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Trng i Hc Y Dc Hu

B mn Dc lm sng

CA LM SNG: VIM D DY
c iu tr ti: Khoa ni tiu ha- bnh vin trng i hc Y Dc Hu
Nhm 3- T II-lp D4
1. Nguyn Vn Quyt
2. Bi Hu Tm
3. Hong Th Thanh
4. Hong Th Thanh Tho
5. Trn Th Kiu Trang
6. Trn Th Minh Thuyt
7. Hunh Th Hong Yn
8. Nguyn Th Hng Yn
9. L Th Yn
10. Trn Th Tho Yn
11. Nguyn Th M Hnh
12. Trn Khnh Yn

Ni dung:
I.
Ca lm sng vim d dy:
1. Thng tin bnh nhn:
Tn: NG VN HONG Tui: 39T
Gii tnh: Nam
a ch: T 10-x Thy Dng-huyn Hng Thy-Hu
Vo vin: 9h30 ngy 24 thng 4 nm 2012
Cp cu: Vim d dy cp
Vo khoa ni tiu ha: 15h20 ngy 24 thng 4 nm 2012
a. L do vo vin: au bng
b. Qu trnh bnh l: Cch y 6 nm, bnh khi pht vi au bng quanh rn, au
lm rm khng thnh cn, khng c t th gim au, khng iu tr g ko di
khong 1 tun, sau i cu phn lng. Ti pht 5-6 ln mi nm.
Ln ny triu chng nh trn nn vo vin.
c. Tin s bnh:
+ Bn thn: - Khng c tin s au bng ngoi khoa
- au d dy iu tr khng thng xuyn
+ Gia nh:

Bnh thng

d. c im lin quan bnh tt:


- Ht thuc l gi / ngy
- ung ru bia thng xuyn
e. Thm khm:
Ton thn:
- Tnh to tip xc tt
- Da, nim mc nht nht
- Mng tay c kha, khng c mng tay khum hay di trng
- Khng ph, khng xut huyt di da
- Mch: 80 ln/pht
Nhit : 370C
HA: 120/80 mmHg
- Nhp th: 20 ln/pht
M t chi tit c quan bnh l:
- au quanh rn, au lien tc, khng tri, khng c t th gim au
- n ung c, khng nn, khng bun nn
- i cu phn lng sau 2 ngy khi pht au, phn km ht m
- Bng mm, n khng au, khng s thy u cc
- Phn ng thnh bng (-)
- im sn sng+sn lng khng au
Cc xt nghim cn thit:
- Huyt hc: Theo di vim d dy

Cng thc mu

Kt qu xt nghim

Tr s bnh thng

WBC

7,28

(4-10)

G/l

NEU%

69,3

(0,5-0,7) (50-70)

LYM%

28,8

(0,3-0,4) (30-40)

RBC

4,53

(4-5.5)

T/l

HGB

128

(120-150)

g/l

HCT

43,99

(0.38-0,45) (38-45)

MCV

97

(80-100)

fl

MCH

28,2

(28-32)

pg

MCHC

290

(300-360)

g/l

PLT

197

Glucose mao mch


-

(150-400)
5,9

G/l
mmol/l

Xt nghim sinh ha nc tiu:


Amylase Tr s XN: 180 BT: <200 v: U/I
Xt nghim sinh ha:

Kt qu xt nghim

Tr s bnh thng

Ure

4,7

(1,7-8,3)

Mmol/l

Creatinin

73

(53-120)

mol/l

TG

2,51

(0,6-1,88)

Mmol/l

Cholesterol TP

4,83

(3,87-5,70)

Mmol/l

Cholesterol HDL

1,23

(>0,9)

Mmol/l

Cholesterol LDL

2,46

(<4,0)

Mmol/l

GOT(ASAT)

31

(0-37)

U/l

GPT(ALAT)

26

(0-40)

U/l

CRP

0,79

(0-5)

Mg/l

Kt qu

Tr s bnh thng

Na+

137,1

(135-148)

Mmol/l

K+

3,48

(3,5-5,3)

Mmol/l

in gii :

Xt nghim Amylase mu: 102 Tr s BT: <220 v: U/l


Xt nghim Glucose
5,6 Tr s BT: 3,89-6,4 mmol/l
Xt nghim KST: Trng giun tc (+)
Theo di HA: 110/70 mmHg

