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Y BAN NHN DN TP.

HCM
TRNG TRUNG CP TY SI GN

Hc vin: Bu Thanh Ton


Lp: Y4

BNH N
I. HNH CHNH

- H tn bnh nhn: Chu Hng Tui: 51 Gii: Nam


- Ngh nghip: nng dn
- a ch: p Ph Hu, X Ph Tm, Chu Thnh, Sc Trng
- Ngy ti khm: 15/6/2017
- Ngy lm bnh n: 17/6/2017
- Thun tay: T

II. L DO N KHM:

- au lng lan xung chn tri

III. BNH S:

- Thng 6/2014 bnh nhn b au lng sau khi khun vc nng. Bnh nhn n khm bnh
vin a Khoa Sc Trng vi chn on l b thot v a m L4-L5. Bnh nhn dc iu
bng phng php tim mng cng. K t , bnh nhn hay b au lng, au lan xung mng,
mt ngoi i tri, mt ngoi cng chn v ngn chn p t. au tng khi ngi lu, khi ho hoc ht
hi, c bit l ban m , au nhi ti im c nh. au gim khi di li nh nhng. Khong 10
ngy nay, bnh nhn thy au tng nn n khm.

IV. TIN CN:


1. Bn thn:
- Ni khoa: cha ghi nhn
- Ngoi khoa: thot v a m L4-L5
- Thi quen sinh hot:
- D ng: khng
2. Gia nh
- Khng ai mc bnh g c bit

3. X hi
- Hon cnh kinh t: yn tm iu tri
- Khng kh gia nh: vui v, khng sang chn tm l

.V KHM LM SNG:
1. Tng trng
- Sinh hiu: - Mch: 84 l/ pht Nhp th: 20 l/pht Huyt p: 130/84 mmHg
Chiu cao: 1m65 Cn nng: 60 kg Nhit : 37
- Tng trng trung bnh BMI= 22
- Hch ngoi bin khng s chm
- Ko ph, kg xut huyt da nim, ko tng sc t da
- Da nim hng, kt mc mt ko vng
2. u mt c:
- u cn i, khng u cc, khng so m c
- Hng hng, li mi kh, khng tm
- Tuyn gip khng to
- Tnh mch c khng ni
- Mch cnh p u 2 bn, khng m thi

4. Vng ngc
- Lng ngc cn xng, di ng theo nhp th, khoang lin sn khng gin, khng hnh
dng bt thng, khng co ko c h hp ph
- Du sao mch (-)
- Rung thanh u 2 bn
- R ro ph nang m du, khng ran.
- Khng du ny trc ngc, mm tim lin sn V ng trung n (T), rung miu (-),
Harzer (-), ting T1, T2 u r, khng m bt thng vng tim.

5. Vng bng
- Bng u, i xng, to b, khng lm, khng tun hon bng h, khng ni u cc, khng
so m, di ng theo nhp th.
- Bng chng, n khng au, khng u cc, gan lch khng s chm
- Khng m thi MC bng, M thn

6. C xng khp:
- Ct sng ko g vo, cc khp ko sng, ko gii hn vn ng, c nho
- 2 gi ko sng nng , ko bin dng, ko gii hn vn ng, bp bnh xng bnh ch (-),
lo xo khp gi (-)
- n au ct sng L3-L5
- Mt ng cong sinh l L3-L5
- Khng teo c vng mng, chn bn tri.
- Du hiu lasegue tri 60
- Du hiu Bonnet (+)
- Du hiu Valeix (+)
- Du nhn chung in : dng tnh ( +)

7. Khm dinh dng;


- C 2 bn u, khng c teo c.
- Khng c ri lon c trn , i tiu tin t ch.
8. Khm thn kinh:
a. Chc nng thn kinh cao cp
- ko pht hin thy du hiu bnh l

b. T th dng b:
- Dng i hi nghing v bn phi

c. 12 i dy thn kinh s no
- Khng pht hin bt thng

d. TK vn ng:
- Vn ng ch ng : Khng ng c bng gt chn
- Vn ng th ng : Nghim php chng i gp mu bn chn (T) yu hn chn (P)

e. TK cm gic:
- Khm cm gic: gim cm gic ngon ci.

f. Phn x:
- phn x gn gi, gn gt 2 bn bnh thng.

g. Du mng no:(-)

.VI TM TT BNH N
- BN Chu Hng , 51 tui , n khm v l do: au lng lan xung chn tri
- Triu chng c nng:
au vng tht lng, lan xung mt ngoi i tri, mt ngoi cng chn, ngn th 4
au nhi, au tng khi vn ng ( ho), tng v m.

