BNH N V THN

BNH N
I-HNH CHNH.
1.h tn bn: H.T.BCH, gii tnh: n, tui: 34
2.a ch
3.ngh nghip: lm rung
4. ngy vo vin: 15 gi 35 pht ngy 20/9/2008.
II-CHUYN MN.
1. l do vo vin: ph ton thn
2. bnh s:
1) Tng qut:
Bnh khi pht cch nhp vin # 1 thng lc u ph 2 mi mt c iu tr
bc s t 1 ngy (thuc khng r loi), bnh khng gim ph n ngy th 2 ph
nhiu hn, ph ton thn km theo tiu t # 500ml/ ngy, mu vng hi ln cn, n
ung km, mt mi. BN c ung thuc nam khng gim ph nhp vin iu tr ti
BV X c 4 ngy (thuc khng r) bnh khng gim ph -> bnh trn vin v
nh 1 ngy thy ph nhiu hn nhp BV Y iu tr 10 ngy c s dng thuc ung
12 vin/ngy vo bui sng bnh c gim ph v c xut vin ung tip tc
thm 6 ngy BN ngng thuc chuyn qua ung thuc bc 3 ngy khng gim ph.

Cng ngy nhp vin bnh st km lnh run, kh th, ph nhiu hn -> nhp vin
BV Z.
2) tnh trng lc nhp vin: ph ton thn. DHST: M 80, HA 150/100,
Nhit 37oC, NT 20 l/p.
3) din tin bnh phng: t ngy 20/9 n 1/10: Qua 11 ngy iu tr bnh
gim ph, ht st. Tiu # 800ml mu vng trong, n ung km, nn i sau khi n.
4) tnh trng hin ti: ngy 1/10/2008
Bnh tnh, n ung km. Cn au m vng thng v. Ho khan.
3. Tin s: bn thn v gia nh - khe.
III-KHM THC TH: ngy 1/10/2008, ngy th 11 ca bnh.
1. Tng trng:
- Bnh tnh to
- Da nim hng nht
- Ph nh ton thn, tiu # 800ml mu vng trong
- Tuyn gip khng to, hch ngoi vi s khng chm.
- DHST: M 90, HA 120/80, T 37, NT 20.
2. Tiu ha
- Nhn: bng cng nh, rn phng
- Nghe: nhu ng rut 8 ln/pht

- G: g c vng thp
- S: gan lch s khng chm.
3. H hp
- Nhn: lng ngc cn di ng u theo nhp th
- S: rung thanh gim 2 y phi
- G: g c 2 y phi
- Nghe: r ro ph nang mt 2 y phi.
4.Cc c quan khc: cha ghi nhn bt thng.
IV-TM TT BNH N.
BN n 33 tui vo vin v ph ton thn. Qua hi bnh s, tin s v khm
lm sng ghi nhn:
1. hi chng nhim trng
1. ph ton thn: ph nhanh v nhiu
2. Tiu t # 500ml/ ngy, vng ln cn
3. Triu chng h hp: hi chng 3 gim 2 y phi
4. au thng v, nn i.
Tin s:
5. HA 150/100 mmHg (lc vo vin, cch 11 ngy).

V-CHN ON
@ Chn on s b: Theo di Hi chng thn h nguyn pht khng thun
ty.
@ Chn on phn bit: Vim cu thn cp.
VI-BIN LUN CHN ON
tathata tm lc chnh ca ngi trnh by B.A:
1. Ngh n HCTH v BN ph ton thn, ph nhiu d di
2. Nguyn pht v khng bnh l km theo
3. Khng thun ty v c tiu vng ln cn -> khng loi tr tiu mu
4. HA cao: khng loi VCTC.
VII- NGH CLS
a. xt nghim thng quy: Tng phn tch nc tiu, SHM, CTM.
b. gip chn on xc nh: m niu 24h.
c. gip chn on phn bit: ni soi.
d. gip tm sot nguyn nhn: LE - cell, Anti HCV, HbsAg, IDR, Anti
HIV.
e. gip theo di iu tr: m niu 24h, ion (K+), albumin.
VIII-KT QU CLS

1. TPTNT: 5g/L, t bo: 10

2. m niu 24h: 3g/24h
3. SHM:
- pro TP 40 g/L
- albumin 24 g/L
- Cholesterol TP 20.6
- Triglycerid 3.1
- HDL-c 0.8
- LDL-c 12.3
- Na+ 130
- K+ 2.7
- AST 19
- ALT 24
- ure 5.9
- creatinin 114
- Glucose 14.4
4. Ni soi:
- vim trt hang v mc trung bnh

- vim hnh t trng.

