Nội Cơ Sở 2nd Edition - Nhóm Sinh Viên Y4, Y5, Y6 [Bongpet Y Khoa]

7/13/2019 Ni C S 2nd Edition - Nhm Sinh Vin Y4, Y5, Y6 [Bongpet Y Khoa]

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NI CSDa trn cun s200 triu chng ca Y3

2ndedition

BIN SON:

NHM SINH VIN Y4, Y5, Y6


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LI TA:Cun schny ch l do 1 nhm sinh vin bin son, nn cha nhiu thiu st.

Nhng thng tin c tng hp t nhiu sch v chng ti u c ch thch ngunca nhng thng tin . Chng ti mong mun n s c ch cho cc bn trong tthc tp lm sng sp ti.

Nu cc bn pht hin ra nhng li sai trong sch, hoc c ch no thc mc, xinhy phn hi li cho chng ti, chng ti c th sa cha kp thi. Hoc trongqu trnh hc mn Ni Khoa ny, cc bn thy c nhng thng tin no hay munchia s, nhng cu hi thi lm sng hay, thm ch nu bn thy triu chng nocha hi lng v tm huyt mun son li th chng ti cng sn sng tip nhn, cun sch ngy cng hon thin, gip tt nht cho cc th h sinh vin tiptheo!Mi kin ng gp gi vemail: [email protected]

09/2010


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Mc lc:Chng 1: Tng qut............................... ..07Chng 2: Tim mch......35

Chng 3: H hp..101Chng 4: Tiu ha143Chng 5: Huyt hc.197Chng 6: Thn tit niu....225Chng 7: C xng khp.263Ph lc 1.281Ph lc 2.283

Ph lc 3.291


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CHNG I

TNG QUT


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Thiu Oxy m khng tm: thmuKhng thiu oxy m tm: a hcu

1. DA XANH TM DA XANH BC THIUMU:DA XANH TM:

NHNGHA

- L tnh trng xut hin khi lng Hb kh >5g/dlhoc >33% (lu, ng vi tnh trng Hbkh tng th lng Hb xy ho cng gim, tuy nhin phi c nh ngha theo Hb kh, chc ngm hiu l xanh tm xut hin trong tnh trngthiu xy).

- Ch con s tuyt i l >5g/dl l quan trng v c gitr hn khi c s thay i v hm lng Hb mu ch sphn trm ch tham kho.

- Tnh trng xanh tm khng t l thun vi t nh trng thiu

oxy t chc. Vn c trng hp gim cung cp oxy chot chc m khng xanh tm v ngc li.

V D

- Khi thiu mu:do lng Hb gim nn khng c Hb trao i Oxy ti phi,dn n gim Hb02 trong mu ng mch. Khi n cc m, t bo tng s dngoxy nn t lHb kh tng cao, nhng khng c xanh tm v nng Hb kh thcra vn thp. (trng hp ny c triu chngDa bc mu)

- Bnh a hng cu:Do s lng Hb cao nn khi ln phi khng trao i ht vioxy, dn n tng Hb kh ngay trong mu ng mch. Nu c ri lon h hp th

rt d b xanh tm hn ngi bnh thng, v s lng Hb kh vn cao.

PHN LOI

Xanh tm trung ng:

Th hin s km bo ha mu ng mch, SaO2


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HbCO khng gy xanh tm vHbCO khng phi l Hb kh

Lu :HbCO khng gy ra xanh tm, v HbCO khngphi l Hb kh, trn lm sng bnh nhn b ng cCO da vn hng ho nh thng, thm ch hng hohn.

N xut hin u tin cc vng da mng hoc nim mc nh mi, u li, di li,

mng tay chn, mi mt di, tuy nhin n c th xy ra bt c ni no trn da v nimmc.

Xanh tm ngoi vi:

Th hin s chm chp, gim hoc tctun hon ngoi vi:

- Shock(tt c cc loi shock tr Shock nhim trng giai on u(shock nng))- Gim cung lng tim (nht l suy tim mn)- Co mch (do lnh, do St, u tit Adrenalin, ri lon Thn kinh thc vt,vv)- Huyt khi tt mch Thuyn tc mch mu

Khng c ni xanh tm ngoi vi l loi xanh tmchkhu tr ngoi vi m thi v n c thnh hng rng (3 nguyn nhn u), tuy nhin xanh tm ngoi vi khng bao gi nh hngnim mc. in hnh, thng thng xanh tm ngoi vi thng xut hin nhng khu vc khngc che y nh ngn tay, ngn chn, mi, tai. Cn mt trong m v di li vn .

i vi xanh tm ngoi vi: Ci thin tun hon ti ch (khng shock lnh xy ra, tng timu ngoi vi bng cch tng cung lng tim bnh nhn suy tim, lm gin mch, gii quythuyt khi...) s ci thin c triu chng.

Ngun: SLB - YDH

METHEHOGLOBIN:

- L 1 dngHb trong st trong nhn Heme dng Fe3+ thay v Fe2+ nh mnh thng. Vth, n khng c kh nng vn chuyn v phn phi O2 cho t chc.

- Bi v Hb l 1 cht vn chuyn chnh O2 ca c th, nn khi 1 lng ln Hb chuyn thnhMetHb s dn n tnh trng XANH TM do thiu O2.

- Tuy nhin, bnh thng vn c 1 lng nh MetHb trong mu (


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NI C S 1

- Mc phi:ph bin hn, do c th tip xc 1 s tc nhn ha hc v thuc nh:o Thuc gy m nh Benzocaine v Xylocaine.o Benzene.o Mts khng sinh ( Dapsone iu tr phong, chloroquin st rt).o Nitrites ( dng bo qun tht).

TRIU CHNG

- Xanh tm.- Mu mu socholate do tng lng Hb kh.

IU TR

- Truyn tnh mch Xanh Methylene ( Methylene Blue) l liu php vng, c tc dng hotha h reductase.

- Acid ascorbic: l 1 tc nhn kh c dng nh liu php h tr.

Ngun: Internet

SULFHEMOGLOBIN:

- L 1 bnh him, xy ra khi Sulfur gn vi phn t Hb. Khi S- lin kt vi Fe2+, Hb khngcn kh nng vn chuyn O2 na.

- Sulfhemoglobin l 1 dng Hb c mu xanh, khng vn chuyn c O2 v gy ra tnh trng

xanh tm 1 nng rt thp.

NGUYN NHN

- Ung thuc cha sulfonamides (v d qu liu Sumatriptan). - Do tip xc ngh nghip vi ha cht cha sulfur.- 1 s thuc khc nh acetanilid, phenacetin, nitrates, trinitrotoluene.

TRIU CHNG

- Da, nim mc tr nn xanh.

- Cng thc mu cho thy hng cu bt thng.

IUTR

- T lnh do s sn xut hng cu t ty xng dn dn thay th nhng hng cu gi.- Truyn mu trong nhng trng hp nng.

NGUN : WIKIPEDIA, SLB-YDH, MEDLINE PLUS, MEDICINENET


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DA XANH BC THIU MU

NH NGHA

- L sgim lng hemoglobin(gim c Hb xy hov Hb khl nhng cht to ra mu cho mu) mu ti n khu vcda hoc nim mc, to nn 1 mu ti. Nguyn nhn c thdobnh l, shock cm xc, stress, thiu mu, di truyn. R nht l mtv lng bn tay. Nc th pht trin t t hoc t ngt, ph thuc vo nguyn nhn.

C CH

- Thiu Hb: bnh thiu mucc nguyn nhn tr Thiu mu huyt tn v triu chng Vng dani bt hn.

- Gim ti mu ngoi vi:gim cung lng tim, huyt khi ng mch, co mch ngoi vi ,chn p khoang (compartment syndrome).

(Cc bn s thc mc ti saoc ch Gim ti mu ngoi viging vi Xanh tm ngoi vi,thc ra nguyn nhn ny ban u c triu chng Xanh tmdo Hb kh, suy tun hon ngoi vi lnguyn nhn chnh gy ra tnh trng . Ngc li,da bc mu l do s gim hoc cn tr sdy chuyn ca Hb k c kh v khng kh ra ngoi vi nn mi gy ra triu chng , chnh vvy ni nDa bc muth ngh ngay n thiu mu, t ngh n cc nguyn nhn khc)

2. NT NHN ( NT SAO, NT MCH):M T

- Kch thc:0,5- 1 cm.- Trung tm nh ln, xung quanh cha ra nh

chn nhn v bng ln, n vo khng binmt. (cn phi m t c)

- V tr: mt, c, vai, ngc, cnh tay, lng bntay, nim mc ca mi v mi.

- 1 nt hoc nhiu nt.

C CH- Gin mch, mu cc mch mu rng lm

cc mch mu l r di da.

NGUYN NHN

- Hu ht cc trng hp l do x gan: gimthi gian bn hy ca estrogentng estrogentrong mu (nhiu nt)


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NI C S 1

- Hng ban:n tay vo th binmt

- Xut huyt:n tay vo khngbin mt (bnh st xuhuyt)

- Cc trng hp tng estrogen khc : Mang thai, thuc nga thai. Chng thng xut hin vothng th 2,3 khi mang thai, sau ln dn, nhn ln v bin mt khong 6 tun sau khi sinh.

- ng 1 s cht gy gin mch ( histamin, leukotrien, serotonin)- HC nhim c gip.- Thnh thong cng gp ngi gi, nhng t v nh(c l lin quan n ni tit t, c bit

l estrogen v progesteron).

CHN ON PHN BIT

- Gin mch:

Rng: Hng ban, bin mt khi tay vo (thnghn, st pht ban, thp khp cp)

Su:Nt nhn

X GAN

Nhiu nt nhn xut hin l du xc nhn ca x gan. Tuy nhin, chng l nhng du hiumun, s lan rng v to ca cc nt nhn l ch im bnh ang tin trin, cn thm khm cc cquan khc pht hin x gan nh tng p tinh mch ca, lch to, nn ra mu, vng da, ban

Tng quan v Tnh trng mt nc v nc trongc th:

Nc trong c th tn ti 2 khoang: Ni bo (trong t bo) v Ngoi bo (mu,khoang c thv khong k). Ngoi ra cn khoang th 3 nh: khoang mng phi, mng bng

Lng nc trong c th cng c 2 dng ri lon chnh: Mt nc v nc.

V vy c th tm gn nh sau:

- nc gi l Ph, nc ni bo c Ph no, Ph nim mc, Ph vim, Ph t bo ca 1c quan no , cn li danh t Ph dng ch nhng ri lon ca nc ngoi bo.(vvy mt cch tng i nhc n Phl ni n nc ngoi bo)

- Mt nc ngoi bo th hin du hiu bnh l v tim mch v du n hi da- nc ni bo gy triu chng no c ch (ph no)- Mt nc ni bo gy triu chng no kch thch (teo no)


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4. TNH TRNG MT NC.

Trong phn ny, bn cnh vic m t triu chng ca 3 loi mt nc, chng ti ch trng thmvic gii thch mt s ri lon in gii.

NGUYN NHNLOI MT

NCNGUYN NHN C CH LM SNG

NGTRNG

- Mt mu

- Tiu chy

- Nn ma

- Mt 1 lng nc v Na+ nhnhau.

- V th khng c s thay i cap lc thm thu v nng Na+

huyt tng.

- Khng c s dch chuyn ncgia ni bo v ngoi bo: nc b

mt ch yu ngoi bo, trong khini bo vn bnh thng.

- Da kh, nhn nheo, n hi da gim(du Casper), mt trng, np vo da

mt chm

- Du chng tim mch: Gim lu lngtim, nh p tim nhanh, mch yu, mtmi, th i gian lm y mao mch

gim.

- Shock gim th tchnu mt nhiunc.

- Lng nc tiu gimsuy thncp.

U TRNG

- Mt mt lng dch nhctrng: ra m hi, i tho

nht, li tiu thm thu (tngglucose niu)

- Ch mt nc: nc bc hiqua da.

-a vo c th mt lngdch u trng: thuc chanhiu Na, truyn NaHCO3,

ung nc mui

- Do mi trng ngoi bo l mitrng u trng, nc s dchchuyn t ni bo ra ngoi bo.

- Nng Osmol mu s tng.

- Nng Na s tng.

- Du chng Tim mch v n hi danh trn, c km theo:

- Tng thn nhit, lo lng, hn m.(Triu chng no dng kch thch)

NHCTRNG

-H Na mu

-Mt mt lng dch utrng.

-a vo c th mt lngdch nhc trng:ungnhiu nc, x gan, hi

chng thn h.

- Mi trng ngoi bo l mitrng nhc trng, nc s dchchuyn t ngoi bo vo ni bo.

- Nng Osmol mu gim.

- Nng Na+ mu gim.

- Du chng Tim mch v n hi danh trn khuynh hng dn n

ngt, t t hn m.

- Tng p lc no ty ( do nc c xuhng i t ngoi bo ni boph

no) cc Triu chng no dng cch.


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TM TC DI DNG S

BNH THNG:

NG TRNG:

1. Mt mt lng Na v H2O tng ng nhau

2. a thm vo mt mt lng Na v H2O tng ng nhau:


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NI C S 16

NHC TRNG

1. Mt mt lng Na+ nhiu hn so vi H2O

2. a vo mt lng nc nhiu hn so vi Na+:

U TRNG

1. Mt mt lng nc nhiu hn so vi Na+: mt nc u trng

2. Thm vo 1 lng Na+ nhiu hn so vi nc:


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KT LUN:

DUNG DCH SALINE (0.9%)

- y l dung dch cp sut thm thu xp x bng vi huyt tng. N c s dng truyn cho nhng bnh nhn b mt dch c cha Na+ (mu, tiu chy, ra m hi) duy trhuyt p bnh thng.

