Tn: Bi Th Thanh Tm Lp: Y07F- t 34

BNH N HUYT HC

I. Hnh chnh:

1.Tn: Dng Th Anh o 42 tui. Gii: n. 2.Ngh: Lm thu. 3.a ch: Thnh An, Cn Th. 4.Nhp vin: 06/4/2011. Phng 101_Khoa: Huyt hc ngi ln. Bnh vin Cn Th chuyn vi chn on: Hi chng tng sinh ty. -Cch nhp vin 25 ngy, BN b tai nn giao thng, t p bng bn no?v ln xung dc cu c ng , sau tai nn BN tnh v c ch vo trm y t gn , khng x l=>chuyn vo BV Long Xuyn c chn on chn thng lch, c m ct lch. BN khai trong qu trnh m:m ln 1 kt thc, ln 2 phi m li sau 60ph do vt thng chy mu (BN nghe ngi nh k li). Sau khi nm hu phu 7 ngy BV Long Xuyn, khng c g bt thng nhng n ngy th 7 chun b xut vin th vt thng chy mu t di vt m, c x l bng cm mu v chuyn BV Cn Th. Ti BV Cn Th, Sau 1 ngy, vt thng ht chy mu v BN nm li 16 ngy.BV Cn Th lm ty nghi c bnh l huyt hc=>chuyn BV TMHH. XN sau ct lch ghi nhn: -Tiu cu : 1500 K/uL. -Bch cu: 22 K/uL. Trong qu trnh bnh, BN khng st, tiu tiu bnh thng.

II. L do nhp vin: III. Bnh s:

IV. Tin cn:

-PARA 4004, hu sn bnh thng. -Khong 1 nm nay, BN hay b chy mu rng, t cm v b au ct sng (iu tr lin tc: ung thuc mi ngy), thnh thong nhc 2 u gi+t 2 bn chn. -Cch y 2 nm, ti BV Cn Th , BN c chn on l thiu mu thiu st, tng tiu cu, c truyn 2 n v mu, sau c ni soi pht hin lot d dy khng ti khm cho n nay. -Cch y 4 nm, BN c m k hoch, lc m xong khng

xut huyt vt m. -Cha pht hin bnh l tit niu, tim mch, i tho ng, tng huyt p b)Gia nh: Cha ghi nhn bnh l lin quan.

V. Lc qua cc c quan:
-Tim mch: khng au ngc, khng hi hp, nh trng ngc, khng tm ti. -H hp: khng ho, khng kh th. -Tiu ha: khng tiu chy, khng to bn, khng au bng, khng cm gic cng tc vng h sn tri. -Tit niu: tiu d, nc tiu vng trong. -Thn kinh- c xng khp: khng nhc u, vn ng tt. -Chuyn ha: khng st, khng ph. VI. Khm bnh: (10h ngy 20/04/2011)

1.Tng trng:
Bnh nhn tnh, tip xc tt, hp tc tt. Sinh hiu: -Huyt p: 120/80mmHg. -Mch: 80ln/pht -Nhp th: 20ln / pht -Nhit : 37oC Chi m, khng xut huyt da nim. Da v da nim hng va, khng ph, khng mt nc. BN v mt bnh thng, khng sc, khng c v mt nhim trng.

2.u mt c:
Kt mc mt khng vng. Tuyn gip, tuyn mang tai khng to. Tnh mch c khng ni t th 45o Kh qun khng di lch. Hch ngoi bin khng s chm. Hng li sch.

3.Tun hon:
Mm tim lin sn 5 ng trung n. Tim u, tn s 80 ln/pht, khng m thi Mch chi u r 2 bn. Khng p bt thng.

4.H hp:
a.Nhn:

-Tn s th: 20 ln/pht. -Lng ngc cn i, di ng theo nhp th. -Khng c du hiu th gng sc, khng xanh tm, khng ngn tay di trng, khng ph, khng sao mch. bNghe: -Ph m u r 2 bn. c.G: G trong khp 2 bn. d.S: -Hch ngoi bin khng s chm. -Rung thanh u 2 phi.