5. CTM:
- BC 13.400, N 75.5%, L 15.8%
- HC 4.4
- Hb 12.2
- MCV 81.4
- MCH 27.3
6. Xt nghim tm sot nguyn nhn
- Tm sot lupus: LE-cell (-)
- Tm sot vim gan: Anti HCV (-), HbsAg (-)
- Tm sot Lao: IDR (-)
- Tm sot HIV: Anti HIV (-).
IX-CHN ON XC NH: HCTH nguyn pht khng thun ty.
X-IU TR
1. Endoxan 50mg 1 vin x 2 (u)
2. Adacton 25mg 1 vin (u)
3. Aprovel 150mg 1 vin (u)
4. Simlor 20mg 1 vin (u)

5. Kalidyum 0,6g 1 vin x 2 (u)

6. Omez 20mg 1 vin x 2 (u)
7. Primperan 10mg 1 ng x 2 (TB).

BNH BNH N

1. Hi chng ca bnh cu thn c cc bnh: 1. Hi chng thn h, 2. Vim

cu thn cp, 3. Vim cu thn mn, 4. Vim cu thn tin trin nhanh.
2. bnh cu thn biu hin bng nhiu sang thng ti thiu -> HCTH. Tuy
nhin, xc nh v sang thng cn lm sinh thit, iu ny VN ni chung,
CT ni ring t lm -> do vy, chuyn sang chn on theo hi chng.
3. sang thng ti thiu -> nguyn pht. D vy, HCTH c: 1. nguyn pht,
v 2. th pht.
4. Nguyn pht: do min dch. Cn th pht: do nhiu nguyn nhn ->
nhim trng, bnh h thng (lupus), siu vi, K...
5. TP -> iu tr nguyn nhn. NP -> s dng c ch min dch: Corticoid,
c t bo.
6. HCTH
1) tn thng mng y cu thn -> tiu m: protein niu/ 24h > 3,5
g/24h; tuy nhin LS > 3 g/24h th chn on (+).

2) gim albu, gim pro/ mu -> LS: ph. m mt t: t ngt ph nhanh

- do mao mch khng iu chnh kp v p lc keo gim nhanh. Ph nhanh, nhiu,
d di: t -> Nguyn pht.
3) Tng lipid/ mu: m gim nhanh - gan tng tng hp lipid, tng pro ->
pro thi ra ngoi.
7. HCTH: tm li -> 1 - pro/ niu > 3,5g, 2 - albu gim, 3 - lipid/mu tng.
T y pht sinh cu hi: tiu m 3,5g -> kt lun HCTH l ng or sai? -> Sai.
V m mu gim: nguyn nhn trc thn (cn cc nguyn nhn ti, sau thn).
8. Vim cu thn cp:
1) tiu t: tng p lc lc lng mch y HC ra dn n:
2) tiu mu: HC bin dng, tr. Trong B.A: t bo 10 -> cha kt lun c
v cn nhiu bnh khc: Nhim trng tiu, si niu, n hnh kinh.. -> HC bt
thng. Nhng bit hnh dng: cn lng nc tiu.
3) ph: do khng tiu c (khng phi do gim m): nu tng ln nhiu > Suy thn cp ti thn. Thng ph nh: thn khng thi c mui nc dn
n:
4) tng HA.
9. VCTC th pht: thng do hu nhim lin cu trng.
10. Nhim trng xong tiu mu ngay: cn c bnh thn urea.
11. Theo di Hu nhim LCT: xem c vim hng? vim da? v thi gian
ko di bnh.

12. C 2: HCTH v VCTC nguyn pht u khng r nguyn nhn, thng

do min dch.
13. 1 BN HCTH th pht c:
1) triu chng khng in hnh
2) > 40 tui b HCTH ln u
3) c bnh l th pht ang din tin.
14. Th pht t tiu ng -> nh hng n thn -> xy ra tiu m (vi
th): t thp -> cao: ph tng dn, m mu gim dn. Gim t ngt -> ph
khng in hnh ca HCTH.
15. Th pht, nhc li nguyn nhn:
1) nhim trng
2) siu vi: HBV, HCV, HIV
3) thuc
4) tiu ng
5) K
6) bnh h thng.
16. TH: ph, vng da -> hng Th pht do Vim gan.
17. TH: ph, tiu chy ko di -> hng TP sau nhim HIV.
18. ph, hng ban cnh bm, au nhc xng -> hng TP do lupus.

