Bnh n Lit Mt

I. PHN HNH CHNH:

- H v tn bnh nhn: Nguyn Th Gio , 33 tui_ N.
- a ch : Ha Dun _Ph Thun_Ph Vang_Tha Thin Hu.
- a ch ngi nh cn bo tin: chng, L Anh Dng cng a ch- T:3867938.
- Ngh nghip : ni tr
- Ngy vo vin : 12/12/2008.
- Ngy lm bnh n : 25/12/2008.
- L do vo vin : Mo ming, mt nhm khng kn.
II. BNH S:
1. Qu trnh bnh l:
Bnh khi pht cch ngy n khm 5 ngy, sau khi thc dy bui sng th cm gic
ming kh chu, soi gng th thy ming mo, mt nhm khng kn,ung nc tro ra
mt bn. C i khm Ty y (khng r s dng loi thuc g). Bc s khuyn i chm cu
nn xin vo iu tr ti bnh vin Y hc C truyn Tnh.
Qua 09 ngy iu tr ti bnh phng TT-CC n bng chm cu, bnh c xu hng p
ng vi iu tr nhng mt vn cn cha nhm kn nn tip tc iu tr theo liu trnh.
2. Tin s:
- Bn thn: Sng khe, khng c t ng chng thng vng u mt .khng c chy m
tai.
- Gia nh : Sng khe.
- Vt cht tm .
- Tinh thn thoi mi, an tm iu tr.
III. THM KHM HIN TI:
A. Khm Y Hc Hin i:
1. Ton thn:
- Tng trng kh, cn nng :, chiu cao:,
- Da nin mc hng.
- Khng ph, khng c du xut huyt di da.
- Tuyn gip khng ln, lng, tc, mng pht trin bnh thng.
- Hch ngoi bin khng s thy.
- Mch : 76/1 pht.
- Nhit : 370C.
- Huyt p : 130/90 mmHg.
2. Cc c quan:
a. Thn kinh:
- Bnh nhn tnh to, tip xc tt.
- khng au u ,chng mt,ng c.
- Nhn trung lch sang tri.
- Ming mo sang tri.
- Mt phi nhm khng kn=1.5cm ,du hiu Charles Bell phi (+).

b. Tun hon:
- Khng au ngc, khng hi hp.
- cha pht hin m bnh l.
c. H hp:
- Khng ho, khng kh th.
- Lng ngc cn i, khng co ko cc khong giang sn.
- Nhp th:18 l/pht
d. Tiu ha:
- n kh, khng nn.
- Khng au vng thng v, khng hi chua.
- i tiu phn hi lng.
- Bng mn, di ng theo nhp th
- Khng c vt m.
e. Thn, tit niu, sinh dc:
- Khng tiu but, tiu rt.
- Nc tiu trong, di.
- Du chm thn (-)
- Bp bnh thn (-)
g. C xng khp:
- Khng teo c cng khp
- i li bnh thng, khng gii hn vn ng.
h. Tai- mi- hng:
Cha pht hin du hiu bnh l
i. Rng- hm- mt:
Cha pht hin du hiu bnh l
3. Cn lm sng:
- Cng thc mu: RBC: 3.65 106/ mm3
WBC: 5.7 103/ mm3
4. Tm tt bin lun chun on:
Bnh nhn n , 33 tui vo vin vi l do ming mo, mt nhm khng kn, n ung kh
khn.
Qua thm khm lm sng kt hp vi cn lm sng nn em rt ra c cc du chng v
hi chng sau:
- Hi chng thn kinh:
+ Nhn trung lch sang tri.
+ Mnh mo sang tri.
+ Mt phi nhm khng kn= 1.5 cm
+ Du hiu Charles Bell phi (+)
- Chun on s b: Lit dy VII ngoi bin phi.
- Chun on phn bit: Lit dy VII trung ng.
+ Khng c np nhn trn.
+ Charels Bell (+).
+ Khng c km lit na ngi i din.

- Chun on xc nh: Lit dy VII ngoi bin phi.

