BNH N HUYT HC

I. Hnh chnh:
H tn: NGUYN C NM

Gii: Nam

Tui: 71

Ngh nghip: lm vn
a ch: Bo Lc, Lm ng
Ngy gi nhp vin:
II. L do khm bnh: xut huyt da nim
III. Bnh s:
Cch NV 2 ngy, sng sau khi nh rng BN thy chy mu li, nim mc m, nu, mu
ti, khng r lng, khong 15 pht th ht chy. BN thy c nhiu vt lot nim mc
m. BN khng st, khng chng mt, khng nn i, khng ho, khng au bng, tiu tiu
bnh thng. Ti cng ngy, Bn thy xut hin nhiu chm xut huyt ton thn, tp trung
nhiu bng, cng tay, cng chn. Sng hm sau, BN i khm BV Lm ng c chn
on Xut huyt gim tiu cu ri chuyn BV Truyn mu huyt hc.
BN st 6kg/2 thng
Tnh trng lc nhp vin
BN tnh, tip xc tt
Sinh hiu:
M: 82 l/p

HA:120/70mmHg

Nhp th: 20 l/p

Nhit : 37oC

Da nim nht
Khng ph, khng vng da
Nhiu chm xut huyt ton thn, nim mc m, y li, kt mc mt
Din tin bnh phng:
-3/4->5/4 bnh tnh, sinh hiu n, khng du xut huyt mi
- 6/4 chy mu mi 15 pht sau t ht,khng x tr g thm
-7/4 -> nay bnh tnh, sinh hiu n, khng du xut huyt mi
iu tr:
-3/4 17h truyn 6 khi tiu cu m c, 18h kt thc truyn tiu cu
1

-5/4 15g45 truyn 6 khi tiu cu m c, 16h50 kt thc truyn tiu cu

- 6/4-> nay : solumedrol 125mg l TMC, nexium 40mg 1v
Acid folic 5mg 1v, b1-b6-b12 1v, amlor 5mg 1v
IV. Tin cn:
1- Bn thn:

Ni khoa:
- Tng huyt p cch y 6 nm, iu tr vi Amlodipine v Nifedipine ngng c
2-3 nm, HA cao nht: 190 mmHg
-

St rt pht hin nm 1978, ti pht nhiu t trong 4 nm, sau BN khng cn ln

cn na

- So lot c hnh t trng, vt trt hang v, HP(+) cch y 4 nm iu tr

Levofloxacine, Amox, Pantoprazol
- Huyt khi TM c chn on BV Lm ng t 2003, ti pht nhiu ln
- Ht thuc l 50 gi.nm
- Ung ru bia: l ru/ ngy trn 10 nm, nhng 2 nm.
- Cha ghi nhn tin cn d ng, khng ri lon ng mu.

Ngoi khoa: phu thut ct t xa ngn chn ci bn T do chin tranh 40 nm trc

2- Gia nh:

- Cha ghi nhn THA, T, bnh l huyt hc, bnh t min hay cc bnh l mn tnh
khc.
V.
-

Lc qua cc c quan.
Tai mi hng : khng chy mu mi, khng chy mu chn rng
Tim mch : khng au ngc, khng hi hp, nh trng ngc.
H hp : khng kh th, khng ho.
Tiu ho : bng khng au, tiu phn vng, 2 ln/ngy
Tit niu : tiu vng trong, khng gt but, tiu m 5,6 ln
Thn kinh : khng au u, khng chng mt.
C xng khp : khng au xng khp, khng gii hn vn ng, khng au c, yu
c.

VI.

Khm (lc 8:30 ngy 31/03/2015)

1) Tng qut:

Bnh nhn tnh, tip xc tt.

