Tài liệu ôn tập cho kỳ thi tuyển viên chức ngành y tế năm 2017 tai lieu ky nang chuyen mon

•• • Is Cac dan vi hx6ng dimg xet nghiem h6a sinh hien DON VI DO WONG DUNG TRONG )(ET NGHIEM HOA SINH MIEN NAY Is IFT HQC "MI) bay altar he thong don -vi luong quoc to Si (SI: System* 11 Io,:al d'Unites) su dung tt.ong hOu sinh lain sang al &rag don vi ci sang don vi SIva tiguac, lai IIi4n nay, theo quy tr6c quoc to cac dan vi dUng xet nghiem boa sinh Nil illy() he thong dun vi chuan SI va 1)6 dan nhang dan vi (3 Viet Nam, da bat dAu phe bien dan vi SI tir han met thap kS7 ft* lai day oily coy nghia rat lon viec th6ng nhat sir dung dan vi tat ca cac phOng liii nghiem tren the giai I t I THONG DON VI DO LUbNG QUOC TE SI SC DUNG THONG HOA SINH LAM SANG 1.1, Citu trio cua dan vi SI Co dan vi chinh va don vi phy: Dan vi chinh: don vi ca sb, dan vi dAn xuAt, don vi Dan vi pho: tip dAu ngil la nhfing bei s6 va Irk s6 thap phan cua he thong SI va don vi ngoai SI /, / / D071 vi C1111111 - Dan vi ca so.: Co clan vi SI + DO clai : met (m) + Khei luang : kilogram (kg) + Th6i gian : giay (s) + CtiOng de deng dien : Ampe (A) + Nhiet de nhiet Ong hoc : Kelvin (K) + Ctramg anh sang : Candela (Cd) + Ltrong chat : mol (mol) Dan vi crdn xudt: tir don vi ca sa, có the ghep cac dan vi ea se vai hoac bang nhan hay chia to co dan vi dan xuat 33 Bai giang dao tao ky nang chuyen mon cho can bO y to tuyOn huyOn - Ky thuat xet nghiem Vi + Dien tich met vuong (m2) + The tich met kh6i + Van t6c met/giay (m3) (m/s) + Gia t6c met/giay binh phtrang (m/s2) + Nong dO mol/met khoi (mol/m3) - Don vi phy: Khong dung y hoc + Don vi gOc phang : Radian + Dan vi kho'i : Steradian 1.1.2 Don vi ph(' - Tiep cl'au ngil: la nhfr'ng bOi so -va vac so th Op phan cilia he thong SI: Co nhftng don vi phai dUng trac so hoc bOi so dm don vi SI mai phii hop Kj, lieu He s6 Tip dau ngit 1018 Exa E 1015 Peta P 1012 Tera T 109 Giga G 106 Mega M 103 Kilo kg 102 Hecto 11 101 Deca da 10-1 Deci 10-2 Centi 10-3 Mili 111 10-6 Micro l-t 10-9 Nano 11 10-12 Pico 10-15 Femto 10-18 Atto p 34 Cac don vi luting dung xet nghi@n hoa sinh hi'en I!on vi ngoai SI: Cu don vi khong thuOc he th6ng SI nhung duqc ligay \fa cac chuyen khoa duqc Dai hOi toan the ye luvng (('GPM) quyet dinh bao luu v4 cho sir dung phO bien I Dili gian phut (min) 60 s gia (h) 3600 s (d) d6 (0) 111180 radian phin (3) 1-I/10800 radian giay (33) 11/648000 radian '1'116 Lich lit (1) dm3 = 10-3 m3 KItiii lacing tan (t) 1000 kg (.16c phang , 3, 86.400 s Ap dvng SI Lim sang It) I Dow vi nemg di) mo! D6i vai mot s6 chtit ma nguai to bi6t rO• lung phim tir thi dirge quy dung don vi mol hoac uac so dm mol Nang d6 chat dirge bi6u thi bang d Iii i Ip mol hoac trac so dm mol/ lit dung dich (khong dung lml hoac dl dung djch) Khi dung mol phai xac dinh chh la: phan tn., nguyen to hay ion Ne'u la inn pliAi ghi them chi.'" ion truac ten chat Ion Kali Vi du: Don vi n'ong d6 mol dm m6t s6 thong s6 hoa sinh: Don vi di Don vi mai mmol/L - Creatinin g/L mg/dL mol/L - Ure g/L mmol/L - Cholesterol mg/dL mmol/L - Triglycerid mg/dL mmol/L - Ion Na+ mEq/L mmol/L - Ion K+ mEq/L mmol/L - Ion Ca2+ mEq/L mmol/L - ion HCO3 mEq/L mmol/L - Glucose 35 Bai giang clao tao ky Wang chuyen mon cho can bo y to tuyen huyi;:n - Ky that xet nghirn 1.2.2 Don vl n 'Jug c10 kl,Ol luvng MCA s6 chat chum bit re)" lung phan tir thi dung dan vi (g/L hoac g/dL hoac mg/dL) Protein ltrang g/L mg/dL Apo Ai, Apo B Fibrinogen MOt so chat có the sir dung ca dan vi n6ng mol Ian dan vi khtii krcmg Vi du: Albumin I-lb ▪ • mol/1 ho'Oc g/L ▪ • mmo1/1 hoac g/L 1.2.3 Dan vi enzym 6M , Dan vi qu6c tocua hog enzym lam biin doi I micromol (1Mmol, 10 ) ca chat phut a cac dieu kien xac dinh ve pH, nong di) ca chat va cac ky hieu la U/L (don vi quoc to /lit) Ngoai ra, don vi hog dO cua enzym dugc biL thi bang s6 mol x s-' (hay molls) = so mol ca chat bi bien doi tiled gian giay boi luang enzym lit dung dich Don vi &rot g9i la Katal (Kat) U.ac so cita don vi microkatal (p.kat: 10-6 kat), nanokatal (nkat: 10-? kat), picrokatal (pkat: 10" 12 kat) la lugng enzym mac the su bien doi micromol hoac nanomol hay picromol ca chat giay Nguai to thuang bieu thi dan vi enzym bang Ul (hay IU) UI = 11,tmol/min = 16,67nmol/s = 16,67nkat 1.2.4 Pascal pCO2, P02 duvc bi6u thi bang kilopascal thay th6 cho mmHg Cite thong s'6 sinh 1j1 khac ve ap suit nhtr.htly& ap, ap suit dich nao tily, cling se dirge tinh bang kilopascal nhati lai: c6 loai don vi chinh biL thi cho hau he't k6t qua xet ngh*n h6a sinh lam sang: - mol, nunol, (mol biL thi ntmg dO phan tir gam) - g, mg, ng thi niong di) kho'i luang - kat, nkat bi6tt Ilij hoat enrym - Kilopascal biL thi tip suat 36 Cite don vi Itrang dimg xet nghiem hoa sinh hien 'IA() ('AO KIT QUA xtr NGHItM HOA SINH TRONG