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- H v tn sinh vin : TRNH MINH CHU

- MSSV : 1253010245

- Lp : i hc Y a khoa kha 5

- Nhm lm sng : 15A

im Nhn xt ca ging vin

BNH N NI THN KINH

A. PHN HNH CHNH


- H v tn: L THNH . Tui: 58 Gii: Nam
- Ngh nghip: th h Dn tc: Kinh
- a ch: hai b trng, ninh kiu, cn th
- Vo vin lc: 7 gi 00 pht, ngy 3/09/2017
B. PHN CHUYN MN
I. L do vo vin: au u
Cch nhp vin 2 gi, ngi nh khai bnh nhn ang v sinh th t ngt au u,
au khp u, au lin tc ,km chng mt,nn i,mt nhn m, khng co git, khng
nn i, khng tiu ra qun,khng chn thng, c ngi nh a n c khm v
nhp vin ti Bnh vin a khoa Thnh ph Cn Th
Tnh trng lc nhp vin:
- Bnh tnh, tip xc c Glasgow 15
-mt nhm kn
- Sinh hiu: Mch: 80 ln/pht Nhit : 37oC
Nhp th: 20 ln/pht HA: 180/90 mmHg
X tr ti khoa cp cu:
-nm u cao 300
- Natricloride 0,9% 500ml: 01 chai (TTM) X g/ph
-furocemid 20mg 1 ng (TMC)
-captopril 25mg 1 vin (ngm di li)
- Chuyn ni thn kinh
II. TIN S
1. Bn thn
a. Thi quen:
- Ht thuc l 20 gi.nm (t nm 17 tui)
b. Bnh l
- Tng huyt p cch y 3 nm, HAmax = 180 mmHg, c iu tr thng xuyn bng
thuc Amlodipin 5mg, mi ngy 1 vin sng
- Cha ghi nhn d ng thuc
2. Tin s gia nh: cha ghi nhn bnh l lin quan (tng huyt p, i tho ng, tai
bin mch mu no)
III. Tin cn
- Tim u
- Phi trong
- Bng mm
- au u
IV. KHM LM SNG: lc 9 gi 00 pht, ngy 03/09/2017
1. Khm tng trng
- Bnh nhm mt, tip xc c
- Da nim hng nht
- Th trang trung bnh, BMI = 21 kg/m2 (CC: 1,7m; CN: 61 kg)
- Tuyn gip khng to, hch ngoi vi s khng chm
- Sinh hiu: Mch: 80 ln/pht Nhit : 37oC
Nhp th: 20 ln/pht HA: 130/80 mmHg
2. Khm thn kinh
a. chc nng thn kinh cao cp:
- Bnh m mt t nhin, tip xc c, G15 im (E4V5M6)
- C mm, du Kernig m tnh
b. t th dng b :
- Bnh nhn nm trn ging
- khng yu lit chi

c. 12 i dy thn kinh s :
- Dy I: khng khm c
- Dy II: mt nhn m
- Dy III, IV, VI: ng t kch thc 3mm, trn u 2 bn, phn x nh sng trc tip v
ng cm
- Dy V:+ phn x gic mc 2 bn cn
+ cm gic vng trn, g m, cm dng tnh
+ h ming c
- Dy VII:
+ Mt nhm kn
+ Np nhn trn cn
+ Np m mi cn
+ Nhn trung khng lch
- Dy VIII :cha ghi nhn bt thng
- Dy IX, X : li g khng lch, phn x nn v du vn mn khng khm c
- Dy XI : c c n chm 2 bn cn i
- Dy XII: li khng teo, khng rung git c li
d. H vn ng
- Trng lc c: tng
. chc: 2 bn bng nhau
. ve vy: 2 bn bng nhau
. gp doi: 2 bn bng nhau

- Sc c: Tay (T) 5/5 Chn (T) 5/5


Tay (P) 5/5 Chn (P) 5/5
e. H cm gic :
- Ri lon cm gic: cha khm c
f. phn x:
-- Phn x gn xng
+ Phn x c t u i 2 bn bng nhau
+ Phn x da bng u 2 bn
- Nghim php da lng bn chn (Babinski): Bn (P) p ng gp
Bn (T) p ng gp
- Nghim php Mingazini chn bn (T, P) m tnh

