BNH N H HP

Sinh vin: Trn Quc Ti Y2011E26

! Hnh ch"nh:
_ Nguyn Th Chm N, 56 tui (1958)
_ a ch: G Cng Tin Giang
_ Ngh nghip: Ni tro
NV: 14h30 ngy 3/5/2014
! #$N%: Ho ra mu
! B&nh '(:
_ Cch NV 4 ngy, BN cm thy nga hong, sau d ho khac ra t mu cuc d thm 0,5-
1cm
3
, khng bot, khng ln dm, 2-3 ln/ngy, dt ngt khi BN dang nm ngh; tu mua
thuc cm mu (khng r loai) ung 1v x 2 ln/ngy. Tnh trang ho ra mu 2 ngy tip
theo tuong tu, BN ung Transamin 2v x 2 ln/ngy nhung khng d.
_ Cch NV 7 gi (sng 3/5), BN cm thy nga hong v ho khac ra #30ml mu d tuoi,
ton bi -> NV Cho Ry
_ Trong qu trnh bnh: BN c dau nguc m lin tuc vng be sun (P), tng dau khi
vn dng, ht su, sau truot chn dp thnh nguc vo b ro xi mng cch NV 20
ngy. Lc chn thuong, BN dau nguc d di, khng lan, tng dau khi ht su, ho, BN tu
ung thuc Panadol + Ampcillin v qua ngy hm sau, dau nguc gim xung cn m .
Cch NV 10 ngy, BN thy tng dau nguc, khm bc s tu ch duoc ch dnh thuc cao
huyt p.
Ngoi ra, bnh nhn cm thy mt, khng kh th, khng ho khan, khng ho dm ko
di, khng st, khng v m hi, khng sut cn
Din tin bnh phng: Bnh nhn d ho ra mu, ht dau nguc.
%! Ti)n c*n:
1+ B,n -h.n:
_ Ni khoa:
Cch 15 nm: vim dy TK V d diu tr khi, CHA diu tr thuc khng du dn, huyt
p tm thu cao nht 140-150 mmHg.
Cch 7 nm: siu m pht hin lot hang v, d diu tr khi.
Cch 2 nm: BN c ho ra mu d tuoi, ton bi, #15ml, diu tr 4 ngy tai BV Pham
Ngoc Thach khng c chun don, BK dm m tnh
Cch 1 nm: pht hin xo va + dn dng mach ch bung, dang diu tr mi ngy
Bisoprolole 2.5mg 1/2v, Troxerutin 300mg 1vx2, Atorvastatin 1vx2, Etodolac 1vx2,
Esomeprazole 1vx2, Clopistad 75mg 1v.
1
Khng ghi nhn tin cn lao, hen, bnh l dng cm mu v cc bnh l ni khoa khc
_ Ngoai khoa: Cch 18 nm, ct amidan
_ Sn khoa: PARA=4.0.0.4, mn kinh nm 46 tui, khng s dung thuc nga thai.
_ D ng: Khng tin cn d ng
_ Thi quen: Khng ht thuc, khng ung ruou bia.
2+ /i0 12nh:
Khng ghi nhn cc bnh l tng huyt p, di tho dung v cc bnh l ni khoa
khc.
%! #34c 5u0 c6c c7 5u0n:
_ Ho ra mu d tuoi #30ml, ton bi
_ au nguc m vng be sun (P), tng dau khi vn dng
%! 8h69 :.9 'n;: lc 19h 5/5/2014
1+ Sinh hi&u:
Mach = 80 ln/pht, Huyt p = 140/70 mmHg, Nhp th = 16 ln/pht, t
O
= 37
O
C
2+ Th< -r=n;:
Bnh nhn m, cao 1,52m, nng 45kg (BM=19,5 kg/m
2
)
>+ Tri&u ch?n; -@n; 5u6-:
_ Bnh nhn tnh, tip xc tt.
_ Da nim hng ho, khng c xut huyt dui da.
_ Hach ngoai bin khng to, khng du vim tc tnh mach nng, su.
_ Khng ph ton thn, khng c ngn tay di trng, khng du dn mach.
A+ 8h69 -Bn; vCn;:
0+ Du 9E- c@:
_ Mi khng kh, lui khng do, hong sach.
_ Kh qun khng lch, tuyt gip khng to.
_ Tnh mach c khng ni tu th 45
O
. Khng m thi vng dng mach cnh.
F+ N;Gc:
_ Lng nguc cn di, di dng theo nhp th, khng c du gy xuong, bm da.
_ Tim: Mm tim khong lin sun 5 dung trung dn tri, din dp 1x1cm, ny nhe.
Khng c du Hardzer, khng c du ny truc nguc, khng c dp bt thung. Nhp
tim du, 80 ln/pht, T1, T2 r, khng m thi.
_ Phi: Nhp th du. Rung thanh du, g trong, m ph bo r 2 ph trung, khng
ran.
c+ BHn;:
_ Bung mm, cn di, di dng theo nhp th.
_ Nhu dng rut 6 ln/pht, khng m thi dng mach, g trong, n khng dau.