NI SANG ,Iti I 1('n.: Ten he thong, phan, ten doi lugng lizo•ng (khong vie't hoa ilAili lioug (16: • 'IN liguoi benh, mAu benh pham • ThAnli phan dinh lugng: glucose, ure, creatinin • Doi luvng luting: nong d9 lugng chat, no'ng d'9 khcii lugng • (ii,i tri bang so • I)trii vi VI (Iv: I lily& Wang ngtthi benh hac doi Glucose, nifing d9 lugng chat: 5,2 11111101d, - I luye't Ion Kali, 1-16ng (19 lugng chit: mmo1/1 Ci I UYEN DOI TO' DON VI CU SANG DON VI SI VA NGU'OC 141 Chuyen doi tir dun vi cu sang don vi SI IUe chuy'L d6i don vi cu sang don vi SI, to chia trgng lugng g/L (ho4c cho tr9ng luting phan tCr (TLPT): Vi du: Glucose mau = 0,90 g/L , (TLPT dm glucose: 180) = 0,90/180 = 0,005 mol/lho4c mmol/L Calci huy6t == 100 mg/L = 0,1 g/L , (TLPT cua calci: 40) — 0,1/40 = 0,0025 mol/L ho4c 2,5 mmol/L 3.2 Chuyen doi tir dun vi Si sang don vi cu Chuy6n mol/L ho-Oc mmoVL sang g/L hoc mg/L Cach chuy&i: Mol/L (ho:dc mmo1/10) x TLPT = g/L(ho:ac mg/L) Vi du: glucose mau: mmol x 180 = 900 mg/1 hoc 0,9 g/1 3.3 Chuyen neng dq lugng chtit sang mEq/I ho4c ngtrtrc lai mEq/L = mmol/L x hoa tri Vi dv : Ca++ = 2,25 mmol/ltuang frng 2,25 x = 4,5 mEq/1 K+ = mmol/L tuang tang x mEq/L 37 = 5mEq/L Bai giang ciao tao kj, ang chuyen mon cho can b0 y to tuyen huyen - Kji thuat xet nghiem Ca++ = 2,25 mmol/L tuvng irng 4, 5/2mEq/L 2,25mEq/L Na+ = 135 mmo1/1 tucrng irng 135/1mEq/1 = 135mEq/1 3.4 Chuyen don vi hoat coo enzym U/1 sang Kat X 16,67 nkat/1 U/1 X 0,06 Vi du: phosphatase kiem la 50 U/L Wang irng vai: 50 x 16,67 = 833,5 nkat/L Bang 5.1 Bang chuyen c of dun vi eft sang dun vi mifri va nguvc1ai STT 10 11 12 13 14 I5 16 17 IX I() 21) 1-1e, so , chuyen dili meri sang cu 0,0069 0,059 38,7 µmol/L mmol/L psnol/L mmol/L mmol/L mmol/L Chat thir Don I/ di Albumin Bicarbonat Bilirubin Calcium Clor Cholesterol- TP CholesterolHDL CholesterolLDL Creatinin Glucose Magnesium Potasium Phosphatassc kiem Protein TP AST ALT Sodium Triglycerid 11re (Inc i g/100mL mEq/L mg/100mL mEq/L mEq/L mg/100mL He so x chuyen doi di sang mil 144,9 17,1 0,5 0,026 mg/100mL 0,026 38,7 mmol/L mg/100mL 0,026 38,7 mmol/L mg/100mL g/L mg/100mL mEq/L 88,4 5,5 0,41 0,0113 0,18 2,43 pmol/L mmol/L mmol/L mmol/L mM 16,67 g/dL pmol/mL/h pinol/mL/h mEq/L g/L g/L mg/L 10 16,67 16,67 1,129 16,65 5,95 38 Dun vi moll U/L 0,1 0,875 0,06 0,168 g/L U/L U/L mmol/L mmol/L mmol/L j_imol/L Ki6m tra dC.) tin cay ke't qua xet nghiem hoa sink KIEM TRA -DO TIN CAY TRONG KET QUA xET NGHICM HOA SINH ;.: Trinh bay Ave cac s.ai so va qui trinh kiem tra dO tin cay xet 010m hoa sink thich (hive 1;• nglda vice clam bao 610 tin c(iy cilia ket qua xet nghiem '01 nghiern lam sang tra Ave chat licong xet nghiem (lam bao d(5 tin cay czia ket qua xet F4, Islam j?ang Mu& biet mot xet nghiem c6 tin cay dugc hay 'thong thi xet nghiem can phtli du9c kiem tra Cong tac kiem tra chat 11K/rig phai qua nhieu khau va dam bao 1110ng qui trinh da duvc chap nhan Do do, nhimg can b6 nhdn vien lam cong tac xel nghiem can phai CO kiem thirc va ky nang nhdt dinh ye linh vuc I DO TIN CAY M6t ket qua xet nghiem duvc coi la tin cay no co du hai thong s6 la d6 chlnh xac va d6 xac thuc: Chinh xac + Xac dive = Tin cay 1.1 Dq chinh xac (con pi IA di) 14p Iii) 1.1.1 Dinh nghia M6t phtrang phap xet nghiem dugc goi la chinh xac nhang ket qua xet nghiem thu dugc c6 dO phan tan it so voi gia tri trung binh DO phan tan cang 11116 thi d6 chinh xac cang cao 1.1.2 Nguyen ttic kiem Ira c10 chinh xac Tien hanh dinh luvng nhieu ran tren ding mot mau xet nghiem cang inOt ky thuat xet nghiem Muon vay hang ngay, nguai to xen vao m6t hodc nhieu inriu ma phan cac chat khong dugc biet Mau g9i la mau de kiem tra d6 chinh xac Cac ket qua xet nghiem lam ten cang mgt mau, neu khong giong (Ili it nhat cling chi &Arc pi-Ian tan mot han nhat dinh Su lap lai c6 the &rye thirc hien teen mot lout xet nghiem cang mot hoac nhieu de tinh toan cac thong s6 tri so trung binh x, d6 lech chudn Q, he so bien thien CV va lap bang kiem tra dO chinh xac de danh gia chat hremg ket qua xet nghiem 39 Bai giang dao tao ky Wing chuyen mon cho can be y t6 tuyen huyen - KS% thu;at xet nghiem 1.2 DO xac thtyc (con ggi la dO dung) Dinh nghia: mot phuang phap,xet nghiem dugc g9i la xac thuc (dung) nhung ket qua xet nghiem thu dugc xap xi bang tri so thkrc: Sr thieu xac thuc la cac nguyen nhan gay sai so he thong: may m6c khong chuan xac, chat lugng thuoc thir khong dac hieu Tri se thkrc la mat khai niem ly Wong khong co thuc t6 ma chi co tri so thuc theo qui trac Vi du: can lg glucose tinh khiet chinh xac ten 0,1mg de pha dung dich glucose 1g/1 The tich ntrac de pha ding phai that chinh xac Tri so theo qui trot goi la thuc va dugc (Ring de chuan icy thuat dinh lugng glucose KIEM TRA CHAT LUVNG ChAt lugng cua cac xet nghiem &mg