2

Sinh hiu:

Mch: 84 ln/pht

Huyt p: 120/70 mmHg

Nhit : 37oC

Nhp th: 20 ln/pht

- Cn nng: 54 kg
bnh

Chiu cao: 1m65

BMI: 19.8 kg/m2 : th trng trung

- Nim nht
- Nhiu chm xut huyt c ton thn,mng bm mu vng tim thuc, chm xut huyt
mi lng bn tay, lng bn tay hng.
- Khng ph
- Hch ngoi vi khng s chm
2)
-

u mt c:
Cn i.
vi chm xut huyt kt mc mt
Mi: c cc mu ng vch mi, khng chy mu
Khng chy mu chn rng, 1 vt lot nim mc m, chm xut huyt 2 bn m, y
li
- Hai bn m c hin tng sung huyt mch mu
- Hch c, nch, bn s khng chm
- Tuyn gip khng to.
3) Ngc:
- Lng ngc cn i, di ng u theo nhp th, khng sao mch, khng tun hon bng h
- Tim: Mm tim lin sn 5, ng trung n (T), khng rung miu, khng p bt
thng. Tim u, T1, T2 u, r, khng m bnh l
- Phi: Rung thanh u 2 ph trng
G trong 2 ph trng
R ro ph nang m du 2 ph trng, khng rale
4) Bng:
- Bng cn i, di ng theo nhp th, khng tun hon bng h, khng so m c
- G: trong, Trauble (-)
- Bng mm, khng im au khu tr.
- Gan, lch khng s chm,
5) Tit niu:
- Khng cu bng quang
- Khng im au niu qun
3

6) C xng khp:
- Sc c 5/5, khng teo c, khng co rt c
- Khp khng bin dng khp, khng gii hn vn ng khp
- Lng tc khng rng, mng cn bng, khng sc.
7) Thn kinh:

- C mm. Khng du thn kinh khu tr

VII.
TM TT BNH N:
Bn nam, 71 tui, NV v xut huyt da nim
- Xut huyt da nim
- Khng st
- Gan lch khng to
- Tin cn:
+ THA iu tr khng lin tc
+ St rt
+ Lot honh t trng HP (+)
+ Huyt khi TM hay ti pht
+ Ht thuc l, ung ru bia
VI. Chn on
- Chn on s b:
Chn on phn bit:

xut huyt gim tiu cu t min / thiu mu mn

1/ suy ty
2/ leucemia cp

VII. Bin lun:

- BN c xut huyt t nhin, a dng ( chm xut huyt, mng xut huyt), ton thn, da
nim, nn ngh nhiu n nguyn nhn do tiu cu
- Khng ngh nguyn nhn do thnh mch v
+ Bn 71 tui mi xut huyt,gia nh khng c ai b bnh v mu -> loi tr nguyn nhn
u mch mu xut huyt c t/c gia nh
+ Khng c tin cn dng thuc gn y nh aspirin,Penniciline ,corticoid ... + khng st
nn khng ngh do siu vi hay c nhim trng nng.
+Mc d Bn 71 tui nhng khng ngh Ban XH ngi gi v Bn XH ton thn,a dng
cn Ban Xh ngi gi thng l dng mng v v tr tip xc vi mt phng xng
- Khng ngh nguyn nhn ri lon ng mu huyt tng v: nhm bnh ri lon ng
mu bm sinh hemophillia khng ngh, nhm bnh ri lon ng mu mc phi do thiu
nhiu yu t ng mu khng ngh v bnh nhn khng c du hiu suy t bo gan, khng
c tin cn tc mt ko di hay dng khng sinh ko di gy thiu vitamin K.
4