5.Tiu ha:

a.Nhn: -Bng khng tun hon bng h, so m dc gia bng di khong 20cm (lnh tt), so m c trn xng mu di khong 5cm (lnh tt), vt dn lu lnh tt, khng sao mch, khng c khi phng bt thng, bng di ng theo nhp th, rn lm. -Vng bn 2 bn cn i b.Nghe: Nhu ng rut:4 ln/pht. c.S: -Bng mm, n dc vt m khng au, gan lch khng s chm. -Rung gan, n k sn (-) - khng thnh bng (-) -2 h chu mm, khng au. d.G: g trong.

6.Tit niu:

-Chm thn, bp bnh thn (-). -n cc im niu qun trn gia 2 bn khng au.

7. Thn kinh s no:

-Du cng gy (-), khng du thn kinh nh v -T chi vn ng tt.

8. Da nim, lng tc mng:

- Kt mc khng vng . Mng bnh thng, khng sc, hng nht.

VII. Tm tt bnh n:
BN n, 42 tui, NV do Bnh vin Cn Th chuyn vi chn on: Hi chng tng sinh ty.. Qua hi bnh s v thm khm ghi nhn c cc triu chng sau:

- TCCN: + c m ct lch ti BV Long Xuyn. M li ln 2 sau m ln 1 60ph do vt thng chy mu. +Khi nm hu phu BV Long Xuyn, di vt thng chy mu t, c x l bng cm mu v chuyn BV Cn Th. +BV Cn Th lm ty nghi c bnh l huyt hc. +Trong qu trnh bnh, BN khng st, tiu tiu bnh thng. - TCTT: Sinh hiu n. Da nim hng va.Kt mc mt khng vng. Nhp nhnh u mng (+), tay chn m. Gan lch khng s chm Chm thn 2 bn (-), rung thn (-), bp bnh thn (-). - Tin cn: +PARA 4004, hu sn bnh thng. +Khong 1 nm nay, BN hay b chy mu rng, t cm v b au ct sng (iu tr lin tc: ung thuc mi ngy), thnh thong nhc 2 u gi+t 2 bn chn. -Cch y 2 nm, ti BV Cn Th , BN c chn on l thiu mu thiu st, tng tiu cu, c truyn 2 n v mu, sau c ni soi pht hin lot d dy khng ti khm cho n nay. -Cch y 4 nm, BN c m k hoch, lc m xong khng xut huyt vt m.

VIII. t vn :
-BN n, 42 tui. -Tin cn thiu mu, tng tiu cu c chn on ti BV Cn Th, khng r chn on v iu tr. -Chn thng v lch, ct lch 1 thng. - XN sau ct lch ghi nhn: -Tiu cu : 1500 K/uL. -Bch cu: 22 K/uL. -LS n nh, vt thng lnh tt, khng xut huyt, khng tc mch.

IX. Chn on:

-Chn on s b: Tng tiu cu nguyn pht. -Chn on phn bit: +Tng tiu cu th pht sau ct lch. +Cc bnh khc trong hi chng tng sinh ty.

X. Bin lun:

XN trc NV cho thy tiu cu tng cao, c th l tng

nguyn pht hoc th pht hoc do nguyn nhn khc. Cc nguyn nhn gy tng tiu cu: -Hi chng ty tng sinh -Tng tiu cu th pht -Ung th. -Phn ng vim do nhim trng. Do lm sng BN bnh thng nn cn thm cc CLS chn on xc nh. Tuy nhin vn ngh nhiu l ET do: -BN c tiu cu tng rt cao. -BN c chn on tng tiu cu cch y 2 nm, trc khi ct lch. =>Ngh nhiu nht.

