: sng R gin rng, c mc nh, sng Q v S bin mt. + Nhnh ni in mun qu 0,055s. - V1 V2: dng rs c mc i khi QS (hnh nh gin tip). - V3V4: dng trung gian (RS). 6.3.3. Blc nhnh phi khng hon ton 52

- V3R, V1 c dng rsR vi R rng v nhnh ni in mun qu 0,03s, QRS: 0,08 - 0,10 sec. - V5 V6 c S rng. 6.3.4. Blc nhnh phi hon ton Triu chng quan trng nht l QRS gin rng 0,11s. - V3R, V1: + Dng rsR vi R gin rng, trt m hay c mc. + Nhnh ni in mun qu 0,055s, c khi qu 0,10s, hai du hiu trn gp li l hnh nh trc tip. -V5, V6, V7: dng QRS vi S gin rng, c mc gi l hnh nh gin tip. 6.4. Hi chng Wolf - Parkinson - White (W.P.W). 6.4.1. Nguyn nhn Bnh nhim khun, d ng, thoi ha, bnh mch vnh, thp tim, tim bm sinh, bnh Ebstein. 6.4.2. Triu chng - PQ ngn li < 0,12s. - Xut hin sng en ta, n l on trt m phn u ca phc b QRS. - QRS (bao gm c sng en ta, c thi gian qu di 0,10s - 0,12s, b tr cho PQ b rt ngn). - on STT bin i th pht ngha l tri chiu vi sng en ta. C 2 kiu: + Kiu A: sng en ta (+) tt c cc chuyn o trc tim khi cu Kent bn tri. + Kiu B: sng en ta (-) cc chuyn o trc tim phi v dng cc chuyn o trc tim tri khi cu Kent bn phi. 6.5. Hi chng Lown - Ganong - Levin (L.G.L) - Khong PQ ngn li < 0,12s. - QRS c hnh dng, thi gian bnh thng khng c sng en ta. 6.6. Bnh mch vnh in tm c mt gi tr rt ln trong vic chn on cc bnh mch vnh. 6.6.1. Thiu mu - T m, nhn, i xng nu thiu mu di thng tm mc. 53

- T dng, cao, nhn i xng nu thiu mu di ni tm mc. 6.6.2. Tn thng - ST chnh ln v cong nh ci vm gp c sng T gi l mt pha. - ST chnh xung, thng un: y l tn thng di ni tm mc. 6.6.3. Hoi t Xut hin mt sng Q su rng, c mc, trt m. 6.7. Nhi mu c tim 6.7.1. Giai on 1 (cp): 1, 2 ngy u. Sng cong vm, xut hin sng Q bnh l, QT di ra. 6.7.2. Giai on 2 (bn cp): t vi ngy n vi tun. - ST chnh ln thp hn, T (-) su nhn, i xng to thnh sng vnh Pardee. Sng Q bnh l r rt v QT di ra. 6.7.3. Giai on 3 (mn tnh): t vi thng n vi nm. ST ng in, T c th dng hay vn m, cn Q bnh l th thng tn ti vnh vin. - Nu 6 - 8 tun nu ST cn chnh ln th thng c phng thnh tim ch nhi mu. 7. CC RI LON NHP TIM in tm c mt gi tr rt ln trong vic chn on cc ri lon nhp tim cc tuyn c s, trn lm sng bng phng php nghe tim chng ta c th pht hin c mt s ri lon nhp tim thng gp sau kt hp vi ghi in tm c chn on chnh xc. 7.1. Ngoi tm thu L mt nht bp ngoi lai gy ra bi mt xung ng pht ra t xut v sm hn bnh thng t mt no ca c tim b kch thch. 7.1.1. Ngoi tm thu tht - Tht QRS gin rng 0,13s, trt m, c mc STT tri chiu khc hn vi nhp c s. Tht phi sm ngha l RR < RR, khong RR gi l khong ghp ca ngoi tm thu. Nu khong ghp ca tt c cc ngoi tm thu bng nhau mt , cn khong ghp khc nhau ngoi tm thu a , tin lng xu. - Ngoi tm thu ngh b, i km vo tht ngoi tm thu c mt sng P c th ri bt k trc, trong hay sau tht . 54

7.1.2. Ngoi tm thu trn tht - Tht QRST rt ging cc tht ca nhp c s. - Mt tht c km mt sng P sm (PP < PP). - Sng P thng bin dng (c mc, dt, m) khc vi P c s. 7.2. Cn nhp nhanh kch pht trn tht (Bouveret). - Nhp tim rt nhanh 140 - 220 chu k/pht, rt u. - Tht QRS c hnh dng bnh thng. - Sng P ln vo tht . 7.3. Cn nhp nhanh kch pht tht (nhp nhanh tht) - Tn s tim 160 - 170 chu k/pht. - QRS gin rng, trt m, c mc, ST v T tri chiu vi QRS. - P khng thy r. - Khng u. 7.4. Rung tht Khng cn hnh nh cc sng bnh thng na m thay bng mt dao ng ngon ngoo vi hnh dng, bin v tn s khng u. 7.5. Rung nh - Sng P v ng ng in u bin mt v c thay th bi nhng sng f l nhng sng ngon ngoo mo m, to nh di ngn khng u vi tn s (f) 400 chu k/pht. - R nht V1, V2, V3R. - Cc khong RR rt khng u nhau l hnh nh lon nhp hon ton. Tn s QRS c th nhanh 100 - 160 chu k/pht. - Hnh dng cc phc b QRST trn cng mt chuyn o c chi tit khc nhau. 7.6. Cung ng nh (Flutter nh) Sng P v ng ng in u bin mt v c thay th bi mt chui nhim sng f rt u nhau v ni ui nhau lin tc v tn ging nh rng ca hay sng nc dao ng. - Cc sng f c tn s (f) = 300 chu k/pht v bin ln hn sng P bnh thng. - Phc b QRST ni chung khng b bin dng, gin rng nhng v chng ln sng f nn trng c v mo m i. 55

- C cc loi cung ng nh 3/1, 4/1, 5/1... - Tn s QRS cn hay thay i (chuyn t loi 2/1 sang 3/1, 4/1 hay ngc li, nht l khi n nhn cu, tn s c th gim hn xung. - C trng hp trn mt on in tm c c rung nh v cung ng nh ta gi l rung cung ng nh.

