BG trieu chung ngoai khoa ha van quyet

BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet BG trieu chung ngoai khoa ha van quyet

TRUftNG DAI HOC Y HA N0I B6 M6N NGOAI BAIGIANG TRIEU CHUNG HOC NGOAI KHOA NHA XUAT BAN Y HOC HANQI-2013 BAN BlfeN SO AN Chu bien: GS.TS Ha Van Quyet TrifcJng Bo mon Ngoai Trifdng Dai hoc Y Ha Noi Giam doc Benh vien Trifdng Dai hoc Y Ha Noi Pho Giam doc Benh vien Hiiu nghi Viet Du"c PGS TS Pham Dufc Huan Pho Tracing Bo mon Ngoai Trifdng Dai hoc Y Ha Noi Tracing khoa Phau thuat Tieu hoa Benh vien Hutu nghi Viet Du"c Thu* ky: TS Difdng Dai Ha Can bo giang day Bo mon Ngoai Trifdng Dai hoc Y Ha Noi Tham gia bien soan: PGS VS Ton That Bach Nguyen Hieu Trifdng Trifdng Dai hoc Y Ha Noi Nguyen Chu nhiem Bo mon Ngoai Trifdng Dai hoc Y Ha Noi Nguyen Giam doc Benh vien Hu"u nghi Viet Difc PGS TS Nguyen Ngoc Bich Nguyen Pho Tnidng Bo mon Ngoai Truing khoa Ngoai Benh vien Bach Mai Can bo giang day Trifdng Dai hoc Y Ha Noi PGS.TS Pham Du*c Huan Pho Trutdng Bo mon Ngoai Trifdng Khoa Phau thuat Tie a hoa Benh vien Hiiu nghi Viet Diic Can bo giang day Trifdng Dai hoc Y Ha Noi PGS.TS Tran Hieu Hoc Pho Truing Khoa Ngoai Benh vien Bach Mai Can bo giang day Trutdng Dai hoc Y Ha Noi PGS.TS Kieu Dinh Hung Pho Trifdng Khoa Ngoai Benh vien Dai hoc Y Ha Noi Can bo giang day Trifdng Dai hoc Y Ha Noi TS Diftmg Dai Ha Phau thuat vien Khoa Phau thuat Than kinh Benh vien Hiiu nghi Viet Difc Can bo giang day Trifdng Dai hoc Y Ha Noi ThS Phiing Ngoc Hoa Pho trifdng khoa Khoa Chan thifdng Chinh hinh Benh vien Hiiu nghi Viet Difc Can bo giang day Trifdng Dai hoc Y Ha Noi TS.BS Bui Ich Kim Khoa Gay me hoi siic Benh vien Hiiu nghi Viet Diic Can bo giang day TrifcJng Dai hoc Y Ha Noi PGS.TS Nguyln Huta Ucfc Pho Trifdng Bo mon Ngoai Trifdng khoa Phau thuat Tim mach Long ngtfc Benh vien Hutu nghi Viet Diic Can bo giang day Trifdng Dai hoc Y Ha Noi LOI GICJI THIEU Bo mon Ngoai xuat ban quyen sach giao khoa "Bai giang trieu chijfng hoc Ngoai khoa" de lam tai lieu hoc tap cho sinh vien Y khoa chu yeu la noi dung hoc tap cua sinh vien nam thu" Quyen sach giao khoa difdc bien soan theo noi dung giang day ma Bo mon Ngoai cua tarn Trifdng Dai hoc Y ca nifdc da thong nhat Quyen "Bai giang trieu chufng hoc Ngoai khoa" la tap hdp cac bai ve trieu chilng, hoi chttng thifdng gSp ma sinh vien can phai hoc va nam vifng Cac noi dung difdc trinh bay cuon sach la nhiing kien thifc kinh dien va da difdc cap nhat Cac tac gia da co gang trinh bay mot each chuan mile va day du nham trang bi cho sinh vien cac kien thvfc, ky nang va thai can thiet, lam cd sd vutng chac chan doan nhiing benh ly Ngoai khoa cung nhu" cac cap cu"u Ngoai khoa thu"dng gSp Tuy nhien quyen sach khong tranh khoi nhiing thieu sot Rat mong nhan difdc sut gop y cua ban doc de cuon sach du*dc hoan thien hdn Ian tai ban sau Xin chan cam dn! GS.TS Ha Van Quyet Chu nhiem Bo mon Ngoai • Trifcmg Dai hoc Y Ha Noi Pho giam doc Benh vien Viet - Dvfc Giam doc benh vien Trufcmg Dai hoc Y Ha Noi MUC LUC Trang Ldi gidi thieu Cach kham bung ngoai khoa, benh an ngoai khoa PGS.VS Ton That Bach Hoi chiing tac ruot PGS.TS Tran Hieu Hoc 20 Hoi chiing chay mau PGS.TS Tr£n Hieu Hoc 35 Hoi chiing tac mat PGS.TS Nguyen Ngoc Bich 47 Hoi chiing viem phuc mac PGS.TS Pham Diic Huan 60 Kham hau mon triic trang PGS.TS Pham Diic Huan 68 Kham chi tren, chi difdi ThS Phung Ngoc Hoa 77 Kham cot song va xifdng chau ThS Phung Ngoc Hoa 93 Trieu chiing hoc gay xifdng ThS Phung Ngoc Hoa 108 10 Trieu chiing trat khdp ThS Phung Ngoc Hoa 118 11 Dai cifdng ve bong ThS Phiing Ngoc Hoa 124 12 Trieu chiing cua nhot, hau boi, ap xe, chin me ThS Phung Ngoc Hoa 131 13 Kham he tiet nieu sinh due nam TS Do Trifdng Thanh 141 14 Kham chan thifdng, vet thifdng ngiic PGS.TS Nguyen Hutu Udc 158 15 Kham mach mau ngoai vi PGS.TS Nguyen Hutu Udc 175 16 Kham benh nhan chan thifdng so nao PGS TS Kieu Dinh Hung 188 17 Hoi chiing chen ep khong chan thifdng PGS.TS Kieu Dinh Hung 18 Hoi chiing tang ap lUc noi so PGS.TS Kieu Dinh Hung 19 Hoi chiing chen ep re than kinh that lu"ng cung TS Difdng Dai Ha 20 V6 khuan va khu" khuan ngoai khoa TS Bui fch Kim 21 Cac phifdng phap gay me - gay te Trieu chiing gay me Cac bien chiing TS Bui fch Kim gay me - gay te 194 200 207 214 226 CACH KHAM BUNG NGOAI KHOA, BENH AN NGOAI KHOA PGS.VS Ton That Bach I MUC TIEU HOC TAP Sau hoc xong bai nay, sinh vien co kha nang: Nam vitng cdc noi dung cua mot benh dn Ngoai khoa Biei each khai thdc va phdt hien cac trieu chiing lam sang, cac ddu hieu co" nang, todn than va thytc the Trinh bay diidcgid tri cua mot sotham can lam sang cd ban Trinh bay duac torn