BNH

N
I. Hnh chnh
H v tn: Dng Vn Ho
Gii: nam
Ngy sinh: 11/11/2016 (3 thng 23 ngy tui)
a ch: Thnh Trung- Thnh Ty- Tn Bin - Ty Ninh
H v tn cha: Dng Vn Nam
Ngy nhp vin: 21/2/2017
Ging 33, phng 3, khoa Tiu ho
II. L do nhp vin: Ho
III. Bnh s
Bnh 7 ngy, b ngoi bnh nhi khai:
Ngy 1: b ho m nhiu, khng khc m ra c, b kh kh, nght mi, th
mt, b c BVK Ty Ninh. iu tr : Cefepim 0,28gx3/ ngy x6;
Gentamycin 0,028g/ngy x5; Sp Astex; Cenparol 250mg; Th oxy
Ngy 2-5: triu chng khng gim
Ngy 6-7: triu chng khng gim, km st 38-38,5oC, xut hin tiu lng 10
ln/ngy, khng m mu; tiu t, vng trong bnh vin Nhi ng 2
Trong qu trnh bnh, b khng co git, khng li b, khng nn tt c mi th
Tnh trng lc nhp vin:
- B tnh.
- Mi hng vi kh tri, SpO2: 100%
- Chi m, CRT<2s; mch r
- th co lm ngc nh, khng co ko c h hp ph
- Sinh hiu:
Mch r: 200 ln/pht
Nhp th u: 58 ln/pht
 Nhit : 38oC
- Phi rale m 2 ph trng
- Tim u, khng m thi
- Bng mm, gan lch khng s chm
- Khng du mt nc
- Cn nng: 5,3kg, chiu cao: 57cm
X tr lc nhp vin:
- Lactat Ringer 500ml: 120ml TTM 60ml/gi
- Raxadin 0,5g/100ml NaCl 0,9%: 170 mg (34ml), TTM/60p x3
- Vancomycin 0,5g: 100mg + Glucose 5% 40ml, TTM/60p x3
- Zinc 70 mg: 1/2v x2
- ORS 2 gi, 1 gi + 200ml nc
- Ch n 1BT sa
- Mc monitor theo di
- Chm sc cp 2, theo di sinh hiu, SpO2/gi
Din tin sau nhp vin:
- Ngy 1: b khng st, ho nhiu, nght mi, b c, tiu phn lng 3 ln
khng nhy mu, tiu t
- Ngy 2-8: b khng st, cn ho m, khng nght mi, tiu phn st 2-3
ln/ngy, tiu bnh thng, b kh.
- Ngy 9-11: b khng st, ho t, khng nght mi, tiu phn st 1-2
ln/ngy, tiu bnh thng, b kh
IV. Tin cn
1. Bn thn:
- Sn khoa:
PARA: 1102, sinh ch huy, 34 tun, cn nng lc sinh 1,7kg
Trong thi gian mang thai sc kho m
- Chng nga: b cha chng nga
- Dinh dng:
Nui bng sa ngoi 10 ngy u sau sinh, b m hon ton t
ngy 11 n 25, sau b sa ngoi hon ton n nay
 Hin ti b cha n dm. B ngoi l ngi chm sc trc tip cho
b
- Pht trin th cht: CC: 57cm, CN: 5,6kg (trc bnh), b ang tp lt,
cm nm c=> b tng trng bnh thng
- Pht trin tm vn: b a, nhn bit c ngi quen l, bit ci=>b
pht trin bnh thng
- D ng: cha ghi nhn tin cn d ng thuc, thc n
- Bnh l:
+Cch nhp vin 12 ngy: b nhp vin Nhi ng 1, iu tr 4 ngy vi
chn on vim tiu ph qun cp
+ tin cn tip xc lao, tiu chy
2. Gia nh:
- M mt cch 2 thng v lao, tiu chy cp
- cha ghi nhn tin cn cc bnh suyn, chm, vim mi d ng
- Mi trng sng: gia nh khng c ngi ht thuc l, khng nhiu
khi bi, trong nh khng c nhang khi
V. Khm
1. Tng trng:
- B tnh, tip xc tt
- Da nim hng vi kh tri
- Chi m
- Mch quay r: 120 ln/pht
- Nhp th u 52 ln/pht, khng co ko c h hp ph, rt lm ngc
nh
- nhit 36,8oC
- Cn nng: 5,4kg, chiu cao 58cm
- Khng ph, khng vng da, khng ni ban, khng xut huyt da nim
- Khng du mt nc
2. Khm tng vng:
- Ngc:
Lng ngc cn i, di ng theo nhp th, khng tun hon bng
h, khng so m c
 Nhp th: 52 ln/pht, rt lm lng ngc nh, khng gt g theo
nhp th, cnh mi khng php phng, th u m
Khng kh kh v th rt
Phi khng rale, m ph bo th
Ting tim u r, 120 ln/pht, khng c m thi
- Bng:
Bng cn i, di ng theo nhp th, khng tun hon bng h
m rut 8 ln/pht
Bng mm, di ng theo nhp th
Gan, lch khng s chm
- Tit niu, sinh dc:
Tinh hon xung 2 bn, bu khng sng
Da quy u khng hp, v sinh tt
- Thn kinh, c xng khp:
C mm, thp phng, khng du thn kinh nh v
- u mt c:
u cn i, khng try xc, khng vt bm
Rng hm mt: khng bin dng s mt, khng st mi ch vm
Tai mi hng: tai khng chy nc chy m, khng sng tai, nim
mc mi v hng vim nh, li khng d
Mt khng , khng vim kt mc
VI. Tm tt bnh n
Bnh nhi nam, 3 thng 25 ngy, nhp vin v ho, bnh 7 ngy, qua hi bnh v
thm khm ghi nhn:
TCCN:
- St 380C
- Ho, c m trng c
- Nght mi
- Tiu lng >10 ln/ngy
TCTT:
- Tnh, tip xc tt
 - Nhp th 58 ln/pht
- Rt lm ngc trung bnh, khng gt g theo nhp th, khng php phng
cnh mi
- Phi rale m 2 ph trng
Tin cn:
- Cch nv 12 ngy: iu tr ni tr Nhi ng 1 trong 4 ngy vi chn on
vim tiu ph qun cp
- Sinh ch huy, lc 34 tun, cn nng 1,7kg
- M mt 2 thng trc v lao, tiu chy cp
VII. t vn
1. Suy h hp 1
2. Hi chng nhim trng ng h hp di
3. Hi chng tc nghn ph qun
4. Tiu chy cp khng mt nc
VIII. Bin lun
1. Suy h hp 1:
Tri gic: B tnh
p ng vi oxy: Da nim hng vi kh tri
H hp: Th nhanh 58 ln/pht (b 3 thng 25 ngy tui),Co lm lng
ngc trung bnh
Tim mch: chi m, mch r, 200 l/p
Suy h hp 1
2. Hi chng nhim trng ng h hp di:
- Vim phi: giai on u, b c biu hin ca nhim siu vi h hp trn
nh st nh, s mi, nght mi, ho; xut hin triu chng ca ng tiu
ha l tiu phn lng khng m mu >10 ln/ngy vo ngy 6-7. Ti
thi im nhp vin N 2 n ngy th 10 sau nhp vin khm phi c
rale m to v va ht khp 2 ph trng--> 1/3 gia phi (P), hin ti
khm m ph bo th, th nhanh> 50 l/p, co lm ngc t trung bnh n
nh. Tin cn sinh non, va xut vin sau t iu tr vim tiu ph qun
cp ngh nhiu
- Vim tiu ph qun: b tui d b vim tiu ph qun, tin cn va
b vim tiu ph qun, b c triu chng nhim siu vi ng h hp
trn trc , c hi chng tc nghn ng h hp di, c kh kh,
suy h hp 1. Nhng b km p ng iu tr BVK Ty Ninh, din
tin nng hn, xut hin st Nu c vim tiu ph qun, ngh nhiu l
vim tiu ph qun bi nhim
- Lao phi: b ho ko di ( 4 tun), vim phi/vim tiu ph qun km
p ng iu tr, tin cn sinh non, tip xc vi lao (m mt v
lao)khng loi tr
3. Hi chng tc nghn ph qun:
B c ho, kh kh, kh th. Km theo s mi, khm phi c ran m--> hi
chng tc nghn. c th c cc kh nng xy ra trn bnh nhi ny:
- Hen ph qun: b cha ghi nhn tin cn d ng, bnh l lin quan ti d
ng (chm, m ay, ban nga,), khng c tin cn ho, kh kh, s mi,
kh th, khi tip xc kh lnh, khi bi, phn hoa,lng ng vt, thc
n, gia nh cng cha ghi nhn bnh l d ng, hen suyn, vim
xoang, t ngh
- Vim ph qun phi c hi chng tc nghn km theo: b c st cao,