vai tr6 quan trong viec chAn doan, diet' tri va tien luting benh Nhiem vu ca ban dm can b6,1am ding tac xet nghiem y sinh hoc, clac bit la xet nghiem hoa sinh la darn bao ket qua xet nghiem cua minh, phai chinh xac, gan tri so thuc cUa no Vi vay, viec kiem tra chat luting (KTCL) xet nghiem la mot nhang phuang phap nham dam bao ket qua xet nghiem ding tin cay Bao dam chat luting nham tao moi dieu kien t6i tru, hap ch8 den mire thAp nhAt nhang sai sot c6 the xay giai doan dm qua trinh xet nghiem: truac, va sau xet nghiem • 2.1 KTCL xet nghiOn truck 1:111 lhm xet nghi01 Giai doan bao gem: khau chuAn bi, lAy benh phAm, chuyen benh phAm, chuAn bi thuoc thu va cac dung cu can thiet cho xet nghiem Viec dam bao lAy mau xet nghiem mot each chinh xac gOp phAn khong nho vao ket qua tin cay cua xet nghi8m 2.1.1 Cach op vri brio quirt, benh pham lam xet nghie:mn (xem hal "Ctich lAy va bao quan benh phAm")' 2.1.2 Nhfing (hay diii sinh If) curt kit qua _vet nghiem - Giai: M6t s6 chAt nhtr hemoglobin, acid uric nam cao han rift; cac hormon phu thuac vao giai; cac enzyin AST, ALT & nam dao d6ng rung han nil - Tu6i: + Tre sa sinh có bilirubin, phosphatase kiem cao han nguai larn nhung ure, creatinin, protein, glucose huyet lai thap han nguai lern Creatinin, cholesterol, phosphatase kiem huyet u nguai cao tuai cao han tr nguai throng 40 Kim tra ciO tin Oy Ice't qua xet ngltiOt hoa sinh t I R' (19 an va tinh bang dinh duang: I lirlyccrid, throng, ure tang nhe sau bira 1'1, AST tang nhc sau ueng nxqu I )► rimg, lipid tang khan huSi acid beo tang sau u6ng ca phe 'he d(;) luyen tap: '11(:1 d) luy'en tap CO the lam tang CK, AST, adrenalin, hormon sinh dvc; 40110 I lb nic'ti Tliti6e: Morphin, cocain lam tang amylase Sullonamid, rimifon lam tang bilirubin Corticoid lam tang cholesterol KTCL giai doan xet nghiem (iiai down bao gem cac btrac tien hanh xet nghiem, tinh ket qua, ghi va "4kiii quit 1,41, Ilan chit caa sai so qua trinh Mm xet nghiem (jm6i bulk qua trinh lam xet nghiem deu CO the có nhang sai s6 ‘11(Ing the tranh khai mac dau ngt.r6i lam xet nghiem thao tac rat than DO la i limn sai so ky thuat gom có loci: Sai s6 bAt ng6: xay mot each ngau nhien, thuong khong the tranh khOi Nul pt') bat ng6 co the nhieu nguyen nhan: + Thu6c thin h6ng + Dung cu khong chuan xac + Dong dien khong on dinh + Thao tac chtra thuan thvc + Thiet bi khong on dinh - Sai s6 he thong: thuOng do: + Chat luvng thu6c Hui xau + Dung dich chuAn khong chinh xac + Ky thuat khong (Ric hieu - Sai se bat thtreyng: g9i la sai se filo bao, thu6ng xay do: + Khong thvc hien dtIng thit tic + NhAm lan thu6c thCr, citing cp lueng, bloc song 41 Bai giang dap tao kj, nang chuyen mon cho can bO y to tuyen huyen - Ky thulat xet nghiem sot ke ca lnc di ngoai) Ngay horn sau, den gior quy dinh dai that vao binh va gui den phong xet nghi6m Nhang xet nghiarr dinh luvng phai lam tren nuov tieu 24 gia vi ca the dao thai cac chat vao nuot tieu luu luvng khac theo tired gian 2.2 Dich nao tuS, Dich nao dry dirac bac si lam sang hoac ky thuat vien (KTV) duvc dao tao chuyen nghi6p tai khoa lam sang lay Dich nao tray duvc hUng vao Ong nghi6m sach: - Ong 1: Hung vai giot dau - Ong 2: Hirng khoang - 7m1 Neu chay mau ch9c de thi chi CO O Ong 1, khong co Ong Ta loai Ong 1, Ong có the dUng de's soi to bao va lam cac xet nghi6rn hoa sinh 1\16u CO mau ca Ong (co the xuat huyet nao) thi khong nen lam nhang xet nghiesm hoa sinh vi sai so rat lon 2.3 Phan Lay phan lam cac xet nghi6m sinh boa chi' y6u la dinh tinh: mau, ma, sac to mat V* lay phan cho xet nghi6m hoa sinh khong,doi hoi cach lay chuyen bit va vo khuan, chi can binh chfra sach tranh nhiem chat la WI ltrang dir cho phan tich dinh tinh Xt IA', BAO QUAN VA VI-NN CHUYEN MOTH PHAM 3.1 Xir ly nhanh, phai tieu chutin hoa khan - Dieu kin cam tay sau lay mau: each thirc lac tr6n de' N6u lay mau chOng dong phai xac dinh thai ,gian tranh nguy ccr bi dong, lac nhe bang tay mau co the bi (long mot phan ma khong nh'dn ra, trai lai lac qua manh có the bi tan huyet, tot nhat nen dung loci may lac nut day that kin quay ton - Dieu kin tach huyet holac huy6t tucrng: Su tach huyet phai ton cac dieu kin 'Jong mau Huy6t duvc tach civic matt da co Cac ky thuat day nhanh qua trinh dOng mau can phai duvc xac dinh ky Six tach huyet tuang phai xac dinh thai gian tiep xuc toi da giira mau va chat caning dOng, thai gian, tOc d6 va nhia d6 ly tarn Thiri gian tiep xuc giira to bao huy6( etia huy6t tinrang nhieu han cua huyet having 3.2 (lan Nnh pham Item (plan b6nh pham can tieu chuan hoa cac di6u kin sau: 56 Cach 14 va bao quail Nnh pham NItiet d6: CO the bao quart o nhiet d6 k lent Ira va bao dam nhiet d6 hang dinh lanh hoac &mg lanh ▪ ThOi gian: thei gian bao quan thuong di kern vai dieu kien nhiet d6 Yeu Au