- Khi truyn vo, hu ht saline s i vo khong k v vo trong t bo, mt phn nhs gili trong lng mch (cn nh l th tch lng mch ch chim 1/3 th tch ngoi bo, v thtch ngoi bo chim th tch ngoi bo)v lm nng huyt p ln.

- Mt s dung dch khc cng c th c s dng nhng gi c hn bao gm Ringers latatev albumin 5%.

TRUYN DCH CHO BNH NHN B H NA+ MU:

- Bt c nguyn nhn g gy h Na+, th vic iu chnh Na+ mu tr v mc bnh thng cnc thc hin mt cch chm ri trong 24h u.

- Nu vic iu chnh Na+ mu qu nhanh, s gy ra t nh trnghy myelin cu no, 1 bnhl khng phc hi c.

PHN LOI MC MT NC THEO IMCI (INTERGRATEDMANAGEMENT OF CHILDHOOD ILLNESS)

- IMCI l mt chng trnh lng ghp x l cc bnh thng gp tr em, s c hc Nhikhoa.

- , ngi ta phn loimt nc tr em nh sau:


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NI C S 18

Hai trong 3 du hiu sau:

- Li b hoc kh nh thc.- Khng ung c hoc

ung rt km- Mt trng.

- Np vo da mt rt chm

MT NC NNG

Hai trong 3 du hiu

- Vt v, kch thch.- Mt trng.- Ung ho hc, kht.- Np vo da mt chm.

C MT NC

Khng cc triu chng trn KHNG MT NC

Da vo s phn loi nh vy, ta c th bit c cc du hiu nng ca mt nc, giai on ubnh nhn s vt v kch thch, rt mun ung nc, nhng sau , bnh nhn s tr nn li b vkhng ung nc c na.

MT S HI CHNG C LIN QUAN N RI LONIN GII:

HI CHNG ADDISON (Adrenal insufficiency):

- Nguyn nhn thng gp l do s ph hy v thng thn c ngun gc t min.- C ch bnh sinh ca nhng ri lon in gii:thiu ht Aldosterol v nhng hormon khong

khc.- Lm sng:

o H Na+ mu v tng K+ mu: Do vai tr ca Aldosterol l gi Na+ v bi tit K+, by gi thiu Aldosterol

s gy mt Na+, v gi K+ (xem minh ha) Mt mt lng Na+ u trng trong nc tiu. Cc triu chng ca mt nc.

o Gi ion H+, gy ra acid chuyn ha.

Do mt hot ng ca bm H+/K+ ATPase.


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NI C S 1

Addison: nhc nng v thngthnConn:cng aldosterol tin pht

Thuc li tiu quai Furosemide

(Lazix) l mt loi thuc c sdng nhiu iu trsuy tim. Cch tc dng ca thuc l c chhot ng ca bm Na+, K+, 2Cl-,t lm gim ti hp thu nhngcht ny. Ngoi ra, thuc cn cs dng iu tr tng Ca+ mutheo 1 cchring.

HI CHNG CNG ALDOSTEROL TINPHT (HI CHNG CONN)

- Do u tuyn vng cu ca v thng thn (vng

cu tit ra aldosterol)- C ch bnh sinh ca nhng ri lon in gii:

tng hot ng ca aldosterol- C ch ca cc triu chng lm sng:

o Tng ti hp thu Na+ v t tng bi titK+, H+.

o Tng ti hp thu Na+ s lm tng Na+ mu.o Tng bi tit K+ s lm gim K+ muo Tng bi tit H+ s dn n nhim kim

chuyn ha.- T ta suy ra cc triu chng lm sng:

o Tng huyt p do gi mui.o Tiu nhiu v yu c do h K+ mu.o Cn lm sng c: Tng Na+, h K+, nhim kim chuyn ha.

HI CHNG BARTTER:

- Dch t hc: thng gp tr em.- C ch bnh sinh:

o Ri lon thn khng c kh nng ti hp thu Cl- bm Clo ( Na+ - K+ - 2Cl-) C ch ging nh thuc li tiu

quai.

o T mt Na+, K+ v Cl- trong nc tiu: MtNa+ s gy ra h Na+ mu.

o Lng Na+ ng lng xa s nhiu hn,t lm tng s ti hp thu Na+ ti v tr (nh Aldosterol), t tng bi tit K+v H+: Gy ra h K+ v nhim kim chuyn ha.

o Tnh trng h K+ s kch thch s sn xut prostaglandinti thn. Gy tng sn t thc cnh cu thn. Tng tit renin v gy ra cng aldosterol.

- Triu chng:

o Huyt p bnh thng (khng phi tng huyt p), do t nh trng gin cc tiu ngmch ngoi bin do prostaglandin.o Yu c do h K+ mu.

- iu tr:o Thucli tiu gi K+: gim bt s mt K+o Thuc khng vim non steroid (NSAIDs: non steroid anti inflamatory drugs):

lm gim bt s tng hp ca prostaglandin.


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NI C S 20

Lu: Nu lng dch mt l nhc trng(mt nc nhiu hn mt mui), ngi ta gi l mtnc u trng, ngc li nu lng dch mt l u trng(mt nc km theo mt rt nhiumui), ta gi l mt nc nhc trng.

Ngun: SLB- YDH

Tng quan Ph:nh ngha:Ph l sng n phn mm do nc trong m k(NCS HYD Hu)

i vi a phn cc trng hp Ph, ngi ta nhn thy bin i lng nc trong Ni bothng biu hin triu chng chm hn so vi bnh cnh Ph, v vy cc triu chng no do mthay nc ni bo t c nhc n.

Ph c 3 loi chnh:- Ph ton: thng lin quan n s ri lon cc loi p lc lng mch-khong k m

nguyn nhn t cc c quan m bnh l ca n nh hng n ton thn nh tim, gan, thn.- Ph khu tr:thng gp l nhngri lon do tng tnh thm thnh mch: vim, d ng,

phn v; Ph do tc nghn lu thng tun hon khu tr: Ph o khoc (do tc TM chtrn), ph bch mch (do giun ch); Ph do lng ng cht peptido-glican: Ph nim

- Ph t th:c th gp nhng ngi phi nm lu, khng c kh nng thay i t th trongmt thi gian di.

Nhng triu chng 5,6,7 ch yu ni v ph ton:


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NI C S 2

Kochar's Clinical Medicine for Students, 5th Edition

5. PH DO SUY TIM

M T

- Gim lng mu v tim phi trong suy tim phi gy mu ngoi vi ph ngoi vi.- Gim lng mu v tim tri trong suy tim tri gy mu phi ph phi

PH TRONG SUY TIM PHI:

C CH:(Trong mi triu chng Ph thng c nhiu c ch phi hp, cn nm C ch chnhv cc c ch ph hiu cho ng)

- C ch chnh:- Suy tim phi mu tnh mchTng p lc thy tnh ti mao mch ngoi

viC ch chnh + c ch khi u.- C ch ph:Gim ti mu thn hot ha h RAA tng gi nc gi mui tng plcthm thu ngoi bo.

- Nhng c ch khc:o Gim p lc keodo gan gim tng hp Protid (giai on saux gan tim).o Tng tnh thm thnh mao mchngoi vi ch yu do thiu O2, toan chuyn ha v

tn thng t bo biu m mch mu v mt vi th,gy gin mch.


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NI C S 22

KHM:

Ph trong suy tim phi:

- V tr:o Ph chi dil ch yuo Lc u ph t v chxut hin v chiusau khi ngi bnh ng lu mt i vo sng

sm khi ngi bnh ng dy.Gin tip phn nh chc nng tng mu ca mt tim bsuy cng km hn sau mt ngy phi lm vic

c im:

- Ph mm, n lm (khng c gi l ph trng cng, 1 s sch ghi l ph tm song trn lmsng chng ti nhn thykhng tht s tm lm).

- Giai on sau c trn dch a mng, Rivalta(-).- Ngh ngi, n nht, tr tim, li tiugim ph.

Triu chng km theo:

- Gan to, mm,n tc(c 2 giai on: Gan n xp vX gan tim). C th to thm hoc nh btty theo mc gng sc.

- Tnh mch c ni, phn hi gan, tnh mch c dng tnh.- Kh th.

PH TRONG SUY TIM TRI:

- Suy tim tri s gy mu phi, t gy ph phi.- Tuy nhin, vo giai on cui khi c 2 bung tim phi v tri u suy th s gy ra ph ngoi

bin nh trong suy tim phi.

Ngun: Ni c s - YHN, SLB YHD

6. PH DO SUY THN:Ph trong suy thn cn phn bit r 2 dng, v c c ch khc nhau, l ph do hi chngthn hv ph do vim cu thn (cp hoc mn).

PH DO HI CHNG THN H:

C ch:

- C ch chnh:Do gim p lc keo huyt tng.o Do mt Protein qua thn gim p lc keo trong mu nc trong lng mch i vo

m k.- C ch ph:T gim th tch trong lng mchgim lng mu n thnhot ha h

RAAgi nc gi muiPh.


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NI C S 2

M t:

- c im:o Ph xut hin t ngt,rt to v pht trin rt nhanh.o Ph trng, mm, n lm.o Ch n nht khng gim ph(v c ch gy ph l gim Protein mu)

- V tr:o u tin xut hin mi mt, mtri cc ni khc.o Khng c s lin quan v thi gian trong ngy hoc t th ngi bnh (1 s ti liu

m t ph bui sng lc bnh nhn ng dy, c l lin quan n s gim mc lc cuthn sinh l trong qu trnh ng, cng lm tng qu trnh gi mui, nc trn nnmt bnh thn c t trc).

o Tuy nhin, nu ph to km theo bnh nhn nm lu, ph c xu hngtp trung nhiucc vng thp nh lngv mt sau i, c bit c kh nng gy trn dch nhiu nnc khi xut hin C chng trc khi xut bin ph ton thn.

- Triu chng km theo:o Trn dch mng phi, trn dch mng bng (trn dch mng bng xy ra nhanh c th

gy cn au bng cp). Khi c trn dch mng bng lng ln cng thc y lm tngph hai chi di do lm tng p lc bng, cn tr lu hi mu ca tnh mch chdi.

o Nc tiu cha nhiu protein (>3,5g/ngy).o Tc lng mu tng, Protein mu gim, Lipid mu tng.o Ure, cre khng cao nu cha c suy thn.

PH DO VIM CU THN CP V MN

C CH:

- Gim thi Na v nc do thn gim lc (tng lng Na c trong c th, tuy nhin xtnghim c th thy Na bnh thng hoc khng tng l do nc)

M T

c im:

- Ph xut hin t t,c th t hoc nhiu.- Ph mm,trng, n lm.- Ch n nht lm gim ph r rt.

V tr:

- Xut hin u tin mi mt, mt ri n ni khc.- Ph thng xut hin vo bui snglc ng dy.

Triu chng km theo:

- Thng km theo tng huyt p, protein niu, hng cu niu. - C th trn dch mng phi v c trng nu ph nhiu.


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NI C S 24

- Nc tiu t.C th khi pht suy thn cp trong bi cnh ca vim cu thn cp.

IU TR LI TIU TRONG HI CHNG THN H:

- Trong hi chng thn h, khi s dng li tiu, phi cn nhc liu lng, loi thuc v th tchhuyt tng bnh thng hoc gim nh.S dng li tiu ba bi, khng ng ch nh cth khi pht suy thn cp (trn nn c hay khng c suy thn mn trc ), cng lm nngthm bnh cnh hin ti.

Ngun: Ni c s - YHN, Bnh hc thn SH

7. PH DO X GAN:C CH

C ch chnh:

- Do tng p tnh mch ca(ni chnh xc l Tng p lc thutnh khu tr ti TM Ca).- Do gim p lc keo huyt tng(Gim tng hp albumin).

C ch ph:

- Tng p lc trong bng do dch bng nhiu gy ph 2 chn.- Chc nng gan suy yu nn gim ging ho cc cht steroid nh MineroCorticoid v

GlucoCorticod gy ng nhiu mui v nc, gin mch, gim sc bn thnh mch.- Ngoi cc c ch trn th ph hai chi di cn l do hu qu ca dch bng lm cn tr hi lu

mu tnh mch ch di.

C IM PH DO X GAN

- Mc khng bng ph do suy tim phi.- Ph trng, n lm.- Thng km theo C trngvi dch thm v tun hon bng h kiuca ch.- (C trng (bng) l mt danh t ring gi mt loi ph ch khu tr trong bng, phc

mc)


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NI C S 2

KHM

HI CHNG SUY GAN:

- Chn n, n chm tiu y bng.- Ph n: Ri lon kinh nguyt. n ng: V ln, lit dng, teo tinh hon, gim kh nng

tnh dc...( gan suy, lm tng thi gian bn hy ca cc hormon sinh dc c bit lestrogen). Vn ny kh t nh nn khi khm thng b b qua, tuy nhin n li rt c gitr trong bi cnh bnh.

- Chy mu chn rng, chymu cam, chy mu di da (gim tng hp cc yu t ng mu,gimt prothrombin).

- Lng tc d rng.- Mng tay khum, ngn tay di trng: gp trong x gan mttin pht (bnh Hanot - mt bnh

t min, c th n choc phi hp vi cc bnh khc nh vim tuyn gip t min, bnhkh tuyn...Cng vi x gan tim, l hai bnh x gan nhng khng bao gi tin trin n ungth gan.. ).

- Vng da (ty nguyn nhn m c vng da nh hay nng. V d: Trong x gan mt, bnh

Wilsonth da rt vng, ngc li trong x gan do vim gan mn th t vng hn..).- Thiu mu.- Nt nhn ngc v lng- Hng ban lng bn tay.- Vim dy thn kinh ngoi bin

HI CHNG TNG P TNH MCH CA:

- Tun hon bng h kiu ca ch hnh u sa rn hoc ch ch phi hp.- Lch ln: lc u mm, v sau x ha tr nn chc hoc cngchm (+).- C trng: th t do.