khng c tin cn kh kh kh th ti pht,khng c c a d ng, c hi
chng nhim trng h hp di r ngh nhiu
- Vim tiu ph qun: b <24 thng, kh kh, kh th, l ln nhim siu vi
th 2ngh nhiu
- Lao ni mc ph qun: b c tin cn tip xc lao, sinh non, d b khng
b suy dinh dng hay st cn nhiu, vn khng th loi tr
4. Tiu chy cp khng mt nc:
B tiu lng >10 ln/ngy, 2 ngy lin tip, phn vng khng m mu-->
tiu chy cp
Khm lm sng: b tnh, tip xc tt; ung c, khng ho hc; du vo da
mt nhanh; mt khng trng--> khng mt nc
B khng nn i, ung v b c, tiu lng khong 2-3 gi/ln, lng va
(tc thi phn khng cao), bng mm khng chng, khng tiu nhiu
 hn sau khi ung ORS (khng c bt dung np glucoza)--> khng c nghuy
c tht bi b dch ng ung
IX. Chn on s b
Vim phi nng do vi trng suy h hp 1-tiu chy cp khng mt nc
X. Chn on phn bit
1. Vim tiu ph qun bi nhim suy h hp 1-tiu chy cp khng
mt nc
2. Lao phi- Suy h hp 1- Tiu chy cp khng mt nc
XI. ngh CLS
Cng thc mu, X-quang ngc thng, CRP, Ure, Creatinine, Ion , Kh
mu ng mch, Soi cy m-khng sinh , Soi BK dch d dy 2 mu,
Soi cy phn,
XII. Kt qu CLS

1. Cng thc mu
WBC 13,5 4-10 K/uL
%NEUT 48,5 37-80%
%LYM 32,3 10-50%
%MONO 13,0 0-12%
%EOS 0,04 0-7%
%BASO 6,14 0-2,5%
#NEUT 6,53 2-6,9 K/uL
#LYM 4,36 0,6-3,4 K/uL
#MONO 1,76 0-0,9 K/uL
#EOS 0,01 0-0,2 K/uL
#BASO 0,83 0-0,2 K/uL
RBC 4,32 3,9-5,8 M/uL
HGB 12,0 12,5-16 g/dl
HCT 36,9 35-50%
MCV 85,5 83-92 fL
MCH 27,9 27-32 pg
MCHC 32,6 32-35,6 g/dL
PLT 472 130-400 K/uL
MPV 4,39 7,2-11,1 fL
Tr 3 thng 25 ngy tui:
RBC 3,2-4,5 HGB 10-12
--> khng thiu mu
WBC 10-12bch cu tng
%NEU 30-45 %LYM 45-60
-->NEU tng
PLT 150-300
-->tiu cu tng
Ph hp vim phi do vi trng
2. Sinh ho mu
CRP-hs 6 <5mg/dl
SGOT 32 <40UL
SGPT 20 <45UL
Ur 0,25 0,1 0,45 g/l
Cratinin 4,0 2,3 10 mg/l
Lactate 2,29 1,8 2,7 mmol/l
Na+ 133 135 145 mEq/l
K+ 4,4 3,5 5,1 mEq/l
Ca++ 2,6 2,2 2,9 mEq/l
Ca total 4,42 4 4,5 mEq/l
Magnesium 21 25 40 mg/l
 Tng CRP-hs; H Na+ mu
ph hp nhim trng ng h hp- tiu chy cp
3. Xt nghim vi sinh
Cy mu (-)
Nhum Ziehl Nellsen dch d dy 2 ln: khng thy hnh dng trc khun
khng cn, khng acid
Soi cy m: vi trng khng mc
Soi phn: Ht m 4+, cy: vi trng khng mc
4. X-quang ngc thng
Tn thng ph nang lan ta 2 ph trng
5. Kh mu ng mch:
Nhit GDS 38 370C
Hb cha c g/dl
FiO2 21,0 21%
pH 7,34 7,36 7,44
pCO2 30,5 36 44 mmHg
pO2 94,8 80 100 mmHg
BE -8,1 (-4) (+4) mmol/l
tCO2 16,8 mmol/l
HCO3- 15,9 22 26 mmol/l
SatO2 96,6 92 96 %
AaDO2 17,7 mmHg
6. HIV Ag/Ab: Cha pht hin khng th khng HIV
XIII. Chn on xc nh
Vim phi nng do vi trng Suy h hp 1 Tiu chy cp khng mt nc
XIV. iu tr
Nguyn tc iu tr:
- H tr h hp: nm u cao, nh mi bng NaCl 0,9%
- m bo dinh dng cho tr: cho tr tip tc b
- Khng sinh: Raxadin, Vancomycin
- B dch bng ng ung: ORS 1 gi pha 200ml nc, cho b ung
khong 50-60 ml sau mi ln b tiu lng (5,3kg x 10=53 ml)
- B sung km: ZinC 70 mg 1/2v x2(ung)