BNH N NI TIU HA

I.

Hnh chnh

H-tn: PHM M PHN

Nam

65 tui

Ngh nghip: th mc ngh hu hn 10 nm

a ch:
Nhp vin lc 8h30 ngy 08/12/2014
Phng 314, khoa ni B- BV Nhn Dn Gia nh
II.
III.

L do nhp vin: chng mt

Bnh s:

Cch nhp vin 3 ngy bnh nhn cm thy chng bng, nng rt vng thng v,
khng lan, khng yu t tng gim, khng st, khng bn nn khng nn, km
theo do bn i tiu phn en, st, mi tanh nng, 3 ln/ ngy, mi ln i khong 1
chn, i xong khng chng mt nhc u.tiu nc tiu vng trong, lng nc
tiu khng gim so vi bnh thng.
Cch nhp vin 1 ngy, bn cn nng rt thng v, chng bng, cn tiu phn
en vi tnh cht tng t, ti bn ang nm ngh th cm thy say xm, chng mt
bn nm ngh tai ging th ht.
Cng ngy nhp vin bn ng dy thy mt mi, say xm, chng mt nhiu hn bn
c o HA ghi nhn 80/50 nhp cp cu bv NDGD
Tnh trng lc nhp vin:
Bnh nhn tnh, tip xc tt.
Nim hng nht
Sinh hiu: mch 102 ln/pht
T0: 36.5

HA 110/70mmHg
th: 20 ln /pht

Tim u, phi khng ran, bng mm, khng im au.

X tr: Natriclorua 9%o LX git/pht
Din tin sau nhp vin:
N1: 22h 8/12 bn c truyn 1 v HCL 350ml.
N1-2: bnh nhn cha i tiu, ht nng rt thng v, bt chng bng(2/10)
Tiu bnh thng.ht chng mt.khng bun nn, khng nn.
IV. Tin cn:
1. Gia nh: cha ghi nhn tin cn bnh l THA, T, ung thu, vim gan siu
vi, vim d dy do HP
2. Bn thn:
a) Ngoi khoa: M ct lch cch y hn 20 nm do tai nn giao thng.
b) Ni khoa:
Tng huyt p, khng r thi gian chn on( # 10 nm), HATT cao nht ghi nhn
190mmHg, HA d chu 130/80mmHg.khm v iu tr ti bv NDGD. Ung thuc
u, y
1 nm nay HA bn ( t o ti nh) khng n nh 130/80-160mmHg
Bnh nhn thng xuyn au chn khi i li khong

pht, gim khi ngh.

Nhn xa m c 2 mt, tng dn.

i khi bn chng mt thong qua ri t ht, khng ngt.
Tiu m nhiu 4-5 ln/ m.
au tht ngc-Thiu mu c tim cch y 4 nm.thnh thong bn c nng ngc
tri, nhng khng iu tr g ch ung thuc hin ti
Cc thuc ang iu tr:
Amlodipine 5mg 1 vin sng
Concor 5mg vin x2

Nitromint 1 vin x 2
Khng r cn iu tr clopinogel hay khng. ngng aspirin hn 1 nm
..
Cha ghi nhn tin cn vim gan, vim d dy tr trng, chua hi, au vng
thng v.
Cha ghi nhn tin cn vng da vng mt trc y hay au h sn phi.
Khng nghi nhn n thc n c mu hay n thc lm t mu ng vt, hay ung
thuc nh st, bismuth, hay thuc gim au khc.
Thi quen: bn ht thuc l 1,5 gi / ngy( 45 gi nm), 4 nm nay gim con 0.5
gi/ ngy.
Ung bia, ru khng thng xuyn 1-2 ln / thng, mi ln # 5 lon bia.
V.

Lc qua cc c quan:

Tim mch: bn khng au ngc, khng hi hp.