- C 2 nguyn nhn gy XH do tiu cu

Do gim cht lng tiu cu t ngh n v Bn khng c bnh cnh nhim trng,khng dng
thuc,khng c tin cn bnh gan thn trc y. BN khng c biu hin tng nht mu (tc
mm vng mc -> hoa mt,chng mt, nhn i) trong CML
Do gim s lng tiu cu c nguyn nhn ngoi bin v trung ng
+NN trung ng :suy ty,bch cu cp, K ni khc di cn ty,c ch ty do ru.
t ngh K di cn v trn LS cha tm thy triu chng ca K nguyn pht.BN mi c triu
chng XH c th l giai on sm ca bnh suy ty,bch cu cp -> khng th loi tr
c ->cn lm ty phn bit.
+ NN ngoi bin
- do min dch: ngh nhiu do BN khng c tin cn xut huyt, khng c triu chng gi
nguyn nhn c hiu no
- khng do min dch:
* c hc : khng ngh v BN khng c bnh l tim mch d to huyt khi
* cng lch: khm khng c lch to
- Thiu mu:
- + Do xut huyt: t ngh ti v BN xut huyt da nim t, khng ghi nhn xut huyt tiu ha
hay XH ni
+ Do tn huyt: t ngh n do BN khng vng da vng mt, nc tiu vng trong
+ Gim sn xut:
* do thiu nguyn liu (Fe, acid folic, vit B12) ngh n do BN ung
ru nhiu + tin cn lot d dy t trng -> gim hp thu acid folic,
BN lm vn -> c th b nhim giun
* do ty xng km sn xut: t ngh cc nguyn nhn do thuc, c
cht, nhim x do tin cn khng ghi nhn,
Cha loi tr xm ln ty: K di cn khng ngh v khng ghi nhn
triu chng nghi ng ca c quan c u nguyn pht -> ngh nhiu l
x ty, Leucemia cp, Leucemia mn
Vy thiu mu y c th do thiu Fe, a.folic, vit B12, x ty, Leucemia cp,
Leucemia mn
ngh CTM (HC, BC, TC, xc nh mc thiu mu, phn loi thiu mu), pht
mu ngoi bin (hnh dng, kch thc, t bo non, t bo l)
VIII. Cn lm sng:
1/ ngh
- Thng quy: ng huyt lc i, ion , AST, ALT, BUN, creatinine. TPTNT. ECG,
Xquang ngc thng
- chn on:

Cng thc mu
5

Pht mu ngoi bin

Ty
Chc nng ng mu (TQ, TCK, Fibrinogen)
Acid uric, LDH, LAP
Billirubin TT, GT
- H tr iu tr:

Nhm mu ABO (trc tip, gin tip), nhm mu Rhesus

SA bng tng qut,

SA tim

2/Kt qu c:
CNG THC MU
*: Sau chit tch
*3/4 *3/4
16:00 20:34
RBC
3,02 2,71
HGB
10,8 9,6
HCT
33,5 30,1
MCV
110
111
MCH
35,6 35,6
MCHC
32,2 32
RDW
18.5 18.5

*4/4
9:38
2,86
10,2
32,2
112
35,5
31,6
18.5

*6/4
9:05
2,85
10,3
31,8
111
36,2
32,4
18.5

*12/4
8:37
2,64
9,9
29,7
112
37,5
33,3
18.5

PLT

36

WBC

3,19

2,3

3,5

4,4

9,82

%NEUT
%LYMPH
%MONO
%EOS
%BASO
%LUC
%RETIC
RETIC#
MCVr
CHCMr
CHr

80,7
10,7
2,9
4,5
0,2
0,9
2,27
68,6
138
27,1
37,4

78
13,1
2,7
4
0,8
1,4

72,8
15,1
8,4
2,3
0,2
1,2

63,8
26,3
6,3
1,8
0,1
1,8

56
12,4
17,6
0
0

ANISO
IMMATURE

++
+

Bnh
thng
4.2-5.4
12-16
37-52
80-99
27-31
32-36
11.514.5
150400
5.210.0
40-74
19-48
3.4-9
0-7
0-1.5
0-4
0,5-2,5
22-139
101-119
23-29
25-30

n
v
M/ul
g/dl
%
fL
pg
g/dl
%
K/ul
K/ul
%
%
%
%
%
%
%
G/L
fL
g/dL
pg

++
+
6

GRANULO
LEFT SHIFT
+
MACROCYTIC
+++
HYPOCHROMIC +

+
+++
+

*3/4 PHT MU NGOI VI

- HC : aniso +
- BC
+ segment neutrophile: 83%

+ mono

4%

+ lympho

+ eso

4%

9%

Thiu mu hng cu to, ng sc

SINH HA MU
*3/4
*8/4
16g11 8g32
AST
19
25
ALT
19
47
Creatinin 112
87
Glucose
10,2
8,5
CRP
31,1
17,6
Na
139
136
K
3,8
3,7
Ca
1,15
1,1
Cl
104
100

