CHUYN

TIU HA
Lo Cai, ngy 24/2/2012

THNG TIN BNH NHN

BN Nam, 82 tui.

Ngh nghip: Hu tr.

a ch: Lo Cai.

Vo vin: 1/2012.
L do: au bng. Tin s: BN c tin s THA 2 nm, iu tr u theo n.

BNH S
Din bin bnh: BN n ung bnh thng, khong 6 thng gn ngy vo vin BN hay thy xut hin i tin phn to, 2-3 ngy i tin 1 ln. Nhng lc thng thy y bng, kh tiu. BN t dng thuc Duphalac v c , cha i khm. Gn y kh i tin xut hin nhiu hn. 1 tun trc ngy vo vin BN au au bng nhiu hn, km theo c nn v st, i tin c t phn khng thnh khun.

BNH S
Lc vo vin Tnh, th trng gy, khng ph. au bng lm dm, khng nn, n ung c. Bng mm, chng va, khng r im au. Khng c phn ng. RRFN u, khng c rales. Tim nhp u, tn s 90 ck/p, T1, T2 r, khng c ting tim bnh l. M 90 l/p, HA 120/70, T 38o3 C, SpO2 98%

XT NGHIM (lc vo)

CT mu: Hng cu = 3.57 T/l Hb = 109 g/l, Hematocrit = 0,30 Bch cu = 28.4 G/l, TT 95%, L 5%. XN sinh ha mu: Ure = 10,5 mmol/l, Creatinine = 110 mol/l Glucose = 7,8 mmol/l, SGOT/SGPT= 17/29 UI/L Triglycerit = 2,3mmol/l, Cholesterol = 4,7mmol/l. Acid uric = 239 mol/l XN nc tiu: Glucose (-), Protein (-), TP khc BT

IN GII (lc vo)

Na = 136 mmol/l

K = 3,6 mmol/l
Cl = 103 mmol/l Ca TP = 2,14 mmol/l Ca ion = 1,10 mmol/l PH = 7,55

SIU M BNG

S bng: bng nhiu hi, Cng khng c dch

HNH NH CHUP X-QUANG

Chp x-quang tim phi khng c hnh nh c bit

HNH NH IN TIM

T c hnh nh Block nhnh P, dy tht tri

CHP CT BNG

C hnh nh hp lng i trng tri, khi p xe quang i trng lin tc vi h chu tri , c tht lng tri

CHP CT BNG

C hnh nh hp lng i trng tri, khi p xe quang i trng lin tc vi h chu tri , c tht lng tri

CHN ON

P XE H CHU, THNH BNG TRI, TC RUT/THEO DI K I TRNG

IU TR
Dinh dng ng tnh mch

Khng sinh ng tnh mch

Hi chn phu thut

 KIN THO LUN

1. Vi ung th i trc trng cc phng php sng lc nhm pht hin ra khi u trong giai on sm, triu chng lm sng ngho nn. Hin nay tuyn c s nn p dng nhng sng lc no ngoi tm hng cu trong phn, soi i trng?
2. Xin cc thy c cho bit thm gi tr ca chp PETCT trong bnh l tiu ha ni chung v ung th i trc trng ?

Xin trn trng cm n !

Thank you!