H hp: bn khng kh th.khng ho
Tiu ha: bn cha i tiu, khng au bng, khng nn i.
Tit niu: bn tiu khng gt but, khng tiu lt nht, nc tiu vng trong.
C xng khp: khng yu lit, khng gii hn vn ng.
Thn kinh: bn ht chng mt. khng nhc u.
VI. Khm( 8h ngy 9/12/2014)
1. Tng qut:
Bnh nhn tnh, tip xc tt.
ang c truyn Nexium 40mg 2 l+ Nacl 9%o BT 5ml/h
Th trng trung bnh, BMI= ( 50/
Sinh hiu:

)=

mch: 84 ln /pht, u, r

kg/m2

HA: 110/60 mmHg

Th: 16 ln/ pht
To: 37oC
Da nim hng nht.
Khng ph,khng vng, khng xut huyt di da.
Tuyn gip khng to.
Hch ngoi bin khng s chm.
2. Khm ngc: cn i, di ng theo nhp th, khng u, so, khng tun hon
bang h, khng sao mch.
Tim: T1,T2 u r, tn s: 84 ln/pht, khng m thi.
Phi: trong khng ran, r ro ph nang m du, rung thanh u 2 ph trng.
3. Khm bng: cn i, rn phng, so dc ng gia 25cm, lnh tt. khng
tun hon bang h.
Nhu ng rut 2 ln/pht, m sc khng tng.
Bng mm, khng im au. Gan, lch, thn khng s chm
B trn gan khoang lin sn VI ng trung n P, b di khng s chm
chiu cao gan P 7cm
4. Thm trc trng: nim mc trn lng, khng u, tuyn tin lit khng to.
Phn en theo gng.
5. Thn kinh: bnh nhn tnh, tip xc tt. khng du tk nh v, khng du
mng no.
6. C xng khp: t chi khng yu lit, khng gii hn vn ng.
VII. Tm tt bnh n:\
Bnh nhn nam, 65 tui nhp vin v chng mt:
TCCN: tiu phn en, nng rt vng thng v.

Chng mt, say xm.

TCTT: sinh hiu: mch 102 ln/ pht.HA 110/70mmHg
Da nim hng nht
Khng vng da, khng sao mch, tun hon bang h.
Thm trc trng: khng u, phn en theo gng.
Tin cn: THA, Thiu mu c tim.
t vn :
1. Xut huyt tiu ha .
2. Nng rt vng thng v.
3. Tin cn:THA, TMCT
IX. Chn on s b:

VIII.

Xut huyt tiu ha trn mc trung bnh do lot d dy-t trng , n/ tng
huyt p, TMCT.
Chn on phn bit
Xut huyt tiu ha trn mc trung bnh do ung th d dy , n/ tng huyt
p, TMCT.
Xut huyt tiu ha di mc trung bnh do k i trng, n/ tng huyt p,
TMCT.

X.

Bin lun:
1. xut huyt tiu ha:

Bnh nhn c i tiu phn en, st, mui tanh nng, 3 ln/ ngy, km theo nng rt
thng v, khng nn i bn xut huyt tiu ha, m ngh nhiu l ng tiu ha
trn do bn ch tiu phn en khng c tiu mu , thm trc trng ghi nhn phn
en, khng thy tn thng, tuy nhin ta vn khng loi tr c xut huyt tiu
ha di do chy mu ca on i trng ln hay on cui hi trng gy tiu phn
en.

