TM TT CA LM SNG

H tn sinh vin:

Phm Th Gm-0801546
ng Th Mai-0901307
Phm Quc T-0901574

Nhm: 4

T:

Lp:

A1

Kha: 64

Ca lm sng bnh: TNG HUYT P (THA)

STT

Mc

Thng tin chung v

bnh nhn

Thng tin
Tn: L Th Trng
Gii: Nam
Tui: 53
Ngh nghip: Bc s
Dn tc: Kinh
a ch: 24 Trn Nguyn Hn, ng Th, Thanh Ha
Cn nng: 60 kg
Chiu cao:
Thi im vo vin: 14h55min ngy 29/3/2013

L do vo vin

Kh th, au ngc

Din bin bnh

Ngy khi pht: Khong 1 thng trc ngy vo vin

Triu chng: Kh th, au ngc m , khng ho, khng st.
au ngc khng lan, tng ln khi gng sc.
Tnh trng nhp vin: Tnh to, khng st; Kh th tc ngc NYHA II; Ho khan; Tiu
tin 1,5 l/ngy.

Bnh s

Tng huyt p 30 nm

Tin s gia nh

Cha c pht hin c bit

Li sng

Ht thuc l: 4 iu/ngy
Ung ru: C ung, khng r s lng
S dng ma ty: Khng

Tin s dung thuc

S dng thng xuyn Amlor 2 vin/ngy iu tr THA

Tin s d ng

Khng

Khm bnh

Ngy 29/3/2013:
Triu chng c nng:

Kh th khi gng sc
au vng trc tim khi gng sc
Ho khan

Triu chng ton th:

Nhit c th: 36,8C

Da v nim mc: Bnh thng
Khng ph
Tnh mch c khng ni
Khng s thy hch ngoi bin

Triu chng thc th:

Tim mch:
o Nhn: Lng ngc cn i
o S: Mm tim p khoang lin sn V ng gia n tri; Khng c
rung miu
o G: Din c ca tim bnh thng
o Nghe: Nhp tim u, 100 chu k/pht; T1, T2 r, khng r ting bnh l.
o Huyt p ng mch 130/80 mmHg
Phi: R ro ph nang r, khng rale
Bng: mm, khng chng
Thn kinh: Tnh to, khng c du hiu thn kinh khu tr.
C xng khp: Bnh thng
Cc b phn khc: Khng pht hin g c bit

Cn lm sng
(Kt qu bt
thng)

Yu cu xt nghim

Kt qu

CSBT Nam

Ngy 29/3/2013
ng mu
Prothrombin (s)

13,6

PT%

66,5

PT-INR

70~140

1,21

APTT (s)

24,7

APTT Bnh/Chng

0,87

0,85~1,2

Fibrinogen bng pp trc tip (g/l)

4,851

2~4

Huyt hc (15h5503)
HGB (T/l)

122

140~160

HCT (g/l)

0,379

0,38~0,50

MONO%
LYM%

10,7
24,9

25~45

MONO#
LYM#

0~8

0,89
2,06

0~0,8
1~4,5

Ha sinh mu (17h5611)
Sinh ha
Glucose (mmol/l)

8,3

4,1~6,7

CRP.hs (mg/dl)

4,9

<0,5

Troponin T hs (ng/ml)

0,110

<0,01

proBNP (pmol/l)

1750

<14,47

Min dch

Siu m tim
Bng tim khng to
Thnh tht tri dy; bung tht tri khng gin
Chc nng tm thu tht tri trong gii hn bnh thng.
HoHL nh
HoC nh
Ngy 30/3/2013
Ha sinh mu
Sinh ha
Glucose (mmol/l)

9,0

4,1~6,7

Min dch
Troponin T hs (ng/ml)

0,095

<0,01

Ngy 2/4/2013
Siu m bng
Gan-mt: Tnh mch trn gan gin; Ti mt gp khc, y c nhiu si 1,4cm
Thn tri: c si 0,6cm

Phi: Mng phi 2 bn c dch

SI TI MT-HNH NH GAN TIM-SI THN TRI-DCH MNG PHI 2 BN
Ngy 6/4/2013 (18h)
ng mu
Prothrombin (s)

14,3

PT%

67,3

PT-INR

70~140

1,24

APTT (s)

27,0

APTT Bnh/Chng

0,96

0,85~1,2

Fibrinogen bng pp trc tip (g/l)

3,477

2~4

Huyt hc (19h2326)
RBC (T/l)

4,23

4,3~5,8

HGB (g/l)

124

140~160

RDW_CV (%)
MONO%
LYM%

15,3

10~15

8,8

0~8

24,7

25~45

Ha sinh mu
Sinh ha
Glucose (mmol/l)
Calci (mol/l)

9,9
2,14

CRP.hs (mg/dl)

4,1~6,7
2,15~2,55

2,3

<0,5

Troponin T hs (ng/ml)

0,077

<0,01

proBNP (pmol/l)

