SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
BNH N
I. THNG TIN BNH NHN
- Bnh nhn: Trn Minh in
- Sinh nm :1984
- Ngh nghip: lm nng
- a ch: An Giang
- Nhp vin: 9h30 ngy 01/10/2012

II. L DO NHP VIN
- To bn

III. BNH S
1 thng trc NV, BN i ng y tr tr chch thuc gia truyn 15 mi/ 1
ngy, mi bi tr 3 mi, v nh bi tr b ra mu bm, chi thy rt ra khi khng
r.
Trong 10 ngy nh, BN c cho ung thuc (khng r loi) th au
qun bng, i cu mi ngy 2 ln, lc u phn c ngn ci sau c ngn t ,
phi ung thuc mi i tiu c. BN ngm nc m v nong n cy nh
sau 3 ngy lin tc BN khng i tiu c bnh nhn nhp bnh vin Long An.
Ti bnh vin Long An, bnh nhn c thm khm hu mn trc trng ,
bc s khng cho lt ngn t qua l hu mn cBN c nong v ct c
vng. Nm vin 1 tun bnh nhn c cho v nh.

13 ngy nh, bnh nhn i cu c phn nh bng ngn t, t khm
thy hu mn rng hn trc khi n BV Long An nhng vn cm thy khng
ht hn nn n BV HYD ngy 01/10/2012.
Trong qu trnh bnh ,bnh nhn khng st, khng nn i.

IV. TIN CN
Bn thn:
- 1 nm trc,BN khi ngi xm hay i cu thy bi tr sa ra ngoi 2-3 cm, sau 5-
10 nm ngh th t tht vo, khng c da tha HM, khng nga HM. BN t ung
thuc tt tr th thy sa bi tr t hn. i cu khng chy mu, c au khng
dch nhy, sinh hot bnh thng.
- 3 thng trc nhp vin, BN ngng thuc tt tr trong 2 thng th thy tr sa
nhiu hn,nh hng cng vic v BN thng ngi xm sa xe
SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
- Lot d dy
- Cha ghi nhn bnh lao, vim gan, bnh l khc v hu mn trc trng.
- Cha ghi nhn chn thng vng hu mn.
- Khng ht thuc, khng ung ru, t n cay.
Gia nh:
- Anh th ba b tr.
V. KHM (01/10/2012)
1. Tng qut
- Bnh nhn tnh tip xc tt
- Sinh hiu: mch: 94 ln/pht; huyt p: 130/80mmHg
Nhp th 20 ln/pht Nhit : 37
0
C
- Cn nng 60kg Cao: 1.65m
- Da nim hng
- Hch ngoi bin khng to
- Khng du mt nc
2. u c
- Khng bin dng
- Tuyn gip khng to
3. Ngc
- Khng bin dng, di ng u theo nhp th, khong gian sun
dn
- Tim:
T
1
, T
2
u, r, khng m thi.
- Phi:
m ph bo 2 bn u, m.
Khng ran.
4. Bng
- Bng cn i ,khng so m c, khng im au khu tr
- S bng mm, n khng im au.
- Gan, lch khng s chm.
- Chm thn 2 bn m tnh.
- Khm hu mn trc trng: Hp st ra hu mn , cn t lt ngn
t, vng hp ngn , hp do vng c sit cng. Nim mc ng hu
mn trn lng
5. T chi
- Vn ng tt
SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
- Khng bin dng khp

VI. TM TT BNH N
Bnh nhn nam 28 tui, nhp vin v to bn bnh 1 thng
Triu chng c nng:
au qun bng
Phn nh dt
Triu chng thc th
Hp st ra hu mn , cn t lt ngn t
Tin cn
Bi tr sa ra ngoi
iu tr ng y chch thuc gia truyn vo bi tr
VII. T VN
1. Hp hu mn
2. Tin cn tr, chch thuc vo bi tr
VIII. BIN LUN V CHN ON LM SNG
Bnh nhn hp hu mn ?
Bnh nhn c triu chng au qun bng + phn nh dt+ khm thy hp st ra
hu mn ch va ngn t bnh nhn c hp hu mn
Hp hu mn cp tnh hay mn tnh
Mn tnh v thi gian din tin 1 thng t t sau vic chch thuc gia truyn vo
bi tr
Nguyn nhn hp hu mn mn tnh
Th pht sau phu thut th thut ng hu mn: ct tr..
Nhim trng: lu ,lao ,amip..
X ha: x tr, lm dng thuc nhun trng
Bnh nhn c tr? rt ngh ti v bnh nhn thy bi tr sa ra ngoi khi ngi xm
tht vo khi ng dy,nh hng sinh hot, bnh nhn c yu t nguy c l hay
khun vc nng
Trn bnh nhn ny ngh nhiu do vic chch vo nhng bi tr lm so trong lp
anoderm, c th cn phn bit vi nguyn nhn nhim trng
Ngoi ra cn phn bit thm nguyn nhn nhim trng v lm dng thuc nhun
trng
Mc hp:
SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
Nng: sau khi nong, thm khm hu mn trc trng ch a va ngn t, trc
khi nong khng a va ngn t
Chn on s b: Hp hu mn sau chch tr( thuc gia truyn ) hp mc
nng /tr III
Chn on phn bit: Hp hu mn do nhim trng , hp mc nng/ tr
III
Hp hu mn do lm dng thuc nhun trng , hp mc
nng/ tr III

IX. NGH CN LM SNG V KT QU
1/Ni soi trc trng
C vng hu mn bnh thng
V tr soi cch b hu mn 20cm
Hu mn : so ng hu mn gy hp ng hu mn
Trc trng nim mc vim trt
i trng chu hng bnh thng
2/Siu m bng
Kt lun: Cha pht hin bt thng trn siu m bng
3/ Xquang : Cha pht hin bt thng trn X quang
4/Cng thc mu (27/09)
WBC 5,58 4-10k/ul
NEU% 65,7 45-75%
NEU# 3,85 4.5-7.5
LYM% 24,4 20-35%
LYM# 1,43 2-3.5k/ul
MONO% 5,2 4-10%
MONO# 0,3 0.4-1k/ul
Eos% 2,2 1-8%
SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
Eos# 0,13 0.1-0.8k/ul
BASO% 0,5 0-2%
BASO# 0,03 0-0.2k/ul
RBC 5,07 3.8-5.5m/ul
HGB 15,1 12-15g/dl
Hct 47,6 35-45%
MCV 93,9 78-100fl
MCH 29,8 26.7-30.7pg
MCHC 31,7 32-35 g/dl
RDW 12-20%
PLT 164 200-400k/ul
MPV 7-12fl
Nh.mu A Rh+
TQ 15,9
TQ chng 14,8
TP
INR
TQ/TQc
TCK 27,8
TCKc 31
TCK/TCKc 0,92
5/Sinh ho mu
Sinh ho 27/09 Ch s bnh
thng
Glucose 90 80-110
SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
Ure 36 20-40
Creatinin 1,03 0.7-1.5
AST(SGOT) 30 <40
ALT(SGPT) 45 <40

6/Min dch (27/09)
Min dch
antiHIV (-)
HbsAg (-)

7/ECG: cha pht hin bt thng
X. CHN ON XC NH
Hp hu mn sau chch tr( thuc gia truyn ) hp mc nng /tr (?)
XI. HNG X TR-THEO DI
-Bnh nhn hp mc nng iu tr phu thut to hnh hu mn
SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3

Operative procedure for the surgical treatment of anal stenosis. A: Martins
anoplasty; B: Y-V advancement flap; C: V-Y advancement flap; D: Diamond-
shaped flap; E: House-shaped flap; F: U-shaped flap; G: Rotational S-flap.
Copyright 2009 The WJG Press and Baishideng. All rights reserved
-Chm sc sau m: ch n giu cht x
Nhun trng mnh thi gian ngn sau m
-Theo di bin chng: Hoi t mnh ghp
Nhim trng khu tr
Bung ch khu do khu cng
Hp tr li
Trc mnh ghp
XII. TIN LNG
Tin lng trung bnh v bnh nhn hp mc nng.


SV Y6: Nguyn L Minh Duy, Nguyn Th Tuyt H, Nguyn Th Anh o, Nguyn Hoi n

Oct. 3
Cu hi
S khc bit gia thm khm lm sng v ni soi trc trng
Li khai bnh nhn tr v KQ soi trc trng
Bnh nhn c lm dng thuc nhun trng x ha lp di nim hp hu mn?