tat benh dn: trieu chiing chinh, ede trieu chiing va ede hoi chiing Nam vitng each thdm kham bung Xdc dinh dttac cac ddu hieu benh ly ve tinh trang thdnh bung, bung Nam dtfQc ede trieu chiing cua mot so'benh ly cap ciiu bung thiCcmg gap II NOI DUNG Hoi benh Trifdc hoi benh, ta bat buoc phai co nhiing ldi chao hoi xa giao de lam quen vdi benh nhan, tao sii tin tifdng cua ngifdi benh vdi minh dong thdi cung de tim hieu trinh dan tri va van hoa cua ngifdi benh de de nhiing cau hoi khai thac benh su" mot each thich hdp Ngoai ra, nhiing cau hoi xa giao cung de tim hieu them ve hoan canh gia dinh, xa hoi benh nhan Doi vdi ngifdi van hoa cao, can co nhiing cau hoi te nhi nhiing doi vdi nhiing ngifdi van hoa thap thi lai chon nhiing cau hoi ddn gian, cu the Hien nay, hau nhif cac bac sy va sinh vien deu bo qua muc va thifdng co mot thai ban dn, trich thifdng doi vdi ngifdi benh Nhiing bieu hien dang lam mat d&n di tinh nhan van, nhiing the hien van hoa toi thieu cua mot ngifdi Trong hoi benh va kham benh, ngifdi lam benh an phai ghi vao nhiing dau hieu difdng tinh (nhiing dau hieu ngifdi benh co) va ca nhiing dau hieu am tinh (la nhiing dau hieu ngifdi benh khong co) vi nhiing dau hieu am tinh co tac dung rat ldn chan doan phan biet va chan doan xac dinh Vi du dau qusin vung mang sUdn co dai mau se khac han dau mang su"dn khong dai mau, hoac dau vung diidi sUdn phai co sot nong va ret se ra't khac dau du"6i sifdn phai khong co sot 1.1 Ly vao vien Ly vao vien la ly khien ngifdi benh di den tiep xiic vdi cd sd dau tien chii khong phai la ly hanh chinh nhif chuyen vien hay hen vao mo Ly vao vien chinh la dau hieu chu dao de khai thac qua trinh hoi benh Vi du nhu1 benh nhan vao vien vi dau bung Khi benh nhan vao vien vi dau bung thi viec khai thac dau hieu xung quanh dau bung la quan nhat Do se la phan chinh khai thac benh su" Neu ngifdi benh di den cd quan y te dau tien la non mau thi viec khai thac cac dau hieu lien quan den non mau se la nhiing ph&n chinh can khai thac benh sii 1.2 Benh sic Benh sii la khai thac cac thong tin xung quanh ly vao vien Dau tien ta phai hoi den cd hoi xuat hien ly roi vi tri xuat hien cua ly vao vien doi vdi nhiing trifdng hdp dau vd thong thifdng moi mot cd quan noi tang deu co mot sii tifdng ling d ben ngoai Ta bat dau ho^ den thdi gian xuat hien cua ly vao vien vi chiing ta biet rang sii tien trien cua benh thifdng tifdng quan vdi thdi gian Do la dieu quan trong sd bo nhin nhan benh nhan co b tinh trang cap ciiu hay khong Neu nhu" ly vao vien cua benh nhan co tif lau thi rat it la mot benh cap ciiu ngoai khoa va neu nhif co cap ciiu ngoai khoa thi day la dieu te hai, co the tuyen y te nhifng cung co the ngifdi benh dan tri tha'p hoSc khong co kha nang kinh te di kham benh va de den khong chiu dting noi ho mdi di kham benh Tiep theo thdi gian xuat hieu dau hieu dau tien ta can hoi den cifdng cua dau hieu Cifdng dut doi hay vifa phai chi cam thay kho chiu Cung vdi hoi cifdng do, ta can hoi tiep den &&c tinh cua dau hieu nay: co cdn hay khong, co lien tuc hay khong, co Ian di theo hifdng nao Sau hoi du va ky cac dau hieu nay, ta mdi hoi den cac dau hieu khac xuat hien kem theo dau hieu Lay mot vi du benh nhan bi dau bung vi phan 16n benh nhan den kham cap ciiu la vi dau bung De khai thac dau hieu nay, ta phai hoi dau tien la cd hoi xuat hien cua dau hieu dau Co the la tii nhien, nhifng cung co the sau an c6 va uong rifdu (viem tuy) sau lao dong nfing (soi tiet nieu), ho&c thay doi thdi tiet (loet da day-ta trang) Tiep den ta hoi dau tif bao gid, dau d vung nao cua bung Neu la vung tren ron thifdng ta hay nghi den da day-ta trang, neu dau vung difdi sifdn phai, ta nghi den gan mat, neii dau ho' chau phai ta nghi den ruot thifa, neu dau vung bung difdi ta nghi den phan phu ho&c bang quang Sii suy nghi xuat phat tii vi tri giai phau va he so' tifdng quan giiia vi tri ben ngoai vdi benh ly cac tang ben Tuy nhien neu chiing ta lai dinh kien vao quan diem thi co the dan den sai lam chan doan Vi du nhu" tre em, bi viem ruot thifa lai thifdng bat dau dau d vung tren ron, hoac khong it cac trifdng hdp dau ho' chau phai lai thuoc ve benh ly phdn phu hay dai trang Cifdng dau cung thuoc vao tiing loai benh Vi du nhu" thung da day thUdng xuat hien dot ngot, cdn dau dut doi nhu" bi dam dao vao bung khien benh nhan phai gkp ngifdi lai va cdn dau dut doi nen ho nhd rat chinh xac thdi gian xay va thifdng di den benh vien rat sdm viem ruot thifa lai chi dau lam ram va vsly ngifdi benh thifdng den vien kha 10 muon, ke ca nhiing ngvfdi co hoc van Tinh chat dau cung mang tinh dkc thu cho tifng benh Dau tac ruot