BNH N N KHOA

.Hnh chnh
-H v tn: o Vn nh
-Gii tnh: Nam
-Tui: 62 tui
-ja chi: ng Nai
-Ngh nghip: Nghi huu (Truc dy lm ti x)
-Ngy nhp vin: ???
-S giung:
-Khoa: Ni tiu ha
. L do nhp vin: Bung to
. Bnh s
Cch nhp vin 3 ngy, BN cm thy bung to dn, to du khp bung, khng dau,
km mt mi, chn n, kh th 2 th, kh th nhiu khi nm, khng lin quan gng
sc, khng kh th kjch pht v dm, kh th tng khi bung cng to ln. BN c ho
khan 9-10 ln trong ngy, ho nhiu khi thay di tu th.
Trong qu trnh pht bnh, bnh nhn khng st, khng lanh run, khng n lanh v
chiu, khng v m hi v dm, khng dau nguc, khng dau bung, khng bun nn,
khng nn, khng o chua. Bn di tiu bnh thung, phn vng, dng khun. i tiu
bnh thung, khong 1000 ml/ngy, nuc tiu vng trong.
Tnh trang lc nhp vin: Tinh to, tip xc tt, bung cng to, kh th 2 th v kh
th nhiu khi nm. Khng st, khng lanh run, khng dau bung, khng bun nn,
khng nn, khng o chua, khng dau nguc.
Mach: 80 l/p, HA: 110/60mmHg Nhit d:37 d, Nhjp th: 20 l/p
V.Tin cn
1. Bn thn
a. Bnh l
-Nm 1988, BN bj dp rut non do tai nan lao dng , d m v seo lnh tt.
-Thng 8/2012, BN dau nguc phi di khm TT Ha Ho v ung thuc 1 thng
nhung khng gim nn chuyn qua khm bv Cho Ry, sau d c ti khm thm 3
ln.
-Thng 10/2012,BN duoc chn don lot t trng tai BV CR.
-Gua thng 1/2013, BN cm thy mt mi,chn n dng thi bung to ln, BN di
khm bv huyn ng Nai th duoc yu cu nhp vin nhung v l do gia dnh nn BN
khng nhp vin. Na thng sau, bung BN to ln nhiu v cng tc khin BN kh
th-> nhp bv huyn N th duoc chuyn ln bv tinh N, chn don xo gan, c
chc tho djch.Nm 10 ngy bung BN xep bt nn duoc chi djnh xut vin.
Sau d, BN 3 ln nhp bv CR v bung cng to, trong thi gian diu trj ni tr c chc
tho djch.Trong d, ln nhp vin gn dy nht (cch nhp vin 1 thng), BN c
km trn djch mng phi v duoc chc djch mng phi T 1 ln
-Thng 9/2013, xt nghim mu tai bv CR c HCV(+)
-Chua chch nga vim gan siu vi B.
-Chua ghi nhn BN bj cc bnh l nhu : THA, bnh van tim, suy tim, T, COPD,
hen ph qun, cc bnh thn, thn kinh, co xuong khp
b. Thi quen
Khng ht thuc l, khng ung ruou
2. Gia dnh: chua ghi nhn mc phi cc bnh gan nhu; vim gan siu vi B,C, cc
bnh chuyn ha : Wilson, gan st, bnh gia dnh do thiu men alpha-1
antitrypsin, cc bnh l T, THA, suy tim,...
V.Luoc qua cc co quan:
-Tim mach: Khng dnh trng nguc, khng dau nguc, khng hi hp
-H hp: kh th nhe, 2 th, tng ln khi nm, ho khan thay di theo tu th
-Tiu ha: Bung cng to, dau nhe, m i vng ha sun phi, di tiu bnh thung
(phn vng, dng khun)
-Tit niu: Nuc tiu mu vng trong, luong nuc tiu khong 1000 ml/ngy, khng
tiu but, khng tiu gt
-Thn kinh: Tinh to, khng dau du, khng chng mt, khng hoa mt
-Co xuong khp: Khng dau nhc xuong khp, khng gii han vn dng
V. Khm: (9 gi ngy 12/11/2013)
1.Tng qut:
-Bnh nhn tinh, tip xc tt
-Th trang gy yu
- Bung cng to
-Da khng vng, khng tm, khng d, khng c cc du xut huyt dui da
-Kt mac mt vng, nim mac dui lui vng
-Ph 2 chn, ph trng, mm, n lm, khng dau
-Khng c lng bn tay son, khng sao mach, khng c ngn tay di trng, khng c
mng trng
-Tc khng d gy rung, mng cn bng
-Hach ngoai vi khng s cham
-Chiu cao: Cn nng
-Sinh hiu: Mach Huyt p Nhjp th Nhit d
2.Vng du mt c:
-Cn di, khng bin dang
-Hng, lui sach
-Kh qun khng lch
-Tuyn gip khng to
-Tnh mach c ni tu th 45 d (-)
-Khng xut huyt chn rng
3.Lng nguc:
-Lng nguc cn di, phi hop tt vi nhjp th
-Khng c sao mach, khng pht hin du xut huyt
-Khng c khi u g ln, khng seo m c
-Khng c tun hon bng h
a. Tim:
Khng dp bt thung
Mm tim: gian sun 4, dung trung dn tri, din dp mm tim 2 cm
Du Hardzer (-), du ny truc nguc (-)
Ting tim du r, T1 nghe r mm tim, T2 nghe r dy tim
Tn s tim: 80 ln/pht
Khng c rung miu, khng pht hin ting tim bt thung, khng nghe m
thi
b.Phi:
Khng nghe rale bnh l, khng nghe ting th thm vo
???