- Tr.- Tnh mch trng thc qun.

NOTE:

- Ngoi 3 loi ph thng gp trn, ta cn c th gp cc loi ph khc do: suy dng, suygip, basedow (ph nim), ph do giun ch (ph bch mch, n au), ph do d ng (phQuinke)...

Ngun: Ni bnh l YDH, Ni c s - YHN


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NI C S 26

8. LN TUYN GIP

Nhn:Phn bu gip ln:

0 : Tuyn gip ko ln. Ia : Nga cvn khng thy, chsmi thy. Ib : Nga cvn nhn thy c (


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NI C S 2

- S thy rung miu, s nng lanh ca tuyn gip:nu thy co rung miu tng ng vi s tngsinh mch mu, nu s thy nng thi nghi ng tuyn gip b vim.

Nghe:

- Nghe ting thi bu nguyn nhn l do tng s cung cp mu ( do tng chuyn ha)trong

cng giphoc thng thng l do s dng thuc khng gip.- Chn on phn bit vi thi ng mch cnh.

nn c, ting ng mch cnh bin mt lin.

Ngun: Oconnor clinical examination

1 S DU HIU QUAN TRNG KHI THM KHM TUYN GIP

- Du Pemberton:o Bo bnh nhn nng 2 tay ln cng cao cng tt. Ch 1 lc sau quan st du hiu xung

huyt v xanh tm mt. Km theo l du hiu suy h hp ( kh th) v m thwheeze (stridor) (bo bnh nhn ht th su nghe). Quan st tnh mch c c scngphng. Du ny nh gis ln ca tuyn gip.Du hiu ny thng gp trong bugip n, bu gip a nhn...

- Du Stellwag:o Co ko mi trn ca mt khi bnh nhn nhn bnh thng.

- Du Von Graefe:o Bt ng vn gia vn ng ca nhn cu vi m trn khi nhn xung (dng ngn tay

hoc cy bt t trc mt bnh nhn ri t t di chuyn xung, sau xem s di chuynca m mt khi mt ca bnh nhn c nh n theo. Du hiu dng tnh khi c b cng mcxut hin gia b m mt trn v ng t)

Hnh: Du Von Graefe

- Du Moebius:o Sai lch ca s xoay nhn cu.

- Du Joffroy:o Bt ng vn gia trn v m trn ca mt tc l mt np nhn trn khi a mt nhn ln.

Ngun: Ni c s - YDH


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NI C S 28

9. HCH BCH HUYT LN

KHM

- V tr : h chm, trc v sau tai, dc M Cnh, di hm, di cm, h thng n, nch,khoeo, bn.

o Hch bn thng ngh n da liu, ung th hch, bnh l c tnh vng tiu khung.- Th tch v mt (hch ung th trong bnh Hodgkin thng to hn, hch trong di cn ca ung

th thng nh).- Hnh th:

o Trn nhn: lao hch.o Khng u: ung th (do dnh vo nhau hoc vo t chc xung quanh)

- Di ng:hch trong bnh bch huyt di ng r rng. Ung th th di ng giai on u, giai

on sau dnh vo t chcsu

ht di ng.- au:Vim hch thng au, nng. Hch ung th v trong cc bnh khc th khng au. Nhngnu c chn p thn kinh th vn c au.

C ch: vim nhim (cc hch gc thng ln, n khng au, di ng...l trng hp khthng gp trong cc bnh l nhim trng cc vng tng ng. Trong trng hp ny, hch str li bnh thng sau khi bnh l nhim trng c chm dt mt cch t nhin hay do ktqu ca iu tr), cc nguyn nhn c tnh ( tin lng xu).

NGUYN NHN

Vim hch cp tnh:- Vim nhim 1 vng: vim hng hch di hm, nht i hch bn, Zona ngc

hch nch.- Bnh dch pht ban : hch ni nhiu ni, c, nch, bn, hch to di ng d d ng. Khng au,

lnh tnh.- Nhim khun c tng bch cun nhn:hch ni ln nhiu ni, khng au, i ng, mt

chc

Vim hch mn tnh:- Hch do c a:Nhng ngi gy yu.- Hoa liu:

o Giang mai giai on 1: Gn ch xm nhp ca xon khun, c 4 - 5 hch, hi rn, di ng,khng au. Giai on 2 th c th gp mi ni.

o Bnh Nicolas- Favre ( hch to bn( Qu xoi)).- Lao hch: lc u hch thng 2 bn c trc v sau c c n chm, sau ni lan ln hch sau

gy v xung h thng n. t gp nch hoc bn. Ni thnh tng chui.- Hch ung th:


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NI C S 2

Hch di n tri (Virchow): ungthbng.Hch di n phi: ung thphiv thc qun.Hch quanh ng mch ch: ungthtinh han.Hch nch: ung thv.Hch nch (Irish), hach quanh rn(Sister Mary Joshep), u bung trng(Krukenberg) : gp trong K d dy.

o U lympho khng Hodgkin:o Ung th hch do di cn.

- Bnh v mu:o L x mi kinh thlympho hch to 2 bn nhiu ni: c, nch, bn, th tch thay i.o L x mi cp : di hm + c ( Hodgkin).

- Hch to trong bnh sarcoidose ( km gan, lch to, tng Ca mu v Ca niu)

- Lupus ban ri rc (c th km theo lch to).

KHM 1 BNH NHN C HCH LN

Da vo nhng d kin sau c th khu tr chn on:

- Tui:o Nu bnh nhn < 30 tui, khm thy hch ln, th thng l bnh lnh tnh (vim chng

hn) (80% trng hp)o Nu bnh nhn > 30 tui, khm thy hch ln, th thng l bnh c tnh (60% trng

hp)- Khm thy hch au:y l 1 ch im ca vim (v d do nhim khun)

o Khu tr: l v tr tp trung ca bch cu gp trong nhim khun, v d nh vim hng. Nhng v tr thng gp: hch c trc, hch bn.

o Lan ta: Ch im ca 1 bnh h thng. V d: bnh tng bch cu n nhn nhim khun (infectious mononucleosis,

bnh lupus ban h thng (SLE)- Khm thy hch khng authng l ch im c tnh

o Hch thng chc v dnh cht vo m xung quanh.o Nu khu tr:

L v tr di cn ca ung th: v d nh di cn hch nch ca ung th v. U lympho horkin

o Nu khng khu tr: Di cn trong bnh leukemia (ung th bch cu, hay cn gi l bnh mu trng) U lympho follicular B cell

MT S V TR HCH DI CN THNG GP

- Hch di cm: Di cn ca ung th t bo vy(squamous cell carcinoma) nn ming.

- Hch c:di cn ca nhng khi u u v c (thanhqun, tuyn gip, mi hu)

- Hch di n tri (hch Virchow):o Cc khi u bng (v d d dy, ty)

- Hch di n phi:o Di cn ca ung th phi v thc qun.o U lympho Horgkin


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NI C S 30

- Hch nch:ung th v.- Hch mm trn rng rc:

o 1 bn: thng l do nhim khun bn tya, u lympho khng Hodgkin.o 2 bn: bnh sarcoidose.

- Hch rn phi 2 bn:o Ung th phi.

- Hch trung tht:o Ung th trung tht.o U lympho Horgkin (c bit l th x ha nt)o T cell lymphoblastic lymphoma

- Hch hch nhn (amydal)o Di cn ca ung th t bo vy ca ming.

- Hch xung quanh ng mch ch:o Di cn ung th tinh hon.o U lympho Burkitt.

- Hch bn:o Ung th dng vt v m h, vng tiukhung.

Ngun: Ni c s - YHN & Bs XunTi


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NI C S 3

10. NGN TAY CHN HNH DI TRNG,NGN TAY KHUM MT KNH NG HNGUYN NHN

Ph binTim mchBnh tim xanh tm bm sinhVim ni tm mc nhim khun.

H hpUng th phi ( thng l ung tht bo khng nh)Bnh phi sng m mn tnh:

Gin ph qun. p xe phi. Vim m mng phi.

X ha phi t phtKm ph bin

H hpX ha phi thyBnh bi phi amiang.U trung biu m mng phi (Loi u x lnh tnh) hoc u x mng phiTiu haX gan ( c bit l x gan mttin pht bnh Hanot)Bnh vim rut.Tiu chy m(celliac)Ng c gipGia nh hay t pht

HimU thn kinhMang thaiCng tuyn cn gip th pht


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NI C S 32

KHM LM SNG

Cch 1: o gc gia nn mng v mng:

- Bnh thng : 160o- Nu n ln hn 180o( 1 s sch ghi l 190o) th lngn tay di trng ( minh ha).

Cch 2: o T s v chiu cao ca t ngn xa (Distal

phalangeal depth) v gian t ngn gia xa(interphalangeal depth).

- T s ny bnh thng 1, th l ngn tay di trng.

Cch 3: (lm sng)

- p 2 mt mng ca 2 u ngn tay ca 2 bn tay vo nhau, thng th gc m gia 2mng nh hoc bng 0, nu gc m ln th chnh l ngn tay khum mt knh ng h.(Cch ny chac tr s c th nhng c th p dng con s >=300)

C CH: hin cha c gii thch c th, tm thi theo 1 s gi thuyt nh:

- Lng ng cc cht, tng sinh mng xng ca GH-like trong mng tay di trng.- Tng sinh mch mu trong mng tay khum mt knh ng h.

Ngun: Professional guide to signs and symptoms, Oconnor clinical examination


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NI C S 3

MCV(mean corpuscular volume):thtch trung bnh hng cu,dng phn loi thiu mu.MCHC(mean corpuscularhemoglobin concentration):lng Hb trong 1lt hng cu.MCH (mean corpuscularhemoglobin): lng Hb trong mihng cu

MNG TAY KHUM MT KNH NG HV NGN TAY DI TRNG L 1 HAY 2?

- Thy c mt y l 2 du hiu khc nhau

-Nhngtheo ti nhn thy n ch l 1 triu chng m thi, bi l nhn vo ngn tay di trng, tithy n cng khum ging mt knh ng h ()

- Y vn cng ch nhc ti 1 thut ng l clubbing hay clubbed finger, theo Wikipedia c vitNail clubbing also known as "Drumstick fingers," "Hippocratic fingers," and "Watch-glassnails"

(Lu : y ch l kin ch quan ca nhm bin son)

BNH L TIU HA NO C NGN TAY DITRNG(1 cu hi thi lm sng):

- Bnh quan trng nht cn nh l bnhX gan mt tin pht( bnh Hanot) l 1 bnh c c cht mingy ph hy v lm x ha nhu m gan v ng mt ngi ta thng khng tm thydu hiu nhim khun v ng mt.

- 2 bnh cn li l vim rutvbnh Celliac.

Ngun: Clinical examination Oconnor, Professional signs and symptoms

11. MNG TAY LM HNH THA:NGUYN NHN

- Thiu mu nhc sc(hng cu nh)

THIU MU NHC SC

Cn lm sng:

- Thiu mu MCV


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NI C S 34

lng Hb trong hng cu gim),nhng hu ht ti liu, ngi ta s dng MCV, tuy nhinph thuc vo cc giai on khc nhau m c nhng s bin thin khc nhau v MCH,MCHC.

Nguyn nhn:

- Thiu st ( nguyn nhn ph bin nht).- Mt mu mn ( tr, chy mu tiu ha...cng gy thiu st).- Thiu mu trong cc bnh vim mn tnh- Thalassemia.- Thiu mu nguyn bo st ( ru, Isoniazid, ng c ch)Km ph bin nht.

(Cc thay i trong thiu mu s c trnh by phn huyt hc)

Ngun: Pathology


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NI C S 3

CHNG II

TIM MCH


36/329

NI C S 36


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NI C S 3

12. KH TH DO SUY TIM KHI GNG SCTHNG XUYNnh ngha :Kh th l cm gic kh khn,vng mt trong khi th ca bnh nhn. Bnh nhnthng cm gic ngt ngt, thiu khng kh phi th nhanh v nng, phi ngi dy th

Kh th lm thay i cc c im, hot ngth bnh thng ca bnh nhn nh:

- Tn s th- Thi gian ca th ht vo,th ra.- S phi hp v tham gia ca c h hp

C ch:

- ng vai tr ln nht l hin tng xung huyt phi ( dch khong gian bo hoc trong phnang (xem s bn di).

- Trong suy tim, kh th l do tr tun hon, tng p lc trong cc mao mch phi, chn p vocc tiu ph qun v c th c thot dch vo ph nang lm hn ch qu trnh trao i kh giaph nang v mao mch phi.

c im kh th do suy tim

- Kh th dai dng mn tnh,t nh ti nng.- Ch yu kh th hai th, trong hen tim cng c th c kh th ra l ch yu.- Kh th hn khi gng sc.

o Trong suy tim phi cn kh th t t din tin trong mt thi gian di, bnh nhn c ththch nghi c.

o Trong suy tim tri, cn kh th c th xy sau mt gng sc hoc vo ban m ( h phgiao cm cng tnh hn so v h giao cm) nh: cn kh th trong hen tim v ph phicp. Trong suy tim khi nm bnh nhn thy kh th hn ngi, d th hn t th Fowler.

- Kh th nhanh nng, c th c nhp tim nhanh, hi hp, nh trng ngc, ph..- Kh th gim khi bnh nhn ngh ngi, n nht, dng tr tim, li tiu.