hoac viem dai trang, giun chui len 6'ng mat, soi nieu quan thifdng dau tifng cdn dien hinh Hvfdng Ian cua dau cung mang tinh dkc thu cho mot sd loai benh: dau cua viem tuy, soi mat thifdng Ian sau lifng, dau cua thoat vi lo bit thifdng Ian xuong mat dui (do chen vao than kinh then), viem tiii mat, ap xe gan, viem gan thifdng Ian sau lifng va len ba vai, soi tiet nieu thifdng Ian xudng bo phan sinh due Cung hoi ve dau, ta phai hoi them benh nhan dau thi tif the nao giiip cho bdt dau: neu nhu- thung da day, benh nhan khong dam thd manh va gap ngifdi lai, hai tay 6m ghi lay vung bung tren cdn dau giun chui len difdng mat, benh nhan thifdng nam chong mong hoac vat chan len tifdng Cac dau hieu kem theo cua dau bung cung mang tinh dac trifng Vi du nhu" soi difdng tiet nieu thifdng kem theo dai mau, dau tac ruot, viem thifdng kem theo non, bi trung dai tien Nhiing trifdng hdp nhiem trung difdng mat hoac ap xe gan hoac nhiing nung mu thifdng kem theo dau hieu sot cao va ret run, dau viem bang quang hay phan phu thifdng kem theo dai budt va dai rat hoac dau viem ruot thifa thifdng kem theo buon non va ngay sot Dieu quan trong hoi benh phai kien nhan, khong gdi y cho benh nhan ke theo dinh hifdng cua ngifdi thay thuoc, nen dat cac cau hoi mang tinh liia chon va neu thay nghi ngd can hoi di hoi lai de tranh nhQng tifdng tifdng cua benh nhan 1.3 Tien sii Khai thac tien sii co mot gia tri quan khong chi chan doan, dieu tri ma cung gop phan cho nghien ciiu Trong tien sii, khai thac nhiing b§nh ly trifdc day lien quan den xua't hien benh Ian Vi du nhu" mot ngvfdi co tien sii tao bdn lau thi la dieu kien het siic thuan ldi de gay nen benh tri; hoac tien sd mot ngifdi tif lau co bieu hien cdn dau kieu giun chui 6'ng mat se lien quan den benh soi mat, hoac la tien su* sot ret se lien quan den lach to Do la khai thac tien sii nham ho trd cho chan doan Dong thdi ta cung phai khai thac tien sii benh nhan co benh gi kem theo hay khong nhif cao huyet ap, dai thao difdng, benh tim mach hoac nhiing tien sif di dng nhu" di ting vdi mot loai thuoc nao de qua trinh gay me va dieu tri ta co ke hoach trifdc, tranh nhiing tai bien dang tie'e xay Do la khai thac tien sii phuc vu cho dieu tri Cung doi vdi khai thac tien sii ho trd cho nghien ciiu khoa hoc, ta can khai thac nhiing thoi quen sinh hoat cua benh nhan nhu" hut thuoc, an man, uo'ng rifdu hoac uo'ng nifdc khong dun soi de tif co the tim den nguyen nhan hoac dieu kien thuan ldi gay nen benh Dong thdi cung can khai thac gia dinh hoSc xom gieng co bieu hien benh gidng cua benh nhan de tif co the phat hien benh mang tinh di truyen hoac benh sinh tac dong cua anh hvfdng moi trifdng Vi vay, tien svf phai difdc khai thac mot each nghiem tiic va ti mi, tranh qua loa, lay le 11 Trong ta hoi benh, dong thdi tien hanh quan sat benh nhan tii sac dien, mau da, moi, kieu thd, hdi thd, kieu noi, tif the va kieu dau, than sac.de co dinh hvfdng dan nhiing viec se can lam kham benh Kham benh Kham benh phai difdc xay diing mot trinh tvf logic de mot thdi quen va nhd thdi quen ma ngifdi thay thuoc gidi it bd sot dau hieu co the phat hien cac trieu chiing khong dang bd qua Trvfdc het ta phai xem da va niem mac, lvfu y niem mac mat (vang, nhdt ) va niem mac lvfdi (ban ), sd mach xem ro, deu, nhanh cham Lay nhiet va huyet ap Neu benh nhan cd bieu hien thd khd ngvfdi kham benh phai dem nhip thd bang each ap ban tay len vung thifdng vi, mat nhin dong ho it nha't mot phan tvf phut Khi thay ngvfdi benh cd bieu hien ba't thvfdng ve mach, huyet ap, nhip thd ma cu the la mach nhanh, nhd, huyet ap tha'p, nhip thd qua nhanh hoac qua cham ta phai co dong tac can thiep va day la nhiing dau hieu cd nguy cd anh hvfdng den tinh mang trvfdc tien hanh kham de phat hien benh Vi du nhu" mot phu nut den kham va dau bung dut doi, vao den phdng kham, ngifdi nhdt, da tai, mach nhanh nhd, huyet ap Trong tinh trang neu ngvfdi chvfa cd kinh nghiem phai lam dong tac u am, truyen dich va xet nghiem mau ngifdi cd kinh nghiem se hvfdng den chan doan la vd khdi chda ngoai da va chuyen vao phdng mo de tiep tuc hoan thien chan doan va sin sang can thiep Neu lvic chung ta tiep tuc tham kham, tim kiem dau hieu chan doan thi nguy cd truy mach de doa tinh mang ngvfdi benh la rat ldn va co chan doan xong thi da qua muon khong thdi gian de xvf ly Neu ngvfdi benh den tinh trang me man, mat y thiic, tai ndi tiep nhan phai cd bien ban cua mot nhdm gom ba ngifdi kiem ke moi loai gia'y td, tai san, tu" trang tren ngifdi va tvii quan dong thdi phai ghi ten tudi dia chi cua ngvfdi dvfa den Mot dieu can lvfu y doi vdi kham cap ciiu bung nguyen nhan tai