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TRl/ONG DAI HOC Y HA NOI CAC BO MON NOI BAI GIANG BENH HOC NOI KHOA TAP II (Tdi ban Ian thit mitdi co sita chiia vd bo sung) NHA XUAT BAN Y HOC HA NOI-2011 Tham gia bien soan: GS.TS TRAN NGOC AN PGS.TS PHAM THI THU HO TS PHAM MANH HUNG GS PHAM KHUE PGS.TS NGUYEN THI NGOC LAN TS NGUYEN VlNH NGOC GS.TS NGUYEN KHANH TRACH GS.TS NGUYEN LAN VIET Thtfky bien soan: GS.TS TRAN NGOC AN PGS.TS PHAM THI THU HO LOTI NOI OAU Bai gidng benh hoc noi khoa can bo gidng day cdc bo mon noi thuoc Trtfbng Dai hoc Y Ha Noi bien soan nham cung cap mot so tdi lieu de sinh vien cdc Idp Y3 - Y6 theo chtfOng trinh cdi each mdi dung de hoc tap vd tham khao hoc ly thuyet cung nhu thUc hanh d benh vien Noi khoa la mot nhiCng mon hoc chinh cua cdc TrUdng Dai hoc Y Noi dung can duac sita doi bo sung cho phii hap vdi sU tien bo khong ngitng cua y hoc Ldn tdi ban hdu het cdc chuang da duac viet lai vd bo sung de cap nhdt cdc kien thiCc mdi cua y hoc Tuy nhien dieu kien so can bo it di, thdi gian han che cudn sdch khong trdnh khdi thieu sot nhdt dinh, mong ban doc gop y de ldn tdi ban sau cudn sdch dUOc hodn thien hdn Xin trdn cam On TRirdNG DAI HOC Y HA NOI Cac bo mon noi Chtftfng TIM MACH SUY TIM GS TS Nguyin Ldn Viet TS Pham Manh Hung Suy tim la mot hoi cluing benh iy thu'dng gap nhieu benh ve tim mach nhu* cac benh van tim, benh cd tim, benh mach vanh, benh tim bam sinh va mot so'benh khac co anh hu'dng nhieu den tim Binh thu'dng chiing ta can lam mot hoat clong gang siic nao (lao dong, chay nhay ) thi lap trie tim se tang tan so'va tang siic co bop de dtfa d\10c nhieu mau (tiic la du"a diio'c nhieu oxy) den cho cac mo ciia cd the Nhifng tim bi suy, thi tim khong kha nang cung cap mau theo nhu cau ciia cd the nufa Vi vay ngiidi ta co the dinh nghia: Suy tim Id trang thai benh ly cung IvCdng tim khong du dap iCng vdi nhu cau cua cd the ve mat oxy moi tinh huong sinh hoat cua benh nhdn Suy tim la mot tinh trang benh ly rat thu'dng gap tren lam sang To chiic Y te The gi6i \idc tinh co khoang trieu ngUdi mdi mac suy tim hang nam tren toan the gi6i Theo nghien cu*u Framingham thi co khoang 2,3 trieu ngUdi My bi suy tim (1981) va cung d My moi nam co khoang 400.000 benh nhan m6i mac suy tim (thong ke nam 1983) Can day, tren cd sd nhufng hieu biet sau sac hdn ve cd che benh sinh ciia suy tim, ve tinh nang va tac dung ciia mot so' loai thuoc m6i dieu tri suy tim, ngLfdi ta da thu dUdc nhi3ng ket qua kha quan viec dieu tri hoi chiing I SINH LYBENH Cung lifting tim thu'dng bi giam suy tim Khi cung lUdng tim bi giam xuong thi cd the phan ling lai bang cac cd che bu trii ciia tim va ciia cac he thong ngoai tim, de co tri cung lUOng NhUng cac cd che bu trii bi vu"dt qua se xay suy tim vdi nhieu hau qua ciia no Cac yeu to anh hirong den cung lu'cfng tim Cung liidng tim phu thuoc vao yeu to' chinh: tien ganh, hau ganh, siic co bop ciia cd tim va tan so' tim Siic co bop cO tim Tien ganh • Cung lifting tim A Hau ganh ! Tan so tim 1.1 Tien ganh (Preload) Tien ganh diiPc danh gia bang the tich hoac ap liic cuoi tarn triidng ciia tarn that Tien ganh la yeu to' quyet dinh miic keo dai spi cd tim thdi ky tam trifting, triidc liic tam that co bop Tien ganh phu thuoc vao: - Ap liic day that, tiic la liidng mau tinh mach trd ve tam that - Dp gian ciia tam that, nhiing d miic dp it quan trpng hdn 1.2 Sue co bop cua cotim Triidc day bang thiic nghiem noi tieng cua minh, Starling da cho ta hieu ro diidc moi tiidng quan giiia ap liic hoac the tich cuoi tam triidng tam that v6i the tich nhat bop Cu the la: Khi ap liic hoac the tich cuoi tam triidng tam that tang, thi se lam tang siic co bop ciia cd tim va the tich nhat bop se tang len Nhiing den mot miic nao do, thi du ap liic hoac the tich cuo'i tam tru"dng ciia tam that co tiep tuc tang len di nufa, thi the tich nhat bop se khong tang ttfdng ling ma tham chi bi giam di Qua day ta co the hieu dWdc mot van de quan trong suy tim la: ap liic hoac the tich cuo'i tam triidng tam that tang cac nguyen nhan khac nhau, se lam the tich nhat bop tang, nhiing sau mot thdi gian se dan den suy tim vi siic co bop cua cd tim kem dan va the tich nhat bop se giam di Tim cang suy thi the tich*nhat bop cang giam 1.3 Hau ganh (Afterload) Hau ganh la siic can cua cac dpng mach do'i vdi su" co bop ciia tam that Siic can cang cao thi sii co bop cua tam that cang phai ldn Neu siic can thap qua cd the se lam giam su" co bdp ciia tam that, nhiing neu siic can tang cao se lam tang cong ciia tim cung nhii tang miic tieu thu oxy ciia cd tim, tu* se lam giam siic co bdp ciia cd tim va lam giam lifu lifting tim 1.4 Tan so tim Trong suy tim, liic dau nhip tim tang len, se cd tac dung bu trii tot cho tinh trang giam the tich nhat bdp va qua se tri dUdc cung lu:dng tim Nhiing neu nhip tim tang qua nhieu thi nhu cau oxy ciia cd tim se lai tang len, cong ciia cd tim cung phai tang cao va hau qua la tim se cang bi suy yeu di mot each nhanh chdng Cac cd che bu trCr trpng suy tim 2.1 Ca chebu trCt tai tim Gian tam that: gian tam that chinh la cd che thich ling dau tien de tranh qua tang ap liic cuoi tam triftmg ciia tam that Khi tam that gian ra, se lam keo dai cac spi cd tim va thed luat Starling, se lam tang siic cd bdp ciia cac sdi cd tim neu dii trii co cd van Phi dai tam that: tim cung cd the thich ling bang each tang be day cac tim, nhat la triftmg hdp tang ap liic d cac buong tim Viec tang be day cua cac tim chii yeu la de ddi phd vdi tinh trang tang hau ganh Ta bie't rang hau ganh tang se lam giam the tich td'ng mau, do de bu lai cd tim phai tang be day len He than kinh giao cam dtftfc kich thich: cd suy tim, he than kinh giao cam du'dc kich thich, lifting catecholamin tii dau tan ciing ciia cac spi giap cam hau hach du'dc tiet nhieu lam tang siic co bdp ciia cd tim va tang tan so'tim Bang ba cd che thich ling nay, cung liidng tim se du'dc dieu chinh lai gan vdi miic