PHN SUY TIM DA VO MC KH TH (THEONYHA):

1- Bnh nhn c bnh tim nhng khng cm thy kh chu, khng kh th khi

gng sc, hot ng bnh thng so vi la tui 2 - Kh th khi gng sc 3 - Kh th khi hot ng trung bnh, khng kh chu khi ngh ngi. 4 - Kh th ngay c khi ngh ngi hay hot ng nh

HI BNH NHN KH TH

- Bnh nhn bt u kh th khi no?- t ngt/t t, kh th nhanh/kh th chm, mt th/hai th, tng cn/lin tc ?- Hon cnh xut hin ( bnh nhn ang lm g th thy kh th/ t nhin)


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NI C S 38

- Triu chng km theo ?- Lm gim cn kh th : thay i t th, th oxy, thuc,...?- Nu kh th khi nm, bnh nhn thng phi k bao nhiu gi k u cho d th?- Tin s: nhi mu c tim, ung ru, kh th kch pht vo ban m ? ho? Khc m?


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NI C S 3

KH TH KHI NM

- L kh th xy ra khi bnh nhn nm. Cn khi bnh nhn ngi dy hoc t th Fowler hock rt nhiu gi th thng thy d chu hn.

- Nu khng c kh th nm bnh nhn t c du hiu suy tim tri.

Khi nm, mu t tnh mch ch di v tim nhiu hn, mu ln phi cng nhiu, tim suy n nkhng th gii quyt c tnh trng mu phi. Tng p lc tiu tun hon, gy ra kh th.

Ngoi ra, khi tim suy thng km tng trng lng( tim to ra ) nn khi nm tim ln phi, cntr qu trnh trao i kh phi.

KH TH V M

nh ngha: l cn kh th kch pht v m (Paroxysmal Nocturnal Dyspnea), l nhng t kh thkch pht km theo lho thng xy ra vo ban m (c th do ban m c tnh trng cng ph giaocm, tr thnh yu t thun li khi pht cn kh th) v thng nh thc bnh nhn sau khi bnh nhni ng khong 1 3h, bnh nhn phi ngi dy th th, th rt nhanh, hn hn, cm gic thiu khngkh nng.

Nguyn nhn: Do tng p lc ng tnh mch ph qun dn n s chn p ng dn kh. Bnhthng cc tnh mch ph qun mu vo chai tm nh: tm nh phi qua tnh mch n v tm nhtri qua tnh mch phi su. Suy tim tri lm cho p lc tng rt cao trong nh tri, dn n mu trongcc tnh mch phi su lm cng cc tnh mch ph qun. Nu qu cng chng c th v, bnh nhn khcra mu. Km theo l tnh trng ph m k phi s dn n s cn tr ng dn kh tng dn. Hn nav m cn c s tng hot h ph giao cm cng lm tng tnh trng co tht. kh th khi nm, triu


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NI C S 40

chng s gim bt khi bnh nhn ngi dy, cn bnh nhn b kh th kch pht v m thng ln cn hov kh th thm ch sau khi h ngi dy. Hen tim cng c lin h mt thit vi kh th kch pht v m,c c trng bi ting th rt do s co tht ph qun.

Ngun:Harrison

PHN BIT KH TH TRONG BNH TIM MCH VKH TH TRONG BNH V H HP

- Kh th do tim rt kh phn bit vi kh th do bnh l phi v nhng nguyn nhn khc.- Cn hi k tin s v nhng bnh l tim mch mc trc y m c th gy ra tnh trng suy

tim.o Tin s nhi mu c timgim sc co bp ca tm tht tri ngh n suy tim tri.o Tin s tng huyt p suy tim tri.o Tin s ung nhiu ru nng Ngh n bnh c tim do ru ( alcoholic

cardiomyopathy).o C s xut hin ca kh th nm gi nhiu hn kh th do suy tim hn l kh th

do bnh l v phi

PHN BIT HEN TIM V HEN PH QUN

Hen Tim Hen Ph QunKh th hai th, kh th nhanh nng Kh th th th ra, kh th chm ( giai on

u cha suy h hp)C tin s bnh tim mch C tin s d ng, bnh h hpPhi m Phi sng ( kh ph thng)Tng huyt p Huyt p bnh thngC rale mdng ln nh nc thy triu (khi giai on ph phi cp)

- Tuy nhin, l nhng trng hp in hnh. Trn lm sng c nhng trng hp rt kh phn

bit. Khi chng ta cn phi thm khm t m, kt hp cc xt nghim thch hp c cchn on.


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NI C S 4

13. HO RA MU TRONG HP VALVE 2 L

NH NGHA

- Ho ra mu ( hemoptysis): Mu t pha di thanh qun c tng ra ngoi sau khi ho

NH GI HO RA MU

- Mu c thc s xut pht t ng h hp hay khng ? phn bit vi nn ra mu, chy muhu hng, ming..

PHN BIT HO RA MU V NN RA MU

BIU HIN HO RA MU NN RA MUTin triu

Nguyn nhn

Hnh thi

Biu hin

Thnh phn km theo

Triu chng km theo

pH

Ho

Bnh l tim phi

C bt

ti

Ln m

Kh th

Thng pH kim

Bun nn, nn

Bnh tiu ho

Khng c hoc bt t

Nu sm, hay nu , mu b c ph

Ln thc n

Bun nn

Thng pH toan

NGUYN NHN GY HO RA MU

BNH NG H HP

- Lao phi - 81%- Gin ph qun - 8.4%

- K phi, K ph qun 3.3%

(3 nguyn nhn ngh n u tin khi bnh nhn ho ra mu)

- Vim phi, vim ph qun- p xe phi.

- Nm phi, sn l phi.- Hi chng Goodpasture.

BNH L TIM MCH

Cc bnh lm tng p lc tun hon phi:- Hp valve 2 l.

- Suy tim tri do cao HA.

- Bnh tim bm sinh

- Tc ng mch phi, v phnh ng mch phi


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NI C S 42

BNH V MU

- Bnh bch cu cp

- Bnh a chy mu- Gim tiu cu tin pht, th pht ( st xut hut)

- Cng lch.

- Suy gan ( gim yu t ng mu)

- Suy thn ( hi chng tng ure mu)-ng mu ri rc trong lng mch.

- Thiu Vitamin C.

CHN THNG NGC, D VT NG TH, TH THUT PHI- PH QUN

V CN - 1,63%.

Hi chng Goodpasture: Bnh l t min do khng th khng mng y cu thn, mng y ph nang gy xuthuyt phi v vim cu thn

Ngun: Ni c s - YDH.

CC BC NH GI V THEO DI BNH NHN HORA MU


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NI C S 4

(Ngun:Answer.com)

UI KHI HUYT TRONG HO RA MU

- ui khi huytl 1 khi nim tng trng, ngha l n khng c hnh dng nht nh mch m t s kt thc ca mt qu trnh ho ra mu.

- Trong trng hp ho ra mu ko di nhiu ngy:o S lng mu ho ra gim dn.o Sau c mu sm ri cui cng l en.

ui khi huyt.o Khi c ui khi huyt l chm dt 1 giai on ho ra mu.

HO RA MU TRONG HP VALVE 2 L

Nguyn nhn: Do v ch ni tnh mch phi v tnh mch ph qun hu qu trc tip ca tnhtrng mu nh tri lm tng p lc tnh mch v mao mch phi

C ch:

- Do tng p tiu tun hon s lm cho cc mao mch ph nang cng nh cc mao mch trongphi cng t, gin ra, thnh mch mng hn. Di p lc mu ln ng thi dng chy b chmli s y hng cu, huyt tng vo trong lng ph nang.

- ng mch ph qun nhn mu t hai ngun: MC v cc ng mch gian sn nui phi.Tnh mch ph qun mu v tnh mch n ri v tim phi( chim khong 1/3 ). T cc phqun cp ba th mu tnh mch ph qun c tnh mch phi thu nhn. l cc shunt tri phisinh l. Do s thng ni m khi p lc tiu tun hon tng s tng vic m cc shunt v tonn cc mch bng h ni tnh mch ph qun vi tnh mch phi. Cc mch mu nh nm giahai h thng c p lc cao s rt d v. Mu vo trong cc tiu ph qun gy ho ra mu.

Tnh cht :

- Thng ho ra mu tng t mt nn him khi gy ra t vong- Khi tin trin hp van hai l nng ln lm tng sc cn cho tun hon phi (gy suy tim

phi) hoc khi xut hin h/ hp van ba l cc triu chng ho ra mu, ph phi cpgim i vtn s v trm trng(gim s chnh lch p lc gia i v tiu tun hon)

Chn on phn bit

Nhi mu phi: khc m mu sm ( do km theo mt phn nhu m phi hoi t)

- L hu qu ca tnh trng tc mch phi: bnh cnh thng cp tnh, au ngc d di, khth. Cc mch mu b tc gy tn thng ni mc mch mu v phn ng ra xung quanhgy gin mch, thot mch dn n tnh trng d vim nhim, hu hoi nhu m nn bnhnhn khc m km theo nhu m hoi t.


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NI C S 44

Ph phi cp:Thng gp trong suy tim tri: do lu lng tun hon t tim tri gim t ngttrong khi tun hon tim phi cn bnh thng hoc tng do yu t bn ngoi ( truynlng dchln)dch trn ngp ph nang khc ra bt hng.

HI CHNG GNG SC TRONG HP 2 L

- Kh th khi gng sc.- Ho ra mu.- Hen tim.- Ph phi cp.

14. AU THT NGCM T

( y chng ti m t c im ca cn au tht ngc nnh)

- V tr: sau xng c.Thng bo bnh nhn dng mt ngntay ch vo ch au nht, trong trng hp ch chnh xc vovng mm tim, au nhi thong qua thng khng phi donguyn nhn mch vnh. .

- Cng : au d di lm bnh nhn ht hong c cm gic

nh sp cht- Tnh cht: nn, chn ngc, co tht, bp nght- Hng lan:

o Hng lan ln mt trong cnh tay tri n ngn tay tri4, 5.

o C th lan ln vai ra sau lng, ln c, hm, rngo Thm ch xung vng thng v

- Hon cnh xut hin: xy ra khi nhu cu oxy v cht dinh dng cho tim tng ln:

Khi gng sc, mt hoc gim khi ngh ngi, hoc dng thuc gin vnh (trinitrin).Mt s thucgin mch ngoi vi khc nh thuc chn canxi lm gim mu tnh mch tr v tim nn lm gim

hot ng c tim nn cng lm gim cn au.

- Sau cm xc- Tri lnh- Hoc mt cn nhp nhanh- Sau mt ba n thnh son


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NI C S 4

Thi gian: thng rt ngn: vi giy n vi pht. Nu cn au ko di qu 30 pht, c khnng tt mch vnh, bo hiu cn nhi mu c tim.

Gi tr chn on:c tnh trng thiu nng mch vnh

PHN LOI

Cn au tht ngc

n nh Khng n nh

in hnh Khngin

hnh

in hnh Khngin hnh

au tht ngc n nh( vi cn au tht ngc in hnh m t trn): xy ra do s hp trn 75%mt hay hp nhiu nhnh ca ng mch vnh. Lu lng vnh c th cung cp oxy cho nhucu c bn ca c tim nhng khng khi tng nhu cu - khi gng sc, do vy cn au gim khingh ngi (do gim nhu cu).

au tht ngc khng n nh(hay au tht ngc thay i hoc tng dn):

L cn au tht ngc c t nht 1 trong 3 c im:

- Mi khi pht cn au tht ngc nng (=3 cn/ngy- au khi ngh ngi hoc l ch khi hot ng rt nh nhng- Cn au tht ngc tng tin: thuc loi n nh nhng gn y au nng hn, au ko di hn,

hay xy ra hn v vi gng sc nh hn trc

(Ngun: sch Bnh hc ni khoa - H Y Dc Hu - Tp 1)


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NI C S 46

Cn au tht ngc khng n nh xy ra khi ngh ngi l 1 du hiu nguy him. N th hincc mu ng c hnh thnh v tr mng x va (m t bn di), nu khng iu tr sdn n nhi mu c tim v nhng tn thng khng phc hi.

20% tin trin n nhi mu c tim cp trong 3 thng

Thiu mu c tim th im lng

Co tht vnh(cn au ngc Prinzental) - xy ra do s co tht t ngt mch vnh ti hocgn mng x va. p ng rt nhanh vi thuc gin vnh.

Nhi mu c tim: Cn au trong cn ko di trn 30 pht, c th c tin s cn au tht ngctrc hoc khng c. au d dilan ta khp lng ngc c cnh tay tri ngn 4, 5 bn tay.

- Khng ht cn au khi dng thuc gin vnh nhanh nh nitroglycerin- Da vo in tim c 3 c im c bn

o Sng Q hoi to Sng ST chnh tn thngo Sng T thiu mu

- Cc men tim tng do hoi t ctimo Troponino CKo CKMBo LDH

AU THT NGC IN HNH V KHNG IN HNH


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NI C S 4

Lu lngvnh im

Oxy nui dng ctim im

S loi tr ccsn phm cno thi gim

Sn phm chuynha nhiu acidlactic, histamin

Kch thch cc u dythn kinh cm gicPHN X AU

Chuyn ha ym

PHN BIT CN AU THT NGC N NH V KHNG N NH.

n nh Khng n nhD on trc D on trc c Xy ra ngu nhin, khng d o

trc cY u t lm d Sau gng sc hoc xc cm mnh Khng c yu t lm d, thm ch

th xy ra lc ngh ngi.Ko di Thng ch ko di trong vng vi pht Ko di lu hn ( >10pht)Vai tr ca Nitroglycerin c lm du bi Nitroglycerin Khng lm du bi NitroglycerinMc tr m trng Trm trng hn, nguy c tin

nhi mu c tim

C ch gy au trong nhi mu c tim

AU THNG V V CN AU THT NGC

i vi bnh nhn au thng v, cn loi tr trng hp l au tht ngc trc khi nghn au d dy. Nht l nhng trng hp nhi mu c tim vng sau dic th khi pht viau vng thng v. Nu khng ch c nhng chn on v iu tr kp thi th s a linhng hu qu nghim trng, thm ch c tnh mng bnh nhn.