titian thai gian cang dai thi nhiet d6 phai Gang thdp • Chat Moo quan thich hop cho tang loai benh phdm va thOi gian bao quan • I ,Am ming tai berth pham tai nhiet d6 lam phan 'frank bay hai hay lam loang benh pham No titian huytt hay huytt twang IIuyet tuong hay huykthanh,(HT) dirge citing 6ng d4y kin, tot nhdt Ildt I IT tri 'n 1/2 den 2/3 the tich orig Tay tiled gian can thiet phai bao quan ma [0,4,11 Oh* dQ thich hop • Trong khoang giO sau ly tam co the ▪Tir - 48 gib can de a a & nhiet d6 phOng 25 °C lanh 4°C - Tren 48 gib can de (long lanh sau han - 20°C Nhiet d6 va thai gian bao quan có anh huang tai nhieu th6ng s6 xet nghi'em 141 litio quart ntrev tieu Cac thong so nuac tieu chiu anh huang nhieu bai chit bao quan, thai nhiet d6 Iltio quan diet! nao tfiy Cach bao quail DNT lily thu6c thai gian can bao quan: - Duori gib.: nhiet d6 phong - Tix - gib.: nhiet d6 4°C, khong can chit bao quan - Tren gib.: ly tarn 14 to bao, &mg lanh -70°C A,6 Vin chuyen 4nh phiim Nen theo mot so nguyen tdc sau: - Khong van chuyen mau than phan Mu6n van, chuyen phai ly tarn tach buy& (HT) Trong tri.rang hop lay HT, mau nen de yen it nhat gia a nhiet pheng, tach nhe nhang cue huyet va ly tam 2000 yang 15 phut - Neu thOi gian van chuyen tir 1- gieY sau ly tam thi van chuyen Ihimg gift lanh, tranh anh sang va lay dOng manh - Neu lau hon gio thi nen &rig lanh (trong niter long) 57 Bai giang dao t4o k'y nang chuy'en mon cho can 1)0 y to tuy6n huyen - Ky thuat xet nghie;m KET LUAN Kit qua xet nghie.m co th6 bi bin di anh htr&ng ctia cac khau sau giai loan tnrac xet ngh*n: Thoi di'&-n lay Nnh pham Tinh trang dOi hay no Ttr the' b'enh nhan lay mau Thai gian bu6c gar6 - B'enh nhan dung chat kich thich - J:31-th nhan van d6ng tnrac lay Nnh pham - Ding cu lay b"enh pham khong chuan, khong sach Nham lan, sai sot hay thi6u kinh nghiem cua ky thuat vien Bao quan va van chuy6n khong chuan 58 Bai giang dao tao kj% Wang chuyen mon cho can boy to tuy6n huyen — Kji thOt xet nghiem CACH LAY VA BAO QUAN BI NH PHAM XET NGHItM VI SINH VAT „ :MIX TIM] HOC; TAP Trinh bay clu'qc mc5t so nguyen Ilk co' ban ye each lay va bao quail benhpluint xet nghiem vi:sinh vat va bao quan berth pluint darting hO hap, du&ng tieu Tiinh bay dircie each boa va berth phain nue.c tieu : .Thtre hien awe each lay va bao quart cac b(mh phetin Bich hung, dick ty ha‘ u, rtuO'c MOT SO NGUYEN TAC CO BAN - Bao dam vo khuAn tuyet d6i sir dung va thao tic lAy benh phAm Dung cu lay benh pham de xet nghiem (Ong nghiem, chai 19, sonde ) phai pheng xet nghiem vi sinh cung cap va phai dam bao vo khuan - Bao dam dimg ky thuat an toan cho ngueyi lam va moi twang xung quanh - Lay dung nai, dung luc, dung thoi gian theo tinh chAt cua benh va thco yeu cau xet nghiem: benh nhan nghi thucmg han Juan thir nhAt lAy mau benh nhan Vi clang sot de cay mau, tuan thir hai lay mau de chan doan huyet thanh, tuan thir lay phan de phan lap mam,benh LAy mau de cay mau phai lay - 10m1, de lam phanimg huyet chi can lay 3m1, lay phan phai lay chiS nghi nger bang dung cu vo trimg va khong cham vao bo, bo khir trung bang nuac soi, khong có h6a chat sat khuan - Benh phAm va vat phAm giri di xet nghiem phai bao quan dung qui dinh: + Benh phAm va vat phAm thuamg: De chAn doan vi khuan khong nhat thiet phai bao quan lanh, nhung phai de 19 vo trimg nut kin, giri di xet nghiem cang serm cang tot, khong de tau qua giey Neu theyi gian van chuyen lau phai cho vao inoi truong van chuyen De chin doan virus va rickettsia can bao quan lanh + Benh phA m va vat phArn nguy hiem, co MIA nang lay lan manh (than, 10, dich hach, virus Arbo ): Benh phAm lAy xong cho vao 19 vo triing nut kin, at ca 10 vao mot 6ng kiln loci hoc go co chen lOt bong tam thuoc sat khuan, sau lai cho tat ca vao mail 176 Cac xet nghiem vi sinh co ban tai tuye'n huyen 110p kint 1(4 hoac g8 c6 chen lot bong nhu tren, dan nhan, niem phong can than, cu Nitriii mang den tan nod xet nghiem - Tat ca benh phAm, vat pham phai co phieu yeu cau xet nghiem kern theo vtl ghi ra: f H9 ten benh nhan + Ten benh pham, vat phAm + Ngay, gia lay + Nai + Chan down so b6 + Yeu cau xet nghiem + Nguat viet plueu xet nghiem CACH LAY VA BAO QUAN BtNH PHAM DU'ONG HO HAP 2.1 Dich hong (ngody filing mi0g) - DUng que tam bong cirng vo khuan, benh nhan mieng to, thay thu6c Iffy de ltrai an luai xu6ng, quet dau bong vao viing benh ly (do, gia mac ) a nga ba hau, hong, hai try truac amidan, sau d4t tam bong vao 'Ong nghiem vo tang hoc mai truang bao quan (neu van chuyen di xa) - Dich hong dung de ch'An down nhfem trimg ho hap a tre em va nguai 16n nhu dung de chart doan bach hau, lien cau, viem h9ng Vincent 2.2 Dich ty, hAu (ngody hong mid) Benh pham dugc lAy bang que tam bong can mem, dan h6i dai x'ap xi 20cm, dau quAn b6ng that chac, to horn hat gao mot chitt, da dugc say hAp v6 khuan Berth nhan ng6i yen, mat hai ngda Neu la tre nh6 thi dugc nguai lan be ng6i tren dui, mot tay giir hai tay tre, tay Om lay tran va ghi nhF vao ngyc minh Ngtx6i lAy benh phAm mot tay phia sau co benh nhan, tay cam tam bong dtra nhc nhang qua 18 mui, vera dAy vua xoay giup cho tarn bong di de dang D6 1.4 dugc benh phAm tir hong mai tam bong phai vao sau mot khoang bang nira d6 dal to canh mai den dai tai ding phia, neu chua dat dugc sau nhu vay ma cam thAy co lye can r6 thi rut tam bong va thin lAy benh pham qua 18 milli ben Khi tam bong da dat dugc d6 sau can thiet (khi cam giac thay que tam bong bi can cham thi dimg lai xoay ton r6i to tir rut tam King T6t vao sau cua h9ng nhAt la benh pham dugc cay tai ch8 vao cac moi tnrang chon loc Co the cho tam bong vao cac 6ng nghi6m vo tang chuyen den phOng thi nghiem cang sam cang tot (truck gi6) Truang hop phai chuyen di xa thi can dat b6nh phArn vao mai twang van chuyen 177 Bai giang dao t4o ky !fang chuyen mon cho can hi) y to tuyen huyen 1(5% thu:at xet nghiem Dich c6 gia tri chAn doan tot dich h9ng vi it ran tap, khuAn Benh pham lay tir h9rig bang tam b6ng mem dugc chirc Y to The gied khuyen cao la rat thich hop cho viec chan doan can nguyen khong chi doi voi viem dung ho hap ten ma ca duang ho hap clued vi ho cac vi trUng dugc ban ngugc len 2.3 Dtrm Ap ,dvng ngoai LAy sang sem ngil day, benh nhan chixa uong, vo nhe nguc va lung tru6c lay Benh nhan suc mieng roi khac dam vao 19 rOng mieng co nap kin, vo tang Benh pham khong dugc Ian nu& b9t Dich mang phoi Khi benh nhan c6 tran dich mang phi thi dung barn kim tiem vo trUng ch9c but dich qua khe lien wan (phoi h9p \Teri bac si lam sang) cho vao Ong nghiem Loai benh phAm chi dugc thy- tai benh vien bai cac thay thuoc c6 kinh nghiem 2.5 Dich htit tir phe quan Benh phAm dugc thy qua Ong soi phe quan Phuang phap thy benh phAm chi ket hop cac thay thuoc chuyen khoa tien hanh thu thuat vi nhimg mvc dich khac Tat nhien dich hut cho phep ta xac dinh chac chan can nguyen viem dirongho hap duot Chu Cac benh phAm duemg ho hAp sau lAy phai chuyen den phorlg xet nghiem khong qua giO, n6u lau him c6 the dung moi twang Amies de van chuyen nhung ding khong qua 24 gib CACH LAY VA BAO QUAN BtNH PHAM DifeiNG TIEU HOA 3.1 Dich day LAy lfic sang sam benh nhan chua an, dung ong thong da day thy dich cho vao 19 vo trung 3.2 Chat non LAy - 10m1 cho vao 19 vo trUng day kin, gir''i den phOng xet nghiem 3.3 Thav an LAy cho thirc an nghi ng6 xet nghiem tim vi khuAn hoc dOe to 3.4 Pita Lay benh phAm sau benh nhan di ngoai bo sach thuOng dugc sir dung vi cho phdp ta chon dugc vi tri c6 kha nang co nhieu vi sinh vat Tuy nhien, cling Co the lay benh pham tir true tang 3.4.1 Lay benh ph am tic plain ha' - ChuAn bi 6ng nghiem dung que tam bong dii say hAp vo trUng - Cho benh di ngoai vao 1)6 khong c6 thuOc sat trUng, da tang nuac soi 178 Cac xet nghiem vi sinh co ban tai tuyen huy'en - DUng que bong lAy benh phAm a ch8 phan co bie'u hien benh ly (mau, nhay, manh yin niem - Cho que b6ng vao ong nghiem, nut kin gin den phOng xet nghiem - Cung có the 14 benh phAm (1 gam) vao mot cai 19 da dugc say hAp vo trimg Benh phAm can dugc xet nghiem cang sam cang tot, chant nhAt khong qua gia 3.4.2 Lay benh pliant tir &tic hying - Chun bi Ong nghiem dtrng que tarn bong da say hAp vo tang (km }", b6ng phai dugc ca dinh chic china dau que) - Lam Am dAu bong bang ntrac muOi vo trimg hoac bang mai truang van chuyen - An dAu bong qua co that trirc tang, xoay que b6ng r8i rut (thay phan barn vao la dugc) - Cho que bong vao ;Ong nghiem, nut chat, giri den phong xet nghiem cang sam cang tot, cham nhat kh6ng qua gia - Ne'u phai chuyen di xa cAn phai cho benh phAm vao mai twang bao quart (Cary-Blair) 3.5 Minh sinh fillet d1 day-ta tring Dugc lAy qua not soi, de chAn down vi khuAn (H pylori) can l'Ay manh (2 manh a ria lOet, mot math a hang vi) B 'enh pham co the dat ntrac muoi sinh ly hoac mei tnrang van chuyen chuyen biet, dem den phOng xet nghiem truac gia dong ho Chu Cac benh phdm &rang tieu hoa van chuyen xa cAn phai cho vao mei truang bao quan (Cary-Blair) CACH LAY VA BAO QUAN BENH PHAM NU'OC TIEU 4.1 Cich lAy 14nh phi'm Trix nhUng twang hgp dac biet benh phArn dugc lAy ti"en hanh cac thd thuat nhu (tat th6ng dai, soi bang quang, chgc hitt tren xucmg mu, da so cac twang hgp 14i benh pham dugc lay theo phucmg pita') lay nuac tieu giira clang 4.1.1 Dai voi nam gioi - Cho benh nhan ve sinh tay, quy dAu va \Tung sinh chic tank lAy - Keo bao quy dau len (n6u throng vat bi phd kin) 179 Bai giang dao tao ky Wang chuyen mon cho can bq y to tuy6n huyen — ICy thulat xet nghiem - Cho benh nhan di au 1)6 di,m6t it mr6c ti6u dau bdi, sau nhin lai Dung 16 vo khuan cho benh