BS: Hunh Phng Lin C DD: ng Th Hi

NHN XT C IM LM SNG
CA RI LON TR NH V CC YU T LIN QUAN
TRONG BNH TM THN PHN LIT
TI BNH VIN TM THN TRUNG NG 2
BS: HUNH PHNG LIN
C D: NG TH HI

BS: Hunh Phng Lin C DD: ng Th Hi

Mc lc
T VN ......................................................................................................................... 4
I. TNG QUAN TI LIU .................................................................................................... 5
1. Khi nim v tr nh: ..................................................................................................... 5
2. Ri lon tr nh .............................................................................................................. 5
2.1: Gim nh: .................................................................................................................. 5
2.2: Tng nh: ................................................................................................................... 5
2.3: Mt nh- qun:........................................................................................................... 5
2.4: Lon nh: ................................................................................................................... 5
3. Din bin lm sng ca bnh tm thn phn lit: .......................................................... 6
4. Tiu chun chn on tm thn phn lit theo ICD 10: ................................................ 6
5. Nguyn tc ch o chn on Tm Thn Phn Lit theo ICD 10:............................... 7
6. Cc nghin cu v ri lon tr nh trn bnh tm thn phn lit: ................................. 7
II. I TNG V PHNG PHP NGHIN CU: ....................................................... 9
1. i tng nghin cu: ................................................................................................... 9
2. i tng loi tr: ......................................................................................................... 9
3. Phng php nghin cu: .............................................................................................. 9
3.1 Thit k nghin cu: ................................................................................................... 9
3.2 C mu nghin cu: .................................................................................................... 9
3.3 K thut chn mu ...................................................................................................... 9
3.4 Cng c nghin cu: ................................................................................................... 9
4. Ni dung nghin cu ................................................................................................... 10
4.1 c im chung ca nhm bnh nhn nghin cu: .................................................. 10
4.2 Nhn xt iu tr ....................................................................................................... 11
5. Thi gian nghin cu:.................................................................................................. 11
6. a im nghin cu: .................................................................................................. 11
7. Phng php x l s liu: .......................................................................................... 11
8. o c nghin cu: ................................................................................................... 11
III. D KIN KT QU NGHIN CU V K HOACH THC HIN ......................... 12

BS: Hunh Phng Lin C DD: ng Th Hi

1. c im chung ca i tng nghin cu ................................................................. 12

2. Ri lon tr nh:........................................................................................................... 15
IV.BN LUN- KT LUN ............................................................................................... 16

BS: Hunh Phng Lin C DD: ng Th Hi

T VN
Tm thn phn lit l mt bnh lon thn nng v ph bin, hin nay cn nguyn cha
r rng, tui khi pht t 16-30 tui v thng dai dng cho n cui cuc i ca ngi
bnh. Cc triu chng lm sng ca bnh a dng v phong ph, lun bin i ty theo
th bnh, giai on tin trin ca bnh chia 2 nhm triu chng:
Nhm triu chng dng tnh: hoang tng, o gic trong ri lon t duy, tri gic
v cm xc.
Nhm triu chng m tnh: th hin s tiu hao, mt mt, mt tnh ton vn, hi
ha ca hot ng tm thn nh tnh thiu ha hp v gim st th nng tm thn:
tnh tnh thay i k d, kh hiu, kh ha nhp, gim tnh nng ng, nhit tnh
trong mi hot ng, cm xc kh lnh.
Km theo ri lon chc nng nhn thc: suy gim tr nh, suy gim tr tu, suy gim
ch . Bnh tm thn phn lit l mt ri lon tm thn ch yu c trng bi nhng bt
thng trong nhn thc biu hin qua thc t, mt s mc ri lon chc nng b nh
c th c mt cc i tng c nguy c b tm thn phn lit. T trc ti nay c
rt nhiu cng trnh nghin cu khoa hc ca cc tc gi trn th gii lm r s ri lon
tr nh trong tm thn phn lit l mt mi lin kt quan trng v n nh. Thm ht b
nh trong tm thn phn lit ln hn ng k so vi trm cm. nc ta vic nghin cu
v vn ny cha c ch nhiu. lm sng t hn na hu ng gp mt phn
ngha quan trng trong vic pht hin sm, tin lng, iu tr c hiu qu, nng cao cht
lng cuc sng ca nhng ngi thuc nhm bnh ny, chng ti tin hnh ti:
Nhn xt c im lm sng ca ri lon tr nh v cc yu t lin quan trong bnh tm
thn phn lit ti Bnh Vin tm thn Trung ng 2 nhm mc tiu sau:
Nghin cu c im lm sng ca ri lon tr nh v cc yu t lin quan trong bnh
tm thn phn lit.