4.Vng bung:
-Bung cng to, phi hop tt vi nhjp th
-Tun hon bng h ca ch
-Seo dung trng gia, khong 20cm ko di t rn tr ln, seo lnh tt
-Khng sao mach, khng c quai rut ni, khng khi g ln bt thung
-Nhu dng rut ??? ln/pht, khng pht hin m thi vng bung
-G vang dinh, duc xung quanh.Du vng duc di chuyn (+), Du sng v (+)
-Khng pht hin cc dim dau trn thnh bung: im Murphy (-), dim dau niu
qun trn (-), dim dau niu qun dui (-), dim McBurney (-), dim Mayo - Robson
(-)
-Khm gan: ???
-Khm lch: ???
-Ti mt ???
-Du cham thn (-), du bp bnh thn (-)
5.Tit niu:
-Khng c cu bng quang
-oam Test ?
6.Thn kinh:
-C mm, khng yu lit vn dng, khng du hiu thn kinh khu tr
-Du mng no (-)
7.T chi:
-Khng teo co, khng bin dang, khng dj dang xuong khp
-Khng gii han vn dng
-Khng xut huyt dui da
V. Tm tt bnh n:
BN nam, 60 tui, nhp vin lc h ngy /13 v bung to, c cc TCCN:
-Bung to du
-Kh th 2 th, kh th tng khi nm
- Ho khan thay di theo tu th
-Sut cn : 15kg trong 6 thng
Khm c:
- Bng bung d 3,thnh lp nhanh(g duc ton th, du song v (+)) km ph
chn
- n dau vng ha sun phi
- Tun hon bng h kiu ca-ch
- Vng nim
- m ph bo gim 2 dy phi, rung thanh gim 1/3 dui phi T (t KLS 4 tr
xung)
t vn d
- Bng bung d 3
- Ph
- Tun hon bng h, vng nim, au HSP Sut cn
- Kh th+ho khan thay di theo tu th+ m ph bo gim 2 dy phi+ rung
thanh gim 1/3 dui phi T
Bin lun
1.Bng bung d 3, thnh lp nhanh
Cc nguyn nhn thung gp ca bng bung
Bnh l ngoi mng bung:
-o gan: ngh nhiu nht. Mc d bng bung trong xo gan din tin tu nhin l bng
bung thnh lp chm, t t nhung vn khng loai tr duoc BN d chuyn sang xo
gan mt b dt ngt, km yu t thc dy nhu khng tun th diu trj (khng tun
th ch d n ung),dot cp vim gan siu vi C??BN n ung km, sut cn, khm
thy BN km vng nim, tun hon bng h ca ch, tin cn d duoc chn don
xo gan truc d, nhiu ln bng bung ti di ti lai t khi duoc chn don xo gan nn
ngh nhiu bng bung ca bnh nhn nm rong bnh cnh xo gan d c
- Suy tim: t ngh mc d BN c bng bung km ph chn, nhung bng bung thnh
lp nhanh. BN khng c cc du chng suy tim phi hay suy tim ton b nhu tnh
mach c ni, BN c Hardzer (-), phn hi gan-tnh mach ca (-), mm tim khng
lch, ngoi dot bnh ny, BN khng kh th khi gng sc, khng kh th khi nm,
khng kh th kjch pht v dm,. Trong dot bnh ny, BN mi thy kh th nhe,
kh th 2 th, tng ln khi nm, tng khi bung to ln. Tin cn BN chua ghi nhn
bnh l THA hay van tim, suy tim truc d. Tuy nhin, trn co dja BN ln tui km
nhiu bnh nng, c bng bung km ph chn, chua th loai tr-> d nghj siu m
ti, CG, men tim tm sot.