nhan di tieu vao 19 khoang - 5m1, sau cho benh nhan dai 1)6 hoan toan 4.1.2 Ddi giol - Rira tay bang xa pheng, lau kh6 bang khan sach b6 phan sinh dvc ngoai bang xa phong that sach, thdm kho bang gac vo khuan, gitr cho cac moi dm am h6 tach bia Dung cac rang mieng vo khuan co nap day d6 lay nude ti6u Di tiL 1)6 phan dau, lay nu& tieu gitra clang nhu cua nam giai 4.2 Bao 'pan bOh phAm Nen lay benh pham nu& au vao bu6i sang WI phai duvc,xet nghiem \Tong gio dau Neu khong,xet nghiem dugc, benh pham phai dugc giti or 4°C, nhung cling khong dugc de qua 18 gio ke tir lfic lay benh pham CONG TliffC CAC MOI TROJNG VAN CHUYEN 5.1 NM truirng Amies - Wit than hoat 10,0 gr - Natri chlorua 3,0 - - Natri hydrophosphat 1,15 - - Kali dihydrophosphat 0,2 - - Kali chlorua 0,2 - - Natri thioglyaholate 1,0 - - Calci chlorua 0,1 - - Magnesium chlorua 0,1 - - Thach 4,0 - - NuOt cat (vira du) 1000m1 Him tan cac phan tren rZii dun soi cho tan hoar' toan thach, chinh pl I 7,2, phan phoi vao cac tube nho Hap ixOt 110°C/15 phut Trong qua trinh de ngt01 phai lac cac Ong cho than hoat h6a deu moi tnr6ng Gifr kin, trit,trong lanh dung dirge yang thang Moi twang dugc dung de van chuyen benh pham clueing ho hap 5.2 MCA trtarng Cary-Blair - Natri thioglycholat 1,5 gr - Dinatri phosphat (Na2HPO4) 1,1 180 Ca.c xet nalai"6Ti vi sink cc( ban tai tuy6nlycli 5,0 _ Natri chlorua 5,0 _ - Dung Bich Calci chlorua 1% 91-n1 1000m1 - Nu& cat (vim du) Dun sei cach thily cho tan het cac chat De nguoi 50°C them ml dung (Lich 1C12 1% mai pha trongntrac Dieu chinhy11,8,4 Dung (ing dtrang kink 16mm, ag 6ng 8m1 Khir khuan laibang ,,dun soi scach thug 15 phitt Mei twang lag d6 van chuyen cac vi khuan thucho o &rang ro t va cac Vibrio 181 Sir dung va phan tich ke't qua xet nghiem biing in dam t6 bao ter dOng Sir DUNG VA PHAN TiCH KET QUA XET NCH' CM BANG MAY DEM TE BAO BONG 1y11,1C TIEU 11QC TAP Trinh hay dirge cac thOng so huye't hoc duvc rlo hang may dun to bao ty• Phan tich dupec mOt so yeu to anh huong den cac thong so (.16 DAI CVOING 1.1 Khai quit vt cac thong so huytt h9c Phan tich cac khia canh hinh thai hoc oh cac to bao mau nhu hOng cau, bach cau, ti6u cau, ham lugng huyet sac to, tS, le % timg loaf bach cau rat quan trong thoc hanh y hoc - Phuong phap xac dinh cac thong s6 huy6t hoc thin cong (tren kinh hi6n vi) rat ton thoi gian va khong chinh xac Phucmg phap xac dinh bang may dm to bao to d6ng cung cap rat nhieu th6ng so chinh xac va nhanh chong 1.2 Cfic luu i ky thu4st - Khi lay mau nghiem, khong nen ga ro qua lau, gay co d4c mau mau nghiem Phai tron deu 'Ong mau twat cho mau nghiem mau vao may dem - Cac to bao (h6ng eau, bach cau, tie4u eau) c8 rat nhiL tron mau mau Do dO, can pha loang rat chinh xac truac dm; neu khong sai so se rat lan - Dem to bao teen may to d6ng sir citing nguyen Vi dm t6 bao theo dang ho4c phan tich bang hinh anh - Phan tich to bao bang hinh anh la phan tich cac to bao teen lam kinh theo tieu chuan da dugc lap trinh sari de dem va phan loaf to bao Phucmg phap ton nhieu thOi gian va luong to bao duoc dem it nen khong chinh xac bang phuang phap dem to bao theo clang Hien nay, ngueri to khong sir citing phuang phap nua - Cac sai s6 dm to bao thuong khau pha loang, tron, sphan b6 hay thuc hien dem to bao Loi dem tang len cac to bao chon&len ho:dc kich dm& hay hinh ding bat thuong cua to bao lam cho may dem to bao tkr d6ng phan tich kh8ng dimg 139 Bai giang ciao tao Icy nang chuyen mon cho can b0 y to tuy6n huyen - Ky thuat xet nghiem NGUYEN LI' DEM TE BAO Cho cac to bao da" dugc pha loang di qua mOt b0 phan dem (co th6 la dOng din mOt chieu cac may theo nguyen ly dien trar khang hay tia laser cac may climg nguyen 13", quang h9c) nhu mOt d6ng to bao Khi to bao di ngang qua d6 thi clang din,hay tia laser se,bien va dugc may ghi lai Sr Nen doi va bien dO cua su oien doi cho biet so lugng to bao va kich thugc cua chimg 2.1 Nguyen 157 din tro khfing (cac hang Coulter, Sysmex ) - T6 bao mau dugc pha loang dung dich din phan Sau do, t6 bao dugc di qua mOt 16 nho MOt clang dien mOt chieu dugc dal gift hai dien cgc platinum hai phia - Vi to bao mau dugc coi nhu khong dAn dien, nen,khi mOt bao di ngang qua 18, se lam giam dO clan din that dAn den thay doi hiOu din the era hai din cue - Cac xung thay doi c6 th6 dm dugc va dugc cu6ng dO SO lugng xung th6 hi'0 so lugng to bao DO km dm moi xung tS, le voi the tich cua to bao Trung binh dO lon cua xung chinh la the tich trung binh cua t6 bao (MCV) - DO chinh xac cua ky thot dugc cai thin xir ly dal*, loci b6 nhang xung sai *h He thong dong chay duge cai tien de bao dam vi tri giira cua to bao qua 16 (nguyen 1S, tap trung thuS, Ong h9c) 2.2 Nguyen Ur quang hoc (cac hang Bayer, Abbott ) Khi to bao di qua mOt \ding dirge chi6u sang, anh sang se bi