au bng tr em

AU BNG TR EM
Mc tiu
1. Trnh by cch khm lm sng v ngh mt s xt nghim hay thm d thng thng xc nh nguyn nhn au bng tr em 2. K mt s nguyn nhn thng gp ca au bng tr em 3. Trnh by nguyn tc x tr au bng tr em au bng l mt bnh cnh thng gp tr em v l mt trong nhng nguyn nhn hng u m tr c em n cc c s y t ( bnh vin, trm x, hay phng mch ca Bc s). Ngoi nhng nguyn nhn au bng do mt s bnh l ti rut th khng c qun rng nguyn nhn ca n c th l do bnh l ngoi ng tiu ha, v mc ca bnh cng nh biu hiu lm sng rt a dng. Cn phn bit y l au bng cp, au bng ti din, au bng ni khoa hay au bng ngoi khoa

1.Thm khm lm sng v cn lm sng

1.1.Tnh hnh chung: Tui, gii,tin s bnh tt ( bnh ni hay iu tr ngoi) 1.2.Hi bnh 1.2.1.Cn au - Ngy, gi au, hon cnh xut hin cn au, cch khi pht: t ngt hay t t - Din tin cn au: Lin tc hay tng cn. Khong cch ca cc cn au - Cng au ( Thng c cng iu do b m) - V tr v hng lan 1.2.1.Nhng triu chng tiu ha khc - Nn, bun nn - a chy, to bn hay b trung- i tin 1.2.2. Du hiu ngoi ng tiu ha - Du hiu Tai mi hng (TMH): Chy mi nc, nut kh, au tai.. - ng h hp: ho,khc m - Tit niu: i kh, i but, 1.3.Khm bng - Xc nh v tr au, phn ng thnh bng. tr nh phn ng thnh bng rt gii hn bi v c thnh bng yu - Thm trc trng c thc hin sau cng khm ph khi u, mu, hay lm tng cn au 1.4. Khm lm sng khc - Tnh trng tng qut: Hi chng nhim trng km hay khng run lnh, ni ban, da xanh ti, st ( Thn nhit < 3708) - Tnh trng chong: H huyt p, nhp tim nhanh, m hi, tay chn lnh - Tnh trng mt nc ( Kht nc, np vo da mt chm, mt trng, tr kch thch hay li b) - Khm TMH, phi, hch, b phn sinh dc pht hin mt vi du chng bnh l - Xc nh v mt vi nt c bit trong i sng ca tr: Nh quan h x hi, ri lon v giao tip, hay tr b i hc qu sm. 1.5. Cn lm sng - Chp phim bng (nm v ng): Tm cc du hiu lim hi di c honh, mc hi nc rut hay dch t do trong bng.. - CTM, in gii , C reactive protin

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- Siu m bng : c th pht hin du hiu vim hch mc treo, bi lng, hay hnh nh rut tha vim hay dch t do hay khu tr trong bng hay hnh nh giun ng mt, ng ty.. - Nu cn thit c th th nc tiu ( t bo, sinh ha hay cn lng), ni soi bng, chp ng tiu c chun b (UIV)