binh thu'dng Tuy nhien cac cd che cung chi cd the giai quye't mpt chiing miic nap ma thdi Thiic vay, neu tam that da gian den miic td'i da va dii truf co cd bi giam thi luat Starling se trd nen rat it hieu liic Cung tiidng tii nhii vay, phi dai cac tim se lam tang cdng ciia tim He than kinh giao cam bi kich thich lau cung se dan den giam mat dp cam thu beta trpng cac sdi cd tim va giam dan dap ling vdi catecholamin 2.2 Cache bu trit ngoai tim Trong suy tim, de dd'i phd vdi viec giam cung lifting tim, he thong mach mau d ngoai vi du'dc co lai de tang ciidng the tich tuan hoan hiiu ich Cu the cd ba he thong co mach ngoai vi du'dc huy dpng: He thong than kinh giao cam: ciidng giao cam se lam co mach ngoai vi d da, than va ve sau d khu viic cac tang o bung va d cac cd He Renin-Angiotensin-Aldosteron: viec tang ciidng hoat hda he than kinh giao cam va giam tiidi mau than (do co mach) se lam tang nong dp renin mau Renin se hoat hda angiotensinogen va cac phan ling tiep theo de tang td'ng hdp angiotensin II Chinh agiotensin II la mot chat gay co mach rat manh, ddng thdi no lai tham gia vao kich thich sinh tong hop va giai phdng nor-adrenalin b dau tan cung cac sdi than kinh giao cam hau hach va adrenalin tCi tiiy thu'dng than Cung chinh angiotensin II kich thich vo thu'dng than tiet aldosteron, tii lam tang tai hap thu natri va niidc d d'ng than He Arginin-Vasopressin: suy tim d giai doan mupn hpn, viing diidi dpi - tuyen yen diidc kich thich de tiet arginin - vasopressin, lam tang them tac dung co mach ngoai vi ciia angiotensin II, dong thdi lam tang tai hap thu niidc d d'ng than Ca ba he thong co mach deu nham muc dich tri cung lifting tim nhiing lau chiing lai lam tang tien ganh va hau ganh, tang ti niidc va natri tang cong va miic tieu thu oxy ciia cd tim, tao nen mot "vdng luan quan" benh ly va lam cho suy tim mot nang hdn 2.3 Cac yeu to khac Ngoai ra, suy tim, nham cd'gang bu dap lai viec co mach khu trii hay toan bp ndi tren, cac he thd'ng gian mach vdi bradykmin, cac prostaglandin (PGI, PGEv) va yeu to peptid tang dao thai natri (Natriuretic Peptid, viet tat la cac NP) Cac yeu to dong vai trd khiem ton qua trinh suy tim Trong so cac peptid tang thai natri cd hai loai quan trpng du'dc biet den trpng lam sang la ANP (yeu to thai natri cd nguon gd'c tu' nhi) va BNP (yeu to tang thai natri cd nguon gd'c tii nao) Thiic te la BNP lai chii yeu diidc tiet tii tam that ciia tim va xua't hien kha sdm tim bi suy Hien nay, xet nghiem danh gia BNP va cac dan xua't ciia no cd gia tri quan trpng sang lpc benh nhan suy tim cung nhii tien lifting benh va theo doi ket qua dieu tri Hau qua cua suy tim Khi cac cd che bu tru (cd che thich ling) noi tren bi viip't qua thi se xay suy tim vdi cac hau qua nhu' sau: 3.1 Giam cung luong tim Cung lifting tim giam se gay - Giam van chuyen oxy mau va giam cung cap oxy cho cac to chute ngoai vi - Cd su" phan phoi lai hiu lifting mau den cac cd quan cd the: lu'u liidng mau giam bdt 6* da d cac cd, d than va cuoi cung d mot so tang khac de u'u tien mau cho nao va dpng mach vanh - Neu cung liidng tim rat thap thi lu'u liidng nude tieu du'dc lpc khoi ong than cung se rat it 3.2 Tang ap luc tinh mach ngoai vi - Suy tim phai: tang ap liic cuo'i tam triidng d that phai se jam tang ap hie d nhi phai roi tii lam tang ap luc d cac tinh mach ngoai vi va lam cho tinh mach cd ndi, gan to phii, tim tai - Suy tim trai: tang ap liic cuoi tam tn.idng d thai trui se lam tang ap liic nhi trai, roi tiep den lam tang ap liic d tinh mach phoi va mao mach phoi Khi mau li cang d cac mao mach phoi se lam the tich d cac phe nang bi giam xuong su" trao doi oxy d phdi se kem di lam benh nhan khd thd Dae biet ap liic mao mach ph6i tang den mot miic nao se pha vd hang rao phe nang - mao mach phoi va buyet tiidng se cd the tran vao cac phe nang, gay hien tiidng phii phdi II PHAN LOAI VA NGUYEN NHAN Phan loai suy tim Co the co nhieu each phan loai suy tim khac nhau, dvta tren cd sd: - Hinh thai dinh khu: suy tim phai, suy tim trai va suy tim toan bp - Tinh trang tien trien: suy tim cap va suy tim man tinh - Lu'u liidng tim: suy tim giam lu'u liidng va suy tim tang lu'u liidng - Suy tim tam thu va suy tim tam triidng Tuy nhien, tren lam sang ngiidi ta thiidng hay chia suy tim lam ba loai: su tim trai, suy tim phai va suy tim toan bp Nguyen nhan suy tim 2.1 Suy tim trai a Tang huyet dp dong mach: la nguyen nhan thiidng gap nhat gay suy tim trai Chinh tang huyet ap da lam can trd su" td'ng mau ciia that trai tiic la lam tang hau ganh b Mot so benh van tim Hd hay hep van dpng mach chii ddn thuan hoac phoi hdp vdi Hd van hai la c Cdc ton thu'dng cd tim Nhdi mau cd tim - Viem cd tim thap tim, nhiem ddc hay nhiem khuan - Cac benh cd tim d Mot so roi loan nhip tim ~ Cd ba loai rd'i loan nhip tim chii yeu cd the diia den benh canh ciia suy tim trai: + Cdn nhip nhanh kich phat tren that, nhat la cdn rung nhi hay cdn cuong dong nhi + Cdn nhip nhanh that + Bloc nhi - that hoan toan e Mot so'benh tim bam sinh: •- Hep eo dpng mach chii - Cdn ong dpng mach - Ong nhi - that chung Chii y: triidng hdp hep van hai la, tang cao ap liic nhi trai va mao mach phdi nen dan den nhiing trieu chiing giong nhu' suy tim trai Nhiing su" thtfc thi hep hai la ddn thuan khong gay du'dc suy tim trai theo diing nghia ciia no vi hep hai la da tao nen mot sii can trd dong mau di tdi that trai, lam cho ap liic (hay the tich) cuo'i tam triidng ciia that trai lai bi giam hdn binh thu'dng; tam that trai khong bi tang ganh nen khong suy du'dc 2.2 Suy tim phai a Suy tim trdi lau Suy tim trai lau se dan den suy tim phai, day cd le la nguyen nhan kha thu'dng gap b Cdc nguyen nhan ve phoi vd di dang long ngitc, cot song Cac benh phdi man tinh: hen phe quan, viem phe quan man, gian phe nang, gian phe quan, xd phdi, benh bui phoi dan dan diia den benh canh ciia tam phe man Nhoi mau phoi gay benh canh tam phe cap Tang ap liicddng mach