NHM IV

BNH N
GV HNG DN: BSCK II HONG DANH TN

BNH N
1/ HNH CHNH
H tn: NG TH C. n, 46 tui
Ngh nghip: Bun bn
Quy Nhn, Bnhnh.
Ngy NV: 23h 3/12/2015
P24- Khoa Ngoi TH-BV DHYD

2/ L DO NHP VIN

AU QUANH
RN

3/ BNH S:( BNH 1 thng)

1 thng

- au qun cn vng
trn rn t ngt, ko
di 1, 1-2 cn/ngy,
gia cn khng au.
Trung i tin(+)
=> khm BS t, iu
tr khng r.

7 ngy
au tng dn
-Khong cch cn ngn li
2-3h/cn
-Bng trng.
=> NV BV Quy Nhn
K manh trng di cn
gan.
: khng r. 3 ngy
khng gim=> BV hyd,
ni soi t=> Cho v

1 ngy

-au khng gim,

khong cch ngn li.
-B trung i tin
- Bng chng
- => BV HYD

S thy di (P) c khi trn, thy r mi khi au bng. Bn chn n,

khng ho, khng khc m, st nh v chiu, km n lnh, m hi
trm v m. i cu 1-2 ln/ngy, vng hi st. St 5kg/thng( t 39kg=>
34kg).

Tnh trng lc NV
BN tnh, tip xc tt, gas(+).
M : 80 l/p
Nhit : 37,5
Huyt p: 110/70 mmhg.
Bng mm, khng khng.
S thy khi di HCP, n au nhiu.
Du rn b(-), du quai rut ni(-).
TR:Trc trng rng, lng trn lng. Rt gng sch. C
vng hu mn tt.

4/ TIN CN

PARA=4004

( sinh thng)

MVRT cch y10 nm

5/ KHM (12H NGY 4/12/2015)

Tng trng
M : 80 l/p
Nhit : 37,5
Huyt p: 110/70 mmHg
Nhp th: 20l/p

Nim hng. Khng mi kh, li d.

Da khng vng, kt mc mt khng vng
Khng du mt nc.
Hch vng c, thng n, hch nch, hch bn (-).
TR:Trc trng rng, lng trn lng. Rt gng sch. C
vng hu mn tt.

Khm 12h 4/12/2015

Khm bng
Bng mm, bng trng u
So m khong 5cm h chu (P), lnh tt
Nhu ng rut tng(10l/p), m sc tng
Du rn b (-)
G vang khp bng.
Bng chng, n au vng hng P+ quanh rn.
khng(-)
Khi vng h chu phi 8x8 cm, mt chc,
b mt trn lng, gii hn khng r, km di ng.
Gan lch khng s chm.

6/ TM TT BNH N
Bn n, 46 tui, NV v au quanh rn, bnh 1 thng
TTCN:- au bng cn.
- Bng trng.
- B trung i tin.
- St cn.
- Hi chng nhim lao chung.
TCTT: - Sinh hiu n.
- Bng mm, trng u
- Vt m h chu (P)
- Khi vng h chu(P)
- Nhu ng rut tng, m sc tng
- TR: trc trng rng.
TC: - M h VRT cch 10 nm
CLS BVQN: CTScan u manh trang nghi K di cn gan.

Bnh nhn c vn g?
Chn on s b?
Xt nghim no cn lm ?

t vn

1. Hi chng tc rut.
2. Khi h chu (P).
3. CLS ca bv QN-B: u manh trng nghi Kdi cn
gan.
4. Hi chng nhim lao chung.
5. Tin cn: m VRT 10 nm trc.

sb :Tc rut nghn do u manh trng nghi K di cn gan,

cha bin chng.
pb Tc rut nghn do lao hi manh trng, cha bin
chng.
PB : Tc rut do dy dnh sau m VRT, cha bin chng.

BIN LUN
1/ C TC RUT
KHNG?

2/ NGHN HAY
THT?