Siu m: tnh trng bnh l: ui ty b khng u + 2 nt gim m


# 10mm v 13mm
Ni soi: tnh trng bnh l: Vim tin mn v

f. Tm tt:
Bnh nhn nam 39T, vo vin v l do au bng 6 nm nay ti pht nhiu ln,
rt ra cc hi chng sau:
- Hi chng thiu mu mn
- Hi chng km hp thu
- Du au bng quanh rn lien tc, khng c t th gim au
g. Chn on:
- Bnh chnh: Vim d dy
- Bnh km theo: Hi chng km hp thu
2. X tr cp cu: 9h40
- Ameprazole 20mg x 1v
- Phosphatgel x 1 gi
- Azpole 40mg x 1l TMC
- Ringerlactate x 500ml CTM xxx git/p
3. iu tr:

ST

Ngy
Tn thuc

25/4

26/4

27/4

28/4

29/4

30/4

1/5

2/5

3/5

T
1

Alluminium x gi
ung chia 3

Ameprazole
20mg x vin ung
chia 2

ORS x gi pha
1000ml ung

Vitamin 3B x vin
ung chia 2

Dung
Glucose

dch
5%

500ml CTM
6

Omegat 40mg x
ng tim TM chia

+3

2 (8h v 20h)
7

Dung

dch

Ringerlactate
500ml

CTM xx

git/p
8

Antibio x gi chia
3 ( Biolac)

4. Theo di iu tr:

Ngy

Gi

Theo di din bin

Thc hin y lnh


chm sc

24/4

15h20

- Nhn bnh
- Mch: 72 ln/p
- HA: 120/70mmHg
- T0: 370C

- o du hiu
sng
- Bc s xem bnh

16h
- Pht thuc cho
BN
- Ly mu lm
XN. Hng dn
ch n

25/4

6h

-Trong m BN i
cu lng nhiu ln,
ngi mt khng
st, cn au bng

-o du hiu sng
-Ly mu lm XN
-Cho BN i ni soi
-Truyn dch, pht
thuc cho BN

quanh rn.
-Mch: 70 ln/p
-HA: 105/70mmHg
-T0: 370C
26/4

7h

- BN m ng

-o du hiu sng

c khng st
cn au thng v,

27/4

6h

-Cho ung thuc

n vo nn.
- Mch: 70 ln/p
- HA: 110/70mmHg
- T0: 370C

-Truyn dch

BN m ng c,

-o du hiu sng
-Cho BN ung

khng st, cn au
thng v
-Mch: 66 ln/p
-HA: 95/60mmHg
-T0: 370C

thuc
-Tim thuc,
truyn dch theo y
lnh
-Dn bnh ngh
ngi

28/4

6h

-BN m ng
c, khng st,
cn au thng v

-o du hiu sng
-Cho BN ung
thuc
-Tim thuc,

29/4

7h

-Mch: 65 ln/p
-HA: 110/60mmHg
-T0: 370C

truyn dch theo y

-BN m ng

- NT

lnh
-Dn bnh ngh

c, khng st,

8h-24h

khng au bng
-Mch: 70 ln/p
-HA: 110/60mmHg
-BN khng c mt

30/4

NT

NT

NT

1/5

6h
8h

-Bnh n, khng

-o du hiu sng
-Pht thuc v

au, khng st, n


ung tm
-Mch: 75 ln/p
-HA: 110/70mmHg
-T0: 370C
2/5

6h

-BN ng c,
khng st, khng
au bng
-Mch: 75 ln/p
-HA: 110/70mmHg
-T0: 370C

II.

cho ung
-Tim thuc v
truyn dch
-Dn BN ngh
ngi
NT
-n ung bi
dng

Phn tch ca lm sng


1: Xc nh mc tiu iu tr
Bo v t bo, hi phc s tit acid tr li bnh thng, loi b nguyn
nhn, hn ch bin i lm teo nim mc d dy gp phn ngn nga
ung th.
Gim au
Lm lnh cc tn thng d dy

2: Da vo thng tin v thuc v phc iu tr la chn thuc cho BN


S dng cc thuc chng vim, chng acid v bo v d dy
Cn phi c ch n ung sinh hot, ngh ngi y , trnh cc tc nhn gy
kch ng d dy.
Bnh nhn cn tranh cc loi thuc gy kch ng nim mc d dy nh
:aspirine, tranh ung bia ru, cc loi thuc khng vim NSAID
Ameprazol (omeprazole):
Ch nh: Tro ngc dch d dy - thc qun. Lot d dy - t trng.
ADR: Ton thn: Nhc u, bun ng, chng mt. Tiu ha: Bun nn, nn, au bng,
to bn, chng bng.
Tng tc: lm gim tc dng ca B12 v alluminium acetylsalicylate.