2. Phn loi
2.1. au bng cp tr em au bng cp l cn au bng xy ra mt cch t ngt, au tng cn, km theo nhng triu chng nh khng hay phn ng thnh bng. Tnh trng thng gp tr em lm b m rt lo lng. Bnh gp bt c la tui no, c th lc tr c 2-3 thng tui hay tr 13-14 tui. Nguyn nhn rt a dng v i lc chn on gp nhiu kh khn 2.1.1.Nguyn nhn - Cp cu ngoi khoa + Vim rut tha + Lng rut + Thot v nghn + Vim phc mc tin pht + Xon rut do xoay rut d dang, thng tng rng, chn thng vng bng - Khng c ch nh ngoi khoa cp cu Khi chn on ban u khng phi l mt cp cu ngoi khoa, th cn lm nhng thm d khc c bit l siu m chn on, transaminase, cy mu, ngoy hng tm vi khun. Hng chn on vn ph thuc vo du hiu lm sng. + Vim phi, vim m mng tim v vim c tim + Nhim trng ng tiu, si tit niu, thn nc + Vim d dy rut cp,vim gan siu vi, si mt, vim ti mt, vim ty, nhim giun a, giun mc, vim lot d dy. + Xut huyt dng thp ( Purpura rheumatoid) + Hi chng tng ur mu huyt tn 2.1.2. Nhng yu t c gi tr chn on - So bng: Hy ngh n bin chng ngoi khoa sau m - Nu tr c nhng ngy sng vng dch t, cn ngh n mt s bnh nh st rt, amip, nhim k sinh trng ng rut - Tr b m cn ngh n lng rut, xon rut, nghn thot v. tr gi, nu cn au khu tr vng h v, th cn ngh n xon bung trng, vim phn ph, hay tr thiu nin cn ngh n tc kinh th pht, bin chng ca c thai , trong nhng trng hp ny cn lm siu m bng. ng trc mt trng hp au bng cp, c 2 im cn : - Xc nh tnh trng nng ca bnh nhn - Nh rng mt trng hp au bng cp tnh ngoi khoa vn phi ngh mt tnh hung ni khoa khi cn thit. Nu khng tm ra vn g, th vim hch mc treo c bit do Yersinia hay bnh cnh Virus loi tng bch cu n nhn nht l bnh nhn c triu chng nhim ng h hp trn vi nhiu hch ln v lch ln cn phi ch . ng trc nhng trng hp ny, cn theo di st v phng din lm sng vi ngy sau c thi x tr kp thi ( nht l nhng bnh cnh ngoi khoa cp tnh)

au bng tr em

S CHN ON AU BNG CP TR EM A. Hi bnh CTM B. Khm lm sng Xt nghim nc tiu Xt nghim phn v cy mu Chn on thai nghn Xc nh: C thai Nhim trng ng tiu C nh gi mc ca bnh Nh Du hiu tiu ha C Khng Trung bnh Nng Rt nng

a chy Theo di trong 24-48 gi Phn c mu Nn ma To bn Nn ra mu D. Du hiu nhim trng hay nhng ri lon khc C Khng Vim mao mch Hi chng tng ur mu huyt tn Nhim trng ng rut Vim vng h v +/hay Khng c g E. Du hiu ca lot khng E. Gi : Lot d dy Vim thc qun Nn lm Siu m Chc nng gan Amylase Immunoreactive trypsinogen Bt thng Nhim trng Abces rut tha Abces bung trng Ct ty vim Vim phi Vimti mt Vim tu. Vim rut Si thn

mu

au bng tr em

U nang bung trng v Vim hch mc treo..

au bng tr em Nng Rt nng F Nhp vin Chp XQ G. Siu m bng Amylase mu +/hay Immunoreactive trypsinogen Khm ngoi khoa Bnh l ni khoa Nhim trng Vim bung trng Ct ty vim Vim ph i Vim ng m t H. Vim ty Nhim trng rut Si thn V u nang bung trng Vim hch mc treo Bnh l ngoi khoa I. Rut tha vim J. Lng rut Nghn rut Thng tng rng K.V gan lch Xon bung trng cp Nghn niu qun h chu

Ghi ch ch dn : A.Hi bnh s: Xc nh cch khi pht, thi gian v tr, s ln v cng ca cn au. Nhng triu chng ca ng tiu ha nh a chy, nn ma, a ra mu, to bn Nhng triu chng ca ng tiu nh tiu t, tiu au St, vim khp,gim cn B. Khm lm sng: nh gi tnh trng mt nc v tun hon. Ghi nhn nhng du hiu ca kch thch phc mc nh au khi xoay cng chn ra ngoi, khi nhy hay khi i ng, du hiu ca c y chu b kch thch. Du hiu ca tc rut nh nn ma, tng nhu ng rut, bng cng chng Du hiu ca vim phc mc nh co cng thnh bng, gim nhu ng rut, chng bng, hay chong, c im au c nh Nu au vng thng v hy ngh n vim lot d dy, thot v qua l thc qun,tro ngc d dy thc qun, vim thc qun, vim ty au trn phi gi vim gan, abces gan hay u gan, HC Hugh-Curtis, vim ti mt, hay vim ng mt. Nu au ton bng hay quanh rut, hay vng bn tri nhng mc nh cn ngh n to bn, vim hch mc treo, ng c thc n, vim d dy rut cp, hay au do tm cn C. nh gi mc au: Nh: mc d au nhng tr vn hot ng bnh thng hay km theo nhng bnh t gii hn Trung bnh:Tr au km theo triu chng nhim trng Nng: Bnh nhi c triu chng ca vim phc mc hay nghn rut D. Nhng triu chng gi bnh h thng hay nhim trng : Vng da ( Vim gan); Sang thng quanh hu mn, st cn, mu trong phn ( Vim rut non: bnh Cronh); a ra mu,sau

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dng khng sinh ( Vim i trng mng gi), a chy phn c mu, st, khng nn ma ( Vim rut nhim khun); xut huyt di da dng chm, vim khp, i ra mu ( SchonleinHenoch); a ra mu, i mu, thiu mu, suy thn ( HC tng ur mu huyt tn); st ko di, vim kt mc , ni ban, sang thng nim mc ( Bnh Kawasaki); st, st cn, gan lch ln, hch to ( Bnh c tnh); thiu mu ( bnh hng cu hnh lim); ho, gim m ph bo, nghe ran phi (Vim y phi phi); au hng v xut tit, vim hch ( Vim hng do Streptococcus pyogenes); bng chng, gy chi (chn thng) E. Gi vim lot d dy khi bnh nhi au bng ti din km theo nn ma, nn ra mu, a ra mu. tr ln thng au vng thng v F. Chp Xquang bng tm si trong rut tha, bng hi thnh rut trong bnh vim rut hoi t tr s sinh, lim hi di c honh ( thng tng rng), mc hi nc ( tc rut), u bng hay nhng nt calci ho trong bng, si ng tit niu. G. Siu m l k thut c hiu qu cao c th chn on nhiu nguyn nhn ca au bng cp nh vim rut tha, lng rut, bnh l ti mt, hay ng mt, vim tu, vim gan, khi u trong bng hay cn chn on mt s bnh l trong h chu. H. Gi vim tu khi au bng c hng lan ra sau lng c km theo nn. Bng, bng chng v du phn ng thnh bng c th gp. Amylase mu tng l du hiu gi , Siu m c th pht hin c vim v gi nang. Nguyn nhn ca vim tu c th do chn thng, ri lon chuyn ho hay nhim trng hoc hi chng tng ure mu huyt tn hay ng thuc hoc nhng d tt bm sinh. I. Rut tha vim vi cc du hiu st, nn ma, au vng h chu phi nht l ti im Mac Burney. J. Lng rut khi cn au bng bc pht t ngt, km theo nn ma, bng chng, a ra mu, v s thy khi u. Vi siu m bi lng c pht hin kh d dng K.Chn thng gy nn v gan lch v bng quang hay chn thng gy nn vim tu 2.2. au bng ti din au bng ti din c nh ngha l nhng cn au lp li t nht 3 t trong vng 3 thng trc . Tn sut mc bnh vo khong 10% tr t 3-15 tui, him khi gp tr < 4 tui, thng gp nht la tui 8-10 v tr gi tui dy th; tr gi chim a s. Nguyn nhn au bng ti din c th gm 3 nhm: thc th, chc nng hay c ngun gc tm l. Nhiu nguyn nhn c th xut hin trn mt bnh nhn. Thng c mi lin quan gia thc th hay chc nng, c tnh v nhn cch hay cm xc cng nh thi quen trong cuc sng. cc nc ang pht trin, au bng ti din c ngun gc tm cn chim khong 80-90% bnh nhn, do thc th hay chc nng chim khong 5-10% 2.2.1.Nguyn nhn Bng chng xc nh nguyn nhn thc th kh gii hn. c bit cn phi ch n nhng yu t tm sinh l. - au bng ti din km theo nhng triu chng khc: + Triu chng gan- mt (au vng h sn phi): Bnh l ng mt ( Vim ng mt) + au vng h sn tri , c hng lan ra xng b vai: Bnh cnh ca ty ( Vim ty, u gi nang ty, tng lipid mu typ1) + Nn ma c th km theo nn ra mu v au bng sau ba n, ngh n nguyn nhn ng tiu ha trn: tro ngc d dy- thc qun, lot d dy thc qun. Mt trong nhng nguyn nhn quan trong ca cn au bng ti din tr em l do Helicobacter pylori.Chn on gin bit quan trng l bnh l trn c honh, nht l vim mng ngoi tim - a chy ti din, thnh thong c mu, tng trng gim km theo hi chng vim: Hng chn on n mt tnh trng bnh l ng tiu ha thp: Bnh Crohn, vim i trng chy mu (chn on xc nh cn phi c nhng thm d chc nng khc nh soi trc trng, chp