phoi tien phat Gii cot sd'ng, cac di dang long ngiic khac c Cdc nguyen nhan tim mach Hep van hai la la nguyen nhan thu'dng gap nhat d cac niidc dang phat trien Mot so' benh tim bam sinh: hep dpng mach php'i, tam chiing Fallot Mot sd' benh tim bam sinh khac cd luong shunt trai ->phai (thong lien nhi, thong lien that vv ) den giai doan mudn se cd bien chiing ciia tang ap dpng mach phoi va gay suy tim phai Viem ndi tam mac nhiem khuan gay ton thu'dng nang d van ba la Mot sd nguyen nhan it gap: u nhay nhi trai, vd tiii phinh xoang Valsalva vao cac buong tim ben phai, tang ap liic dpng mach phoi tien phat v.v Chii y: triidng hop tran dich mang ngoai tim hoac viem mang ngoai tim co that se cd bieu hien gid'ng nhii suy tim phai, nhiing thiic chat chi la nhiing triidng hdp thieu nang tam triidng chii khong phai suy tim phai theo diing nghia ciia no 2.3 Suy tim toan bo a Thu'dng gap nhdt la cdc trUdng hdp suy tim trdi tien trien suy tim toan bo b Cdc benh cd tim, gian c Viem tim toan bo thap tim, viem cd tim d Cuoi cung cdn phai nhdc den mot sd nguyen nhan dac biet gay suy tim toan bo vdi "lu'u lUdng tang": 10 - Ciidng giap trang - Thieu vitamin B^ - Thieu mau nang - Rd dpng - tinh mach III TRIEU CHLTNG Suy tim trai 1.1 Trieu chiing carnang a Khd thd: la trieu chiing hay gap nhat Liic dau chi khd thd gang siic, ve sau khd thd xay thiidng xuyen, benh nhan nam cung khd thd nen thu'dng phai ngoi day de thd Dien bien va miic dp khd thd cung rat khac nhau: cd khd thd mot each dan dan, nhiing nhieu den dot ngot, duE dpi nhu" cdn hen tim hay phii phoi cap b Ho: hay xay vao ban dem hoac benh nhan gang siic Thu'dng la ho khan nhiing cung cd ho ddm Ian it mau 1.2 Trieu chung thut the a Khdm tim Nhin, sd tha'y mom tim dap hdi lech sang trai Nghe tim: ngoai cac trieu chiing cd the gap ciia mot vai benh van tim da gay nen suy that trai, ta thiidng tha'y cd ba dau hieu: - Nhip tim nhanh - Cd the nghe tha'y tie'ng ngiia phi - Cung thiidng nghe tha'y mot tie'ng thdi tam thu nhe d mom, dau hieu ciia hd van hai la cd nang vi buong that trai gian to b Khdm phdi Thu'dng tha'y ran am rai rac hai ben day phoi Trong triidng hdp cdn hen tim cd the nghe du'dc nhieu ran rit va ran am d hai phoi, cdn triidng hdp phu phoi cap se nghe tha'y rat nhieu ran am to, nhd hat dang nhanh tii hai day phoi len khap hai phe triidng nhii "thiiy trieu dang" c Do huyet dp: da so' cac triidng hdp, tmyet ap dpng mach td'i da thu'dng giam, huyet ap td'i thieu lai binh thu'dng nen so' huyet ap chenh lech thu'dng nhd di 1.3 Cac xet nghiem chan an a Cdc xet nghiem mau - Cac xet nghiem mau cd ban: giiip cho danh gia tinh trang chung ciia benh nhan va cac roi loan, benh ly lien quan - Xet nghiem BNP va cac dan xua't: thuc te, suy tim, se tiet pro BNP va chuyen hda NT-proBNP va BNP Xet nghiem ca hai chat BNP hoac NT- pro BNP deu cd gia tri suy tim Tuy vay, NT-proBNP cd dp ben viing hdn 11 la nhdm IX - tieu hoa (14,3%) nhdm VI - than kmh (11,6%) va nhdm VIII - hd hap (8,1%,), cac nhdm khac khdng dang ke Tinh hinh tu* vong ngirdi co tuoi Theo tai lieu ntidc ngoai 44% ngtidi gia chet tai nha, sdcdn lai chet tai benh vien, nha dtidng lao Nguyen nhan trtic tiep gay chet tai benh vien la tim mach (51.7%,), hd hap (28.6%), tieu hoa (7%), ndi tiet chuyen hoa (1,5%), nhiem khuan (5,7%), benh mau va cd quan tao mau (1,7%), nguyen nhan khac (3,8%) Chting tdi cd nghien ctiu hoan canh tti vong d benh nhan gia nam dieu tri tai cac khoa ndi Benh vien Bach Mai, tha'y tudi chet ctia ngtidi gia trung binh la 67 tudi, 69,5% chet vao mtia lanh, 72,7%, chet vao ban dem Xet ve thdi gian tti vao vien den chet tha'y 34,6%, trtidng hdp chet xay tti dau, 64% 10 dau: dieu ndi len benh nhan gia thtidng vao vien cham, tien Itidng khd biet trtidc, benh de chuyen nang nhanh chdng Benh thudng gap d ngirdi co tuoi Trong cac benh tim mach thtidng gap la cdn dau that ngtic, nhdi mau cd tim, xd cd tim, rd'i loan nhip tim va dan truyen, tai bien mach mau nao, tang huyet ap, cac bien chting ctia xd vtia ddng mach, tam phe quan ttii phinh ddng mach Benh hd hap: viem phe quan man tinh, gian phe nang, ung thti phdi, gian phe quan, xd phdi lao phdi mang phdi, phe quan phe viem Benh tieu hoa: loet da day ta trang, viem dai trang man, ung thti da day, dai trang, ung thti gan xd gan, viem gan man, sdi than, viem man, tao bdn, tri Benh than - tiet nieu: viem be than - than man, viem cau than man, xd mach than, sdi tiet nieu u xd va ung thti tuyen tien liet, viem nhiem dtidng tiet nieu Benh ndi tiet - chuyen hoa: tang dtidng mau, tang cholesterol mau tang acid uric mau, suy giap trang, suy sinh due, suy vd thtidng than, rd'i loan thdi ky man kmh Benh mau va cd quan tao mau: thieu mau thieu sat, thieu acid folic hoac yeu to ndi tai, thieu nang xtidng, da u xtidng, Agamma globulin mau, ung thti hach, benh bach hau (man va cap) Benh tti mien: tudi cang cao cang gap nhieu tti khang the khang lipoprotein, khang insulin, khang mem mac da day, khang niem mac ddng mach chti, khang giap, khang nhan d ngtidi gia rat hay tti mien dich the tiem tang Benh tam than: cd hai loai ldn la loan than trtidc tudi gia va loan tam than tudi gia Trong loan tam than trtidc tudi gia hay trang thai tram cam hoang ttidng Trong loan tam than trtidc tudi gia hay gap sa stit tri tue kieu Alzheimer Benh than kmh: hay gap la rdi loan tuan hoan nao dti cac kieu va cac mtic u so, hdi chting ngoai bd thap nhat la benh Parkinson, viem da day than kmh, chen ep than kmh thoai hoa cot sdng 38b Ve ngii quan khoa Trong cac benh d mat hay gap due thuy tinh the tudi gia, Gldcdm thoai hoa vdng mac va mach mac, teo day than kinh thi giac, giam thi ltic Trong cac benh tai mtii hgng hay gap giam thinh ltic, rd'i loan tien dinh, ung thti (xoang ham, xoang sang, vdm mtii hgng) Trong cac benh ngoai da hay gap ngtia tudi gia, xua't huye't dtidi da, rung tdc, ung thti hac to', ung thti bieu md Trong cac benh rang ham mat hay gap tinh