BS: Hunh Phng Lin C DD: ng Th Hi

I. TNG QUAN TI LIU

1. Khi nim v tr nh:
Tr nh l qu trnh tm l phn nh nhng kinh nghim, hiu bit ca con ngi
bng cch ghi nh, gi gn v ti hin chng.
2. Ri lon tr nh
2.1: Gim nh:
Theo quy lut Ribot: nhng s vic mi xy ra kh nh hn nhng s vic c
2.2: Tng nh:
Nh theo kiu lin h my mc.
2.3: Mt nh - qun:
a) Theo s vic:
Qun ton b, qun tng phn.
b) Theo thi gian:

Qun thun chiu - qun v sau

Qun ngc chiu - qun v trc
Qun trong cn
Qun va thun va ngc chiu

c) Theo qu trnh c bn ca tr nh:

Qun do ghi nhn km
Qun do nh li km
d) Theo tin trin:

Qun c nh
Qun thoi trin
Qun tin trin

2.4: Lon nh:

L hi tng sai lm khng tht
a) Nh gi: (tri gic nhm tr nh)
b) Nh ba: (o gic tr nh)

BS: Hunh Phng Lin C DD: ng Th Hi

Nh gi nh ba gp trong lon thn tui gi, tm thn phn lit vi hoang tng
k qui, bnh thc th nng no.
c) Nh ln:

nh v vo mnh
nh vic mnh thnh vic ngi

d) Nh ang sng trong d vng

3. Din bin lm sng ca bnh tm thn phn lit:
C bn giai on: giai on tin bnh, giai on khi pht bnh, giai on ton
pht bnh, giai on khi v di chng.
Trong giai on ton pht bnh cc triu chng khi u nng dn ln v ng
thi xut hin rm r cc triu chng dng tnh nh: o gic hoang tng Ty theo
triu chng no ni bt ln hng u v thi gian ko di trong giai on kch pht ngi
ta chia cc th bnh khc nhau. Theo bng phn loi bnh quc t ln th 10 (ICD 10)
cc th loi ca bnh tm thn phn lit bao gm:

F20.0 TTPL th paranoid.

F20.1 TTPL th thanh xun.
F20.2 TTPL th cng trng lc.
F20.3 TTPL th khng bit nh.
F20.4 TTPL th trm cm sau phn lit.
F20.5 TTPL th di chng.
F20.6 TTPL th n thun.
F20.8 TTPL cc th khc.
F20.9 TTPL khng bit nh.

4. Tiu chun chn on tm thn phn lit theo ICD 10:

4.1. T duy vang thnh ting, t duy b p t hay b nh cp hoc t duy b pht
thanh.
4.2. Cc hoang tng b kim tra, b chi phi hay b ng, c lin quan mt cch r
rng ti nhng vn ng c th hoc tay chn, hoc nhng ngh, hnh vi hay
cm xc c bit, tri gic hoang tng.
4.3. Cc o thanh bnh lun thng xuyn v hnh vi ca bnh nhn hoc tho lun
vi nhau v ngi bnh, hoc cc loi o thanh khc n t mt b phn no
ca c th (o thanh gi).