Mc : bnh nhn tiu phn en 4 ngy, 3 ln / ngy, bn co chng mt, say xm

Mch nhanh, HA 110/70 gim so vi Ha bnh thng ca bn, da nim hng
nhtmc trung bnh ngh CTM.
ROCKALL lm sng 4 im
Bn khng ghi nhn s dng thuc gim au NSAID, aspirin, corticoidung ru
trc hay nn i nhiu trc nn nguyn nhn xut huyt tiu ha trn c th
gp trn bn ny l:
- Lot d dy t trng: ngh nhiu: do bn c nng rt vng thng v, km
theo vi tiu phn en, tuy tin cn khng ghi nhn bl d dy t trng, khng
chua, hi nhng khng loi tr c o lot d dy t trng co th c
tnh trng lot cm khng triu chng.--> ngh ni soi thc qun-d dyt trng.
- K d dy: t ngh do bn khng c chn n st cn, th trng trung bnh,
khng c hi chng cn ung, tuy nhin khng loi tr c do bn ln tui v
k d dy c dng lot.
Tuy nhin bnh nhn ln tui ta khng th loi tr bl c tnh ng rut nht la
ai trng cng c th gy tiu phn en nn khng loi tr c k i trng phi.
nhng ta thng gp l tiu mu n trong phn nn t ngh.--> chp i trng cn
quang.
2. Tng huyt p:
Bn c chn on THA cch y 10 nm, HA cao nht ghi nhn 190mmHg, hin
ti bn ang iu tr nhng c ghi nhn HA khng n nh v bn c cc triu chng
nhn m, au cch hi 2 cng chn, tng c nhng ln chng mt thong qua,
tiu m. Tng nhp vin v au tht ngc-TMCTCB
Bn c cc bin chng ca THA
ngh: soi y mt, creatinin, urea, siu m Doppler TM chi di, ECG,
siu m tim.
XI. ngh cn lm sng:
- Cng thc mu, ni soi thc qun- d dy- t trng.chp i trng cn
quang. creatinin, urea, ECG, siu m tim, soi y mt.

ng huyt, AST, ALT, ion , ECG, TPTNT.

Kt qu cn lm sng:
Cng thc mu
ngy

9h00
8/12

RBC (T/L)

2.76

16h10
8/12
ni soi cm
mu
2.43

HgB( g/L)

8.6

7.5

HCT (L/L)

0.26

0.226

MCV(fl )

94.4

92.9

MCH( pg)

31.1

31

MCHC( g/l)

329

330

WBC(G/L )

7.94

12.5

NEU (%)

67.9

82.1

LYM (%)

24.1

12.8

MONO(% )

4.6

3.4

EOS(%)

0.4

1.1

BASO(%)

0.5

0.1

PLT(G/L)

266

256

SAU TRUYN
MU

Bn c thiu mu mc trung bnh, ph hp vi lm sng. Nhng sau ni soi cm

mu tnh trng thiu mu bn din tin xu hntheo di chy mu ti pht.
Ni soi TQ-DD-TT:
Thc qun: nim mc trn lng.
Tm v: cch cung rng 38cm, co bp u.
D dy: nim mc trn lng.
Mn v: trn, ng m u.
Hnh t trng: c 1 lot KT # 1,2cm, ang rn mu .

T trng D2-D3: nim mc trn lng.

KL: XHTH do lot hnh t trng( Forrest IB)
XT: chch cm mu bng Adrenaline pha long 1/10000
Xut huyt tiu ha do lot t trng
Rockall 6 im nguy c chy mu ti pht cao.
Nhm mu: O+
Chc nng ng mu: ( trong gii hn bnh thng)
PT

102%

INR

APTT

25s

UREA

106.8 mg/dl

Creatinin

1.03 mg/dl

ph hp vi xut huyt tiu ha

khng ngh c bc thn do THA

Bilan lipid:
Cholesterol

2.88 mmol/l

Triglycerid

3.23 mmol/l

HDL

0.61mmol/l

LDL

1.79 mmol/l

Ion :

Na

136.1 mmol/l

4.11mmol/l

Cl

104.4mmol/l

AST

16.7 U/L

ALT

17.1 U/L

XII.

ri lon lipid mu tng LDL

trong gii hn bnh thng

trong gii hn bnh thng.

Chn on xc nh:

Xut huyt tiu ha trn mc trung bnh do lot t trng, n/THA, TMCTCB

XIII.

iu tr:
Hng iu tr: 1/ hi sc ni khoa( lp ng truyn, b dch ng trng:
2/ ni soi TQ-DD-TT:chn on v iu tr( cm mu) khi
huyt ng hc n nh
3/ c ch tit acid( PPI liu cao truyn lin tc do bn xut
huyt mc TB, Rockall 6 im nguy c chy mu ti cao)
4/ d tr mu
Y lnh:
1/ nexium 40mg/10ml

2 l (TTM)

Sau Nexium 40mg/10ml

2l

Nacl 9%o pha 50ml

Bm tim in

5ml/h (tng ng 8mg/h)

2/ ni soi TQ-DD-TT
Theo di nc tiu, phn
Mch. HA mi 4h