Alluminium:
Ch nh:cc bnh l c km tng tit dch v ( nng,vim thc qun hi lu,
vim d dy cp v mn tnh,thot v honh, lot d dy t trng, cc dng bun

nn khc).
ADR:
o Him khi: to bn hoc tiu chy.
o Rt him: phn ng qu mn. Dng lu d c th nh hng chuyn ha

Ca,P.
Tng tc: aluminium hydroxide c th lm gia tng nng ca alluminium

acetylsalicylate.
Vitamin 3B:
Ch nh: Phng v iu tr vit nhm B do n ung khng y hoc thiu vit B6
do thuc gy ra. Liu cao iu tr au do bnh l thn kinh,yu c, ri lon do

nghin ru lu nm.
ADR: him gp:st, v m hi, bun nn, nn, ni mn, tiu chy, m ay.
Dung dch ORS, glucose 5%, dung dich Ringerlactate
m bo th tch tun hon v nui dng c th bng ng chuyn tnh
mch.
Antibio (lactobacillus acidophilus).

Ch nh: Phng ri lon tiu ha do khng sinh hay ha tr. Trng bng, tiu
chy, to bn, vim rut cp v mn tnh ngi ln v tr em. To mi trng
axit nh tit ra axit lactic, y l mi trng trng thun li cho h vi sinh ln
men ng rut pht trin v ngc li, c ch s pht trin ca vi khun gy
bnh dng Gram m.

Hot cht
Aluminium

Tng tc vi
hot cht
Sodium citrate

Omeprazol

Cyanocobalamin

Dung dch
ORS

Antibio

Mc
tng tc
5 (nghim
trng)

Cp
chng c
Well
Established

Tc hi

Good

Mc 4

Good

omeprazole lm
gim hiu lc cacyanocob
alamin
ORS l nguyn nhn lm
tng c tnh ca Antibio

natri citrate lm tng c


tnh ca nhm

C th xy ra c ch:
Citrat c
th
lm
tng s
hp
thu ng rut nhm bng
cch
hnh
thnh citrate nhm, m l ha tan v hp thu, dn n tng nng nhm trong huyt
thanh. iu ny c th dn n bnh no, tch lyv c tnh nhm, c bit l nhng
bnh nhn suy thn. T vong c bo co bnh nhn suy thn, do s kt hp
ny cn phi c nghim chnh trnh bnh nhn thn.

3: Phn tch n thuc ang s dng, t a ra kt lun v tnh hp l


ca n thuc.
a. Cp cu:
- Ameprazole 20mg/v: Liu duy nht c ch nhanh s tit dch v do bt k
tc nhn kch thch no.

Phosphatgel: Lp mng bo v gm nhm phosphate phn tn mn lm


lin nhanh vim, bo v nim mc d dy chng li tc ng bn ngoi

v lm BN d chu ngay.
b. Thuc iu tr:
- Khng iu tr di ngy Omeprazole do cc nghin cu trn sc vt cho
thy xut hin cc u bu d dy dng ung th i vi liu cao. Thay th
-

bng Omegat 40mg x 1 ng.


Nn ch nh cc cht tc dng d dy rut nh Alluminium xa khong
2h i vi Omeprazole. Alluminium trung ha acid dch v nn c

dng khi i v trc khi i ng.


Dung dch ORS cha Natri citrat dihydrat => tng tc vi Alluminium
=> thay th bng dung dch Ringerlactate.
Khi vo vin bnh nhn b tiu chy nn dng dung dch ORS cung
cp in gii.
Ban u dng dung dch ORS v dung dch Glucose 5%. Sau
chuyn sang Ringer lactat trong thnh phn bao gm c Glucose.
Glucose c ch nh do bnh nhn b km hp thu.
Vitamin 3B gip cung cp vitamin nhm B cn thit cho c th, khi khng
th hp thu.
Antibio l enzym tiu ha dit vi khun, gip ti to cn bng ng rut,
hp thu tt hn=> c b sung thm sau khi bnh n.
Kt lun:
- Liu dng l hp l, ph hp vi tnh trang ca BN.
- BN c tin trin trong qu trnh iu tr.
- BN vn c tip tc theo di v iu tr.