Lm sng cp cu: Mt bnh nhn (khong trung nin) vo vin vi triu chng c authng v, th cn phi khm k v bnh tim mch: Hi k tin s, nghe tim, o ngay ECG(lu cc chuyn o DII, DIII, aVF) gin bit. Nu cn nghi ng c th yu cu lm xt nghimmen tim.


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NI C S 48

Xva mch vnhau tht ngcn nh.Cc mu ng hnh thnh autht ngc khng n nh

C CH GY RA CN AU THT NGC KHNG N NH

Minh ha c ch gy ra cn au khng n nh

Cn au tht ngc khng n nh thng do s vra ca 1 mng x va trong ng mchvnh.

- Trn nn ca v tr v ny trn mng x va ,cc mu ng thng s c hnh thnh, vo to ra 1s tt nghn cc b ng mch.- Tuy nhin, cc mu ng ny li khng nnh, n c th ln ra ri . V v th, gy ra 1 cn aun ri i khng d on trc c v khng h linquan n s gng sc.

o Cc mu to ra cht hp au thtngc

o Cc mu tan i hoc tri iht cht hp ht au- Khng lin quan n gng sc: khi no c cc mu ng au, ht cc mu ng ht

au- Nu cc mu ng gy ra s tt nghn hon ton ng mch (xy ra ph bin), s gy ra cn

nhi mu c tim v gy ra nhng tn thng khngphc hi cho c tim.- Hay ni cch khc, nguy c xy ra nhi mu c tim l rt cao bnh nhn c cn au tht

ngc khng n nh.- Cn au tht ngc khng n nh l 1 cp cu y khoa.

Ngun: http://heartdisease.about.com/cs/coronarydisease/a/unstableangina.htm


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NI C S 4

t vmng xva hnh thnhnt tiu cu Hi chng vnh cp

HI CHNG VNH CP

- Hi chng vnh cp (acute coronary syndrome) baogm nhi mu c tim c ST chnh, nhi mu c timkhng c ST chnh v cn au tht ngc khng nnh.

- Nguyn nhn do snt vca mng x va, hnhthnh huyt khi do tiu cu v co tht mch mu.

- Bnh cnh lm sng gm c au tht ngc lc nghngi, au tht ngc mi xy ra, nhi muc tim c ST chnh v au tht ngc sau nhi mu c tim.

SUY MCH VNH (SMV)- SMV l hin tng tc nghn mt phn hay ton b ng mch vnh, do x va ng mch

hoc do co tht mch vnh. Hu qu dn n thiu mu nui dng cho c tim.- X va ng mch vnh l do lng ng m lp dini mc ng mch vnh. Tnh trng

x va tin trin dn dn lm hpngmchhoc hnh thnh cc mu ng gy thuyn tctrong lng mch. Gy cn au tht ngc, nhi mu c tim v cht t t.

- Suy mch vnh c ngha rng hn hi chng vnh cp.

PHN LOI AU THT NGC KHNG N NH THEO BRAUNWALD

c i mI au ngc khi gng sc:

Mi xy ra, nng, tin trin nhanhau ngc mi trong vng 2 thngau ngc vi tn s dy hnau ngc gia tng khi gng sc nhKhng c au ngc khi ngh trong vng 2 thng

II au ngc khi ngh, bn c p:au ngc khi ngh xy ra trong vng 1 thng nhng khngphi mi xy ra trong vng 48 gi

III au ngc khi ngh, cp:

au ngc xy ra trong vng 48 giCc hon cnh lm sngA au ngc th pht:xy ra do cc yu t khng phi bnh

tim mch nh thiu mu, nhim trng, cng gip trng,thiu xy...

B au ngc t phtC au ngc khng n nh sau NMCT:trong vng 2 tun

sau NMCT


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NI C S 50

15. TNH MCH C NI TNH MCH CNHTRONG

( y chng ti m t cch o p lc tnh mchc (Jugular venous pressure (JVP)).

Tnh mch c ni l php nh tnh, o p lc

tnh mch c l php nh lng. C s tngng trong 2 phng php.

T VN :

- Do khng c valve gia tm nh phi v tnhmch cnh trong. Nn mc cng phng catnh mch ny c th cho ta bit c p lc trong tm nh phi.

- Tnh mch cnh trong nm pha sau c c n chm ri tin vo nguc gia u c v un ca c v th ch c th khm tnh mch ny khi cc c c t th hon ton gin.

- Tnh mch cnh ngoi nng hn v d nhn thy hn. Tuy nhin, khng nn khm n nh gip lc nh phi v n ngon ngho v b nghn 1 phn khi i vo lp mc su c.


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NI C S 5

PHN BIT NG MCH CNH V TNH MCH C

NG MCH CNH TNH MCH C- Di chuyn ra pha ngoi - Di chuyn vo trong- 1 nh (nhp p) trn mi nhp tim - 2 nh (nhp p) trn mi nhp tim (nhp

xoang)

- S thy c - Khng s thy c- Mch p khng b nh hng khi ta

nn c- Mch p gim i hoc bin mt khi ta

nn c- Khng ph thc vo nhp th - Chiu cao ca mch thay i theo nhp th- Khng ph thuc vo t th bnh nhn - Thay i ph thc vo t th bnh nhn- Khng ph thuc vo p lc bng - Tng ln cng vi p lc trong bng.

(Tnh mch c c 2 nhp p trn mi nhp tim: nh th nht khi tm nh phi co, ngay trc ting tim th nht. nh th 2 dos y ca tm nh phi trong sut thi k tm thu khi valve 3 l ng)

Thng nh gi TM cnh trong phi hn TM bn tri:

- TM cnh trong phi phn nh trc tip tnh trng nh phi- TMC tri c th b gp, bi nhiu cu trc xung quanh v bi MC (nu MC gin).- TMC bn tri phi chy vng sang bn phi trc khi vo nh phi v th khng phn nh

chnh xc p lc trong nh phi.

BNH THNG

- p lc trung bnh trong tm nh phi bnh thng l 7mmHg ( 9cmH20).- Do gc c cao hn tm nh phi khong 5cm, v th mch p ca tnh mch c (jungular venous

pulse) nhn thy khng cao hn 4cm trn gc c.


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NI C S 52

- Khi bnh nhn t th ngi, s khng thy mch v n b n pha sau xng n v xngc.

- Khi bnh nhn t th fowler, gii hn trn ca mch s ngang mc xng n. Nu khngthy mch, chng ta c th n nh vo bng ca bnh nhn 1 vigiy t lm tng lng mu tr v tim, v lm tng p lc trm tht phi, t chiu cao ca mch tnh mch c c th tngln khong 2-3cm.

BNH L:

Nu t th Fowler, mch p ca tnh mch cnh trong caohn 4cm trn gc c c tng p lc trong tm nh phi.

CCH KHM- Bnh nhn t th Fowler 45o.

- m bo cc c c bnh nhn phi gin hon ton bng cch cho bnh nhn gi u ln 1 cigi.

- Nhn c bnh nhn t pha bn phi.- Xc nh mch p ca tnh mch cnh trong ( nu cn thit c th lm phn hi gan tnh mch

c).- c tnh chiu cao (cm) t nh trn ca nhp p v gc c cho ta nh gi p lc ca tnh

mch.- Nu cn thit, c th iu chnh t th bnh nhn mch ni r hn.


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NI C S 5

Gan ln + phn hi gan tnh mchc(+) Suy tim phi

LU NHI KHOA

- Tnh mch cnh ni rt kh nh gi ( i khi khng th) phn ln tr nh do chng c cngn v dy (m). Ngay c vi nhng a tr tui i hc th, vic o lng tnh mch cni i khi khng ng tin cy do gc c khng c cng khong cch ( 5-7 cm) trn nh phinh ngi ln.

16. PHN HI GAN TNH MCH CCCH KHM

- T th bnh nhn nh trn- t bn tay ln vng h sn phi, p trong vng t nht

10 giy (thi gian phi lng mu t gan v TMCnhiu), ngi bnh th bnh thng

KT QU

- Bnh thng: TMC cng ln mt t ri li tr v bnh thng- Phn hi gan TMC (+) TMC phng to hn trong sut thi gian lm nghim php. Tnh

mch ni lu hn, khi th tay ra tnh mch xp tr v bnh thng lu hn

NGHA

- Bnh thng cc tnh mch trn gan cng nh cc tnh mch ngoi bin mu vo tnh mchch v nh phi ri a xung tht phi tht phi bm mu ln phi, thc hin chc nng


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NI C S 54

trao i kh. Khi chc nng ny ca tht phib gim st gy ra tnh trng tr tun hon, tngp tnh mch h thng. Mu li gan, ngoi bin. Khi n vo gan lm tng lng mu tr vnh phi nhiu tuy nhin do chc nng tng mu ca tht phi b suy gim nn khng th tnght lng mu thm vo trn nn mu li nh phi lm tng p lc ti nh phi, tnh mch chcng nh cc tnh mch ngoi vi khc.

NGOI L

- Gan to, nhng phn hi gantnh mch c m tnh: Gp trong hi chng Budd-Chiari, s cntr mu tr v tim khi lm nghim php phn hi gan-TMC l do tnh mch trn gan b chn p(c th do khi u bn ngoi chn vo, huyt khi, kn sn l gan, p xe.., gn v tr ca tnhmch trn gan vo tnh mch ch di)

- H ba ltnh mch c p theo nhp tm thu (do mu tr v gan tng t trong tm thu dovan ba l b h)

- Gan to, tnh mch c ni nhng khng suy tim phi:( gi suy tim phi, tng t nh hp vanhai l l trng hp gi suy tim tri) gp trong :

Vim mng ngoi tim co tht (Hi chng Pick).

Hi chng p tim cp. Trong hai hi chng ny thc cht tim phi cha suy nhng do tim b

dch, t chc x lm cn tr s gin ra ca tim trong th tm trng, giatng p lc trong cc bung tim. Nn lng mu tim nhn v trong th tmtrng gim xung,gy mu gan, cc tnh mch ngoi bin ( gi lsuy tm trng).

Trong hi chng chn p tim cp do trn dch mng ngoi tim khi ht vo,tnh mch c phng to hn (nghch thng)- Du Kussmal. Km theo tamchng Beck ( huyt p ng mch h, p lc tnh mch tng, ting timm, xa xm), trn ECG c du hiu giao lu in th, trn siu m c du sp tht phi..

Do khi ht vo tng lng mu v TMC nhiu hn, nhng do tht phi hn ch trong vic y do trn dch nn lm cng lm tng p lc nh phi cng nh p lc tnh mch ch.

KHI NO KHNG LM PHN HI GAN TNH MCH C

- Khi tnh mch c ni t nhinkhng lm phn hi gan tnh mch c na.- Khi suy tim m gan khng ln.

Ngun:Bs.XunTi


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NI C S 5

17. XC NH MM TIM

NHN:

- Bnh thng mm tim p trn khong gian sn 4-5 , trn ng trung n tri- Khi tht tri gin ln, mm tim p thp xung di (gian sn 5-6), chch ra ng

nch trc.- Din p ca tim c bn knh khong 1-2cm. Tht tri gindin tim p rng.- Tht phi ln c th nhn thy mm tim p mi c.

S

- Ngi bn phi bnh nhn, bnh nhn nm nghing bn tri, s tt nht th th ra.

- Thy thuc dng bn tay p ln vng trc tim. Ngn tr v ngn gia xc nh giansn 4, giao im gia gian sn 4 v ng trung n tri.

THAY I V TR CA MM TIM

Sinh l: thay i t th thay i v tr ca mm tim

Bnh l:

- Trn dch mng ngoi tim: khng s thy mm tim- Bnh l tim to ra: mm tim thp xung di hoc ra ngoi ng trung n.

- Trn dch, trn kh mng phi mt bn, dy dnh mng phi v mngtimmmtim b y lch sang mt bn ( trong trng hp ny, kh qun cng b y lch)- Dy dnh mng tim, dnh vi phi tip cnlm din tim nh li v mm tim khn

thay i khi thay i t th- Trn dch mng bng, hoc mt khi u to trong bng c honh b nng ln

mm tim t th nm ngang.


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NI C S 56

THAY I V CNG KHI S

- Mm tim p mnh: gp trong cng kch thch( Basedow, cng giao cm, h vanMC),ph i tht trido hp valve ng mch ch, tng huyt p hay thng lung tri phi ( cn phnbit vi din tim p rng do s gin tht tri trong h valve ch, hvalve 2 l)

- Mm tim p yu:bnh nhn bo ph, thnh ngc dy, kh ph thng, trn dch mngngoi tim, xp phi, tim p yu.

MT S BT THNG KHC

- Din tim p kiu vm Bard: gp trong h van MC- mm tim p v tr thp, sangtri mnh, di vo lng bn tay trong tm thu, rt mnh v pha lng ngc trong tmtrng.