nan giao thong hoac sinh hoat nhu1 danh hay dam chem Day la nhutng tnfdng hdp cd lien quan den yeu to' phap luat sau viec dinh toi hoac giam dinh thifdng tat vi vay moi vet tich cd d tren ngifdi nan nhan phai difdc thong ke day du, mo ta ty my ho sd benh an 2.1 Kham bung Kham bung la nhiing tham kham vung bung, vung ben biu va tham trvfc trang hoac tham am dao vi vay phai cd ndi kham kin dao va doi vdi phu nut ngvfdi thay thuoc la nam gidi kham benh thi cho kham benh bat buoc phai cd tif hai ngifdi trd len 2.1.1 Tham kham vung bung Tham kham vung bung ngifdi kham benh phai yeu cau ngifdi benh boc 16 day du tii ngang nvim vu xudng tdi phan tren cua dui Ngifdi benh nam ngiia, chan chdng xuong givfdng de bung va dui tao mot gdc ldn hdn 45 lam chiing cd bung Ngifdi kham ngoi ben phai neu thuan tay phai va ngoi ben trai neu thuan tay trai Tuy nhien cd mot so' tru"dng hdp dau dut doi, benh 12 nhan khong the nam ngvfa difdc vi du nhif thung d loet da day ta trang Trong nhiing trifdng hdp can an ui nhe nhang, da thong benh nhan va nhanh chdng xac dinh benh nhan cd co cdng bung hay khong de cd chan doan quyet dinh 2.1.2 Quan sat Trifdc het la nhin Nhin xem bung benh nhan cd di dong theo nhip thd hay khong, bung 16m hay trifdng Neu bung khong di dong theo nhip thd, ta cd the phat hien dau hieu co cving bung qua quan sat: cac mui cd thang cua bung ndi ro lien tuc nhif ngvfdi len gan bung Neu bung 16m, dong tac tiep theo la tim kiem da'u hieu Bouveret Neu bung trifdng, dong tac tiep theo la xac dinh trvfdng hdi hay dich bang each go Ngoai can quan sat xem tren bung cd vet md cu hoac cd cho nao go len hay khong cung nhu" vung ben biu cd gi khac la hay khong Dieu ra't quan trong moi lien quan chan doan Neu nhu" benh nhan cd seo mo hay seo thifdng tich tren bung thi thvfdng lien quan den tac ruot sau md Neu benh nhan cd nhiing cho ldi len d viing ben, neu tren difdng Malgaine (difdng noi tif gai chau trvfdc-tren den bd tren phai xvfdng mu) thifdng la kho'i thoat vi ben, difdi difdng thifdng la kho'i thoat vi dui; ldi len d quanh ron thifdng la thoat vi ron, ldi len difdi seo md thvfdng la sa ldi bung Nhiing 16 thoat vi la diem yeu cua bung (bam sinh hoac mac phai) lam cho mot so' quai ruot nam ngoai d bung va cd the bi that nghet lai Trong quan sat, ta cung can nhin den cac cha't thai cua benh nhan nhif cha't non, nvfdc tieu, phan de cd the hvfdng tdi chan doan vi du nhu" non mau hay di ngoai phan den, dai mau hay dai mu, dich non cd dich mat hay khong de phan biet giuta tac ta trang vdi hep mon vi 2.1.3 Sdnan bung Muc dich cua sd nan bung cap ciiu ngoai khoa tap trung cho phat hien tinh trang bung dong thdi cung tim cac da'u hieu khac kham bung Tinh trang bung the hien ton thvfdng cua cac tang d d bung vi vay viec tham kham mot each ky cang cua nhiing ngvfdi cd kinh nghiem mang lai nhieu gia tri chan doan cap ciiu bung va cho den nay, vdi nhiing ap dung tien bo cac tham bd trd, kham lam sang van mang tinh chat quyet dinh chan doan va chi dinh cap cufu bung ngoai khoa De danh gia tinh trang bung, ngvfdi kham can ap nhe toan bo ban tay cua minh len bung benh nhan, mem mai a'n tif tu\ khong kham bang cac dau ngdn tay vi cac dau ngdn tay se kich thich bung tao nhiing dap iing cua bung phan xa Nguyen tac dat kham bung la kham tvf vung khong dau den vung dau, de so sanh tinh trang cd bung d cac viing bung doi dien Thong thvfdng, chi cd bung mem hoan toan mdi xac dinh dvfdc cac khdi u hoac cac tang d bung nhif gan, lach, tui mat, than to cdn bung phan iing hoac co cdng, da'u hieu ra't khd xac dinh 13 Ta thdy dung dich cd mot sd chd't dien giai de nd tQdng dd'i gidng dich gian bdo nen thudc khdng kich thich tai chd, cd the tiem mdt khd'i lQdng ldn - Ngodi cd the dung cac thudc te d cac ndng khac nhau: Xylocaine: 0,25%, 0,5%, 1%, 2%, 5% Novocaine: 0,25%, 0,5%, 1% Bupivacaine (Marcain) 0,25%, 0,5% Chi dinh: + De md phan mem + De md b mot so'benh hdm mdt, thoat vi ben, thoat vi dui kyst dQdi da, cac phdu thuat ngdn chan, tay, nhd rdng, tiet nieu, tai mui hpng, mdt + De nan xQdng Chi dinh ttfdng ddi: dung gay te trong: + Phdu thuat d bung (vi ddi hdi co keo, mem cd) + Mdt so' phau thuat ldn Chdng chi dinh: + Benh nhan khdng chiu dQdc hay di Qng vdi thudc te + Tac dung vdo vung nhiem trung (vi tac dung tha'p va dQa vi khuan di xa) + Cd hoai thQ sinh hdi 6.3.2 Gdy te vung gdy te ddm rd'i thdn kinh canh tay a Gidi phdu: dam rdi than kinh canh tay ca'u tao bdi nhanh nguyen phat tQ C5, C6, C7, C8 va DI (Tl) Ngoai cdn cd nhanh D2; D3; ddi D4 - Dam rd'i thdn kinh canh tay di giQa cd bde thang giQa cd bac thang giQa vd bac thang trQdc rdi vat qua