19. lipid mu tng: iu tr tt cng khng h lipid.

20. Nguyn pht: c
- thun tu: ch biu hin n thun HCTH.
- khng thun tu: kt hp thn vim (km tiu mu) v thn h.
21. khng thun tu: bnh cnh VCTC - tng HA (vi iu kin trc y
khng tng - khng phi v cn), ure tng, creatinin tng.
22. c trng ca tiu mu trong VCTC: mu ra tht.
23. B.A: BN c tng HA -> khng thun tu.
I VO BNH N:
24. bnh l cp: HCTH, VCTC; nu ti i ti li: VCT mn, Suy thn mn.
25. Ph kiu thn, tiu t, tng huyt p - triu chng in hnh bnh thn.
26. BN gi, ph do bnh l khc: phn bit ph trong cc bnh cnh. V d:
ph trong x gan km tng huyt p.
27. Thiu mu: suy dinh dng: ph thiu dng?
28. BN: ph nhanh, nhiu, d di.
Mc ph:
- Khu tr -> nh
- Ph ton thn khng km trn dch a mng -> TB

- Ph ton thn c km trn dch a mng -> nng. Nu LS: thy trn dch
a mng, ph khu tr -> c th BN s dng thuc (li tiu) trc .
29. TH: Ln u tin ph, ph nhanh nhiu d di -> HCTH; tuy nhin ph
ny cng c th gp trong VCTC (15%).
30. Phn tch bnh cnh: bin lun - tuy nhin ph km tiu t, tng HA nn
ngh nhiu HCTH. Km theo BN c tng HA nn y l HCTH khng thun tu.
31. Nguyn pht:
1) triu chng in hnh
2) tui < 40
3) khng bnh l th pht km theo.
Cu hi t ra:
Nu bnh l c th pht th c th th pht sau bnh g d phng? -> ty
tui d phng khc nhau. BN ny: n 33 tui -> Theo di sau lupus (4/11
triu chng), ban ri rc, da (thng nm BV da liu), tng; dch t: Vim
gan siu vi.
32. nn bnh: tiu ha -> vim d dy (BN c au vng thng v), h hp
-> Vim ph qun cp (BN c ho khan).
33. HCTH v VCTC khng thun ty khc nhau v m niu.
34. thng quy: TPTNT, m niu 24h, cn lng. Cn lng c tr hay HC
bin dng -> bnh thn. Lm tip protid mu, alubumin, lipid -> HCTH? . Lm
tip LE - cell: (-) -> nguyn pht, loi tr th pht.

35. Chn on vim d dy -> ni soi iu tr, chp X quang, th CTM:

BC?
36. RL chc nng thn -> ion ? Nu nguyn pht khng thun ty -> ure,
cre?
37. BN ny: lipid mu tng, pro TP gim, albu gim -> ph hp HCTH.
Tip theo: t bo HC: 10, tng HA, cre tng nh -> cha cn lng cng ph hp
HCTH khng thun tu.
38. VGSV: HbsAg (-), Anti HCV (-); lupus: LE cell (-); HIV: anti HIV (-),
Lao: IDR (-) -> loi tr nguyn nhn th pht.
39. ni soi: vim trt, BC: N tng, s lng BC tng -> Chn on xc
nh: HCTH nguyn pht khng thun tu/ vim d dy + vim ph qun cp.
40. iu tr: c 2 phn. 1, HCTH NP ktt. 2, vim dd + VPQ cp. ng thi
2 vic chnh: 1, iu tr triu chng. 2, iu tr nguyn nhn th pht: c ch MD.
41. iu tr triu chng: UCMD khi nguyn pht, loi ny c 2 nhm: 1.
Corticoid, 2. c t bo. Cu hi t ra: s dng thuc bao nhiu ngy sau th xy
ra tc dng ph?
42. c t bo: nhiu tc dng ph - tr b v sinh, ln b K, trc mt
gim BC ht. V vy, Cor CCD hoc khng th mi chuyn sang s dng c t
bo.
43. Cor: RL chuyn ha -> c th kim sot c.
44. Khi cho DTB, lm ngay xt nghim CTM: xem BC c gim?