trang mat nhieu rang, viem thoai hoa quanh rang, viem khdp thai dtidng ham III DAC DIEM DIEU TR| HOC VE BENH TUOI GIA Nguyen tac chung Cung nhti bat cti mot benh nhan nao, dieu tri phai toan dien, dieu tri nguyen nhan cd che, trieu chting Rieng vdi benh nhan gia, can chti y hdn den viec nang dd cd the, tao dieu kien thuan ldi cho viec chtia benh, dac biet ve phtidng dien dinh dtidng, hd trd ve tinh than tti ttidng Sti dung thuoc d ngirdi co tuoi Do nhting dac diem ctia cd the ngtidi gia, tac dung thud'c khdng hoan toan gid'ng nhti ngtidi tre ntia Viec hap thu thud'c kem hdn ve td'c cting nhti mtic chuyen hoa khdng hoan chinh dtidc cac chat, kha nang chd'ng ddc cua cd the kem, kha nang bai xua't kem, nhay cam ctia cd the dd'i vdi thud'c giam Vi nhting ly tren bien chting xay nhieu hdn so vdi ngtidi tre; tac dung chtia benh ctia thud'c xua't hien cham hdn, kem hdn, hay gap tac dung phu Nhting dieu can chti y la: Neu cd mdt phtidng phap chtia benh nac hieu nghiem ma khdng can den thud'c thi khdng nen dting thudc Neii nhat thiet phai dting thud'c de chtia mdi khdi benh thi dting cang it loai thud'c mdt ltic cang tot Khi da chgn dtidc thudc phai dting thi nen sti dung dtidng nao an toan va ddn gian nhat Can chgn lieu Itidng thich hdp nhat, dat hien qua cao nhat khdng gay tai bien, nhiem ddc Nen bat dau vdi mdt lieu tham dd, thap bang ntia lieu tre, rdi tang dan Neu phai dting thud'c cd ddc tinh cao, can ap dung nhting bien phap han che ddc tinh (che an ud'ng sti dung ngat quang ) Dti la thud'c khdng ddc, cting phai de phdng tai bien di ting, phan ting thudc theo cd dia Khi dting thud'c mot thdi gian dai phai theo ddi, kiem tra, ghi chep, sd ket tting ddt, tong ket Phau thuat doi vdi ngirdi cd tuoi Ddi vdi van de phau thuat, can phan biet hai loai: loai md phien (theo ke hoach) va loai md cap ctiu Ddi vdi md cap ctiu van de dat la phai can nhac gitia 389 nguy hiem neu khdng md va nguy cd md Dd'i vdi md phien, cd thi gid nen phai chuan bi ky dac biet chti y den bd'n viec sau day: Kiem tra loan dien tren cd sd danh gia tinh trang stic khde, benh tat va kha nang chiu dting cudc phau thuat Cdng tac tti ttidng lam cho benh nhan yen tam tin ttidng vao hdp tac vdi chuyen mdn Nang cao the ltic stic khde ngtidi benh de san sang vao cudc phau thuat dtidc thuan ldi nhai Chuan bi that ky viec vd cam, Dd'i vdi van de gay me can ltiu y la so vdi co the tre, tai bien cd phan nhieu hdn tinh trang thieu oxy, kem thich nghi Phuc hoi enure nang d ngirdi cd tuoi Phuc hdi chtic nang nham dam bao boat ddng the ltic, tam ly, tti quan he gia dinh va xa hoi, kha nang lao ddng hoat ddng nghe nghiep Thtic te da chting minh la ngtidi cd tudi biet luyen tap phuc hdi chtic nang - da suy giam tudi tac - van cd the thu dtidc ket qua td't dieu ma rieng thud'c men khdng the dat dtidc Sd di nhti vay la cd the mac dau tudi cao van cdn nhting dti trti dang ke, neu cd phtidng phap thich hdp cd the buy ddng dtidc Mudn dat dtidc yeu cau phai: Bat dau thtic hien phuc hdi chtic nang cang sdm cang td't Tien hanh dieu tri phuc hdi mot each tti giac tren cd sd khoa hgc, cd nhti vay mdi cd the kien tri lau dai dtidc Ket hdp tti ren luyen vdi hd trd ctia chuyen mdn Van dung theo dieu kien cu the: tai benh vien, tai cac cd sd an dieu dtidng, tai cac cau lac bd ngtidi cd tudi, tai nha nhting phai cd nhting thdi ky den kiem tra Thudc nang cao tuoi tho Hien chtia biet dtidc that ro nguyen nhan cd che ctia tudi gia nen chtia cd cd sd de ndi den cac loai thud'c cd kha nang nang cao dtidc tud'i tho Nhting tudi gia hay kem theo stic yeu nen ngtidi ta nghi cd the dting nhting thud'c bao tho (geroprotecteurs) ma chu yeu la cac chat chd'ng oxy hoa, cac yeu to' vi Itidng, cac vitamin, sam va nhung KET LUAN Lao khoa la mdt mdn hgc mdi hinh tudi thg cang cao, so'ngtidi cd tudi cang nhieu, nhting mac dau mdi, da cd mot ndi dung mdi ba linh vtic sinh hoc, y hgc, xa hdi hgc Vdi tudi cao, cd the cd nhieu thay ddi, tao dieu kien cho benh phat sinh va phat trien Viec chtia va phdng phai dtia tren nhting dac diem cd the gia va benh ly ctia dd'i ttidng, ndi chung khdng the gid'ng nhti ltic tre tudi 390 KHAM BENH NGlTOI GIA Kham benh ngtidi gia khdng hoan toan gidng nhti nhting ngtidi tre vi benh ly tudi gia cd mdt sd dac diem can chti y: Ngirdi gia thirdng mac nhieu benh Cting mdt ltic cd the cd nhieu benh, nhat la cac benh man tinh, d nhieu cd quan khac nhau, tren cd sd dd van cd the mac them nhting benh cap tinh mdi Viec mac nhieu benh vdi tinh chat khac nhau, vdi anh htidng qua lai rat phtic tap, lam cho viec kham phai rai, ty mi, viec phan tich va td'ng hdp phai rat day dti xdng mdi chan doan, tien Itidng, dieu tri dtidc chinh xac Trieu chting benh thirdng khong dien hinh Phan ting cua cd the gia ddi vdi tac nhan gay benh khac ddi vdi cd the tre, hdn ntia lai mac nhieu benh mdt ltic cho nen trieu chting khdng cdn dien hinh ntia ca ve phtidng dien lam sang lan can lam sang tudi gia, ranh gidi smh ly (qua trinh lao hoa tri nhien) vdi benh ly thtidng khdng cdn dtidc rd ntia Tien trien ctia benh khdng dien hinh, khien cho viec tien Itidng benh cting khd khan, khdng ddn gian Tam ly ngirdi gia khac vdi tuoi tre Cd benh nhan de tiep xtic, hdp tac vdi thay thudc viec tham kham va dieu tri, nhting cting cd cac benh nhan tinh tinh bat thtidng khd tiep xtic, it hop tac Tri nhd thtidng giam, sti mmh man bi han che, lam cho ddi phan ting cac trieu chting khach quan kem phan chinh xac Khdng it benh nhan trang thai tram cam, khdng mudn giao thiep vdi va khtidc tti ca sti tham kham, xet nghiem va ca viec chap hanh moi bien pluip dien tri Cac benh ngirdi gia mac thirdng khdng gid'ng vdi ngirdi tre ngtidi gia cac benh thoai hoa, ung thti, tti mien, tai nan thudc men cd phan nhieu hdn ngtidi tre Cd nhien benh man tinh vdi cac bien chting phd bien va da dang nen ltic kham phai chti y trtidc het den mdt sd benh thtidng gap d ngtidi gia Sau tham kham, tham dd chtic