HNH CHNH

H v tn bnh nhn: TRN TH PH. N

Nm sinh: 1968
Ngh nghip: ni tr
a ch: G Vp, TP.HCM
n khm: 9h30, 21/12/2015
LDNV : khi vng c
BNH S

Cch NV 2 thng, bnh nhn nhn thy khi vng c,

khng r kch thc, khng au km nut nghn, BN
khng iu tr g. Khi vng c ngy cng to dn, BN
nhp vin Bnh Dn.
Trong qu trnh bnh, BN khng st cn, khng hi
hp, khng nh trng ngc, n ung bnh thng,
tiu tiu bnh thng, khng nng ny, cu gt.
DIN TIN

Tnh trng lc nhp vin:

Tng trng trung bnh, nim hng khng vng
Hch c (-)
Tuyn gip a nhn 2 thy, III, di ng, khng
au
Gan, lch khng s chm
Sinh hiu:
M 104 l/ph, N: 370C, NT: 20 l/ph, HA: 110/80 mmHg

Chn on lc nhp vin: u gip a nhn 2 thy/ THA

TIN CN

a) Bn thn
Ni khoa:
- THA, ri lon tin nh: pht hin cch y 3 thng, iu tr
n
Ngoi khoa: cha ghi nhn bt thng
PARA 2002
Khng tin cn d ng
b) Gia nh: cha ghi nhn bt thng
LC QUA CC C QUAN

- Tai mi hng: khng khn ting, khng au hng

- H h hp: khng ho, khng kh th
- H tim mch: khng hi hp, khng nh trng ngc
- H tiu ha: nut nghn, khng tiu chy, khng to bn
- H tit niu: tiu vng nht, khng gt but
- H thn kinh: khng yu lit chi, khng nng ny, khng l
, khng m hi
 KHM LM SNG (9h
22/12/2015)

Tng qut:
- Sinh hiu :
+ Mch : 88 ln/ pht + Nhit : 370C
+ Huyt p : 130/70 mmHg + Nhp th : 20
ln/ pht
- Tng trng :
+ BN tnh, tip xc tt
+ Chiu cao: 1,45m ; cn nng : 58 kg BMI = 27,5 kg/m2
+ Khng ph, khng vng da vng mt, nim hng, mi khng
kh, li sch, khng nhiu m hi
+ Hch ngoi vi khng s chm
U MT C

+ Kt mc mt khng vng, khng sung huyt , mt khng li

+ C khng so m c, kh qun chnh gia, y lch c
+ Tuyn gip :
Nhn thy bu gip, khng thay i mu sc da, di ng
theo nhp nut
Bu gip 2 thy: thy (P) d#1x2 cm, thy (T) d#2x3 cm, s
c cc di bu, mt mm, b mt ln nhn, n
khng au, khng rung miu
Khng m thi
+ Hch vng c, thng n khng s chm
 NGC

Lng ngc cn i, di ng u theo nhp th, khng sao mch,

khng tun hon bng h, khng so m c
Tim : mm tim lin sn 5 ng trung n tri, khng p
bt thng; tim u 88 ln/ pht, T1 T2 r, khng ting tim bnh
l
Phi : lng ngc dn n u, rung thanh u 2 bn, g trong, r
ro ph nang m du 2 ph trng, khng rale
BNG

+ Cn i, di ng u theo nhp th, khng tun hon

bng h, khng so m c
+ NR 4 ln/ pht
+ G trong, khng g c vng thp
+ Bng mm, khng u cc, khng im au khu tr,
gan lch khng s chm, chm thn (-). Bp bnh
thn (-)
T CHI CT SNG

+ Chi trn : M cnh tay M quay u 2 bn,

lng bn tay v mng hng; khng run tay
+ Chi di : M khoeo, M chy sau, M mu
chn u r
+ Khp khng sng au, ct sng khng g
vo
TM TT BNH N

Bnh nhn n, 47 tui, n khm v khi vng c, hin c cc vn

- Cm thy khi vng c, nut nghn
- Khm bu gip:
Nhn thy bu gip, khng thay i mu sc da, di ng theo
nhp nut
Bu gip 2 thy: thy (P) d#1x2 cm, thy (T) d#2x3 cm, s c
cc di bu, mt mm, b mt ln nhn, n khng au,
khng rung miu
Khng m thi

-Khng hi chng cng gip, khng hi chng nhc gip

- Tin cn: THA, RLT
CHN ON S B

BU GIP A NHN 2
THY N THUN III /
TNG HUYT P, RLT
CHN P THC QUN
BIN LUN LM SNG

BN nhp vin v l do khi vng c qua thm khm tnh

cht bu ngh nhiu bu gip a nhn 2 thy, ngh c
chn p thc qun gy nut nghn.
BN khng c hi chng cng gip, nhc gip ngh bu
gip a nhn 2 thy n thun.
Khm thy kh quan khng lch, s c cc di bu
gip nn khng ngh bu gip thng
CN LM SNG

ngh:

- Cng thc mu, nhm mu, glycemie, TQ,

TCK, fibrinogen
- Bilan lipid, ure, creatinin
- Soi y mt, siu m tim, ECG siu dng
mch cnh, siu m bng
- Siu m tuyn gip, XQ ngc thng
- fT3, fT4, TSH
Kt qu CLS:
CTM 21/12/2015 ng mu 21/12/2015
WBC 9,87 K/uL PT 11,0
Neu 54,1 % PT chng 12,0
Lym 40 % APTT 29
Mono 4,44 % APTT chng 32
Eos 0,55 %
Baso 0,98 %
RBC 4,51 M/uL
Hb 13 g/dL
Hct 40 %
MCV 88,7 fL
MCH 28,8 pg
MCHC 32,5 g/dL
RDW 11,3%
PLT 407 K/uL
Sinh ha mu 21/12/2015
Urea 3,7 mmol/L
Glucose 4,5 mmol/L
Creatinine 62 umol/L
Protein total 77 g/L
AST 20 U/L
ALT 12 U/L

21/12/2015
TSH 0,62 uIU/mL (0,5 4,7)
TT3 0,99 ng/mL (0,8 2,0)
TT4 7,32 ug/dL (4,5 12,5)
SA tuyn gip Thy T Thy P
K ngang 17 mm 18 mm
B dy 12 mm 10 mm
Echo Dy hn c C
Tn thng C nhn phn m C nhn phn m
dy d#19*11 mm, km d#5mm, gii
tng sinh mch mu hn r, b u
vin
Hch c Khng
Kt lun Bu gip a nhn 2 thy ngh nhn lnh
tnh
X- quang ngc thng, ECG
Trong gii hn bnh thng.
CHN ON XC NH

BU GIP A NHN 2
THY N THUN III
chn p thc qun/ THA,
RLT
iu tr

Ngoi: phu thut