g. Du mng no
- c mm
-kernig m tnh , brudzinski m tnh
h. Cc thnh phn khc: nh hp s, ct sng, mch mu, h thn kinh tht vt cha
ghi nhn bt thng
3. Khm tim
- Lng ngc cn i, di ng theo nhp th
- Khng rung miu, Harzer (-), TM c khng ni
- T1, T2 u r, tn s 80 ln/pht, cha nghe m thi bnh l
- Mch mm mi, p r vi tn s 80 ln/pht
4. Khm phi
- Rung thanh u 2 bn
- G trong khp phi
- R ro ph nang m du, cha ghi nhn ran bt thng
5. Khm bng
- Bng mm, di ng u theo nhp th, khng co u cu c, khng c tun hon bng h,
khng c du sao mch, khng c so m c, khng du xut huyt
- Cha nghe m thi bnh l, nhu ng rut 5 ln/pht
- G trong
- Gan lch s khng chm
VI. TM TT BNH N
Bnh nhn nam, 58 tui vo vin v au u. Qua hi bnh s, tin s, v thm
khm lm sng ghi nhn:

- Bnh tnh, tip xc c Glasgow 15


-mt nhm kn
- au khp u, au lin tc ,km chng mt,nn i,mt nhn m
- Tin s:
+ Tng huyt p cch y 3 nm
+ Ht thuc l 20 gi.nm
VII. CHN ON V BIN LUN
1. Chn on
a. Chn on s b: au u ngh do xut huyt no /Tng huyt p III theo JNC VII
b. Chn on phn bit:
au u ngh do nhi mu no /Tng huyt p II theo JNC VII
2. Bin lun:
Ta thy sau hot ng gng sc(bnh nhn ang v sinh) th t ngt au u, au khp
u, au lin tc ,km chng mt,nn i,mt nhn m, ta ngh nhiu n xut huyt no
nhiu hn, tuy nhin cng khng th loi tr trng hp nhi mu no do cc mu ng
lm nghn mch, cn lm thm cn lm sng h tr chn on
VIII. CN LM SNG
1. Cn lm sng ngh:
- Tng phn tch t bo mu ngoi vi bng my m laser t ng: Hng cu, Hb, Hct,
MCV, MCH, MCHC, tiu cu, bch cu (BCNTT, BC a acid, BC a base, BC Mono,
BC lympho)
- Ha sinh mu: ure, creatinin, glucose, Na+, K+, Cl-, GOT, GPT
- Chp CT scan s no khng tim thuc cn quang (t 1-32 dy)
- o ECG
2. Cn lm sng c (ngy 19/06/2017):
- Tng phn tch t bo mu ngoi vi bng my m laser t ng:
. HC: 5,08.1012/l . MCV: 91 fl . BC: 8,32.109/l . BC a acid: 2,37%

. Hb: 136 g/l . MCH: 32 pg . BCNTT: 53,2% . BC a base: 1,14%

. Hct: 44% . M CHC: 327 g/l . BC lympho: 32,6% . BC Mono: 7,77%

. TC: 213.109/l

cha ghi nhn bt thng

- Ha sinh mu: .ure: 3,6 mmol/l .creatinin: 103 mol/l .glucose: 4,5 mmol/l
.Na : 135 mmol/l .K+: 3,9 mmol/l
+
.Cl-: 103 mmol/l
.GOT: 25 U/L .GPT: 15 U/L
cc ch s nm trong gii hn bnh thng
- Chp CT scan s no khng tim thuc cn quang (t 1-32 dy)
M t
* Ca s nhu m
+ Tng trn lu:
- Tn thng tng m thy nh chm (P)
- H thng no tht bn khng dn, khng tng m
- Cu trc ng gia khng di lch
+ Tng di lu:
- Cha pht hin bt thng m trn tiu no
- No tht IV khng dn, khng tng m
Kt lun: xut huyt no vng chm (P)
- ECG: Nhp xoang u, tn s # 80 ln/pht
IX. CHN ON SAU CNG: xut huyt no vng nh chm (P) /Tng huyt p
III theo JNC VII
X. IU TR :
1. Hng iu tr
-nm u cao
- Chng ph no
- Kim sot huyt p
- iu tr triu chng
2. iu tr c th
a. Thuc
- Manitol 20% 250ml
chai x 3(TTM) C g/ph
-pantocid 40mg
01 l (TMC)
- Losartan 50mg
01 vin (u)
b. Chm sc
- thc n d tiu ha, sp, cho, sa x 4,5 c/ ngy
- Theo di sinh hiu
XI. TIN LNG :
Gn: Nng, nu khng iu tr tt c th dn n t vong, hoc di chng v sau
Xa: Nng, tin s tng huyt p, cn phi kim sot huyt p v thuc trnh nguy c
t qu
XII. PHNG BNH
- Kim sot huyt p
- Ch n gim mm, du m, ngt
- Vn ng thng xuyn