nang, phai lam cac xet nghiem can lam sang, phai di den ket luan chan doan benh chinh, benh phu, giai doan benh, bien chting benh I HOI BENH • Tiep xuc ngUdi benh Tiep xtic vdi ngtidi gia de hdi benh va tham kham, can ltiu y den thai dd va tac phong 391 Phai the hien tmh than thtidng yeu, kinh trong, thdng cam vdi tudi gia, tti each xting hd, ldi ndi, thai den each cham sdc hang Ngtidi gia ndi hay khdng ndi ra, de tti ty va de cd mac cam cho la mgi ngtidi it quan tam den minh, la ganh nang ctia xa hdi, vi vay hg trinh bay benh tat nhting dieu hg ban khoan, can chti y lang nghe vdi thai quan tam thtic sti khdng nen vdi ngat ldi Vi dtidc giai bay y kien, tam tti, nguyen vgng cung da lam cho ho yen tam tm ttidng hdn Neu hg ndi lan man qua ltic dd se lai kheo mot each nhe nhang ve trgng tam Can kien nhan, tranh to thai sd't rudt tac phong vdi va lanh nhat, coi thtidng Can phan biet tti dau ba loai ddi ttidng tiep xtic: - Cd ngtidi stic khde cdn td't, tiep xtic de vi tri dc cdn mmh mln Trong trtidng hdp nay, viec hdi benh cd the khdng cd gi khac him so vdi kham benh thdng thtidng d ngtidi dting tudi - Cd ngtidi da suy yeu vi cd the gia da cd nhieu bien ddi, cd nhieu benh man tinh tmh than hoan toan khdng binh thtidng Viec tiep xtic, hdi benh, tham kham d day khd khan hdn, cdng tac ddng vien tinh than de tranh thti tdi da sti cdng tac ctia ngtidi benh la rat can thiet - Cd ngtidi cd the da suy kiet qua gia hoac benh tat lau nhieu dai ia khdng tti chti, tmh than lti lan Viec tiep xtic, hdi benh tham kham rat khd khan Can tranh thti sti gitip dd ctia gia dinh, ngtidi quen de cd the khai thac dtidc tien sti, trieu chting Ltic can bd khuyet cho sti hdi benh khd khan bang each tham kham ky Itidng va tan dung cac phtidng phap can lam sang de cd gang cd dtidc chan doan chinh xac, td'i da pham vi cho phep • Khai thac cdc trieu chUng chu quan De viec khai thac cac trieu chting dtidc ket qua, btidc dau cd the nhin bao quat, nham muc dich danh gia tinh trang chung ctia benh nhan, sau dd mdi bat dau hdi benh mdt each cd he thdng, di sau vao nhting phan lien quan den benh - Danh gia tinh trang chung ctia dd'i ttidng: Phan nham muc dich xem kha nang cdng tac ctia ngtidi benh nhti the nao qua dd de danh gia xem cac trieu chting ma ngtidi benh cung cap cd gia tri den dau Co the bao ngtidi benh ngdi xud'ng, dting len, di lai vai btidc de xem xet sti hieu biet ctia hg tinh trang chung ctia toan than, kha nang van ddng, kha nang chap hanh nhting yeu cau ctia chuyen mdn Kiem tra nhanh chdng kha nang nghe, nhin, cd the dtia cho hg mot td bao va de nghi dgc mdt doan de danh gia tmh than ctia hg - Hdi benh mot each cd he thdng: Trtidc het ta tim hieu xem benh nhan da mac chting benh gi tti trtidc cho den nhat la cac benh man tinh hay gap d ngtidi cd tudi nhti loet da day ta trang, 392 viem dai trang man, viem phe quan man, viem cau than man, tang huyet ap, dai thao dtidng, thoai khdp Neu tien sti cd nhting benh dd thi phai can than trgng dieu tri nhting benh dang mac hien vi de cd nhting tai bien Cting can hdi xem da nam benh vien chtia va da du'dc dieu tri nhting gi vi ngtidi gia thtidng cd nhieu benh lam cho ta kham cac trieu chting khdng cdn dien hinh va ddn thuan ntia, de dan den bd sdt benh va sai lac chan doan Can dac biet khai thac nhting trieu chting sdm ctia ung thti vi benh rat phd bien d ngtidi gia va benh da ro thi thtidng mudn khd be ctiu chtia Chti y trieu chting chay mau khdng cd nguyen cd ro ret nhti dai mau, chay mau cam, ia mau, ho mau, ndn mau, chay mau am dao Cting phai hdi xem benh nhan cd hach, u cue d dau khdng, cd gay sut can nhanh mdt each vd cd khdng Trong hdi benh can chti y dieu tra tinh hinh sinh sd'ng hien nay: Dieu kien an d, hoan canh gia dinh, dieu kien kinh te xa hdi Cd nhting ngtidi cd gia dinh cham sdc chu dao, day dti, nhting cting khdng it gap khd khan rat ldn, can sti hd trd ctia xa hdi Neu hdi benh lan dau khdng thu dtidc ket qua mong mudn thi can tim nhting dip khac de khai thac dtidc ky hdn nhting lan sau, nen kiem tra lai nhting ldi khai trtidc de xem cd chinh xac khdng vi tri nhd va kha nang tiep thu y kien kha nang dien dat ctia ngtidi gia thtidng rat han che Khi cd dieu kien cd the hdi them ngtidi nha Hdi benh phai rat kien nhan, edgang khach quan tranh dinh kien va cd dc suy xet mdi tiep thu dtidc nhting thdng tin bd ich II KHAM BENH Ve cd ban, each kham benh ngtidi gia khdng khac vdi ngtidi dting tud'i Nhting nhting dac diem cd the va benh ly tudi gia, nen chti y mdt sd trieu chting sau day • Khi kham chung toan than Ve da - Can quan sat mau da xem cd vang khdng Da vang nhat phai tim xem cd ung thti d cd quan tieu hoa khdng, cd benh thieu mau tan huyet khdng Khi vang ro ret phai tim xem cd sdi mat, ung thti ndi khac di can den gan Neu da nhdt nhat phai tim nguyen nhan thieu mau, suy tuy, xua't huyet ndi Da sam phai nghi den benh Addison, benh Hanot, da tim nghi den suy tim, suy hd hap man, tam phe man - Tinh trang ctia da thtidng phan anh kha sdm va kha ro ret tinh trang hoa gia Da thtidng nhan, giam tinh dan hdi, cd nhieu vet sac to' dam (da mdi) cd xua't huyet dtidi da (vet bam) vet sting hoa d da - Tim cac u dtidi da hay da Hay gap u vang, ban vang, u md, u mach Cting cd gap ung thti da, di can ung thti vao da 393 - Ve long tdc mong, danh gia tinh trang tdc bac, tdc rung Nhting ngtidi gia cd suy hd hap man, ung thti phdi hay cd ngdn tay dtii trd'ng mong tay khum Trong kham toan than phai chti y phat hien cac hach dac biet tim ky d vting thtidng ddn (hach Virchov Troisier) vting cd gay, nach, ben, vting bung (mac treo) Khi cd hach phai chti y den tinh chat dinh, mat so'Itidng, neu nghi ngd thi nen lam smh thiet xac dinh nguyen nhan Ve tti chi - Quan sat xem cd hien ttidng bien dang, thu teo, ngan chi u cue - Ddi vdi chi tren: quan sat xem cd bien dang viem da khdp dang thap, di chting gay xtidng cd tay (Poutau - Colles) cac cue ldi xtidng thoai khdp, cac hdn