H v tn sinh vin: Nguyn Hu Tuyn

T 14- Lp Y5D

BNH N
Khoa: D ng V Min Dch Lm Sng
I, Hnh Chnh
1, H v tn bnh nhn: Giang Th c
Tui 91
2, a ch: Cm Thnh Cm Xuyn H Tnh
3, Ngh nghip: Lr
4, Ngy vo vin: 23/12 / 2016
5, Ngy lm BA: 29/12/2016

Gii N

II, Chuyn Mn
1, L do vo vin: au, lot hoi t ngn chn hai bn
2, Bnh s:
Bnh nhn c chn on X Cng B cch 2 nm vi cc triu
trng: au khp, nut kh, nn, bun nn, ri lon tiu ha, bnh phi k. Hin
iu tr Medrol liu 16mg/ ngy, truyn Endoxan 5 t t t6 2015.
Cch vo vin 5 thng bnh nhn xut hin au, lot ngn chn 2 bn
vi c im: Sng tm au 10 u ngn chn, au d di v m, nhiu vt lot
hoi t kh mi thi kthc 2x3 cm v tr: Chn P: u ngn 2 3, mt c ngoi,gan
bn chn, chn tri: u ngn 2, mu chn.
Bnh nhn tiu tin nc tiu vng, s lng bth, khng au u
khng ho, khng au tc ngc, khng au bng, khng r nhit .
3, Tin s:
A, Bn thn: X cng b cch 2 nm
THA cch 2 nm iu tr amlordipine, Ha khng n
nh
Khng c tin s T, cha pht hin tin s d ng
Cc bnh l ni ngoi khoa khc: Khng

B, Gia nh: Cha pht hin bt thng

4, Khm
A, Ton trng
Bnh nhn tnh, tip xc c
Da nim mc nht nh
Khng ph, khng XHDD
Rng tc, mng tay khum c kha
Tuyn gip khng to hch ngoi vi khng s thy
M: 80l/p, HA: 140/80 mm Hg, T: 37 *C, Nhp th: 20l/p
B, Tn thng c bn
- Mt : Da vng mt, trn phng mt np nhn, mi mng, da
vng quanh ming nhn nheo hnh nan hoa, khng lot ming
- Tay: Gin mch u ngn kthc 5 mm
- Chn: da cng chn dy, cng, teo da
- Nhiu vt lot hoi t kh ngn chn, mt c, gan chn, mu
chn 2 bn, ranh gii r, da xung quanh tm, sng n

C, H h hp:
Lng ngc cn i di ng theo nhp th
Phi RRPN r, u 2 bn, khng rales
D, H tim mch
Lng ngc cn i, khng tun hon bng h
Mm tim khng s thy
T1 T2 u, tn s 80 ck/p, khng c ting thi bt thng
Mch mu: Mch mu chn, mch khoeo hai bn kh bt, P < T
Mch quay, mch cnh 2 bn bt c
E, Khm bng
Bng cn i, khng so m , khng tun hon bng h
Gan, lch, thn khng s thy
G trong

F, C xng khp
au khp gi, c chn ngn chn 2 bn, au nhiu v m
Cc khp khng sng nng , khng bin dng
Cng, kh vn ng cc ngn chn, c chn
Cc khp ngn tay khng sng au vn ng c
G, Thn kinh

5, Tm tt bnh n:
Bnh nhn n 91 tui tin s XCB , THA 2 nm, iu tr Medrol
16mg/ ngy, truyn Endoxan 5 t, vo vin v au, lot hoi t ngn chn 2
bn, bnh din bin 5 thng nay. Qua hi bnh v thm khm pht hin cc triu
chng v hi chng sau:
- Ton trng: bnh nhn tnh, da nim mc nht
M 80 l/p, Ha 140/80 mmHg, T: 37 *C
- Lot hoi t kh phn mm,r anh gii r, da xung quanh tm sng n
v tr: ngn 2 3 chn P, gan bn chn, mt c ngoi chn P, ngn 2 chn T, mu chn
T
- Mch mu chn, mch khoeo 2 bn kh bt, bn P < T, da u chi
lnh
- Tn thng da: Da mt mt np nhn, da vng ming nhn nheo
hnh nan hoa, da cng chn dy cng.
- Cng cc ngn chn, cc ngn tay bth
- Bnh nhn i tiu vng, s lng bnh thg, khng ho khng au tc
ngc, khng au u
6, Chn on s b: Hoi t u chi nghi do tc mch/ X Cng B
7, Chn on phn bit: Hoi t u chi do T, Tng ng mu,.