- Du p ca MC trn hm c- Nhp p bn phi do phnh quai MC- Du chm phu( gian sn 2 bn tri): do phu phi gin (thng gp trong suy tim

phi)- Du Hazer: do tht phi gin hay ph i, khi t ngn tay di gc sn mi c tri

v hng ln trn, (c th cn phi ht su mi thy bnh nhn mp ph , thnh ngcdy) Cn phn bit vi: nhp p ca ng mch ch hoc gan p : hng p t

sau ra trc (nhp p c hng t tri sang phi, t trn xung di )

Rung miu:

- Cm gic xc gic do dng mu xoy mnh (tc dng mu i nhanh) vo cc bung tim,ccmch mu ln xung ng do dng mu v chm lm rung cc cu trc van, thnh c,

thnh mch mu ln c truyn n tay nh cm gic s ln lng mo- C cm gic rung miu khicng ting thi 4/6- Gi trc rung miutn thng thc th

o Rung miu tm thu: pht sinh t ting thi tm thu. Gp trong:

mm tim: h 2 l van MC(GS 3 bn tri, GS 2 bn phi v hm trn xng c) hp

van MC (rung miu thng lan ln pha bn phi c ri xung mm tim) van MP(GS 2 tri hoc thp hn) hp van MP (thng l rung

miu ti ch nhng cng c th lan ta ln pha c tri)

( mm tim, khm t th nghing tri, y tim khm t th nghing ra trc)

o Rung miu tm trng pht sinh t ting rung tm trnggp trong hp van2 lo Rung miu lin tc,mnh ln cui thm thuthng lin tht (rung miu tm

trng thng khu tr vng GS 3 , 4 bn tri)


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NI C S 5

P KIU VNG BARD TRONG H VALVE NGMCH CHNNG

- Gp trong h valve ng mch ch nng.- Mm tim p thp, chch sang tri.- Mm tim p mnh, di vo lng bn tay lc tm thu, rt mnh v pha lng ngc

lc tm trng.

p di dng vm ca tc gi BARD

BNG TM TC CC DU HIU KHI S MM TIM V DIN TIM.

M T NGHA BNH LCng mm

timp mnh

Ph i tht tri Tng huyt p

Hp valve M ch Shunt tri phi

Cng kch thch Basedow

Cng giao cm

p yu Bo ph

Thnh ngc dy

Kh ph thng

Trn dch mng ngoi tim

Bn thn tim p yuV tr mm tim

Xung di v ra ngoiPh i v gin tht

tri

Lch ra ngoi trung n tri Trn dch mng phi

Trn kh mng phi

Ct b phi.

Xp phi

Nm ngang Tng p bng Trn dch mng bng(C honh nng

ln) Khi u ln trong bng.

Din tim p rng Gin tht tri H ch.

H 2l

Rung miu Tm thu Mm tim H 2 l valve ng mch

ch Hp valve ng mch ch valve ng mch

phi Hp valve ng mch phi

Tm trng Hp valve 2 lH valve ng mch ch

H valve ng mch phi.

Rung lin tc Thng lin tht.

Cn ng ng mchCc bt thng

khcThy tim p cnh c tri

(Harzer)Ph i v gin tht

phi Tng p phi

Du chm phu Suy tim phi

Din tim ku vng Bard H valve ng mch ch


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NI C S 58

18. GAN TO TRONG SUY TIM(Khm gan ln c m t k hn phn tiu ha)

- Gan to trong suy tim l do suy tim phi hoc suytim ton b cn tr mu tun hon tr v timphi mu ti gangan to.

C IM

- Gan to u gim khi ngh ngi hoc iu tr tchcc vi thuc li tiu (khi gan to va) gan nxp.

(Tuy nhin gan mu lu ngy gan thiu Oxy ko di hoi t t bo nhu m ganquanh tnh mch trung tm tiu thy hnh thnh t chc x (b gan sc, mt chc)+ khng nh li khi iu tr bng thuc li tiu x gan tim)

- B t- Mm, mt nhn- n vo au tc, phn hi gan tnh mch c dng tnh

( Hay ni ngn gn: Gan to bt mt nhn n autc)

19,20:Ni triu chng 17.

21,22. MCH NY, MCH YU (tru mch)NH NGHA: Mch ngoi vi m ta bt c (mch quay, mch cnh,) l do sng mchc truyn ra t mch p ca ng mch ch trung tm c c b s co bp, tng mu cac tim.

MCH NY: c ch l do :

- Tng th tch tng mu tm thu tht tri ( H van MC, bnh l c th tch tm thu cao btthng , block nh-tht, h van hai l, thng lin tht)

- Tng ng tun hon : lo lng,thiu mu, tp luyn, st,- Mu thot nhanh bt thng qua khi ng mch (cn ng ng mch, l d ng- tnh mch

ngoi vi)- Gim sc cn ngoi vi- Ch nhi khoa: Mch ny c th l bnh thng tr nh do cc ng mch nm nng di

da. N cn c th l do cn ng ng mach nu shunt tri phi ln.


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NI C S 5

MCH YU:

- Do gim th tch tm thu tht tri, gim p lc mch p, tng sc cn ngoi vi.- Do gim sc cn ngoi vi nh trong trng hp try mch.

MCH YU DO TRY MCH:

- L do gim sc cn mu ngoi vi m c ch ch yu l s gin t ngt ca h thng tiu ngmch. Nhng nguyn nhn thng gp:

Xut pht t trung tm vn mch: nh nhim c, nhim khun. Ti mch: ng c thuc gin mch, chc rt qu nhanh dch t trong c th (dch bng,

dch mng phi..)

LM SNG

- Huyt p tt- Xay xm, ti mt, bn rn tay chn, nhp tim nhanh, yu, thiu oxy no

1 S DNG MCH BT THNG KHCMch khng u Ngoi tm thu

Lon nhp hon tonRung nh

Mch nh Hp l khtHp valve ng mch ch(Mch ln nhanh xung chm)

Mch nhnh Tt huyt pMch ny mnh, cng

cng Tng huyt pMch ny mnh, chm su Hvalve ng mch ch.

Mch Kussmaul

(Mch nghch thng)

Trn dch mng ngoi tim

Hen phqun, COPD

(gy kh thnng)Mch lun phin Suy tim nng(1 nhp bnh thng, 1 nhp

yu)Mch nhp i(2 nhp i lin, sau l

khong nghdi) Ngoi tm thu


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NI C S 60

Ngun: Ni c s - YDH

MINH HA

MCH BNH THNG

Mch bnh thng khi bt, ta c cm gic nh 1 ci g nh vo u ngn tay.

HP VALVE NG MCH CH

Do c s cn tr dng mu ra ng mch ch. Nn khi bt mch, ta khng c cm gic nh 1 ci

g nh vo u ngn tay na, m c cm gic nh c 1 ci g vut ve u ngn tay (

), 1ci y nh nhng.

Bn cnh , ta c ths thy rung miu ch yu ng mch cnh trong bn tri.

(NOTE: Nu ng mch cnh p chm hn so vi mm tim, khi c th d on vng valvehp


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NI C S 6

- c im chung: Th tch tng mu tng, nhngp lc mch bnh thng.

(p lc mch:hiu gia huyt p tm thu v huyt p tm trng)

Th tch tng mu tng trong h valve 2 l l do 1 lng mu ln tr v tm tht trong thi ktm trng, lng mu t tnh mch phi v lng mu b tro ngc trong thi k tm thu.Trong thng lin tht, tm tht tri nhn mu thm t shunt t tht phi chuyn sang.

Theo nh lut Starling, tm tht tri s tng sc co bp, tng mu mnh hn trong

Mch ny rt mnh.

MCH TRONG H VALVE NG MCH CH, CN NG NG MCH

- c im chung: th tch tng mu tng, p lc mch cng tng.

H ch: Huyt p tm thu rt cao, do 1 th tch mu ln c tng ra. Th tch mu ln n y ldo 2 ngun: mu t tm nh tri v mu pht ngc t ng mch ch trong thi k tm trng.Theo nh lut Starling, tht tri s tng co bp.

Tuy nhin, huyt p tm trng li thp, v c 1 lng mu pht ngc tr li tm tht tri(thng


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NI C S 62

(Mch ny mnh chm su d bt nht bng cch a tay bnh nhn chch thng ln tri.Khi huyt p tm trng s gim xung).NOTE: Nu o huyt p tm trng khi chch thngcnh tay ln tri < 15mmHg so vi t th truyn thng bnh nhn c l b h valve ch)

MCH DI I (PULSUS BISFERIENS)

- Tc l c 2 nhp p trn mi nhp tim khi bt mch. Trong 1 nhp u t hi k tm thu, v 1nhp gia thi k tm thu.

Nguyn nhn: Do tc dng mu chy rt nhanh qua valve ng mch ch. Ti nh caonht ca dng chy, do hiu ng Bernoulii (hiu ng ht, ging khi 1 on tu i ngang quath n s to ra 1 p lc m pha sau n ht nhng vt xung quanh vo)lm gim t ngtp lc vch ca ng mch ch t gy ra 1 ting p th 2.

Khi c mch di i, gi bnh l kt hp gia h ch nng km theo hp ch tngi.

- nhn bit mch di i, bt mch nh nhng ng mch cnh, cnh tay, ng mch quayhoc i. (Mch d bt nht ng mch cnh). Cng lc y lng nghe ting tim bnh nhn nuc 2 nh bt lc th tm thu. Nu c bn s cm thy c mch i gia ting tim th nht v thhai.

(H ch 1 th tch mu ln c tng ra, hp ch vn tc dng mu tng ra ln) Hoctrong trng hp valve ng mch ch kt hp vi ph i c tim

MCH LUN PHIN

- Ngha l nhng mch mnh v mch yu lun phin nhau, th hin th tch tng mu lc caolc thp.

- Gi tinh trng suy tim tri.


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NI C S 6

Tin lng xu.

C CH:

- Trong suy tim tri, phn xut tng mu ( ejection fraction) s gim ng k, v gy ra s gimth tch tng mu, v lm tng th tch cui tm trng. T s to ra c ch b tr c th

m bo cung lng tim khng i Kt qu l trong thi k tm thu tip theo, do c tim ginra qu mc s tng sc co bp theo nh lut Frank Starling. Gy ra 1 nhp mnh hn.

MCH NGHCH THNG (KUSSMAUL)

C ch:

- Ht vo gim p lc nh P ( tng p sut m )v p lc trong khoang mng tim tng lngmu tnh mch tr v tng kch thc tht P y vch lin tht v bn T gim th tchnht bp ca tht T v lu lng tim (chn p tim lm gim s ph thuc ln nhau ca tht)

- L mch m thi k ht vo, mch gim i ng k, nguyn nhn l do s tng p lc m trong

lng ngc, ht mu v tim, hn ch s tng mu t tht tri. Nu mch nghch thng c hiuhuyt p tm thu k th vo v th ra >10mmHgBt thng.

Gp trong:

- Chn p tim cp: do trn dch mng ngoi tim, vim mng ngoi tim co tht.- Bnh phi nng: Hen, COPD...

TM TC 1 S SNG MCH BT THNG:


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NI C S 64

23. TING TIM BNH THNG:CC NGHE TIM

4 thnh im chnh


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NI C S 6

- Ch rng mi thnh im khng phi l hnh chiu v tr ca cc van trn thnh ngc m l vtr cc sng m di mch nht ln thnh ngc t van tng ng

(Khng hon ton tuyt i: v d thi tm trng trong h van MC thng nghe r mmtim hn y tim)

Cc v tr khc- ng mch c 2 bnting thi trong hp van MC- Vng di xng nnghe ting thi lin tc trong cn ng ng mch- B tri b phi xng c- Vng trong mm timcc triu chng ca van hai l thng r vng ny- Vng nch lng- Vng b vai ct sng

T TH NGHE TIM

- Nm ngav c th lm mt s ng tc gng sc- Nm nghing tri lm r thm cc triu chng xut hin mm tim nh rung tm trngtrong hp hai l, ting thi tm thu trong h hai l.

- Ngi ,ci ngi ra trc, 2 tay dui thng th ra ri nn th nghe r ting thi tm trngtrong h van ng mch ch.

- ng dy lm gim cung lng tim, phn bit c T3 bnh l hay sinh l.Khi ng, lmgim th tch tht tri, a s ting thi gim tr hai ngoi l l ting thi ca bnh c tim ph itr nn to hn v ting thi ca sa van hai l s di ra v thng tng cng .

- Nm chn caolm tng lng mu v tim, nghe r cc ting tim bnh l c ngun gc tht phinh: ting thi tm trng trong h van ba l, ting thi tm thu trong hp van ng mch phi.


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NI C S 66

Nn th phn bit ting cmngtim vi mang phi

- Ngi xm, lm tng c lng mu tnh mch tr v ln lc cn ng mch to n phn v nh vylm tng hu ti tht, a s ting thi tr nn to hn nhngting thi ca bnh c tim ph i va sa van hai l thngnh i v c th bin mt. Du hiu ngi xm thnggp trong t chng FALLOT. Trong F4 c s thng thnggia hai bung tht, mu ng mch ch nhn i nui c

th l mu ca c hai tht c bo ha oxy thp (do nhnmu ngho oxy t tht phi) gy ra triu chng kh th (ty mc t nh ti nng). Khi ngixm lm tng p lc trong bng lm tng p lc bn ngoi tc ng ln ng mch ch bnglm tng p lc bn trong bung tht tri, gim c dng mu ngho oxy t tht phi chy qua.Lm tng bo ha oxy mu ng mch gy ra cm gic d th hn.

CC BC PHN TCH TING TIM

- Nhp tim: u hay khng u, nu khng u th do h hp hay do tim. Nu c ngoi tm thuth nh gi tn s ngoi tm thu/nhp ; nhp tim

- S lng ting tim: nhp 3, nhp 4- Cc ting tim bnh thng.- Cc ting bt thng- Cc ting thi

CC YU T BN NGOI NH HNG N NHP TIM

Nn th: nghe c cc ting thi c cng yu do nhp th c th che lp(nht l khi c ccrale phi).Ngoi ra nn th cn l phng php n gin v quan trng c th phn bit


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NI C S 6

c ting c mng tim hay ting c mng phi nu ting c mang phi th khi nn th smt.Ngc li ting c mng tim vn cn

Nhp h hp: nh hng n p lc bn trong lng ngcnh hng n huyt ng ca tim

(NOTE:H hp c th gy lon nhp ngi ln ht vo lm tng nhp tim/ th ra lm tng

nhp tim.)

