BNH N NI KHOA

I. Hnh chnh
- H v tn: NH H.
SN:
1961
Nam
- Ngh nghip: K s ch to my
- a ch: 86/16 Bu Ct 2 Phng 12
Qun Tn Bnh
- Ngy nhp vin: 03/10/2013
- Ngy lm bnh n 17/10/2013

II. L do nhp vin

au ngc

III. Bnh s
BN pht hin THA cch y vi nm
(BN k nh r thi gian), khng iu tr.
HA bnh thng 140/90mmHg, HA cao
nht 160/100mmHg.
1 nm nay BN thnh thong au nhi
ngc tri trong vi giy, cm gic p
tim thong qua ri t ht, khng km
kh th.

III. Bnh s (tt)

1h tra ngy NV, BN ang ngh ngi t nhin
au tht ngc tri, cm gic nh b chn p tim
v nng ngc khin BN kh th c khi ht vo v
th ra. Cn au ngc ko di lin tc, khng c
t th gim au, au lan ln cm khin BN cng
hm, trong cn BN v m hi nhng khng cm
thy t tay chn. Cn au ngc ko di hn 30
pht khng nn BN n khm ti phng khm
t, cha iu tr v c chuyn n BVTN
Ngoi ra, BN khng st, khng nn i hay chng
mt

DHST khi nhp vin

-

Mch: 134 ln/pht

Nhit ; 37oC
Huyt p 140/110mmHg
Nhp th: 26 ln/pht

IV. Tin s
1. Tin s c nhn:
a. Ni khoa:
-. THA cch y vi nm khng r iu tr
-. Khng T
b. Ngoi khoa:
-. Cha tng phu thut
c. Thi quen:
-. HTL: 30 gi-nm
-. Khng ung ru bia
2. Tin s gia nh
- Ngi thn trong gia nh cha ghi nhn bnh l: THA,
T, Tim mch

Khm
1/ Ton thn:
BN tnh, tip xc tt, u nm cao 30

Lng tc mng bnh thng: khng

ngn tay di trng, mng tay khng
sc khng mt bng.
Khng ph, hch ngoi vi khng s
chm, tuyn gip khng s chm.

 2/ Tun hon
- Tnh mch c t th 45 khng ni, khng thy
din p mm tim
- s: khng s thy mm tim, khng c p bt
thng, rung miu (-), du Hardzer (-)
- Nghe: nhp tim 80 ln/ pht; T1 ,T2 nghe m ti
lin sn 5 ng trung n, nghe r ti lin
sn 2 cnh c tri. Cha pht hin m thi
bnh l.
- Mch mu: khng c gin tnh mch chi, mch
ngoi bin u r 2 bn

3. H Hp
Lng ngc cn i, di ng theo nhp
th. Khng co ko c h hp ph
Rung thanh u 2 bn, g trong 2
ph trng, r ro ph nang m du,
khng ran.

4. Tiu ha:
Bng cn i, di ng theo nhp th, rn
khng li, khng tun hon bng h, khng
sao mch, khng so m c
Nhu ng rut 8 ln/ pht, khng pht
hin m thi ng mch ch bng v m
thn.
Bng g trong, b cao gan 10cm
S: bng mm, khng phn ng thnh
bng, khng khng thnh bng, khng u
so, gan lch khng s chm.

5. Thn-Tit niu:
Chm thn (-), bp bnh thn(-),
im au niu qun (-), cu bng
quang (-)
6. C xng khp:
Khng gii hn vn ng, khng bin
dng khp
sc c 5/5
7. Thn knh: c mm, khng c du
TK nh v.

V. Tm tt bnh n
Bnh nhn nam 53 tui nhp vin v
au ngc. Qua hi bnh v thm khm
BN c vn sau
- Hi chng vnh cp
Cn au tht ngc tri lan ln cm
km cng hm, ko di lin tc hn 30
pht, khng c t th gim au, trong
cn BN c v m hi v kh th
- THA 1 (JNC7) (140/90mmHg)

VI. Chn on
1. Chn on s b
Nhi mu c tim cp/THA I (JNC 7)
2. Chn on phn bit
- Bnh mch vnh mn
-. Vim mng ngoi tim
-. Phnh bc tch MC

VII. Bin lun

- BN c cc yu t nguy c ca bnh l
mch vnh nh THA khng iu tr, HTL
30 gi-nm, cao tui, nam gii. Trn LS,
BN c hi chng vnh cp th hin r qua
cn au tht ngc in hnh, khng n
nh: au ngc tri sau xng c, au lan
ln cm km cng hm, cn au lin tc
khng c t th gim au v ko di trn
30 pht, trong cn BN v m hi v kh
thnn ngh nhiu n NMCT cp.

- ngh lm CLS chn on

+ ECG: th hin qua ST chnh ln/
khng chnh, sng T m chuyn
o????
+ Men tim: CKMB, Troponin I, pro-BNP
tng
+ Siu m tim
+ Chp ng mch vnh

Bin lun CPB

- Bnh mch vnh mn: BN tuy khng
c tin s v bnh l tim mch nhng
c nhiu yu t nguy c k trn v
cn au tht ngc ny khi pht t
nhin sau khi n, khng phi sau mt
gng sc, thi gian ko di trn 30
pht, cn au tng dn, khng gim
nn khin BN phi nhp vin. V vy
khng ngh nhiu n bnh MV mn,
tuy nhin cng khng th loi tr cn

- Vim mng ngoi tim: Bn khng au

ngc kiu mng phi, nghe tim khng
c ting c mng ngoi tim, LS BN k c
hi chng nhim trng (st, mi kh,
li d) nn khng ngh nhiu VMNT
cp. loi tr ngh lm CLS: ECG,
siu m tim

- Phnh bc tch MC: cn au ngc d di nh

dao m, nh x khi pht t ngt, ko di
dai dng, lan ra sau lng. Trn Ls, Bn cng c
cn au ngc khi pht t ngt tuy tnh cht
au khng mnh lit nh trong phnh bc tch
MC, HA BN 140/110mmHg ti thi im
khm khng gim so vi bnh thng nn
khng ngh nhiu n bnh l ny tuy nhin
cng khng th loi tr cn lm thm CLS: X-q
tim phi thng, (c lm ECG???? V sao???)

Chn on xc nh
Nhi mu c tim thnh trc ST chnh
ln gi th 4.