mdt tren xQdng sQdn 1, dQdi xQdng ddn di vdo dinh nach - Dam rdi than kinh canh tay nam bao nach va cd lien quan vdi ddng mach va tinh mach dQdi ddn Luc ddu d tren sau dd b ngodi ddng mach vd tinh mach dQdi ddn b Chi dinh gdy te: - De md, cat doan chi tren - De nan khdp vai, khdp khuyu c Chdng chi dinh: - - Vung choc kim bi viem nhiem hodc ung thQ d Ky thudt: 242 - Ve chuan bi benh nhan (nhQ phdn chuan bi) - Cd bdn dQdng chinh vao dam rdi thdn kinh canh tay de gay te: + DQdng canh cdt sd'ng (Kappis) + DQdng nach (Hirschel) dQdng ngQdi ta cai tien ky thuat choc canh ddng mach va choc xuyen qua ddng mach nach + DQdng dQdi xQdng ddn (Louisbazy) + DQdng tren xQdng ddn (Kulen Kampf) * Phtfdng phdp gdy te qua dtfdng tren xtfdng don: - De benh nhan ndm ngQa, tay xudi theo than, dau quay sang ben ddi dien, ke vai ben dinh choc kim gay te - Diem choc kim: la diem 1cm ngoai diem giQa xQdng ddn cat mdt dQdng tren xQdng ddn 1cm - hodc gdc tao bdi tinh mach cd ndng va bd tren xQdng ddn - Kim tiem bao gid cung phai lap vdi bdm tiem cd thudc te Choc kim vao bd tren xQdng sQdn Khi gdp bd tren xQdng sQdn 1, nhac kim len khoang 0,5cm Rut nhe pistdng, neu khdng cd mau thi bdm thudc ThQdng tac dung te khoang 15 -20 phut sau bdm thudc - Thudc te va lieu lQdng: Xylocaine 2%: - 8mg/kg trgng hfdng Marcain 0,5%: - 2mg/kg hfdng - Thdi gian tac dung cua thudc te mdt lieu dau khoang 60 den 90 phut Mudn keo dai thdi gian te dung nhieu lieu each quang Pha them thudc co mach (adrenalin 1/200.000) - Bien chQng: + Choc kim vao mach mau, tiem thudc lieu cao se gay ngd ddc + Thudc te ngam vao khoang ngoai mang cQng b cd gay liet hd ha'p + Tran mang phdi + Liet than kinh (thQdng la hdi phuc) 6.3.3 Gdy te xtfdng - Cd sd ly ludn cua thvfc nghiem: Khi garo chi rdi tiem xanh methylen vao ddu xQdng xdp tha'y xanh methylen tha'm ca phan mem va da NgQdi ta da tha'y rang sau tiem thudc theo cdc tinh mach sau ngoai xQdng rdi di ve phia gdc chi vd tQ se lan toa cac phan mem d ndng Thdi gian tQ luc tiem den thudc phan mem khoang phut - PhQdng tien de gay te: + Bdm tiem 20ml, kim gay te xQdng dai 6cm dQdng kinh 1mm, cd ndng thdng de chgc qua xQdng xQng 243 + Garo - Chon ndi ddt garo can chu y dat phia tren chd md, vung cd nhieu cd, tren cai xQdng dinh chgc kim Garo de luc md Vung mo - Chgn ndi chgc kim gay te - Chi tren: + Ldi cau xQdng canh tay + Mem khuyu + Mom dQdi xQdng quay ve phia mu tay + Mem dQdi xQdng tru + Dau cdc xQdng dot ban tay - Chi dQdi: + Ldi cau xQdng dui + Hai mdt ca (mat ca ngoai hay dung) + Dau tren xQdng chdy (mam chay la tdt nha't) + XQdng gdt (mat ngoai) + Dau xQdng dot ban thQ nha't - LQdng thudc te: vdi dung dich visnhepski, novocain 0,25% - Chi tren: + Bdn va cd tay 50 - 70ml + Cang tay 80 - 100ml + Khuyu tay 60 - 80ml - Chi dQdi: + Bdn va cd chan 70 - 90ml + Dau gd'i 80 - 100ml + Dui 150 - 200ml Vdi xylocain chi nen dung khoang 5mg/kg hfdng cd the - 244 Bien chQng: + Nhiem ddc thudc te (do garo khdng chat, thao garo nhanh) + Liet chi tam thdi garo, budt chd garo - Chi dinh: + Cac phdu thuat b each gdc chi 10cm + Benh nhan tren tudi + Phdu thuat ngan dQdi gid 6.3.4 Gdy te tinh mach - Ve ban chat gay te tinh mach gidng gay te xQdng nhQng can kim gay te tinh mach, tot nha't ludn polyte rdi quan garo de ep ddn mau - Chgn ndi dat garo phia tren chd md ve hQdng gdc chi ddt garo ddn ep mau ve gdc chi - rdi mdi ddt gard lQu qua trinh md - Chgn tinh mach d phia nggn chi, tiem hoac ludn polyten - Thudc dung: + Dung dich visnhepski, nococain 0,25% + Xylocain 0,25%, 0,5% hodc 1% - Lieu lQdng: thudc vi tri dat garo vi du vdi dung dich visnhepski + Chi tren: neu garo 1/3 giQa canh tay cho 120ml 1/3 giQa cang tay cho 60 + 50ml + Chi dQdi: Garo 1/3 dQdi cdng chan cho 120 - 150ml Garo 1/3 dQdi dui cho 150 - 200ml Garo 1/3 giQa dui 200 - 250ml + Vdi xylocaine 0,25%: Chi tren 80 - 100ml Chi dQdi 160 - 200ml Thvfc te vdi chi tren neu garo 1/3 dQdi cang tay cd the dung dung dich Xylocain 2% x 20 - 15ml * Chu y: cac tinh mach cd dQdng kinh nhd hdn 2mm khdng cd van, tinh mach ldn hdn cd van, bdm thudc dp hie mach se thdng dQdc van luc benh nhan se hdi choang vang (do phan xa) - Bien chQng: nhQ gay te xQdng - Chi dinh: de md cac chi vdi thdi gian ngan (1 gid) Ket ludn: viec gay me va gay te vung md ddi hdi phai danh gia chinh xac tinh trang benh nhan de cd chi dinh cho thich hdp Ddc biet can chu y benh nhan d tinh trang sdt nang, la ngQdi gia, tre em va ngQdi cd benh phdi hdp 245 6.3.5 Gdy te be mat a Gdy te be mat da - Thudc dung: kelen (chlorua dethyl) C2H4CL2 Id dung dich khdng mdu Sdi b 12,5°C 0* 20°C ty trgng la 0,921 hdi chlorua dethyl ty trgng Id 