-Tc tnh mach trn gan/huyt khi tnh mach ca: t ngh dn do BN khng tri qua
phu thut hay chn thuong g truc d (tin cn BN m rut non d lu( nm
1988))
-Hi chng thn hu/ suy thn: BN bng bung km khng ph mt, tiu duoc, khng
but rt, nuc tiu vng trong, luong 1000ml/ngy, tin cn chua ghi nhn bnh l
thn-> t ngh
-Bnh rut mt protein: t ngh dn do BN khng tiu chy truc d, khng hi
chng nhim trng, khng ghi nhn bnh l chuyn ha g truc d
-Suy dinh dung: t ngh, mc d BN c tng trang suy kit, nhung BN khng ph
mu bn tay, da khng mng, khng thay di phn b lng
Bnh l tai mng bung:
- Lao mng bung: t ngh dn do BN khng c hi chng nhim lao chung (st
nhe, n lanh v chiu, v m hi v dm), djch mng bung thnh lp nhanh, trong
khi bng bung trong lao mng bung thnh lp chm, din tin t t. BN tin cn
khng lao phi, lao mng bung truc d.
- K mng bung: c ngh dn do djch mng bung trong K mng bung thnh lp
nhanh, ph hop vi bnh nhn. BN ln tui, tng trang suy kit, sut cn 15kg trong
6 thng, tin cnxo gan, u gan phn thy V (ln nhp vin 23/9/2013, tai BV CR)
- Vim phc mac nhim khun nguyn pht: c ngh dn trn BN xo gan d
duoc chn don, khm thy BN n dau vng HSP -> d nghj xt nghim sinh ha
djch mng bung( SAAG djch mng bung, protid djch mng bung, LDH , glucose djch
mng bung)cy vk, dm bach cu tm sot.
- Vim phc mac nhim khun th pht: t ngh dn do BN khng hi chng
nhim trng, chua ghi nhn BN bj thng rut non, thng ti mt hay thng lot da
dy t trng truc d
Vy bnh cnh ngh nhiu gy ra bng bung d 3 trn BN ny l xo gan.
Cc nguyn nhn thung gp ca xo gan:
- Ruou: khng ngh do BN khng ung ruou
-Siu vi: Ngh nhiu nht do BN duoc chn don HCV (+) tai BV CR (theo giy ra
vin dot diu trj ni tr ngy 23/9/2013> 10/10/2013)
- mt nguyn pht/th pht: t ngh do BN pht hin xo gan mun (60 tui), khng
vng da truc khi pht hin xo gan, trn lm sng BN khng thy hi chng tc
mt, khng tin cn phu thut/ bnh l dung mt truc d.
-Bnh chuyn ha: st, dng, bnh thiu alpha 1 antitrypsin; t ngh do khng
thy da xam, khng thy bt thung thn kinh, khng thy vng Kayser leischer
mt, khng ghi nhn BN hay ngui nh bj bnh l tai phi hay gan do thiu men
antitrypsin
-o gan tim: t ngh do BN khng thy cc du chng suy tim nhu d bin lun trn
Phn d xo gan: d nghj xt nghim sinh ha: albumin mu, bilirubin mu, xt
nghim dng mu: PT, NR d phn d theo Child-Pugh
Bin chng xo gan:
HTH: chua ghi nhn do BN khng c tin cn i ra mu hay tiu phn den truc
d
VPMNKNP: c ngh dn do khi khm BN thy n dau vng HSP
HC gan thn: BN di tiu duoc, nuc tiu vng trong, luong 1000ml/ngy nn t ngh
BN c bin chng ny. Tuy nhin khng th loai tr-> d nghj BN, creatinin HT
HC gan phi: t ngh dn do BN khng biu hiu tm ti, khng kh th tng ln khi
chuyn t tu th nm sang ngi hoc dng v khng pht hin ngn tay di trng
BN
Bnh no gan: t ngh do khm thy du rung vy (-), BN khng hn m, kch thch
Bng bung kh cha: ngh d c bin chng ny do BN d nhiu ln bng bung ti
di ti lai trn bnh cnh xo gan d chn don
K gan: c ngh do BN d duoc chn don u gan phn thy V
2. Ph: ngh nm trong bnh cnh xo gan
3. THBH ca ch, dau HSP, sut cn: ngh nm trong bnh cnh xo gan, trong
d:au HSP: dau m i, dau nhe khi n vo, c lan ra xung quanh-> ngh dy l triu
chng goi bin chng VPMNKNP hoc K gan trong bnh cnh xo gan. Sut cn:
ngh dy ltriu chng ca bin chng K gan
4.