BNH N NI THN

I.

II.
III.

IV.

V.

I.
-

Hnh chnh :
- H v tn : Nguyn Th Phng D.
- Tui : 31
- Gii tnh : n
- Ngh nghip : ni tr
- a ch : Bnh Phc
L do vo vin : sinh thit thn
Bnh s :
Cch nhp vin khong 1 nm bn i khm tng qut bv Bnh Phc pht hin vim cu
thn v c bc s khuyn nn i sinh thit thn kim tra km c cho thuc ung ,
trong vng 1 nm bn ch ung thuc ti nh n nay khi c iu kin bn n bv NDG
xin c sinh thit
Trong qu trnh bnh 1 nm nay bn c au hng lng 2 bn , au m , tng khi lm vic
lu, gim khi nm ngh, thnh thong thy nc tiu c bt , bn ung ngy khong 2-3l ,
nc , tiu ngy khong 2-3l
Tnh trng bn lc nhp vin:
Mch : 82l/p nhit : 370C
huyt p : 120/80mmHg
nhp th :20l/p
Tin cn :
1. C nhn :
- Tng huyt p cch y 2 nm c ung thuc iu tr y huyt p cao nht l
160mmHg , huyt p bn thy d chu l 130mmHg,t khi nhp vin ti nay huyt p
bn dao ng khong 120 110 mmHg
- Vim gan siu vi B mn ang iu tr vi thuc Lamivudin stada 100mg sang 1v
- Cha ghi nhn tin cn phu thut
- Cha ghi nhn tin cn di ng
- PARA 1001 sinh thng
2. Gia nh : cha ghi nhn bt thng
Lc qua cc c quan :
- Tim mch : khng hi hp, khng au ngc, khng nh trng ngc
- H hp : khng ho,khng au ngc , khng kh th .
- Tiu ha :khng au bng, khng bun nn , khng nn, tiu bnh thng .
- H niu : tiu d, nc tiu vng trong thnh thong c bt ngy khong 3l
- Thn kinh : khng au u, khng chng mt
- C xng khp : khng yu lit , khng gii hn vn ng.
Khm : (lc 8h ngy 15/6/2012)
1. Tng trng :
bn tnh, tip xc tt, th trng trung bnh .
Sinh hiu :
Mch : 92 ln/pht
huyt p : 110/80mmHg
nhit : 370C
nhp th : 18 ln/pht
Da nim hng , khng vng , khng ph . khng xut huyt di da.
Li sch
Chi m , mch r.
M = 54kg
Chiu cao : 1m55=> BMI = 22.47=> trung bnh
2. u mt c :
Mi hng , kt mc mt khng vng

VI.

Tuyn gip khng to, tnh mch cnh khng ni

Hch ngoi bin khng s chm.
3. Ngc:
Nhn : lng ngc cn i, khng bin dng, di ng u theo nhp th, khng co rt hm
c, khng co ko c h hp ph , khng ph, khng xut huyt di da , khng so m c .
Tim : mm tim khoang lin sn V ng trung n tri, din p 1x1cm
T1 T2 u r khng m thi , hazder (-)
Phi : rung thanh u 2 bn, g trong, r ro ph nang m du khp 2 ph trng.
4. Bng :
Nhn : bng cn i , di ng theo nhp th , khng u, khng so m c, khng tun hon
bng h , khng xut huyt di da, khng sao mch, khng du rn b .
nghe : nhu ng rut 6 ln / pht
g vang quanh rn , g c vng trc gan.
Chiu cao gan : 10cm ng trung n (P)
S : gan lch khng s chm
o im mayo - robson (-), Murphy (-), Mac burney (-), im niu qun trn gia (-)
o rung gan (-), n k sn (-), chm thn (-), bp bnh thn (-), cu bng quang (-)
5. thn kinh : c mm , khng yu lit
6. c xng khp : khng au nhc khp , khng gii hn vn ng .
Tm tt bnh n :
Bnh nhn n 31t nhp vin xin sinh thit thn :
TCCN:
- au hng lng
- Tiu bt
- Tiu nhiu
TC:

VII.