2,28 - Cdche tdc dung: nhd nhiet sdi tha'p (12,5°C) nen tdc bde hdi nhanh mang theo nhiet d da di ma cd the khdng dieu hod kip vi vay nhiet hdi nQdc d khdng xung quanh vung vd nQdc b da xudng nhanh, nQdc ddng lai gay te cdng cac nggn thdn kinh cam giac - Cdch dung: + TQ xi vao da sau 1-2 phut se te, khdng xi nQa chi 1-2 phut se het te vi vay chi ldm phdu thuat vien da san sang md + MQc te chi sau 5mm nen chi dung cho cac phdu thudt ndng d da, thdi gian ngdn (trich nhot, cat thit thQa sinh thiet) - Bien chiing: hau nhQ khdng cd bien chQng NhQng can chu y kelen cdn la thudc me nen khdng dung gay te d vung hgng hau b Gdy te be mat niem mac - Thudc dung: + Xylocaine 2%, 5%, 10% - Carcain 0,25% - 0,5% + Dicaine 1% - Citanest 4% + Thiocaine 1% - Cocain 2% + Percaine 0,02% + Dung dich Bonin gdm: Cocain Acid phenic Meto (LQdng nhQ nhau) - Cdch dung: + Dung bdng tam thudc te tha'm len be mdt niem mac + Phun bui (gay te dat NKQ) + Nhd gipt (mat) - Bien chtfng: chu yeu ia ngd ddc thudc te 6.3.6 Gdy te cdc ddy thdn kinh - ThQc te Id mdt phQdng phap gay te vung nhQng cd chon loc vdo tQng vung chi phdi cua cac day thdn kinh 246 - Chi tren: + Thdn kinh quay + Than kinh tru - Chi dQdi: + Thdn kinh dui + Than kinh hong to 6.3.7 Gay te ngodi mdng ctfng a Dinh nghia Gay te ngoai mang cQng (NMC) la dQa thudc te vao khoang NMC ldm te cac re than kinh sd'ng qua nd, tQ gay te cac vung b ngoai bien phu thudc cac day than kinh (Vi vay thvfc cha't la gay te vung) 1885: Corning ldm tren chd 1921: Pager dp dung tren lam sang Giai phdu khoang NMC - TQ da vao khoang NMC phai qua cac ldp: da, td chQc dQdi da, day chang sau gai, day chang lien gai, day chang vdng, khoang NMC - Qua mdi ldp deu gdp sQc can khac nhau, nha't Id b da rdi den day chang vang - Khoang NMC nam giQa day chang vdng vd mang cQng tQ Id cham den khe xQdng cung Mang cQng tan cung b dot cung nhQng khoang NMC tdn cung d khe xQdng cung (hiatus) each dinh xQdng cut khoang 5cm - The tich khoang NMC = 115 - 275 ml (ngQdi ldn) mdt sdbenh nhan b Id cham mdng cQng khdng dinh hoan toan nen khoang NMC sd'ng thdng vdi khoang NMC tren nao c Chudn bi benh nhdn Kham ky benh nhan: cot sd'ng, dot sdng, mach, huyet dp (HA < 90mg Hg khdng nen gay te NMC) Ve sinh todn than: ddc biet vung lQng, chd dinh choc kim Nhin dn, udng nhQ cac phdu thuat khac Chuan bi ve tam ly tinh than Chuan bi ve thudc: + Tdi hdm trQdc vd sang hdm md nen cho gardenal + Tien te: atropin 0,01mg/kg can ndng, dimedrol 0,05mg/kg can ndng 247 d Chi dinh - Phau thuat dQdi cd hoanh nhQng ngoai d bung: tiet nieu, phu khoa, day chau, chi dQdi - Mo cac cd quan d bung (chi tQdng ddi) - Phau thuat ldng ngvfc (khdng tdt ldm) Gay te NMC + gian cd + ho hap nhan tao - Phau thuat dau, cd, chi tren (khong nen lam) e Chdng chi dinh - Nhiem trung da vung lQng - Nhiem khuan huyet - Huyet ap tdi da < 90mgHg - Mach < 60 lan/phut ma dung atropin mach khdng len - Dang shock (vi huyet ap cdn giQ dQdc chi la cd che tvf bao ve) - Di Qng thudc te - Di dang cdt sdng Lao cot sdng Cd suy hd ha'p Khdng cd phQdng tien ho ha'p nhan tao - Rd'i loan ddng mau - Dang dung thuoc chdng ddng mau f Ky thudt NgQdi gay me: - RQa tay, mdc di gdng nhQ phdu thuat vien - Tvf minh kiem tra lai cac thudc va phQdng tien TQ the benh nhan: - Nam ceng lQng tdm (dau cui, lQng cong, dui gap vao bung, cang chan gap vao dui, hai tay dm dau gd'i) - Ngdi tren bdn, de chan xudng mdt ghe dau, kieu de xac dinh dot sdng nhQng de nga, can cd mot ngQdi phu giup benh nhan Sat trung da: Dung cdn idd rdi cdn trang 70° cho sach iod hodc dung Betadin Xac dinh dot sd'ng: Cd ndm md'c (theo thQ tvf gia tri) - DQdng nd'i hai mdo chau phia king di qua khe dot L4 - L5 (cd trQdng hdp qua than dot L4) - Ddt sdng 12, mang xQdng sQdn 12 248 - Neu benh nhan ngdi thang hai tay xuoi theo than Ke mot dQdng ngang cvfc dQdi hai xQdng ba vai, dQdng ndy se di ngang qua khe ddt D8 - D9 (T8 - T9) - DQdng ndi lien dau cua gd xQdng ba vai hai ben se di ngang dQdi mem gai cua D3 (D3 - D4) - Khi benh nhan ngdi dau cui toi da thi mom gai sd'ng nho cao nha't la C7 Chgn vi tri chgc kim: Cat vu: D4 - D6 Chi dQdi: L3 - L4 - L5 Long ngvfc: D7 - D8 Bd phan sinh due: Ll - L2 Bung tren: D8 - D9 Tuyen tien liet: L2 - L3 Bung dQdi: D10 - Dll Day chau: L3 - L4 Than nieu quan: D12 - Dll (Phan chi tham khao) NhQ vay khdng bao gid len qua D4 vi: + TrQdng hdp mdng cQng dinh qua Id cham khdng hoan todn thi thudc len nao se nguy hiem + Khoang NMC d tren hep nen de chgc vao khoang dQdi nhen va sdng + Thudc te len cao tac ddng vao than kinh hodnh gay liet ho hap - Thvfc te khong doi hdi chinh xac den nhQ vay vi bdm thudc vao khoang