BNH N NI KHOA

I) PHN HNH CHNH:

H v tn: ng Th T. nam 23 tui
Ngh nghip: ti x
a ch: Phan Thit, Bnh Thun
Ngy gi nhp vin: 11h am, 03/01/2017
Ging s 7, phng s 8, khoa ni thn, bnh vin Ch Ry
II) L DO NHP VIN: st
III) BNH S:
5 ngy trc NV, BN st lc 11h ti, khng r , km theo n lnh,
khng lnh run, khng v m hi, BN mua thuc ung th ht st. BN
tiu khng gt but, khng lt nht, khng tiu gp, nc tiu vng trong.
BN khng au bng, i tiu phn vng ng khun
3 ngy trc NV, BN st lc 1h sng, khng r vi tnh cht tng t
nh trn nhng nng hn, BN nhp vin BV An Phc (Bnh Thun)
(iu tr 2 ngy). Sau NV BN gim st nhng bt u au hng lng.
au bn phi, khi pht tng dn, au m , m h ko di, khng lan,
i khi au qun thnh cn ko di 5 10 pht, khong cch gia cc
cn khng r, khng c yu t tng gim au. BN i tiu v i tiu vi
tnh cht tng t nh trn, ung 1,5l nc/ngy, nc tiu lng 600
ml/ngy
Chn on ca BV An Phc:
Mch: 90 ln/pht
Huyt p: 80/50 mmHg
Nhit : 41 C
CRP: 150 mg/ml, albumin: 9,89 g/dl
Chn on: chong nhim trng/ nhim trng tiu/ hi chng thn
h
iu tr 2 ngy ti BV An Phc khng gim, BN xin chuyn ln BV
Ch Ry
Din bin sau NV CR: BN cn st nh, au hng lng gim cn 3/10,
sinh hiu lc nhp vin:
Mch: 80 ln/pht

 Nhit : 37,5 C
Huyt p: 100/60
Nhp th: 20 ln/pht
Trong sut qu trnh bnh, BN khng au u, khng chng mt,
khng chy m tai, khng s mi, khng au hng, khng ho, khng
au ngc, khng au bng, khng tiu chy, khng to bn, khng au
h v, khng au l tiu, khnng vim lot ngoi da
IV) TIN CN:
1) Tin cn ni khoa
Nm 8 tui, BN ph ton thn c chn on hi chng thn h ti
BV tnh, sau khi ht ph BN khng ti khm v iu tr g thm
Nm 16 tui, BN li ph ton thn, nhp vin Ch Ry, khng r
chn on, sau khi ht ph BN khng tip tc iu tr
Ngoi hai ln trn, BN khng mnh c ph hay khng
Cha chch nga VGB
Cha ghi nhn tin cn si thn, tng huyt p, i tho ng, suy
gim min dch v cc bnh l lin quan khc
2) Tin cn ngoi khoa: cha ghi nhn
3) Thi quen:
Khng c tin cn d ng
BN khng ht thuc l, khng ung ru
BN quan h tnh dc cch y 2 thng, khng s dng bin php trnh
thai
4) Tin cn gia nh: khng ghi nhn tin cn gia nh
V) LC QUA CC C QUAN:
1) Tim mch: BN khng au ngc, khng hi hp, khng ngt
2) H hp: BN khng ho, khng kh th
3) Tiu ha: BN khng au bng, khng tiu chy, khng to bn
4) Tit niu: i tiu khng khng gt but , khng gp, khng lt nht, nc
tiu vng trong, lng 600 ml/ngy
5) Thn kinh c xng khp: khng au u, khng chng mt, khng au
nhc cc khp
VI) KHM LM SNG: cch NV 9 ting
1) Khm tng qut:
Bnh nhn tnh, tip xc tt, nm u bng
Sinh hiu lc khm:
Mch: 90 ln/pht

 Nhp th: 20 ln/pht

Huyt p: 110/90
Nhit : 37,5 C
Chiu cao: 1m7, cn nng: 65kg, th trng cn i
Hch ngoi bin khng s chm
Mi khng kh, li khng d, da nim hng, khng du xut
huyt, khng so m c, khng tun hon bng h
BN ph hai chn i xng, t bn chn ln u gi, ph nh, n
khng lm, khng au. Ph nh hai bn tay i xng. BN khng
ph mt, khng bng bng
2) Khm c quan:
a) u mt c:
Cn i khng bin dng
Tuyn gip khng to
Kh qun khng lch
TMCN 45 (-), phn hi bng cnh (-)
b) Lng ngc:
Cn i, khng bin dng, di ng u theo nhp th, khng du
xut huyt, khng so m c, khng p bt thng
Tim: mm tim KLS 5, ng trung n tri, din p 2x2cm2,
du ny trc ngc (-), Harzer (-), T1, T2 u r, tn s 90
ln/pht, khng m thi bt thng
Phi: rung thanh u i xng hai bn, g trong khp phi, RRPN
lan ta khp hai ph trng
c) Tiu ha:
Bng cn i, phng, di ng u theo nhp th, khng du xut
huyt, khng tun hon bng h, khng du sao mch, khng so
m c
Nhu ng rut 5 ln/pht, khng m thi bt thng
G vang khp bng
Bng mm, khng im au khi s n, khng u g bt thng
B trn gan KLS 5, b di gan khng s chm, chiu cao gan 7
cm, lch khng s chm
Chm thn (-), bp bnh thn (-), rung thn (-)
d) Thn kinh: c mm, khng du thn kinh nh v
e) C xng khp: khng yu lit chi, khng gii hn vn ng

VII) TM TT BNH N:
BN nam, 23 tui, NV v st, bnh din tin qua 5 ngy, qua hi bnh v thm
khm pht hin nhng bt thng sau:
1) TCCN:
St cao, km n lnh, khng lnh run, khng v m hi, gim khi
ung thuc h st
au hng lng phi, tng dn, khng lan, au tc m , i khi qun
thnh cn, khng c yu tng gim
BN tiu khng gt but, khng lt nht, khng gp
2) TCTT:
St 41 C
Huyt p ti BV An Phc: 80/50 mmHg
Ph hai chn i xng t bn chn ln u gi, ph nh, n khng
lm, khng au
Ph nh hai bn tay i xng
3) TC:
Chn on hi chng thn h nm 8 tui
VIII) T VN :
1) St
2) au hng lng phi
3) Ph ton thn
IX) BIN LUN: