Bnh n

I/ Hnh chnh: BN L Vn Ho nam,, 59 tui Ngh nghip : cng nhn a ch: 18/45 nguyn Duy, F3, Q. Biunhf thnh Nhp vin lc 23h, 10/4 /2011 II/ L do nhp vin: St III/ Bnh s: Cch nhp vin 12 ngy, bnh nhn i cu phn en, st, mi khm, ngy 6-7 ln, xen k nhng ngy phn vng ng khun. Cch nhp vin 10 ngy BN st, lnh run, khng lin tc( ngy no cng st, nhng thi gian khng c nh), khng r nhit . Cch nhp vin 8 ngy, BN thy bng to ra, km au m khp bng, khng t th gim au, cha iu tr g, cng ngy nhp vin BN st cao NV Trong qu trnh bnh, BN kh th khi nm, ngi d th hn, thnh thong c ho khc m trng c lng t, khng km au ngc. Tiu vng sm, tiu 400ml/ngy Khng : hoa mt chng mt, hi hp nh trng ngc, nhc u. TTLNV: BN tnh, tip xc tt, kh th SH: M 100l/pht, HA 120/ 80mmHg toC: 38,5oC, NT 20l/ph Sp 02: 89% Tim u, phi trong Bng bng, tiu phn en. X tr: Acemol 0,325 2v ung Ceftriaxone 1g 2 l( TMC) Din tin lm sng t lc nhp vin n lc khm Vn cn tiu phn nu en, lc st lc lng, 8 ln ngy, Hin ti tiu phn vng st, 4 ln/ngy. Ht st 2 ngy, bng cn au, nhng gim so vi lc nhp vin. IV/ Tin cn: 1) gia nh: Khng THA, T , khng tin cn tim mch, bnh l v gan, 2) Bn thn: Ngoi khoa: Khng tin cn bnh l ngoi khoa Ni khoa: - X gan chn on v iu tr ti bnh vin Gia nh cch y 10 nm. - Nhim siu vi C 2 pht hin 2 nm - Lao phi iu tr cch y 2 nm ti BV Phm Ngc Thch. - Ung ru 500ml/ngy trong 40 nm, ngng ung c 20 ngy nay. - HTL: 40 gi_nm - Cha tng truyn mu trc y V/ Khm: 1) Tng trng: BN tnh, tip xc tt.

CN 40kg, CC 1,6m BMI: 15,6 suy kit SH: M 78l/pht; HA 120/70mmHg toC 37oC NT 17 l/pht Xut huyt di da, mng bm 2 tay Kt mc mt vng. Ph chn (++) Sao mch, lng bn tay son Hch ngoi bin khng s chm 2) Lc qua cc c quan: - Khng au ngc, khng hi hp nh trng ngc - Khng kh th, ht ho khc m - Khng au u, khng hoa mt, chng mt - Cn au m khp bng - Tiu phn vng, st. 4 ln/ngy, tiu vng sm, khng gt but, 400ml/ngy - au khp gi 2 bn. 3) u mt c: - Mt cn i, khng v mt nhim trng - Hng sch, nim mc li vng - Tuyn gip khng to - Kh qun khng di lch - Tuyn mang tai 2 bn to. - Tnh mch c t th 45oC (-) 4) Ngc - Lng ngc cn i, di ng u theo nhp th, THBH(-) - Mm tim KLS V ng trung n (T), din p 1x1cm2 - T1,T2 u r, khng m thi - Phi: RT u 2 bn, g trong khp phi, RRPN m du 2 ph trng, khng rale 5) Bng - Bng b 2 bn, rn phng, THBH(-), khng so m, khng du rn b, khng quai rut ni - NDR m sc bnh thng - Bng mm, khng u, n khng au. - G c vng thp. - Gan to di b sn T 5cm, b sc, mt chc, khng au, chiu cao gan 15cm. - Lch khng s chm - Chm thn(-). 6) Thn kinh c xng khp: - Khng du mng no, khng du thn kinh nh v - Khng bin dng khp, khng gii vn ng - Sc c t chi 4/5. VI/ TTBA: BN nam 59 tui, nhp vin v st ngy 10