eberden, xem ky xem cd run tay (run tudi gia hay Parkinson) tinh trang rd'i loan than kmh thtic vat (hdi chting Raynaud) - Dd'i vdi chi dtidi: chti y xem nhiet da (lanh cd viem tac ddng mach chi) cac btii gian tinh mach, cac bien dang cac td phi ctia benh gtit Danh gia mtic va tinh chat phti Kiem tra xem cd di chting gay cd xtidng dtii, gay xtidng cang chan kieu Duppuytren - Ve cot sdng danh gia gti tim nhting diem dau, cac di dang • Khdm he tim mach - Ngtidi gui dti be ngoai cd ve binh thtidng, cung thu'dng hay cd suy tim tiem tang Do bang nhting cau hdi gian ddn va de hieu, cd'gang phat hien tinh trang khd thd gang stic, nam dau ttic vting trtidc tim gang stic, phti budi chieu, trd'ng ngtic hdi hop Phat hien cdn dau each hdi d chi dtidi - Khi nghe tim, chii y phat hien tieng thdi nhai, la tieng thdi Lam trtidng cua hd van ddng mach chti vtia xd ddng mach, tieng thdi tam thu d mom ho van hai la (lhtidng la cd nang) Phat hien loan nhip tim cac loai (thtidng gap nhai la ngoai tam thii loan nhi]) hoan Loan run thd nhi) Cung cd gap nhip qua cham nhi that phan ly - Do huyet ap ddng mach la mot thu Luc bat budc Lrong mdi lan tham kham Dd'i vdi ngtidi gia nhat la lan dau kham phai huyet ap hai ben, ltic nam va ltic dting (vi hay gap Linh trang tut huyet ap Lti Lhe dting) Do ddng mach ngtidi gia hay bi xd cting cho nen can xac dinh cho dung huyet ap Lam trtidng (vi cd nhieu trtidng hop den sd khdng van cdn nghe tieng dap nhat la de manh) Nhting lan dau kham nen huyet ap nhieu lan vi d ngtidi gia hay gap loai huyet ap dao ddng Kham cac mach mau: + Dd'i vdi ddng mach, bang nhin va sd cd' gang phat hien dau hieu giat chudng, xac dinh cting ctia ddng mach Khi nghe nen chti y nghe ca ddng mach co ddng mach bung Dd'i vdi he tinh mach can danh gia tinh trang suy gian Linh mach chti y tinh mach cd ndi, hay gap cd suy tim xem day mat cd the phat hien Linh trang mach mau, xua't huyet vdng mac, phti gai mat 394 • Khdm he ho hdp - Quan sat ky nhip thd, cac bien dang long ngtic Go ngtic hai ben, phia trtidc phia sau de phat hien va danh gia mtic gian phe nang (trang thai phd bien d ngtidi gia) - Nghe hdi ky de phat hien cac benh ctia phe quan, nhat la viem phe quan man, gian phe quan, ung thti phe quan Chti y mtic dd ri rao phe nang (giam gian phe nang) cac ran am hay gap suy tuan hoan kinh dien d ngtidi gia nam lau - Chieu va chup X quang phdi: danh gia mtic gian phe nang, canh giac vdi mgi dam md, can lam rd nguyen nhan Neu cd tdn thtidng nghi lao (dti cti) cung phai tim BK nhieu lan ddm (vi lao d ngtidi gia thtidng cd trieu chting kin dao khdng dien hinh va do de bi bd qua • Khdm he tieu hod mom: kiem tra bd rang va tinh trang rang, ldi, mieng Ve ltidi can chti y xem cd hien ttidng viem (viem ltidi Hunter) khd niem mac (hdi chting Sjogren), choc mep, teo ldi (hdi chting plummer - Vinson) - Kham bung: can dac biet ltiu y den gan (tim xem cd dau hieu ctia ung thti gan viem gan man, xd gan viem dtidng mat sdi viem ttii mat) Chti y nan vung dai trang xud'ng, hay gap nhting u phan (de lam la moi u ac Linh) Neu cd benh lui Lhtia Lhi nan vting do, benh nhan hay keu dau * - Tham hau mdn bao gid cting phai lam kham ngtidi gia Cd the nhd dd ma phat hien khd'i n Luyen Lien liet, khdi u trtic Lrang, Lri O nti can canh giac vdi mot ung thti lan rdng ctia cac bd phan smh due Neu qua tham hau mdn cd gi nghi van, can soi trtic trang kiem tra • He tinh than kinh - Hdi chting rdi loan tuan hoan nao nhat la thieu nang tuan hoan nao rat phd bien Vi vay can chti y den cac trieu chting nhti: chdng mat, cam giac cang nang d dau, thoang quen, rdi loan giac ngu ndi ngpng - Khi kham can quan saL mat xem cd can ddi khdng, cd the phaL hien ligt day VII kha nang phaL am, ban manh, hien itidng run nha'L la run Lheo kieu Parkinson Bao benh nhan lam mdL so ddng Lac, di lai, de phaL hien liet rd'i loan dieu hoa, phd'i hdp ddng Lac - Cac rd'i loan cam giac rat da dang d ngtidi gia, can xem ky, danh gia tinh he thdng ctia cac rdi loan de xac minh phan nao la nguyen nhan mach mau, ndi tiet va nguyen nhan khac (benh ngoai da, benh toan the ) - Khi kham phan xa, ngoai viec kiem tra cac phan xa gan xtidng can chti y phan xa ddng tti - Kham ve mat Lam Lhan rat quan Ben canh nhting rd'i loan thoai trien cdn cd nhieu rdi loan vtia xd ddng mach Chti y den tri nhd (cac tesL Lri 395 nhd), kha nang dinh htidng, tti duy, xtic cam PhaL hien cac bieu hien tti nhe den nang ctia benh sa stit tam than tudi gia • He thdng ndi tiet vd chuyen hod - Chti y phat hien benh dai thao dtidng, rat phd bien d ludi gia, cac Lrieu chting lam sang Lhtidng mudn Phai Lim dtidng nieu va dinh htidng dtidng huyet moi each nhaL loaL Neu tha'y binh thtidng nhting van nghi ngd phai lam nghiem phap tang dtidng huyet - Suy giap trang can dtidc chti y phat hien mdt each cd trinh tti Sti dung tti lam sang den cac xet nghiem va phtidng phap tham dd hien dai Benh rat phd bien nhat la d nti Chan doan bang lam sang thtidng khd vi trieu chting kin dao va khdng dac hieu Gipng chi hdi khan, da khd, tdc rung, thieu mau, dn lanh tao bdn cham chap Cac trieu chting Lren cung cd Lhe gap d rat nhieu ngtidi gia khdng cd suy giap trang d mtic thap hdn Vi vay vai trd ctia can lam sang d day rat quan Lrong - Ctidng Luyen giap khdng phai la hiem d ngtidi cd tudi Nhting thtidng bd qua vi trieu chting khdng dien hinh Nhieu chi bieu hien bang run thd nhi, loan nhip hoan toan (trong Lrtidng hdp de cho la xd cd lim vtia xd ddng mach vanh) hoac gay khdng rd nguyen nhan, sd ndng - Suy Lhtidng Lhan kinh dien kieu Addison thtidng bieu hien bang mau met, huyel ap lha'p (la nhting Lrieu chting khdng cd gi dac hieu va hay gap d Ludi gia) Trieu chting sam da it gap Neu khdng chti y phat hien va lam cac xet nghiem can thiet thi de bd sdL khdng chan doan • He xUdng khdp Benh thudc he xtidng khdp rat hay gap d ngtidi gia, tham kham can chti y phat hien - Thoai khdp gan nhti bao gid cting cd Chti y den cdL