1963

<14,47

Min dch

10

Chn on bnh
trong bnh n

11

Thuc s dng trn

bnh nhn

T 29/3~2/4: Tng huyt p, au ngc tri

T 3/4~5/4: Ngh iu tr
T 6/4~8/4: Suy tim, suy 3 thn ng mch vnh
Theo di din bin bnh

iu tr
Ngy 29/3/2013

15h:

Bnh nhn tnh

Khng st
Ho khan
NYHA II~III
Tim nhanh
f=100 ck/min
HA=130/80 mmHg
Phi r ro ph nang r, khng rale
Gan khng to, khng ph
Tiu bnh thng
Ghi xt nghim: 3 ng; T; Siu m
tim

Betaloc Zok 25mg x 1 vin (v);

ung
Nitralmyl 2,6 mg x 2v; ung
Vitamine 3B x 1v; ung
Re-liver x 1v; ung
Seduxen 5mg x 1v; ung vo
21h
*Ch xt nghim thm
thuc

KQ: Bng tim khng to; 2 trng

phi sng
Ngy 30/3/2013
10h10:

Bnh nhn tnh

NYHA II~III
Tc ngc tri nh, khng lan xuyn
Nhp tim nhanh, u
f=103 ck/min
H=160/90 mmHg
Phi khng rale
Bng mm, gan mp m b sn
Khng ph
Xt nghim: Ha sinh mu

Vinzix 20mg x 2 ng; tim tnh

mch, chia sng, chiu
Verospiron 50mg x 1v; ung
bui sng
Nitromint 2,6mg x 2 vin; ung
chia sng, chiu
Procoralan 7,5mg x 2 vin;
ung chia sng, chiu
Zestril 5mg x 1v; ung bui
sng

Ngy 31/3/2013: Thuc tng t ngy 30/3/2013

Ngy 1/4/2013

Bnh nhn tnh

Kh th-nm u cao khi ng
Khng tc ngc
Nhp tim nhanh, u
f=84 ck/min
H=140/90 mmHg
Phi khng rale, RRPN r
Bng mm, gan khng to
Xt nghim: Siu m tim, siu m
bng

Furosemide 20mg x 2 ng;

tim bui sng
Verospiron 50mg x 1v; ung
Diovan 80mg x1 v; ung bui
sng
Kalium 0,5g x 2v; ung
Procoralan 7,5mg x 2v; ung
Celabee x 2v; ung chia sng,
ti
Seduxen 5mg x 1v; ung bui
ti

Ngy 2/4/2013

Bnh nhn tnh

au u, kh ng
Kh th t, nm c u bng
Tc ngc tri nh
Tim u
f=90 ck/min
HA=140/90 mmHg
Phi khng rale
Bng mm, gan khng to
Tiu c

Tng t thuc 1/4/2013, dng thm:

Tanakan x 3v; ung chia sng,

chiu, ti
Seduxen 5mg x 1v; ung bui
chiu

Ngy 3/4/2013~5/4/2013: Bnh nhn xin vng mt iu tr v l do ring.

Ngy 6/4/2013: Bnh nhn quay li vin
18h:

Bnh nhn tnh to

Kh th nhiu
Mi tm nh
Tim nhanh, u
f=94 ck/min
HA=130/70 mmHg
Phi c rales m 2 bn, 1/3 di
Gan to 3~4 cm di b sn
MMM=10,3 mmol/l
Xt nghim: cp cu Ha sinh mu;
Cng thc mu; ng mu cc b.

21h:

MMM=7,3 mmol/l

Furosemide 20mg x 2ng; tim

tnh mch
Nitro 10mg x 1ng + NaCl 0,9%
va 50 ml; truyn tnh mch
3ml/min
Kalium 0,5g x 4v; ung
Verospiron 50mg x 1v; ung
Zestril 5mg x 1/2v; ung
Crestor 10 mg x 1v; ung
Th Oxy bnh, 3l/min

NaCl 0,9% x 500ml; truyn tnh

mch x 1 git/min
Lovenox 0,4ml x 1 bm; tim
di da

Ngy 7/4/2013
6h:

MMM=11,6 mmol/l

9h:

Bnh nhn tnh

NYHA III

Furosemide 20mg x 2 ng;

tim tnh mch; bui sng
Diovan 80mg x 1v; ung; bui
sng

Tim nhanh, u
f=100 ck/min
HA=140/90 mmHg
Phi khng rale
Bng mm, gan to 2cm di b
sn

Verospiron 50mg x 1v; ung;

bui tra
Kalium 500mg x 4v; ung, chia
sng, ti
Lovenox x 0,4ml x 1 bm; tim
di da

Ngy 8/4/2013
9h:

Bnh nhn tnh

Khng kh th
Khng au ngc
Tim u
f=88 ck/min
HA=130/80 mmHg
Phi khng rale
Tiu tt
Xt nghim: Siu m tim

Furosemide 20 mg x 2 ng;
tim tnh mch
Lovenox 0,4ml x 1 bm; tim
di da bng vo 9h
Diovan 80 mg x 1v; ung
Verospiron 50mg x 1v; ung
Kalium 500mg x 2v; ung