- Triu chng thc th:


Du nhn chung in dng tnh (+)
Lasegue: 60
Du hiu Bonnet (+)
Du hiu Valeix ( +)
Khng i c bng gt chn

.VII CHN ON S B:
- au r dy thn kinh L5

.VIII NGH CN LM SNG:

- X quang ct sng tht lng- thng, nghing

.IX KT QU CLS:

- Thot v a m L4-L5
.X CHN ON XC NH:
- au r dy thn kinh L5 do thot v a m

.XI YHCT:
.1 Vng:
- Cn thn, mt tinh anh
- Th trng trung bnh
- Da nim hng, kt mc mt ko vng, mt khng sng khng , khng au
- Dng i hi nghing v phi.tay chn khng run
- Khng i bng gt chn c.
- Hng hng, mi khng kh
- Li tm, c im huyt, ru vng. Khng c du rng. Khng lch, khng rung.
- Mng nhun
- Mi, tai ko chy dch bt thng
- Thi ha nh, khng cu gt
.2 Vn:
- Ting ni r, va
- Ko ho, ko nc, ko kh th
- Hi th ko hi, ko mi l
.3 Vn:
- Khng s nng, khng s lnh, khng st
- Khng t hn, khng o hn
- n ngon ming, khng kht
- Nc bnh thng, mu vng, khng tiu m
- i tin khng to khng lng
- Khng au u, khng hoa mt chng mt, khng au tai, khng tai
- au vng ct sng tht lng tri, lan xung mng, mt bn i tri, au nhi im c nh, au
tng khi ngi nhiu, khi v m.
- Khng au ngc, khng au bng
- Hay tnh gic v m do au.

.4 Thit:
- Xc chn: da khng kh, tay chn khng lnh
- Kinh lc chn: au dc theo ng kinh m
- Phc chn: khng au
- Mch chn: sp

.XII CHN ON YHCT:

- Chng: ta ct phong
- V tr tn thng: kinh m
- Bt cng: biu thc hn
- Nguyn nhn: bt ni ngoi nhn ( huyt )

.XIII BIN LUN YHCT:


Huyt lm b tc ng kinh m gy au dc theo ng kinh

Huyt
au nhi im c nh
au tng v m
Li c im huyt

Biu chng

Bnh nng, ti kinh lc, c xng khp

Hn chng:

Ru li trng, mng,
Tiu trong, nhiu
au tng v m

Thc chng

Ngi khe mnh


Ting ni to r, c lc
Mch hon hon, c lc
C n: n au Gip tch L3-L5, hon khiu, y trung, tha sn

.XIV IU TR:
.1 Nguyn tc iu tr:
- iu tr theo nguyn nhn
- Gim au v phc hi vn ng nhanh
- iu tr ni khoa

.2 Phng php iu tr:


a. Dng thuc:
- Ty y:
Thuc gim au: Paracetamol 0.5g 01vin x 03 ln/ ngy, hoc Efferalgan 01vin x 03 ln/
ngy
Thuc khng vim Non Steroide: Diclofenac 50mg 01vin x 03 ln/ ngy, hoc Ibuprofen
0.2-0.6g 01vin x 03 ln/ ngy, hoc Celecoxib 0.1g 01vin x 02 ln/ ngy, hoc Rofecoxib
0.025-0.05g 01vin x 02 ln/ ngy.
Thuc khng vim Steroide: C th s dng n c hoc phi hp vi khng vin Non
Steroide. C th s dng mt trong cc loi sau: Prednison 0.005g 01-02vinx 03 ln/ ngy,
Dexamethason 0.5mg 01-02vinx 03 ln/ ngy.

- ng y: Hnh kh hot huyt kh , thng kinh hot lc - T Vt o Hng Gia V


ng Qui 12 g
Sinh a 12g
Xch thc 12g
Xuyn khung 12g
o Nhn 8g
Hng Hoa 8g
an sm 12g
K huyt ng 10g
Trn b 8g
Ngu tt 12g
Ut kim 8g
Cam tho 6g

b. Khng dng thuc:


- Chm cc huyt: Hp cc, Tam m giao, Cch Du, Hong khiu, Dng Lng tuyn, ngoi
khu, khu kh, i tr, tm du, huyt hi.
- Vt l tr liu: ngm chn nc nng, chiu tia hng ngoi