BNH N THNG D DY DO LOT

I/ HNH CHNH:
- H tn BN: NGUYN VN T

Tui: 45

- Ngh nghip: cng nhn vin

Gii: nam

a ch: Nh B

- Ngy nhp vin: 8h30 13/4/2013

- Ngy m: 16h 13/4/2013
- Ngy lm bnh n: 8h 17/4/2013
II/ CHUYN MN
1. L do nhp vin: au bng
2. Bnh s:
Cch nhp vin 2 ngy, bnh nhn au m vng quanh rn, khi pht t nhin, au
lin tc, tiu tiu bnh thng, khng bun nn nn, khng iu tr g
Sng ngy nhp vin, sau khi n 10 pht, BN au qung tng cn d di vng
thng v lan HSP, sau lan vai P, khng t th gim au, khng km st, khng
bun nn nn, trung tin c, BN thy au nhiu nn nhp vin 115
3. Tin s:
+ Bn thn:
- Cha ghi nhn tin cn ngoi khoa
- au thng v 10 nm nay, au khi n thc n chua cay, au khi i, t iu tr
vi Phophalugel, cha tng Ni soi d dy thc qun
- Ht thuc 10 gi/nm
- Ung ru thnh thong
+ Gia nh: Cha ghi nhn bt thng
4. TTLNV :
- M 80L/P, HA 120/90 mmHg, N 37oC , NT 20L/P
- V mt nhim trng
- khng thnh bng thng v v HSP
- G vang vng thng v, mt vng c trc gan
5. Chn on lm sng: Vim phc mc do thng tng rng
6. CLS trc m:
CTM: WBC: 11.85 K/uL
HGB: 14.7g/dL

NEU%: 86.3%

HCT: 43,5%

PLT: 176 k/uL

ng mu: PT: 12,5 s

INR: 0.98

aPTT: 26.2 s

Nhm mu: O, Rh (+)

Ion : Na+: 140 mmol/L

K+: 3.3 mmol/L

Sinh ha mu: Bun 10.5 mg/dL

Cl-: 103 mmol/L

Creatinine: 0.87 mg/dL

AST 54 U/L, ALT 57 U/L

Bilirubin direct 0.16 mg/dl , Total Bilirubin 0.87 mg/dl
Amylase mu 54 U/L
Siu m bng : t dch di gan

X-quang ngc: khng pht hin bt thng

CTscan : Trn kh t do trong khoang bng vng di vm honh P- sau thnh bng
trc P v vng h chu, c dch t do quanh gan v Morrison -> nghi thng tng rng
nghi thng d dy

7. Chn on xc nh:
- Chn on trc m: Vim phc mc do thng tng rng
- Chn on sau m: Vim phc mc do thng d dy
- Phng php m: Phu thut vim phc mc do thng d dy
- Din tin m:
Bnh nhn nm nga m NKQ
St trng da thng quy
Rch da theo ng gia trn rn vo bng thm st: bng d, dch vng c
quanh d dy, di gan, ti cng douglas, thy 1 l thng tin mn v, x chai d #
77 mm.
Tin hnh ct ra l thng gi GPB
Khu l thng ch soie 2.0
p mc ni ln ct chung l thng
Ra sch bng nhiu ln bng nc mui
Lau kh, dn lu di gan
ng bng tng lp
8. Din tin hu phu
Din tin t lc m n lc khm: bnh nhn khng st, hin bt au, trung
tin, tiu phn st vng, tiu bnh thng. Ngy 2 c rt ng dn lu di gan
9. Khm: (8h 17/4/2013)
1.

Khm ton thn:

Bnh tnh, tip xc tt

Mch: 80 ln/pht Huyt p: 120/70 mmHg Nhit : 37oC

Nhp th: 20 ln/pht

Tng trng trung bnh, cn nng 55 kg, chiu cao 165cm, BMI 20.02
Da nim hng, kt mc mt khng vng, khng du xut huyt di da, ph (-)
Hch ngoi vi khng s chm.
2.

Khm ngc:

Lng ngc cn i, di ng u theo nhp th, khng du sao mch, khng tun hon
bng h
Tim u, nhp tim 80l/p, mm tim nm khoang lin sn V ng trung n tri, T1 T2
u r, khng m thi
Phi : Rung thanh u 2 ph trng, khng im au khu tr. G trong. R ro ph nang
m du, khng ran bnh l
3.

Khm bng:

Bng cn i, di ng theo nhp th, khng chng, khng tun hon bng h
So m ng gia bng di 12 cm, cha ct ch, ln m ht tt, khng vim , khng
r mu hay dch
Vt thng ch ng dn lu di gan hnh trn, ng knh khong 1 cm, khng nht
mess, ln m ht tt, khng sng nng , khng chy mu m
Bng n khng au
Gan lch khng to
G trong khp bng
m rut 5 l/p
4.

Cc c quanh khc: cha ghi nhn bt thng

10. Tm tt bnh n:
BN nam, 45 tui, vo vin v au bng
Tin cn vim lot d dy 10 nm
BN au vng thng v m 2 ngy ri t ngt au d di, khm c khng vng
thng v v mt vng c trc gan, CTscan c kh t do trong bng, c chn on
l vim phc mc do thng tng rng, c x tr phu thut khu l thng d dy, ra
v lau bng, sau t dn lu, c chun on sau m l vim phc mc ton th do
thng d dy.
Hu phu ngy th 4 : BN trung tin c, tiu phn st vng, cn au nh vt m khi
c ng, vt m kh, lnh tt
11. Hng x tr tip theo
Theo di Mch, nhit / 12h
Ra vt m, thay bng hng ngy

Dinh dng n thc n lng, d tiu, giu cht dinh dng

i li, vn ng nh
12. Bin lun :
-BN vo vi triu chng au bng cp, khm c khng thnh bng thng v, mt
vng c trc gan, CTscan c dch di gan v hi t do trong bng, amylase mu
khng tng -> vim phc mc do thng tng rng -> m cp cu
- Trc m ngh nhiu l thng d dy v BN c tin cn vim lot d dy 10 nm, khng
iu tr, au vng thng v m 2 ngy ri t ngt au d di sau n. Kim chng
trong lc m thy l thng tin mn vi -> thng d dy
- Vn hin ti ca BN:
+ Ch kt qu gii phu bnh mu sinh thit lot -> nu c tnh phi nh gi giai on
v iu tr ha tr cho BN
+ BN hu phu ngy 2, tiu c, trung tin c, nhu ng rut bnh thng ngh ng
tiu ha phc hi tt chc nng
+ BN khng st, vt m lnh tt, khng r dch, mu, nn khng ngh c nhim trng vt
m
+ CTM v ion cho thy khng c nhim trng, khng thiu mu, khng ri lon in
gii -> tin lng tt