8, Bin lun:
Triu chng lm sng ngh ti hoi t v khun u chi do tc mch
vi cc biu hin:
- Lot hoi t kh, khng chy dch chy m
- Mch mu chn, mch khoeo 2 bn kh bt
Bnh din bin trn nn bnh nhn x cng b 2 nm, c ch tn
thng nghi do x ha cc mch mu kch c nh.
Cha loi tr tn thng do T hoc phi hp vi T gm bn
chn do thn kinh, bn chn do mch mu

9, Tm tt kt qu CLS:
A, Tng ptich TB mu ngoi vi
Hc: 3. 75
Hb 117
Bc: 13. 02, NEU: 77,5 %
Tc: 94
B, ng mu c bn
PT(s ) 9,9 PT% 119
PT- INR : 0,9
APTT : 23,8
APTT ( b/c ): 0,8
Fibrinogen: 3,41
C, Sinh ha mu:
Ure: 14,9
Glu: 13,3
AST: 23
CK: 85

Cre : 93
HbA1C: 5,5
Alt: 20
CK- MB: 15

Protein TP: 54,8.

Bilirubin: bht
Cholesterol tp: 5,12

Albumin: 31,6
Triglycerid: 1,97 HDL: 1,23 LDL:

3,00
RF: 0,0
C3 : 0,88
Troponin T: 0, 06
Pro- Cal : 0,1

C4: 0,21
NT- Pro BNP: 481

D, Tng phn tch nc tiu:

Pro: 0,3
ERY: Neg
A/C: 17.0
E, Siu m tim:
Thnh tht tri dy bung tht tri khng dn, CN TTTT trong
ghan bth
H HL nh
H ch nh
ALMP: PAPs 27 mmHg ( Bth < 30mmHg)
F, in tm :
Block nh tht cp I
G, Doppler ng mch tnh mch chi di
X va ri rc h ng mch chi di 2 bn khng nh hng
n tc dng chy
H, Xq tim phi
Dy t chc k 2 bn
I, Sa bng: si ti mt
10, Hng iu tr:
Bnh nhn gi yu, nghi ng c tnh trng suy tim, ngh n
iu tr ni khoa
Hi chn chuyn khoa ngoi, chuyn khoa tim mch, chuyn
khoa ni tit, chuyn khoa dinh dng, gii thch gia nh.

Thuc:

1, c ch min dch Corticoid

2, Khng ch huyt p: Amlordipine
3, Khng sinh ti ch, ton thn chng bi nhim
4, Tng cng dinh dng: Pentoxipharm
5, iu tr phc hi thn kinh: Nivalin
6, Gim au, chng vim: Arcoxia
7, Chng ng: Aspirin km bo v d dy

11, iu tr:
1,NaCl 0,9 % 500ml Truyn Tm
2, Dalacin C: 600 mg-4 ml x 3 l Truyn Tm 9h 15h 21h
3, Medrol: 16mg x 1 vin ung 1 ln 8h sng
4, Amlor 5mg x 2 vin chia 2 ln
5, Pentoxipharm 100mg x 2 vin chia 2 ln
6, Nivalin 2,5 mg x 1 ng, Tim bp 1 ln
7, Synapain, Perfalgan, Arcoxia
8, Aspirin 100mg x 1 vin ung 1 ln
9, Pantoloc 40mg x 1 l Tim Tm 1 ln