CNG N TP SINH L BNH Cu 1 khi nim v bnh ,bnh nguyn , v bnh sinh? TL: Khi nim v bnh c s khc nhau qua cc thi k x hi lch s.N ph thuc ch yu vo 2 yu t: -trnh vn minh ca x hi ng thi -th gii quan(gm c trit hc) ca thi i Quan nim v bnh bao gi cng chi phi cc nguyn tc phng v cha bnh *Thi k nguyn thu cho rng : Bnh l s trng ft ca cc ng siu linh i v con ngi trn th gii, y c s ln ln gia b/c cu bnh vi nguyn nhn gy bnh.Vi quan nim ny,con ngi thi k ny cha bnh ch yu bng cch dng l vt cu xin,nhng h bt u bit dung thuc. *Thi k nn vn minh c i : -Trung Quc c i cho rng bnh l s mt cn bng m dng , v s ri lon q h tng sinh tng khc cu ng hnh trong c th.T nguyn tc cha bnh ca h l kch thch mt yu(b),ch p mt mnh(t) -Hi lp v La M c i : c th c 4 dch tn ti theo t l ring c quan h cn bng nhau to ra sc kho , l :->mu do tim sn xt ra mang tnh nng ;dch nhy : ko mu dio no sx ra th hin tnh lnh ; Mu en : lch sx mang tnh m t ; Mt vng : do gan sxut ra mang tnh kh => bnh l s mt cn bng gia 4 dch y.Cch cha bnh l iu chnh li,b sung ci thiu v yu,kim ch ci mnh v tha. *Cc nn vn minh khc: Ai Cp c i da vo thuyt Pneuma (sinh kh ) cho rng kh em li sinh lc cho c th, c th fi thng xuyn h hp a kh vo c th.Bnh l do ht fi kh ym ,khng trong sch.n cor cho rng bnh ch l 1 bphn ca vng lun hi:sinh,lo,bnh,t. *Thi k th k :18-19 thuyt t bo cho rng l do cc tb b tn thng hoc cc t bo tuy kho mnh nhng thay i v slng v v tr v v thi im xut hin * Quan nim hin nay : Bnh l s thay i v lng v cht ca cc hot ng sng ca c th do tn thng cu trc v rlcnng do tc nhn t mt hoc bn trog c th gy nn . Mt cch c th hn,c 1 nh ngha hin ang c s dng rng ri:Bnh l bt k s sai lchhoc tn thng no v cu trc v chc nng ca bt k b phn,c quan,h thng no ca c th biu hin bng 1 b triu chng c trng gip cho thy thuc c th chn on xc nh v chn on phn bit,mc d nhiu khi ta cha r v nguyn nhn,v bnh l hc v tin lng(t in y hc Dorlands 2000). 2/ Bnh nguyn L nhng yu t quyt nh s pht sinh bnh tt v quyt nh c im ring ca tng bnh. Trc khun lao l nguyn nhn gy bnh lao vi nhng c im ring ca bnh; plasmodium l nguyn nh gy bnh st rt vi nhng c im ring ca bnh, ch khng phi l nguyn nhn gy cc bnh thng hn, t Cho nn mi bnh u c nguyn nhn ca n. Tuy nhin, hin nay vn cn nhng bnh cha xc nh c nguyn nhn (ung th, bnh bch cu, mt s bnh tm thn).

1

Ngi ta phn bit: 2.1. Nguyn nhn bn ngoi: l nhng mm bnh, nhng yu t ngoi mi tc dng ln c th v gy bnh ung nh: - Yu t c hc: chn thng, tai nn. - Yu t vt l: bng, qu nng, qu lnh, dng in, thay i p sut t ngt - Yu t ha hc: cht c, ha cht - Yu t sinh hc: cc vi sinh vt (vi khun, virut), nm. - Yu t x hi: iu kin, hon cnh sinh hot, t chc v tm l x hi. 2. 2. Nguyn nhn bn trong: tui tc, th tng v di truyn. Trong thc t bnh c th do nhiu nguyn nhn gy nn hoc c nguyn nhn nhng khng nht thit pht sinh bn tt khi khng c iu kin thch hp. Mt khc,, cng c th nguyn nhn l yu t duy nht quyt nh s pht sinh bnh tt (mt s bnh truyn nhim gy nn do cc vi sinh vt c tnh mnh). Do phi lun cnh gic vi quan im nguyn nhn n thun. Thuyt nguyn nhn n thun ra i t khi Pasteur tm ra vi khun l nguyn nhn ca mt s bnh. L mt hc thuyt duy tm cc oan v bnh cn hc, cho rng h c nguyn nhn (vi khun) l nht nh c bnh. Hc thuyt ny ch ch trng ti nguyn nhn, cha ch ng mc vai tr ca cc iu kin gy bnh, coi nh kh nng thch ng, phng ng ca c th v tc ng qua la gia c th v ngoi mi. Vi quan im ny, trong iu tr ch yu l tiu dit nguyn nhn (vi khun); mi ch iu tr bnh m cha quan tm ti ngi bnh, khng ch ti hon cnh lao ng, sinh hot, tmt tnh cm ca bnh nhn cng nh cha ch ti cc bin php nng cao sc khng, chng ca c th ngi bnh nn cha pht huy c hiu lc to ln ca iu tr ton din. ng thi hc thuyt ny cn gy 1t tng tiu cc trong cng tc d phng bnh tt. 2.3 ieu kien bnh tt pht sinh ph thuc vo cc yu t c bn sau y: 1. Nguyn nhn v iu kin gy bnh: l nhng yu t hin nhin quyt nh s pht sinh bnh a s trng hp. 2. c im ca c th: vi mt s bnh c th, ngoi cc nguyn nhn, iu kin bnh pht sinh cn ph thuc vo nhng c im c th ca con ngi (tnh phn ng ca c th di vi bnh tt, th tng, di truyn). 3. iu kin v hon cnh x hi: cng l nhng yu t quan trng nh hn ti s pht sinh ca bnh tt. Cc yu t ny thng lin quan cht ch vi nhau trong tng trng hp c th, c th yu t ny hay yu t khc ni bt ln hng u. Cng c th xp chung l nhng nguyn nhn v iu kin gy bnh v iu kin hon cnh x hi cng nh nhng mm bnh, iu kin hon cnh ngoi mi u l cc nguyn nhn, iu kin bn ngoi v c im c th l nhng nguyn nhn, iu kin bn trong, s xut hin bnh tt trong cc trng hp ny khng chu nh hng ca cc nguyn nhn, iu kin bn ngoi. 3/ Bnh sinh L qtrnh psinh , pht trin v kt qu ca bnh * Vai tr ca yu t bnh nguyn trong qu trnh bnh sinh : yu t bnh nguyn c vai tr khc nhau trong cc bnh :

2

Yu t bnh nguyn ch tc dng trong thi gian ngn, c tc dng khi ng, sau qu trnh bnh sinh t n pht trin. th d trong bng do la yu t nhit ch tc ng trong mt thi gian ngnv gy ra tn thng t chc nghim trng, nhng tn thng ny li gy ra c mt chui phn ng phc tp (sc bng, nhim c, nhim trng, suy mn,vv...) to iu kin cho bnh pht trin, mc d nguyn nhn ban u ht tc dng. b) Yu t bnh nguyn c th tn ti trong sut qu trnh bnh sinh vi cc tnh cht khng thay i v ng vai tr quyt nh trong qu trnh ny, lm cho ngi bnh cht nhanh chng nh khi b in git, nhim c nng, vv... c) Ngoi ra nguyn nhn gy bnh c th tn ti trong c th trong sut qu trnh bnh l, song tc ng ca n thy i tu theo trng thi ca c th. Th d trong bnh thng hn, vi khun Samonella l yu t gy bnh, pht sinh nhim khun huyt lc ban u, sau hnh thnh min dch, gy hin tng d ng tun th 3, cui cng vi khun khu tr ti mt v khng cn kh nng gy bnh cho chnh ngi d na nhng vn c th reo rc bnh cho ngi khc.a)

Cu 3: Ti sao trong lm sng li khng c hai ngi bnh hon ton ging nhau v biu hin lm sng v din bin lm sng. Cho v d chng minh v ngha thc tin ca vn Bi lm Trong LS khng c hai ngi bnh (mc cng mt bnh) hon ton ging nhau v biu hin v din bin LS bi v qu trnh bnh sinh ca h ph thuc vo cc yu t nguyn nhn gy bnh, yu t bn trong v bn ngoi c th 1. Yu t nguyn nhn gy bnh Cng mt yu t bnh nguyn nhng bnh sinh c th thay i theo cng liu lng thi gian tc dng v v tr tc dng ca bnh nguyn -S lng, cng , c lc ca bnh nguyn: yu t gy bnh ko nhng phi c s lng,mt nht nh m pah c cng , c lc mnh ti 1 mc no mi gy bnh v s thay i din bin bnh nu thay i cc tnh cht trn. VD: nicotin nu a vo c th 1 lng ln qua ng h hp th s xy ra ng c cp nhng nu chia ra liu nh ,ko di th s gy VPQun mn, gim kh nng khng c th gy ung th phi. Mt s yu t c cng thp nhng tc dng lien tc trong thi gian di cng gy ra bnh nh ting n,ng c ru mn tnh. -Ni xm nhp ,thi gian tc dng ca bnh nguyn: cng 1 cht c cng 1 VK s gy nn cc bnh khc nhau v mc khc nhau khi chng xm nhp vo cc b phn khc nhau ca c th v mi c quan b phn li c chc nng v phn ng tnh khc nhau. VD: T cu vo da gy bnh apxe, vo rut gy bnh tiu chy hay cng l 1 cng va p nhng vo s no s c bnh sinh khc hn vi vo tay chn.

3

Cng 1 nng bnh nguyn cng ni tip xc nu thi gian cng di th ni chung bnh cng nng 2. Yu t bn trong c th: Trong nhng iu kin nh nhau, bnh sinh mi c th c th khc nhau iu ny ph thuc v gii tui v tnh phn ng ca tng c th. - Tnh phn ng l kh nng p ng ca c th vi mi kch thch bnh thng hay bnh l. Ngoi nhng c tnh do i trc truyn li th tnh phn ng cn bao gm nhng c tnh ca c th hnh thnh trong i sng. Do nhng c th khc nhau th tnh phn ng thng khc nhau, bnh pht sinh hay khng c im din bin ra sao kt qu nh th no ch yu ph thuc vo tnh phn ng ca c th.C rt nhiu yu t nh hng n tnh phn ng ca c th: -Thn kinh, tm thn: Trng thi v no hng phn hay c ch lm thay i b mt ca bnh sinh. Loi TK yu thng km chu ng 1 yu t kch thch nh cng c th gy bnh, loi TK mnh nhng ko thng bng cng d b ri lon nng trc 1 s tc nhn gy bnh.H TK giao cm chi phi cc phn ng khng tch cc. H TK ph giao cm c vai tr to ra trng thi trn tnh,tit kim nng lng tng chc nng tiu ho. Yu t tm l:li ni thi ca ngi xung quanh c bit thy thuc c nh hng xu hoc tt n tm l v din bin bnh. TK thc vt : Khi TK giao cm b HP th chuyn ho c s tng, thc bo tng, sn xut khng th c hiu b C, sn xut khng th khng c hiu tng. Ngc li khi TK ph giao cm HP th thc bo gim sn xut khng th khng c hiu gim v sn xut khng th c hiu tng,cc hang ro bo v nh hch bch huyt tng cng hot ng. - Ni tit: cc HM c nh hng r rt ti bnh sinh.Cng 1 bnh nhng tnh trng ni tit khc nhau c th din bin bnh khc nhau VD ngi cng gip d st cao khi nhim khun. ACTH v corticoid: c tc dng chng vim, chng d ng. C tc dng gim tnh thm mao mch, gim ph n v tit dch, c ch thc bo STH, DOC v Aldosteron : Ngc tc dng ca ACTH v Cortison lm tng qu trnh vim kch thch t chc lin kt tng sinh v chng nhim trng. STH c tc dng chng hoi t, tng tng hp Globulin v khng th cn DOC v Aldosteron th c tc dng tng chuyn ho nc v in gii -nh hng ca gii tnh Mt s bnh hay gp nam gii nh lot DD-HTT, nhi mu c tim cn bnh hay gp n nh vim ti mt u v .. -nh hng ca la tui:Mi tui c c im phn ng ring i vi bnh tt.Tnh phn ng ca c th yu khi cn nh,tng ti tui dy th v gim khi v gi.Do cc bnh c chia thnh bnh ca tr s sinh,bnh ca tr em,bnh tui dy th v bnh ca ngi gi V d:Vim hay st c th tr thng mnh hn ngi gi v triu chng lm sng thng in hnh, c th tr c th mau lnh bnh nhng cng c th lm vo tnh trng phn ng qu mc cn c th ngi gi th cc biu hin c th km r rng d bin chng nguy him khi vim st 3.Yu t ngoi

4

-Mi trng: a l kh hu nh hng r rt ti qu trnh pht sinh pht trin ca bnh.V d: Nhit mi trng, m, kh hu u nh hng n bnh sinh ca nhiu bnh nh bnh phi, hen Ha cht , tia x,nghin ru lm thay i kh nng phn ng ca c th -Yu t XH: Ch XH, trnh vn ho, dn tr cng nh hng ti c cu tnh hnh bnh tt cu qun th dn c - Ch dinh dng : Protein v vitamin nh hng r rt ti bnh sinh ca nhiu bnh, khi c th thiu ht protein lm c th d mc bnh phi v bnh nhim khun. Vitamin c tc dng lm tng cng sc khng ca c th Do cc nh hng trn nn trong LS khng c hai ngi bnh hon ton ging nhau v biu hin v din bin LS. Mi c th sinh trng v pht trin trong mt iu kin mi trng khc nhau th c cc phn ng khc nhau vi cng mt tc nhn gy bnh qua qu trnh bnh sinh v biu hin ca mi ngi l khc nhau Trong y hc mi ngi bnh l mt c th, cn phi ch n c im phn ng ca mi c th. i tng ca ngi thy thuc khng phi ch l bnh tt m l mi mt bnh nhn c th, c nghin cu k v tnh phn ng ca c th mi hiu c c ch bnh sinh, kh nng phc hi ca c th khi mc bnh to iu kin tt cho cng tc phng v cha bnh Cu 4: Ti sao ni bnh c tnh cht l mt cn bng mi km bn vng cho v d chng minh Bi lm + mt c th bnh thng khng mc bnh lun lun tn ti mt cn bng ni mi c hiu, cn bng ny t c xu hng thay i khi c th kho mnh l s hng nh ca ni mi, n l h qu ca mt cn bng sinh l v d nh s lng hng cu v bch cu trong mu lun n nh l s n nh ca hai qu trnh to v hu hng cu + Khi c th mc bnh vn c mt trng thi cn bng, song trng thi cn bng ny khc vi trng thi cn bng sinh l bnh thng v n c tnh cht km bn vng. Tht vy khi nhn t gy bnh tc dng ln c th th c th s c phn ng p li nhm duy tr cn bng ni mi ca mi trng ri lon + Do vy trong mi qu trnh bnh l lun lun xy ra hai hin tng gn lin vi nhau v nh hng ln nhau l hin tng hu hoi bnh l v hin tng phng ng bnh l V d nh trong qu trnh vim RLCH v tn thng t chc s nh hng khng tt ti qu trnh hot ng ca c th gy ra nhiu ri lon chc nng thm ch uy hip s an ton ca c th, i song song vi hin thng ph hoi c th cn ng vin c mt h thng phng ng thch ng nh xung huyt ng mch, bch cu tng xuyn mch thc bo, tng xn xut khng th v cc t bo tng sinh mnh + Bt k mt kch thch bnh l no ngay t u gy ra phn ng phng ng, c th p ng li kch thch nhm chng li nguyn nhn gy bnh ng thi hn gn li tn thng phc hi s hng nh ca ni mi