BS: Hunh Phng Lin C DD: ng Th Hi

4.4. Cc loi hoang tng dai dng khc khng thch hp v mt vn ha v hon ton
khng th c c (nh ang c kh nng iu khin thi tit) hoc ang giao
tip vi nhng ngi xa l t th gii khc.
4.5. Nhng o gic dai dng bt k phng thc no.
4.6. T duy gin on hoc thm t khi ni dn n t duy khng lin quan, ba li
khi ni
4.7. Tc phong cng trng lc nh kch ng, gi nguyn dng hoc un sp, ph
nh, khng ni hoc sng s.
4.8. Nhng triu chng m tnh nh v cm r rt, ngn ng ngho nn, p ng cm
xc cn mn hoc khng thch hp thng a n cch ly x hi hay gim st
hiu sut lao ng x hi ( phi r rng l cc triu chng trn khng do trm cm
hay thuc chng lon thn gy ra)
4.9. Bin i thng xuyn v c ngha v cht lng ton din ca tp tnh c nhn
nh l mt thch th, thiu mc ch, li nht, thi m mi suy ngh v bn
thn v cch ly x hi.
5. Nguyn tc ch o chn on Tm Thn Phn Lit theo ICD 10:
5.1. C t nht mt triu chng r nt (t 5.1 n 5.4), nu khng r phi hai tr ln.
5.2. Cc triu chng phi ko di t nht mt thng. Khng chn on bnh tm thn
phn lit khi c cc triu chng ri lon kh sc (hi chng hoc triu chng) in
hnh, tr khi cc triu chng phn lit xut hin trc.
5.3. Khng chun on bnh tm thn phn lit khi c nhng bnh no r rt, bnh
nhn nghin ma ty, ru, chn thng s no, chm pht trin tm thn hoc ri
lon tm thn do nhim trng, nhim c hoc do bnh c th gy nn.
6. Cc nghin cu v ri lon tr nh trn bnh tm thn phn lit:
Bnh nhn tm thn phn lit chim 1/3 tng s bnh nhn trong cc bnh vin
tm thn cp tnh v 2/5 trong cc bnh vin tm thn mn tnh, t l bnh nhn tm thn
phn lit so vi bnh nhn nm vin chung l 41/10.000 dn. T l tm thn phn lit
mi nc khc nhau nhng theo T chc Y t Th gii t l ny l 0.6-1.5% dn s v
trung bnh l 1%. nc ta, theo kt qu iu tra ca Ngnh tm thn hc Vit Nam
(2002) trn 67380 dn cc vng dn c khc nhau, t l bnh tm thn phn lit l
0.47% dn s. Tm thn phn lit thng din bin mn tnh, hay ti pht sut i. Ch
c 1/3 bnh nhn tm thn phn lit c th sng ha nhp mt phn vi x hi, a s
khng cn kh nng lao ng, lang thang, c cc cn kch ng gy nguy him cho bn
thn v ngi xung quanh. Sau nm n mi nm, ch cn 20% bnh nhn c xem l
c kt qu tt, trn 50% c kt qu xu vi nhiu ln nhp vin do tng nng cc triu

BS: Hunh Phng Lin C DD: ng Th Hi

chng, ni bt l cc hoang tng v o gic, y l th thng gp nht a s cc nc

trn th gii.
Trong vi thp k qua, bng chng tch ly c rng tm thn phn lit c lin
quan vi s suy gim ng k trong chc nng nhn thc. C th thm ht trong s ch
, tr nh v chc nng iu hnh c bo co thng xuyn nhng bnh nhn tm
thn phn lit. B nh c coi l mt trong nhng khu vc chnh ca thm ht nhn
thc trong tm thn phn lit. Mc d nhng ngi tin phong nghin cu tm thn phn
lit, Kraebelin v Bleuler c coi l chc nng b nh tng i c bo tn trong tm
thn phn lit. Nhiu nghin cu c tin hnh trong na cui ca th k ny ch ra
rng nhng bnh nhn tm thn phn lit hot ng km trn mt lot cc nhim v b
nh. Nghin cu cho thy suy gim tr nh trong tm thn phn lit l ph bin v khng
tng xng vi mc tng th v s suy gim tri tu. Mc. Kenna v cc ng nghip
cn gi s tn ti ca mt chng mt tr nh tm thn phn lit. Cc triu chng tiu
cc nh hng tiu cc n hiu nng b nh. Theo cc phn tch gn y ca Heinrichs
v Zakzanis th tm thn phn lit v nhm so snh s khc bit c lp ch mc trn
nhiu bin php b nh, ch , tr thng minh, chc nng iu hanh, ngn ng v hiu
sut ng c ch ra rng tm thn phn lit c c trng bi mt suy gim nhn thc
c s rng ri, vi mc khc nhau ca thm ht trong cc lnh vc kh nng khc
nhau. Cc m hnh v s suy gim c th l du hiu ca ri lon chc nng no c th.
Suy yu trong m ha v hp nht c lin quan n vng i th v thi gian ri lon
chc nng thy trn. Nghin cu hnh nh no cung cp bng chng v bnh l, khi
lng gim trong cc cu trc trong tm thn phn lit. u nhng nm 1990 cc nh
nghin cu cho rng cc vn b nh lm vic l mt triu chng ph hp tm thn
phn lit. tm hiu r hn nhng g ang xy ra trong no c th gy ra nhng vn
ny? Bn cu no phi thng c tuyn dng trong qu trnh s l thng tin khng
gian nhng nu n l h hng, n c th l tm thn phn lit. Bn cu no tri cng c
th c tuyn dng, Park ni: Mt li gii thch c th l bnh nhn tm thn phn lit
gp kh khn hn vi nhng cng vic ny, v kt qu l tuyn m thm cc vng no
h tr h.