VIII.

IX.

X.

- Vim cu thn
- Vim gan siu vi B mn
- Tng huyt p
t vn :
1. Vim cu thn
2. Vim gan siu vi B mn
3. Tng huyt p
Chn on s b :
Vim cu thn mn / vim gan siu vi B mn / tng huyt p 1 theo JNC VII cha bin
chng
Chn on phn bit :
- Vim cu thn mn / vim gan siu vi B / tng huyt p 1 theo JNC VII cha bin
chng
- Suy thn mn / vim gan siu vi B mn /tng huyt p 1 theo JNC VII bin chng
ln thn
Bin lun :
1. Vim cu thn :
- 1 nm trc bn tng c chn on vim cu thn km theo cc triu chng nh
au hng lng m 1 nm km tiu nhiu => ngh nhiu l vim cu thn mn =>
bun,cre, siu m bng, tptnt, sinh thit thn

T n nay bn ch ung thuc m khng h i khm kim tra li khng loi tr

c l bnh din tin n suy thn mn .
- Nguyn nhn : trn bn c tng huyt p 2 nm ngh nhiu l do tng huyt p .
- Trc khi cho bn sinh thit thn phi lm thm cc xt nghim ng cm mu
2. Tng huyt p
- Huyt p cao nht ca bn l 160mmHg => 1 theo JNC VII
- Nguyn nhn : trn bn khng ghi nhn tin cn s dng thuc , khm khng pht hin
cc bt thng v thn , ni tit ...=> ngh nhiu l nguyn nhn v cn
- Bin chng :bnh thn xut hin sau tng huyt p ngh nhiu l nguyn nhn dn n
bnh thn
- Nn tm sot cc bin chng khc trn bnh nhn => siu m tim, soi y mt , chc
nng thn
3. Vim gan siu vi B mn :
- Lm cc xt nghim marker vim gan cho bn : HBsAg , anti HBs
ngh cn lm sng :
- Thng quy : cng thc mu , tptnt, AST, ALT, bun, cre , x quang ngc thng ,siu
m bng , ng huyt , ion
- Chn on :
+bnh thn :tptnt, siu m bng , sinh thit thn , trc khi lm sinh thit kim tra
chc nng ng cm mu.
+ tng huyt p : siu m tim, soi y mt .
+ vim gan siu vi B mn HBsAg, anti HBs
Cn lm sng :
- Cng thc mu :
-

XI.

XII.

WBC
6.6 K/ul
NEU
4.41
66.4%N
LYM
1.73
26%L
MONO
0.34
5.1%M
EOS
0.11
1.7%E
BASO
0.05
0.8%B
Large immature cell 0.04k/ul
0.7%
Atypical lymphocyte 0.07k/ul
1%
RBC
4.05 T/L
HGB
129g/L
Hct
0.403 L/L
MCV
100fl
MCH
31.9pg
PLT
211g/l
Cng thc mu c

ng cm mu :
PT
12.4s
PT% 100
INR
1
TCK 28.3
Cha ghi nhn bt thng
- Tptnt:
Urobilinogen nor
Bil
(-)
Protein
0.75g/l
Glu
nor
Ery
150ery/ul
Leu
25
pH
6.5
color
pale yellow
Ghi nhn trong nc tiu c m v mu ph hp vi tnh trng bnh
- Sinh ha mu :
Glu
5.06mmol/l
bt
Ure
5.5mmol/l
bt
Cre
139.4umol/l
tng
AST
19.4u/l
bt
ALT
15.2u/l
bt
GFR hiu chnh = 56.72 ml/ph/1.73m2da=> suy thn 1
- Sinh thit :???
XIII. Chn on xc nh :
-