phan xa, khilc xa, tan xa Cac to bao quang din se ghi nhan su thay doi cua cac xung anh sang va suy so lugng to bao Dong thai, dO lan ciia,xung anh sang tS, lOsvai kich thuac ' thong quang hoc sir dung de dem hong cau, bach cau, tieu cau vOi cua to bao 1-1 dO chinh xac tuang ducmg N thong theo nguyen ly d*Itr6 Ichang PHAN TICH KET QUA Cac may d6m tá bao to Ong thu6ng co cac th6ng so chinh sau - Cac thOng so hang au + So lugng hang au (RBC: red blood cell) + Hematocrit (Hct) + Hemoglobin (Hb) + The tich trung binh hang (MCV: mean corpucular volume) + Lugng huyet sac to trung binh hang au (MCH: mean corpucular hemoglobin) 140 I IC Sir dung va phan tich ket qua xet nghiem bang may am to bao lir d + Ham luting huy'et sac t6 trung binh h6ng cAu (MCHC: mean corpucultir hemoglobin concentration) + DO phan rai kich thuac Wong cAu (RDW: red cell distribution width) - Cac thong s6 bach cau + S6 luting bach cau (WBC: white blood cell) + S6 luting va % timg loaf bach cAu - Cac thong s6 tfeu cau + S6 luting tfeu cau (Plt: platelet) + The tich trung binh ti'eu cAu (MPV: mean platelet volume) + DO phan rai kich thuac tiL cau (PDW: platelet distribution width) 3.1 Phan tich cac thong so hiing eau S6 luting ht:ing cau dugc dm dung dich mau pha loang chira bach cau va tieu cau - Bach cau duac dem ding vai h6ng cAu, nhung s6 luting bach cAu qua it so vai Wong cau nen sai se:1'1(11611g gang ke Tuy nhien, bach cau tang qua cao se anh huang tai so luting hong cau - Cac chi s6 va s6 luting h6ng cAu có the thay d6i CO y nghia bach cAu tang cao tren 50 x 109/L Kich thuac tie'tt cau qua nho, nen thueyng khong gay 176i dery hong cau - Hct dugc tinh to tong cac kich thuac tong htmg cAu duac dm Gia tri thtremg thap han gia tri Hct lam thil cong vi khong có them khoang glib cac hong cau nen chinh xac han - Ham luting Hb thtleyng duac bang phuang pha') quang h9c Dung dich ly giai lam vO hong cau giai phong Hb Sau do, Hb duac chuyen cyan-methemoglobin, mat dO quang h9c dm dung dich t57 le vai luting Hb mau - The tich trung binh hang cAu (MCV) duac tinh bang each lay Hct chic cho so *mg hong ,cAu Gia tri thuang rat chinh xac MCH va MCHC dtrot tinh tir cac th6ng so so luting h6ng cau, ,hemoglobin va hematocrit, bach cau qua cao lam tang MCV, hong cau bi ngung ket lanh lam tang MCV gia tao, vi cac hOng cau ngung ket dugc xem nhtr mot h6ng cau lon Tuy nhien, neu cac hong cau ngung ket co kich thuac lan,han nguang tren (> 360f1 doi vai may Coulter) se khong duac dem, lam Hct thap gia tao, lam tang MCH va MCHC Trong truarng hap nay, it am a 37°C qua trinh phan tich se tang dO chinh xac cua Hct, MCV, MCH, MCHC 141 giang ciao tao kj, nang chuyen mon cho can 130 y to tuye'n huyen - Kj, thuat xet nghiem - Dutmg mau tang cao se lam tang MCV va Hct gia tao, dan d6n giam MCHC Di'eu la Wong cau bi tnrcrng ph6ng len pha vori dung dich dang truang MCH c6 the bi anh huang bad tang lipid mau, tang mat dO quang hoc cua huy& tuang, lam tang Hb gia tao S6 luting bach cau tang cao teen 50 x 109/L cling c6 the tang Hb mot cach dang ke, cling nguyen nhan - Th6ng s6 RDW cho biet scr thay d6i kich,thirac quail th6 h6ng cau RDW phan biet gifra thalassemia chua c6 Wen chimg (RDW binh throng, MCV thdp) va thieu mau thieu sat (RDW cao, MCV binh thralls hay thap) RDW ding la mOt chi so nhay cam nhung kh6ng (lac hieu thieu mau thieu sat Binh nhan chay than nhan'tao kelp dai 3.2 Phan tich cac thong so b#ch cau 3.2.1 So laying birch din S6 luting bach cau dugc dEm tren mau mau dugc pha lodng \Teri dung dich lam tan h6ng cau So lutingbach cau dem bang may dem tg dOng c6 sai so tir 3% S6 luting bach cau co the, tang gia tao tieu cau ket chum, cac sgi fibrin, ngung tap tieu cau EDTA, hong cau c6 nhan ho4c hong cau khong bi tan 3.2.2 Phan loci bach din - Cac the he may phan biet loai bach cau a Mau mau dugc pha bang dung dich dac biet lam tan toan 130 h6ng cau va lam thfing mOt 16 tren mang bach cau Mang t6 bao se co sat vao nhan Sau d6, cac bach cau da thay d6i hinh clang dugc dem NIA kich thuac dua vao hinh dang va kich thuot nhan Vi may dm hang Coulter + Tir 30 - 90 fl (Lym) dugc xem la lympho + Tir 90 - 160 fl (Mix) dugc xem la bach cau "hi3n hop" (monocyte, tien tuS, bao, tug' bao, to bao blast ) • + Tir 160 - 450 fl (Gra) dugc xem la bach cau hat trung tinh, bach cau hat ira axit, bach cau hat ua baza, bach cau dua, hau tuSr bao He thing dm dm mOt so hang (Sysmex ) ding phan loai dirge loai bach c?iu (Lym, Mix, Gra) nhu tren, nhtmg loai bach cau "Win hop" (Mix) lai bao gom monocyte, bach cau hat ua axit, bach cau hat ua baza Do do, de hieu ket qua chinh xiic can phai biet kieu phan tich cua tirng loai may Phan tich k6t qua + May se cho chfing to biet loai bach cau la: lymphocyte, bach cau "Mn hap", bach cau hat trung