BS: Hunh Phng Lin C DD: ng Th Hi

II. I TNG V PHNG PHP NGHIN CU:

1. i tng nghin cu:
Cc bnh nhn c chn on tm thn phn lit ang nm iu tr ti Bnh vin tm
thn trung ng 2 trong thi gian tin hnh nghin cu. Bnh nhn c chn on theo
tiu chun chn on ca bng phn loi quc t ICD_X
2. i tng loi tr:
Cc bnh nhn mc bnh c th.
Cc bnh nhn khng hp tc nghin cu.
3. Phng php nghin cu:
3.1 Thit k nghin cu:
S dng phng php nghin cu: ct ngang m t.
3.2 C mu nghin cu:
Chn mu thun tin khong 40 bnh nhn.
3.3 K thut chn mu
Sng lc cc bnh nhn ang c iu tr ni tr ti Bnh vin Tm Thn Trung
ng 2 vi chn on: tm thn phn lit. Tt c cc i tng nghin cu u
c lm bnh n theo mu bnh n nghin cu
Phng vn trc tip ngi bnh, ngi thn trong gia nh thu thp cc thng
tin v qu trnh pht trin bnh l.
Khm lm sng mt cch ton din v tm thn, thn kinh, ni khoa.
Hi chn vi cc bc s iu tr xc nh chn on, theo di v iu tr.
Ghi chi tit h s bnh n ca bnh nhn trong qu trnh iu tr ti bnh vin
3.4 Cng c nghin cu:
Thang nh gi trng thi tm thn: MMSE.

BS: Hunh Phng Lin C DD: ng Th Hi

4. Ni dung nghin cu
4.1 c im chung ca nhm bnh nhn nghin cu:
Tui: chia 5 nhm tui
Nhm 1: < 20 tui
Nhm 2: t 21- 30 tui
Nhm 3: t 31- 40 tui
Nhm 4: t 41-50 tui
Nhm 5: >50 tui
Gii: chia 2 gii:
Gii nam
Gii n
Trnh hc vn: chia 5 nhm
Nhm 1: khng bit ch
Nhm 2: tiu hc
Nhm 3: trung hc c s, ph thong
Nhm 4: i hc, cao ng
Nhm 5: trn i hc
Tnh trng hn nhn: chia 3 nhm
c thn: ngi cha tng kt hn.
lp gia nh: hin ang sng cng bn i.
ly thn: khng cn tnh trng hn nhn, ga v hoc chng.
Ngh nghip: chia 6 nhm
Nhm 1: nng dn.
Nhm 2: cng nhn, bun bn.
Nhm 3: vin chc
Nhm 4: hc sinh, sinh vin.
Nhm 5: ngh khc.
Tin s gia nh: chia 2 nhm
Nhm 1: gia nh c ngi b bnh tm thn.
o B m
o Anh, ch em rut
o C, d, ch, bc
Nhm 2: gia nh khng c ngi bnh tm thn
Tnh trng kinh t: chia 4 nhm
Nhm 1: ngho ( thu nhp < 2 triu VN ng/ thng)
Nhm 2: trung bnh (thu nhp 2-3 triu VN ng/ thng)

10

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Nhm 3: kh (thu nhp 4-5 triu VN ng/ thng)