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i trng vi baryt hay chp rut non vi thuc cn quang), bt dung np protein sa b, vim i trng do vi khun hay k sinh trng.. + Tuy nhin mt s trng hp ngoi khoa bit r nh bnh l ca ti tha Meckel ( xut huyt ti din, thiu mu thiu st) rt kh chn on vi cc k thut thm d c in nh chp khung i trng m ch xc nh c nh chp nhp nhy ( Scintigraphie); rut i hay nang mc treo + Bnh l ng tit niu sinh dc nu km theo cc triu chng nh nh i kh, i ra mu, au vng h v hay vng hng. C th l bnh cnh ca nhim trng ng tiu, d tt ng tiu hay si tit niu; hay bnh l ca bung trng hay phn ph tr tin dy th + Hi chng vim + Du chng thn kinh nh nhc u, nn ma, km theo nhng du cng thn kinh bt thng khc cn ngh n tng p lc ni s, hay migraine hay ng kinh th bng + Bnh l v chuyn ha nh h ng mu, porphyries, - au bng ti din n c: V tr cn au rt quan trng xc nh nguyn nhn au. + au vng h sn : ngh n nguyn nhn gan mt + au vng thng v : bnh l thc qun, trung tht, hay d dy + au vng quanh rn : Bnh l khung i trng, rut non hay r thn kinh + au vng h sn tri: Bnh l ty hay si tit niu, hay cng c th l au do to bn + au vng h v: Bnh l ng tiu hay ph khoa ( tr gi), Cn phi thm trc trng. 2.2.2.Xt nghim - Cng thc mu, VS. transaminase, amylase mu, xt nghim phn tm k sinh trng, hng cu v t bo ), siu m bng - Thm d khc : chp khung i trng, chp d dy vi baryt, UIV. Chp ct lp vng quanh rn ( tt c nhng au bng quanh rn cn xc nh nguyn nhn thc th). - nh gi v nhn cch ca tr v tm hiu nhng mi quan h ca tr i vi gia nh v tr i vi mi trng xung quanh 3.X tr: - X tr nguyn nhn. Ty thuc nguyn nhn c mt thi x tr khc nhau. Cn ch nhng trng hp au bng cp c nguyn nhn t ngoi khoa nh vim rut tha hay lng rut chn on chnh xc v sm hu c thi iu tr kp thi. - Thuc: Rt thn trng khi dng thuc gim au, gim nhu ng rut khi cha xc nh nguyn nhn - Cn v v an i tr, v ng vin b m, trnh to s lo lng hay kch thch cho b m tr khi khng cn thit. Ti liu tham kho 1.Ti liu ging dy ca b mn nh Hu( gio trnh ca b mn nhi Hu) 2.Bi ging Nhi Khoa ca B Mn Nhi- Trng i hc y khoa TP HCM ( 2000). 3. Bi ging Nhi Khoa ca B Mn Nhi- Trng i hc Y Khoa H ni ( 2000) 4. Morris Green.(2000).Pediatric Diagnosis. W.B.Saunders company .2000; 234-245 5. Nelson (2000) . Text book of pediatrics. Behrman and Vaughan 6. Stephen Berman. ( 1999) Pediatric decision making.B.C. Decker. Philadelphia, 1999; 308315