(Phn nh hng ca h hp n ting tim l 1 phn hay, c chng ti m t phn ring bndi)

Tc dng ca dc l

- Thuc co mch nh: phenylephrin,methoxanthin...- Thuc gin mch:amyl nitrit, trinitrin- Cc ting thi tro ngc nh ting thi tm trng do h van ng mch ch, ting thi tm thu

do h hai l th thuc co mch s lm gia tng ting thi. V thuc s lm tng sc cn ngoi

bin, lm tng hu gnh, tng p lc mu ng mch vo k tm trng, lm mu pht ngc litm tht nhiu hn (i vi h cc van bn nguyt). Hoc do lm tng p lc ng mch nn kotheo th tch tng mu tm thu gim, gia tng p lc trong bung tht, tng lng mu t tht l nnh (i vi van nh tht ).

- Thuc gin mch c tc dng ngc li.- Ngc li cc ting thi tng mu s mnh hn khi dng thuc gin mch v yu i khi dng

thuc co mch.

CC TING TIM BNH THNG V BNH L

T1,T2, c th c T3 sinh l

T1:

Nghe ti a mm, trm, di

Trn tm thanh c cc thnh phn :

- C tim co v cng ra trong u tm thu- ng van 2 l- ng van 3 l- Ct mu tng ln ng mch tng gia tc khi di chuyn

Cng T1 ph thuc vo:

- V tr l van 2 l khi bt u tm thu- Tc tng mch p ca p lc tht tri- C hoc khng c bnh ca van hai l- S lng m.khng kh hay dch gia tim v ng nghe

T1 to hn:


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NI C S 68

- Tm trng b rt ngn do nhp tim nhanh.- Lu lng nh tht gia tng do cung lng tim cao hay ko di do hp van hai l( T1 to

trong hp van hai l thng biu th l van d un cong v cn m lc bt u co ngth tch do p lc nh tri tng.)

- Nh co i trc tht co bng mt khong cch ngn bt thng ( biu hin trn ECG lPR ngn )

T1 gim cng :

- Dn truyn km qua thnh ngc: ngi bo, thnh ngc dy, trn dch mng ngoi tim.- Tng chm mch p p lc tht tri- PR di.- ng van khng hon ho v gim cht liu trong van: h van hai l, ba l, vim c tim,

vim ni tm mc gy ph n cc l van nh tht.

c bit :

- T1 cng yu khi l trc van hai l ng im v cng v vi ha, ngay c khi c hp vanhai l r rt.

- T1 tch i sinh l: do bnh thng valve 3 l ng mun hn valve 2 l


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NI C S 6

T3 sinh l

- Ting u tm trng, do sy tht nhanh v thng, mu tnh xung tht lm tht gin

nhanh v mnh, lm rung cc cu trc trong bung tim- Sau T2C khong 0.12-0.2s (sau T2P) (phn bit vi T2 tch i sinh l)- Thng nhng ngi trtui khi nm , ng dy th mt T3 sinh l do gim lu lng mu v

tim. Khc vi T3 bnh l l ting nga phi ( du gallop ) u tm trng, khng mt khi ng.- Nghe T3 bn tri : mm tim, nghe bng u nhca ng nghe, vo th thra, v bnh nhn

nm nghing tri.- T3 bn phi nghe r btri xng c hoc ngay di mi c vo th ht vo.- Phn bit vi ting clack mvalve hai l (ni sau)

NHP TH V TING TIM

NH HNG CA NHP TH N TING THI V S TCH I CA T2 SINHL.

Hu ht ting thi v cc ting tim bnh thng, bt thng xut pht tbn phi tim utng ln khi ht vo. Ngc li cc ting tim xut pht t bn tri tim u gim i khi ht vo.

V d:

- Ting thi tm thu ti valve ng mch phi do hp valve ng mch phi s tng ln khi htvo.

- Ting thi tm thu ti valve ng mch chdo hp valve ng mch chsgim i khi ht vo.

Gii thch:

- Khi ht vo, lm tng p lc m trong long ngc, v thc xu hng ht mu vtim phi nhiuhn, v ngn cn mu ri tim tri.

Tng th tch tng mu (H van MC..)Hp van hai lKhong PR ngn li (nhp tim nhanh)U nhy nh (him gp)

Thayi Rung nhNgoi tm thu

Block nh tht hon ton


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NI C S 70

- Do 1 lng mu ln vtim phi cc ting tim xut pht tbn phi sto hn. Mu t tng rakhi tim tri ting tim xut pht ttim tri snhhn.

Khi ht vo, T2 sinh l tch i rng hn.

Gii thch:

- Ting T2 gm 2 thnh phn, 1 thnh phn do ng valve ng mch ch( A2), 1 thnh phn dong valve phi (P2).

- A2 thng n trc, P2 n sau: l do l v p lc trong ng mch ch ln hn ng mchphi, v thvalve ng mch chc xu hng ng trc valve ng mch phi.

- th ht vo, slm gim p xut bn trong lng ngc (lm cho n m hn), t c tc dnght mu ttnh mch chtrn v tnh mch chdi vo cc bung tim bn phi. Phi chng tanh 1 thng m khi gin ra ng vai tr l 1 ci my ht ht, ht mu t2 tnh mch chvotm nh v tm tht phi. T l tng th tch tht phi tng th tch mu tng qua valve

ng mch phi thi gian tng mu lu hn lm chm sng ca valve ng mch phiP2 n mun hn.

- Hn na, th ht vo, cc mch mu phi gin ra lm gim p lc trong ng mch phigp phn gii thch sn mun ca P2.

Nghim php Valsava lm gim hoc mt s tch i ca T2.

- Nghim php Valsava: thra ht sc, ri nn th(mc ch lm tng p lc trong lng ngc).- Do p lc trong lng ngc tng gim sy 2 tht.- Nn nhrng: khi lm nghim php Valsava a sting thi gim vdi v cng . Hai

ngoi ll ting thi tm thu trong bnh c tim ph i thng trnn to hn v ting thi tmthu trong sa van hai l trnn di hn v to hn.


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NI C S 7

1 S BNH L LIN QUAN N S TCH I CA T2

T2 TCH I RNG:

c nh ngha l 2 thnh phn A2 v P2 cch xa nhau t nht l 60ms (bnh thng: 30 -40ms)

Gp trong(ch yu l cc bnh l lm cho thnh phn P2 n mun hn):

- Bnh l lm chm skhcc tht phi :Block nhnh phi.- Nhng bnh l lm tng th tch mu trong tht phi lm ko di thi gian tng mu ca tht

phi: Thng lin tht, thng lin nh.- Nhng bnh l lm tng gradient p lc qua valve ng mch phi:Hp ng mch phi- Nhng tnh trng gy ra suy tim phi cp hoc mn: Tng p phi nguyn pht giai on sau,

cc mu ng phi.

T2 TCH I C NH ( khng c s thay i th ht vo ln th ra)

Thng lin nh.

Gii thch:

- Thng lin nh, do p lc bn tm nh tri cao hn nh phi, nn mu c xu hng i tnh triqua nh phi ( shunt tri phi).

- tim bnh thng, thi kht vo, lng mu vtht trist hn so vi thi kthra (do thikht vo, p lc m trong lng ngc stng ln, lm mu ht vpha tht phi nhiu, km theo cc mch mu phi gin ra, cha nhiu mu gim lng mu vtim tri, ngc li, th thra cc mao mch phi co li, tng mu xung tim tri)


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NI C S 72

- Trong thng lin nh, lng mu vtht tri skhng gim i th ht vo v thm ch cn nhiuhn hn do th ht vo, mu tcc tnh mch chc ht vtm nh phi, t lm tng plc nh phi v lm gim bt lng mu i tnh tri sang nhphi. Lng mu khng i quanh phi sc tng xung tht tri, v thc xu hng duy tr 1 thtch mu khng i tm tht tri th ht vo.


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NI C S 7

TING T2 TCH I O NGC

- L ting T2 tch i theo thtP2A2 thay v A2P2.- Dng nh lun lun do sng li chm ca valve ch.

Nguyn nhn:

- Ri lon dn truyn lm chm skhcc tht tri:block nhnh tri hon ton v 1 sdngca hi chng Wolff-Parkinson White ( WPW)

- Hp valve ng mch ch: lm tng gradient p lc qua valve ng mch ch. p lc tm tht

tri tng qu cao lm cho thi gian p lc tht tri gim xung valve ng mch chng li ko di ra.

- Tng huyt p km tn thng c tim.

24.TING TIM TH NHT ANHL 1 du hiu trong hp hai l

NGHE R :

- Mm tim

NGUYN NHN

- Valve 2 l dy, x cng, vi ho do tn thng ng t ngtcc l valve p vo nhau khi ng- Mu dn v tht t trong giai on cn b, tht tri p ng bng cch tng co bp tm thu

ngnnghe gn.


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NI C S 74

KHI NO T1 KHNG CNANH NA TRONG HP 2L

- Khi valve vi ha nng.- Khi c h2 l phi hp- Khi c hchphi hp- Khi valve bgim di ng.

Ngun: Ni tim mch Thy Minh

KHONG P R V LN CAT1

- Sng P th hin tm nh co lm tng p lc trong tm nh tri.- S co ny ca tm nh lm cho valve 2 l m rng hn vo cui

thi k tm trng.- Sng R th hin tm tht co. Khi p lc tm tht vt qu p lc

tm nh. S lm cho valve 2 l ng li, to ra ting T1.

A. Nu P- R ngn, tm tht tri co trc khi tm nh tri c thi gian gin ra v gim plc n xung. V p lc nh cn cao nh vy, p lc tm tht mun vt qu p lc nh ng valve 2 l th phi cn 1 thi gian lu hn v t ti 1 p lc rt cao, to ra 1 s

gim tc t ngt ca dng mu v to ra 1 mthanh ln.B. Nu khong P R di, tm tht co mun hn so vi trng hp A trn, tm nh cthi gian gin ra v h p lc n xung. V th tm tht khng cn thi gian lu vt p lc tm nh, v ti thi im p lc tm tht vt p lc tm nh, p lc 2 bncng khng cao lm, to ra s di chuyn ca l valve chm hn, m thanh du hn.

(NOTE: ngi ta cn gii thch nh sau, ting T1 ln trong trng hp khong P R ngn ldo ti thi im tm tht co, l valve 2 l ang m rng v pha tht. V h v l valve nh 1cnh ca, cnh ca m cng rng th khi ng li th ting ng ca cng to. Cn trng hp


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NI C S 7

khong P R di, th ti thi im tht co, nh c phn gin ra, 2 l valve khng m rng mc phn co li v pha nh. V th khi ngcnh ca li th ting to ra nh hn. Nhng iuny ny c v khng chun bng gii thch trn, v c th xy ra trng hp cnh ca m rng,nhng vn tc ng ca yu, th chc chn ting cng khng to)

LON NHP TIM V TING T1

Thay i ca ting T1 trongmt sri lon nhp

Block nh tht 1:

- L dng Block trong khong PR c nh v lun ln hn 0.2ms.- Do PR ko di nn ting T1 rt nh.

Block nh tht 2 Mobitz 1:


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NI C S 76

- L dng block trong khong PR dn dn ko di ra, nhp sau di hn nhp trc, cho nkhi mt lun 1 nhp.

- Do khong PR ko di ra dn dn nh vy, nn ngi ta ngh ting T1 s nh dn, nh dncho n lc mt 1 nhp. Tuy nhin, nu PR qu di (>0.36s), do lng mu t tm nh tritip tc xung nh tri, plc trong nh tri khng gim na, valve 2 l vn m rng, v th ting T1 c to hn 1 x.

Phn ly nh tht:

- L dng Block trong nh p theo ng nh, tht p theo ng tht (P v QRS khng c stng quang).

- Nu P ting n gn QRSting T1 to. P tin xa QRSting T1 nhli.- V thta snghe thy ting T1 thay i tht thng.

Trong block nhnh tri:


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NI C S 7

L dng block do c ri lon lm chm dn truyn inth vo tht tri, nn lm tm tht tri co bp chm li.

Ting T1 nh li.

cim:

QRS >1.0 s

Phc b QRS m V1, V2

Phc b QRS dng V5, V6 km theo c mc

25. TING TIM TH 2 MNH VALVENG MCH CH

Gp trong:

- Bnh l lm tng p lc ng mch ch: tng huyt p ting T2 ging nh tingtrng.

- Nhng tnh trng gy tng huyt ng htun hon: cng giao cm, ngc gip, vnng vin...

- Nhng bnh l lm tng lng mu qua ng mch ch: Tchng fallop.

26. TING CLAC M VALVE 2 L (opening-snap)


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NI C S 78

Gp trong hp valve hai l

- Vtr:nghe r mm hoc trong mm- m sc: cao, nghe gn (phn bit vi

T3 trm, v n sau clack m valvehai l)

- Thi gian: sau A2 khong 0.04-0.12s nn thng bln vi P2 gian sn tri, nhng r dc btri xng c (phn bit vi T2 tch i)

- Nguyn nhn: do valve hai l x nhng cha cng , cc mp valve khi mtch ra khi nhau gyting clack, cho thy valve cn mm, mt i trong hp van hai l kht.

- Khng thay i theo nhp h hp.

MI QUAN H GIA KHONG THI GIAN T2 CLC VMC TRM TRNG CA HP VALVE 2 L

- p lc tht tri khi gim xung thp hn p lc ng mch chvalve ch ng li TingA2. Sau p lc tht tri tip tc gim, cho n khi thp hn p lc nh tri valve 2 l mrating Clc.- Ting A2 tng ng vi lc valve ng mch ch ng xy ra sm hn thi im m valve 2l 1 x. Thi im t lc ng valve ng mch ch n lc m valve 2 l gi l thi k ginng th tch (isovolumic).- Trong hp 2 l cng nng, s cn tr dng mu t nh tri xung tht tri cng ln, v th plc trong nh tri cng cao.