St lnh run i cu phn en au khp bng Tng trng suy kit Tuyn mang tai to Hi chng suy t bo gan Hi chng tng p lc TMC TC x gan chn on, HCV, Ung ru, HTL nhiu, lao phi iu tr. VII/ t vn 1. X gan chn on v iu tr 2. XHTH trn I, n 3. St + au bng 4. Th trng suy kit 5. Tin cn lao VIII/ Bin lun: 1. Trn bnh nhn hi chng suy t bo gan( vng da, xut huyt di da, sao mch, lng bn tay son). Hi chng TALTMC ( bng bng, gan to) x gan. 2. XHTH trn: Khng ngh XHTH di v: thng s tiu mu , XHTH trn thng nn ra mu + i cu phn en, tuy nhin XHTH trn lng t c th k nn ra mu. Bnh nhn ny i cu phn en, st, mi khm ngh nhiu XHTH trn. Sinh hiu bnh nhn n, nn ngh lng mu mt t < 10% I Hin ti tnh trng i tiu phn en gim, tiu phn vng tr li n 3. St + au bng / X gan bng bng, c nhng nguyn nhn sau: VPMNK nguyn pht, X gan K ha, Lao mng bng/ X gan V mt lm sng khng th loi tr, tuy nhin VPMNP nguy him nht, c th gy t vong nhanh, do ngh VPMNP nhiu nht ngh CLS: Chc d dch bng lm : Sinh ha, t bo, cy IX/ Chn on: 1. X gan mt b bin chng VPMNKNP, yu t thc y XHTH trn I, n do lot d dy t trng, vim phi 2. X gan mt b bin chng VPMNKNP, yu t thc y XHTH trn I, n do v TMTQ gin, vim phi 3. X gan mt b, yu t thc y XHTH trn, I n nghi do lot d dy-tt, bin chng K ha, vim phi 4. Lao mng bng/ X gan, XHTH trn I n, nghi do lot d dy-tt. X/ ngh CLS: - CTM - Sinh ha mu: Protein TP, Albumin, ALT, AST, LDH, GGT, Bilirubin TP, TT, GT, BUN, Cretinin - ng cm mu: TQ, TCK.

XN DMB X-Q phi thng Ni soi Tng phn tch nc tiu Ion mu

XI/ Kt qu cn lm sng: 1.CTM: 11/4 13/4 - WBC: 2.54 k/ul - %N: 62,8% - %L: 20% - RBC: 2,8 T/ul - Hb 113g/l - Hct : 31,8 % - MCV : 113fl - MCH 40,1pg - PLT 33 k/ul 2. ng cm mu PT: 29 giy 28% INR 2,76 APTT 50,6s 3. Sinh ha: Glycemia: 3,52 mmol/l Ure 1,4mmol/l Creatinin 7,3 micromol/l Albumin 20,7 g/l Bili TP 115,16 umol/l Bili TT 54,05 Bili GT 61,1 4. Dch mng bng Vng chanh, trong Protein 14,5 g/l Glucose 4,32mmol/l LDH 90.7 U/l T bo: BC 20/ml N 75%. L 25%, 5. Ion : Na: 138 K 2,43 Ca 0,92 XI Chn on xc nh Nhim trng dch bng/ x gan mt b, XHTH trn I n, thiu mu nh, ri lon in gii. XII. Nguyn tc iu tr: 1. iu tr nguyn nhn 2. iu tr triu chng

3. iu tr bin chng 4. Nng tng trng Trn BN x gan mt b, ch yu iu tr triu chng v bin chng: iu tr bng bng: - Ngh ngi ti ging - n lt 1-2g mui/ ngy - Nc nhp < 1,5l/ngy - Khng dng li tiu v nhim trng dch bng cha kim sot hon ton - C C iu tr albumin: v BN lc nhp vin c tnh trng kh th, kh th khi nm, d th hn khi ngi, bng cng. iu tr nhim trng - Khng sinh B Kali. C th: - Morihepamin 200ml TTM XXXg/ph - Ceftriaxone 2 l ( TMC) - Vt K1 0,01g, 1 ng TDD - Kalion 0,5g 2v x 2(u)