56

HEN PH QUN1. I CNG Hen ph qun l bnh bit n t rt lu. T hng ngn nm trc cng nguyn, ngi Trung Quc bit dng ma hong cha cn kh th, n th k XII Areteus m t cn hen ph qun v m. Dn dn ngi ta hiu bit c phn no c ch gy kh th, v mt lot cc thuc c sn xut iu tr v d phng. Hen ph qun l bnh rt ph bin, gp mi ni trn th gii, hin c khong 150 triu bnh nhn hen (theo T chc Y t Th gii). M c khong 6-8 triu ngi hen ph qun (B.Weiss). Anh nm 1992 - 1993 c 12% dn s mc hen ph qun, Australia l 11,9%. Vit Nam c khongl% dn s sng nng thn, 2% dn s sng thnh th mc hen ph qun, gp mi la tui ; chim 18,7% trong cc bnh phi (Chu Vn ), 25 - 30% (L Vn Tri - 1984). S ph bin ca bnh ph thuc vo kh hu v thin nhin vng bnh nhn sinh sng, t l mc bnh cc nc pht trin gp nhiu hn cc nc chm pht trin. Ngi ta ni nhiu n nguyn nhn ch yu l do s gia tng cc bnh d ng, s th ha, nhim mi trng, s dng rng ri ha cht, thuc, vacxin... C bnh nhn khng c cn hen ph qun trong thi gian ny, nhng c ngi li lin tc, sinh c th lm bnh hoc nng nn. Cui cng thng l tm ph mn tnh. Trong iu tr cn ch trng iu tr cn hen v iu tr d phng. nh ngha: hen ph qun l trng thi lm sng ca s phn ng cao ph qun do nhiu kch thch khc nhau, biu hin c trng l cn kh th vi ting c c do hu qu co tht c trn ph qun, ph n nim mc ph qun v tng tit dch nhy ph qun. Cn kh th c th hi phc (t khi hoc do iu tr). Hen ph qun l mt hi chng ch khng phi l mt bnh. 2. TN THNG GII PHU BNH Tu theo tng mc , c nhng biu hin sau: - i th: Nhng mng nhy, qunh dnh lp lng ph qun, nht l ph qun nh. C nhng vng ph nang b xp xen ln vng ph nang b gin. - Vi th: Trong lng ph qun c bch cu i toan, bch cu a nhn trung tnh, tinh th Charcot - Leyden, mng y nim mc dy v c thoi ha nhy, ph i c nim ph qun v cc tuyn, ph i mch mu. 57

3. TRIU CHNG 3.1. Triu chng lm sng Biu hin cn hen ph qun thng xy ra v m, khi thay i thi tit hoc khi tip xc vi d nguyn. - Giai on tin triu (triu chng bo trc): ht hi, s mi, nga mt hoc mt (do vim mng tip hp d ng), ho khan. - Giai on kh th cao : bnh nhn kh th chm, kh th ra, c ting c c, kh th tng dn, phi t tay vo thnh ging, i m ca th, mt, tot m hi, ting ni t qung, cn kh th ko di 5 - 10 pht hoc hng gi hoc hng ngy. - Giai on hi phc: cn kh th gim dn, kt thc l trn ho v khc m di trong qunh v dnh, cng khc nhiu cng cm thy d chu. Ht cn hen th bnh nhn ng c. Khm thc th trong cn hen thy: + G lng ngc: trong. + Nghe phi: r ro ph nang gim, c vng phi th b, c ting ran ngy v ran rt khp hai phi. Ngoi cn hen khng c g c bit. + Tim mch: nhp tim thng nhanh, huyt p tng, c khi lon nhp ngoi tm thu. 3.2. Cn lm sng - Xt nghim mu: t l bch cu i toan tng, bch cu a nhn trung tnh tng. - Xt nghim m: c bch cu i toan, tinh th Charcot - Leyden, bch cu a nhn trung tnh, i thc bo, vi khun. - Chn on hnh nh: chiu phi trong cn hen thy phi sng, rn phi m, khoang lin sn nm ngang v gin rng. - Chc nng h hp: (Ch lm sau cn hen) VEMS gim, dung tch sng bnh thng, ch s Tiffeneau gim. o lu lng nh thy thay i. - Phn tch kh mu (bng my Astrup): Hay lm, nht l trong cn hen nng. + PaO2 gim di 70 mmHg. + SaO2 gim trong cn hen nng. + pH mu gim khi toan h hp. - Soi ph qun: nim mc xung huyt, ph n, tng tit dch, ph qun co tht. - Prick test vi d nguyn nghi ng thy dng tnh. 58

- IgE trong mu tng. 4. PHN LOI HEN PH QUN 4.1. Hen ngoi sinh (hen d ng) c c im - Bnh xy ra tr em v ngi tr. - C tin s gia nh. - Tin s bn thn c mc bnh d ng (chm...). - Cn hen c lin quan vi d nguyn c hiu. - Test da: dng tnh. - IgE trong mu tng. - iu tr bng gii mn cm c hiu qu. - Tin lng tt, t t vong. 4.2. Hen ni sinh (hen nhim khun) c c im - Bnh xy ra ngi ln thng trn 35 tui. - Khng c tin s gia nh. - Tin s bn thn khng mc bnh d ng. - Cn hen lin quan n nhim khun h hp. - Test da: m tnh. - iu tr bng gii mn cm khng kt qu. - Tin lng khng tt hay c bin chng. 4.3. Phi hp gia hen d ng v nhim khun Bnh nhn ho ko di, khc m c. 4.4. Hen c tnh c c im Cn hen ko di hn 24 gi, c suy h hp nng, dng cc thuc thng thng khng c kt qu, c th t vong. 4.5. Cc th hen khc - Vim ph qun mn th hen: va vim ph qun mn, va c cn hen. - Hen do gng sc. 5. CHN ON 5.1. Chn on xc nh. Da vo: - Cn hen ph qun. - Cn hen xy ra trong nhng iu kin ging nhau: ban m, khi thay i thi 59

tit. - Chng kin c cn hen. - Thi gian: c cc cn hen xut hin trong 2 nm. Nh vy c th chn on xc nh c cn hen ph qun t tuyn c s. 5.2. Chn on phn bit - Hen tim: bnh nhn c cn kh th kch pht, kh th hai th, kh th nhanh, nghe phi c ran m nh ht y phi lan nhanh ln nh phi. Chiu hoc chp phi thy phi m do huyt. C th xy ra ngi b bnh hp van 2 l, tng huyt p. - Vim ph qun mn t cp: thng ngi ln tui, ngi gi, ngi c vim ph qun nng, c cn kh th ging nh hen, c biu hin nhim khun ng h hp. - Khi u v polyp kh ph qun: bnh nhn kh th lin tc, c c. Cn soi ph qun xc nh. - D vt ph qun: cn khai thc tin s kt hp soi ph qun xc nh. - Hch trung tht v khi u trung tht: chn p vo kh ph qun gy kh th, nghe phi c ran rt. Cn chp phi, chp ph qun xc nh. - Cn kh th do gng sc: ngh ngi s ht. 5.3. Chn on mc 5.3.1. Trc y - Cn hen mc nh: bnh nhn kh th nh, nghe phi thy c ran rt lan to. - Cn hen mc trung bnh: bnh nhn kh th nhanh, nghe phi c ran rt r, c biu hin suy h hp nh. PaO2 gim, PaCO2 tng. - Cn hen mc nng: biu hin suy h hp r, r ro ph nang mt. Tinh thn l ln, mch o ngc. PaO2 gim nhiu, PaCO2 tng nhiu, pH mu gim.