45. BN c ph, tiu t, tng HA, gim (pro, albu, K+), tng lipid -> do u
c tr/c ny? iu tr?
46. V BN c vim d dy: khng s dng Cor -> sd c tb.
47. c tb: Endoxan 50mg.
48. ph -> sd li tiu. Tc dng ph: tng lipid mu. Cor: td ph K+ gim.
49. Mc ph: ty truyn albumin.
Vi:
1sao

ch

(gim

xem

http://www.diendanykhoa.com/showthread.php?t=988)
2sao = LT Thiazid
3sao = LT gi K: Spiro
4sao = mt K: LT quai
5sao = Truyn albumin.
1) Nh: al > 30: 1, 2, 3 (trong 3 khi c tng kali)
2) TB: al 20 - 30: 1, 2, 3, 4 (ty ion m la chn)
3) Nng: al < 20: 4, 5 (trong < 10: rt nng -> OAP: 5) - s dng 5 khi
dch khng gi c trong lng mch.
50. iu tr ph, kt hp 2 pp: 1. ch n: gim m; gim mui nc ->
ci thin tt tnh trng ph. V 2. Li tiu: gi K: Spiro, mt K: quai, Thiazid. Nu
nng th 3. truyn albumin.

Lu : gim ph khng qu 1kg/ ngy -> cn trng lng BN sau cho

thuc mi ngy.
51. BN c trn dch a mng (g c vng thp, g c 2 y phi) -> mc
nng.
52. khng thun ty: km VCT, cre tng -> LS: gim m, gim lc biu hin ca thn vim.
53. Nhc li: tr/c ph -> ch n. Nng -> quai. TB -> truyn kali, LT
thiazid : da vo ion quyt nh iu tr. Truyn albu : mc ch? -> phc
hp Lasix + pro c hp thu quai Henle ri thi ra ngoi, tuy nhin BN chc
nng thn gim -> ng lng gn khng m bo to ra lng pro nh bnh
thng -> pro gim: ging nh xe (pro) ti Lasix khng , v vy phi truyn
albu (pro) - tng xe ti (li tiu tt).
54. C th: BN ph mc nng -> li tiu Quai: mt kali nn kt hp LT
tit kim kali (gim liu Quai) hoc truyn kali.
55. Cc cu hi t ra:
1) b Li tiu: li ch? bt li?
2) lipid mu tng? khi no iu tr?
3) s dng li tiu xong -> h p. Nu HA vn cn cao: s dng UCMC, c
ch AT2: gim tiu m. Ti sao?
56. HCTH - tnh hung: BN tun th iu tr - c th xy ra:
1) ti pht
2) ph thuc

3) khng Cor
4) p ng: hon ton, > 50%, < 50%.
57. Gii thch: v d
- Ngng thuc trong vng 2 tun b li. Hoc: p ng xong gim liu: tng
m niu tr li -> l thuc.
- Sau 2 tun ti li (khng ngng thuc) -> ti pht: chia ra: 1. thng
xuyn - ( > 2 ln/ 6 thng ); 2. khng thng xuyn - (< 2 ln/ 6 thng).
- iu tr lin tc 6 - 12 tun: khng p ng/ p ng km -> khng.
- Trc p ng ri m m niu vn cn cao: > 1g/ 24h -> ti pht:
tng gp i liu.
58. Gim liu t t sau khi m niu (-), d mc gi c m niu (-) ri
duy tr.
59. C 2 th: 1.thn h (huyt ng): p ng iu tr; v 2. so c: iu tr
hoi khng p ng -> ngng.
60. tr con: (-) sm nht -> 2 tun, gim -> 1 tun. Ngi ln: (-) sm nht
-> 4 tun, gim -> 2 tun (TE 2-1, NL 4-2) : do s dng UCMC, UCAT2.
V cui cng:
* Tnh hung: BN b HCTH. Nhng m niu/24h < 3g: c nhng nguyn
nhn no?
-> Cn bit quy trnh t ly nc tiu n khi hon thnh xt nghim:

1) 7h: BN tiu ra, sau tiu vo bnh (trc ra sch), 7h hm sau: tiu
vo.
2) bnh c ly ri lc u, sau chuyn sang chai nh
3) Li tm tnh lng m ri nhn ln theo th tch.
Vy c cc nguyn nhn:
1. NT ly khng . Nu ly : trng hp v niu or thiu niu -> NT ly
c < 300ml: KQ khng chnh xc.
2. Khng lc. Nu c lc: li tm khng u.
3. Tiu > 300. Lc u. Ly ng. My ng. Vn < 3g: do u? -> do iu
tr c p ng.