3/ V TR TC

4/ NGUYN NHN

-HI CHNG TC RUT

- NR, M RUT TNG

-BN TC
- BT HON TON(+/-)

- NN(-)
- BNG TRNG U
- KHONG CCH GIA CC
CN AU DI HN SO TR
NON.

J-KHI HC (P)
- -SUT> 10%m/Thng
- -CLS BV QN

C TR C
HC

NGHN

TR GI

U MANH
TRNG NGHI
K

+ KHNG HI
CHNG NHIM
TRNG
- KHNG DU MT
NC, KHNG NN
I

CHA BIN
CHNG

 NGH CLS
CLS

CHN ON: Xquang bng khng

sa son, siu m bng, CT-scan bng

CLS

THEO DI V iU TR: CTM, ion ,

BUN, creatinine, AST, ALT, Bilirubin , Xquang
ngc thng.

X QUANG
BNG
KHNG
SA
SON

KT LUN
-

Mc nc hi chnh nhau
TR c hc
Cc quai rut xp chng ln nhau di
(p), chn hp vm cao, np nim mc chy
di ht quai rut.
- Cn thy bng hi i trng chu hng=>
tc rut thp.

Siu m bng

Kt lun: Theo di k i trng ln di cn gan.

C T SCAN BNG

 Kt

lun

Tc khng hon ton rut non on thp, v

tr chuyn tip gia gc hi manh trng, ngh do
k manh trang (T4N2aM1).
Dy thnh on cui hi trng ngh do k
xm ln hoc vim phn ng.
Tn thng gan a ngh do di cn.
Dch bng lng t.

XQUANG PHI

- Cung MC phng.
- Cha pht hin bt thng
khc.

CTM
Khng

thiu mu (Hb: 12.1g/dL, Hct:

33.4%, WBC: 8,1k, %Neu 63,3)
AST, ALT, BILIRUBIL
Cc ch s trong gii hn bnh thng

 BUN,

creatinin trong gii hn bnh thng

khng suy thn cp trc thn

Ion

Natri
Kali
Clo
Cacil
=> Bnh thng.

136,9 mEq/L
3,88 mEq/L
99,9 mEq/L
4,7 mEq/L

CHN ON XC NH

Tc rut do K manh trng di cn gan.

1/ C CH NH M KHNG?
Ti thi im nhp vin
A. iu tr ni
- Ngh ngi ti ging
- Nhn n ung hon ton.
- B nc in gii ng tnh mch
- Khng sinh d phng
- Theo di st bnh nhn, tnh trng au, i bng, trung
i tin, v trn Xquang bng khng sa son.
B. iu tr ngoi( Nu tc rut tm lui)

1/ C CH NH M KHNG?(tt)
Ti thi im khm, sau 13h khng ci thin vi iu tr bo
tn, din tin tng dn.
iu tr ni:
-t ng thng mi d dy, ht dch d dy ngt qung tng t.
-Khng sinh ph rng:
Ceftriaxone 1g 1 l tim tnh mch chm
Metronidazole 1l 100ml TTM chm XXX git/pht.
-Truyn dch b nc v in gii:
NaCl 0,9% 500ml TTM XXX git/pht.
- iu chnh ng huyt, huyt p trc m.
iu tr ngoi:
iu tr bo tn khng hiu qu.=> M.
Cn gii thch cho ngi nh bit nguy c phu thut.

2/ NU M D KIN LM G?
Tc rut do K manh trng:
- Ct ni c.
- Ct ni khng c: ni tt, dn lu gii p.
Tc rut do Lao: ct khi lao, hch mc treo gi GPB.
Tc rut do dnh: tho dnh rut, ti lp lu thng ng
rut.

3/ TIN LNG SNG?

- Sau

m: cn theo di cc bin chng sm ca

cuc m.
- T vong sau m 20-30%.
- Tin lng sng 5 nm giai on IV l 11%.
- Bnh nn + suy kit.
=> XU

Ti liu tham kho

iu tr Ngoi khoa Tiu ha-HYD TP H Ch Minh.

Bnh hc Ngoi Khoa Tiu ha- HYD TP H Ch Minh.
ACS Surgery 2008 Chap V.