60

5.3.2. Hin nay (theo T chc Y t th gii)Bc Triu chng Triu chng Lu lng Dao ng lu v m nh lng nh

1. Nh < 2 ln/ tun. cch - Khng triu chng v bnh thng cc < 2 ln/ thng 80% qung cn t pht. - Cc cn t pht ngn. 2. Nh 2 ln/ tun. dai dng - Cc cn t pht c th nh hng n 2 ln/ thng 80% sinh hot 3. Trung - Triu chng xy ra hng ngy. bnh dai - S dng thuc ct cn hng ngy. dng - Cc cn t pht nh hng n sinh > 1 ln 1 tun > 60-80% hot. - Cn t pht > 2 ln/ tun v ko di c ngy. 4. Nng - Triu chng xy ra lin tc. dai dng - Gii hn hot ng hng ngy. - Cc cn t pht xy ra thng xuyn. Thng xuyn 60%

< 20%

20 - 30%

> 30%

> 30%

5.4. Chn on nguyn nhn C nhiu nguyn nhn gy hen ph qun nhng hay gp l do d ng v do nhim khun. 5.4.1. D ng: (chim 50 - 60%). - Ht phi nhng cht v mi gy kch thch nh: phn hoa, bi nh, lng da cm, bi bng, bi g, bi kim loi, xng du, khi thuc l, ha cht, nm mc, vi khun... - Thc n: tm, cua, c, trng... - Thuc: Aspirin, penicillin, vacxin... cn gi hen d ng v hen ngoi sinh (Atopi). 5.4.2. Nhim khun Nguyn nhn nhim khun lm khi pht cn hen c ni n nhiu mc d c ch cn cha r gm virus, vi khun, cc nhim khun mn tnh nh: vim xoang, vim amydal, t nhim khun ng h hp lm bnh nng thm. 5.4.3. Do yu t vt l Thay i thi tit, nhit , gi ma, m... 5.4.4. Do gng sc 61

Sau gng sc (chy...) xut hin cn hen, hay c tr em, ngi tr tui. C ch cha r rng, cho rng khi gng sc s lm thay i nhit v p sut ca kh th vo gy kch thch nim mc ph qun. 5.4.5. Stress tinh thn Yu t tinh thn rt quan trng, nhng Stress tinh thn lm khi pht cn hen, c th lm bnh nng ln hoc gim nh. Ngi ta cho rng do ri lon cn bng thn kinh - th dch. 5.4.6. Cc yu t khc nh: c a di truyn (trong gia nh c ngi mc hen ph qun). 5.5. Chn on bin chng - Nhim khun phi do tp khun hoc lao phi. - Gin ph nang. - Trn kh mng phi. - Tm ph mn tnh (c th 5 - 10 nm sau). 6. IU TR V D PHNG 6.1. iu tr trong cn Nguyn tc: - Tng kh nng thng kh. - Gin c trn ph qun. - iu ho nc v in gii. C th: - Vi cn hen nh: + Theophyllin 0,1g x 4 - 6 vim 24h (hin nay t dng). + Kh dung Ventolin. + Seduxen 2,5 mg - 5mg /24h. + C th chm cu hoc bm huyt. - Vi cn hen trung bnh: + Nm u cao, ht m di. + Th oxy qua bnh nc, th hn hp oxy 70 - 75% qua ng thng. + Aminophyllin 0,24g x 1 ng (tim tnh mch chm 5 - 10 pht). + Hoc Adrenalin 1mg x 1 ng (tim bp hoc tim di da). 62

+ Nu khng , sau mt gi tim nhc li. + Kh dung Ventolin. + Khi iu tr cn hen nh v trung bnh, phng thc iu tr ny l ph hp vi tuyn c s. - Vi cn hen nng: + Nm u cao, ht m di, th oxy. Nu c suy h hp nng phi t ni kh qun, th my. + Corticosteroid: Depersolon hoc Solumedrol truyn tnh mch, c th kt hp Aminophyllin. + iu ho nc v in gii: qua ng ung v truyn dch: dung dch Glucose 5%, dung dch Natribicarbonat 14 + Nu khng , phi chuyn tuyn trn iu tr trnh suy h hp v nguy c t vong. 6.2. iu tr ngoi cn (d phng) - Hn ch v loi b tip xc vi d nguyn: thuc l, thuc lo, bi... - Gii mn cm bng d nguyn c hiu. - Khng vim Corticoid dng ht. - iu t cc nhim trng mi, hng, xoang... - Thay i ni lm vic v sinh sng, lm sch mi trng sng. - Trnh mi sang chn tinh thn. - Tp th dc liu php. - Bo v s bn vng ca mng t bo Mastocyte: Coromolyn ntal, Zaditen). - iu tr ngoi khoa: ct hch giao cm ngc (kt qu khng r). Kt lun: hen ph qun rt ph bin, gp mi la tui, nguyn nhn phc tp, c ch cha tht r rng, cha c thuc iu tr khi bnh. iu tr HPQ thng lu di, i hi cn c s hp tc cht ch gia thy thuc v bnh nhn d phng xut hin cn kh th, nhn bit sm cn hen, bit theo di tnh trng bnh n bnh vin kp thi. Cn phi phi hp nhiu phng php, gio dc sc khe qun l bnh nhn hn ch bin chng ca bnh v tai bin do iu tr.

63

VIM PH QUN CP, MNVim ph qun cp l tnh trng vim nhim nim mc ca ph qun ln v ph qun trung bnh. Bnh c th xy ra bt k tui no, nhng gp nhiu tr em v ngi gi, thng vo ma lnh v u ma xun. Biu hin lm sng chnh l ho v khc m nhy m, khi khi khng li di chng, nhng cng c th lm khi pht cn hen ph qun nhim khun. Vim ph qun mn l bnh thng gp, chim 5% dn s (Php), khong 47% ngi tui 55 (Anh). Cn gi l bnh phi tc nghn mn tnh, v c nh ngha nh sau: Vim ph qun mn tnh l tnh trng tng tit dch nhy ca nim mc ph qun, gy ho v khc m lin tc hay ti pht t nht l 3 thng trong 1 nm v t nht l 2 nm lin. 1. NGUYN NHN 1.1. Vim ph qun cp - Nhim khun ng h hp trn do vi khun v virus: vim mi, vim xoang, vim amydal. Thng do Staphylococus, hoc do Streptococus pneumonia (68,5% theo Nguyn Vn Thnh). Adenovirus, Hemophylus... - Do bnh truyn nhim: cm, si, ho g... - Ht phi hi c: Chlore, amoniac, khi thuc l, dung mi cng nghip... - Yu t d ng: c a d ng. - Yu t thun li: c th suy yu, suy tim, m, lnh, khi bi... 1.2. Vim ph qun mn - Thuc l, thuc lo. - Bi trong khng kh, kh hu m t. - Ngh nghip: cng nhn m than, luyn kim, dt, nha... - Nhim khun, d ng. - Tui, gii: thng trn 40 tui, nam gp nhiu hn n. - Yu t x hi: sinh hot thiu thn. 2. TRIU CHNG 2.1. Triu chng ca vim ph qun cp 2.1.1. Triu chng lm sng Bnh bt u bng vim long ng h hp trn, s mi, ht hi, rt hng, ho khan. Khi vim nhim lan xung ng h hp di l bnh ton pht, gm 2 giai 64

on: * Giai on kh: Bnh nhn cm thy cm gic rt bng sau xng c, tng khi ho. Ho khan hoc ng ng, ho tng cn, khn ting. Triu chng ton thn: st c th st cao 39-40oC, nhc u, mt mi, bing n. Khm phi c ri rc ran rt v ran m to hoc va ht. * Giai on t: Cm gic rt bng sau xng c gim v ht, kh th nh, ho khc m nhy, m vng m. Nghe phi c ran rt, ran ngy, ran m to v va ht. Din bin 4 - 10 ngy th khi hn. C trng hp ho khan ko di vi tun. C th bnh bt u rm r biu hin st cao, ho nhiu, ho ra mu... 2.1.2. Triu chng cn lm sng - Xquang phi: rn phi m. - Xt nghim mu: s lng bch cu tng, tc mu lng tng. 2.2. Triu chng ca vim ph qun mn 2.2.1. Triu chng lm sng a s gp tui 50, nam gii, nghin thuc l, thuc lo. Bnh thng din bin m thm, sau biu hin cc triu chng sau: Ho v khc m vo bui sng, m nhy, trong, dnh hoc xanh vng, c m. Lng m khong 200ml. Mi t ko di 3 tun vo nhng thng ng - xun. - t cp ca vim ph qun mn thng c cc biu hin sau: + Ho, khc m c m. + Kh th nh cn hen. + Phi c ran rt, ran ngy, ran m, r ro ph nang gim. + St hoc khng. + C th c suy h hp. 2.2.2. Triu chng cn lm sng - Xquang: rn phi m, c th thy cung ng mch phi phnh ra. Nu c gin ph nang cn thy hnh nh kh, hnh tim di v b. Nu chp ph qun c cht cn quang (Lipiodol) thy vch ph qun khng u c ch tc. Chp ng mch ph qun thy gin. - Soi ph qun: vch ph qun dy, nim mc nht mu, xung huyt v vim nhim tng vng. Kt hp ht dch tm t bo, sinh thit nu nghi ng khi u. 65

- Thm d chc nng h hp: + VEMS gim. + VC gim. + Tiffeneau gim. + RV (th tch cn) tng khi gin ph nang. - Xt nghim: + m: tm vi khun, lm khng sinh . Nn tm trc khun BK nhiu ln. + Mu: thy hng cu tng, hematocrit tng, bch cu tng, tc lng mu tng (khi c t bi nhim). 3. CHN ON 3.1. Chn on xc nh * Vim ph qun cp da vo: - Triu chng ca vim ng h hp trn: + Nh: vim hng , chy nc mi. + Nng: vim mi m, vim xoang, vim amydal, vim tai gia. - Triu chng ca vim ng h hp di: + Nh: ho, khn ting, th kh kh v du hiu ca vim ng h hp trn, nghe phi c ran rt. + Nng: ngoi nhng triu chng trn, kh th r rt, co ko lng ngc, tm, nhp th nhanh trn 50 ln/ pht. Nghe phi thy c ran rt, ran m vng y phi pha sau lng. * Vim ph qun mn da vo: - Nam gii, tui 40-50, tin s nghin thuc l thuc lo, ho v khc m v bui sng tng t 3 tun, 3 thng trong nm v trong 2 nm lin. - C t kch pht. - Xquang: rn phi m hai bn. Ti tuyn c s thng chn on xc nh c ngay l vim ph qun cp. i vi vim ph qun mn phi hi k tin s gip chn on. 3.2. Chn on phn bit 3.2.1. Cn phn bit vim ph qun cp vi - Hen ph qun tng tit dch: sau cn hen th ht cc triu chng. - ng phi trong suy tim: c biu hin suy tim. 66

- Mt s bnh phi c biu hin vim ph qun: lao phi, bnh bi phi, ung th phi... khng ngh n vim ph qun nu triu chng nghe phi ch mt bn. 3.2.2. Cn phn bit vim ph qun mn vi - Gin ph nang: c th vim ph qun mn tnh m khng c hoc cha c gin ph nang, hoc gin ph nang m khng c triu chng ca vim ph qun mn tnh, phn bit nn da vo mt s c im sau: Xem bng 3.1. Bng 3.1.Gin ph nang - Kh th: nng - Ho: xut hin sau kh th - Vim ng h hp t - Suy h hp: vo giai on cui - Xquang: lng ngc cng, phi qu sng - R (sc cn ng th) tng nh - Khuch tn kh ca phi: gim nhiu - Va - Xut hin nc kh th - Rt thng gp - Tng t cp - Cc nhnh ph huyt qun tng m - Tng nhiu - Gim t Vim ph qun mn tnh

- Lao phi: tm BK (+), c tn thng trn phim chp phi. - Hen ph qun: cn hi k tin s hen, hoc chng kin c cn hen ph quan. - Ung th ph qun: iu tr khng sinh khng , cn phi chp phi, soi ph qun phn bit. - Gin ph qun: chp ph qun thy gin hnh ng, hnh ti. 3.3. Chn on giai on vim ph qun mn tnh * Giai on O: - Khng kh th - Khng c ri lon chc nng h hp. * Giai on l: - Ho dai dng 3 tun. - Khc m dai dng 3 tun. - Kh th 2 (khi leo tng 2- theo Sadoul) * Giai on 2: ging giai on 1 v - Ho, khc m trn 3 tun trong nm. - Kh th 3 (khi i bnh thng) - Phi c ran rt, ran ngy. 67