sd'ng nhaL la vting LhaL lting, vting cd, khdp gd'i Tim cac cue gai xtidng chdi xtidng Thoai hoa col sd'ng cd Lhe gay chen ep Lhan kinh - Viem khdp dang Lha'p ddi dan den cac bien dang khdp rai nang d Lti chi - Benh gtii hay gap d ngtidi nhieu Ludi cd chi bieu hien nhti moi benh lha'p khdp cd acid uric Lrong mau Lang Khi da lhanh kinh dien hay cd cac cue tophi, bien dang khdp - Dau d'ng xtidng e am thtidng lien quan den loang xtidng cd Lhe de dang phaL hien Lren phim chup X quang Loang xtidng la nguyen nhan Lhtidng gap ctia gay xtidng, dac bieL la gay cd xtidng dtii Nhtin xtidng it gap hdn loang xtidng • He tiet nieu sinh due - Chti y kiem Lra hoaL ddng cd Lrdn, bang quang la nguyen nhan phd bien ctia rd'i loan ntidc Lieu, dai khd, dai ri, dai khdng het bai Chti y den tinh chat ntidc tieu, can xac dinh can ntidc Lieu 396 - U xd Luyen tien liet Phan tich tinh chat tieu tien, tham Lrtic Lrang danh gia khd'i u can thi smh thiet de xac dinh u lanh hay u ac - Tim cac Lrieu chting lam sang va xel nghiem ctia viem be Lhan - Lhan man Linh rat thtidng hay gap d ngtidi gia Nhiem khuan dtidng tiet nieu kha phd bien lien quan den sdi tiet nieu, u xd tuyen tien het d nam, benh phu khoa d nti - Mot each kin dao va te nhi, nen hdi them kha nang smh due - nti khdng nen quen tim cac dau hieu ctia ung thti tti cung III XET NGHIEM • Xel nghiem mau - Td'c lang mau: + La mdt xet nghiem ddn gian, de thtic hien, khdng cd gi dac biet nhting nhieu trtidng hdp cung gitip cho dinh htidng chan doan d ngtidi gia td'c lang mau cd the tang nhe ma khdng cd y nghia benh ly Tuy nhien, neu tang nhieu can xem cd d nhiem khuan, trang thai viem d mdt bd phan nao il bieu Id bang Lrieu chting lam sang, Linh phan ting ctia cd Lhe ngtidi gia da giam stiL Neu Lang rat nhieu can lam dien di protein va cac xet nghiem mien dich khac de phat hien da u luy xtidng + Xem hinh thdi tebao mdu rat can Neu benh nhan chi den vi Ihieu mau nhting xet nghiem ky te bao hgc cd the phat hien thieu mau kieu Biermer, cac benh mau ac tinh, mdt so' benh hdi chting tang smh Thieu mau huyet tan thti phat kha phd bien nhieu nguyen nhan khac + Ure mdu: thtidng cao hdn d ngtidi tre, nhieu kin khd xac dinh y nghia Nd cd the gap d tinh Lrang suy than thtic ton hay chtic nang Trong nhting trtidng hdp phan van, nen dinh Itidng creatinin trung thtic hdn + Do benh dai thao dtidng, benh gtit, benh vtia xd ddng mach rat phd bien d ngtidi gia, xet nghiem cd ban phai lam dtidng mau, dtidng nieu, acid uric mau, cholesterol mau, lipid mau va dien di lipoprotein + Neu phosphatase kiem tang nen kiem tra xem cd benh Paget, nhuyen xtidng, ung thti xtidng phosphatase acid tang cd the gitip phat hien ung thti tuyen Lien liet, dac biet da cd di can vao xtidng - Xet nghiem ntidc Lieu Can khai thac cac xet nghiem ntidc tieu vi de thtic hien, cd the kiem tra nhieu lan Dieu quan trgng la lay ntidc tieu 24 gid va dting ky LhuaL Thdng Lhtidng phai Lim mot each nhat loai protein nieu, dtidng nieu Le bao, tru hat ngtidi gia nen chti y la creatin cd Lang cac benh Leo cd giam Lrong viem Lhan man Ure nieu giam suy Lhan man, urobilin Lang Lrong cac benh gan Khi cd nghi van viem khdp - be Lhan, phai Lim vi khuan Lrong ntidc Lieu 397 • Cdc tham chuyen khoa Do stic chiu dung ctia cd Lhe gia da giam, nen het stic tranh lam qua nhieu xel nghiem va lham dd chtia LhaL can Dd'i vdi cac phtidng phap lham dd nen tiu Lien ltia chgn cac ky thuat khdng chay mau, it gay sang chan Lam ly Do sti cdng Lac vdi ngtidi gia (nhaL la ngtidi it nhieu da lti lan, hay cd nhting Lac ddng khdng Lti chti) nen nhting ket qua thu dtidc cd the kem chinh xac, ddi hdi phai phan tich suy xet ky hdn Thdng thtidng cd Lhe lam: Chup da day La trang, rudt sau ud'ng baryt Chup Lhan, dtia thuoc can quang theo dtidng Linh mach Chup Lhan ngtidc ddng (chti y nhiem khuan tiet nieu) Soi d bung, soi da day bang dng mem Dien tam dd nhat la gang stic (theo ddi ky, cd chuan bi san phtidng tien cap ctiu) HuyeL do, Luy (Lhan Lrpng vi hay cd loang xtidng Ludi gia) Cac bien phap Lham dd dtidi day chi nen lam that can thiet: Sinh thiet da (thti tim vi mach dai thao dtidng) sinh thiet than Chup can quang ddng mach Khi cd dieu kien nen sti dung cac ky LhuaL khdng chay mau nhti sieu am, Doppler, ltiu huyeL, CT Scanner, R.M.N (cdng htidng Lti hai nhan), chup nhap nhay, dao ddng ke, Lam cd ddng dd IV X QUANG Trong cdng tac chan doan benh d ngtidi cd tudi X quang ddng vai trd quan lrong Nhting kmh nghiem dtidi day riit Lti X quang 12.000 benh nhan gia, Ludi trung binh la 81, nam tai benh vien Lao khoa d Geneve • X quang ngUc tudi gia binh Lhtidng cting da thay hinh anh calci hoa sun stidn (80%) gti (55%)) ddng mach chti gian nd va nhiem calci (75%)), quan lech sang phai {40%) trung LhaL Lren phai rdng gian Linh mach chti Lren (45%)), phdi qua sang, rdn phdi dam (25%) 2/3 benh nhan cd tim to - Viem phe quan phdi 30%) khdng phaL hien dtidc kham lam sang - Ap xe phdi ddi khd phan biet gitia hoai tti Lac mach phdi, ap xe nhiem khuan, ap xe tren cd sd ung ihti - Tac mach phdi: Lhtidng gap hinh anh cd hoanh bi nang cao, dam md d phdi cd kem Lheo phan ting mang phdi, ddng mach phdi gian nd Ve phtidng dien X quang cd den 75%) chan doan bi nham Chi cd chup can quang ddng mach phdi mdi cd the chac dtidc nhting it lam dtidc vi nguy hiem 398 - Lao phdi: hinh anh lao phdi hoaL ddng gap Lrong 0,8%) trtidng hdp (65% la nti va 35% la nam) Ve maL lam sang cd sdi (70%) suy kiet (40%) Lao ke chiem 20% trtidng hdp lao, lao hang it gap hdn (7%) - Uphdi Lien phaL (1%) Nen ket hdp vdi chup cai Idp Can canh giac dd'i vdi dam md chtia bang khang smh khdng het Thdng thtidng la mot d bdi nhidm tren cd sd mdt vting xep phdi u - U thti phat Di can ung thti vao phdi va xtidng long ngtic chiem 2% benh nhan dieu tri 33% trtidng hdp di can la mot ung thti ngoai phdi da dtidc biet trtidc, 45% la dau hieu dau tien nhd dd phaL hien ung thti nguyen phaL - Tran dich mang