5

+ Do hai nguyn nhn trn nn to ra mt cn bng mi nhng n khng lu bn m lun c xu hng thay i theo chiu hng thit lp cn bng c, cn bng c c ti lp nu c th phng ng tt v mt cn bng nu c th lm bnh nng V d Khi c th mt mu nhanh th HA gim c th s c nhng thay i nh mch mu co li, tim tng co bp, tng tn s lm tng cung lng mu i v v tim mt khc c th tng h hp nhm cung cp thm oxy, huy ng lng mu d tr trong gan lch b p lng mu b mt tng tit ADH tng ti hp thu nc lm tng khi lng tun hon,sau tu xng tng sinh tng xn sut HC,BC nhm b p li lng mu ban u. Tt c cc p ng trn u nhm lm tng HA v thit lp cn bng ban u. + Do vy trong mi mt bnh i hi ngi thy thuc phi thy r u l tn thng l bnh tht s phi cha tr v u l nhng trng thi sinh l ca c th. Phi tng cng gip c th chng li bnh tt mt cch ch ng. Nghin cu k lng c ch thch ng ca c th l mt vn quan trng tin hnh tt cng tc phng bnh v cha bnh, nu sc chng ca c th tt th bnh s nh hay khng pht sinh v thy r phng chm ly d phng lm chnh l c c s khoa hc vng chc + Tuy nhin duy tr trng thi hng nh ni mi trong khi ngoi mi lun thay i th c th phi lun thch nghi vi s thay i ca ngoi mi phi huy ng c ch thch ng mnh m thm ch c th dn n bnh l khi c gng tn ti Cu 5: Mi quan h gia nguyn nhn v iu kin gy bnh Bi lm + Gia nguyn nhn v iu kin gy bnh c mt mi quan h cng lc rt r rng, nguyn nhn vi c tnh mnh c th n c gy bnh nhng nu n kt hp vi iu kin xu th bnh li cng pht sinh d di v nghim trng. Nguyn nhn vi c tnh khng mnh lm nhng li gp cc iu kin kt hp ( n ung km, mt mi qu sc, i, lnh ) lm cho bnh d pht sinh, ngc li nu c th trong iu kin tt ( th lc kho mnh, sc chng tt, dinh dng y ) li c tc dng ngn nga bnh rt hiu qu, bnh s khi hon ton hay khng pht bnh (bnh tim tng) + Trong mi quan h ny th nguyn nhn l yu t quyt nh l nhn t khch quan, nguyn nhn bao gi cng pht huy tc dng trong nhng iu kin c th nht nh + C bnh th t phi do nguyn nhn no , nguyn nhn c th tm ra hay cha tm ra, phi c nguyn nhn th mi gy c bnh, bnh khng t dng sinh ra, nguyn nhn quyt nh tnh c hiu ca bnh, trong nhiu trng hp bnh c nhng biu hin khc nhau do n xy ra cc iu kin khc nhau + iu kin to thun li cho nguyn nhn gy bnh do n lm gim sc chng ca c th do lm tng kh nng gy bnh ca nguyn nhn lm cho bnh d pht sinh ng thi nh hng n din bin v kt thc ca bnh + iu kin khng th gy c bnh nu thiu nguyn nhn v khi c nguyn nhn th cn phi i hi nhiu iu kin mi pht huy c tc dng nhng cng c nguyn nhn i hi t iu kin thm ch c nguyn nhn khng cn iu kin vn c th gy c bnh

6

+ Trong nhiu trng hp c s hon i gia nguyn nhn v iu kin gy bnh, nguyn nhn trong bnh ny li c th l iu kin trong bnh khc nh n ung thiu thn l nguyn nhn ca bnh suy dinh dng nhng li l iu kin ca bnh lao v ngc li iu kin trong bnh ny li l nguyn nhn trong bnh khc nh lnh l iu kin VR gy bnh cm nhng li l nguyn nhn ca nhim lnh ( thn nhit gim ) cm lnh ( st, nhit tng ) + Nguyn nhn thng thng bao gi cng pht huy tc dng trong nhng iu kin nht nh, iu kin c tc dng lm gim sc chng ca c th, v d VK E.coli k sinh ng rut ngi v ng vt bnh thng khng gy bnh nhng khi sc khng gim th n gy nn cc bnh ca ng tiu ho Trong thc t lm sng th mt s trng hp iu tr nguyn nhn c kt qu tt nhng nu bnh nhn lm v tnh trng xu bt li ( b nhim lnh, dinh dng km, chn thng tinh thn ) th bnh tr thnh nng din bin nghim trng c th gy t vong + Hiu r mi quan h mt thit gia nguyn nhn v iu kin gy bnh ta phi ph v kt cu v nh vy mi c th tin hnh tt cng tc d phng v iu tr Hn ch nguyn nhn: - Tiu dit cc mm bnh l bin php c hiu nht nhng kh thc hin trit - Hn ch iu kin thun li lm cho bnh d pht sinh nh ci to thin nhin ci thin i sng vt cht tinh thn cn i lao ng v ngh ngi. Nng cao sc chng ca c th nh rn luyn th lc tp th thao, n ung y - Nh vy kh nng phng bnh l rt ln v c rt nhiu bin php ngn nga bnh hiu qu bo v sc kho m bo nng xut lao ng v nng cao tui th t ra quan im d phng l chnh , iu tr ton din m ra trin vng to ln khi con ngi u tranh vi bnh tt Ngi thy thuc khng ch phi u tranh vi bnh tt m mun bo v sc kho cho con ngi mt cch c hiu qu th phi tham gia hot ng x hi tham gia u tranh ci to thin nhin mi trng ci thin i sng vt cht tinh thn ca nhn dn Cu 6 : Phn tch vng xon bnh l trong bnh sinh, cho v d chng minh v ngha thc tin ca vn . Bi lm + Nhng bnh phc tp thng din bin qua nhiu khu ni tip nhau theo mt trnh t nht nh v cc khu co lin h mt thit vi nhau . V d : LCK gy ra bnh vim hng ri t c th gy vim mng trong tim m hu qu l dn n hp h van tim. Nhng s thay i v cu to van tim dn n ri lon mu trong tim,lc u tim cn mnh nn cn b p c, song dn dn mt b tim b suy dn n mu tnh mch m hu qu l ph v trn dch ,ri lon chc nng ton thn v c th din bin ngy cng lm cho bnh nng thm. + Cho nn trong qu trnh bnh sinh nguyn nhn ban u gy ra nhng hu qu nht nh v nhng thay i ny li tr thnh nhng nguyn nhn ca nhng ri lon mi v nhng ri lon ny li dn ti nhng hu qu khc v kt qu l qu trnh bnh l khng ngng pht trin v ngy mt nng thm

7

V d: trong sc chn thng nng gy ri lon thn kinh trung ng nghim trng ( hng phn ri c ch ) m hu qu l thiu oxy do ri lon tun hon ( suy mch cp ) v ri lon h hp ( suy h hp cp ), thiu oxy li tng cng trng thi c ch h thn kinh trung ng khin cho ri lon h hp v tun hon li nghim trng thm c nh vy khu n tc ng ln khu kia lm cho sock nng thm to thnh vng xon bnh l dn ti sock khng hi phc. Vng xon bnh l trong sockTm l,mt mi ,mt mu , dp nt c au n Nhim nng Nhim lnh

TKTW

Thiu nng h hp

Hng phn , c ch Suy kit

Ri lon tit niu

Thiu nng tim mch

Thiu oxy

Ri lon chuyn ho

Thiu nng tun hon gan thn Ri lon huyt ng hc , gim huyt p

Tng tnh thm thnh mch

+ Nhim v ca ngi thy thuc l thy r c mi quan h gia cc hin tng bnh l nh gi ng nhng thay i y v kp thi pht hin nhng thay i ch yu ,ngha l nhng khu chnh trong qu trnh bnh sinh . iu ny rt quan trng c mt cch iu tr ng n thch ng , kp thi ngn chn vng xon bnh l xy ra v mt khi xy ra phi kp thi ct t ph v vng xon nhm tr b cc ri lon v phc hi cc chc nng b ri lon . V d : Trong suy tim th trng tm iu tr l phc hi sc co bp ca c tim kt hp vi ch ngh ngi gim bt ngnh nng ca c tim suy hay trong sock th trng tm iu tr l phc hi khi lng mu lu thng bng cch truyn dch v trong nhiu trng hp th phi tc ng ln nhiu khu trong cng mt lc , in hnh trong sock th phi tc ng ln nhiu khu phc hi cc chc nng ca h thn kinh, tiu ho ,tun hon ,chuyn ho Trong iu tr thng chia ra: -iu tr triu chng -iu tr nguyn nhn -iu tr theo c ch bnh sinh.

8

Cu 8 : Ti sao ni i tho ng l mt bnh c RLCB ni tit t . Hn m i tho ng ch yu do nguyn nhn no gy ra . Bi Lm + Trc y ngi ta cho rng i tho ng l do tn thng tu o nhng trn thc t lm sng nhng ngi b bnh ny th khng phi bao gi cng l do tn thng tu o + Mt s thng k cho thy T n thun tng i t gp m n hay i km cc ri lon ni tit khc v thng th c 1 trng hp T n thun th thy c 2 T c km theo u nng tuyn gip, 5 T c km theo u nng v thng thn, 20 T c km theo u nng tuyn yn . Khi m xc thy 25% c tn thng tu o, 50% thy t bo beta tng tit cn 25% th tu o hon ton bnh thng . + Thc t bnh sinh i tho ng rt phc tp nhng ch yu do hai nguyn nhn sau gy nn : + Bnh pht sinh do nguyn nhn tu : do thiu nguyn liu tng hp insullin,tn thng mao mch tuyn tu , nhim trng, nhim c ,u tu , l thiu insulin tuyt i . + Bnh pht sinh tuy t bo beta hot ng bnh thng i khi cn tng tit insulin v do nhiu nguyn nhn ngoi tu gy ra hn ch tc dng ca insulin l thiu insulin tng i. Thiu insulin tng i c th l do tng tit hormon lm tng ng mu ch yu l STH, ACTH v glucocorticoid . Bnh ny xy ra khi tin yn hay v thng thn tng cng hot ng hay khi gim chc nng hoc ct b tin yn th thy triu chng i tho ng gim r rt. Bnh nhn c u v thng thn hay u tu thng thn sau khi ct b u th bnh chm dt . + Nhng l do trn chng t bnh i tho ng khng nhng l do thiu insulin m cn do tng tit hormon tin yn, v thng thn v c bit khi chc nng t bo beta gim sn + Do c th quan nim rng bnh i tho ng l mt bnh do ri lon cn bng ni tit t . + Vi khi nim ny c th a ra phng php iu tr thch hp nht nh ct b u tin yn v hay tu thng thn , c ch chc nng ca cc tuyn ni tit khc + Bnh i tho ng cn do insulin tng cng phn hu di tc dng ca enzym insulinase v khng th khng insulin c tc dng trung ho , kt hp, phong b insulin, ngi tim insulin di ngy thi trong mu nng khng th khng insulin cao nn phi tim insulin nng cao hn so vi bnh thng + Tm li nguyn nhn gy bnh i tho ng rt phc tp cho nn cn quan nim i tho ng l hi chng ch khng phi l mt bnh . Nguyn nhn gy hn m i tho ng + C rt nhiu nguyn nhn gy nn trng thi hn m trong hi chng i tho ng nhng nguyn nhn ch yu l do tng mnh th ceton trong mu . + Nguyn nhn tng th ceton trong mu l do thiu insulin nn enzym pyruvatkinase khng c hot ho dn ti gim tng hp acid pyruvic t PEP m acid pyruvic l nguyn liu tng hp acid oxaloacetic , m mui ca oxaloacetic l oxaloacetat li l cht mi ca AcetylCoA trong vng Krebs , nn khi gim insulin th AcetylCoA khng vo c vng Krebs dn ti gim s dng vng Krebs ( chuyn ho i kh ) thiu nng lng nn c th s tng chuyn ho ym

9

kh, chuyn ho ym kh to t nng lng nn gim tng hp glucid, protid v lipid t AcetylCoA do qu trnh tng hp cn nhiu nng lng. + AcetylCoA khng c s dng tng hp khng vo c vng Krebs nn chuyn sang s dng tng hp cholesterol v cc th cetonic gy nhim c t bo v c ch thn kinh gy trng thi hn m, tng tng hp cholesterol trong mu dn ti x cng mch mu c th gy nhi mu c tim, vim thn + Tuy nhin trong mt s trng hp th cetonic trong mu tng nhiu song vn khng pht sinh hn m i tho ng do c nhng yu t khc cng gp phn gy nn trng thi ny nh : + Thiu insulin gim s dng glucose trong t bo do hn ch nng lng gii phng lm hn ch chc nng bnh thng ca mi c quan c bit l v no, mt khc th t bo no hp thu oxy cng vi glucose nn khi gim hp thu glucose th no thiu oxy lm gim hot ng gp phn to trng thi hn m + Ngoi ra th khi c th mt nc mt mui hay ri lon cn bng in gii cng l yu t ng k gy hn m trong i tho ng . Cu 9: Ri lon chuyn ho trong bnh i tho ng , Hn m i tho ng ch yu do nguyn nhn no gy ra Bi lm Trong bnh i tho ng cc loi chuyn ho u pht sinh ri lon c bit l chuyn ho Glucid v Protid . 1 Ri lon chuyn ho Glucid + Khi thiu insulin th tc vn chuyn glucose mu vo t bo gim. Trong t bo hot tnh enzym hexokinase gim km hm phn ng phosphoryl ho glucose ni bo gy gim G_6P , G_6P gim lm gim qu trnh s dng glucose ni bo nh gim tng hp glycogen t glucose, lm gim s dng vng pentose vng krebs, gim qu trnh ng phn ym kh v i kh, gim tng hp acid bo v protid + Gim G_6P c b p bng tng tn to glucose v glycogen t acid amin do tc dng ca glucocorticoid, khi thiu insulin th glucocorticoid tng tit hot ho enzym Fructose_1,6DP lm tng tn to glucose v glycogen . Mt khc khi thiu insulin th Adrenalin v glucagon tng tit hot ho enzym phosphorylase v tng glucocorticoid hot ho enzym G_6Phosphatase lm tng thoi bin glycogen . + Qu trnh phn ct glycogen chim u th hn so vi qu trnh tn to glycogen lm cho glucose t gan vo mu nhiu ln v khi nng glucose mu vt qu 1,6 g/l th s pht sinh glucose niu ko theo c mt nc ( a niu thm thu ), bnh nhn mt nc nghim trng nn ung nc rt nhiu mt khc t bo khng s dng c glucose nn lun trong tnh trng i bnh nhn n rt nhiu nhng vn khng b p c nng lng mt nn gy nhiu . + Ngoi ra khi thiu insulin th enzym pyruvatkinase khng c hot ho dn ti lm gim qu trnh tng hp acid pyruvic t PEP m acid pyruvic l nguyn liu tng hp acid oxaloacetic, mui ca acid ny l cht mi ca AcetylCoA trong vng Krebs , Khi AcetylCoA

10

khng c s dng trong vng Krebs v tng hp acid bo th n s c s dng tng hp cholesterol v cc th cetonic + Glucose mu l ngun cung cp glucose duy nht cho no nn khi thiu insulin th no lun trong tnh trng thiu glucose v oxy nn v no lun trong tnh trng b c ch su sc . 2 Ri lon chuyn ho Lipid + Khi thiu insulin th gim qu trnh tng hp acid bo do thiu nng lng v vng Krebs b hn ch , thiu coenzym kh NADPH2 do vng pentose t s dng + Gim tng hp triglycerid do thiu acid bo v thiu _glycerophosphat . + Ngoi ra khi thiu insulin th tng phn ly lipid do c th tng tit cc enzym khng insulin, lm lng acid bo trong mu nhiu ln trong mu i ti t chc thoi bin b p nng lng do thiu glucose trong t bo. Tng phn ly lipid lm cho c th gy nhiu v st cn nhanh lng acid bo t do tng trong huyt tng s c a ti gan ti tng hp tryglycerid gy nhim m gan + Insulin gim s gim to acid oxaloacetic lm cho AcetylCoA khng vo c vng Krebs nn c tng s dng to cholesterol v cc th cetonic gy nhim c t bo c ch thn kinh c th gy hn m i tho ng , nng cholesterol tng cao trong mu gy x cng thnh mch gy nhi mu c tim x thn hay vim thn 3 Ri lon chuyn ho Protid Gim tng hp protid do : + Thiu insulin acid amin t mu kh qua c mng t bo + Thiu nng lng do vng Krebs b hn ch km hm qu trnh tng hp protid + Thiu insulin khng hot ho c h thng enzym tng hp protid + Thiu insulin th glucocorticoid tng tit tng thoi bin protid tng tn to glycogen t acid amin + Ri lon chuyn ho protid trong hi chng i tho ng c ch qu trnh to hnh, tng chy mu do gim tng hp cc yu t ng mu, lu lnh vt thng gim kh nng to khng th hn ch sc chng ca c th vi cc tc nhn gy nhim trng . 4 Nguyn nhn gy hn m i tho ng + C rt nhiu nguyn nhn gy nn trng thi hn m trong hi chng i tho ng nhng nguyn nhn ch yu l do tng mnh th ceton trong mu . + Nguyn nhn tng th ceton trong mu l do thiu insulin nn enzym pyruvatkinase khng c hot ho dn ti gim tng hp acid pyruvic t PEP m acid pyruvic l nguyn liu tng hp acid oxaloacetic, m mui ca oxaloacetic l oxaloacetat li l cht mi ca AcetylCoA trong vng Krebs, nn khi gim insulin th AcetylCoA khng vo c vng Krebs dn ti gim s dng vng Krebs ( chuyn ho i kh ) thiu nng lng nn c th s tng chuyn ho ym kh, chuyn ho ym kh to t nng lng nn gim tng hp glucid, protid v lipid t AcetylCoA do qu trnh tng hp cn nhiu nng lng. + AcetylCoA khng c s dng tng hp khng vo c vng Krebs nn chuyn sang s dng tng hp cholesterol v cc th cetonic gy nhim c t bo v c ch thn kinh gy trng thi hn m, tng tng hp cholesterol trong mu dn ti x cng mch mu c th gy nhi mu c tim, vim thn

11

+ Tuy nhin trong mt s trng hp th cetonic trong mu tng nhiu song vn khng pht sinh hn m i tho ng do c nhng yu t khc cng gp phn gy nn trng thi ny nh : + Thiu insulin gim s dng glucose trong t bo do hn ch nng lng gii phng lm hn ch chc nng bnh thng ca mi c quan c bit l v no, mt khc th t bo no hp thu oxy cng vi glucose nn khi gim hp thu glucose th no thiu oxy lm gim hot ng gp phn to trng thi hn m + Ngoi ra th khi c th mt nc mt mui hay ri lon cn bng in gii cng l yu t ng k gy hn m trong i tho ng . Cu 11: RLCB nc in gii v RLCB acid baz bnh nhn nn ma, i lng ko di, phn tch c ch bnh sinh v nguyn tc iu tr Bi lm Cn bng nc in gii v cn bng acid baz l nhng yu t c bit quan trng vi s sng. Nhng ri lon cn bng nc in gii v cn bng acid baz s lm cho c th lm vo tnh trng bnh l v c th gy t vong. bnh nhn i lng v nn ma ko di nu khng c iu tr ng v kp thi s gy RLCH nc v in gii, RLCB acid baz C ch bnh sinh + bnh nhn nn ma : Khi nn ko di s gy mt dch v ko theo mt nc cng vi acid HCl dch d dy lm cho c th nhim kim, s lng dch mt i khng nhiu nhng ko di, cc bin php n ung kh b p c nn lng nc mt nu nn ko di l rt ln khi c th s c nhng ri lon v c bit l RLCH glucid gy ng cc sn phm trung gian lm cho c th t nhim kim tr thnh nhim toan + bnh nhn i lng ko di : - Dch tiu ho tit ra khong 8l mi ngy km theo nhiu cht in gii bao gm phn ln l cht in gii ng trng, nc bt (1,5l), dch d dy (2,5l), dch mt ( 0,5l), dch tu ( 0,7l), v dch rut (3l) Dch tiu ho c hp thu ton b cng 2-3 l nc t thc n nc ung. Khi cn ng tiu ho c th hp thu v o thi 30-40 l/ngy. Do vy khi i lng mt nc nhanh vi s lng ln . - Mt dch tiu ho lm c th nhim toan rt nng do trong dch c rt nhiu thnh phn kim gy nn nhng hi chng suy sp tun hon nng n, HA gim - C th RLCH nng n gy nn vng xon bnh l nghim trnga lng cp Mt nc Mt mui

RL hp thu, gim Glucose mu Mu c ( gim O2 , tng CO2 )

Gim khi lng tun hon

RLCH

Nhim toan

12

Tru tim mch

Chc nng gan thn gim

Thot huyt tng

Gin mch

Huyt p gim

sn phm c sn phm toan

Nhim c thn kinh

Trong a lng nhng ri lon quan trng xut hin l + Ri lon huyt ng hc do mt nc nhiu lm gim khi lng tun hon dn ti huyt p gim + Nhim toan nng do tru tim mch lm thiu oxy cng ri lon hp thu lm RLCH , c th nhim toan + Tru tim mch lm mu qua gan thn gim dn ti ng sn phm c sn phm toan mt khc c th mt dch kim dch mt v dch tu lm c th nhim toan nng thm + Nhim c thn kinh do thiu oxy, nhim c, nhim toan quay li c ch tun hon, h hp hnh thnh vng xon bnh l Biu hin lm sng + Huyt p gim, mch nhanh, nh, kht, i t , thn nhit gim + Th nhanh v su , nn nhiu + Vt v, bun ng , hn m Nguyn tc iu tr + Truyn dch ng trng trong giai on u nu nn v i lng nhiu + Ung nc n thun hay huyt thanh ngt cho n khi lng nc tiu tr v bnh thng nu l mt nc u trng + Nu nhim toan nng , dng dung dch NaHCO3 trung ho acid Cu 12: C ch bnh sinh ca ph v trn dch Bi lm Nguyn nhn ca ph v trn dch l do nc khong gian bo. C ch bnh sinh ca ph v trn dch gm + C ch thn + C ch mao qun C ch thn

13

+ Chc nng lc cu thn gim song chc nng THT ng thn vn bnh thng : Vim cu thn, RLTH + Tng ti hp thu do tng tit Aldosteron sau m, dng thuc nhm corticoid ko di C ch maoMao ng mch qun Mao tnh mchMao mch trung gian HA

Pt chcHA

Pt chc

Pkeo

Pkeo

+ Tng p lc thu tnh : Huyt p mao mch tng, tc chy mu gim lm cho nc d thm qua thnh mch ra khong gian bo, gp trong xung huyt tnh mch ( suy tim mt b, x gan ) + Gim p lc keo huyt tng , khi protein huyt tng gim, c bit l albumin gy hin tng ph + Tng tnh thm thnh mao mch : thnh mao mch b vim nn cho qua nhng cht c khi lng phn t ln nh protein , dch ph c cha nhiu protein + Gim sc khng ca t chc: Trong c th bnh thng mi t chc c mt sc khng nht nh, trong cc iu kin ging nhau th dch thm vo t chc lng lo d hn t chc c do khi gim sc khng ca t chc th ph pht sinh + Ri lon tun hon bch huyt: Mt phn dch gian bo tr v dng mu theo ng bch huyt nn khi tc mch bch huyt th ph pht sinh Trong thc t lm sng th ph thng do nhiu yu t kt hp vi nhau gy ra v trong c mt yu t l ch yu Cu 13: Nguyn nhn v c ch gim protein huyt tng Bi lm - Gim protein huyt tng c th l du hiu gim protein ton phn c th v protein huyt tng phn nh tng lng protein ton c th - Gim protein huyt tng ch yu l gim albumin. Nguyn nhn gy gim protein huyt tng c th do ri lon tng hp, tng thoi bin hay c th mt protein + Ri lon tng hp protein : Do cung cp thiu nguyn liu tng hp, do ri lon tiu ho v hp thu ( bnh ng rut ) , khng hp thu c protein ( thiu vitamin, c th suy kit, nhim trng, nhim c ko di ). Tng hp protein gim do ri lon chc nng cc c quan to protein, c bit trong bnh gan ( vim gan, x gan ) nng albumin, fibrinogen v prothrombin huyt tng gim . Ngoi ra gim protein huyt tng cn gp trong bnh di truyn nh gim albumin mu , gim globulin mu v fibrinogen mu + Tng thoi bin protein : Gp trong st , nhim trng, i tho ng , u nng tuyn gip , u c . u thy gim protein huyt tng + Mt protein ra ngoi : Gp trong chy mu, chn thng , RLTH , nn , tiu chy , bng

14

- Protein niu trong thn h nhim m , tng tnh thm thnh mao mch , vim xung huyt tnh mch . c bit trong bng th protein huyt tng gim r rt , tc mt v mc mt ph thuc vo din bng do tng tnh thm thnh mao mch huyt lm huyt tng thot ra ngoi - Gim protein th hin r trnh thi suy mn ca c th v n gy ra nhiu hu qu + Lm gim p lc keo ca mu gy ph , tuy nhin ph ch xut hin khi lng protein mt l ln + Gy ri lon kh nng kt hp , vn chuyn ca protein vi nhiu cht nh cc cation v cc hormon , vitaminB, bilirubin.. gy nn mt s ri lon chc nng lm c th nhim c - V d thiu vitamin B dn ti ri lon hot ng cc enzym chuyn ho G,L,P , gim kh nng tng hp protein gan v cc c quan khc , gim hot tnh ca cc enzym xc tc cc qu trnh chuyn ho nh to ure lm ure mu gim v NH 3 mu tng gy hn m gan + Gy ri lon ng mu , tng chy mu do gan gim tng hp cc yu t ng mu ( fibrinogen, prothrombin ..) + Gim kh nng vn chuyn mt s cht , tng nhim trng do gan gim tng hp khng th . Cu 14: nh ngha, c ch pht sinh phn ng st , ngha ca phn ng st Bi lm 1. nh ngha : St l trng thi c th ch ng tng thn nhit do trung tm iu ho nhit b kch thch bi cc nhn t gi cht gy st dn ti kt qu l tng sn nhit kt hp gim thi nhit 2. C ch pht sinh phn ng st - Vai tr ca HTKT v cc tuyn ni tit trong c ch pht sinh phn ng st + V no : c ngha quan trng tong c ch pht sinh phn ng st , do v no c nhiu trung khu iu khin hot cm xc v hot ng ca c th c kh nng lm HP hay C trung khu iu nhit di v + Vng di th : L trung khu iu ho nhit t ng quan trng , c cc nhm nhn u tham gia vo cc phn ng st, c th l nhn gia v sau th iu ho sn nhit gi nhit lng trong c th thng qua h TK giao cm cn nhn trc iu ho thi nhit thng qua h TK ph giao cm, trung tm hyphothalamus + Tuyn ni tit : H tuyn yn - thng thn b kch hot di nh hng ca cc cht gy st , phn ng st khng tham gia vo c ch pht sinh st 3. C ch tng thn nhit trong st C quan nim cho rng tng thn nhit l do sn xut tha nhit lng ( tng sn nhit ) v tng cng cc qu trnh chuyn ho . Tuy nhin trong qu trnh st khng phi u c tng nhit V d trong st rt thng hn , sn nhit ch tng 60% so vi bnh thng trong khi ngi bnh thng kho mnh lao ng va phi sn nhit ln ti 100-200% so vi

15

bnh thng , nh vy st l do qu trnh nhit b c ch c t VK gy ri lon cc qu trnh oxy ho chuyn nng lng trong t bo, c th kt lun c ch ca tng thn nhit l do s tch lu tm thi ca nhit lng tong c th do tng sn nhit v c ch thi nhit Trong c ch pht sinh st do nhim khun c s tham gia ca cht gy st ngoi sinh v c s to thnh cht gy st ni sinh Cn c ch bnh sinh ca st c gii phng t cc tn thng ( hu hoi t chc, bng, mt mu ) . Ngoi ra hot tnh gy st cn thy mt s ch phm dc l , hormon chng khng ch tc dng vo trung khu iu nhit m cn tc dng ln nhng mt xch ring bit nh v no, h thn kinh trung ng, trung tm iu ho trng lc c Di nh hng ca cht gy st th tnh cm th ca tung tm iu nhit vi kch thch nng gim ( tng sn nhit, hn ch thi nhit ) ngc li th cm th vi kch thch lnh tng do ngi st d cm lnh Cu 15: nh ngha phn ng st ,cc giai on ca st , thi s tr ca ngi thy thuc trc mt bnh nhn st cao ko di Bi lm 1. nh ngha : - St l trng thi c th ch ng tng thn nhit do trung tm iu ho nhit b kch thch bi cc nhn t gi cht gy st dn ti kt qu l tng sn nhit kt hp gim thi nhit 2. Cc giai on ca st - St thng din bin qua 3 giai on, di ngn tu theo mc v tnh cht ca bnh + Giai on st tng : C th bt u t ngt , st cao sau vi gi ( vim phi , cm ) hay tng dn sau vi ngy ( thng hn , si ) . Trong giai on ny thn nhit thng tng cao hn so vi thi nhit ( sn nhit > thi nhit ) do cc cht gy st ngoi sinh v ni sinh kch thch trung khu iu nhit gy tng sn nhit v gim thi nhit . Sn nhit tng nh tng cc qu trnh oxy ho v chuyn ho nng lng ch yu gan v c , tng trng lc c v xut hin rng mnh . Rng mnh pht sinh theo c ch phn x , cc xung ng thn kinh t da ( do mao mch b co ) ti vng di i qua phn bn th li theo dy thn kinh vn ng ti c gy co c km theo cm gic lnh run ni gai c l do cc c trn ca chn lng co li lm lp khng kh cch nhit dy ln do c ch qu trnh thi nhit cn gim thi nhit l do co mch ngoi vi nn da nht nht c ch qu trnh bi tit m hi + Giai on st ng : Thn nhit duy tr mc cao do sn nhit tng ng thi thi nhit cng tng nn c mt cn bng mc nht nh nhng vn cha thi c lng nhit tch lu trong thi gian u nn thn nhit vn duy tr c mc cao . S xut hin thi nhit biu hin bng dn mch ngoi vi do kch thch cc si thn kinh

16

ph giao cm nn da t trng thi nht nht chuyn thnh xung huyt nhit da tng c th ht rt run + Giai on st lui : Thn nhit gim xung ti mc bnh thng, sn nhit lc ny < thi nhit . Thi nhit tng mnh bng cch ra m hi , i nhiu .Thi nhit c th gim hn hay gim t t nhng cng c trng hp gim nhanh t ngt sau vi gi tnh trng ny c th dn ti thiu nng mch cp tru tim mch do gim trng lc cc mao mch nghim trng Khi bnh nhn st cao ko di ( >420C ) th thng pht sinh cc ri lon nghim trng h thn kinh trung ng v pht sinh nhim nng. Trong qu trnh bnh l nhim c hay nhim khun th c th pht sinh nhng bin chng nng km theo tng thn nhit qu mc lm cho bnh nhn mt thc lm vo tnh trng co git thm ch c th t vong. Do ngi thy thuc phi c thi s ch ng n phi dng thuc h st kt hp vi iu tr c hiu vi nguyn nhn gy bnh ng thi phi ch ti iu tr ton thn dinh dng hp l gii quyt kp thi cc ri lon chuyn ho v chc phn ngi bnh chng hi phc Cu 16: nh ngha, cc giai on ca phn ng vim . Ti sao c th dng thuc chng vim chung cho cc phn ng vim mc d nguyn nhn gy vim khc nhau Bi lm 1. nh ngha : Vim l mt phn ng phc tp ca c th i vi nguyn nhn gy bnh , mt mt ni ln tc hi ca bnh, tc dng ph hoi gy tn thng ca cc nhn t bnh l nhng mt khc ni ln sc khng chng ca c th nhm tiu dit cc nguyn nhn gy bnh hn ch tn thng phc hi cc chc nng ri lon ca c th 2. Cc giai on ca phn ng vim - Biu hin bn ngoi ca vim c miu t bi cc du hiu sng, nng, , au . Ti vim ngoi cc tn thng t chc v RLCH cong thy RLTH gm cc hin tng sau a) Ri lon vn mch + Pht sinh vi cc giai on lin tip : co mch chp nhong , sung huyt ng mch v tnh mch , mu v tc mch + Co mch chp nhong : giai on ny din ra nhanh kh quan st , cc yu t gy vim kch thch thn kinh co mch v cc t bo c trn ti vim + Dn cc tiu ng mch v mao mch hay xung huyt ng mch ch ng pht sinh theo c ch thn kinh th dch , thn kinh b kch thch bi cc cht gy vin nh histamin, serotonin Biu hin l tng tc chy mu , tng p lc mu lm tng lng oxy v bch cu n vim c tc dng thch ng phng ng + Dn cc tiu tnh mch, mao mch hay xung huyt tnh mch th ng, c ch ch yu do sn phm c hot tnh sinh vt c to thnh vi s lng ln b li t chc vim gy hu hoi t chc lin kt ( si chun, si to keo ) lm dng mu chy chm li. S pht sinh v pht trin ca hin tng ny ph thuc vo nhiu nhn t

17

TK chi phi trng lc c ca mch mu nht ca mu ( do nc thm qua thnh mch ) BC bm mch, huyt cu , t bo ni m trng ln lm mu chy chm Nc trn vo t chc gy ph chn p vo mao mch lm chm tc dng mu Tn thng thnh mch nn tng tnh ng mu + mu v tc mch : Cc mao mch dn lm dng mu chy chm dn ri li c hin tng lc l dng mu, mu b li, vim thiu oxy v dinh dng dn n ri lon chuyn ho nh tng chuyn ho ym kh tng sn phm toan gy tn thng t chc b) Thot dch r vim + Dch r vim l cc thnh phn hu hnh ca mu thot khi mao mch trn vo t chc vim gy ph + Thot dch r l hin phn ng phc tp chu nh hng ca nhiu nhn t : Tng p lc mch mu mao tnh mch Tng tnh thm thnh mch Tng p lc keo v p lc thm thu Cc sn phm c hot tnh sinh hc : Histamin. Serotonin.. + Dch r vim c ngha quan trng v cc cht m trong dch r vim c tc dng kt hp vi cht c trung ho cc cht to hng ro bo v khu tr vim khng cho lan rng c) Bch cu xuyn mch v thc bo + ng thi cng vi hin tng thot dch r th c hin tng BC bm mch , xuyn mch ti vim lm nhim v thc bo Cu 17: C ch to dch r vim , thnh phn tc dng ca dch r vim Bi lm 1. nh ngha : Dch r vim l cc thnh phn dch th v hu hnh ca mu thot khi mao mch trn vo t chc vim , t chc vim tng khi lng do thot dch r vim gi l ph vim 2. C ch to dch r vim + Tng p lc thu tnh trong cc mao mch khu vc tnh mch ca t chc vim , tng to iu kin cho cht dch thot ra ngoi vo t chc vim + Tng tnh thm ca mng mao mch l yu t quan trng nht , tng cng p lc thu tnh ca mu trong cc mao mch v tiu tnh mch ca t chc vim lm gin cc khe h thnh mch to iu kin cho protid huyt tng thot ra d dng gy ph vim + Tng p lc keo v p lc thm thu trong t chc vim to iu kin gi cht dch ti vim 3. Thnh phn dch r vim

18

- Tu theo nguyn nhn gy vim v giai on vim m tnh cht mu sc v thnh phn dch r vim c khc nhau - Dch r vim c nng protid cao, giu cc thnh phn hu hnh ng thi tng lng acid lactic , ceton do pH ca dch r vim gim - Dch r vim c hai thnh phn ch yu l thnh phn v hnh nh nc, mui, protid huyt tng v cc thnh phn hu hnh ca mu nh BC,HC + Protid : Thot ra ngoi theo trnh t t nh n ln qua cc giai on ca vim nh albumin, globulin gm cc KT c tc dng trung ho tc nhn vim , fibrinogen lm ng dch r vim to hng ro bo v khu tr vim lm cho cc tc nhn vim khng lan rng + Thnh phn hu hnh : HC ,BC, TC tu tnh cht v giai on m s lng mi loi khc nhau 4. Phn loi dch r + Dch r huyt thanh : trong sut , hi vng khng c hay c rt t thnh phn hu hnh ( tng t nh huyt thanh ) + Dch r t huyt : tng t huyt thanh nhng vng hn do c fibrinogen ( tng t huyt tng ) + Dch mu : c nhiu HC + Dch m : c nhiu xc BC 5. Tc dng ca dch r + Thnh phn dch r bao gm cc cht mi c to thnh do RLCH hay t thng ni mi + Cc cht c hot tnh sinh hc : Histamin, Serotonin, Acetycholin c tc dng gy co mch, lm ng mu + Cc kinin huyt tng nh bradykinin , heparin c tc dng gin mch gy au + Cc cht chit t dch r c hot tnh sinh l nh leukotaxin lm tng tnh thm thnh mch ho hng ng cho BC , leukotrien , cytokin ,IL1,6,8 t TB + Cc acid : lm tng tnh thm thnh , ho ng ng BC kch thch BC xuyn mch , kch thch sn xut BC ti to m , tng to KT + Cc enzym : Hydroxylase , hyaluronidase, lm tng tnh thm thnh mch - Qua dch r vim c tc dng bo v , cc protein trong dch r c tc dng kt hp vi cc sn phm c trong vim trung ho , BC xuyn mch lm nhim v thc bo , cc yu t ng mu c tc dng ngn s chy mu to hng ro bo v khu tr vim khng cho c t lan rng - Tuy nhin nu dch r vim qu nhiu gy chn p t chc xung quanh gy au nhc hn ch hot ng ca cc c quan gy trn dch c th dn n hu qu xu Cu 18: Cc mediater vim , ngun gc, phn loi, tc dng, ngha Bi lm 1. nh ngha : Cc sn phm c hot tnh sinh vt c sn sinh trong t chc vim c gi l cc mediater tnh thm

19

2. c im + Tn ti ngn , khng tun hon trong c th + Sinh ra ti ch v bt hot nhanh chng ti vim + Gy au, st, c tc dng ho ng ng li ko BC + Gy dn mch, tng tnh thm thnh mch + Kch hot h MD kch thch phn chia t bo 3. Phn loi a) Nhm amin hot mch * Histamin - Ngun gc : + Hnh thnh t histidin ( phn ng kh amin) di tc dng ca enzym decacboxylase, c nhiu phi, da, TK giao cm v t bo mastocyte, BC,TC . Bt hot di tc dng ca Histidin - Tc dng : + Gy dn mch nh, co t bo ni mc do lm tng tnh thm thnh mch + Gy co mch mu ln lm tng lu lng mu ti vim , gy xung huyt ti vim + Lm co c trn , tng tit HCl d dy - ngha : Bo v c th trong vim, trong chn thng, nhim x * Serotonin - Ngun gc : T tryptophan c nhiu nim mc rut , t bo mastocyte , tiu cu v synap - Tc dng : Gin mch , tng tnh thm thnh mch, co c trn , gy au - ngha : Bo v c ch qua c ch TKTD , tng cng tc dng ca histamin b) Nhm dn xut ca acid bo: Prostaglandin - Ngun gc : + Hnh thnh nh tc ng ca tc nhn gy vim, cc men lysosom ca BC - Tc dng : + Gy dn mch nh dn n tng tnh thm thnh mch + Co c trn ph qun + Ho ng ng dng tnh vi BC + Gy au , gy st + Thoi ho hong th, xy thai, non + Lm gim hot ng ca t bo, gim gii phng cc mediater vim t t bo mastocyte v BC - ngha : Bo v c th c) Nhm men lyosom ca BC - Ngun gc : T BC N , gm cc men Protease, Catalase, Collagenase - Tc dng : + Phn hu glucid, lipid v protid ca sinh vt + Trc tip tc dng trn ni mc v thnh huyt qun ph hu t chc ( si keo, chun , collagen ) + Gin tip tc dng gy gii phng v to cc mediater tnh thm gy

20

* Gii phng Histamin, Serotonin t t bo mast quanh huyt qun * Hot ho v to thnh polypeptid ca h kinin * Hnh thnh nhm Prostaglandin c tc dng gy tn thng t bo t chc v tng tnh thm thnh mch - ngha : tiu dit vi khun d) Cc cht tit ca t bo - Ngun gc : * T Lympho bo gi l lymphokin * T Mono bo gi l Interleukin * T cc cht MIF v MAF - Tc dng : + Ho ng ng dng tnh vi BC + Kch thch thc bo + Tng tng hp Prostagladin v Collagen + Ngoi ra cn c cc gc oxy t do c BC sn xut c tc dng gy tng tnh thm thnh mch lm tn thng t chc , tng hot ng ca men tiu protein - ngha : Bo v c th e) Nhm peptid ca kinin - Ngun gc : l globulin ca huyt tng di dng tin men l kininogen , di tc dng ca kalicrein chuyn thnh kinin - Tc dng : + Gin mch, ch yu l tiu ng mch, tiu tnh mch v mao mch gy mu + Lm tng tnh thm thnh mch do lm gin khe gia cc t bo ni m + Gy thot BC , gy au - ngha : Dng lm thuc tng bn mng lysosom nh steroid v cortisol Cu 19 : nh ngha t chc u, c tnh c bn ca t bo u, phn bit tnh cht tng sinh v hn v thot khi s kim sot ca c th ca t bo u Bi lm - Trong c th sinh vt sng lun din bin qu trnh pht trin t chc do cc t bo t chc gi hoc bnh l b tiu hu v cc t bo t chc mi c ti sinh thay th. Bnh thng , mi tng quan gia hai qu trnh tiu hu v ti to ca qu trnh pht trin t chc c iu ho bi HTKT, thng qua h ni tit, cc yu t th dch v cc kch thch ho hc t nhng sn phm hu t bo cht.Trong trng hp bnh l qu trnh pht trin t chc c th b ri lon vi nhiu hnh thc khc nhau: u sinh hoc nhc sinh.Ri lon theo hng u sinh l do qu trnh ng ho mnh hn d ho nh hin tng tng sinh ph i,hoc pht trin thnh cc khi u. - Vy u l khi t chc pht trin vt mc gii hn ca t chc bnh thng, thot khi s kim sot ca c th. S pht trin vn tip tc din ra ngay c khi nguyn nhn gy u ngng tc ng. - c im c bn ca t bo u

21

1/ S pht trin v hn v ko chu s kim sot ca c th. - i sng ca mt t bo bnh thng qua 4 thi k: pht sinh, pht trin,tin trin v kt thc.Trong c th t bo cng lun i mi nh vy v t bo cht i chia lm 2 cch chnh: - T bo cht do hoi t: di tc dng ca cc nhn t tn cng , mng t bo b ph v gii phng cc men trong t bo l cc yu t gy u. - T bo cht theo chu trnh: di tc dng ca mt s tn hiu ca cc men trong t bo ct nhn t bo thnh nhiu mnh nh kch thc khc nhau.Cc mnh nhn ny vn c bc trong bo tng, trong v ngoi l mng nn khi b thc bo ko gy ra vim v ko gii phng ra cc men. - Cht theo chu trnh ny xut hin ngay c trong giai on bo thai, to ra cc c quan, i mi cc m ang pht trin loi tr t bo gi v t bo tham gia p ng min dch. Ngoi ra cn gp trong mt s bnh: cht theo chu trnh tng nh bnh thoi ho ngi gi, bnh Parkinson, bn Anjermer, bnh t min, bnh suy gim min dch; cht theo chu trnh gim gp trong bnh ung th. Ngi ta thy trong t bo c nhng gen kim sot qu trnh cht theo chu trnh ca t bo. - Cc t bo, t chc bnh thng pht trin ti mt s lng nht nh th s pht sinh ngng li do s c ch ca tu xng. Nhng t bo u ko c tnh cht ny, ko chu s kim sot ca tu xng m pht trin v chng cht ln nhau n khi kit dinh dng ca mi trng th thi.S mt tnh cht ny lin quan ch yu n lng AMPv bn trong t bo, khi t bo b gim lng AMPv s thot khi s c ch ca ty xng. Ngoi ra cn nhiu yu t khc cng lin quan n qu trnh pht trin ko gii hn ny nh t bo u ko p ng vi nhng nh hng c ch bnh thng ca nhng t bo xung quanh.S gim dnh gia nhng t bo lm t bo d di chuyn v c th sng trong mi trng ko c t chc m . Do vy m t bo u pht trin ko theo quy lut, ko xp lp cng nh ko theo trnh t nht nh. - Ngay c trong s pht trin ca khi u, tng giai on khc nhau tc pht trin cng khc nhau, giai on u pht trin nhanh, khi kch thc u ln tc pht trin chm dn, gim lng t bo tng sinh,tng t bo u b cht b hoi t, t bo bong ra gy ra hin tng di cn . 2/ C s bin i v cu trc : - T bo u ging t bo t chc non, lin kt gia cc t bo rt lng lo do gim lng Ca2+ ni bo, in tch b mt t bo tng, tnh vn ng tng, kh nng bm dnh ca t bo gim nn t bo u di cn c.Ngoi ra s bm dnh ca khng th trn mng t bo u cng gp phn tng kh nng vn ng cng vi vic gii phng cc yu t ng mu d to ra cc mng t bo b vn lai ,b bong ra s theo dng bch huyt vo mu di cn n cc t chc xa.

22

- Mng t bo cng rt linh ng do b mt 1 protein mng cng vi cc men trong t bo c bit l men tiu m tng ln rt nhiu v c gii phng ra nhiu gip khi u xm ln ph hu t chc xung quanh. 3/ T bo u c s thay i v khng nguyn: - T bo u l t bo ca c th mang c nhng khng nguyn c hiu ca c th v c nhng khng nguyn mi khi thnh c tnh.Cc khng nguyn mi gm c: + Khng nguyn ghp c hiu u: mng t bo, l th th tip nhn khng th. + Khng nguyn T (turmo): nm trong nhn t bo ,kh pht hin khi hnh thnh min dch, thng gp trong cc tc nhn do virus. + Khng nguyn S : b mt t bo. + Khng nguyn ho tan: l nhng khng nguyn c trong giai on phi thai, ngi bnh thng c rt t cn ngi b ung th th c rt nhiu. Vd : AFP ( anpha foeto protin) l khng nguyn c nhng t bo gan trong giai on phi thai. Trong t bo vim gan mn, x gan, c bit nhng ngi b ung th gan nguyn pht hm lng AFP tng cao, c th pht hin sm bng phn ng min dch( phn ng KN-KT). Cu 20 : Phn bit u lnh , u c , p ng ca c th chng li t bo u Bi lm 1. inh ngha : U l khi t chc pht trin vt gii hn ca t chc bnh thng v thot khi s kim sot v iu ho ca c th , s pht trin vn tip tc ngay c khi nguyn nhn gy ra u ngng tc dng + Cu trc bnh thng ca khi u chc, c, gm t bo c bn u v t chc m xung quanh. Trong t bo u thng c hnh thi v cu trc phn no tng t m sinh ra n + Da vo hnh thi v cch sn sinh ra u th chia u lm hai loi l u lnh tnh v u c tnh 2. Phn bit c im U lnh U c - Ti ch - Pht trin tng i chm - p t trin nhanh, mc thnh mi c Pht chc xung quanh , pht trin c gii chn xuyn su vo m lnh gy chn hn p hu hoi t chc , gy hoi t - Gy chy mu lm c th suy kit, xut - Ton thn - Gy p , tc nghn cc c quan di cn xa hin - Ti pht - Di cn - t ti pht sau khi phu thut ct-b ti pht ti ch v khu vc xung D quanh, c nhng ch di cn xa - Khng di cn - Di cn, d lan i xa tao u th pht , di cn theo mu , bch huyt ti cc t chc khc

23

+ Biu hin tn thng t bo v t chc U lnh U c - U c ranh gii r rng , xung quanh c v U xm ln cc t chc khc do c chn , - bc r , xung quang khng c v bc - U tng t nh t bo gc c kh nngT bo u khc t bo gc , mt hay kh - bit ho cao nng bit ho km - U gy chn p t chc lm tc nghn s lu trin lm c th suy kit , u hay di - U pht thng tun hon nhng iu tr khi t ti pht xa lan rng khp c th gy t vong cn 3. p ng ca c th chng li t bo u - Khi h thng KSMD ca c th b suy gim th cc t bo u s pht trin khng kim sot c, Thc t lm sng cho thy + bnh nhn K thy suy gim HTMD qua TGTB + T l bnh nhn iu tr cn c ch MD th c nguy c mc K cao + T l mc u c tnh tng theo la tui do cng cao tui HTMD cng suy gim + bnh nhn bi K c iu tr bng cc bin php h tr nng cao MD th thi gian sng tng t l di cn gim v ngc li - V vy MD qua TGTB l p ng c hiu qu ca c th chng li cc t bo u c tnh - T bo u l t bo mang KN l nn kch thch c th sinh KT v cc MD qua TGTB nhm hn ch s pht trin ca khi u - Mt s KN u bit nh CEA-1_Glycoprotein, bnh thng ch thy trn b mt t bo biu m trong thi k bo thai hay FP t bo gan - C th vt ch thng qua cc t bo nh LT gy c , cc TB , t bo NK ch tit ra IFN- c tc dng hot ho cc i thc bo, Lympho .. - Cc TB c hot ho bi Lymphokin trong giai on qu mn mun nh s tc ng ca t bo TCD4 hay bi s tc ng trc tip ca t bo TCD8 gy c trc tip cho t bo u , mt khc s kt hp gia KT-BT c tc dng lm mt tnh n nh v tnh thm thu ca mng t bo u lm t bo u tan v v ra - Khi tt c cc MD ca c th khng th tiu dit hay km hm s pht trin ca t bo u th t bo u s pht trin mnh di cn xa lm c th b RL v cht Cu 21 : Cc ch tiu nh gi cht lng dng hng cu . ngha ca gi tr hng cu v ch s nhim sc Bi lm Cht lng dng hng cu b bin i c th do cc yu t bnh l tc ng trc tip trn hng cu hoc do qu trnh sn xut b ri lon , c biu hin bng cc ch tiu sau : 1.Thay i ch s nhim sc ca hng cu

24

Ch s nhim sc l m huyt sc t trong hng cu th hin gi tr chc nng 2 s theo cng 2 ca hng cu v c tnh u ca HC xthc n ginCSS =

Gii hn bnh thng ca ch s nhim sc l 0,9 1,1. Trong bnh l tu theo s thay i ca ch s nhim sc c th phn bit : + Thiu mu ng sc khi hng cu v huyt sc t gim tng ng ,cc trng hp thiu mu c hu HC va phi, t hoc khng b thiu st do st c gi li ti to HC + Thiu mu nhc sc khi CSNS gim di 0,9 do huyt sc t gim nhiu hn so vi HC , gp bnh nhn suy nhc thiu protid, thiu st, hoc kh nng tiu ho hp thu km kh nng tng hp protid b ri lon + Thiu mu u sc khi CSNS trn 1,1. y khng phi l tha d huyt cu t, s lng Hb tuyt i trong mt n v th tch mu gim tuy s lng s lng Hb trong tng HC c tng hn bnh thng, nguyn nhn l do th tch HC tng. Bnh thng mi HC ch cha mt lng Hb nht nh khong 33% - 34%, khi th tch HC tng th lng Hb trong HC cng tng, thiu mu u sc gp trong bnh thiu mu c tnh . 2. C kh khng u hay hin tng a c + Trong mu xut hin mt s HC to hn bnh thng d= 8 -10 m l nhng HC gn trng thnh v HC li ang c tng sinh thay th l biu hin tt do mu ang c phn ng tng sinh phc hi . Nu mu c nhiu HC nh l biu hin khng tt l HC gi ci, mnh v ca HC hay l nhng HC b teo nh di tc dng ca yu t bnh l hoc c sn xut trong tnh trng thiu nguyn liu . 3. Bin i v hnh dng hay hin tng a dng + Do mng HC km bn vng nn khi dn trn lam knh th HC mo m khng u to hnh dng khc nhau hay do bnh l di truyn gy bin i cu trc v hnh dng HC, nh HC hnh bia trong bnh huyt cu t F, hnh lim trong bnh huyt cu t S. 4. Bin i v mu sc hay hin tng lon sc + Biu hin bng s bt mu khc nhau ca HC , HC nhn l HC khng bt mu gia do thiu huyt cu t, nhc sc. HC a sc l HC trng thnh nhng do qu trnh chuyn ho vi vng nn vn c tnh cht i kim trong nguyn sinh cht nh t bo non, gp trong trng hp thiu mu, mt mu cp tnh v qu mc 5. Xut hin HC bt thng trong mu ngoi vi + Tng Erythroblast kim, a sc, toan gp trong thiu mu nng gy phn ng mnh vi tu xng hoc trong bnh nguyn HC c tnh + Xut hin HC mang d tt trong trng hp thiu mu nng c ri lon chc nng tu xng . Xut hin HC c ht i kim trong thiu mu do nhim c Cu 22. ngha ca tng s lng chung ca BC v ch s chuyn nhn Bi Lm

25

S lng chung ca BC gii hn t 5000 9000/mm 3 mu. Trong trng hp bnh l BC c th thay i theo hai chiu hng l tng hay gim S lng BC tng khi s lng tng trn 9000/mm3 y l phn ng tch cc ca c th i vi cc nhn t gy bnh ch yu l nhn t nhim khun, BC tng cao trn 15000/mm3 v thy xut hin cc BC non gp trong cc trng hp nhim khun nng v tng cao hn na l trong cc bnh ca c quan to mu 1. ngha ca tng s lng chung ca BC a) Trong s thay i sinh l ca c th - tr s sinh th s lng BC 18000 20000mm3 ko di hng tun - Trong lao ng, tiu ho, cm xc s lng BC cng tng ngoi vi do tc dng ch yu trn khu vc d tr BC trong cc xoang t/m tu xng b) Vim v nhim khun - L nguyn nhn hng u gy thay i s lng BC, VK Gr(+) gy kch thch tng t bo ht cn cc VK Gr(-) th ngc li, VR th nh hng ln h thng vng ni m nn gy tng t bo BC mono c) Nhim c - Cc cht c l ho v sinh vt khc nhau c th lm bin i s lng BC, nh tia phng x, Asen, pyramidon, sulfamid d) Thn kinh, ni tit - Chn thng s no c tn thng vng di th gy tng BC 2. Ch s chuyn nhn CSN =Tu bo + H u tu bo +Nhn a Stab a nhn trung tnh BC = 0,03 0,08

ngha ca h s chuyn nhn - Trong trng hp bnh l th h s chuyn nhn c th thay i theo hai chiu hng a) Chuyn tri : L tng ch s nhn trn 0,08 l biu hin tng sinh cc t bo BC tr do tu xng b kch thch tng hot ng p ng nhu cu ca c th, tu mc c th phn bit + Chuyn tri va phi : khi ch s nhn t 0,08 0,25 do cc t bo tr c tng sinh va phi thng ch tng Stab mc nhim khun khng nng lm v chc nng tu xng hot ng tt + Chuyn tri mnh : Khi ch s nhn 0,25 0,5 do cc t bo tr tng sinh nhiu v mu ngoi vi xut hin nhiu Stab c th gp c hu tu bo i khi c tu bo, thng gp bnh nhn nhim khun nng chc nng tu xng b ri lon kh nng bit ho gim st sc khng ca c th gim + Chuyn tri qu mnh : Ch s nhn 0,5 1 hay hn na thng l bnh ca c quan to mu kh nng bit ho ca tu xng b ri lon b) Chuyn phi - Khi ch s nhn gim di 0,02, rt t hay khng c BC tr Stab l biu hin ca tu xng b c ch v km theo gim s lng BC

26

- Chuyn phi biu hin gim t l cc t bo t nhnh v tng s lng cc t bo nhiu nhnh Kt lun : Theo di ch s nhn ca BC c s dng trong lm sng ch yu ngoi khoa v nghin cu khoa hc nh gi tnh trng v chc nng to BC ca tu xng Cu 23: S thay i s lng ca tng loi BC c ngha g .Phn tch ngha ca h s chuyn nhn Bi Lm Nhng bin i ca tng loi BC ( tng hoc gim s lng ) thng c ngha nht nh trong chn on theo di v iu tr bnh . 1. Bch cu trung tnh N - Tng trong tt c cc trng hp nhim khun cp c vim m , chn thng s no , nhi mu c tim, mt mu cp do tnh trng kch thch tu xng to bch cu ht - Gim N gp khi dng mt s thuc (sunfamit, pyramidon..) trong mt s bnh c c ch trng thnh bch cu ht (thng hn, si) , suy dinh dng v trong cc phn ng t min lm suy yu sc khng ca c th pht sinh nhim khun nng. Gim BC t ngt trong giai onh din bin nng ca nhim c, nhim khun do tu xng b c ch 2. Bch cu toan tnh E - Tng E trong bnh nhim KST ng rut , trong trng hp d ng (hen ,st) v trong cc phn ng d ng trong qu trnh nhim khun do E c kh nng hp th histamin v cc cht tng t gii phng ra trong qu trnh din bin ca bnh - Gim E thy trong giai on u ca nhim khun cp v trong Strees do E ti ch tn thng lm nhim v gii c hoc do tng ni tit tuyn thng thn tng tit corticoid c tc dng c ch to E 3. Bch cu lympho L - Tng tuyt i trong mt s bnh tr em (ho g, cm, si, thng hn, nhim khun) lm nh hng n h thng gan lch (st rt, lao, giang mai) Trong nhim khun cp th L tng mun do cn c giai on kch hp h thng MD ca c th - Gim L tng i trong giai on u ca nhim khun cp v gim tuyt i khi tn thng h thng to lympho 4. Bch cu mono M - Tng trong nhim khun v virt cp (thu u, si, vim hng ) tng di trong cc bnh vim mng trong tim, st rt l du hiu kch thch h thng vng ni m . Tng M trong giai on cui ca nhim khun lm nhim v thc bo tham gia vo phn ng tng sinh m lin kt lm lnh tn thngvim - Gim M trong bnh nhim khun, nhim c v nhim khun m lu ngy, nhim khun huyt , l du hiu h thng vng ni m b c ch v sc khng ca c th suy yu

27

5. ngha h s chuyn nhn - Ch s chuyn nhn l ch s tng quan gia BC non v BC trng thnh trong mu ngoi vi c biu hin bng cng thc sauTu bo + H u tu bo + Nhn CSN = a B ch c u a nhn trung tnh = 0,03 0,08

- CSN chuyn tri : L tng s nhn >0,08 y l biu hin tng sinh ca cc t bo tr do tu xng b kch thch tng hot ng p ng nhu cu ca c th + Chuyn tri va phi : CSN khong 0,08 0,25 , cc t bo tr tng va phi thng tng BC a mc nhim khun khng nng lm v chc nng tu xng hot ng tt + Chuyn tri mnh : Khi CSN 0,25 0,5 do t bo tr tng mnh , mu ngoi vi xut hin nhiu BC a c th thy c hu tu bo v tu bo, thng l nhim khun nng chc nng tu b ri lon kh nng bit ho ca t bo gim st sc khng c th gim + Chuyn tri qu mnh : CSN 0,5 1 hoc cao hn thng l bnh ca c quan to mu kh nng bit ho ca tu xng b ri lon - CSN chuyn phi + Gim di 0,02 thng rt t hay khng c BC a l biu hin ca tu xng b c ch km theo gim s lng BC , tin lng xu + Biu hin gim t l cc t bo t nhnh tng cc t bo nhiu nhnh , c th xut hin cc t bo tng phn nhnh nh trong nhim c, nhim phng x Ni chung theo di CSN BC c s dng trong lm sng v ch yu ngoi khoa v trong nghin cu khoa hc nh gi tnh trng chc nng to BC ca tu xng Cu 24: Khi mt mu cc phn ng b p v khi lng mu ca c th biu hin nh th no Bi lm - Khi mt mu c th s ng vin c mt chui phn ng phc tp nhm bo v c th mt mc nht nh 1. Phn ng cm mu - Tn thng huyt qun gy co mch ti ch, hnh thnh cc nt tiu cu bt kn vt thng , tng sn xut cc yu t ng mu nh thromboplastin v fibrrinogen 2. Phn ng nng huyt p ( phn x tim mch ) - Do mt mu lng mu lu thng gim , huyt p ng mch gim kch thch cc TCT p lc quai ng mch ch v xoang tnh mch cnh gy tng co bp c tim m mch nhanh v mnh ln lm tng tc dng mu. - ng thi c hin tng tng tit Adrenalin gy co mch ngoi vi v dn mch no mch vnh - Kt qu l tim tng cng hot ng, lng mu ngoi vi gim, huy ng lng mu d tr gan lch lm tng lu lng tun hon nn huyt p ng mch c nng

28

ln do tm thi iu ho c hin tng mt cn bng huyt ng lc v phn phi c lng mu cung cp cho tim v no 3.Phn x tng h hp - Do nng O2 trong mu gim v nng CO2 trong mu tng cao kch thch trung khu h hp lm c th th nhanh v su nhm tng cng lng O2 v o thi CO2 4. Phn ng b p khi lng mu - Lu lng mu gim gy tng tit ADH v Aldosteron c t dng tng ti hp thu nc v mui ti ng thn do gy gim lng nc tiu , ng thi c hin tng huy ng dch giam bo vo dng mu do p lc dng mu gim. 5. Phn ng tng to cc t bo mu - Phn ng ny xut hin mun nht sau 4 -5 ngy, pht sinh do tnh trng thiu O 2 mu kch thch tu xng tng sinh to cc t bo mu c tnh cht thch ng b p - Phn ng ca tu xng v tc to t bo mu ph thuc v tnh trng bn thn, mc mt mu v nguyn liu to mu Nh vy nu mt mu khng nhiu lm v iu tr gii quyt kp thi th cc phn ng b p ca c th c th n nh c tnh trng bn thn nhng nu mt mu nng hay bnh nhn trng thi khng thun li th c th dn ti sc mt mu gy bin c nguy hi cho i sng Cu 25: Thiu mu do tan mu , nguyn nhn, c ch bnh sinh v c im Bi lm Thiu mu do tan mu l tnh trng HC b v trong lng mch sm hn i sng bnh thng do bnh ca bn thn HC hoc c cht ph hu HC trong huyt tng 1. Tan mu nguyn nhn do yu t HC a) Ri lon cu to mng HC - Bnh HC hnh cu di truyn : l loi bnh do tn thng mng HC , nguyn nhn l do khuyt thiu cht spectrin khung t bo HC v hu qu l cc HC d b bt gi khi i qua vng tu v lch, i sng gn do mt nng lng nhanh v hnh dng thay i - Bnh HC hnh bu dc : him gp b) Do ri lon Hb bm sinh - Bnh thalassemia : l bnh do ri lon gen iu ho s tng hp protein ca Hb, nguyn nhn l trong chui polypeptid th HbA ( 2 , 2 ) b chuyn thnh HbF ( 2 , 2 ) loi huyt sc t thi k bo thai do gen iu ho tng tng hp chui thay cho - Bnh do ri lon cu trc Hb : do bt thng ca gen cu trc mt aa b thay th bi mt aa khc trong mt dy polypeptid s to nn mt loi Hb bt thng V d bnh HC hnh lim do chui polypetid ca HbA , aa l glutamin v tr s 6 b thay th bng valin c) Ri lon enzym ca HC - Nguyn nhn l do thiu ht men G_6PDH v enzym pyruvatkinase bnh ny di truyn ln lin quan n gii tnh (NST-X) thng l nam gii 2. Tan mu do nguyn nhn bn ngoi HC

29

- nguyn nhn do trong huyt tng c cc yu t chng HC a) Do min dch - Tan mu t nhin + Tan mu t min KT m : T KT m thng l IgG hot ng ti u 37 0C l loi hay gp nht gy tan mu khi c hoc ngay c khi khng c c nh b th v thng c hiu vi KN Rh + Tan mu t min KT lnh : T KT thng l IgM i khi l IgG. Tnh phn ng vi lnh do KN ch khng phi do KT, t0 thp lm cho KN bc l r hn trn mng do d tc dng vi b th - Tan mu do truyn nhm loi : Do KT kt hp c hiu vi KN trn mng HC ngi cho gy hot ho b th v tan HC + Do yu t Rh : Ngi m Rh(-) ,con Rh(+) , HC ca con s vo mu m trong lc kch thch c th m to KT ,ln sinh 2 KT m vo tun hon ca con kt hp vi KN Rh(+) gy tan mu con b) Do cc cht c c trong mu gy v HC + Cht ho hc , thuc , tho mc + Do KSTSR, VK, VR + Do yu t vt l : Bng, truyn dung dch nhc trng c im thiu mu do tan mu + Thiu mu ng sc c th chuyn sang nhc sc nu nghim trng + St huyt thanh tng + Tu xng tng sinh : HC non , a sc + Hb niu , c th tc ng thn + Bililrrubin t do tng trong mu + Da vng nh , phn sm mu , nc tiu vng

Cu 26: Thiu mu do ri lon chc phn to mu Bi lm I. Thiu mu do thiu nguyn liu to HC 1. Thiu mu do thiu protid hay thiu dinh dng - Nguyn nhn : do cung cp khng ( i, suy dinh dng ) , do hp thu km( bnh d dy, rut ) , do gim tng hp protid ( bnh gan , RLCH ) , tng thoi bin protid , mt protid ( st , nhim khun ,bnh thn , bng ..) - c im : Thiu mu nhc sc ,s lng HC v huyt sc t gim ph thuc vo mc thiu mu v thiu protid , da nim mc nht nht, teo c , ph n . Protid mu ton phn gim , Albumin gim , gamma globulin tng , BC v TC ngoi vi gim 2. Thiu mu do thiu st - St l nguyn liu tng hp huyt cu t cn thit cho s trng thnh ca HC . St t thc n dng Fe3+ ti d dy b kh bi HCl thnh Fe2+ sau hp thu qu rut

30

vo mu kt hp vi beta glubulin dng transferrin v c a v d tr gan di dng Feritin - Nguyn nhn : + Mt mu , chy mu ra ngoi c th + Cung cp thiu v nhu cu cao + Ri lon hp thu st : bnh DD , ct on DD hay rut .. + Ri lon chuyn ho st : Thiu nng tuyn gip, bnh l v gan .. - c im: + Thiu mu c tnh cht nhc sc, s lng HC , huyt cu t ngoi vi gim , ch s nhim sc gim c nhiu HC nh v HC hnh nhn + Trong tu xng t l nguyn HC kim tng , t l nguyn HC a sc v toan gim + St huyt thanh gim + Thiu mu c ti sinh nhng tc v tnh trng ti sinh ph thuc vo s cung cp nguyn liu v trng thi ca bnh nhn 3. Thiu mu do thiu B12 v acid folic * Qu trnh to HC RiboseC cht c ngun NH2 , C Purin Pyrimidin

+Vitamin B12

Desoxyribose Acid phosphoric

Acid folinic Acid folic

Acid nucleic AND,ARN

* Thiu mu do thiu B12 - Thiu nguyn pht + Nguyn nhn : do thiu cht GMP d dy nn khng hp thu c B12 + c im : Thiu mu c tnh u sc, s lng HC gim rt thp , huyt cu t gim hn mc bnh thng + Trong mu ngoi vi thy gim s lng BC v TC , xut hin HC khng l megalo + Thiu mu c tnh cht c tnh, s lng HC li gim thp hoc khng xut hin + C RLTK nh gim tr nh , vim dy TK - Thiu th pht : + Nguyn nhn : do cung cp khng y , RL hp thu ( Thiu GMP, cc bnh v DD v rut ) . + c im : Thiu B12 thng kt hp vi thiu protid v thiu st nn tnh cht thng l thiu mu nhc sc c c im nh thiu mu do thiu protid v thiu st II. Thiu mu do tu xng b c ch - nguyn nhn + Do nhim khun nng, c t ca VSV tc ng mnh ln tu xng , thng ch c ch tm thi + Do nhim c cc ho cht nh kim loi , cht c trong bnh l ca gan , nhim x ..

31

+ Do lon sn tu hay tu xng b c ch, chn p trong mt s bnh c tnh : bnh BC , K cc loi , x ho tu xng + Do ni tit : cng lch gy thiu mu km theo gim TC , thiu erthropoietin vim thn mn , thiu nng tuyn gip , sinh dc , tuyn yn .. - c im : + Thiu mu nhc sc , cht lng HC gim + Chc nng tu xng b c ch nn gim sn xut 3 dng t bo lm suy nhc tu - ngha Qua thy r gi tr v v tr ca tng loi thiu mu ring bit , nhng thc t th thiu mu thng do nhiu nguyn nhn kt hp chnh v th ngi thy thuc phi bit phn tch tnh trng mu ngoi vi, chc nng tu xng v cc du hiu lm sng khc xc nh yu t bnh sinh ch yu th iu tr mi c kt qu Cu 27: Chy mu v sc chy mu thc nghim : phng php tin hnh , din bin, phn tch ri lon ch yu v nguyn tc iu tr Bi lm 1. Phng php tin hnh : - Vt th nghim : ch - Tin hnh : gy sc bng cch ly 200 250 ml mu tnh mch i 2. Din bin Thng theo 3 giai on a) Giai on 1 ( Sc cng ) - ph thuc vo mc mt mu v trng thi ca tng c th - Huyt p ng mch gim do gim khi lng mu tun hon, mt mu cng nhiu th HA gim cng r c th gy tru tim mch dn ti t vong do phn ng b p khng pht huy tc dng - Mch nhanh v mnh pht sinh theo c ch phn x, nu lng mu mt ln th th tim p yu lon nhp l c s chn on - Tng h hp, th nhanh v su, ri lon khi mt mu nghim trng b) Giai on 2 ( Sc tim ) - Ph thuc vo kh nng thch ng ca c th - Nu c ch thch ng b p ca c th pht huy tc dng th tnh trng bnh nhn c xu hng hi phc : + Huyt p ng mch tng ln ,mch nhanh v mnh hn + H hp u v su hn - Nu din bin xu i th: + Huyt p khng tng tip tc gim + Mch yu v nhanh , lon nhp + H hp ri lon th nhanh v nng c) Giai on 3 ( Sc nhc )

32

- l giai on suy sp h thng TKTW v ton b chc nng ca c th . y l giai on mt b pht sinh do mt yu t thun li nh gy m su, chn thng , au n 3. Bnh sinh - Gim khi lng mu tun hon v thiu O2 mu gy ri lon nghim trng h TKT . Cc t bo no thiu O2 nng t HP nhanh chng chuyn sang C gy RL iu ho cc chc phn v C c ch thch ng ca c th - RL trung khu h hp, huyt p ng mch gim gy RL hot ng ca c tim lng mu v O2 n cc c quan gim gy RLCH nng n . Cht trong mt mu pht sinh do lit trung khu h hp v ngng tim - Do tc dng ca catecholamin nn h thng ng mch b co tht , tun hon no v mch vnh dn ra l c ch bo v nhng li lm tn thng h thng tun hon gan thn, h thng tnh mch xp tun hon mu v tim gim nh hng ti hot ng ca tim gy nh tim. H thng mao mch dn nghim trng do RL c tht tiu mao mch lm mu li ni tng to vng xon bnh l 4. Nguyn tc iu tr - Nguyn tc ch yu l khi phc tun hon , tr li khi lng mu mt gi cn bng huyt p - Trong s tr cn m bo cm mu tt nn cho bnh nhn nm u dc - iu tr sm, truyn mu ngay trong hai giai on u phc hi s cn bng huyt ng hc , phng sc v ngn nga hu qu do thiu O2 gy ra - iu tr trong giai on ny d dng v c hiu qu v khi chuyn sang sc nhc th kh iu tr - Sau khi thit lp c th cn bng th cn theo di v tip tc cc bin php hi phc ngn nga s th pht

Gi phn tch huyt 1. HC : 3,8 - 4,2 triu/mm 3 Nam : 4 - 4,5 triu/mm3 N : 3,8 triu/mm3 . Nu < 3 triu/mm 3 => thiu mu nh Nu 2,5-3 triu/mm3 => thiu mu va . Nu thiu mu nng . 2. HST : > 75% 3. Gi tr HC

33

Ch s nhim sc = %HST / ( 2 ch s u HC x 2 ) GTHC = 0,9 - 1,1 : thiu mu ng sc. < 0,9 : thiu mu nhc sc > 1,1 : thiu mu u sc. 4. HC li 0,5 - 1,5 % ( mu ngoi vi) => kh nng hi phc ca tu v mt HC l km . => khng hi phc . 5. BC : 5000-9.000/mm 3 Khi BC >10.000 /mm3 => l tng. Khi BC< 5000 /mm3 => l gim. CTBC = (TB% + HTB% + S %) / (N% + E% + B%) : 0,03 - 0,08 ( BC non trn BC trng thnh) Chuyn tri : > 0,08 nh + va : 0,08 - 0,25 : c th c tng sinh BC => chng nng : 0,25 - 0,5 : sc chng ca ct ko tt, ct nhim trng 0,5 : chuyn tri dng bnh BC => ct nhim trng nng. Chuyn phi: ko chia mc, xu bnh nhc tu hoc suy tu v tu xng ko tng sinh, ko c BC non. 6. TC : 150.000- 300.000/mm 3 < 150.000 /mm3 l xut huyt. 7. Neutrophine : 62% ( 60-70%) : trong NK cp, nhi mu c tim, chy mu cp, chn thng s no. trong NK cp nng, thng hn , si, cm, nhim c cc cht c ch tu xng. 8. Eosinophine : 9- 11%: trong d ng, nhim KST ( thng l giun mc). trong giai on u ca NK cp, tng tit corticoid:c ch E. 9. Lymphocyte : 22% ( 20-30% ) trong bnh nhim khun mn tnh . trong bnh hch Lympho, st rt. 10. Monocyte 2% ( 1-3%): trong nhim khun huyt giai on cui.

34

trong NT Nc nng, c ch h thng vng ni m. 11. Stab : 1- 2% khng c, ch c trong trng hp nhim c, nhim x.

Cu 28: Huyt : HC: 2.800.000 /mm3, Hb: 40%, BC: 7.200/mm3, S: 1%, N: 41%, E: 30%, L: 26%, M: 2%. Bi lm 1. Phn tch + HC=2,8 triu =>thiu mu va. + Ch s HC=%HST/ (HCx2)= 40/( 28 * 2)= 0,71 < 0,9 => thiu mu nhc sc. +BC +Trong cng thc BC th E cao => nghi ng nhim KST hoc di ng. 2. Kt lun + : Nghi ng nhim KST +XNo phn :soi ti tm trng giun =>ct nhim KST(thng do giun mc). +D ng: phi hp hi v khm LS . 3. Gii thch - N do E cao ln p . Cu 29:Huyt : HC: 4.200.000 /mm3 ,Hb: 80%, BC: 15.000/mm 3 , hu tu bo: 0,5%, S: 5% , N: 81%, E: 0,5% , L: 11%, M: 2%. Bi lm 1. Phn tch + HC: ,Hb: 80% => khng c thiu mu. + C BC cao v s lng. + CT Silling = (5+0,5)/(81+0,5) = 0.067 => bnh thng. + Trong cng thc BC c xut hin giai on trung gian ca BC ht mu ngoi vi( HTB: 0,5%), ng thi lng N cao (81%) v E(0,5%) => 2. Kt lun : + : Nhim khun cp giai on u v SK ca BN tt ( v Silling vBC, N ch lc ). Cu 30: Huyt :HC: 3.800.000 /mm3, Hb: 75%, BC: 9.100/mm 3 , hu tu bo: 14%,S: 50% , N: 31%, E: 0%, L: 5%, M: 0%. Bi lm 1. Phn tch

35

- HC v HB : => Ko thiu mu. ( ko cn tinh CSHC). - SLBC : nh . - Trong CTBC c : +BC trng thnh : dng M v E = 0, N. + S lng BC non cao trong mu ngoi vi( HTB= 14%, S= 50%) => gp trong g u ca NK cp ( N nhng cng b cht nhiu => N). - CSCN=2,06 => chuyn tri dng bnh BC=> tin lng bt u xu v tu xng tng sinh vi vng cha bit ho ra mu ngoi vi ). 2. Kt lun - NK cp nng giai on u vi tin lng bt u xu . - GT: L : 5% c th do c t ca VK mnh qu gy c ch L . Cu 31: Huyt :HC: 2.500.000 /mm3 , Hb: 45%, BC: 3.100/mm 3 ,S: 0%, N: 44%, E: 2%, L: 45%, M: 9%. Tiu cu: 80.000/mm 3 Bi lm - HC=> thiu mu. - Hb => ch s HC=45/(25*2) = 0,9 =>thiu mu ng sc mc va . - SLBC. + Trong CTBC : + Dng BC ht . - L tng tng i. - S lng TC . - HC, BC ht, TC => tu xng sn xut. Nhng L => ngh n bnh mn tnh gy c ch tu xng => cn phi hp vi LS, ngh XNo tu ( M v L ko v n c sn xut mu ngoi tu xng nh lch v h thng bch huyt). Cu 32: Huyt :HC: 2.300.000 /mm3 , Hb: 50%, BC: 3.600/mm3 ,nguyn tu bo 60%, tu bo:4%, hu tu bo:0%, S: 0%, N: 28%, E: 4%, L: 2%, M: 1%. Bi lm + SLBC , c cc t bo non cha bit ho mu ngoi vi. + C khong trng BC. => Kt lun : Nghi ng bnh BC tu cp th BC. ngh lm thm XNo tu. GT: HCdo bnh c tnh ca dng BC c ch cc dng cn li. Cu 33: Huyt :HC: 2.800.000 /mm3 , Hb: 52%, BC: 62.500/mm 3 nguyn tu bo 1%,tin tu bo:4%, tu bo: 16% hu tu bo: 8%, S: 13%, N: 45%, E: 3%, L: 9%, M: 1%.

36

Bi lm + HC , Hb => thiu mu. + SLBC cao trong mu ngoi vi. + Xut hin cc TB non( NTB) ca dng BC ht mu ngoi vi + C cc giai on pht trin => ko c khong trng BC. => KL: Nghi ng bnh BC tnh mn. ngh NXo tu lm tu nh gi c.n tu) .(GT : HCdo bnh c tnh ca dng BC c ch cc dng cn li).

Cu 34: Thay i khi lng mu lu thng trong sock . Phn tch c ch bnh sinh , hu qu v nguyn tc s tr Bi lm 1 nh ngha : - Sock mt mu l hin tng th pht xy ra ngay sau khi mt mu nng , din bin sau mt thi gian h huyt p ng mch , s oxy ho khng y dn ti suy sp h thng TKT v ri lon nghim trng ton b chc nng ca c th biu hin r nht l h thng tun hon . Mt mu cng nhanh cng mnh th sock mt mu pht sinh cng c tnh cht ph bin v din bin cng nng 2. Thay i khi lng mu lu thng trong shock 3. Bnh sinh - Gim khi lng mu tun hon v thiu O2 mu gy ri lon nghim trng h TKT . Cc t bo no thiu O2 nng t HP nhanh chng chuyn sang C gy RL iu ho cc chc phn v C c ch thch ng ca c th - RL trung khu h hp, huyt p ng mch gim gy RL hot ng ca c tim lng mu v O2 n cc c quan gim gy RLCH nng n . Cht trong mt mu pht sinh do lit trung khu h hp v ngng tim - Do tc dng ca catecholamin nn h thng ng mch b co tht , tun hon no v mch vnh dn ra l c ch bo v nhng li lm tn thng h thng tun hon gan thn, h thng tnh mch xp tun hon mu v tim gim nh hng ti hot ng ca tim gy nh tim. H thng mao mch dn nghim trng do RL c tht tiu mao mch lm mu li ni tng to vng xon bnh l 4. Nguyn tc iu tr - Nguyn tc ch yu l khi phc tun hon , tr li khi lng mu mt gi cn bng huyt p - Trong s tr cn m bo cm mu tt nn cho bnh nhn nm u dc - iu tr sm, truyn mu ngay trong hai giai on u phc hi s cn bng huyt ng hc , phng sc v ngn nga hu qu do thiu O2 gy ra - iu tr trong giai on ny d dng v c hiu qu v khi chuyn sang sc nhc th kh iu tr

37

- Sau khi thit lp c th cn bng th cn theo di v tip tc cc bin php hi phc ngn nga s th pht

Cu 35. Vai tr ca thiu oxy trong bnh sinh ca sock Bi lm HA au Do m Shunt Toan chuyn ho Gp cht trung gian ho hc Gin mch (Co c sau mm gin c tin mm) Mt mu Thiu O2 t chc Tng tnh thm thnh mch Thot huyt tng

mu

p lc thu tnh trong mm

Tng thot huyt tng Qunh mu, nghn

KLTH

Hoi t t chc

- Vy O2 l yu t u tin khi pht cho vng xon bnh l ca sock - Hu qu ca n : lm cho hin tng thiu O2 ngy cng nng hn v lm cho sock nng hn dn n sock khng hi phc nn trong sock cn iu

38

tr sm bng tng khi lng tun hon v iu tr ct cc qu trnh ca vng xon bnh l - iu tr : + iu tr triu chng + iu tr nng c th

Cu 36: Phn tch c ch bnh sinh ca thiu oxy trong 3 loi sock : chy mu , chn thng v bng , nguyn tc iu tr Bi lm * Trong shock chy mu: Chy mu gim KLTH (KLMLT) thiu O2 KLVTH KLCH

* Chn thng:Chy mu

gim KLTH

thiu O2

toan CH

KLTH

mu

(-)au

HPTK

tng sd O2

gim chc nng cc CQ

TKT

* Shock bng: (-) au HPTK tng sd O2 thiu O2 (gim HA) gim KLTH

KL huyt ng,gim c/n cc CQ do (tun hon,h hp) m.mu

RLVTH

thot htg,mu tn th ng

39

RLCH

Cu 38: Sock chn thng thc nghim: phng php tin hnh, din bin, phn tch cc ri lon ch yu , nguyn tc phng v iu tr sock chn thng Bi lm I. Phng php tin hnh - Vt th nghim : ch - Tin hnh :Gy sock chn thng ch bng cch gy dp nt c, o huyt p h hp, mch, nc tiu, phn x, tc tun hon v hematorid II. Din bin 1. Giai on t b p a) Trng thi t b p qu mc v tm thi ( sock cng ) - c im : tng cng hot ng ca ton b chc nng trong c th th hin trng thi HP ca TKT b) Trng thi t b p kn o v tm thi ( sock tim ) - c im : mch nhanh nhng yu , khi lng mu lu thng gim song nh c c ch b p, huy ng lng mu d tr gan lch, co mch nh nn HA ng mch vn gi c mc bnh thng nhng tim phi tng hot ng tng lng mu lu thng do tiu hao nng lng d tr v tin ti giai on mt b 2. Giai on mt b ( sock nhc ) - c im : Giai on ny biu hin s suy sp ca ton b chc nng quan trng ca c th ni ln trng thi c ch ca h TKT , con vt th yu mch nhanh nhng yu , huyt p gim, thn nhit gim, hu nh mt ton b cc phn x III. Cc ri lon ch yu 1. Ri lon tun hon - Xut hin ngay giai on sock cng l yu t ch yu chi phi qu trnh pht sinh, pht trin v kt thc ca sock - Catecholamin tng tit gy co c tht trc v sau mao mch( tr tun hon no v vnh) gy thiu O2 cho t chc do thiu mu v m h thng mch tt nhm dn mu cho c quan quan trng nh tim v no - giai on nhc do thiu O2 nn c th nhim toan chuyn ho lm cho h thng c trc mao mch khng chu tc dng ca Catecholamin nn m cn h thng c sau mao mch vn chu tc dng nn mu trn vo mao mch nhng kh ra c gy thiu O2 do mu lm hoi t t chc ni tng c bit l rut - Do mu nn p lc thu tnh trong mao mch tng, thiu O2 nn tnh thm thnh mch tng gy thot huyt tng lm gim khi lng mu tun hon 2. Thay i huyt p

40

- Sock cng : Huyt p tng do trung khu co mch HP tng tit Catecholamin gy co mch c tc dng nng huyt p - Sock tim : Huyt p gim nh ch yu do gim khi lng mu lu thng ngoi ra cn do suy mch cp do trung khu vn mch b c ch - Sock nhc : Huyt p tt mnh, mch nhanh v yu do huyt p gim kch thch TCT p lc quai ch v xoang cnh lm tim p nhanh nhng yu l do gim khi lng mu tun hon nn tim co bp rng 3. Ri lon h hp - Sock cng : H hp nhanh v su c tc dng b p do trung khu h hp hng phn - Sock nhc : H hp nng, nhanh hay chm, lon nhp, c th theo chu k do trung khu h hp b c ch ( thiu O2 v gim khi lng tun hon ) 4. Thay i ca mu - Mu long do thot protein lm gim p lc trong lng mch nn dch gian bo trn vo nhm b p lng mu mt i - Gim s lng HC v huyt sc t 5. Ri lon tit niu - Lng nc tiu gim do gim khi lng mu tun hon - Tng tit ADH v Aldosteron c tc dng tng ti hp thu nc ng thn IV. Nguyn tc phng v iu tr - Gim au : Bng b, c nh, bt ng v dng thuc gim au mnh - Truyn dch : nhm b p v tng khi lng tun hon - Ngn nga v loi b cc yu t ngoi lai nh nng, lnh v i...

Cu 40: Ph bnh nhn suy tim do nhng yu t no gy ra, hng iu tr ch yu l g Bi Lm - Suy tim xy ra khi tim mt mt phn hay ton b kh nng co bp y ra khi tim mt lng mu thch hp vi i hi ca c th. - Khi suy tim tri th kh nng ht mu v tim gim trong khi mu vn tip tc c a n phi nhng khng c gii phng nn mu b gi li phi. - Nu nhng biu hin ca suy tim tri phn ln thuc v triu chng phi th nhng biu hin ca suy tim phi ch yu thuc v khu vc tnh mch ngoi vi. Nguyn nhn chnh gy ph gm c : - p lc thu tnh trong lng mch. - p lc keo huyt tng. - p lc thm thu gian bo.

41

- tnh thm thnh mch. - Tc mch bch huyt. - Ph thuc vo mt m:khng quan trng lm. Vy ph bnh nhn suy tim l do nhng yu t sau: 1.Bnh nhn suy tim tri Ph phi : Mu phi gy tng p lc thu tnh trong mao mch phi khin nc thot vo ph nang gy ph phi mn tnh, nghe thy ting rn t c hai th, c bit r nn phi. i khi, c th pht sinh ph phi cp.y l bin chng nguy him nht ca suy tim tri, thng do tim phi vn cn kho bt cht tng ln hot ng( do gng sc chng hn) y mt lng mu qu nhiu ln phi ,tim tri ht yu nn mu b li phi lm tng p lc thu tnh trong lng mao mch phi. Mt khc khi mu b li phi lm cho qu trnh nui dng ca thnh mao mch phi khng tt, mao mch phi gin ra v tng tnh thm thnh mch. ng thi, lm gim p lc keo huyt tng v khi tnh thm thnh mch tng t th ch c nc v cc ion thot ra ngoi c tip tc tng s ko theo c cc phn t c khch thc ln thot ra ngoi nh albumin...Kt qu l mu s t vo ph nang gy ph phi cp, lm cho BN cht trong trng thi ngt ti cp din nu ko iu tr kp thi. Ngi bnh giy da, lo s lm cho tnh trng nng thm v cng lm tim phi tng cng co bp cng lm dn mu ln phi. Cho nn trong iu tr, ngi ta lm garo chi( hoc trch mu tnh mch) lm gim gnh nng i vi phi,dng thuc tr tim (Uabain) phc hi sc co bp ca tim tri b suy, dng thuc li tiu(Lasic),kt hp vi tim mocphin ngi bnh yn tnh. 2.Bnh nhn suy tim phi Ph : Trong suy tim phi do nhiu yu t kt hp li: - Huyt p tnh mch tng lm cho nc thot ra khi mch nhiu, ng thi cn tr s ti hp thu nc t gian bo vo lng mch. y l yu t ch yu. - Gim p lc keo trong lng mch do gim protein huyt tng(hu qu ca ri lon chc nng gan). - ng nc v mui do gim lc cu thn .

Cu 41 : Phn tch c ch nhng biu hin ca suy tim tri Bi lm C ch biu hin chnh ca suy tim tri 1 Kh th : y l biu hin thng thy v quan trng nht. Ngi bnh thng th nng v nhanh, c cm gic ngt nht l sau khi gng sc lao ng, tp th dc

42

+ Kh th trong suy tim tri l do tim tri co bp yu khng y ht mu dn dn sinh mu phi, mu phi lm cho cc t chc phi bp co gin ng thi cc mao mch mu phi cng mu gy chn p cc ph nang kt qu l hn ch thng kh gy kh th. + Ngi bnh hay kh th khi nm l do t th ny gy mu phi nng nht cho nn ngi bnh thng ngi th d th hn. Kh th khi nm l mt biu hin thng thy khi suy tim tri nhng khi suy tim phi th triu chng ny gim i v my tnh mch ngoi vi nn v phi t . + Ngi suy tim tri c nhng cn kh th xy ra vo ban m ging nh cn hen gi l hen tim do dy X tng cng hot ng trong lc ng gy xung huyt phi co tht c trn ph qun 2 Ph phi : Mu phi gy tng p lc thu tnh trong mao mch phi khin cho nc thot vo ph nang gy ph phi mn tnh. Khi nghe phi thy ting rn t c hai th c bit nghe r nn phi . + i khi c th pht sinh ph phi cp, y l bin chng nguy him nht ca suy tim tri, thng do tim phi cn kho bt cht tng hot ng y mt s mu qu nhiu ln phi ng thi trng thi thiu oxy ca t chc lm cho thnh mao mch tng tnh thm kt qu l mu s o t vo ph nang gy ph phi cp lm cho bnh nhn cht trong trng thi ngt ti cp din nu khng c iu tr kp thi . + Ngi bnh lo s, giy da lm cho tnh trng thm nng thm v tim phi tng cng co bp nn cng dn mu ln phi . Cho nn trong iu tr ngi ta lm garo chi lm gim gnh nng vi phi, dng thuc tr tim phc hi chc nng co bp ca c tim tri suy kit kt hp ch ng ung v ngh ngi, n nh tinh thn 3 Ph dung sinh hot gim + Tnh trng mu phi lm gim tnh co gin ca t chc phi lm hn ch thng kh phi lm gim ph dung sinh hot . Suy tim tri ko di c th dn ti x phi

Cu 42: C ch bnh sinh nhng biu hin ca suy tim phi Bi Lm Nu nhng biu hin ca suy tim tri phn ln thuc v triu chng phi th nhng biu hin ca suy tim phi ch yu thuc v khu vc tnh mch ngoi vi, biu hin ca n th hin cc triu chng sau :

43

1 Ph Nguyn nhn ph trong suy tim phi do nhiu yu t kt hp li + Huyt p tnh mch tng ln lm cho nc thot ra khi mch nhiu ng thi gim ti hp thu nc t gian bo vo lng mch, y l yu t ch yu + Gim p lc keo trong lng mch do gim protein huyt tng l hu qu ca ri lon chc nng gan + ng nc mui do gim lc cu thn 2 Gim bi tit nc tiu Do lu lng mu qua thn gim, ng thi mu tnh mch thn gy gim p lc lc cu thn, gim lng nc tiu dn ti mui v nc gy ph 3 Ri lon chc nng gan Trong suy tim phi mu gan rt ln lng mu ny c th gp i bnh thng lm th tch gan to ra b di c th xng ti ng rn. Nu iu tr tt tim phc hi chc nng co bp bnh thng th gan s nh li bnh thng v li to khi suy tim tr li do gan s to nh tu theo kh nng co bp ca tim ( gan dn xp ). Dn v sau tnh trng thiu oxy do tun hon km di ngy gy thoi ho m ri x ho pht trin t khong xung quanh tnh mch gan lu dn dn ti x gan gy tng p lc tnh mch gnh v trn dch mng bng 4 Xanh tm Triu chng ny hay gp ngi suy tim nng, thy r mi v mng tay c ch l do + Khi lng mu lu thng gim nn huyt sc t khng c bo ho vi oxy, hemoglobin kh tng + Cc mao mch v tnh mch b gin nn mu

Cu 43 : Phn tch bnh n suy tim ton b do hp van 2 l, Gan to 4cm di b sn, s hi cng, kh th r nht khi nm, c ting ra t lc c hai bn nn phi, protein mu 4,8% Bi Lm C ch bnh sinh: Hp van 2 l

mu nh tri mu xung tht tri gim mu git li TMF,MF

44

cung lng tim gim h HA

tng gnh p lc tht phi gy suy gim k/n tng mu ca tht phi ph i tht phi cao p M,TM phi suy tim phi thot dch vo PN

kh th,hen tim,rn phi ph phi cp

mu TM ngoi vi,TM ca

TM c ni,gan to,ph,c trng,trn dch mng ngoi tim mng phi Suy tim phi lu ngy suy tim tri suy tim ton b *Vy trong bnh n trn:c gan to di b sn 4 cm s hi cng l do mu gan,lu ngy dn n x gan(x gan tim) s chc,phn hi TM ca(-) + Tng p lc TM ca gy lch to,c trng + Suy gim c/n gan + Kh th:do thot dch vo PN lm din tch trao i kh gim.khi nm cao p ng mch phi ln hn thot dch nng n hn kh th hn + C ting ran t lc c 2 nn phi l do thot dch vo PN,nng c th ph phi cp + Protein:4,8g% gim. Bnh thng: 6,8-7,2g% Nguyn nhn do x gan c/n gan gim kh nng tng hp protein gim protein huyt tng gim. Cu 44: Nguyn nhn, c ch bnh sinh, nguyn tc iu tr trong ngt Bi Lm

45

1. nh ngha : Ngt l hin tng tc nghn hon ton ng lu thng kh o gy thiu O2 v ng CO2 trong mu dn ti suy sp chc nng ton b c th v cht nu khng kp thi c bin php cp cu hp l Bnh thng thnh phn kh bao gm : + O2 : 20,96% + CO2 : 0,04% + N2 : 79% 2. Nguyn nhn : Do 3 nhn t chnh + Do c ch trung tm h hp : Thuc m + Lit v co cng c h hp + Do tc nghn hon ton ng lu thng kh o : tc d vt, ph n thanh qun + Do trn dch ph nang: cht ui, ph phi cp 3. C ch bnh sinh Ngt thng din bin theo 3 giai on : + Giai on kch thch: ng lu thng kh o b tc, lit c h hp, thay i thnh phn khng kh th tt c cc nguyn nhn trn u gy nn trng thi thiu O2 v tha CO2 trong mu, khi CO2 trong mu tng th gy kch thch cc phn x c ch trung tm h hp v qu trnh vn mch, biu hin ban u l h hp nhanh v su, th th vo ko di mch nhanh v mnh, huyt p ng mch tng cao, tng trng lc c c tc dng b p + Giai on suy sp: Sau khi c mt lot cc p ng b p nhng c th vn thiu O2 v tha CO2 trong mu qu nhiu gy c ch h hp, h hp chm li, huyt p h tim p chm dn, thn kinh lm vo tnh trng c ch su xut hin co git ton thn, thn kinh chi phi c trn hu mn v bng quang t lit nn mt kh nng kim sot tiu i tin + Giai on suy sp: V no v trung tm h hp b c ch su sc, c th mt ton b cc phn x, ng t gin mt hon ton h hp, tim p chm dn, huyt p tt nhanh v tim ngng p 4. iu tr Nh vy cht do ngt l do thiu oxy trm trng v ng qu nhiu CO 2 trong mu gy c ch trung tm h hp v h thn kinh trung ng. Phn p CO2 trong mu tng rt cao nh vy nn nguyn tc iu tr trong ngt alf phi h hp nhn to loi b CO2 , tr b cc nguyn nhn cn tr ng h hp cung cp oxy cho bnh nhn nhng khng c dng oxy nguyn cht v s lm mt phn x th b p vi trng thi thiu oxy

Cu 45: Phn tch cc ri lon thng kh v ri lon khuych tn trong cc bnh hen, vim phi . Bi lm 1. Hen ph qun

46

- L 1 bnh d ng do kthch loi reagin, gy co tht h thng f.q m bh LS ch yu l cc cn kh th b l th th ra - RL thng kh, RL k.tn trong hen ph qun + Cn hen thng pht sinh do tc dng ca d nguyn gy kt hp kng-kth gph cc cht ho hc tr.gi nh histamin, bradykinin, prostaglandin kthch cc si li tm ca dy TK f v gy co tht h c trn cc f.q, tng tit nim dch, f n v vim cc n.m f.q dn ti cc cn kh th ra bnh nhn kh th nh lng ngc b p, thng fi ngi dy th, mt xanh tm, tit nhiu m ri, thng kh trb gim, dung tch sng gim, VEMS v h s Tiffaneau gim, lng cn tng. Tn s cc cn hen, thi gian ko di f thuc vo t/cht ca bnh, thng nng v cn ko di ngi tr.th. + Hen lu ngy c th lm gim tnh n hi ca t chc fi gy ttr trng f.n, cc f.n to ln bt thng, mt vch ngn vi f.n bn cnh ng thi x ho v chn p cc f.n tng i cn lnh ln, chn p vo mao mch, n.m f.q f i gy trt fi b c khi bnh thng. Ph bo cng, lun p cc mao qun lm tr ngi tun hon fi, gy tng HA M fi, tm tht F tng cng h lu di c th dn ti suy tim F c gi l tm-f mn l bnh fi mn tnh do bnh l tim gy ra. T dn n lng mu qua fi rt thp, do vy din k.tn c.n gim ngh.trng s a n x fi v suy h hp. + Cc cn hen c tnh l do tc ton b f.q nh c th gy suy th cp, rt ng.him nu ko cp cu kp thi. Ngoi ra, thng kh gim lm chm i mi kk trg nhiu f.n, thm ch b loi khi c.n k.tn. 2. Vim phi - L 1 trt bnh l f bin trg nhn dn cng nh trg qun i, chim 49,3% trg tng s bnh h hp, 17% trg s cc bnh ni khoa.Trg vim fi thng thy: +kh th, th nng v nhanh do t chc fi b vim, tng tit dch r vo trg f bo gy tng h.f cc cm f TB c ch lm th th vo sm b c ch ng thi din h hp v k.tn kh cng gim, hu qu l thng kh f bo gim v dung tch sng cng gim gy ttr thiu O2. + mu qua vng fi b vim ko c bo ho y O2 nn bo ho O2 ca mu gim r rt ( c khi ch cn 70%), thnh f.n b f n dy ln cng lm a/hng n kn k.tn ca fi. + do cc khu vc lm tng thng kh b p nn thng ko c u thn. Thiu O2 xanh tm v u thn r ch gp cc TH c km vim f.q ( f.q- f vim), cc f.q nh b vim, f n, bt kn cc dch nhy or co tht cc f.q nh.

Cu 46: M t bnh ln cao thc nghim (thiu oxy do gim phn p) Phn tch kt qu

47

Bi Lm Cc du hiu bnh l xh f thuc vo cao v sc chu ng ca c Thiu O2 l 1 qtr bnh l f.tp do cc c quan bo ko cung cp c O2 y v 1 l do no ko sd c O2.Trong c th k n TH thiu O2 do gim p. - Ng.nhn ca loi thiu O2 ny l do khi ln cao trn mc ca mt bin, p lc KQ gim do p lc O2 trg kk cng gim gy gim pO2 trg f bo v trg mu ng mao mch v thiu O2. + C th tnh theo cng thc sau: pO2 kk = [O2 kk] .(P k.quyn 47) pO2 kk: p lc O2 trg kh th ( mmHg) [O2 kk] mc bthg = 0,21 P k.quyn: p lc kh quyn = 760mmHg Bthg pO2 kk =0,21.( 760 47) = 150 mmHg Khi ln cao 3000 m: pO2 kk = 0,21. (550 47) = 80 mmHg do gy thiu O2. 1. Bnh cao + L htng thiu O2 cp khi ln cao t ngt trn 3000 m or bay cao trn mc gh m ko c or hng bnh O2. cao 4000 5000 m c coi l gh ko cn cung cp thm O2 th, dh sm nht l cc RL thn kinh, RL ng quan: mt mi bt thng, nhc u, gim tr nh, fx chm chp, bun nn, RL th gic, thnh gic u l nhng dh ng.him nht l vi fi cng chin u. Do c th b p bt lc gy tng o thi CO2 nn l loi thiu O2 km nhc thn v nhim kim hi.Tim p nhanh, yu c th lon nhp. Nu ko x l kp thi h TK b c ch su sc dn ti co git, hn m v cht. Bin php iu tr ch yu l cung cp O2 ng.cht. + Ln cao trn 8000 m: pO2 kk = 0,21.(270 47) = 47 mmHg + Cung cp O2 ng.cht: 1.(270 47) = 223 mmHg + Ln cao trn 10000 m th d cho O2 ng.cht cng ko m fi c bung p lc mi trnh c ttr thiu O2 v v trng lng. 2. Bnh ni cao + L htng thiu O2 cp khi leo ln ni cao trn 6000 m (cc nh thm him). Nguy him ca thiu O2 cng f thuc vo cao v 1 s yt f thm nh: mt mi th cht, lnh, t/d ca tia cc tm, tia v tr Khi ln cao trn 3000 m cc dh thiu O2 bt u xh: h.f TK, trt kthch, khoan khoi, hay ci ni. Ln cao trn 4000 m dh r rt hn nh: nhc u, bun nn, mt mi tht thng, km tr nh, kh th, tm ti, h hp chu k cao 6000 m l gh cui cng con ngi c th chu ng c m ko cn c thm O2. + Cht trg bnh cao v ni cao l do t lit tr.tm h hp v c ch h TKTW v cc tr.khu TK, bnh leo ni cn c trt nhim toan chuyn ho do cc c fi lm vic trg hon cnh thiu O2, sn sinh nhiu a.lactic v cc acid khc.

48

+ Vi nhng dn tc sng trn ni cao th ttr thiu O2 mn c c th thch nghi b p gq n nh cn bng ni mi , HC c th tng t 7-8 triu/mm3 mu, nhim kim hi c b p bng thi tr bicacbonat ca thn do s cung cp v sd O2 ca TB c m bo v nhng ngi ny c th sng v lao ng sx bthg. Cu 47: Ph phi cp thc nghim, Phng php tin hnh, din bin, phn tch nhng ri lon ch yu, bin php iu tr ( nu l ph phi cp trong bnh tim ) Bi Lm PP cp l hin tng cac ph nang b ngp nc do hin tng trn ra lng mch hoc hin tng ngp ht lng PN(SPN=90m2) 1. P2 tin hnh - V th nghm l ch kho mnh - Dng AgNO3 0.03% tim vo M i ch khong 20-30mltruyn dch cho n khi xut hin cn PPC . 2. Din bin - Do mao mch phi thnh mng v k/n v/c chm cho nn t.g AgNO3 tip xc vi mao mch phi lu hn lm ph hu mao mch phi trn dch vo PN (huyt tng + hng cu)gy ra ph phi cp. - Ton thn:g u H2 tng,HA tng ,mch nhanh ,con vt trong trng thi kch thchsau H2 ,HA ,mch chm nng ,con vt trong trng thi c ch l . - Ti phi: thy ran m t y phi dng ln ,c bt kh mu hng trn ra KQ ,bp t chc phi thy lo xo. - Khi ch cht m thy vt m khng c mu, tim mu sm mu phi vng y thm tm cn phn trn cn hng nht ( ct 1 phn y th vo nc th n s chm trc mu nh phi). 3. Phn tch nhng RL ch yu - Do mao mch phi tn thng ,ph nang cha y dch mng khuych tn,h s K/tn ,din k/tn RL k/tn thiu O2 kthch TKT trg c Tr.khu HH v TH gy HP lm cho HA , HH, tim p nhanh cng thiu O2 v CO2 chuyn sang g C HA, HH, tim p chm. - Ngoi ra do dch trn y PN KLTH HA tt rt nhanh, c th dn n tru tim mch. - Khi dch trn vo PN, do c nht ca htg, nn khi th ra th vo k2 vo khuy ng htg to nn ting ran.Khi HH tng CO2 trg PN + htg to nn bt kh mu hng v ran m dng t y phi ln.

49

Khi bt kh y PN bt kh tro ra ngoI KQ to ra dch mu hng, bp t/c phi thy lo xo. - Do KLTH gim co mch ngoi v dn mu v Tr.tm do vy vt m ko c mu & tim mu sm mu ,c th mu TT trI hoc TT fI f thuc vo tim ngng p th no & do KTV kp th no. 4. Bip fp iu tr PPC trg ST - PPC trg ST l do TT trI suy ht mu v tht trI km mu mmch phi nhng tht phI cn kho nn tng c 1 lg mu ln nn phi lm tng AL TT t ngt PPC. - Vy trg iu tr ta fI gim AL TT gim lg mu v tht fI & gim lg htg trn ra trg lng PN ta fi : + Gar gc chi ( 3/4 chi v fI lun chuyn), trch mu TM . + Li niu. + Trnh ng mu phi = tr tim trI ht mu v tht tri. + Dng an thn, gim au = morphin, trnh gng sc & xc cm mnh Cu 50 : Phn ng b p ca c th khi thiu oxy Bo Lm 1. Tng cng h hp v tun hon - H hp nhanh v su fs theo c ch fx do gim pO2 kthch cc R xoang M cnh v quai m ch v kthch trc tip ca tng pCO2. ng thi vi c ch fx, h hp tng cng lm cho sc ht lng ngc tng , mu v tim F tng lm cho tim tng h dn n tim p nhanh v mnh, lu lng mu trg 1 min c th tng 4-6 ln hn so vi bthg, trng lc hqun v tc mu chy tng nhm cung v/chuyn cho t chc . 2. Thch ng ca h mu - u tin l p/ phn phi li mu, mu c dn ti bo cho cc c quan qtrg( no, tim) v mu d tr c a ra sd thng qua t/d ca tng tit adre. - Kh nng kt hp HbO2 c tng cng tuy pO2 mu gim r rt + Khi pO2 =100 mmHg th kt hp HbO2 t 95-97% + Khi pO2 = 50 mmHg th kt hp HbO2 duy tr mc 80%, pO2 gim thp hn th HbO2 mi gim - Kh nng phn li ca HbO2 tng cng t chc sd oxy d dng, do ti [CO2] v cc cht acid khc ca RLCH tng. - Xn xut HC tng, do tnh trng thiu oxy kthch tng tit erythropoietin v kthch c.n to HC ca ty xng. 3. Thch ng ca t chc - T chc tn dng oxy ca mu M nn h s sd oxy t 0,3 tng ti 0,85 v mu TM t oxy tr thnh mu tm sm. - CH vt cht g u tng nhng sau gim r rt, thn nhit cng gim, c t/d gim bt nhu cu oxy ca c th to k phc hi cc chc fn v tng cng sk ca c th vi thiu oxy.

50

4. Thch ng ca h TK v h ni tit - Khi thiu oxy, lc u h TK hf sau ft sinh c ch bv v no v ton b h TKTW, ng thi vi gim CH, gim thn nhit, gim h cc chc fn khc ca c th, nhng nu ng.nhn thiu oxy vn tip tc h TK b c ch su sc s gy nhiu RL ng.him b l c RL tng hp v lng ATP. Nh vy ATP gim nhanh trg g hf v c xu hng phc hi trg g c ch bv, lng ARN cng gim trg g hf v tng trg g c ch bv. Nhng nu thiu oxy nng v ko di, s gim cc h/c phosphas cao nng v ARN ngh.trg s dn n htg thiu NL cho TBTK v thng l ng.nhn ca ci cht. - Nh vy thch ng vi thiu oxy, vai tr qnh l tng kn ti tng hp cc cht phosphas cao nng, tng hot tnh tng hp acid nhn v P, c.yu l trg t chc TK. Do ng. tc c bn cho d phng v iu tr nhng hu qu do thiu oxy = bin php gim th nhit nhn to, sd thuc c ch TKTW hn ch r rt s thoi bin