5. iu tr:
- Vitamin 3B x 2vin chia 2 ln sng, chiu.
6. Tin lng v phng bnh:
* Tin lng:
- Tin lng gn: Kh quan.
- Tin lng xa: Nu gp lnh d ti pht nn phi phng.
* Phng bnh:
- Trnh n ung sng, lnh.
- Ra mt bng nc m.
- eo khu tranh.
- Trnh gi la.
- Xoa bp vng mt b lit.
B. Khm theo Y hc C truyn:
1. Vng chn:
- Tnh to, tip xc tt.
- Da hng
- Ru li trng
- Ngi cn i,c ng nhanh nhn.
- Ming mo sang tri, nhn trung lch sang tri.
- Mt phi nhm khng kn.
2. Vn chn:
- Ting ni r rng, khng ho.
- Khng hi, chua, khng nc cc.
- Hi th khng hi.
3. Vn chn:
- Bnh khi pht cch ngy n khm 5 ngy, sau khi i tp th dc bui ti v th cm
gic ming kh chu, soi gng th thy ming mo, mt nhm khng kn, n ung kh
khn.
- Bnh c cm gic s lnh, thch ung nc m, thch n nng.
- Khng au u chng mt.
- i tin phn hi lng, tiu tin trong, di.
- Kinh nguyt bnh thng.
4. Thit chn:
* Phc chn:
- Bng mm, di ng theo nhp th.
* Mch chn:
- Mch ph khn.
5. Tm tt bin lun chun on:
* Tm tt:
Bnh nhn n 33 tui vo vin vi l do ming mo, mt nhm khng kn, n ung kh
khn.
- Du chng do phong: Gy bnh phn trn c th.

- Du chng do hn: S lnh, riu li trng, thch ung nc m, nc tiu trong, thch
xoa bp.
- Chng biu:ru li trng,mch ph khn.
- Chng thc:bnh mi mc,thin n.
* Bin lun: Do phong hn xm nhp vo kinh lc, gy kh huyt tc nghn khng lu
thng lm co cng c vng mt m sinh bnh.
* Chun on:
- Bnh danh: Nhn khu oa t.
- Th bnh :phong hn
- Bt cng: Biu_ thc_ hn _m.
- Nguyn nhn:ngoi nhn
- Chun on tng ph: Kinh lc.
- Php cha: Khu phong tn hn, hnh kh hot huyt, thng kinh lc.
6. iu tr:
* Bi thuc:
i tn giao thang gia gim.
Khng hot 8g (khu phong)
c hot 8g (khu phong)
Tn giao 8g (khu phong)
Bch ch 8g (tn phong hn)
Xuyn khung 8g (hot huyt hnh kh)
Ngu tt 12g (hot huyt)
ng quy 8g (b huyt hot huyt)
Bch thc 8g (dng huyt, th cn)
ng sm 12g (b kh)
Phc linh 8g (thm thp kin t)
Cam tho 6g (iu ha cc v thuc)
Bch trut 12g (kin t,bkh)
Hong cm 8g ( )
Thc a 12g (b huyt, b m)
Sc ngy ung 1 thang chia 2 ln (sng, chiu).
* Chm cu:
- Chm t bn phi: dng bch xuyn ng yu, thi dng, ton trc, a thng xuyn
gip xa, quyn liu, h quan, thnh cung, nhn trung, nghinh hng, phong, phong tr.
- Chm Hp cc bn tri.
* Xoa bp:
- Day, mit, phn, hp, xt, vo,Bp m 3 ln.
- Bm cc huyt tnh minh, ton trc, ng yu, nghinh hng, a thng, gip xa, h
quan, bm huyt hp cc i din.
- Ngy xoa bp 1 ln, 1 ln 20 pht
7. Phng bnh:
- Khng n ung sng, lnhnh :s, c,hn, ln,ug nc .
- Ra mt bng nc m.

- Ra ng eo khu trang.
- Trnh gi la, gi m c th.
- Kt hp xoa bp vng mt b lit
- Khuyn bnh nhn kin tr iu tr.