Bnh
n v
thng
0-41
U/L
0-37
U/L
44-133
umol/l
3.89-6.38 Mmol/l
0-6
Mg/dL
135-145
mmol/l
3.5-5.2
mmol/l
1.13-1.35 mmol/l
98.0mmol/l
107.0
*6/4
bilirubin total
11,6 umol/L
Bilirubin direct
4,2 umol/L
Ferritin
560,92
ng/ml
(M 21-274, F4,6-204)
Folate
4,8
ng/ml
7,2-15,4
Vitamin B12163
pg/ml
240-900
Free T3
2,13
pg/ml
1,71-3,71
TSH
0,95
uIU/ml
0,35-4,94
Free T4
0,95
ng/dL
0,7-1,48
3/4 MIN DCH:
HIV Ag/Ab 0,14 Nonreactive
(<1) S/Co
HBsAg
0,22 Nonreactive
(<1) S/Co
Anti HCV 0,09 Nonreactive
(<1) S/Co
7

 CHC NNG NG MU
3-4
10/4
PT (TQ)
11,3
11,5
giy
PT chng
11.5
PT (bn)/PT (chng)
0,98
1
<1.2
APTT (TCK)
27,6
27,9
giy
APTT chng
32.0
APTT (bn)/APTT (chng)
0,86
0,87
<1.3
Fribrinogen
5,22
5,11
(1.5-4.0)

g/l

4/3 NHM MU:

Nhm mu ABO:
PP trc tip O
PP gin tip O
Kt lun
O
Nhm mu RHESUS
D+
CNG THC TY (%): *3/4
T bo
Kt qu
Bnh Thng
Neutrophil series 56
45.1-66.5
Myeloblast
0.5-1.8
Promyelocytes
2.6-4.6
Myelocytes
8.1-16.9
Metamyelocytes
9.8-25.3
Band and
Segments
Eosinophil series
Myelocytes
Metamyelocytes
Band and
Segments
Basophil series

Kt qu
38

16.5-36.8

T bo
Erythroid series
Proerythroblast
Baso.erythroblast
Poly.erythroblast
Acida.erythroblas
t
Monocytes

1.2-6.2
0.3-1.9
0.5-2.3
1.4-4.4

Lymphocytes
Plasma cells
Histiocytes
Megakaryocytes

0.0-0.2

Other cell

Bnh Thng
14.2-30.4
0.4-1.4
0.7-3.7
12.2-24.2
2.0-22.7
0.2-2.8

50

10.8-22.7
0.2-2.2
0.0-0.5
Hin din
0.0-0.0

Hnh thi ty:

Ht ty kh. Mu tiu cu # 50 t bo trn lam, y giai on. Dng hng cu tng, ch yu
E.poly acidophile. Dng bch cu ht: u th Metamyelocyte-S.neutrophile. T l blast # 4%.
Khng gp t bo l.
Lam mu: tiu cu gim, ch yu S.neutrophile, lymphocyte
8


Khng th khng nhn ANA dng tnh 115,4 (m tnh <40, dng tnh >55 U/ml)
Khng th antids-DNA m tnh 0,91 (m tnh <25, dng tnh >40 U/ml)
Nc tiu: blood: large, cc ch s khc bnh thng
Cn lng

HC 100-200, BC 0-1, TB: 0-1, nm, vi trng (-)

X-QUANG NGC THNG: bnh thng

ECG: bnh thng
SIU M TIM: bnh thng
SIU M BNG:
Gan: kch thc (T= 5,1; P= 15,2) cm, ng nht, b u
Lch: 9,8 cm, cu trc ng nht
Thn: si nh thn P 7mm
Cc c quan khc cha ghi nhn bt thng
Kt lun: si nh thn P
IX.

Chn on xc nh: xut huyt gim tiu cu t min / thiu mu mn do thiu folic
B12

X.
iu tr:
1/ iu tr triu chng:
Truyn tiu cu m c
2/ iu tr c hiu:
Corticoide: prednison 1-2 mg/kg/ngy trong 3-4 tun
Vinca alkaloide : vinblastine 4-6mg/m2 da
c ch min dch:
XI.

Tin lng: