TRIU CHNG HC NI KHOA 2.0

TI LIU SU TM TNG HP DCH

Gii thiu Information Mc lc

Bin son ebook : L nh Sng

I HC Y KHOA H NI

Trang web : www.ykhoaviet.tk

Email : Lesangmd@gmail.com, bachkhoayhoc@gmail.com

in thoi : 0973.910.357

THNG TIN

THNG BO V VIC XUT BN BCH KHOA Y HC 2010 :

Theo yu cu v nguyn vng ca nhiu bn c, khc vi Bch Khoa Y Hc cc phin bn

trc, bn cnh vic cp nht cc bi vit mi v cc chuyn khoa mi,cng nh thay i cch

thc trnh by, Bch Khoa Y Hc 2010 c chia ra lm nhiu cun nh, mi cun bao gm mt

ch ca Y Hc, nh th s gip bn c tit kim c thi gian tra cu thng tin khi cn.

Tc gi xin chn thnh cm n tt c nhng kin ng gp ph bnh ca qu{ c gi trong thi

gian qua. Tt c cc cun sch ca b sch Bch Khoa Y Hc 2010 bn c c th tm thy v ti

v t trang web www.ykhoaviet.tk c L nh Sng xy dng v pht trin.

NG H :

Tc gi xin chn thnh cm n mi s ng h v mt ti chnh gip cho Bch Khoa Y Hc

c pht trin tt hn v ngy cng hu ch hn.

Mi tm lng ng h cho vic xy dng mt website dnh cho vic ph bin ti liu hc tp v

ging dy Y Khoa ca cc c nhn v Doanh nghip xin gi v :

Tn ngn hng : NGN HNG U T V PHT TRIN VIT NAM

Tn ti khon ngn hng : L nh Sng

S ti khon : 5111-00000-84877

CNH BO :

TI LIU NY CH MANG TNH CHT THAM KHO nhm mc ch nng cao hiu bit v Y khoa.

Tuyt i khng c t p dng cc thng tin trong ebook ny chn on v t iu tr

bnh, nht l vi nhng ngi khng thuc nghnh Y . Tc gi ebook ny khng chu bt c

trch nhim g lin quan n vic s dng thng tin trong cun sch p dng vo thc tin

ca bn c. y l ti liu su tm t nhiu tc gi khc nhau, nhiu cun sch khc nhau,

cha c kim chng , v th mi thng tin trong cun sch ny u ch mang tnh cht tng

i . Cun sch ny c phn pht min ph vi mc ch s dng phi thng mi, bt c

hnh vi no lin quan n vic mua bn, trao i, chnh sa, in n cun sch ny vo bt c

thi im no u l bt hp l . Ni dung cun ebook ny c th c thay i v b sung bt

c lc no m khng cn thng bo trc.

GII THIU

B sch ny c L Sng su tm , bin dch v tng hp vi mc ch cung cp mt ngun ti

liu tham kho hu ch cho cc bn sinh vin y khoa, v tt c nhng ai c nhu cu tm hiu,

nghin cu, tra cu , tham kho thng tin y hc.

Vi tiu ch l b sch m , c xy ng da trn ngun ti liu ca cng ng , khng mang

mc ch v li, khng gn vi mc ch thng mi ha i bt kz hnh thc no , nn trc

khi s dng b sch ny bn phi ng vi nhng iu kin sau . Nu khng ng , bn

khng nn tip tc s dng sch :

B sch ny c cung cp n tay bn , hon ton da trn tinh thn t nguyn ca bn.

Khng c bt kz s thng lng, mua chuc, mi gi hay lin kt no gia bn v tc gi b

sch ny.

Mc ch ca b sch phc v cng tc hc tp cho cc bn sinh vin Y khoa l chnh, ngoi

ra nu bn l nhng i tng ang lm vic trong nghnh Y cng c th s dng b sch nh

l ti liu tham kho thm .

Mi thng tin trong b sch u ch c tnh chnh xc tng i, thng tin cha c kim

chng bi bt c c quan Php lut, Nh xut bn hay bt c c quan c trch nhim lin quan

no . V vy, hy lun cn trng trc khi bn chp nhn mt thng tin no c cung cp

trong b sch ny.

Tt c cc thng tin trong b sch ny c su tm, tuyn chn, phin dch v sp xp theo

trnh t nht nh . Mi bi vit d ngn hay di, d hay d d cng u l cng sc ca chnh

tc gi bi vit . L nh Sng ch l ngi su tm v phin dch, ni mt cch khc, ngi

gip chuyn ti nhng thng tin m cc tc gi bi vit cung cp, n tay cc bn .

B sch ny l ti liu su tm v dch bi mt sinh vin Y khoa ch khng phi l mt gio s

tin s hay mt chuyn gia Y hc dy dn kinh nghim, o c th c rt nhiu li v khim

khuyt khng lng trc , ch quan hay khch quan, cc ti liu b tr c th cha hp l , nn

bn cnh vic thn trng trc khi thu nhn thng tin , bn cng cn c k phn mc lc b

sch v phn hng dn s dng b sch s dng b sch ny mt cch thun tin nht.

Tc gi b sch in t ny khng chu bt c trch nhim no lin quan n vic s dng sai

mc ch , gy hu qu khng tt v sc khe, vt cht, uy tn ca bn v bnh nhn ca bn .

Khng c chuyn mn , khng phi l nhn vin y t , bn khng c ph p t s dng nhng

thng tin c trong b sch ny chn on v iu tr. T trc ti ny, cc thy thuc IU

TR BNH NHN ch khng phi l IU TR BNH. Mi ngi bnh l mt thc th c lp

hon ton khc nhau, o vic b nguyn xi tt c mi thng tin trong b sch ny vo thc

tin s l mt sai lm ln . Tc gi s khng chu bt c trch nhim g do s bt cn ny gy ra.

V l b sch cng ng, to ra v mc ch cng ng, do cng ng , b sch ny c pht trin

c hay khng mt phn rt ln, khng ch da vo sc lc, s kin tr ca ngi to ra b

sch ny , th nhng ng gp, xy ng, gp , b sung, hiu chnh ca ngi c chnh l

ng lc to ln b sch ny c pht trin. V mt mc tiu tr thnh mt b sch tham

kho y khoa tng hp ph hp vi nhu cu v tnh hnh thc tin trong lnh vc y t ni ring v

trong cuc sng ni chung . Tc gi b sch mong mi bn c nhng li ng gp chn

thnh mang tnh xy dng, nhng ti liu qu m bn mun san s cho cng ng , v mt

tng lai tt p hn. l tt c nim mong mi m khi bt u xy dng b sch ny , ti

vn kin tr theo ui .

Ni dung b sch ny, c th ch ng trong mt thi im nht nh trong qu kh v hin ti

hoc trong tng lai gn. Trong thi i cch mng khoa hc cng ngh tin nhanh nh v bo

nh hin nay, khng ai bit trc c liu nhng kin thc m bn c c c th p dng

vo tng lai hay khng . tr li cu hi ny, ch c chnh bn thn bn , phi lun lun

khng ngng-T MNH-cp nht thng tin mi nht trong mi lnh vc ca i sng, trong

c lnh vc y khoa. Khng ai c th, tt nhin b sch ny khng th, lm iu thay bn.

Nghim cm s dng b sch ny i bt kz mc ch xu no, khng c ph p thng mi

ha sn phm ny i bt c anh ngha no. Tc gi b sch ny khng phi l tc gi bi vit

ca b sch , nhng mt rt nhiu cng sc, thi gian, v tin bc to ra n, v li ch

chung ca cng ng. Bn phi chu hon ton trch nhim vi bt kz vic s dng sai mc ch

v khng tun th ni dung b sch ny nu ra.

Mi l thuyt u ch l mu xm, mt cun sch hay vn cun sch cng ch l l thuyt, ch c

thc t cuc sng mi l cun sch hon ho nht, bn khng phi l c gi m l din

vin chnh. V Bch Khoa Y Hc cng ch l mt ht thc nh, vic s dng n xo nu hay

nhn ging l hon ton ty thuc vo bn c. V ngi to ra ht thc ny s vui mng v

c truyn thm ng lc tip tc c gng nu bit rng chnh nh bn m bit bao ngi

khng cn phi xp hng ch cu tr.

Mi ng gp lin quan n b sch xin gi v cho tc gi theo a ch trn. Rt mong nhn

c phn hi t cc bn c gi cc phin bn sau c tt hn.

Knh chc bn c, gia quyn v ton th ngi Vit Nam lun c sng trong khe mnh,

cuc sng ngy cng m no hnh phc.

Lng, Ngh An. Thng 8/2010

ABOUT

ebook editor: Le Dinh Sang

Hanoi Medical University

Website: www.ykhoaviet.tk

Email: Lesangmd@gmail.com, bachkhoayhoc@gmail.com

Tel: 0973.910.357

NOTICE OF MEDICAL ENCYCLOPEDIA PUBLICATION 2010:

As the request and desire of many readers, in addition to updating the new articles and new

specialties, as well as changes in presentation, Medical Encyclopedia 2010 is divided into many

small ebooks, each ebook includes a subject of medicine, as this may help readers save time

looking up informations as needed. The author would like to thank all the critical comments of

you all in the recent past. All the books of the Medical Encyclopedia 2010 can be found and

downloaded from the site www.ykhoaviet.tk ,by Le Dinh Sang construction and development.

DONATE

The author would like to thank all the financially support to help the Medical Encyclopedia are

developing better and more-and-more useful.

All broken hearted support for building a website for the dissemination of learning materials

and teaching Medicine of individuals and enterprises should be sent to:

Bank name: BANK FOR INVESTMENT AND DEVELOPMENT OF VIETNAM

Bank Account Name: Le Dinh Sang

Account Number: 5111-00000-84877

DISCLAMER :

The information provided on My ebooks is intended for your general knowledge only. It is not a

substitute for professional medical advice or treatment for specific medical conditions. You

should not use this information to diagnose or treat a health problem or disease without

consulting with a qualified health professional. Please contact your health care provider with

any questions or concerns you may have regarding your condition.

Medical Encyclopedia 2010 an any support from L nh Sng are provi e 'AS IS' an without

warranty, express or implied. L Sng specifically disclaims any implied warranties of

merchantability and fitness for a particular purpose. In no event will be liable for any damages,

including but not limited to any lost or any damages, whether resulting from impaired or lost

money, health or honnour or any other cause, or for any other claim by the reader. Use it at

Your risks !

FOR NON-COMMERCIAL USER ONLY .

YOU ARE RESTRICTED TO adapt, reproduce, modify, translate, publish, create derivative works

from, distribute, and display such materials throughout the world in any media now known or

hereafter evelope with or without acknowle gment to you in Authors ebooks.

FOREWORD

These ebooks are Le Dinh Sangs collection, compilation an synthesis with the aim of provi ing

a useful source of reference-material to medical students, and all who wish to learn, research,

investigate to medical information.

Just a set of open-knowledge, based on community resources, non-profit purposes, not

associated with commercial purposes under any kind, so before you use this books you must

agree to the following conditions. If you disagree, you should not continue to use the book:

This book is to provide to you, completely based on your volunteer spirit. Without any

negotiation, bribery, invite or link between you and the author of this book.

The main purpose of these books are support for studying for medical students, in addition to

others if you are working in health sector can also use the book as a reference.

All information in the book are only relative accuracy, the information is not verified by any law

agency, publisher or any other agency concerned. So always be careful before you accept a

certain information be provided in these books.

All information in this book are collected, selected, translated and arranged in a certain order.

Each artical whether short or long, or whether or unfinished work are also the author of that

article. L nh Sng was only a collectors in other wor s, a person to help convey the

information that the authors have provided, to your hand. Remember the author of the

articles, if as in this book is clearly the release of this information you must specify the author of

articles or units that publish articles.

This book is the material collected and translated by a medical student rather than a professor

Doctor experienced, so there may be many errors and defects unpredictable, subjective or

not offices, documents can be arranged not reasonable, so besides carefull before reading

information, you should also read carefully the contents of the material and the policy, manual

for use of this book .

The author of this e-book does not bear any responsibility regarding the use of improper

purposes, get bad results in health, wealth, prestige ... of you and your patients.

7. Not a professional, not a health worker, you are not allowed to use the information

contained in this book for diagnosis and treatment. Ever, the physician treating patients rather

than treatment. Each person is an independent entity and completely different, so applying all

information in this book into practice will be a big mistake. The author will not bear any

responsibility to this negligence caused.

8. As is the community material, these books could be developed or not are not only based on

their strength and perseverance of the author of this book , the contribution, suggestions,

additional adjustment of the reader is great motivation for this book keep developed. Because

a goal of becoming a medical reference books in accordance with general requirements and the

practical situation in the health sector in particular and life.

9. The contents of this book, may only correct in a certain time in the past and the present or in

the near future. In this era of scientific and technological revolution as sweeping as fast now, no

one knew before is whether the knowledge that you have obtained can be applied in future or

not. To answer this question, only yourself, have to always update-YOURSELF-for latest

information in all areas of life, including the medical field. No one can, of course this book can

not, do it for you.

10. Strictly forbidden to use this book in any bad purpose, not be allowed to commercialize this

product under any mean and any time by any media . The author of this book is not the

inventor of the book-articles, but has made a lot of effort, time, and money to create it, for

the advanced of the community. You must take full responsibility for any misuse purposes and

does not comply with the contents of this book yet.

11. All theories are just gray, a thousand books or a book are only theory, the only facts of life

are the most perfect book, in which you are not an audience but are the main actor. This Book

just a small grain, using it to cook or fry breeding is completely depend on you. And the person

who created this grain will begin more excited and motivated to keep trying if you know that

thanks that so many people no longer have to queue to wait for relief.

12. All comments related to the books should be sent to the me at the address above. We hope

to receive feedbacks from you to make the later version better.

13. We wish you, your family and Vietnamese people has always been healthy, happy and have

a prosperous life.

MC LC -------*---------*-------*---------

CHNG I : I CNG

BNH N V BNH LCH

KHM BNH V CHN ON

CHNG II. TRIU CHNG HC TIM MCH

TRIU CHNG C NNG TRONG BNH TIM

TRIU CHNG C NNG TRONG BNH MCH MU

THM KHM TIM LM SNG

THM KHM TIM CN LM SNG

THM D CHC NNG TIM

PHNG PHP KHM MCH MU

C BN V IN TM

KHM MT NGI BNH TIM MCH

BNH VAN TIM

HI CHNG SUY TIM

RI LON HUYT P NG MCH

CHP NG MCH VNH

LON NHP TIM

NGHIM PHP GNG SC

NHI MU C TIM CP

CHNG 3. TRIU CHNG HC H HP

TRIU CHNG C NNG H HP

CCH KHM LM SNG H H HP

CC TING BNH L KHI NGHE PHI

THM D CLS V H HP

THM D CHC NNG H HP

HI CHNG TRN DCH MNG PHI

TRN DCH TRN KH MNG PHI PHI HP

HI CHNG NG C

HI CHNG HANG

HI CHNG TRUNG THT

HI CHNG PH QUN

CHNG 4. TRIU CHNG HC TIU HA

KHM LM SNG TIU HO

TRIU CHNG C NNG TIU HO

KHM CN LM SNG NG TIU HO

CC PHNG PHP CN LM SNG GAN MT

AU BNG CP TNH V MN TNH

A CHY CP MN TNH

TO BN V KIT L

CHY MU NG TIU HO

CHN ON HONG N

CHN ON GAN TO

CHN ON TI MT TO

CHN ON C TRNG

BNH HU MN TRC TRNG

TRO NGC D DY THC QUN

HI CHNG LCH TO

HI CHNG RI LON TIU HO

HI CHNG AU BNG

TRIU CHNG HC D DY

TRIU CHNG HC GAN MT

TRIU CHNG HC RUT NON

TRIU CHNG HC TY TNG

TRIU CHNG HC THC QUN

TRIU CHNG HC I TRNG

XUT HUYT TIU HA

CHNG 5. TRIU CHNG HC THN TIT NIU

TRIU CHNG C NNG THN TIT NIU

KHM LM SNG THN TIT NIU

CN LM SNG H THN TIT NIU

CHN ON THN TO

I RA PROTEIN

HI CHNG TNG NIT MU

I NHIU, I T, V NIU

RI LON TIU TIN

I RA MU

I RA M

I RA HUYT CU T

KHM V CHN ON PH

CHNG 6. TRIU CHNG HC V MU

GII PHU - SINH L TO MU

KHM LM SNG HUYT HC

CC XT NGHIM MU

XT NGHIM TU

C CH NG - CM MU

XT NGHIM NG MU, CM MU

XT NGHIM MIN DCH HUYT HC

CHN ON THIU MU

HI CHNG CHY MU

CHN ON HCH TO

CHN ON LCH TO

HI CHNG XUT HUYT

HI CHNG HEMOGLOBIN

HI CHNG THIU MU

XT NGHIM T BO HCH

CHNG 7 : TRIU CHNG HC C XNG KHP

THM KHM B MY VN NG

TRIU CHNG C NNG BNH KHP

TRIU CHNG THC TH BNH XNG KHP

TRIU CHNG HC BNH KHP

HI CHNG AU THT LNG

CHNG 8. TRIU CHNG HC NI TIT

CCH KHM MT NGI BNH NI TIT

TRIU CHNG HC TUYN GIP

TRIU CHNG HC TUYN CN GIP

TRIU CHNG HC TUYN THNG THN

RI LON GLUCOZA MU

TRIU CHNG HC TUYN YN

CHNG 9 : TRIU CHNG HC THN KINH

KHM VN NG

KHM H VN NG, TIN NH, TIU NO

KHM PHN X

KHM CM GIC

KHM DINH DNG V C TRN

KHM 12 DY THN KINH S NO

THM KHM CHUYN KHOA

HI CHNG LIT NA NGI

HI CHNG RI LON CM GIC

HI CHNG RI LON THN KINH T CH

HI CHNG RI LON VN NG

HI CHNG TIN NH TIU NO

HI CHNG TNG P LC NI S

HI CHNG AU U

KHM HI CHNG MNG NO

KHM THT LNG HNG

KHM V CHN ON HN M

HI CHNG GUILLAIN BARRE

HI CHNG NG C TAY

X QUANG S NO

IN NO

CHN ON NH KHU H THN KINH

XT NGHIM DCH NO TY

GHI IN C V IN THN KINH

CHNG 10. RI LON CHUYN HA

RI LON CHUYN HA NATRI

RI LON CHUYN HA CANXI

RI LON CHUYN HA KALI

RI LON CHUYN HA MAGIE

HI CHNG PORPHYRIN NIU

HI CHNG PROTEIN NIU

RI LON CHUYN HA PHOSPHO

RI LON CHUYN HO GLUXIT

RI LON CHUYN HO LIPIT

RI LON CHUYN HO NC, IN GII

RI LON CHUYN HO PROTEIN

RI LON CN BNG AXIT-BAZ

---------***-----------

CHNG I : I CNG

1. BNH N V BNH LCH

KHI NIM BNH N V BNH LCH:

Bnh n v bnh lch l hai phn trong h s bnh ca ngi gm:

- Bnh n l vn bn do thy thuc lm ngay khi ngi bnh vo bnh vin, ghi chp li tt c

cc vn c lin quan n ngi bnh t tn tui, a ch, ngh nghip n tnh trng pht

sinh, tin trin cng nh tnh hnh t tng hon cnh sinh sng vt cht ca h. V cng trong

bnh n ny ca ngi thy thuc s ghi li cc biu hin bnh thng v khng bnh thng

m thy thuc pht hin thy trong khi khm ln u tin cho ngi bnh ca mnh.

- Bnh lch l vn bn k tip bnh n trong sut qu trnh iu tr ti bnh vin, ghi chp li cc

din bin ca ngi bnh kt qu cc xt nghim v cc phng php iu tr c p dng.

Bnh n v bnh lch u l nhng ti liu cn thit chn on bnh c ng, theo i

bnh c tt v o p ng c kp thi cc phng thc iu tr ng n, ngn chn

c cc bin chng chng tr ngi bnh v sn xut. V cng nh cc ti liu m sau khi

ngi bnh khi v ra vin, thy thuc c th tip tc theo i ngi bnh ngoi tr, ch dn

cho h cc phng php phng bnh c th khi hn khng ti pht, khng c bin

chng hoc di chng hay ly truyn sang ngi khc, cng phi nh vo cc ti liu m

trong cc trng hp ngi bnh t trn v c gii phu kim tra thi th, ngi thy thuc mi

rt c kinh nghim chn on, iu tr v phc v ca mnh ci tin cng tc phc v mi

ngy mt tt hn cho cc ngi bnh khc sau ny.

Ngoi tc dng v chuyn mn ni trn, c ch li phc v trc tip cho ngi bnh, bnh n v

bnh lch c gip ch cho cng tc nghin cu khoa hc: cc s liu Vit Nam, cc hnh thi lm

sng c bit ca bnh l Vit Nam, gi tr chn on cc phng php thm mi cng nh

tc dng ca cc phng php tr liu mi ch c th lm c da trn tng kt cc bnh n,

bnh lch.

Khng nhng th, bnh n v bnh lch cn l nhng ti liu hnh chnh v php l na. V

phng in hnh chnh cc ti liu s gip ta nm c s liu ngi bnh ra vo vin, s

ngy nm vin ca ngi bnh, tnh hnh khi bnh, khng khi hoc t vong nhiu hay t

t d tr v thuc men, lng thc v nhn vin cho ng, cng nh t cc ch tiu phn

u nng cao cht lng iu tr cho st. V phng in php l bnh n v bnh lch l nhng

ti liu rt cn thit cho vic kim tho t vong, nht l khi c vn khc mc trong ci cht

ca ngi bnh.

Vi cc tnh cht quan trng ni trn, m bo y cc yu cu bnh n v bnh lch

cn phi:

1. Lm kp thi:

- Bnh n phi c lm ngay khi ngi bnh vo vin.

- Bnh lch cn phi c ghi chp hng ngy nhng din bin ca bnh.

2. Chnh xc v trung thc:

C ngha l cc triu chng, cc s liu a ra cn phi ng vi s thc v tht c th.

3. y v chi tit:

y tc l cc mc trong bnh n cn phi s dng v mi mc u c tc dng ring ca n.

y v phng in ghi chp cc triu chng cn c ngha l khng nhng ghi ch p cc triu

chng c m c cc triu chng khng v s khng c ca mt vi triu chng no rt

cn thit cho s chn on xc nh ( +) v nht l chn on phn bit ( ) cng nh

nh gi tin lng (p) ca bnh.

Chi tit c ngha l mi triu chng cn c nu t m vi cc yu t v thi gian, tnh cht v

tin trin ca n.

i vi bnh lch y cn c ngha l:

- Ghi ch p c nhng nhn x t thu c khi lm cc th thut cho ngi bnh (chc d mng

phi, chc d c trng, chc nc no tu, sinh thit hch, gan, o huyt p tnh mch).

- Tng thi kz cho lm li cc xt nghim, nht l nhng xt nghim m cc ln lm trc c kt

qu khng bnh thng.

4. c lu tr li:

sau ny nu bnh ti pht hoc v mt bnh nhn no khc ngi bnh phi vo nhp vin

li, chng ta c y nhng ti liu ca nhng ln bnh trc, nhiu khi gip ch rt nhiu cho

vic chn on v iu tr ln ny. Ngoi ra, vic lu tr h s bnh c lm c tt th v

phng in nghin cu khoa hc, vic tng kt h s mi c y v trung thc.

Cng tc bnh n, bnh lch c lm tt hay khng ch yu o trnh chuyn mn nhng cng

cn do tinh thn trch nhim ca ngi thy thuc i vi bnh nhn, c tht quan tm n

tnh trng bnh ca bnh nhn nh i vi gia nh rut tht ca mnh hay khng. C quan

im phc v ngi bnh tt, nm c yu cu bnh n bnh lch, kt hp vi trnh nht

nh v chuyn mn, cng tc h s bnh ca chng ta chc chn s lm c tt.

NI DUNG BNH N, BNH LCH

Bnh n v bnh lch l nhng ti liu ghi chp li cc triu chng ca ngi bnh. Cc triu

chng c th cha lm hai loi:

1. Triu chng ch quan:

L nhng biu hin do bn thn ngi bnh, do ch quan ngi bnh nhn thy. Cc triu

chng ch quan ny ch o ngi bnh pht hin, v thy thuc rt kh nh gi mc nhiu

t ca n mt cch tht chnh xc v hon ton da vo li khai ca ngi bnh, hoc mt vi

biu hin c bit do triu chng ch quan gy ra: au bng phi ln ln qun qui; au

ngc nhiu phi p ngc vo i; nhc u nhiu n ni phi ly tay bng u. Thuc loi ny

l cc triu chng nh: au bng, nut kh, tc ngc, nhc u, au c, nhc khp, i but,

m mt.

2. Triu chng khch quan:

L nhng biu hin do thy thuc pht hin ra khi khm bnh. Trong cc triu chng khch

quan ny, c cc triu chng:

- Ch quan ngi bnh cng c th nhn thy v pht hin c nh: st, sng khp, cng

hm, vng da, u hch bng to Tuy vy, ngi ta khng xc nh vo loi triu chng ch

quan m vn gi l triu chng khch quan, v thy thuc c th kim tra c c th v nhn

nh c chnh xc mt cch khch quan.

- Ch quan ngi bnh hon ton khng bit ch c thy thuc khm bnh mi pht hin c

nh c xt nghim mi bit: cc thay i khng bnh thng phi, tim, khi nhn, s, g,

nghe tim phi, cc biu hin khng bnh thng bng (bng cng, bng c nhu ng, gan,

lch, hoc thn to) cc thay i khng bnh thng v cm gic, v phn x khi khm thn

kinh, hoc bch cu tng trong cng thc mu, c nhiu protein nc tiu.

Ngoi cch chia cc triu chng ra lm triu chng ch quan v triu chng khch quan ngi

ta cn chia ra lm triu chng chc nng, thc th v ton th:

a) Triu chng chc nng: L nhng biu hin gy ra bi nhng ri lon v chc nng ca cc

ph tng: ho, kh th, khc mu, au ngc, au ngc, a lng, a to, nn, i t, v niu

b) Triu chng ton th: L nhng biu hin ton thn gy ra bi tnh trng bnh l: gy mn,

st cn, st.

c) Triu chng thc th: L nhng triu chng pht hin c khi khm lm sng: cc thay i

bnh l phi, tim, cc thay i khng bnh thng bng.

Ngi ta cng chia ra lm triu chng lm sng v cn lm sng:

+ Triu chng lm sng: l nhng triu chng thu thp c ngay ging bnh bng cch hi

bnh nhn v khm bnh (bao gm ch yu nhn, s, g, nghe..).

+ Triu chng cn lm sng: l cc ti liu thu thp uc bng cc phng php:

- X-quang

- Xt nghim.

- Thm bng dng c hoc my mc khc: thng tim, in tm , o chuyn ho c bn, o

chc nng phi, soi d dy, soi bng, soi bng quang

C mt s trng hp bnh l{ khi in hnh bnh thng biu hin bng mt s triu chng

nht nh, nhng triu chng nht nh tp hp li gi l hi chng: hi chng trn dch

mng phi, hi chng ng c (nhu m phi), hi chng van tim, hi chng suy tim, hi chng

tc rut, hi chng tc mt, hi chng nhim khun, hi chng kit nc..

Ni dung ch yu ca cc bnh n l vic ghi chp li cc triu chng ni trn cng vi cc din

bin ca n t khi ngi bnh bt u mc bnh cho n khi ngi bnh n bnh vin c

th c mt chn on s b v lm sng ngay khi ngi bnh vo vin v t c mt

hng iu tr thch ng.

I- NI DUNG BNH N

Gm hai mc ln: hi bnh v khm bnh.

A- HI BNH

C 4 phn:

1) Phn hnh chnh:

Ngoi tc dng hnh chnh n thun, phn ny cng cn c tc ng chuyn mn.

- H v Tn: cn c ghi r rng v y c tn ln h v ch m trnh nhm ln ngi

bnh.

- Gii (Nam, n), tui, ngh nghip, a ch: cng cn ghi r v ty theo mi gii, mi loi tui

hoc tuz theo mi ngh, mi a phng c tr m c nhng bnh thng gp. Ngh nghip v

a ch nn hi c trc y v hin nay v c nhng bnh do ngh nghip c sinh ra nhng mi

n nay mi th hin hoc c nhng bnh mc phi trong thi gian ti vng no trc y

nhng n nay mi th hin r rt hoc mi c bin chng. Ring ngh nghip cn ghi c th

khng nn ghi chung chung nh: cng nhn, cn b m cn ghi c th cng nhn m sng

than hoc cn b hnh chnh hay cn b k thut ho cht.

- Ngy gi vo vin, thi gian iu tr:

2) Phn l do vo vin:

L u mi ca phn bnh s cn hi ngay sau khi lm xong phn hnh chnh. Mi ngi bnh

vo vin c th l v mt hoc nhiu l do cho nn cn ghi c v nu c th c th phn

bit l do chnh v l do ph.

T cc l{ o chng ta bc vo hi bnh s.

3) Phn bnh s:

Cn hi theo mt th t nh i y:

- Hi cc chi tit ca l do vo vin: bt u t bao gi, tnh cht, tin trin ra sao. Nu c nhiu

l do vo vin, cn hi r s lin quan gia cc l{ o : ci no c trc, ci no c sau v

trc sau bao nhiu lu.

- Hi cc triu chng km theo cc triu chng ni trn, thng l cc triu chng thuc b

phn b m.

- Hi tnh hnh cc b phn khc v cc ri lon c th: rt cn thit cho ta nm c cc ri

lon do bnh chnh gy ra cc ph tng khc v c gip cho ta khi b st mt bnh khc c

th song song tn ti vi bnh chnh (v mt ngi c th c 2, 3 bnh).

- Hi cc phng php iu tr m ngi bnh c p dng cho ngy vo vin v tc dng

ca cc phng php .

- Kt thc bng tnh trng hin ti: lc thy thuc ang khm bnh, cc ri lon ni trn cn

nhng g.

4) Phn tin s:

- Tin s bn thn: bn thn ngi bnh trc y b nhng bnh g nm no v iu tr ra

sao?.

Nu ngi bnh l ph n khng nn qun hi tnh trng kinh nguyt), thai ngh n sinh ra

sao?.

- Tin s gia nh: tnh trng sc kho, bnh tt ca b m, v (chng), con ci, anh em, nht l

nhng ngi bnh c lin quan n bnh hin nay ca bn thn ngi bnh). Nu c ai cht

cn hi thm cht t bao gi, v bnh g.

- Tin s thn cn: tnh hinh bnh tt ca bn b thng hay tip xc vi ngi bnh, hay ni

cch khc vi mi trng tip xc ca ngi bnh.

Trong cc mc tin s ni trn, cn ch hi k v cc bnh c lin quan n bnh hin nay ca

ngi bnh.

- Kt thc bng cch sinh hot vt cht, iu kin cng tc v tnh trng tinh thn: cn thit v

c nhng bnh pht sinh ra do hon cnh vt cht thiu thn, iu kin cng tc vt v hoc

tnh trng tinh thn b cng thng. Cn hi thm mt s tp qun ca ngi bnh nh: nghin

ru, nghin c ph.

Mc hi bnh lm c chu o v t m s gip cho ta rt nhiu trong hng khm bnh v

chn on, thm ch c nhng trng hp "hi bnh ng mt vai tr ch yu trong chn

on lm sng (v trong lot d dy). Chng ta c th ni rng tin hnh c tt vic hi

bnh l i c na on trn con ng chn on bnh.

B- KHM BNH

Mc ny ch yu ghi chp li cc triu chng thc th pht hin c bng cc phng

php lm sng ngha l bng s, nhn, g, nghe. Chng ti s c mt bi ring ni v cng tc

khm bnh.

Vic hi bnh" chu o t m kt hp vi vic khm lm sng k lng trong phn ln trng

hp c th gip cho thy thuc tp hp c thnh hi chng v t c c mt chn on

s b v lm sng. T chn on s b , mi ra mi ra cc phng php cn lm sng

:

- Xc nh chn on (thng vit l +).

- Loi tr mt s bnh khc cng c mt bnh cnh lm sng tng t. Thng gi l chn

on phn bit ( ).

- Xc nh nguyn nhn.

- nh gi tng lai ca bnh, gi l tin lng (p).

II- NI DUNG BNH LCH

Bnh lch tip tc nhim v ca bnh n: ni dung ch yu ca n bao gm 3 mc ln:

A- GHI CHP MNH LNH IU TR

Mnh lnh iu tr bao gm cc mt: thuc men, h l{, n ung. Cn phi ghi:

1. R rng v chnh xc:

- Khng c vit tt hoc vit k hiu ho hc.

- Trong lng ca n v v s n v: v d: aspirin 0,05g x 3 vin; emetin clohydrat 0,04g x 2

ng.

- ng dng thuc: ung; tim bp, i a hay tnh mch

- Cch dng: chia lm bao nhiu ln ung, ung lc no hoc tim lc no.

2. Ghi hng ngy:

Mc d mnh lnh iu tr khng thay i, hng ngy vn ghi li ton b ch khng c vit

nh trn.

B- THEO DI DIN BIN CA BNH TRONG QU TRNH IU TR

Cn phi ghi li hng ngy:

- Din bin cc triu chng c.

- Cc triu chng mi xut hin thm.

- Kt qu cc th thut thm lm ti ging bnh, v d: chc mng phi tri lc 9 gi

ngy 23/3 ly ra c 50ml nc vng chanh.

- Nhit v mch trn biu . Trn bng biu ny, thng c thm cc mc huyt p,

nc tiu, nhp th

C- THEO DI KT QU CC XT NGHIM CN LM SNG

Cc xt nghim ny cn phi:

- Lm li tng thi kz. Nht l cc kt qu khng bnh thng ca nhng ln lm trc.

- Cc xt nghim cng mt loi cn c xp cng vi nhau theo th t thi gian tin theo

di din bin ca bnh v phng in cn lm sng, tt hn ht nn sao li cc kt qu cc xt

nghim trn mt t giy c k nhng ct ginh ring cho mi loi xt nghim.

Nu c nhng trng hp d ng m ngay khi ngi bnh vo vin, chn on lm sng s b

c th ng hng v mi mt ( +, nguyn nhn cng nh p), th cng c rt nhiu trng

hp m chn on v tin lng ch c th lm c sau mt thi gian vo vin, da trn:

- S din bin ca bnh, nht l s xut hin thm cc triu chng lc u cha c hoc khng

r.

- Kt qu xt nghim cn lm sng.

- Kt qu iu tr.

Ni nh th lm cho ta cng thy r tm quan trng ca bnh lch.

Khi ngi bnh khi v ra vin hoc cht, chng ta phi tng kt bnh n bnh lch.

III- TNG KT H S BNH

Trong phn ny, cn ghi li:

- Cc nt chnh v triu chng lm sng v cn lm sng.

- Cc phng php iu tr ch yu.

- Cc din bin ch yu ca bnh trong qu trnh theo di theo di ti bnh vin.

Kt qu iu tr: tnh trng ngi bnh khi ra vin (hoc cht) v lm sng v cn lm sng. Nu c m t thi, phi ghi c chn on i th v vi th.

Vic tng kt h s bnh lm c tt s a n mt chn on chnh thc (chn on khi ra vin) tht chnh xc v y c th ch dn cho ngi bnh cc phng php iu tr v theo di ti nh, phng bnh ti pht, c bin chng hoc ly truyn sang ngi khc.

H s tng kt xong cn phi c lu tr ti mt phng h s.

IV- LU TR H S

Lu tr h s l mt cn gtc quan trng, m bo tt s gip rt nhiu cho vic chn on

trong nhng ln vo vin sau ny ca ngi bnh cng nh cho cng tc nghin cu khoa hc.

Khng nn quan nim y l mt cng tc hnh chnh m y thc s l mt cng tc chuyn

mn, cho nn khi phn cng cn b ph trch phng h s, cn chn ngi c trnh hiu

bit kh v chuyn mn, tng ng vi mt cn b y t trung cp, tt hn ht l y s, nu

hon cnh cn b cho php.

Trong cng tc lu tr h s ngoi yu cu m bo lu tr c y v vn ton h s,

khng h hng v mt mt (t bnh n, bnh lch n cc kt qu ca phng xt nghim,

bin bn phu thut hoc m t thi ), phi coi h s nh l mt ti sn khc (thuc men, dng

c), cn ra hai yu cu chnh:

1. m bo vic su tm h s c nhanh chng khi cn n, khng phi tm ti qu

nhiu s sch.

2. Sp xp c theo tng loi bnh vic lm thng k bnh tt c d dng.

2. KHM BNH V CHN O\N

Khm bnh l mt khu quan trng, c l l khu ch yu trong cng tc ca bc s iu tr v n quyt nh kh nhiu cho s thnh cng hay tht bi ca cng tc iu tr: cng tc khm bnh c lm c tt mi pht hin c ng v y cc triu chng c th lm c mt chn on tht chnh xc v y , ri t mi nh c tin lng, cch iu tr v phng bnh cho ng n.

y l mt cng tc:

- Khoa hc: ngoi kin thc y hc m tt c cc thy thuc bt buc phi c y , cn phi c mt quan nim bin chng con ngi l mt khi thng nht trong mi b phn u c lin quan hu c vi nhau, v th khng ch khm n c b phn c bnh m lun lun phi khm ton b c th.

- K thut: phi theo ng quy tc khm v k thut khm mi pht hin c ng triu chng (v d: khi nghe cc ting khng bnh thng tim, phi, khi s l lch hoc gan mp m b sn, hoc khi g phn x gn)

Khng nhng thy, y cn l mt cng tc:

- Chnh tr: cch khm bnh k lng t m ca thy thuc ngoi vic gip thy thuc pht hin ng bnh cn cng c lng tin cy ca ngi bnh n nh t tng bi quan lo s ca h, gip

h tin tng vo vic iu tr vo s khi bnh sau ny: yu t rt cn thit cho vic iu tr bnh c tt.

Ngy nay mc d s tin b v pht trin ca cc phng php cn lm sng, vai tr ca khm bnh lm sng vn quan trng v n cho hng chn on t cc ch nh lm cc xt nghim cn lm sng cn thit, trnh tnh trng lm trn lan hoc ngc li khng lm nhng xt nghim cn thit. Vy cng tc khm bnh nn tin hnh nh th no?

CCH TIN HNH KHM BNH

A- NI KHM

Cn phi:

- Sch s, thong kh nhng trnh gi la.

- m p, nht l v ma rt.

- C nh sng.

- Kn o, nht l nhng ni dng khm bnh ph n.

B- PHNG TIN

Ngoi cc bn gh cn thit cho thy thuc v ging thm bnh ngi bnh nm khm, ni khm cn c trang b mt s phng tin ti thiu l:

- ng nghe bnh.

- My o huyt p.

- Dng c li: khm hng ngi bnh.

- Ba phn x v kim: khm v thn kinh.

- Gng tay hoc bao ngn tay (doigtier) cao su: khm trc trng hoc m o khi cn thit.

Nu c thm mt n pin kim tra phn x ng t khi cn thit th cng tt.

C- THY THUC

- Cn lu n cch n mc: o qun bn thu, c o cu en, mng tay di bn, u tc ri b s lm gim s tin tng ca ngi bnh i vi thy thuc rt nhiu.

- Thi cn phi thn mt, nim n ngi bnh d tip xc, d th l nhng vn kn o ca mnh. Cn trnh nhng thi lm ngi bnh hiu lm l thy thuc ban n cho h.

- Khi hi bnh nhn cn dng nhng ting d hiu, trnh dng nhng danh t y hc m ngi bnh kh bit (hong m, huyt niu) v nht l cn nhn ni khai thc cc triu chng ch quan ca ngi bnh: nu cn th khng ngn ngi hi i hi li hoc thay i cch hi nm bt ht ca ngi bnh.

- Khi khm bnh cn phi c tc phong nh nhng, t m, trnh th bo, trnh day tr ngi bnh nhiu m khng cn thit nht l i vi cc ngi bnh nng. Ngi thy thuc, nht l thy thuc nam gii, cn ch n bn cht e thn ca ngi ph n trnh nhng cch hi v nht l cch khm bnh qu s sng l liu, lm tn thng n s t trong ca ngi bnh ph n, nh vy h khng ni ra nhng iu cn thit cho chn on v iu tr.

- Khi nhn nh cc triu chng cn khch quan v thn trng: khng nn c thnh kin trc, nht l i vi ngi bnh c, thy thuc thng d c t tng l bnh c ti pht. Cn phi nh gi ng mc cc triu chng, nht l cc triu chng ch quan ca ngi bnh: vic nhn nh, phn tch, nh gi cc triu chng phi da trn mt c s khoa hc.

- Phi thn trong khi ni vi ngi bnh v tnh trng bnh ca h; ni chung, phi suy ngh trc khi ni khng ni nhng vn g c th lm cho h lo s, hoang mang hoc bi quan vi bnh ca mnh; phi gii thch nng tinh thn, n nh t tng cho h yn tm iu tr tin s khi bnh.

i vi gia nh ngi bnh, chng ta c th ni tht trong mt phm vi nht nh, ngha l tu theo vn , tu theo quan h ca ngi i vi ngi bnh.

D- NGI BNH

- Cn c khm mt t th thoi mi. Nu tnh trng sc kho cho php, nn khm ngi bnh c cch i.

- Phi bc l cc vng cn phi khm. Tt hn ht, ngi bnh nam gii ch mc mt qun lt khi khm bnh nu ni khm bnh m bo c m p y . Ngi bnh ph n nn bc l tng phn: ngc, bng, ri cc chi V ma rt, cn ch nhc ngi bnh tho b khn qung c v khn c th che giu mt s vn rt quan trng c: bu gip, cc tnh mch c ni, cc so hch c

NI DUNG KHM BNH

Sau khi hi k phn bnh s (xem bi trn), vic khm bnh thng tin hnh lm ba phn:

- Khm ton thn.

- Khm tng b phn.

- Kim tra cht thi tit.

A- KHM TON THN

Cn nhn xt:

1. Dng i,ng ca ngi bnh:

Ngay pht u tin tip xc vi ngi bnh, chng ta c th ch ngay n mt v vi cch nm, cch i, cch ng ca ngi bnh gi ngay cho chng ta mt hng bnh hoc hi chng no :

- Cch nm c sng, quay mt vo pha ti nhng ngi bnh c bnh mng no.

- Cch nm cao u hoc na nm na ngi (t th Fowler) ca nhng ngi bnh kh th.

- Cch i cng , ton thn nh mt khc g ca ngi bnh Parkison.

- Cch di pht c mt tay co qup ln ngc ca ngi bnh lit na thn, th co cng.

- Cch va i va m h sn phi ca nhng ngi bnh p xe gan.

2. Tinh thn ca ngi bnh:

Cn ch xem ngi bnh trong tnh trng:

a. Tnh to: Ngi bnh c th t khai c bnh, nhn nh v tr li c r rng cc cu hi ca thy thuc.

b. M sng: ngi bnh nhn khng nhn nh c v khng tr li c ng n cc cu hi, khng nhng th ngi bnh cn trong tnh trng ht hong, ni lm nhm, thm ch c khi chy hoc p ph lung tung. l tnh trng tm thn ca cc ngi bnh:

- Sp bc vo hn m gan.

- St nng bt c v nguyn do g, nhng thng thng nht nc ta l st rt cn c lit.

- Bnh tm thn.

c. Hn m: ngi bnh cng khng nhn nh c v cng khng tr li c cu hi ca ta. Nhng y ngi bnh khng ht hong, khng ni lm nhm nhng tri li mt lin h nhiu hay t vi ngoi cnh, thm ch trong trng hp hn m su:

- Ngi bnh khng bit au khi cu vo.

- Khng nut c khi ta nc vo mm.

- Mt phn x gic mc.

Hn m l mt bin c rt nng, hu qu ca nhiu bnh nhim khun nhim c v ca rt nhiu b phn, cn khm v hi k mi pht hin nguyn do.

3. Hnh dng ni chung:

Cn nhn nh ngi bnh:

a. Gy hay bo, gy ngha l:

- Mt hc hc, m hp li, xng mt li, nht l xng g m.

- Xng sn, xng b vai ni r.

- Bng lp, da bng rn reo.

- S cn nng di s cn trung bnh 20% ( s cn trung bnh bng s phn mt ca b cao tr 100; v d: mt ngi cao 1m62 th s cn trung bnh l 62 kg).

Gy thng gp trong cc trng hp

- Thiu inh ng do:

+ n ung thiu v cht hoc v lng.

+ n ung nhng b phn tiu ho khng s dng v hp th c, hp thc qun, hp mn v, bnh rut mn tnh, vim tu mn tnh).

+ n ung tng i nhng khng p ng c nhu cu ca c th tng ln do lao ng qu sc hoc do bnh tt.

Bnh mn tnh: lao, x gan, ung th

Mt s bnh ni tit: i tho ng, Basedow.

Bo ph ngha l:

- Mt phnh, m phnh, cm x.

- C thng b rt khng nhn thy.

- Chn tay to trn v c ngn.

- Da bng c nhng lp m dy lm bng to v x xung.

- S cn cao hn s cn trung bnh trn 15%.

- Bo bnh thng l do:

+ Nguyn nhn inh ng: thng thng nht, nht l khi n nhiu v hot ng t.

+ Nguyn nhn ni tit:

- Ph n n tui ht kinh

- Nam gii sau khi b mt tinh hon

- Bnh Cushing do tuyn yn hay do cng tuyn thng thn.

+ Nguyn nhn tm thn: mt i khi xy ra do chn thng mnh v tm thn.

b. Cao hay thp. Cn ch n hai trng hp bnh l:

- Ngi va cao qu kh va to n thun hoc kt hp thm vi hin tng to u v chi: y l bnh khng l (gigantisme), mt bnh ca tuyn yn.

- Ngi va thp va qu nh:cng l mt trng hp bnh l tuyn yn, bnh nhi tnh (infantilisme).

c. S cn i gia cc b phn: thng c mt s cn i nht nh gia cc b phn ca thn, u v chi. Trong mt s trng hp bnh l, ta thy mt s cn i :

- Bnh to u (hydrocphalie): u rt to khng tng xng vi ton b c th.

- Bnh to cc (acromgalie): u v nht l hai bn tay v hai bn chn u to qu kh, khng tng xng vi phn chi v c th cn li.

- Teo mt on chi, c mt chi hay c hai chi i xng: thng gp trong cc bnh thn kinh nh x ct bn teo c (sclrose latrale). Bnh ng so tu (syringommyllie) v thng thng nht l di chng ca bnh bi lit tr em (P.A.A). Nhng c khi l bnh ca c:

- Hai bn lng ngc khng cn i do mt bn b trn dch hay trn kh mng phi lm cng ra hoc ngc li do vim mng phi dy v dnh co ko lm xp xung.

4. Mu sc da v nim mc:

Mt s tnh trng bnh l th hin trn mu sc ca da v nim mc nh:

a. Da v nim mc xanh tm: th hin tnh trng thiu oxy thng thy trong:

- Mt s bnh tim bm sinh, bnh tim phi mn tnh v cc trng hp suy tim nng.

- Cc bnh phi gy kh th cp: vim ph qun phi tr em, trn kh mng phi nng, cn hen.

- Cc bnh thanh kh qun gy ngt th: lit thanh hu do bch hu.

Trong cc bnh trn, trng hp xanh tm ch xut hin mi, mt ngi bnh, nng lm mi xanh tm n cc ni khc, thm ch c khi ton thn.

Tri li trong mt s bnh khc, xanh tm ch khu tr mt vng, v d trong:

- Vim tc ng mch: xanh tm cc ngn chn, ngn tay, c khi c bn chn, bn tay hoc c mt on chi do ng mch chi phi.

- Ri lon vn mch mao qun: xanh tm tt c cc u chi nht l cc u ngn tay.

b. Da v nim mc xanh xao nht nht. Tnh trng xanh xao c khi th hin r rt trn sc mt ca ngi bnh, nhng c khi kn o phi tm nim mc mt, nim mc mm, li hoc lng bn tay bn chn. l th hin lm sng ca bnh thiu mu cp hoc mn tnh do rt nhiu nguyn nhn.

c. Da v nim mc vng: da ca ngi bnh c nhiu hnh thc vng:

- Vng rm: trong cc bnh ung th.

- Vng bng: trong cc bnh thiu mu nng.

- Vng ti nhiu hay t: do ung nhiu quinacrin hoc santonon. Cng c khi c nhng sc t vng lng bn tay v bn chn.

Trong cc tnh trng trn, tnh trng vng ch th hin da hoc lng bn tay, gan bn chn. Tri li trong bnh vng da. Tnh trng vng c th hin c trong nim mc mt, mm, li: y l nhng triu chng rt c gi tr gi chn on, v vng da l mt triu chng gn nh c hiu ca h thng gan mt.

d. Da v nim mc xm en (m lano ermie): y khng phi l trng hp sm nng bnh thng ca ngi lao ng ngoi tri m cn l mt trng hp bnh l gp trong bnh:

- Suy tuyn thng thn (bnh Addison).

- ng hc t (Mlannose de Richl).

e. Mt vng da nht mu: nu vng li c thm mt cm gic au khi ta chm chch th phi ngh n v tm k nguyn nhn phong.

5. Tnh trng da nim mc:

Cn pht hin:

a. Cc bnh tch ngoi da: ngoi mc ch pht hin cc bnh ngoi da vic nhn nh ny cn ch n cc so di chng ca bnh no trong tin s v cc bnh phu thut, v cc bnh tch ny c khi gii quyt c cho ta nguyn do ca cc ri lon hin ti nh:

- So trng nhc lm ngh ti c a lao.

- So di leo (zona) ngc, c th l nguyn nhn ca chng au dy thn kinh gian sn hin ti.

- Vt so do n ngc hng cho ta ngh n nguyn nhn ca chng ho ra mu hin nay.

b. cc nt chy mu: thng l biu hin ca cc bnh v mu v biu hin di nhiu hnh thi:

- Mng bm mu (ecchymose).

- Ban chy mu (purpura).

- Chm chy mu (ptchre).

c.Tnh trng kit nc. Biu hin bng:

- Da kh, rn reo thm ch c c nhng mng vy.

- S tn ti ca cc np nhn ssau khi beo da.

Thng thy trong cc trng hp:

a chy cp din nng hoc a chy ko di.

- Nn nhiu.

- St, nhim khun ko di.

d. Tnh trng nc: biu hin bng: ph c n lm (ph mm) hoc khng c n lm (ph cng), cn pht hin mt (nht l mi mt), cng chn c chn (tm du hiu n lm mt trong xng chy v mt c).

Thng thy trong cc trng hp:

- Vim cu thn cp hoc mn, bnh h thn m.

- Suy tim

- X gan.

- Thiu dinh dng.

- T ph th t.

- Vim hch mch hoc tnh mch.

6. Tnh trng h thng lng v tc

C th c nhng hin tng bnh l nh sau:

a. Qa nhiu lng nam gii hoc mc lng nhng ni ph n bnh thng khng c (ru): mt trong nhng trng hp ca bnh cng tuyn thng thn (Cushing).

b. Khng mc lng hoc rng lng, rng tc. Biu hin ca:

- Mt tnh trng c th suy nhc do mt bnh nhim khun hay nhim c.

- Mt bnh ti ch ca da v da u.

- Mt ri lon ni tit: ri lon bung trng, suy tuyn gip trng.

B KHM TNG B PHN

Thng nn khm ngay b phn nghi c bnh, s hi bn chu o lc u kt hp vi s nhn xt ton thn s gip cho ta ngh n b phn no c bnh.

Sau mi khm n cc b phn khc, u tin l cc b phn c lin quan n sinh l hoc gii phu vi b phn m, ri mi khm n cc b phn cn li v nn i tun t t trn xung di (u, c, ngc, bng, cc chi) khi b st.

V ni dung khm tng b phn, chng ti khng ni k y, v c nhng bi ring trong cc trng hp sau ny, chng ti ch nhn mnh n nhng vn cn ch mi b phn :

1. u

Ngoi vic nhn xt da, nim mc v hp s, tc ni trn, cn kim tra:

- 12 dy thn kinh s no (s ni trong chng trnh thn kinh) nht l khi ngi bnh li c mt bnh v tinh thn kinh.

- Rng, li, hng: s ni trong chng trnh tiu ho.

2. c

Cn ch n:

- Tuyn gip trng.

- Cc so c hoc cc so trng nhc c.

- Tnh mch c: tnh mch c ni to l mt biu hin ca suy tim phi.

3. ngc:

Cn nhn xt:

- Hnh thi v s hot ng ca lng ngc theo nhp th.

- Cc xng sn v cc khong lin sn.

- Khm tim v phi.

- Khng nn qun hai v v cc hch nch.

4. bng

- Hnh thi v s hot ng ca cc thnh bng theo nhp th.

- Kim tra bng ni chung (s ni trong chng tin ho) ri cc ph tng bng.

- Cn ch n vic thm trc trng v m o lmt ng tc bt buc lm cho tt c cc ngi bnh c biu hin bnh l bng, nht l bng di.

- nam gii, khng nn qun khm dng vt, bu sinh dc, thng tinh, v cc l thot v.

5. cc chi v ct sng

Cn ch n:

a. D dng hoc bin dng ca cc chi v ct sng do:

- Ct sng b cong, g hoc veo: mt im au chi bn ct sng, nht l y ct sng li g ln, phi lm cho ta ngh n mt lao t sng.

- Di chng ca gy xng v mt bnh c v xng.

b. Cc khp: mt hoc nhiu khp b sng to, phi lm cho ta ngh n mt bnh v khp nh:

- Thp khp cp.

- Vim khp mn tnh.

- Lao khp.

- Vim m khp.

c. Cc u ngn tay v mng tay: mng tay mt knh ng h ngha l mng tay khum trn nh mt knh ng h, l mt biu hin cn ch . Hin tng lc u ch n c, v sau kt hp thm vi u ngn tay to b ra nh di trng thnh mt triu chng gi l ngn tay Hippocrate th hin ca:

- Mt s bnh tim bm sinh (bnh Fallot).

- Bnh tim - phi mn tnh.

- Bnh nhim khun mn tnh ni tng, thng gp trong vim mng tim bn cp xle v p xe phi mn tnh hoc gin ph qun, nhim khun mn tnh.

- Mt s trng hp u phi: hi chng Pierre Marie

- Bnh x gan mt tin pht: bnh Hannot.

Sau khi khm k ton thn v tng b phn kt hp vi s hi bnh chu o, bao gi chng ta cng phi kt thc vic khm lm sng bng kim tra cc cht thi tit v mt s th dch.

C- KIM TRA CC CHT THI TIT

y ch l nhn xt s b trn lm sng, cn c b sung thm bi cc kt qu xt nghim cn lm sng cc cht . Tuy vy, s nhn xt s b ny rt c ch v n cung cp cho chng ta ngay ging bnh nhng yu t cn thit cho chn on.

1. Nc tiu

- Mu vng kh: xc nh cho chng ta mt hong n.

- Mu : xc nh cho chng ta ngi bnh i ra mu.

- c: c th l mt nhim khun ng tit niu.

2. Phn

- ly nhy mu mi: trong hi chng kit l.

- en nh b c ph: gi mt chy mu ng tiu ho.

3. m

- C tia mu hoc ln mu cc trong ho ra mu.

- C m trong p xe phi.

- m c m mu scla trong p xe phi do amp.

4. Cht nn

Cn xem k thnh phn v mu sc cht nn.

5. Trn tinh thn nh i vi cc cht thi tit, chng ta c th ly mt s th tch bng cc th thut thm d tu theo bnh cnh lm sng.

- C trn dch mng phi hoc mng ngoi tim: phi chc d mng phi hoc mng tim.

- C c trng, phi chc d c trng.

- C hi chng mng no: phi chc d nc no tu.

Cng nh cc cht thi tit, nhng th dch ny ngay bng nhn xt s b ging bnh, c th gip cho ta chn on ng:

- Chc d mng phi c m, lm cho ta chn on ngay l mt vim mng phi m; nu m c mu scla s lm cho ta ngh n nguyn nhn do amp.

- Chc d nc no tu thy c, lm cho ta chn on ngay l mt vim mng no m.

Bng cch khm ni trn, c nhng trng hp:

- C th chn on c ngay nhng khng y chi tit.

- Nhng c khi cha th c chn on ngay c m ch mi c mt hng no .

Do cn phi s dng thm cc phng php cn lm sng.

CC PHNG PHP CN LM SNG

S tin b ca khoa hc trong mi lnh vc gp phn vo vic pht trin cc phng php cn lm sng gip cho s chn on ca y hc thm chc chn. Cc phong tin ngy cng nhiu, cng chnh xc v tinh vi. Cc thm d cn lm sng c th nhm vo 4 loi mc ch:

1. nhn nh hnh thi

Thng l cc phng php:

- X quang; chiu v chp, chp thng hoc c thuc cn quang.

- Soi ni tng.

- ng v phng x.

2. nhn nh tn thng

y l cc phng php sinh thit ph tng (sinh thit m hoc tt hn ht sinh thit di s kim tra ca mt) ly ra mt mu t chc em xt nghim.

- Vi m: tm cc tn thng gii phu bnh hc, thng c gi tr chn on chc chn nht.

- Sinh ho m p dng cc nc c khoa hc tin b.

3. tm tc nhn gy bnh

Xt nghim gii phu bnh hc ni trn cng l mt phng php tm tc nhn gy bnh (sinh thit mt hch to bit tc nhn gy bnh l ung th hay lao tu theo hnh thi gii phu bnh hc c t bo ung th hay t bo khng l ca lao).

Ngoi ra cn phng php khc tm mt cch trc tip hay gin tip:

- Vi khun, virus.

- K sinh vt.

- Nm

cc th dch v cc cht thi tit.

4. thm chc nng

Mt phn ln cc phng php ny l cc xt nghim sinh ho hc. Ngoi ra cn cc phng php dng my mc (do chuyn ho c bn thm d chc nng gip trng in tm thm d chc nng tim) v gn y dng thm cc phng php ng v phng x.

A- S CN THIT CA CN LM SNG

n nay, cha c ai dm ph nhn s cn thit ca cc phng php cn lm sng v thc t cc phng php ny gip cho thy thuc chn on:

- Tht chnh xc.

- Tht y .

- V nht l tht sm, c khi chn on c bnh ngay khi cn thi k tin lm sng.

Nhng n khng trnh khi c nhc im.

B. NHC IM CA CN LM SNG

S ng sai trong cc phng php cn lm sng ph thuc vo nhiu yu t:

- Phm cht ca my mc hay ho cht dng trong .

- Cch ly v bo m bnh phm t bnh phng n ni lm xt nghim.

- Tinh thn trch nhim v kh nng chuyn mn ca ngi lm xt nghim.

Cho nn i vi cc phng php cn lm sng chng ta:

a. Khng nhng cn phi da trn s khm lm sng c ch nh ng trnh tnh trng lm trn lan khng cn thit va lng ph ho cht, my mc v sc lao ng ca ngi lm xt nghim, va lng ph bnh phm nht l mu v huyt thnah ca ngi bnh, c khi li lm mt ngi bnh m khng cn thit.

b. Cn da trn lm sng nhn nh cc kt qu , ngha l phi i chiu cc kt qu cn lm sng vi bnh cnh lm sng: nu khng ph hp th cn kim tra li, c lm sng v cn lm sng nu cn thit th cho lm li xt nghim cn lm sng.

C nh th chng ta mi c c nhng ti liu chnh xc v lm sng cng nh cn lm sng, nhng yu t cn thit chng ta i sang phn chn on.

CHN ON

Cc ti liu lm sng v cn lm sng ni trn cn c tp hp li thnh hi chng: mt ngi bnh c th c mt hoc nhiu hi chng. Cn c vo cc hi chng m chng ta s lm nhng chn on xc nh, chn on phn bit, chn on nguyn nhn v nh gi tin lng bnh.

Trong vic chn on bnh, cn tn trng mt s nguyn tc:

1. Phi da vo nhng triu chng ca ngi bnh tht c th, tht r rng khng ai c th chi ci c, lm sng cng nh cn lm sng.

2. Nn ngh trc ht n nhng bnh thng c nht v phi cn c vo nhng triu chng c hiu c gi tr chn on ca bnh .

3. Nn c gng tm mt chn on bnh c th bao gm c tt c cc hi chng v triu chng chnh ca ngi bnh. Nu khng th c th mi c coi nh ngi bnh b 2 hay 3 bnh cng mt lc.

KT LUN

Chn on bnh l mt cng tc kh. Mun chn on ng bnh c c mt thi iu tr v phng bnh thch ng, ngi thy thuc cn phi c:

- Kin thc y hc y ton din.

- Tc phong khm bnh k lng, t m.

- Phng php suy lun khoa hc v bin chng.

- Tinh thn yu thng ngi bnh nh rut tht ca mnh.

y cng l 4 yu cu chnh m mi sinh vin phi t rn luyn cho mnh trong qu trnh thc tp lm sng

CHNG II. TRIU CHNG HC TIM MCH

3. TRIU CHNG C NNG TRONG BNH TIM

I. I CNG

Ngi mc bnh tim thng tm n thy thuc v mt s triu chng do ri lon chc nng ca tim khi suy. Trong cc ri lon c nhng triu chng c gi tr ch im nhng cng c vi triu chng khng c hiu cho bnh tim.

Mt s ngi c nhng triu chng ny c tng l mnh thc s b bnh tim nn lo lng v c i khm bnh lun. V th ta cn phn bit:

- Cc triu chng c hiu.

- Cc triu chng khng c hiu.

nh gi ng mc gi tr tng loi triu chng, gip ch cho chn on v iu tr, ta cn nhc li nhng nt chnh v sinh l ca tim:

1. Bnh thng tim c nhim v:

a. Lu thng mu trong c th: mu t tim tri ra ngoi vi v t ngoi vi v tim phi ln phi ri tr v tim tri, s lu thng m bo nhu cu ca c th v cung cp oxy t oxyhemoglobin v thi tr kh cacbonic t cacboxyhemoglobin.

b. Tim c lin quan cht ch vi phi qua h thng tiu tun hon thc hin vic cung cp oxy v thi tit CO2.

c. S dinh dng ca c tim c bo m nh h thng ng mch vnh.

d. S iu ho nhp tim do hai h thng thn kinh: trung ng v ni tm.

2. Trong trng hp bnh l:

Tim b suy khng m bo c nhim v na, nn:

a. S lu thng mu b ri lon: mu li h thng tiu tun hon, c th l phi nn ngi bnh kh th v ho ra mu. ng thi mu gan, lm gan to ra, ngoi bin lm thot dch ra khong gian bo, gy nn ph.

b. S thi tit CO2 khng c m bo, lng hemoglobin kh tng ln gy ra xanh tm.

c. Tim phi lm vic nhiu hn, p nhanh hn c gng m bo nhu cu, cho nn ngi bnh hi hp nh trng ngc, cng c th do thn kinh tim b ri lon gy ra triu chng ny.

d. C tim khng c nui dng tt, do bnh tim mch hoc bnh ton thn, v d bnh x va ng mch vnh b tc hoc b co tht gy ra cn au tim.

e. Mng ngoi tim cng nh mng trong tim b vim c th gy ra nhng triu chng au nhi vng tim.

II- CC TRIU CHNG C NNG TIM MCH

A- TRIU CHNG C HIU

1. Kh th

Kh th trong bnh tim l mt triu chng ph bin c gi tr chn on v tin lng bnh. Ta c th chia kh th ra lm ba loi:

- Kh th khi gng sc.

- Kh th thng xuyn.

- Kh th xut hin tng cn.

a. Kh th khi gng sc, ngi bnh thy:

- Kh th khi ln dc, ln cu thang, kh i nhanh hoc lm vic nng.

- Khi ngh ngi th khng kh th na.

- Nhng dn dn s dn ti giai on kh th thng xuyn.

b. Kh th thng xuyn. Xy ra sau mt thi gian b kh th khi gng sc. giai on ny, ngi bnh khng lm vic g nng, nm cng kh th (kh th do t th) cho nn ngi bnh thng mt ng hoc phi ngi ng lng m ng. Kh th thng xuyn chng t tim b suy nng.

c. Kh th xut hin tng cn. Gp trong cc trng hp.

+ Ph phi cp. Loi th ny c th xut hin mt ngi c bnh tim ri by gi b suy tim t ngt, cng c th l mt tai bin xy ra tc thi mt ngi trc b bnh tim nhng khng th hin ra cc ri lon chc nng g, hoc cng c th xy ra mt ngi hon ton khng c bnh tim. V d: ng c bi hi c, tai bin khi dng adrenalin tim mch mu, tai bin trong bnh vim thn, bnh thn kinh, v.v

+ Hon cnh xut hin: cn ph phi cp thng xy ra ban m hoc xy ra khi c mt iu kin thun li cho bnh pht sinh nh: gng sc, b thm mt bnh nhim khun khc, khi b lnh, v.v

+ Triu chng: ngi bnh thy nga c hng, ho khan tng cn v sau chng 15 thy:

- Tc ngc, kh th d di, ngi bnh phi ngi m th, sau b xanh tm v:

+ Khc ra rt nhiu m bt hng.

+ Thn kinh b kch ng, ht hong.

Nu khm s thy:

+ Tim p rt nhanh.

+ Hai phi c nhiu rn nh ht, lc u l rn n hai y phi, cc rn c tng nhiu nh nc triu dng dn ln n mc c hai ph trng ton rn m.

+ Xt nghim m c nhiu protein v xt nghim nc tiu cng c protein thong qua.

y l mt trng hp cp cu ni khoa, cn phi x tr ngay, nu chm ngi bnh s cht.

+ Cn hen tim: cng l mt loi kh th cp gp cc ngi b bnh tim. Hon cnh xut hin cng ging nh trong ph phi cp.

Triu chng:

- Ngi bnh th hn hn, c cm gic nh thiu kh phi ngi dy th.

- Mt, mi xanh tm.

- Tim p rt nhanh.

- Khm phi thy nhiu rn kh (rn rt v rn ngy) ging nh trong cn hen ph qun.

T trng thi ny ngi bnh c th qua khi do iu tr, nhng cng c th nng hn v dn ti cn ph phi cp.

+ Kh th cp trong nhi mu phi:

- Hon cnh xut hin: y l mt bin chng tc ng mch phi xy ra do cc mu ng ti ch hoc cc mu ni khc do dng mu chy ti lm tc ng mch phi. Bin chng ny thng gp:

+ nhng ngi b bnh tim, c bit l bnh van hai l c suy tim.

+ Nhng ngi b vim tnh mch.

+ Nhng ngi va mi b sy, hoc sau khi m tun u.

- Triu chng:

+ au d di ngc nh x ngc, c ngi bnh ng xung cht ngay.

+ Kh th, th nhanh.

+ Sau 24 n 48 gi, ngi bnh st, khc m ra ln mu.

- Khm thy vng ngc au:

+ Mt rn n khu tr, c th thy hi chng ng c. Cng c th: Phn ng tit dch mng phi nhiu (thanh dch hay c mu) lm cho ta khng nghe c rn n na, m ch thy hi chng trn dch mng phi.

+ Tim p nhanh

+ Soi Xquang c th thy hnh m tam gic, trong trng hp in hnh, nhng thng th hnh m ny b khng r rt, hnh ny tn ti t 3 n 6 tun d c iu tr.

d. Bnh sinh ca kh th trong bnh tim:

+ Bnh sinh ca cc cn kh th cp v cn hen tim: ch yu l do vai tr ca hin tng xung huyt phi, xung huyt phi cn tr h hp v:

- Ngn cn s khuch tn oxy nn mu km bo ho oxy.

- T chc phi xung huyt km n hi, cng ra kh, thu li cng hn ch, do th nng nh vy nn ngi bnh b suy h hp, thiu oxy v li kh cacbonic gy kh th.

- Ngi ta chng minh vao tr ca xung huyt phi trong cn kh th cp, v hu nh loi kh th ny ch gp nhng ngi b bnh tng huyt p, bnh l ng mch ch, bnh van hai l, ng mch vnh v cc trng hp suy tht tri. Nhiu tc gi kho st v huyt ng trong cc trng hp thy khi lng mu qua phi tng ln, ng thi dung tch sng gim xung.

Trong lm sng cng thy r biu hin xung huyt phi trong cn kh th: cc rn phi xut hin nhiu dn, ting th hai ca tim ng mch phi mnh ln, c khi mnh hn c ting th hai ng mch ch ngay trong nhng ngi bnh cao huyt p.

Trong gic ng, c s tng cng ca hot ng thn kinh ph v, gy xung huyt phi, co tht c trn nn d lm cho cn hen tim xut hin.

+ Trong cn ph phi cp: Cng do yu t xung huyt tiu tun hon, p lc mao mch phi tng vt p lc keo ca huyt tng, cho nn ph phi cp hay xut hin cc ngi bnh suy tht tri hay nh tri, v cc trng hp ny c xung huyt phi v cao p mao mch phi, mu tr lu, gy tn hi thnh mao mch, d huyt tng thm qua ri v mt nguyn do thun li, t nhim gim lu lng tim tri m tim phi cn kho th ph phi cp xut hin v tim phi tng mt lng mu kh nhiu m tim tri, v yu khng tiu lng mu y i kp. V d khi truyn mt lng ln huyt thanh, khi gng sc, khi c thai giai on sp , khi sn ph mi hoc khi n nhiu mui. Chnh v th nn trong ph phi cp, ngi ta chch mu hoc buc garo lm gim lu lng mu tnh mch tr v tim.

+ Trong suy tim phi: do mu ngoi vi, lm gim p lc ring phn suy v tng p lc CO2 trong tnh mch, thiu oxy xoang cnh v trung tm th, s gy kh th. Cng do mu, dn ti trn dch mng phi, mng bng lm cn tr hot ng ca phi, ca c honh v gy kh th.

+ Cc yu t th dch v huyt ng trong kh th.

- Vai tr lu lng mu: c kin thc cho rng do lu lng mu trong suy tim gim nn trung tm h hp b thiu nui dng gy kh th.

- Vai tr Oxy v CO2: ngi suy tim c hin tng thiu oxy trong m v p lc ring phn oxy

trong tnh mch h xung trong khi p lc CO2 trong tnh mch tng ln, buc c th thch nghi bng thng kh nhanh nn kh th.

- Trong t th nm ngi b bnh tim thng kh th v trong t th ny khi lng mu phn di c th dn ln lm xung huyt phi, mu li kh lu thng do tr ngoi vi nn kh th.

2. Ho ra mu

Trong cc bnh tim, ho ra mu thng xy ra trong ba trng hp:

- Hp van hai l, trng hp ny thng gp nht.

- Tc ng mch phi gy nhi mu phi.

- Trng hp suy tim tri (ph phi cp).

a. C ch:

+ Trong bnh hp van hai l, do s cn tr ca dng mu t nh tri v tht tri, mu li phi lm p lc mao mch phi tng ln, c th lm v cc mao mch v ngi bnh b ho ra mu.

+ Trong trng hp tc ng mch phi, v cc mch tc gy h hi ni mc ca mch, ng thi c nhng hin tng phn ng xung quanh gy gin mch, thot huyt qun v d b vim nhim lm h hi cc m nn ngi bnh khc ra mu ln nhng mnh m b hu hoi.

+ Trong cc trng hp ph phi cp, c ch ho ra mu cng tng t nh trong hp van hai l, y cng c yu t xung huyt phi v tng thm tnh mao mch phi, nhng thng xy ra khi lu lng tun hon pha tim phi vn nhiu nh lc bnh thng, hoc tng hn do yu t bn ngoi (v d truyn nhiu dch vo chng hn) nn huyt tng trn ngp ph nang, ngi bnh khc ra rt nhiu bt hng.

b. c tnh ca ho ra mu trong bnh tim:

Trong trng hp ph phi cp, ngi bnh si ra bt hng l chnh nn d phn bit v cng kh lm.

Cn cc trng hp hp van l nhi mu phi th mu ra thng t, ln vi m; mun phn nh xem ho ra mu thuc nguyn nhn bnh tim hay bnh phi ta cn kt hp thm khm tim phi ngi bnh, cn lu xem c tn thng van hai l khng, da vo bnh cnh cp tnh, au ngc d di v kh th l nhng triu chng ca nhi mu phi, ng thi cn xem hnh nh Xquang phi, v trong a s trn hp nu c tn thng cc nh phi v ph trng th hin bi hnh m khng ng u hoc hnh hang th ngh nhiu n lao phi v phi th m nhiu ln tm vi khun lao, mt s t trng hp khc b ho ra mu l ung th phi v gin ph qun th phi c din bin t trc v c th chn on v sinh thit hch thy t bo ung th (trng hp ung th), thy hnh gin ph qun khi chp ph qun c cht cn quang (trng hp gin ph qun).

3. Xanh tm

- Tm t: ch tm mi, mng tay, mng chn, c khi ch xut hin khi ngi bnh lm vic nng km vi kh th hoc khi em b khc.

- Tm nhiu: D pht hin: thy thuc, ngi nh ngi bnh v bn thn ngi bnh cng thy. Thng l tm mi, li, u ngn tay, ngn chn. Xanh tm xut hin khi lng Hemoglobin kh trong mu mao mch c trn 5g trong 100ml mu (hu qu ca s ri lon thi tit kh cacbonic t cacboxyhemoglobin).

Xanh tm trong bnh tim mch xy ra trong cc trng hp sau:

- Cc bnh tim bm sinh c lung mu thng t tim phi sang tim tri nn mu tnh mch qua trn vo mu ng mch.

- Khi suy tim do tun hon b cn tr.

- Mt s trng hp tm khu tr do cc bnh ca mch mu.

4. Ph

a. C ch: Trong giai on suy tim c nhiu yu t phi hp gy nn ph.

- Do mu ng ngoi vi nn huyt p tnh mch cao ln (thng l trn 17cm nc).

- p lc keo ca mu gim xung.

- ng thi c ri lon thm tnh ca mao mch.

- V s thi tit mui khng thc hin c y , mui li trong c th.

b. Tnh cht ph trong bnh tim:

- Ph lc u khu tr chi di, dn dn v sau xut hin bng, ngc, v ton thn hoc trong cc mng bng, mng phi.

- Da v nim mc c th hi tm v t l bo ho oxy gim trong mu.

- C km theo cc triu chng ca suy tim nh kh th, gan to, tnh mch c ni,v.v

- Nu ph mi hnh thnh th c th iu tr cho ht ph nhng nu din bin lu hoc khng c iu tr cho y , bnh cnh suy tim s dn theo hin tng tng cht andosteron trong mu, v th Na+ li b gi trong c th, ngi bnh cng ph v suy tim khng hi phc c.

5. au vng trc tim

au vng trc tim l mt triu chng lm cho ngi bnh v c thy thuc ch trng n h tun hon, nhng khng phi c c au vng tim l nht thit phi c bnh tim.

Trc mt trng hp au vng trc tim ta cn ni thm:

- Tui: cn bit tui ngi bnh v c nhng trng hp au trc tim ch yu xut hin ngi ng tui.

- Hon cnh xut hin au: V d: au t ngt hoc sau khi gng sc khi b lnh,v.v

- V tr, cng v hng lan ca au: V d: au mm tim hay sau xng c, au d di hay ch lm rm, au ng khung mt ch trc tim, hay cn lan ln vai, ra cnh tay,v.v

- Thi gian au: au vi chc giy, vi pht hay ko di?. Nhng tnh cht u gip ch chn on v phn loi au:

a. Phn loi au vng trc tim:

Ta chia lm hai loi:

- au tng cn.

- au thng xuyn.

+ au tng cn. in hnh nht l cn au tim:

- Cn au tim hay xut hin ngi c tui (ngoi 40 tui).

- Hon cnh xut hin: ngi bnh hay b au lc gng sc (nh i ln cu thang, ln dc, chy nhanh), khi b lung gi lnh, khi xc cm, i khi xut hin au sau khi n mt ba thnh son, c khi xut hin cn au tim sau khi c tim p nhanh.

- V tr au v hng lan: au sau xng c lan ln vai tri, xung pha trong cnh tay v cng tay ri lan sang hai ngn tay th t v th nm.

- Cng au: ngi bnh au d di nh dao m, c cm gc nh c mt vt rt nng p ln lng ngc, bp nght tri tim li, ng thi ngi bnh ht hong, lo lng c cm tng l sp cht.

- Thi gian au: thng rt ngn, t vi giy n vi pht. Nu cn au xut hin v ko di qu na gi l phi ngh n kh nng tc ng mch vnh.

- Gi tr chn on: cn au tim xut hin l mt triu chng c hiu chng t ngi bnh b thiu nng ng mch vnh, c tim b km dinh dng. Nguyn nhn gy thiu nng ng mch vnh c th l:

+ X ho ng mch vnh do va x ng mch vnh.

+ Vim ng mch do giang mai.

+ Hp l ng mch ch.

+ Bnh thp

+ Bnh thiu mu.

+ nc ta, t gp cn au tim, ngay nhng ngi b bnh v ng mch vnh cng t c cn au. Cng Vit Nam, trong s bnh nhn tim mch th loi bnh v ng mch vnh ch chim 3%, cn li l bnh tim do thp chim 81% ( theo s liu bo co ca gio s ng Vn Chung hi ngh tim mch ton Lin X ln th II (26-30 thng 06 nm 1973).

+ ng thi vi au, ngi bnh cn b kh th, ho, st.

+ Khm thc th ly cc triu chng ca vim mng tim nh: in tim to ra, ting tim m, ting c mng tim, du hiu ST chnh ln cc chuyn o trc tim, hoc du hiu gim in th trn in Tm .

+ Nhi mu c tim: do mt vng ca c tim khng c dinh dng (thng nhng ngi nhiu tui). Trc khi b nhi mu c tim, ngi bnh cng c mt giai on b cn au tim ri n mt lc thy au nhiu, au lan rng ko di, ngi bnh rt lo lng, kh th, c cm gic sp cht: dng thuc gim au mnh nh mocphin cng khng , ngi thuc gin ng mch vnh nh trinitrin cng khng (trong cn au tim dng thuc ny th r rt). Sau 2 n 36 gi c bin chuyn: ngi bnh st, nghe tim thy c ting c mng tim, ting nga phi, ng thi huyt p ti a tt xung.

Trong cn au ngi bnh c th cht cng c th qua khi nhng cha chc thot cht v d ti pht.

C th chn on sm bnh ny nh o men transaminaza, men lactatdehydrogenaza v ghi in tim. Lnh ny ta cng him, theo ti liu ca gio s V Cng Ho tng kt 11.657 trng hp m t thi trong 18 nm, t 1955 n 1972 th nhi mu c tim ch chim 0,069% tng s ngoi cht t nm 1955 1964 v 0,18% tng s ngi cht t nm 1965 n 1972.

b. au vng trc tim cng cn gp trong mt s bnh ngoi tim nh:

- au y thn kinh lin sn:

+ au dy thn kinh lin sn t trc ra sau.

+ Nu ta n ngn tay theo khong lin sn, ta s pht hin cc im au l ch c nhnh dy thn kinh lin sn xuyn ra.

- au o vim mng phi tri, vim phi tri. Khm ngi bnh s thy cc triu chng trn dch hoc hi chng ng c phi tri.

6. Ngt:

l mt trng thi bnh xy ra t ngt lm ngi bnh bt tnh, da ti nht, mt tr gic. Khm ngi bnh lc s thy tim khng p hoc p rt chm, rt kh, ngi bnh khng th hoc nh ngi ngt th. Ngt xy ra v mu khng trong hnh no do nhiu nguyn nhn: bnh tim mch, bnh h hp, thn kinh, ni tit

a. Ngt trong cc bnh tim mch (ngt tim). Do tim ngng p, ngi bnh trong tnh trng cht lm sng. Ngt c th gp trong tt c cc bnh tim mch, nhng thng gp trong cc bnh.

- Blc nh tht hon ton (hi chng Stokes Adams) v tim p chm qu, di 40 ln mi pht nn no thiu mu.

- Bnh ng mch vnh v c tim. V km dinh dng, c tim khng sc y nhiu mu n cung cp cho hnh no.

- Bnh hp van ng mch ch. V mu t tht tri ra i tun hon b cn tr, gim lu lng xung nn no thiu mu.

- Bnh h huyt p.

b. Ngt trong cc bnh khng do tim mch.

+ Ngt trong cc bnh h hp: do ngng h hp nh trng hp gy m, trng hp b in git, cht ui, vim tu xm, nhi mu phi, ng c hi c (oxyt cacbon chng hn).

+ Ngt trong ri lon thn kinh: C ch do phn x, gp nhng ngi d cm xc, trong trng hp chn thng vng cm th thn kinh nh: chn thng thanh qun, dy ph v, m ri dng (nh quyn anh), chn thng s no, v.v.

+ Ngt trong cc bnh ng tiu ho: y hi, vim rut, c bit chy mu ng tiu ho d gy ngt.

+ H Glucoza huyt t pht do tu cng hay ngt.

+ Cc trng hp thiu mu nng cng gy ngt.

Trn y va k triu chng ca cc bnh tim, trong cc triu chng: Kh th, ho ra mu, xanh tm,ph, cn au tim, ngt tim, l c hiu cho bnh tim, cn cc triu chng hi hp v nh trng ngc khng tht c hiu cho bnh tim.

B- TRIU CHNG KHNG C HIU

Hi hp v nh trng ngc: l mt cm gic lm cho ngi bnh ch v ngh ti bnh tim ri ni vi thy thuc.

Ngi bnh c cm gic tim p nhanh v mnh trong lng ngc, c khi c cm gic tim ngng li mt lc nh ngi bc ht chn, sau tim li p nhanh, ng thi ngi bnh c cm gic tc ngc, kh th.

Cm gic ny thng xut hin khi ngi bnh gng sc hoc b cm giac mnh. Hin tng ny c th c trong bnh tim: tt c cc trng hp suy tim, cc ri lon nhp tim nh: nhp tim nhanh, nhp ngoi tm thu, lon nhp hon ton. Tuy vy s ngi khng b bnh tim m c triu chng hi hp li rt nhiu, ph bin gp trong cc trng hp sau:

- C a d xc ng, thn kinh giao cm hot ng mch.

- Dng nhiu ch, thuc l.

- Thiu mu.

- Bnh cng tuyn gip

- Cc bnh v tiu ho (chm tiu, vim rut).

- Cc trng hp nhim khun cp v mn tnh.

4. TRIU CHNG C NNG TRONG BNH MCH M\U

I- TRONG CC BNH CA NG MCH

1. Ri lon chc nng.

Tuz theo cc nhn t t trong lng ng mch hoc t bn ngoi tc ng n. V d nhn t

c gii (chn thng thnh mch, tc mch), nhn t tinh thn, lnh, nng, ho cht,v.v lm

tn thng ng mch hay lm ri lon thn kinh vn mch, ta gp cc triu chng sau:

a. T cc ngn tay: cm gic ny thnh thong xy ra nht l v ma lnh, ngn tay, ngn chn

t nhin trng nht, lnh i v t, mt cm gic. Hin tng ny do co tht mch mu cc

ngn. Tuz thoe v tr ng mch b co tht s th hin ra cc triu chng sau:

- Ngi bnh b m thong qua nu ng mch mt co tht.

- Ngi bnh b bi mt chi. Na thn, ni kh, tri gic mt thong qua nu ng mch no co

tht.

b. Du hiu au cch hi: ngi bnh khi i hi xa c cm gic chut rt bp chn, au bp

chn, phi ng li ngh, xoa bp chn thy cc triu chng dn; khi tip tc i li thy cc

triu chng xut hin, v sau khi bnh tin trin, ngi bnh au ngay c khi ngh ngi.

Ngi ta chng minh c ch ca hin tng ny l do thiu mu cc b kho c gng, v vy

khi ngh ngi th ht au.

2. Chy mu:

Do v mch. Ngi bnh c th chy mu mi, chy mu vng mc (gy gim th lc trm

trng), chy mu no (gy lit na thn, hn m, c th dn ti t vong).

3. Hi chng Raynaud:

y lm mt cn au khi gp lnh. Cn au c c im l:

- Hay gp cc ngn tay (t khi chn).

- Ngn tay t bun ri tim nht, mt cm gic.

- C th khi hoc tin ti cn au di hn, lc y c cm gic ngn tay b rn cn hay b

gm.

- Nhng tay vo nc nng, ngi bnh thy au.

- Cn au c th t vi pht ti vi gi.

- Nu b nhiu ln th v sau tin ti hoi th u chi.

Ngi ta cho rng cn au xut hin o c tht ng mch nh, chnh v vy khi nhng tay vo

nc nng

II- TRONG CC BNH CA TIM MCH

Ri lon chc nng: khi tnh mch b gin, b vim, b tc, th tuz theo tn thng s lm tr

ngi chc nng tun hon tnh mch th hin ra cc triu chng:

a. au c tnh mch: trong trng hp vim tc tnh mch chi i (hay xy ra sau phu thut

vng y chu, sau , sau chn thng), ngi bnh b st, mch nhanh, mt mi. Nhng ch

yu l an vi nhng tnh cht sau:

- au c th t pht. Mc c th t cm gic kin b, cm gic nng chi cho n mc au

d di bp chn. C khi au kch pht; n vo gt chn cng chn hoc p mnh vo cc

ngn chn lm ngi bnh rt au.

- au lan thng thng theo hng tnh mch (tnh mch hin, tnh mch i, tnh mch

khoeo), cng c khi ch khu tr mt on chi.

b. Ph chi: Trong trng hp vim tc tnh mch chi, chnh v ri lon thn kinh vn mch v

tc tnh mch (thng phi hp vi tc tn mch) nn sinh ra ph. Trong cc trng hp tn

dch khng lu thng, p lc keo ca dch khe tng ln lm ngi bnh ph.

Ph trong vim tc tnh mch l loi ph trng v au, c th thy hnh tnh mch ni ln da,

nom nh mt ng xanh nht, ph ny thng khng li du lm l mc khi n vo.

c. Cm gic nng chi i: trong trng hp gin tnh mch. C khi bin chng lot ch

tnh mch gin hoc vim tnh mch .

5. THM KHM TIM LM SNG

I. HI BNH

Ngi bnh tim thng biu hin mt s triu chng do ri lon chc nng tim, cc triu

chng l: kh th, ho ra mu, tm ti, ph, au trc tim, hi hp, ngt (xem bi ri lon

chc nng trong bnh tim mch).

Trong khi hi bnh, ta cn khai thc cc triu chng trn v lu { thm mt s vn sau:

- Lc nh, ngi bnh c tt bm sinh g khng?

- Trc kia ngi bnh c b thp khp khng?

- Ngh nghip v iu kin lm vic ca ngi bnh c cng thng qu khng? C phi tip xc

vi cht c g khng?

- Tnh trng thn kinh nh th no? Mc ch l xc nh mt s triu chng tim mch m

nguyn do thuc v thn kinh tm thn nh ri lon thn kinh tim, tim kch ng.

- Ngi bnh c hay dng nhiu ch, ru, c ph, thuc l khng? (v nhng th ny u nh

hng n hot ng ca tim mch).

- C ri lon g v h ni tit t khng ? c bit ph n nh trong giai on mn kinh chng

hn.

II- KHM THC TH

A- NHN

T th ngi bnh: ngi bnh nm u v lng gi hi cao, hai chn co, ci khuy o bc l

c ngc trc. Y sinh ngi bn tri ngi bnh (trong c qu trnh khm tim) hoc bn phi

cng c.

Quan st: trc ht xem ngi bnh c kh th khng? C ph khng? Tnh trng tinh thn

nh th no? C lo lng hong ht khng? Sau :

- Nhn xt mu sc da v nim mc ngi bnh: mi tm, trong cc bnh tim bm sinh, trong

suy tim. Ngn tay v ngn chm di trng gp trong cc bnh tim bm sinh hoc vim mng

trong tim bn cp v mt s bnh phi mn tnh hoc u phi.

- Nhn xt hnh dng lng ngc: lng ngc ra trc nhng ngi c bnh tim t b v lc

s ct ho cha hon ton nn lng ngc d bin dng. tr em b trn dch mng ngoi

tim, lng ngc cng hi phng.

- Nhp p ca tim: nhng ngi bnh thng ta c th thy mm tim p i v trn

ng gia xng n vo khong lin sn 4-5. mm tim p mnh trong trng hp tht

tri to hoc tim to ton b, mm tim p yu trong trng hp trn dch mng ngoi tim hoc

nhng ngi bo c thnh ngc dy.

- nhng ngi b ti phnh ng mch ch: ta c nhn thy mt khi u p khong gian

sn 2 st hai bn xng c, khi u p theo nhp tim.

- Vng c:

* Tnh mch c ni trong suy tim phi, ng mch c p mnh trong bnh h van ng mch

ch.

* Cn khm xem tuyn gip trng c to khng? V c mt s ngi b cng tuyn gip c bin

chng tim.

- Vng thng v v vng h sn phi: c th thy vng thng v p theo nhp tim khi tim

phi to, khi suy tim phi hoc suy tim ton b: gan thng to ra, ta nhn thy vng h sn phi

y hn bn kia.

Phng php nhn ch cho thy s b mt s biu hin ca bnh tim cho nn cn phi b

sung bng cc phng php khc.

B- S

Tm mm tim: s mm tim hai t th: nm nga v nghing sang tri.

Bnh thng mm tim p khong lin sn 4,5 trn ng gia xng n bn tri. Mun

s mm tim, ta dng lng bn tay p st vo lng ngc ch mm tim. Mm tim c th thay i

v:

a. V tr:

- Thay i sinh l: nm nghing sang tri mm tim s lch sang tri khong hai khot ngn tay,

t th ny s thy mm tim r nht. Khi nm nghing sang phi: mm tim lch sang phi rt

t.

- Thay i bnh l: trong trn ghp bnh l tim to ra, mm tim thp xung i hoc ra ngoi

ng gia n tri. Trong cc trng hp trn dch v trn kh nhiu mng phi mt bn,

tim b y sang bn kia. Trn ghp dy dnh mng phi v mng tim, tim s b co ko v

pha vim dy dnh, nu ch c cc mng tim dnh vo nhau v dn vi phi tip cn th in tim

nh li v mm tim khng i v tr ngi bnh thay i t th.

Trng hp c trn dch mng bng nhiu hoc c khi u to trong bng c honh b y cao ln

v m tim cng thay i v tr: tim t th nm ngang.

b. Cng :

- Mm tim p khng r ngi bo qu, trong bnh vim mng ngoi tim c trn dch hoc

dy dnh mng tim.

- Mm tim p mnh trong trng hp tim tri to, trong bnh h van ng mch ch hoc

trng hp cm ng.

c. S cc ting rung miu: trong cc bnh tim, c th gp cc trng hp dng mu phi xoy

mnh qua mt ch hp (v d hp van ng mch ch, hp van hai l) o tc mu i

nhanh, xoy qua ch hp lm rung cc t chc van, thnh tim, thnh mch ln cho nn khi t

tay vo thnh ngc gn ch lung mu qua ch hp ta s thy mt cm gic rung rung ging

nh khi t tay ln lng mo lc n rn. Cm gic gi l rung miu, tuz theo rung miu, th

tim bp hay tim gin m ta gi l rung miu tm thu hoc rung miu tm trng (trong phn

nghe tim s gii thiu thm cc ting ny).

C- G

Mc ch xc nh v tr, kch thc tim v ng mch ch, c trng hp g ng vai tr rt

quan trng trong chn on bnh, v d trong trn dch mng ngoi tim, ta gn g xem in tim

to ra n u. Din c ca tim bnh thng chiu ln thnh ngc l mt hnh bn cnh gn

ging hnh thang.

1. Tm mm tim:

Dng phng php nhn v s trnh by trn tm mm tim, nu trng hp nhn v s

vn cha xc nh c th g cho t i ln trn, t tri sang phi n ch bt u c,

l v tr mm tim.

2. Tm b trn gan:

t ngn tay gia dc theo k lin sn bt u t i xng n, g t trn xung i cho

n lc va ti vng c ca gan, l b trn gan, bnh thng gii hn c ca b trn gan

mc lin sn 5.

3. Tm b phi tim:

Tay tri t ngn gia song song vi xng c, u ngn trong rnh lin sn, dng tay

phi g vo ngn gia tri, g t ng nch trc tr vo theo khong lin sn cho n khi

tht vng c ca b phi tim, c nh th g t trn xung ghi ly im g nhau ca b phi

tim v b trn gan. Bnh thng vng c ca b phi tim khng vt qu b phi xng c,

tr ch st b trn gan th c ra bn phi xng c t 1cm n 1,5cm.

B phi tim ng vi tm nh nh phi, chiu cao ca b ny thng khng qu 9cm.

4. Tm b i tim:

Ni mm tim vo giao im ca b phi tim v b trn gan, ta c b di tim, b ny ng

vi tm tht phi, thng thng b ny khng di qu 12cm.

5. Tm b tri tim:

Ta g chch t hm i nch tri v pha mi c, g t ngoi vo trong, t trn xung i,

song song theo hng thng thng ca b tri tim cho n khi c mt ng gii

hn in c ca b tri tim. Bnh thng gii hn ny i t st b tri xng c ch xng

sn 2 i xung ct ngang ng cnh c ri phnh ra thnh mt ng cong cho n lin

sn 4-5 pha trong ng gia xng n t 1cm n 2cm, b tri ch yu ng vi tm

tht tri.

6. Tm b trn tim:

G t trn xung st hai bn cnh c xc nh b trn tim, thng b trn ny t c gi tr

chn on trong thc t, gii hn c ca b trn thng t xng sn 2.

Cc gii hn ni trn l gii hn vng c tng i ca tim, tc l khong chiu ca tim ln

lng ngc ni c phi xen gia tim v thnh ngc .

Cn mt vng c tng i ca tim nh hn vng c tng i, vng c tuyt i l gii

hn c ca in tim trc tip tip xc vi thnh ngc. Gii hn bnh thng ca vng c

tuyt i nh sau:

Bn phi i t sn sn th t ch b tri xng c to thnh mt ng hi cong sang phi

v i xung ti ng gii hn b trn gan. Gii hn tri cng xut pht t sn sn th 4 i

xung i v ra ngoi theo mt ng cong ti lin sn th 4-5 gn ng cnh c hoc

gia ng ny vi ng gia xng n, gii hn i c xc nh bi hai im ni u

phi v u tri ca hai gii hn k trn.

Cc vng c tng i v tuyt i s thay i trong cc trng hp tim thay i v tr v tim

to ra.

D- NGHE

Trong cc phng php khm vng trc tim, nghe tim l phng php quan trng nht s

gip ngi thy thuc trong chn on.

NHC LI SINH L

Chu chuyn tim

trong 1 pht tim co bp khong 70 n 80 ln. Trong thi kz tin tm thu,hai tm nh co li,

tng nt mu vo tm tht. Khi hai tm nh va co bp xong th hai tm tht co bp tip ngay

v to nn thi kz tm thu ca tm tht. Trong thi kz ny van nh ng li, nhng van t chim

(sigma) m ra, mu tng vo n gmch ch v ng mch phi.

n thi kz tm trng, tm tht gin r, van t chim ng li, van nh tht m ra, mu t tm

nh n vo tm tht do trng lng mu v sc ht ca tm tht.

Ting tim:

ting th nht ch yu do tm tht co bp kt hp vi ting ng ca van nh tht.Ting th

hai ch yu do ting ng ca van sigma ca ng mch ch v ng mch phi.

PHNG PHP NGHE TIM

C hai phng php nghe:

- Nghe trc tip.

- Nghe bng ng nghe.

1. Nghe trc tip:

Nghe bng tai phi, p tai vo mt khn mng tri trn ngc ngi bnh. Hin nay khng dng

phng php ny na v bt tin khi nghe vng nch, nht l i vi ngi bnh n.

2. Nghe gin tip:

Bng ng nghe eo vo hai l tai, phng php ny ng ph bin.

Cch nghe:

a. Nn nghe t th: nm nga, nm nghing sang tri, ngi.

b. Nghe nm van tim:

+ van hai l: mm tim vo khong lin sn 3 hoc xng sn 5 trn ng v tri. Khi b

bnh mm tim c th sa xung thp hooc sang tri th phi nghe v tr mi c mm tim.

+ Van ba l: trn sn sn 6 bn phi.

+ van ng mch ch: mt khong lin sn 2 b bn phi xng c v mt na lin

sn 3 st b bn tri c gi l Eck-Botkin.

+ van ng mch phi: khong lin sn 2 bn tri st xng c

i khi mun nghe xc nh r hn nhng ting khng bnh thng ca tim th bo ngi

bnh lm vi ng tc ri nghe, hoc ht vo mnh, ri nn th (lm nh vy ph nang phnh ra

lp kn cc xoang tim phi, ting thi ngoi tim s mt i hoc gim cng xung, cn ting

thi thc th trong tim th khng i.

NGHE TIM

TING TIM BNH THNG

Trong mi chu chuyn timta nghe c hai ting:

- Ting th nht nghe trm di.

- Ting th hai nghe thanh v gn hn.

Ting th nht cch ting th hai bimt khong ngh ngn, ting th hai cch ting th nht

ca chu chuyn sau bng mt khong ngh di. Ting th nht xem nh ng thi vi ting

mch p, tc l m u th tm thu. Ting th hai tng ng vi lc mch chm, m u th

tm trng.

Ting th nht nghe r mm tim, ting th hai nghe r hn y tim. mt s tr em v

thanh nin, c khi ta nghe c mt ting th ba theo sau ting th hai. Tin th ba ny ch l

ting tim sinh l do mu dn mnh t nh xung tht thi kz u tm trng. Nu ta bo

ngi bnh th vo su ri nn th th ta khng nghe thy ting th ba na. Ting th ba khi

nghe c th thy sau lc tn cng ca ting th hai t 0,05 n 0,1 giy.

Ngi ta cn ni ting tim th t bnh thng nhng rt him gp, ting tim ny cn gi l

ting tm nh. Trong trng hp phn ly nh tht hon, ta c th ghi c ting ny trn tm

thanh . Ngi ta cho rng ting ny pht sinh v khi nh bp y mu qua van nh tht xung

lm gin tm tht nhanh do lung mu xung mnh hn cui tm trng.

S THAY I TING TIM

1. Thay i cng .

a. Thay i cng c hai ting tim ph thuc vo cc yu t sau:

+ Thnh ngc.

+ Mi trng gia tim v ngc.

+ Mu.

+ C tim v van tim.

+ Cng tng: Hai ting tim u mnh hn khi b kch thch nh khi b cm ng, sau khi

tp th thao, lao ng nng, khi st, trong bnh cng tuyn gip.

ngi gy, do thnh ngc mng, ting tim nghe r hn nhng khng phi bnh l.

+ Cng gim: c tim yu nn van tim cng p yu, mt khc van c bao ph bi lp

mng. Bnh thng mng trong tim nhn nhi, khi b vim, b ph van p khng mnh na.

Bnh thng l thnh v l tng ca mng ngoi tim trt st vo nhau, khi c nc gia hai l

th ting tim truyn ra lng ngc b cn li nn nghe ting tim khng r na, o ta gp

hai ting tim nghe nh trong:

+ Trn dch mng ngoi tim.

+ Vim c tim, nhi mu c tim.

+ Vim mng trong tim cp.

Cn ch . ngi bo, n gii do tuyn v cn tr, ting tim nghe cng nh.

b. Thay i cng ca ring ting th nht mm tim

+ Ting th nht anh trong bnh hp van hai l, l do v:

Cc van b dy, cng o vim, khi ng li cc van p vo nhau gy ra ting anh. C tc gi

da vo kt qu quay phim bung tim, cho rng s thay i ny l o van hai l ng t ngt.

+ im na, trong bnh hp van hai l, mu dn v tht tri t nn khi cn b, sc co bp ca

c tim cn tt, n khng b gin ra nhiu trong th tm trng nn khi bp s nhanh, tm thu

ngn v th ting gn, anh.

+ Ting th nht m: trong cc bnh c tim v vim mng trong tim v c tim b vim nn bp

yu, v cc van b vim nn ph khp khng kn lm cho ting tim b m.

c. Thay i cng ting th hai:

+ ng mch ch:

+ Gim: Cng vi ting th nht, trong vim mng trong tim cp, l{ o cng nh trng hp

trn.

+ Tng: Trong bnh tng hut p v trong trng hp huyt p cao, mu dn v thnh van mch

lm van ng mnh trong u th tm trng.

+ ng mch phi:

+ Bnh thng ting th hai ng mch phi vn mnh hn ting th hai ng mch

ch v ng mch ch st thnh ngc hn.

+ Trng hp bnh l, ting th hai anh trong bnh hp van hai l, v trong bnh ny mu li

nh tri ri li tiu tun hon nn mu ng mch phi dn mnh v thnh van khi

ng gy ra ting anh.

2. Thay i v nhp.

Bnh thng nhp tim rt u do h thng thn kinh t ng chi phi. Khi h thng ny b tn

thng, nhp tim s nhanh, chm hoc lon nhp. (xem chng ri lon nhp phn sau).

3. Thay i v s lng tim: nhp 3 ting.

Khi nghe k tim mt s ngi bnh c khi chng ta thy ting th nht hoc ting th hai

c hai ting chng nhau. Trong nhng trng hp ny, ta thy tim p theo mt nhp ba ting.

Nu c hai ting tim u phn i, ta s nghe c nhp 4 ting.

a. Ting th hai phn i sinh l{. Nghe r khong lin sn hai hoc ba bn tri vo cui th

th vo, khng nghe thy thng xuyn (ch c chu kz). Nhng tnh cht gip ta phn bit

vi ting th hai phn i bnh l thng c lin tc trong bnh hp van hai l. Tuy vy cng

c trng hp mt ngi bnh thng vn lun lun c ting th hai phn i. V vy ch

n thun c mt triu chng ny th cha m chc chn tnh cht ca bnh l.

Cn phn bit ting th hai phn i vi ting th ba ca tim, c hai u bnh thng nhng

phn bit nhau v ta nghe chng nhng a im khc nhau, thi gian khc nhau ting th hai

phn i nghe rt gn nhau trong ting th ba ca tim bao gi cng nghe sau ting th hai

mt thi gian di v v tr nghe ting th ba li mm tim.

Trong tm thanh , ting th hai phn i sinh l cch nhau mt khong yn lng t 3% n

7% giy, tri li ting th ba cch ting th hai mt khong yn lng l 10% n 16% giy.

b. Ting th nht phn i. Gm hai ting rt st nhau, nghe r vng mm tim hoc pha

trong ng gia xng n trn lin sn 5 bn tri.

Thng nghe c khi ngi bnh ng, cn khi nm ting nh i hoc khng nghe thy.

Ting th nht phn i sinh ra o cc van nh tht ng khng u, c th gp ngi kho

mnh cng nh trong mt ngi tim hay kch ng, mt s ngi mc cc bnh nh hng ti

c tim. ng nhm ting ny vi ting nga phi.

c. Ting clc m van hai l. L mt ting thm vo ting th hai, nghe ging ting clc, m sc

kh, nghe r khong lin sn 4, 5 tri vng trong mm tim, i khi nghe c y tim.

Ting ny c gi tr trong bnh hp van hai l, n pht sinh o van hai l x cng, cc nhnh

van khi m ra tch khi nhau nghe thnh ting clc. Trn thanh tm , n i sau ting th hai

t 7% n 11% giy.

d. Ting nga phi: nhp ba ting ny do mt ting nh thm vo thi kz tm trng. Ting

ny sinh ra trong trng hp tm tht b suy nhiu, d gin ra khi mu t nh dn xung tm

tht v y mm tim chm vo thnh ngc lm ta nghe c theo mt ting trong th tm

trng.

Ting nga phi nghe r nht vng trong mm tim, hoc mm tim, khi ngi bnh nm

nghing v bn tri s nghe r hn, ting ny thng khu tr mt ni nht nh khng lan xa.

Ta thng gp ting thm vo ny th tin tm thu (gi l nga phi tin tm thu). Nga phi

tin tm thu sinh ra o nh bp y mu xung lm gin thnh tm tht. Cn loi nga phi u

tm trng sinh ra o tm tht nho qu nn ngay khi cc van nh tht m, lung mu t

tm nh xung di vo thnh tm tht lm gin thnh tm tht ngay.

Ngi ta gi l ting nga phi phi hay tri tuz theo tm tht phi hay tm tht tri b suy.

Nga phi phi nghe r cnh mm c, nga phi tri nghe r mm tim. Loi nga phi tri

thng gp hn. Mun phn bit phi da vo triu chng lm sng ca suy tm tht no.

Ting nga phi thng km theo nhp tim nhanh, nu c lon nhp hon ton, nga phi s mt.

Ch :

1. Cn phn bit ting nga phi tin tm thu vi ting th nht phn i. Hai ting phn i

nghe rt gn nhau cn ting nga phi c mt khong yn lng gia ting nga phi tin tm thu

v ting th nht; im na, ting nga phi c m sc trm hn v nhp tim nhanh hn.

S phn bit ny quan trng v ting th nht phn i ch chng t tim d b kch thch cn

ting nga phi li l triu chng ca suy tim.

2. Cng phn bit ting nga phi u tm trng vi ting th ba, ting th ba khng c

thng xuyn, hay thy tr em v ngi tr, kho mnh ch ht vo su l khng nghe thy

ting th ba na.

Gi tr: Ting nga phi l du hiu ca suy tm tht, tin lng ni chung xu, nht l i vi

tm tht tri, tuy vy iu tr c th mt ting nga phi.

Mt s bnh dn ti suy tm tht tri nh:

- Tng huyt p.

- H l ng mch ch.

- Vim thn cp v mn tnh.

- Vim v phng ng mch ch do giang mai.

- Hp l ng mch ch.

- Thp tim.

CC TING THI

I CNG

Trong mt s trng hp khm tim, ngoi cc ting tim bnh thng chng ta cn nghe c

cc ting tng t ting khng kh thi qua mt ming ng, ta gi l cc ting thi.

C ch sinh ra ting thi. Mt dng mau khi chy xoy mnh, s gy ra ting thi. Cc nguyn

nhn ca tnh trng gy ra dng chy xoy c nhiu. Theo Reynolds nu P l t trng mu,v N

l s Reynolds, t l vi xoy ca mu, th cc yu t trn lin h vi nhau theo cng thc:

N= P VD

M

Nh vy ta thy khi tng tc dng mu, khi dng mu chy t ch rng sang ch hp hoc

t ch hp sang ch rng, hoc c khi thng hai mch mu hay thng hai bung tim, hoc hki

nht ca mu gim, th lm tng xoy ca mu v gy ra ting thi.

Trn lm sng, ngi ta c th nghe c:

- Ting th tm thu.

- Ting thi tm trng

- Ting thi lin tc.

Ting thi tm thu l tin gthi nghe thy ng thi vi thi gian mch ny, ting thi tm

trng vi thi gian mch chm, o khi nghe tim, ta cn phi hp vi bt mch, tin ghti

lin tc nghe c c hai th nhng mch dn cui tm thu v u tm trng.

Ngi ta cn da vo in tm , tm thanh , mch , ghi ng thi xc nh cc

ting thi trn y.

Thng th nghe ting thi tm thu xut hin ngay sau ting th nht ca tim nhng v tai ch

phn bit c nhng thi khong khng qu ngn, cho nn khi nghe tim thy ting thi tm

thu chim ht c th tm thu, che lp c ting th nht.

Ting thi tm trng thng ch chim mt phn th tm trng v nghe st lin ting th hai

ca tim.

Trong ting thi lin tc, khng c khong ngh cui tm thu sang u tm trng.

PHN LOI CC TING THI

Ngi ta thng phn bit hai loi ting thi:

Gm c:

- Ting thi thc th.

- Ting thi chc nng.

Ting thi thc th l do c tn thng thc s cc van tim gy nn, v d vim gan hai l,

vim van ng mch ch. Nu khng c tn thng van tim nhng v bung tim b gin to v

mt l{ o no m cc van tim khng ng c kn mi khi co bp, s gy nn ting thi

chc nng.

1. Ting thi thc th.

a. Tnh cht lm sng ca ting thi thc th.

+ V tr: tuz theo tn thng van no, ting thi s nghe r nghe ca l van (van hai l,

van ba l, van ng mch ch, van ng mch phi). V d: ting thi tmthu mm tim trong

bnh h van hai l, ting thi tm trng lin sn hai bn phi v lin sn 3 tri xng c

trong bnh h van ng mch ch.

+ Thi gian: ting thi c th chim c hoc chim mt phn th tm thu hoc tm trng. Nu

ting thi c lin tip c hai th tm thu v tm trng th gi l ting thi lin tc, ting thi

ny nghe nh ting xay la nhng thng mnh hn trong th tm thu.

+ Lan truyn: trong a s cc trng hp ting thi thng lan truyn theo hng i ca dng

mu. Sau khi nh r ni ting thi nghe r nht, ta thay i dn v tr nghe ta s thy cng

ting thi gim dn n mt lc khng nghe r na. Ni ting thi nghe r nht l v tr tn

thng, cc ni khc nghe t r hn l ni ting thi lan n.

V d: ting thi tm thu mm lan ra nch gp trong bnh h van hai l.

+ Thng xuyn: ting thi nghe thy thng xuyn mt th no ca chu chuyn tim. N

khng thay i nu ngi bnh thay i t th. V vy bao gi ta cng phi nghe tim ngi

bnh nhiu t th khc nhau: nm nga, nm nghing, ngi

Cng , m thanh, m sc: ting thi nghe trm trm nu dng mu qua mt l tng

i to, m thanh nghe cao nu l nh hn. Am sc cao, th rp khi cc thnh ca van tim

chai cng. Ti