_ Gan khng to, b trn khong lin sun 6, b dui mp ha sun phi, cao 8cm
dung trung dn phi.
_ Lch khng s cham.
2
_ Khng c du cham thn, bp bnh thn, rung thn.
I+ Thn Jinh:
_ Khng c du thn kinh dnh v.
K+ L7 M37n; JhNO:
_ Khng gii han vn dng
_ Khng yu lit co.
%! TP9 -Q- F&nh 6n:
Bnh nhn n, 58 tui, nhp vin ngy 3/5/2014 v ho ra mu, bnh 4 ngy.
Triu chng co nng: Ho khac #30ml mu d tuoi, ton bi, truc d c ho khac mu
cuc d thm 0,5-1cm
3
, ton bi, 2-3 ln/ngy, 3 ngy.
au nguc m vng be sun (P)
Triu chng thuc th: Huyt p = 140/70 mmHg
Th trang m, BM=19,5 kg/m
2
Mm tim khng lch, tim du, T1, T2 r, khng m thi
Phi trong, khng ran.
Bung mm, cn di, di dng theo nhp th, n khng dau.
Tin cn: Ho ra mu d tuoi #15 ml, ton bi, cch 2 nm, diu tr khi.
Cao huyt p 15 nm
Xo va + Dn dng mach ch bung 1 nm
Khng tin cn lao, hen
Mn kinh nm 46 tui, khng s dung thuc nga thai.
Khng ht thuc, ung ruou bia.
%! DE- vRn 1):
_ Ho ra mu
_ Tng huyt p tm thu don dc, bin chng xo va + dn dng mach ch bung
S! LhTn 1U6n:
1+ LhTn 1U6n '7 FV:
Ho ra mu t ngh do dn ph qun / Tng huyt p bin chng xo va + dn dng
mach ch bung
2+ LhTn 1U6n Oh.n Fi&-:
Ho ra mu do lao phi / Tng huyt p bin chng xo va + dn dng mach ch bung
Ho ra mu do vim ph qun / Tng huyt p bin chng xo va + dn dng mach ch
bung
Ho ra mu do u phi / Tng huyt p bin chng xo va + dn dng mach ch bung
3
S! Bi&n :uWn:
1+ HU r0 96u: Ho ra mu c th do cc nguyn nhn thung gp sau:
_ Phi:
+ Dn ph qun: ngh nhiu v bnh nhn c ho ra mu, mt mi, cch 2 nm c ho
mu #15ml, bnh nhn khng c ho dm m, mi hi man phi khng ran, khng st,
khng sut cn.
+ Vim ph qun: t ngh do bnh nhn khng c ho dm truc t nht 3 thng truc
d, khng kh th, phi khng ran, khng st.
+ Lao phi: t ngh do bnh nhn khng c ho ko di, st, sut cn, v m hi, nhung
bnh nhn trn 40 tui xc sut ho ra mu do lao cao nn khng th loai.
+ Thuyn tc phi c nhi mu phi: khng ngh do khng c dau nguc kiu mng phi,
nhp tim khng nhanh, nhp th khng nhanh, khng st, v m hi, ph chn, khng
gim m th, khng c ting co mng phi.
_ Nhim trng:
+ Vim phi: t ngh do khng c khng c hi chng dp ng vim ton thn, hi
chng dng dc, phi khng ran, khng gim m th, khng ting thi bt thung
+ K sinh trng: khng ngh do khng c hi chng Loeffler (st, ho dm, hen suyn)
_ Khi u: t ngh do u v bnh nhn ch c ho ra mu, khng c ho, chn n, sut cn,
st, khm lm sng khng pht hin gim ph m, tuy nhin bnh nhn 58 tui cng
khng th b qua.
_ Linh tinh:
+Tim mach mu:
- Hep 2 l: khng ngh do khng c m thi, khng c du hiu ln tht phi.
- Phnh dng mach ch: khng ngh do khng c ho mu luong nhiu, khng
dau nguc lan ra sau lung.
- D dang dng-tnh mach: khng ngh do khng c du dn mach nim mac
+ Huyt hoc: khng ngh do khng c tin cn bnh l huyt hoc, khng c du xut
huyt dui da, khng du vim tc tnh mach nng, su.
+ Chn thuong:
- Chn thuong lng nguc kn: t ngh do tn thuong nguc cch 20 ngy, triu
chng dau khng r rng, khng c du gy xuong, bm da nhung khng th
loai.
+ Thy thuc: khng ngh do khng tin hnh cc th thut lin quan ti phi nhu soi
ph qun, sinh thi phi, choc ht xuyn ph qun truc d.
+ Thuc: Khng ngh do bnh nhn khng s dung cc thuc aspirin, penicillamine,
thuc khng dng.
S! LWn :.9 'n;:
1+ LWn :.9 'n; -h3Xn; 5uY:
_ Cng thc mu
_ Phn tch nuc tiu
4
_ K sinh trng dung rut
_ ung huyt
_ re huyt
_ Xquang phi
2+ LWn :.9 'n; chTn 1U6n:
_ CT nguc
_ Siu m bung
5