- Kh th ging hen. - Thay i thng kh phi. * Giai on 3: ging giai on 2 v - Ri lon chc nng h hp. - Kh th nhiu. * Giai on 4: bnh phi tc nghn mn tnh nng. * Giai on 5: bnh phi tc nghn mn tnh nng, ri lon chc nng thng kh nng. Bnh tin trin 5-10-20 nm, thnh tng t, trong qu trnh tin trin ca bnh, c th c nhng bin chng sau: - Bi nhim phi - Gin ph nang, suy h hp. - Suy tim phi. 4. IU TR V PHNG BNH 4.1. iu tr v phng bnh vim ph qun cp * Th nh: ngh ngi ti ging. Ung nc Cho Codein Khng cn dng khng sinh * Th nng: c vim mi m, vim amydal, vim VA, vim tai gia, vim ph qun: - Cho khng sinh: c th dng Erythromycin 1- 2 gam/ ngy cho 10 ngy. - Nn cho khng histamin khi c du hiu co tht ph qun. - H st, gim au. - Long m: Natri Benzoat - iu tr nguyn nhn. - Phng bnh: + Loi b cc yu t kch thch: trnh khi bi, mi trng nhim. + Gi gn sc khe, gi m trong ma lnh. + Tim vacxin chng virus, vi khun. + Dng khng sinh tng t, nht l nhng ngi c vim ng h hp mn 68

tnh. 4.2. iu tr v phng bnh i vi vim ph qun mn tnh 4.2.1. Trong t cp - Dn lu m theo t th, kt hp v rung lng ngc. - Dng thuc long m: Natri Benzoat, Mucomyst. - Nu c suy h hp: th oxy ngt qung. - Nu c tc nghn, co tht ph qun: cho Aminophyllin tim tnh mch, Ventolin kh dung... - Corticoid: Depersolon, hoc Prednisolon 30mg/24 gi. - Khng sinh: dng nhm Cyclin, hoc Erythromycin 1-2 gam/ ngy. .2.2. Ngoi t cp - Tim vacxin phng cm ma thu- ng. Vacxm chng vi khun. - iu tr nhim khun ng h hp. - Tp th bng. - B thuc l, thuc lo. 4.2.3. Phng bnh - B, hn ch cc yu t kch thch: thuc l, thuc lo. - Bo h lao ng cho nhng ngi tip xc vi mi trng c nhiu bi nh cng nhn lm vic hm m... - Xy dng cc x nghip xa vng dn c v ngc chiu gi. - Tim phng cm vo ma thu - ng. - iu tr tt cc nhim trng ng h hp trn. Dng khng sinh vo nhng thng lnh mi t 10 ngy (c th dng nhm cyclin, hoc Erythromycin) - Tuyn truyn, gio dc sc khe cho cng ng, qun l bnh nhn tt.

69

VIM PHI THY1. I CNG nh ngha: vim phi l hin tng vim nhim ca nhu m phi, bao gm vim ph nang, ti ph nang, ng ph nang, t chc lin kt khe k v vim tiu ph qun tn cng. Nguyn nhn do vi khun, virus, k sinh vt. * c trng ca thng tn l khi ng c nhu m phi. Vit Nam vim phi chim 12% cc bnh phi. Bnh gp c nam v n. * Tn thng gii phu bnh: Thng gp thy di phi phi hn, t khi b c hai bn. Theo Laennec, c ba giai on: - Giai on xung huyt: vng phi b tn thng xung huyt mnh, gin mch mu, thot hng cu, bch cu vo ph nang, nu cy dch vim ny thy c nhiu vi khun. - Giai on gan ha : sau b bnh 1 - 2 ngy, vng phi c mu chc nh gan, ct mnh phi b vo nc thy chm. Trong ph nang cha nhiu hng cu, bch cu. Nu cy dch ph nang c nhiu ph cu. - Giai on gan ha xm: vng tn thng chc nh gan, mu xm, trn mt c m, trong ph nang c nhiu hng cu, bch cu, i thc bo. 2. NGUYN NHN - Do ph cu Gr(+) c phn lp t 1883 (Talamon). Hin nay c > 75 chng loi, typ 1, 2, 3 gy bnh ngi ln, typ 4 gy bnh tr em. - iu kin thun li: + Lnh. + C th suy yu, ci xng, gi yu. + Nghin ru. + Chn thng s no, hn m. + Mc bnh phi nm iu tr lu. + Bin dng lng ngc, g, vo ct sng. + TMH: vim xoang, vim amydal. + Bnh tc nghn ng h hp. - ng vo: thng do 70

+ Ht phi vi khun mi trng, khng kh. + Ht phi vi khun do nhim khun ng h hp trn. + Vi khun theo ng mu t nhim khun xa. 3. TRIU CHNG * C nng: bnh thng xy ra t ngt ngi tr tui. - Bt u bng cn rt run khong 30 pht, nhit 39 40oC, mch nhanh, mt , sau vi gi thy kh th, tot m hi, mi tm, c mn herpet mi, mp. - ngi gi, ngi nghin ru c l ln, tr em c co git. - au ngc bn tn thng. - Ho: lc u ho khan, sau c m hoc mu g st. - C khi nn ma, trng bng. * Thc th. - Lc u thy r ro ph nang gim bn tn thng, g v s bnh thng. C th c ting c mng phi v ran n cui th th vo. - Thi k ton pht: c hi chng ng c r, c ting thi ng. * Cn lm sng: - X quang: thy mt m m ca mt thy hay mt phn thu hnh tam gic, y quay ra ngoi, nh quay vo trong. - Xt nghim mu: BC tng 15.000 - 25.000/mm, 80 - 90% l BC a nhn trung tnh. Tc lng mu tng. Cy mu c khi c ph cu. - Nc tiu: c protein thong qua. * Tin trin: thng st khong mt tun, sau gim st, ra nhiu m hi, i c nhiu, bnh nhn d chu v khi bnh. Khm phi vn cn hi chng ng c, hnh nh X quang tn ti vi tun na. Nu c bin chng th triu chng nng ln. 4. CHN ON 4.1. Chn on xc nh Da vo: - Khi pht t ngt ngi tr. - Cn rt run, st cao 39 40oC. - Hi chng nhim khun: mi kh, li bn, bch cu tng, i t. - au ngc bn tn thng. 71

- Ho, khc m mu g st. - Hi chng ng c phi. - X quang phi c m m u hnh tam gic y quay ra ngoi. Ti c s chn on thng da vo hai biu hin : + Hi chng nhim khun + Hi chng ng c. Do vy vic thm khm lm sng l rt quan trng. 4.2. Chn on phn bit - Xp phi: trung tht b ko v bn xp, c honh ln cao. - Trn dch mng phi: va vim va trn dch (chc d chn on). - Nhi mu phi: au ngc d di, sc, st, ho ra mu. Thng xy ra ngi c bnh tim, hoc phu thut vng h chu. - p xe phi giai on u: da vo din bin ca bnh. - Ung th phi: sau iu tr ht nhim khun m tn thng cn tn ti > 1 thng nht l ngi c tui, nghin thuc l. - Gin ph qun bi nhim: ho, khc m ko di, nn chp ph qun c cn quang chn on. 5. BIN CHNG 5.1. Bin chng ti phi - Bnh lan rng hai hoc nhiu thu phi: kh th tng ln, tm mi, mch nhanh, c th cht. - Xp mt thu phi: do cc m gy tc ph qun mt thu. - p xe phi: st dai dng, m nhiu m, X quang c mt hoc nhiu hnh hang c mc nc mc hi. - Vim phi mn tnh: bnh tin trin ko di, thy phi b tn thng x ha. 5.2. Bin chng ngoi phi - Trn dch mng phi: thng nh, chng khi. - Trn m mng phi: st dai dng, chc d mng phi c m. - Vim mng ngoi tim: au vng trc tim, c ting c mng ngoi tim. - Vim ni tm mc cp tnh do ph cu: (t gp): st rt run, lch to. - Vim khp do ph cu: khp sng , nng, au. - Vim mng no do ph cu t gp. - Vim phc mc: hay gp tr em. 72

- Vim tai xng chm. - Lon nhp ngoi tm thu, suy tim. - Sc 6. IU TR * Chng nhim khun. - Nn dng khng sinh sm. - Penicillin 2 - 3 triu n v/24h tim bp tht 3 - 4 ln. - Kt hp vi Gentamycin 80 - 120 mg/24 h. n khi ht st 4 - 5 ngy hoc dng Ampicillin 2 - 3 g/24h. * iu tr triu chng. - Gim au ngc: cho Codein 2 - 4v/24h. au qu c th dng Morphin 0,01g x 1 ng (tim di da). - Nu c trng bng. Prostigmin 1ml dung dch 0,05%, 1 - 2 ln/24h (tim di da). - Nu c mt nc: cho n lng, bi ph nc v in gii bng dung dch ng trng (Ringer Lactat, dung dch Glucose 5%). * Vi th nng (kh th nhiu, tm, mch nhanh...) - Th oxy. - Khng sinh liu cao: Penicillin 5 triu n v/24 h kt hp Gentamycin 80 - 120mg/24h. - Nu c tru mch. Truyn dch. Prednisolon (Depersolon). Dopamin. - Chuyn tuyn trn nu iu tr khng hoc c bin chng. 7. PHNG BNH - iu tr tt nhim khun vng tai mi hng, nht l vim xoang c m, vim amydal c m vim hng: bng khng sinh hoc kh dung - iu tr tt t cp ca vim ph qun mn tnh: bng khng sinh ung mi thng 10 ngy trong 5 thng ma ng. - Loi b yu t kch thch c hi: b thuc l, thuc lo. - Gi m c, ngc trong ma lnh. - Tim vacxin phng bnh. (Vacxin ph cu a gi). 73

P XE PHI1. NH NGHA V DCH T HC - nh ngha: p xe phi l m trong nhu m phi, sau khi c m ra ngoi th to thnh hang mi, qu trnh hoi t do vim nhim cp tnh phi (do vi khun, k sinh vt, nm khng do lao). - Dch t hc: trc y bnh gp nhiu hn do c t khng sinh, hin nay p xe phi l bnh gp t hn so vi cc bnh phi khc do c chn on sm v iu tr tch cc. 2. NGUYN NHN * Vim nhim hoi t. - Do vi khun lm m: t cu vng, Klebsiella, lin cu khun nhm A v nhng Cocci ym kh khc. - Mycobacteria: Mycobacterium, tuberculosis... - K sinh vt: amp, sn l phi. * nhi mu phi do: - Tc mch. - Tc mch nhim khun. - Vim mch mu (vim nt quanh ng mch). * Ung th nguyn pht ph qun. * Nguyn nhn khc. - Kn hi nhim khun. - Tn thng hoi t trong bnh bi phi. - Vit Nam p xe phi thng do t cu vng, lin cu, ph cu, trc khun m xanh, amp (p xe gan v ln phi). * Cc iu kin thun li: - Chn thng lng ngc c mnh n nm trong phi. - Sau gy m t ni kh qun, th my. - Sau phu thut vng TMH, RHM. - B bnh khc: i ng, suy mn. - C bnh phi mn tnh: gin ph qun. - Nghin ru, nghin thuc l. 74

- t ng thng tnh mch di ngy. Cc nguyn nhn v cc yu t thun li ny c th gy p xe phi theo ng ph qun (do ht vo), hoc theo ng mu, theo ng k cn (p xe di c honh...). 3. GII PHU BNH V tr tn thng 3/4 thy di phi, 1/4 l thu trn. C th b c hai phi. - i th: + p xe cp: vng tn thng l mt khi c, mu hi vng, khi ct ngang mt trong thng cc lp m, c ph qun thng ra ngoi. + p xe m thi: tn thng rng, lan to, ct ngang mt ct c mu xm, mt khng u, m rt thi. - Vi th: + p xe cp: vch p xe c cc lp m, thanh t, ph nang vim ph, thnh p xe c t chc ht, vim ni mc, c huyt khi mch mu ln cn. + p xe mn: thnh p xe c t chc x dy c khi 2 cm, x phi, ph nang, vim m cha nhiu t huyt v bch cu, ph nang thnh dy v x ha. 4. TRIU CHNG LM SNG p xe phi din bin qua ba giai on: 4.1. Giai on vim * Hi chng nhim khun: a s l bt u nh vim phi nng, st cao 39-40oC, mi kh, li bn, i t v nc tiu sm mu. Mt s trng hp biu hin ging tnh trng cm. * Triu chng phi: ho v khc m c, c khi c mu. au ngc bn bnh, c th kh th, khm phi c hi chng ng c mt vng, c ran n mt vng, c khi c hi chng ba gim. 4.2. Giai on c m Triu chng c m c khi xut hin sm 5 - 6 ngy, sau khi bnh bt u, c khi xut hin mun 50 - 60 ngy sau. M c th c ra nhiu mt lc 300 - 500ml/24h, hoc m khc ra t mt nhng ko di. Tnh cht m tu theo nguyn nhn: nu do vi khun ym kh th hi thi, do amp th c mu chocolate, do p xe ng mt thng ln phi th c mu vng. Cn phi cy m xc nh vi khun v lm khng sinh . Sau khi c m s gim st, bnh nhn thy d chu hn nhng vn tip tc khc m. Nu m ra t, hoc cn p xe khc cha v th bnh nhn vn st cao. 75

Khm phi thy c c ran n mt vng, c hi chng ng c hoc ba gim, triu chng hang khng r. 4.3. Giai on thnh hang Bnh nhn vn khc m nhng t hn, c th nhit tng cao (khi m cn nhiu trong phi). Trng hp in hnh c th thy hi chng hang: nghe thy ting thi hang r. Cng c th ch thy hi chng ng c hoc hi chng trn dch (do hang su hoc cn cha nhiu m). 5. TRIU CHNG CN LM SNG - Xt nghim mu: s lng bch cu tng, t l bch cu a nhn trung tnh tng, tc lng mu tng. - Xt nghim m, cy m tm thy vi khun, k sinh trng gy bnh. - X quang phi: + Giai on vim: thy m m nh vim phi. + Giai on thnh hang: thy hnh hang trn, hoc bu dc, c mc nc v hi. Cn chp nghing bit hang pha trc hay sau, su hay nng so vi thnh ngc, nu cn thit th cho chp ct lp. 6. CHN ON XC NH Da vo lm sng v cn lm sng, ch yu thy: - Hi chng nhim khun. - Triu chng c m. - X quang phi c mc nc, mc hi. Nh vy cn ch nhng triu chng ban u chn on sm p xe phi l: mt mi, chn n, au ngc, hi th thi, khm phi c hi chng ng c hoc hi chng 3 gim, hnh nh X quang phi thy m m, ko di mt tun cn nghi ng p xe phi v nu ch n triu chng c m l mun. 7. CHN ON PHN BIT * Giai on vim: chn on phn bit vi vim phi nhng nhiu khi kh khn, do vy nu nghi ng l p xe phi th dng khng sinh mnh thch hp ngay. * Giai on c m: phn bit vi. - Gin ph qun bi nhim: l bnh rt hay gp thng c biu hin: + C hi chng nhim khun. + Khc m ko di, c th ho ra mu. 76

+ C tin s ho v khc m lu ngy. + X quang: hnh m khng u. + Chn on xc nh bng chp ph qun c cn quang thy gin ph qun hnh ng hoc ti. - Kn hi phi b bi nhim: + Thng l kn hi bm sinh, nhiu kn v hai bn phi. + C hi chng nhim khun. + C khc m. + X quang c hnh mc nc, mc hi, sau iu tr ht nhim khun hnh nh kn hi vn gi nguyn. Cn hi k tin s bnh nhn v tm nhng d dng bm sinh khc. - Ung th phi (khi u b hoi t bi nhim): chn on thng da vo cc biu hin nh ngi ln tui 45-55 tui, nghin thuc l, c ho khan, ho ra mu trong tin s, triu chng lm sng v X quang ging p xe phi, iu tr ht nhim khun nhng triu chng X quang vn cn tn ti. - Lao hang: da vo tin s, c hi chng nhim khun mn tnh, X quang c hnh hang hoc m m h n, cn tm BK trong m nhiu ln xc nh. - p xe thc qun: nguyn nhn do hc xng gy p xe thc qun c th gy l r vi kh ph qun, chn on xc nh cn hi tin s hc xng, chp thc qun c cn quang hoc soi ph qun, thc qun. - R mng phi- ph qun: cn chc d mng phi chn on. - p xe di c honh: gy l r c honh - ph qun. - Nang t mu do chn thng lng ngc. - Kn sn ch: X quang thy m m, c th tm u sn trong bnh phm. Trn thc t: giai on u thng chn on phn bit vi vim phi, ung th phi. Giai on sau thng chn on phn bit vi hang lao, kn hi phi. 8. CHN ON BIN CHNG Mc d hin nay c nhiu khng sinh ph rng iu tr nhng nu khng c chn on sm, iu tr kp thi, tch cc vn c th c nhng bin chng sau: - Trn m mng phi (do p xe thy di thng vi mng phi), c khi km theo trn kh, trn dch. - Ho ra mu nhiu do v mch mu ln. 77

- Nhim trng mu. - Vim m trung tht, vim mng ngoi tim c m. - Gin ph qun v x phi. - p xe no, thn nhim bt. - Bi nhim lao, suy mn. - T vong. 9. IU TR 9.1. Nguyn tc - Dng khng sinh liu cao phi hp, da vo khng sinh , iu tr theo nguyn nhn. - iu tr triu chng v bin chng (nu c). 9.2. C th 9.2.1. iu tr ni khoa - Dng khng sinh liu cao phi hp theo khng sinh , nu khng lm c khng sinh th chn: Penicillin 5 - 10 triu n v/24h tim bp, truyn tnh mch. Hoc Cephalosporin th h mi nh Cefotaxim 2-4g/24h kt hp vi Gentainycin 160mg/24h. Thi gian dng thuc n khi ht triu chng lm sng, hnh nh X quang ch cn nhng di m nh. - Dn lu t th. cho bnh nhn nm t th thch hp (v d: p xe nh phi phi th cho bnh nhn nm nghing sang tri, u cao, p xe thy y th cho bnh nhn nm u dc xung, bng gp vo thnh ging). Kt hp g, lc, rung lng ngc. - Thuc long m: Acemuc 4-6 gi/24h. Natribenzoat: 4-6g/24h. - Soi ht ph qun ch lm khi c tc ph qun do d vt hoc m khng thot ra c. - Chc ht m qua thnh ngc nu p xe gn thnh ngc. - iu tr c hiu: cho Emetyl, Flagyl trong p xe do amp. - Nu p xe phi do tc mch nhim khun: cn trch rch nhim khun bn ngoi. 78

- iu tr triu chng: gim au, h st bng Paracetamol 0,5 - lg/24h. Nu iu tr khng thy th cn phi chuyn tuyn trn kp thi. 9.2.2. iu tr ngoi khoa C th ct thy phi, l phi. Ch nh: - p xe phi mn tnh. - Ho ra mu ti pht nhiu ln v nng. - p xe phi phi hp vi gin ph qun. - Ung th phi p xe ha. Thc t rt him khi phi iu tr phu thut do c iu tr ni khoa sm v hiu qu. 9.3. Phng bnh - Tuyn truyn gio dc sc khe, v sinh rng ming tt, phng tc d vt tr em, khng ht xng du bng ming. - iu tr nhim khun vng tai mi hng, rng hm mt. - Khi phu thut vng tai mi hng, rng hm mt cn ch phng p xe phi. - Bnh nhn hn m, ng kinh, nhc c... khi nui dng bng ng thng phi cn thn trnh sc.

79

LOT D DY T TRNG1 C IM DCH T HC Lot d dy t trng l mt bnh ph bin trong cc bnh ng tiu ha. T l mc bnh ti M: 1,9%, Nga 3-4%. Vit Nam cha c thng k chnh xc song mt nghin cu s b trc y ti Bnh vin Bch Mai thy khong 5% dn s c triu chng ca bnh lot d dy hnh t trng. Mi la tui u c th gp nhng gp nhiu hn 20- 40 tui. Thng nam mc nhiu hn n vi t l 3:l. Lao ng cng thng, thnh ph mc nhiu hn nng thn, thi chin nhiu hn thi bnh. Lot hnh t trng gp nhiu hn lot d dy. Lot d dy hnh t trng nh hng nhiu n sc khe ca bnh nhn, lm gim kh nng lao ng v quan trng hn c mt s bin chng c th nguy him n tnh mng. 2. C CH BNH SINH, BNH NGUYN C nhiu thuyt gii thch s hnh thnh v tn ti lot. Thuyt huyt qun ca Wirchov, thuyt n mn ca Claude Bernard, thuyt c gii ca Aschoff. Thuyt vim, thuyt ri lon chuyn ha, thuyt ri lon thn kinh thc vt... Cc thuyt ny cui cng u dn n gii thch l do mt cn bng gia hai yu t bo v v hu hoi: tng tit HCl, pepsin - Gim tit cht nhy bo v. - Mt s yu t c coi l yu t thun li hoc nguy c nh: s cng thng thn kinh qu mc v ko di, stress tinh thn [Curling], cc tn thng thc th nh bng nng, chn thng, cc bnh l cp tnh khc [Cushing], yu t gia nh, thiu dinh dng, n khng ng ba, thc n cng, la tui: 20- 40 tui, nam d mc bnh hn n, cc thuc h st gim au chng vim khng steroid, thuc chn giao cm... Gn y vi khun Helicobacter pylori (HP) c nh gi l nguyn nhn gy vim, lot d dy, hnh t trng. HP l tht xon khun c kch thc 0,5 x 3m, u c 46 roi, giam (-). Xon khun lm thoi ha lp nhy do sn xut ra men urease to NH4+ khi nim mc d dy mt cht nhy, acid HCl tc ng ln vng khng cn cht nhy gy lot [Marshal.1983]. Vi khun HP c th ly truyn theo ng tiu ha nn trong gia nh thng c nhiu thnh vin cng mang HP trong d dy, tuy nhin khng phi tt c cc thnh vin ny u mc bnh lot. 3. TRIU CHNG 3.1. Lm sng Triu chng thng a dng, din bin theo chu k. - au: l triu chng chnh, au m , c tnh cht chu k, tng t. Thng au theo ma nht nh, hay au vo ma rt, mi t au thng ko di 1 n 2 tun. V tr au thay i tu v tr lot. 80

+ Lot tm v, mt sau d dy c th au khu tr thng v, lan ln ngc tri, d chn on nhm. au ngay sau khi n + Lot b cong ln - hang v: au sau khi n 2-3 gi + Lot mn v: thng khng lin quan n thi gian n v thng au qun. + Lot hnh t trng: au lc i, hi lch sang phi, ra sau lng, cm gic au bng rt + C lot d dy- hnh t trng c th lm sng khng au gi l lot cm. y l mt th lm sng kh c bit ca lot d dy hnh t trng thng khng pht hin triu chng g, ch thc s pht hin khi c cc bin chng nh thng hoc chy mu lot. - Ri lon dinh dng d dy: hi, chua, nc, nn, bun nn. - Ri lon thn kinh thc vt: trng hi, to bn, t gp hn lot t trng. - Thm khm: Phn ng nh khi khm vng thng v, n tc hoc cm gic au tng ln. Ngoi cn au khm khng thy g c bit. Nu c hp mn v nn ra thc n ca ngy hm trc, lc c ch lc i. Trong cn au khm thy co cng thng v hi lch phi. i khi bnh nhn c th xc nh c mt im au khu tr vng thng v khong 3 cm2. 3.2. Cn lm sng - Chp X quang d dy, hnh t trng c ung cn quang: thy ng thuc d dy, hnh t trng bin dng. Hnh nh rt phong ph ty theo hnh thi lot. Tuy nhin c nhiu hn ch - Soi d dy bng ng soi mm rt c gi tr chn on xc nh v sinh thit chn on phn bit. Cn ch cc c s tuyn huyn th Xquang l phng tin kh hu hiu khng nh cc chn on lm sng. Ti cc bnh vin ln c iu kin, ni soi l mt thm khm cn lm sng c gi tr hn. - BAO (Basal acid output): ht dch v lc i tnh lu lng toan c bn, ngoi ra cn o hot lc ca pepsin, xt nghim t bo: hng cu, bch cu, t bo khc. - nh gi tnh trng bi tit khi kch thch: nghim php Histamin, nghim php Insulin. y l hai nghim php thm d kh nng bi tit khi kch thch th dch hoc kch thch thn kinh nht l thm d trong ch nh phu thut ct dy X. Ngy nay thm d chc nng t lm v c ni soi pht trin v ni soi c u vit hn hn. Thm d chc nng ch lm trong nghin cu v khi nghi ng c thiu toan d dy. 81

4. CHN ON XC NH V CHN ON PHN BIT 4.1. Chn on xc nh - au thng v c tnh cht chu k. - X quang hoc ni soi c kt lun lot d dy hay hnh t trng. - Thm d chc nng ca d dy c ri lon. - Trong vic chn on cng ng cn ch hi bnh k nhm pht hin tnh chu k ca au. y l triu chng quan trng v c th chn on c bnh, khng nht thit bt buc phi c y cc xt nghim nh trong phn triu chng cn lm sng nu. Ch nh ni soi hoc Xquang cn tu thuc hon cnh ca c s v l xt nghim tham kho. 4.2. Chn on phn bit - Vim d dy mn: lm sng c au thng v, tnh chu k khng r; soi chp khng c lot. - Vim ti mt: thng c st hoc chn on nh siu m. - Ung th d dy: da vo soi v sinh thit. - Vim i trng, nht l i trng ngang: ch