tinh 142 Sir dung va phan tich k6t qua xet nghiOt bang may am t,4`) bao tkr d2! + Cdc nghien cfru cho thdy s6 luting lymphocyte va bach cau hat trung doh la tuong dal chinh xdc (d4c biet cdc may cila hang Coulter, Sysmex, Abbott) + He thong phan lam loai bach cau ten dugc sir di,ing rOng rai nghiem cong thirc mau thuong quy Tuy nhien, mot so throng hgp nhu cdc Nnh v6' mau c6 bach cau noli mau ngoai vi nhieu hay nhiem virus, tS, le lymphocyte kich thugc lon tang cao, hay or nh&ng ngoai co bach cau hat ua axit cao thi may se dgc khOng chinli xdc Khi nay, tS, le bach cau "hon hop" se tang cao Can kiem tra lai bang tieu ban Giemsa - Cdc th6 he may phan bit loai bach cau Co nhi'eu phucmg phdp khdc de phan b* loai bach cau Hang Coulter sir dung nguyen 15P Dien tra khang (impedance) xdc dinh the tich to bao; DO tan xa dnh sang laser (laser light scatter) xdc dinh hinh clang to bao, tinh chat be mat to bao, so luting va cdc loai hat to bao chat Tinh dan din (conductivity) xdc dinh tinh chat nhan to bao, phan cac hat va phan hod h9c cua to bao Tinh dan din giup phan bit cdc to bao c6 ding kich thirac nhu lymphocyte nh6 va bach cau ua baza , Hang Bayer sir dung nguyen NhuOm hod hgc bao phan bit dugc loai to bao la bach cau hat trung tinh, bach cau ua axit, monocyte, lymphocyte va bach cau ua baza; Dung chat ly giai dac de ly giai cdc loai bach cau trir bach cau ua baza Hang Abbott phan bit loai bach cau dua vao nguyen ly tan xa dnh sang phan cgc da g6c (multiangle polarized light scatter - MPLS) Hang Sysmex, sir dung nguyen trey khang; Tan se; radio (radio frequency); Dung chat ly giai dIdc b*, ly giai bach cau trir bach cau Ira baza va bach cau ua axit Phan tich ke't qua + Du theo nguyen ly nao thi may cling se cho tS, le % cua loai bach cau la bach cau hat trung tinh, lymphocyte, monocyte, bach cau hat tra baza va bach cau hat ua axit Ngoai ra, doi voi may Technicon c6 them loai bach cau lon, 'thong bat mau thuoc nhuOm (Large unstained cells - LUC) gom lymphocyte Wn, tuang bao, hay to bao blast + Phan tich loai bach cau bang may d6m to dOng cho k6t qua rat chinh xdc dOi vai bach cau hat trung tinh va lymphocyte, sau d6 la bach cau tra axit Ket qua it chuan xac hon doi vai monocyte va nhat la bach cau Ira baza 143 Bai giang dao tar) ky nang chuyen mon cho can b0 y to tuyen huyen - Icy thuat xet nghiem 3.3 Phan tich cac thong so tieu cau - D6i vai cac may dung nguyen lg dien tra khang, tieu cau thuang dugc dem cling vai hong cau, vai ngtrang phan tich khoang - 20 fl - Ca N th6ng quang h9c va dien tra khang deu dem tieu eau va Wong cau mau pha loang.,V1 Vey, neu c6 hong cau nho, cac manh va cua h6ng eau va bach cau may c6 the dem nham la tieu cau Trong nMng truarng hop nay, bieu dO cua tieu au se bat thuang va may dem tkr dOng se nhen bat thuang - S6 luting tieu cau giam gia tao co th6 tieu cAu ngung ket hay tieu cAu barn xung quanh bach cau hoac tieu cau ket chum lay mau sai ky thuet The tich trung binh tieu cau (MPV) thuang c6 quan he nghich vai, s6 luting lieu cau Tieu cau phong len 15 - 25% gia dau mau dugc chong dong bang EDTA, lam cho ket qua thong so MPV co the khong chinh xac MPV c6 the tang 1.6 mot vai tnrang hgp dien hinh nhu cuang giap, hOi chirng tang sinh tug HAN CHE CUA HE THONG DEM TE BAO TIf BONG - Cac phuang phap luting, Neu thi tS/ le dm to bao mau so vai huyet tuang c6 the kh6 giai thich hoc them chi c6 the bi sai mot so benh 1S, vi gia tri khong tinh den nhang bien d6i dm the tich huyet toting hoc nhang bat thuang anh huang den so luting to bao Vi du: Mat nuac lam giam the tich huyet tucmg, se lam tang so luting cac to bao mau Trong benh tan mau cap, c6 nhieti hong cau, non mau se lam tang so luting bach Trong cac benh ly ve mau, cac (long to bao bat thuang hinh thai, kich thuac bat thuang xuat hien nhieu mau, he thong dem to dOng se kho phan tich chinh xac Khi nay, may thuang bao dOng mot so km g Trong nhimg truang hgp nay, cac chuyen gia huyet hgc can kiem tra lai tren kinh hien vi - Nguyen tac sau xet nghiem phai dra fan , neu khong sach protein barn Ong lam sai xet nghiem, do neu lam don chiec thi se rat ton dung dich a tuyen huyen dieu la han che, can luu 3% 144 ... phOng thi nghiem cang sam cang tot (truck gi6) Truang hop phai chuyen di xa thi can dat b6nh phArn vao mai twang van chuyen 177 Bai giang dao t4o ky !fang chuyen mon cho can hi) y to tuyen huyen... cua to bao lam cho may dem to bao tkr d6ng phan tich kh8ng dimg 139 Bai giang ciao tao Icy nang chuyen mon cho can b0 y to tuy6n huyen - Ky thuat xet nghiem NGUYEN LI'' DEM TE BAO Cho cac to bao... sach va kho (lay day du, khong 1)6 55 Bai giang dap tao kj, nang chuyen mon cho can bO y to tuyen huyen - Ky thulat xet nghiem sot ke ca lnc di ngoai) Ngay horn sau, den gior quy dinh dai that