lien ddt ndo, thudc se lan toa len tren vd xudng dQdi - Chgc kim giQa D4 D5, cd the md ldng ngvfc (trQ mdng ngoai tim phai them thudc te vao mang tim) D7 - D8 de md cac cd quan d bung tren D10 - Ll de md bung dQdi, cac cd quan tiet nieu L2 - L3 de md cac cd quan tiet nieu tha'p (tuyen tien het, bang quang, chi dQdi) - Ddn gian hdn chi can diem d hing (md cao), b that lQng (md thd'p) rdi dieu khien thudc lan toa: + Thay ddi tQ the + Ludn polyten rdi bdm thudc (cdn cd tac dung giam dau sau md) Thudc te vd lieu lQdng thudc te: Xylocain: DQdi 18 tudi dung dung dich - 1,5% 6mg/Kg Tren 18 tudi -> 70 tudi 2% 8mg/Kg 70-80 tudi 1,5% 200 - 250mg (tdng lieu) 80 - 90 tudi 1% 150mg (tdng lieu) Novacain: dung dich dung gidng xylocain, lieu lQdng (mg) gap rQdi den ldn xylocain 249 Dicain: 3%: lOOmg + 33ml huyet mdn 9%o 10 - 18 tudi 15ml 18 - 50 tudi 20 - 25ml > 50 tudi cQ tudi bdt ml Pontocain 5%: NgQdi ldn 10 - 15ml Cd the dung: Pontocain 5% + Gelatin 5% + Adrenalin 1/100.000 vdi lieu nhQ tren cd the gay te dQdc tieng Chu y: &hi het thdi gian te tuyet dd'i neu phdu thuat cdn co keo nhieu nen bd sung them bdng cac thudc giam dau trung Qdng thi thdi gian te cd the keo ddi (90 phut - 120 phut) Bupivacain (Marcain): 1,5 - 2mg/Kg Levcbupivacain: 1,5 - 2mg/Kg g Tai bien Dtfa thudc te vdo khoang dtfdi nhen: choc thung mang cQng, di dang ndn cung kim nhd nQdc nao khdng ra, ludn polyten thung mang cQng - Lam sdng: + Sdm nha't benh nhan ngQng thd hoan toan, mdi mdt tai nhdt + Mat tri giac hoan todn + Mach khdng bat dQdc, huyet dp khdng dQdc - XQtri: + Hd ha'p nhan tao vdi 02 + Neu huyet ap < 70mmHg cho: Truyen huyet mdn 9/1000 + 3g CaCl2 nhd gipt • Ephedrin 10-60 mg hodc adrenalin lmg (pha truyen tinh mach) • Cafein den dng (tinh mach) + Neu mach cham < 60 lan/phut thi cho atropin (Tinh mach cho tdi mach > 80 ldn/phut thi thdi) * De phong: - ThQ test nhieu lan, tdn trgng lieu thQ (bang lieu gay te sd'ng, xylocain: 2mg/Kg chd phut) - Hut piston trQdc bdm thudc - Trong qua trinh bdm thudc te phai giQ kim cd' dinh tuyet ddi - Khdng dung polyten cQng qua va phai thQ trQdc 250 - Khdng dung kim dau qua nhgn Tut huyet dp Thdyeu hodc ngtfng thd Ret run Cogiat, nhiem ddc thuoc te Nhe: Seduxen 0,2mg/kg (Tm) Nang: Thiopental 1,25% - 20ml Mach chdm Nhiic ddu Budn ndn, ndn: can kiem tra huyet dp Dau Itfng: (1/400) dung kim to 10 Liet thdn kinh: thudc te bien cha't: pH thd'p (coi nhQ acid huy hoai than kinh), dQa iod vao, nham thudc (CaCl2) (6 thang hdi phuc nhanh, thang den ndm: cham, > nam: khdng hdi phuc) 11 Nd'c: md hoac hau phdu cQdng phd giao cam hodc da ddy day hdi ddn den kich thich cd hodnh 12 Biddi: dat sonde 1-3 ngdy se het 13 Viem mdng ndo tuy: - Do benh nhan cd nhiem trung - Do thu thuat khdng vd trung 14 Thung ddng mach hodc tinh mach nho: choc kim hoac ludn polyten se cd mau chay XQ tri: lui kim lai, bdm rQa den dich trong, chd mdt luc rdi bdm thudc te, neu khdng dQdc thi chuyen phQdng phap khac 15 Ditt polyten mdng ciing: rut ngQdc polyten h Ifu diem - Te tot, te sau - Vung md it chay mau, kho sach - Benh nhan tinh, cd the bao benh nhan phdi hdp vdi phdu thuat vien, de phat hien tai bien (do thudc, truyen mau) - Rudt ndm im md, nhu ddng rudt trd lai nhanh - Hau phau nhe nhang - Khdng ddc cho gan, than (benh tim, benh gan, ure huyet cao cd the gay te NMC) - benh nhan cao huyet dp cd the dung lieu nhd rai rac 251 - Thuan tien cho cdng tac lQu dong i Nhtfdc diem - Ky thuat khd - Tao nhQng vung te khdng can thiet - Benh nhan sd, can che tien me nhe - Ddi hdi than trgng di chuyen benh nhan - Gay tut huyet dp - Lieu lQdng thudc te cao (4 ldn te sdng, dl nhiem ddc, ton thuoc) - Cdn cam giac dung cham - Khong Qc che het cam giac b o bung (khi md thap loi keo ruot thQa benh nhan tQc vung thtfdng vi) - Cam giac tQc khdng het (chen meche, gac benh nhan khd chiu) 6.3.8 Gdy te song a Mdt vdi diem ve sinh ly - Khi choc dd sdng: + Ap ltfc ntfdc nao bi do: • Mot sd ntfdc nao (NNT) bi chay ngoai • Mdng cQng dan hdi cQng, nen nit kim nd khdng bit kin Id ldm cho NNT khoang NMC Binh thQdng dp hie NNT la 12 cmH20 + Ap hie NNT nhieu hay it dc: • Ltfdng NNT mat • Ld chgc kim td hay be Chenh lech ap ltfc giQa khoang NMC va khoang dQdi nhen + Phan Qng cua cd the ma't mot lQdng NNT: • Neu phan Qng cua dam rdi nhen kem, thdi gian phuc hdi lau • Neu dam roi nhen bi kich thich se tdng tiet lam tang dp hie so + Dong tac choc dd it nhieu gay sung huyet mang cQng (gay nhQc dau) - Hien tQdng khuyech tan cua thudc phu thudc vao cac yeu to sau: + Quy luat chung cua hai cha't ldng hoa vao nhau: • nhiet 37°C thudc khuyech tan nhieu nha't • So'lQdng nQdc nao (nhieu thi khuyech tan kem) 252 Dam thuoc (cao thi khuyech tan tdng) Ty trgng thudc (ty trgng NNT 1,003 - 1,009) - Chu y: benh nhan ndm ngang hoan toan diem cao nha't cua cdt sd'ng md thudc te ty trgng tha'p dgng lai la L3, diem tha'p nha't ma thudc te ty trgng dgng lai Id D5 - Anh hQdng cua gay te sdng: + Mot phan nhd thudc te nga'm vao sdng nhQng so' lQdng khdng du cdt ngang sc'ng ve mat sinh ly + Thudc te ngam vdo cac re than kinh tQ chd xua't phat den Id lien ddt + Ket qua gay te se Qc che than kinh giao cam, phd giao cam, cam giac, van ddng va mat cac phan xa b vung sdng bi phong be b Chudn bi benh nhdn NhQ gay te NMC c Phtfdng tien Gidng nhQ gay te NMC, nhQng khac Id can kim nhd, cQng, mui nhpn (thtfdng dung sd 24, 25, 26 vi kim nhd thi it gay thddt dich ndd vd tdn thtfdng mang cQng nen it nhQc dau) - Thudc te (neu pha vdi adrenalin 1/200.000 thdi gian te tdng gap rQdi): Tac dung: Nevocain tyle 5% 1,010 x 2ml 90 phut Percain 5% 1,0016 x lml 2-4gid Entocain 1% 1,007 x 1,6ml 90- 20 phut Xylocain 5% 1,007 x 2ml 120 phut 1% 1,007 x 5ml 60 - 90 phut - Marcain (Bupivacain): 0,5% - 0,25 - 0,3mg/Kg, chu y vdi ngQdi Viet Nam tdng lieu khong dQdc qua 15mg - Levebupivacain 0,5%: 0,2 - 0,3mg/Kg - Ngddi cdn dung ddlargan de gay te song, lieu lQdng lmg l,4mg/Kg (tuy kinh nghiem ngtfdi ldm, thtfdng dung l,2mg/Kg) d Ky thudt TQ the benh nhan: nhQ gay te NMC Vd trung, sat trung vd xac dinh dot sdng: nhQ gay te NMC Chgc dd sd'ng: den cd nQdc nao chay thi bdm thudc te cung cd cd the gay te lien tuc (ludn polyten), luc lieu sau bdng 2/3 lieu dau, b Viet Nam chQa nen lam vi khdng du phQdng tien 253 Lam sdng hien ttfdng te va phan xa : - Sau tiem thudc te vai phut benh nhan te Neu te tha'p benh nhan cd cam giac kien bd d hai chi dQdi, mat cam giac, mat phan xa gan banh che va phan xa da biu - Cam giac mat dan tQ tang sinh mdn, vung xQdng cung cut, hai mdng - biu, am hd, phia tren sau mdt dui, cang chan ban chan, mat trQdc dui, vi, mat phan xa da bung rdi md't van ddng, sau nQa se gian cd trdn - Sau te vai phut se xuat hien tut huyet dp - Sau tut huyet dp se xuat hien trieu chQng cc mach bu trQ d vung khdng te nen mau sdc da khdng hong hao e Tai bien - Nhin chung nhtf gay te ngoai mdng cQng: + Tut huyet dp, mach cham + Thieu nang hd hd'p + Budn ndn, ndn + Bi dai -i- NhQc dau Dieu tri dung xanh methylen 5% - 3ml tiem tinh mach - phut Cafein: 0,25mg (Tinh mach) MgS04 50g % x 5ml Vitamin Bx 50-100mg + Vitamin PP 100mg/24 gid + Viem mdng nae dan den liet than kinh sg VMN, dinh mang nao + Ton thQdng dd chan thQdng, chen ep, dung thudc te hong gay liet + Rdi loan cd trdn 17 quy tac de phong bien chQng: Chgn kim nhd du cQng (Gauge 24, 25 ) Khi choc, vd bdm thudc phai giQ kim chdc Khdng de nQdc nao chay nhieu qua Kim, bdm tiem, piston phai vQa khit (khdng mat thudc) Khdng bdm thudc vdo va hut nhieu lan Bu khdi ltfdng tuan hodn tdt Cho ngQi oxy Nam vQng ty trgng thudc te trtfdc dung de dieu khien te 254 TrQdc bdm thudc phai hut thvf 10 Sdn sang phQdng tien cap cQu hd hd'p va tuan hoan 11 Theo sdi sat benh nhan (hd ha'p, huyet dp, vung te) 12 Thay ddi tQ the benh nhan nhe, cdn tac dung te de ndm tai giQdng gid - gid sau het te 13 Tien te phai cd atropin 14 Trong md khdng nen ban chuyen anh hQdng den benh nhan 15 Thudc va dung cu phai vd trung 16 Kiem tra thudc trQdc dung 17 Khi md ndi tang can phong be them bdng thudc te f Chi dinh (Nhtf gdy te NMC) g Chdng chi dinh (Nhtf gdy te NMC) h Vu diem (Nhtf gdy te NMC) i Nhtfdc diem (Nhtf gdy te NMC) III TAI LIEU THAM KHAO Bai giang Gay me hdi sQc - Nha xua't ban Y hgc 2002 Michael F.Mulroy, Regional anesthesia -• an illustrated proceducal guide - second edition 1996 255 NHA XUAT BAN Y HOC BAI GIANG TRIEU CHUNG HOC NGOAI KHOA Chiu trach nhiem xuat ban HOANG TRONG QUANG Bien tap: BS DANG CAM THUY SCra ban in: DANG CAM THUY Trinh bay bia: NGUYET THU Kt vi tinh: NGUYEN THI HUONG GIA: 88.000 In 1000 cuon, khd 19 x 27 cm tai Cong ty in Y hoc So dang ky ke hoach xuat ban: 23 - 2013/CXB/22 - 185/YH In xong va nop ltfu chieu quy II nam 2013 ... nen nhQng da'u hieu bung ngoai khoa gia nhQ suy tim, viem phdi HI TAI LIEU THAM KHAO Sach giao khoa: Ngoai khoa cd sd Trieu chQng hoc ndi, ngoai khoa Benh hoc ngoai khoa 19 HOI CHlfNG TAC RUOT... bi mot phan giup cho chan doan xac dinh (nhQ liem hdi dQdi cd hodnh thung tang rdng) hoac chan doan phan biet (dau ho'chau phai cd hinh anh soi nieu quan phai phan biet vdi dau ho' chau phai viem... den lach to Do la khai thac tien sii nham ho trd cho chan doan Dong thdi ta cung phai khai thac tien sii benh nhan co benh gi kem theo hay khong nhif cao huyet ap, dai thao difdng, benh tim