phdi Phan ldn nguyen nhan lao va ung Lhti - Xd phdi tudi gia Hinh anh bien ddi mach mau kem theo gian phe nang, tdn Lhtidng dang bong bdng chii yeu d phia Lren va phia Lrtidc phe Lrtidng • Bd may tieu hod - Thtic quan: qua ntia benh nhan cd LhoaL vi hoanh U thtic quan ac tinh nhieu hdn u lanh tinh - Da day ta trang: loeL da day hay gap hdn loeL La trang, khac han dd'i vdi ngtidi Lre va ngtidi dting Ludi LoeL da day chti yeu d bd cong nhd,cd rat cao d vting phinh vi ldn Ung thti da day khdng hiem, cang nhieu tudi cang hay gap Dieu dang chti y la cd nhieu ung Lhti da day rat ro ma khdng cd trieu chting lam sang dang ke - Tieu Lrang (rudL non) Cac Ldn Lhtidng phan ldn la thieu mau cue bo vi vay khd phat hien X quang chi ltic md tti tin, tha'y kha phd bien - Dai Lrang, 90% benh nhan chup baryt dai trang thay cd nhieu tui thtia d cac mtic khac nhau, kem theo viem gay hep nhaL la d vting dai Lrang Sigma, d vting cting hay gap u ac tinh Gap kha nhieu Lrtidng hdp viem dai Lrang thieu mau cue bd - U phan Benh lanh tinh, cd the chtia ndi khoa neu phat hien sdm Neu phat hien cham, cd phai md cap ctiu, Lham chi cd the gay tti vong Dac biet phd bien d benh nhan phai nam lau Thtidng khu trti d vting trtic trang va Sigma Nguyen nhan chti yeu la Lao bdn lau - Thting rudL Thting mot hoac thiing da day La Lrang cd Lhe chi cd Lrieu chting kin dao ve lam sang Phai chup bung khdng chuan bi de benh nhan dting hoac nam nghieng de phat hien hem hdi - Ttii mat va dtidng maL Sdi ttii mat rat hay gap, phan ldn dtidc phat hien bang Xquang ltic ve mat lam sang chtia cd gi ro reL Cting hay gap vang da Lac maL, nguyen nhan phan ldn sdi ung Lhti dau Luy, chen ep dtidng maL dam hach hoac u d cud'ng gan • He tiet nieu 399 Phi dai Luyen Lien liet va ung thti tuyen tien liet rat hay gap chup X quang dtidng tiet nieu d ngtidi gia it gap benh Lhan nguyen nhan nhiem khuan hay ung Lhti ve mai X quang • He xUdng khdp Loang xtidng la mot benh thtidng hay gap hang Nhting cting cd khd phan biet vdi nhtin xtidng ctidng Luyen can giap Lrang Lien phaL hay thti phaL, da u Luy xtidng Hinh anh day Idp sun vdi rai, hay gap Ton Lhtidng thoai hoa khdp cdL sd'ng cd - lting - LhaL lting gap hau het tren cac benh nhan gia Gap rat nhieu trtidng hdp gay cd xtidng dtii - Lrong thoai hoa khdp xtidng chau can ltiu y den kha nang bien chting nhiem khuan hoac hoai tti vd khuan Di can tao xtidng phan ldn ung Lhti Luyen Lien liet, di can huy xtidng phan ldn ung thti vti Luyen giap phdi V TONG HOP KET QUA Sau khdi benh Lham kham va da cd ket qua xet nghiem X quang tham dd chtic nang can cd sti danh gia Long hdp ve benh lai va Lien Itidng Viec khd hdn d ngtidi Lre vi ngtidi gia hay ddng lhdi cd nhieu benh, cac benh lai d cac giai doan khac nhau, qua Lrinh hoa gia cua cd the khdng ddng Lhi va khdng ddng toe nen viec phan tich Long hdp phai Linh Loan den nhieu yeu id mdi cd Lhe xac dinh chan doan chinh xac dtidc Nhin chung viec Long hdp ket qua phai di den nhan dinh phan loai nhti sau: Ddi ttidng chi cd nhting bieu hien cua sti thoai trien ttidng ting vdi Ludi khdng ddi hdi sti can thiep gi dac biet Dd'i ttidng cd nhting benh man tinh khdng can dieu tri ndi trti tai benh vien Viec chtia chay nen sti dung cac bien phap dting thudc hoac khdng dting thud'c ket hdp vdi phuc hdi chtic nang Ddi ttidng mac mdi benh cap Linh tren cd sd nhieu benh man Linh cd Lti trtidc, can dieu tri Lai benh vien san sdc lich ctic Ddi ttidng mac mot benh mdi vi du ung Lhti can dieu Lri ket hdp gitia can bo lao khoa va chuyen khoa KET LUAN Kham benh ngtidi gia cd nhting dac diem khdng hoan toan gid'ng vdi ngtidi tre cd benh ly, smh ly rieng Ngoai viec kham lam sang, lam cac xet nghiem, can lam cac tham dd chtic nang, tiu tien sti dung cac phtidng phap khdng chay mau it hai, can cti vao ket qua Lren ma chan doan phan loai, Lien Itidng va xti Lri cho thich hdp vdi tting trtidng hdp cu Lhe 400 MUC LUC Chtidng TIM MACH (GS.TS Nguyin Ldn Viet, TS Pham Manh Hung) Suy tim Tang huyet ap 31 Viem ndi tam mac nhiem trting 53 Benh mang ngoai tim 65 Hep van hai la 80 Nhdi man cd tim cap 95 Chtidng TIEU HOA (Nguyin Khdnh Trach, PGS.TS Pham Thi Thu Ho) Ndi soi tieu hda gan mat 120 Chan doan hoang dam 125 Hoang dam ti mat 134 Ap xe gan amip 142 Viem gan man tinh 152 Sdi mat * 168 Ung thti gan nguyen phat 181 Chan doan va dieu tri xd gan 189 Hdi chting tang ap ltic tmh mach ctia 199 Chan doan va dieu tri xua't huyet tieu hda cao 209 Dai ctidng benh ly tang 216 Chan doan va dieu tri loet da day - ta trang 225 Viem dai trang 236 Benh dai trang chtic nang hay hdi chting rudt kich thich 242 Ung thti dai Lrang 245 Lao cac cd quan Lieu hda 259 Chtidng BO MAY VAN D0NG (GS.TS Train Ngoc An, PGS.TS Nguyen Thi Ngoc Lan, TS Nguyen Vlnh Ngoc) Phan loai cac benh khdp 267 Viem khdp dang thap 270 Nhdm benh ly cot sdng va benh viem cot sdng dinh khdp 284 401 Viem cdL sd'ng dinh khdp 286 Thap khdp cap 291 Thoai hda khdp (Hti khdp) va Lhoai hda cdL sd'ng 297 Lao xtidng khdp 308 Benh gut (GouL - goutte) 320 Benh Nhtidc cd (myasthenic) 331 Loang xtidng nguyen phat 336 Dau vting that lting va dau than kinh Lpa LhoaL vi dia dem 343 Lupus ban he thdng 355 Xd cting bi Loan Lhe 367 Loan dtidng cd va cac benh cd man tinh khac 376 Chtidng BENH HOC NGtfdl CO TUOI 402 (GS Pham Khue) Dai ctidng ve benh tudi gia 385 Kham benh ngtidi gia 391 ... song Cac benh phdi man tinh: hen phe quan, viem phe quan man, gian phe nang, gian phe quan, xd phdi, benh bui phoi dan dan diia den benh canh ciia tam phe man Nhoi mau phoi gay benh canh tam... Thtfky bien soan: GS.TS TRAN NGOC AN PGS.TS PHAM THI THU HO LOTI NOI OAU Bai gidng benh hoc noi khoa can bo gidng day cdc bo mon noi thuoc Trtfbng Dai hoc Y Ha Noi bien soan nham cung cap mot so... roi loan ve dien giai va thang bang toan kiem, can dac biet lu'u y cd tinh trang K+ mau khdng? Neu cd K+ mau can cho benh nhan ud'ng khoang 20 - 50 ml dung dich kalichlorua 10%) Triidng hdp can