Nhm 4: giu (thu nhp > 5 triu VN ng/ thng)
Ni c tr: chia 4 nhm:
Nhm 1: thnh th
Nhm 2: nng thn
Nhm 3: min ni
Nhm 4: khc
Tin s gia nh c ngi mc cc bnh tm thn
4.2 Nhn xt iu tr
_Thi gian nm iu tr:
T khi xut hin triu chng lon thn n lc nhp vin
T khi nhp vin n lc kho st
_ Cc loi thuc an thn khi s dng:
Thuc an thn kinh c in, liu lng, tnh trng p ng iu tr
Thuc an thn kinh th h mi, liu lng, tnh trng p ng iu tr
_ Cc tc dng khng mong mun:
Hi chng ging Parkinson
Hi chng ngm thuc an thn kinh
Hi chng ng c thuc an thn kinh
_ Cc liu php iu tr tm l (nu c)
5. Thi gian nghin cu:
T thng 5/2014 n thng 10/2014.
6. a im nghin cu:
Nghin cu c thc hin ti cc khoa lm sng Bnh vin tm thn TW 2.
7. Phng php x l s liu:
Mi bnh nhn s c thu nhp cc d liu theo mu bnh n v thang im MMSE, x
l s liu theo phng php thng k y hc bng phn mm thng k SPSS 16.0
8. o c nghin cu:
Tn trng b mt ring t ca bnh nhn, khng gy tn hi n th xc, tinh thn ca
bnh nhn. Bnh ng cc bnh nhn.

11

BS: Hunh Phng Lin C DD: ng Th Hi

III. D KIN KT QU NGHIN CU V K HOACH

THC HIN
1. c im chung ca i tng nghin cu
Bng 3.1 Phn b tui khi pht bnh
Ch s thng k

T l (%)

T l (%)

T l (%)

La tui
< 20 tui
21- 30 tui
31-40 tui
41-50 tui
>50 tui
Cng
Bng 3.2 Phn b gii ca bnh nhn
Ch s thng k
Gii tnh
Nam
N
Cng
Bng 3.3 c im hc vn
Ch s thng k
Hc vn
Khng bit ch

12

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Tiu hc
Trung hc c s, ph thng
i hc, cao ng
Trn i hc
Cng

Bng 3.4 c im tnh trng hn nhn ca nhm bnh nhn

Ch s thng k
Tnh trng hn nhn

T l (%)

Cha kt hn
C gia nh
Ly thn, ly hn, ga
Cng

Bng 3.5 c im ngh nghip ca nhm bnh nhn nghin cu

N

T l (%)

T l (%)

Ch s thng k
Ngh nghip
Nng dn
Cng nhn
Vin chc
Hc sinh, sinh vin
Ngh khc
Cng
Bng 3.6 c im tnh trng nhp vin
Ch s thng k
Tnh trng nhp vin
Ln u
Ln hai

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Ln 3 tr ln
Bng 3.7 c im thi gian nm vin
Ch s thng k
Thi gian nm vin

T l (%)

T l (%)

T l (%)

1-7 ngy
8-15 ngy
16-30 ngy
>30 ngy

Bng 3.8 c im tnh trng kinh t

Ch s thng k
Tnh trng kinh t
Ngho
Trung bnh
Kh
Giu
Bng 3.9 c im ni c tr
Ch s thng k
Ni c tr
Thnh th
Nng thn
Min ni
Khc

Bng 3.10 Tin s gia nh c ngi mc bnh tm thn

Ch s thng k
Tnh trng gia nh

14

T l (%)

BS: Hunh Phng Lin C DD: ng Th Hi

Cha, m
Anh, ch, em rut
C, d, ch, bc
Cng

2. Ri lon tr nh:
Bng 3.11 Ri lon tr nh nhm nghin cu
Bnh nhn
Ri lon tr nh

T l (%)

Gim nh
Tng nh
Mt nh- qun
Lon nh
Cng
Bng 3.12 nh gi trng thi tm thn nhm bnh nhn nghin cu
Nhm bnh nhn
Trng thi tm thn
nh hng
Kh nng ghi nhn
S ch v tnh ton
Kh nng hi c li
Ngn ng
Kh nng tng tng v tru tng
Cng

15

T l (% )