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NI C S 7

- Khi p lc nh tri cao, p lc trong tm tht tri khng cn gim xung qu thp m valve 2

l. V th khong cch t A2 ti ting Clc m valve s ngn li.


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NI C S 80

Kt lun: Hp 2 l cng nng, khong cch t A2- OS cng ngn li. Tc l thigian t ting T2 n ting clack cng ngn chng t van hai l hp cng kht. Do khivan cng hp kht th p lc mu trong bung nh tri cng cao ( do van hp, mu

xung thttri t, li nhiu nh tri). Nn sau khi tht tri va tng mu i ( thik cui tm thu u tm trng)p lc trong tht tri va gim xung th vi p lccao trong bung nh lm m nhanh v mnh van hai l. Van m cng sm nup lctrong nh tri cng cao.

PHN BIT A2 P2 V A2 - OS

NHNG IM GING NHAU

- Ting Clc m valve thng nghe c v tr gia mm tim v b tri xng c, hoc ngay tib tri xng c. V y cng l v tr thng nghe thy ca P2.

- Khong cch t A2 P2 v A2 OS cng khng khc nhau nhiu lm.

CCH PHN BIT

- Ting clc thng nghe mm tim to hn khu vc btri xng c. Ngc li P2 li nghe rbsn tri

- thi kht vo, ting OS strnn du hn, nhhn trong khi ting P2 sto hn.- Nu T2 c dng b3 nghe bc tric sxut hin ca OS.- Nu khong cch gia 2 ting T2 rng hn khi ng dy, th l ting OS.- Da vo T1, nu n m du, th thnh phn th2 ca T2 c thkhng phi l ting OS. Nu T1

anh, th thnh phn th2 l ting T2 c thl OS.

(Nhc li quy lut: nhng m thanh xut pht t bn phi tim s to hn th ht vo, vngc li nhng ting xut pht t bn tri s nh i th ht vo)

27. TING THICC NGUYN NHN GY RA TING THI.


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NI C S 8

(A)S cun xoy ca dng mu chy vi tc cao trong lng mch c khu knh khng i.

(B) v (C):c s cht hp ti ch hoc mu chy vo 1 khu vc c khu knh ln hn, cnglm cho dng mu tr nn cun xoy mc d vn tc dng mu khng cao.

(D)Kt hp ca (B) v (C), v d nh gin ng mch ch sau hp valve ng mch ch, tora s cun xoy ca dng mu d tc rt thp.

PHN LOI

- Ting thi tng mu (EJECTION MURMUR).- Ting thi pht ngc (REGURGITANT MURMURS).

TING THI TNG MU:

- L ting thi do dng mu c tng qua cc valve t chim trong thi k tm thu (valve ngmch ch v valve ng mch phi).

- Chng bt u sau T1. Ting thi t valve ng mch ch kt thc trc A2, t valve phi ktthc trc P2. (Nu ni chung l kt thc trc T2 l khng chnh xc)

N c dng hnh qu trm (crescendo decrescendo).


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NI C S 82

Gii thch:

- ln ca ting thi ti valve ph thuc vo 2 yu t, vn tc v gia tc ca dng mu quavalve.

- Trong hp valve ng mch ch, giai on u p lc trong tm tht tri tng chm, vn tc

dng mu qua valve tng chm v v th ting thi sbt u nhnhng. Hn na, trong giaion u, sau khi p lc tm tht tri vt qu p lc ng mch ch, cn 1 thi gian ngn nan c th thng c qun tnh ca mu ng mch chang tnh trng tnh (ging nhcng 1 lc y chic xe, lc u xe tng tc chm, sau xe mi chy nhanh c).

- Vo gia thi ktm thu l lc tm tht co bp mnh nht, vn tc v gia tc ca dng mu tnglnting thi mnh hn.

- Sau tm tht gim co bp dn, vn tc dng mu gim xungv kt thc lc ng valve tchim.

TING THI PHT NGC

- Trongting phi pht ngc, ngi ta chia thnh ting thi pht ngc thi ktm thu v ting thi phtngc thi ktm trng.

THI PHT NGC K TM THU:

- L ting thi to ra do dng mu chy ngc tni c p lc cao ca tim n ni c p lc thpqua nhng lbt thng trn tim.


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NI C S 8

Gp trong trng hp:

- Hvalve 2 l.- Hvalve 3 l- Thng lin tht.- Cn ng ng mch

(Cn ng ng mch ngi ta thng xp vo thi lin tc)

THI PHT NGC THI K TM TRNG.

- Hvalve ng mch ch.- Hvalve ng mch phi.

Thi pht ngc thng c dng hnh ch nht (pansystolic).


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NI C S 84

27.TING THI TM THU VALVE 2 L:

THI DO H VALVE 2 L.

- V tr:t ti a mm (gian sn 4-5 trn ng trung ntri)

- Hng lan: lan ra nch ri c th ra sau lng, khng thay itheo t th(nu ln th c thlan qua bn phi)

- m sc:th rp, c khi m du nh ting hi nc pht- Thi gian: bt u cng lc vi T1, kt thc cng lc vi T2, chim ton bth tm thu( hnh

chnht trn tm thanh )- Nguyn nhn: mu tro ngc ttm tht tri ln nh tri trong thi ktm thu do valve 2 l

ong khng kn.

SA VALVE 2 L ( Hi chng clic thi tm thu, HC Barlow, HC van ri tm, HC l vancun).


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NI C S 8

- L hin tng 1 hoc c2 l ca valve 2 l bbung ln vpha nh tri trong thi ktm thu.

Nguyn nhn ph bin:

a. Hi chng Marfan (bnh m lin kt)b. Suy chc nng c nh do nhi mu c tim.c. Bnh c tim ph i tt nghn (lm p lc trong tht tri qu cao)d. Thng lin nh.

Savan hai l c th lm cng qu mc cc c nh, nn lm cho cc ct c b ri lon hot ng,thiu mu ca c tht vng di ; t dy chng v dn dn vnh van hai l, vi ha cng lmcho van h thm, b my van cng hn, to nn vng xon bnh l.

Ting tim trong sa valve 2 l:- Ting thi trong sa valve 2 l cng l ting thi pht ngc thi ktm thu.- Ting thi ny thng xut hin mun trong thi ktm thu do p lc tm tht tri phi t n

1 ngng nht nh c thy l valve 2 l vpha nh tri. Ting thi thng kt thc cngvi A2.

- C 1 ting Click mvalve trc ting thi. Ting click tng mu r nht trong sa van hai l. Dol van bbung khi tm thu. y l du hiu quan trng gip phn bit sa hay hvan hai l.

- Ting click gia hay cui th tm thu l triu chng quan trng nht. Ko di 0,14s hay lu hnsau ting tim u tin. C chto ra ting click l cng t ngt ca cc dy gn tim vn b

trng v ko gin. Ting click cn c thc gy ra bi l van hai l bsa xung khi n t tisdy chuyn ti a.

- Ting click v ting thi xut hin sm hn khi ng, khi lm nghim php Valsava hay khi htamyl nitrate. V cc can thip ny c tc dng lm gim thtch tm tht v lm tng cng mcsa van hai l. Ngc li, ngi xm li lm tng thtch tht tri cui tm trng v ng thilm gim mc sa xung ca cc l van hai l. Khi phc hp ting thi-ting click xut hinmun hn v c thbin mt.


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NI C S 86

28.TING THI TM THUDO HP VALVE NG

MCH CH

L ting thi tng mu (crescendo decrescendo).

- Vtr:t ti a gian sn II bn phi, hoc GS III bn tri- T thnghe:bnh nhn ngi ci ngi ra trc- Hng lan:lan ln c, di khi xung mm tim (phn bit vi ting thi tin tm thu trong hp

valve hai l)- m sc:th rp- Cng : ting thi mnh dn ln n na th tm thu th li gim xung, hnh nh qutrm

trn tm thanh - Thi gian:bt u ngay sau T1, kt thc trc T2, tm thanh ) .- nh hng ca nhp th:tng ln khi thra (ngun gc: bn tri tng ln khi thra)- Nguyn nhn:mu ttht tri tng vo ng mch chqua chhp tng gia tc.


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NI C S 8

29.TING THI TM TRNG TRONGNG MCH CH.

- Vtr:nghe r nht Erb-Botkin- Hng lan:lan ln c, di khi xung mm tim (phn bit vi ting thi tin tm thu trong hp

valve hai l)- m sc: m du, xa xm- Cng :nh, nghe bng phn mng ca ng nghe.nghe r hn cho bnh nhn thra ri

nn thsau ci ngi ra trc (phn y tim nm st lng ngc hn)- Thi gian:xy ra sau T2, chim mt phn th tm trng hoc ton bth tm trng tumc

h- Nguyn nhn:dng mu tro ngc tMC vtht tri trong tm trng do l van ng mch

chng khng kht. Hu quca stro ngc ny lm tng thtch tm thu tht tri nn lmlvan MC trnn hp so vi lu lng ny nn c thnghe thy ting thi tm thu i km viting thi tm trng.


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NI C S 88

30. RUNG TM TRNG TRONG HP 2 L:

V tr: nghe r mm tim (nghe r hn bng u chung ca ng nghe, khi bnh nhn nmnghing tri)

- m sc:trm v th (nghe nh ting v di trng trn mt trng cng)- Thi gian: xy ra sau T2, thng theo sau ting clack mvalve hai l, v ko di n cui tm

trng v trthnh ting thi tin tm thu- Nguyn nhn: van hai l bhp , lm lng mu tnh xung tht bxoy lm rung cc cu trc

ca tim

- Phn bit vi:o Rung Flint

RUNG FLINT (Austin Flint Murmur).

- L ting thi gia thi ktm trng hoc u tm thu m thp, nghe nh ting rung, ngher nht mm tim. N thng gp trong hvalve ng mch chnng.

C CH:Dng mu tro ngc t ng mch ch xung to p lc ln b mt ca valve 2 l lm cho nb y ln pha trn, to ra s hp tng i ca valve 2 l

(Xem hnh minh ha bn di)

(NOTE: Thc t khi lm siu m tim cho 1 s bnh nhn b rung FLINT, ngita thy l trcca valve 2 l c rung. Cho nn ngi ta tng ngh rng, rung Flint l do dng mu chy mnh


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NI C S 8

lm l trc valve 2 l rung. Tuy nhin, c 1 s bnh nhn c valve 2 l rung nhng li khng crung Flint, ngc li 1 s bnh nhn c rung Flint nhng l trc valve 2 l khng rung)

Cng c thm cho 2 gi thuyt trn:

- Thng thy nhng tn thng (cc mu ng) vtr l trc ca valve 2 l do dng mu chy

nhanh.- Trn siu m bnh nhn brung Flint c hp valve 2 l.

TRIU CHNG C NNG, THC TH CA HP 2 LKHT

- C nng:hi chng gng sco Kh thkhi gng sc.o Ho ra muo Hen tim

o Ph phi cp- Thc th:

o T2 mnh tch io Rung tm trng chim ht ktm trngo Thi gian tT2 n clac mvalve 2 l cng ngn th hp cng kht.o Thi Gramham Steel

- Cn lm sng:o ECG bao gicng c dy tht (P)


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NI C S 90

HP 2 L TRN SIU M

PHN HP 2 L TRN LM SNG

KHI NO DNG CHNG NG TRONG HP 2 L

- Gin nh tri.- C rung nh- C cc mu ng

X QUANG CA HP 2 L


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NI C S 9

31.TING THI TM THU CHCNNG:GP TRONG:

Van tim khng b tn thng m do gin cc vng van, hu qu ca gin cc bung tim. V d

trong hp van hai l, lm gin bung tht phi gy h vng van ng mch phi, to ra ting thiGraham-Steel.

Gim nht ca mu, hay gp trong thiu mu.

Thay i lu lng mu qua van: cng gip, st, c thai, van ng mch tr nn hp tng iso vi lu lng mu ln (v d thng lin nh, h van MC)

PHN BIT TING THI THC TH L TING THI CHC NNG (C NNG)

Ting thi thc th Ting thi chc nngV tr - C c 5 van tim - Hay c van hai l v

valve MC,Thi gian - Tm thu, tm trng, lin

tc- Ch yu l thi tm thu,

nhng t khi chim ton btm thu.Him khi gp tingthi tm trng

Cng ,m sc - Thng mnh r, th rp,3/6

- Thng nh, m du, t khimnh , 3/6

Hng lan - Lan xa theo dng mu - t lan

Rung miu - C rung miu khi thi mnh - Ting thi d mnh cngkhng c rung miu

Tnh cht thngxuyn

- C thng xuyn , khngthay i theo t th.

- C th thay i , thm chmt i khi ht su, thay i tth v sau kt qu iu tr.

38.RUNG NH:nh ngha:

- RN l ri lon nhp nhanh trn tht c trng bi s hot ha nh khng ng b lm cho suychc nng c hc ca nh.

- RN gnlin vi s gia tng nguy c t qu, suy tim v t l t vong do mi nguyn nhn,nht l ph n.

Phn loi RN:c nhiu cch phn loi


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NI C S 92

- Da trn ECG.- Da trn ghi thng tm mc hay ni bung tim bn in hc hot ng ca nh.- Da vo lm sng.

C ch:

Thuyt t ng:

- Gi thuyt RN khu tr c ph hp vi m hnh thc nghim ca aconitine ( cy ph t )v RN to ra bng to nhp trong lon nhp tim ch tn ti trong nhng vng c nh b clp.

.Thuyt a sng nh( do Moe v cng s a ra)

- Nh l c ch vo li ca RN. Moe cho rng phn on ca cc sng thng lan truyn quanh dn ti s

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Nội Cơ Sở 2nd Edition - Nhóm Sinh Viên Y4, Y5, Y6 [Bongpet Y Khoa]