BS: Hunh Phng Lin C DD: ng Th Hi

IV.BN LUN- KT LUN

16

BS: Hunh Phng Lin C DD: ng Th Hi

MU BNH N NGHIN CU
I PHN HNH CHNH
1.1 H v Tn: ........................................................... Tui: .............. Gii ...................
1.2 a ch: .............................................................. Trnh hc vn: .......................
1.3 Ngh nghip: .................................. Dn tc: .............. Tn gio: ...........................
1.4 Tnh trng hn nhn:

Cha lp gia nh
lp gia nh
Hin ang ly thn
ly hn

1.5 S ln vo vin: ............................. Ngy vo vin: .............................................

1.6 Ngy ra vin: ................................. S ngy nm vin: .......................................
1.7 Ngi cung cp bnh s: ....................................................................................
Quan h vi bnh nhn:......................................................................................
II L DO VO VIN
III TIN S:
3.1 Gia nh:
3.1.1 Tm thn: Trong gia nh (dng h 3 i) c ngi bnh tm thn khng?
C

Khng

17

BS: Hunh Phng Lin C DD: ng Th Hi

Quan h vi bnh nhn:

Chn on: Ri lon tm thn

Ri lon cm xc

3.2 Tin s bn thn:

3.2.1 Lc nh
3.2.2 Chn thng s no
3.2.3 Nghin cht
IV. BNH S:

..
V. KHM LM SNG
1. Khm ton trng
Th trng: Gy
Cn nng: Kg
Mch:

Trung bnh

Bo

Chiu cao: cm
Nhit :

Huyt p: mmHg

Tnh trng da, nim mc: ..........................................................

2. Khm tm thn:
2.1 thc:
2.1.1 Ri lon nng lc nh hng:
Thi gian

Khng gian

Xung quanh

2.1.2 Cc hi chng ri lon thc:

2.2 Cm gic tri gic

18

Bn thn

BS: Hunh Phng Lin C DD: ng Th Hi

Cc ri lon tri gic:

o tng

o gic

Lon cm gic bn th

Ni nhiu

Nhp chm

2.3 T duy:
Hnh thc t duy:

Nhp nhanh

Ni dung t duy:

Hoang tng ghen tung

Hoang tng b truy hi
Hoang tng b chi phi
Hoang tng lin h
Hoang tng pht minh
Hoang tng t cao
Hoang tng khc

2.4 Cm xc
2.4.1 Cc triu chng ca trm cm

Kh sc gim
Dao ng
Tng
Mt quan tm thch th
Gim nng lng v tng mt mi
Mt lng tin hoc s t trng
Cm gic ti li, khng xng ng, t trch bn thn
C ngh ti ci cht hoc nh t st
Phn nn v gim kh nng suy ngh, thiu quyt on
Kch ng hoc chm chp
Ri lon gic ng
Gim cm gic ngon ming

2.4.2 Cc triu chng khc:

2.5 Hnh vi: ........................................................................................................................
2.6 Tr nh:
Tc th: ....................................................................................................................
Gn: ..........................................................................................................................
Xa: ............................................................................................................................

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2.7 Tr tu: ..........................................................................................................................

2.8 Ch : ...........................................................................................................................

3. Khm ni khoa- thn kinh

3.1 Khm ni:
3.1.1 Tng trng: .................................................................................................................
3.1.2 Tim mch: ...................................................................................................................
3.1.3 H hp: .......................................................................................................................
3.1.4 Tiu ha: .....................................................................................................................
3.1.5 Dinh dng: ................................................................................................................
3.2 Khm thn kinh:

Run:
Co git:
Hi chng no - mng no:
Lit b thp:

C
C
C
C

Khng
Khng
Khng
Khng

3.3 Cc c quan khc:

VI. CN LM SNG:
VII. CHN ON:
VIII. IU TR:
1.Thi gian nm vin:
2.Cc loi thuc chng lon thn s dng:
1 loi:

2 loi:

3 loi tr ln

3. Cc tc dng ph ca thuc chng lon thn:

C

Khng

Hi chng ngm thuc chng lon thn: C

Khng

Hi chng ging Parkinson:

20

BS: Hunh Phng Lin C DD: ng Th Hi

Ri lon vn ng mun:

Khng

Hi chng c tnh:

Khng

kin xc nhn cu ngi ph trch c s:

Ngy Thng Nm

21