XI. ngh cn lm sng: XII. Kt qu cn lm sng:

1. Huyt : 6/4
Gi tr Bnh thng RBC 4.92 4.2-5.4 M/L HGB 11.2 12-16 g/dL HCT 38.7 37-52% %RETIC 0.5-2.5 MCV 78.64.18 80-99 fL RETIC# 22-139 MCH 22.8237. 27-31pg MCHC 29.02 32-36 g/dL MCVr CHCM 30.2103.6 101-119 33-37 g/dL CHCMr 23-29 CH 23.6 25.0 27-31 pg CHr 25-30 RDW 19.2 25.8 11.5-14.5% ANISO ++2.2-3.2 g/dL HDW 3.51 MICROCYTIC 1417 150-400 ++ PLT HGB CONC-VAR + K/uL HYPOCHROMIC MPV 8.5 +++ 7.2-11.1 fL RBC WBC 22.8+ 5.2-10.0 FRAGEMENT 2 K/uL NUCLEATED 68.1 +++ %NEUT 40-74% RBC %LYMPH 13.8 19-48% PLT CLUMP 2.2 + 3.4-9% %MONO LEFT SHIFT 12.6+ 0-7% %EOS RBC GHOST 1.2 + 0-1.5% %BASO %LUS 2.0 0-4% # NEUT 15.5 1.7-7.0 K/uL 5 # 3.15 1.0-4.0 K/uL LYMPH # MONO 0.51 0.1-1 K/uL # EOS 2.87 0-0.5 K/uL # BASO 0.28 0-0.1 K/uL # LUS 0.46 0-0.4 K/uL

RBC Morphology: Blast 0%

HNG CU LI

Kt qu khng ph hp CML,PV,PMF

2. Cng thc ty

T bo Neutrophil series Myeoblast Promyelocytes Myelocytes Metamyelocytes Bands and segments Eosinophil series Myelocytes Metamyelocytes Bands and segments Basophil series Erythroid series Pro.erythroblast Baso.erythroblast Poly.erythroblast Acido.erythroblast Monocytes Lymphocytes Plasma cells Reticulum cells Megakaryocytes Other cells: blast

Kt qu 76

11

11

02 20

Bnh thng 45.1-66.5 0.5-1.8 2.6-4.6 8.1-16.9 9.8-25.3 16.5-36.8 1.2-6.2 0.3-1.9 0.5-2.3 1.4-4.4 0.0-0.2 14.2-30.4 0.4-1.4 0.7-3.7 12.2-24.2 20-22.7 0.2-2.8 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 # 20 t bo trn lam, c rt nhiu m tiu cu trng thnh.Dng hng cu ch yu E.poly-acidophile. Dng bch cu tng, u th Metamyelocytes-S.neutrophile, tng t l Eosinophile. Khng gp t bo l. Lam mu: tiu cu t nhiu m, tng S.neutrophile, Eosinophile. Kt lun: Hi chng ty tng sinh.

3. Tng phn tch nc tiu:

Glucose Bilirubin Ketones SG- t trng Blood pH Protein Urobilinogen Nitrite Leukocytes Cn lng Hng cu Bch cu T bo Tinh th Nm Vi trng Khc ALT AST Creatinine Acid uric CRP LDH Ion Na K Ca pH HIV Ag/Ab HBs Ag Anti HCV CMV IgG CMV IgM Negative Negative Negative 1.015 Negative 7.5 Negative Negative 0.2 Negative 0-2 0-2 6-8 Amorphous phosphate m tnh m tnh

4. Sinh ha
10 19 33 72 27.8 73.2 143 3.9 1.14 7.445 0-41 U/L 0-37 U/L 44-133 mol/L 143-416 mol/L 0.0-6.0 mg/L 135-440 U/L 135-145 mmol/l 3.5-5.2 mmol/l 1.13-1.35 mmol/l 1.35-7.45 U/L

5. Min dch

6. Xt nghim t bin gen JAK2 V617F

Bnh phm: ty K thut: ASO-PCR Kt qu: pht hin t bin gen JAK2 V617F.

0.27 Noncreative 0.31 Noncreative 0.08 Noncreative POS 2.8 Index NEG 0.6 Index

7.ng mu:

TQ (PT=Prothrombine time) 13.8s TQ chng 12.3 T l Prothrombine 80

(>70%)

INR PT(BN)/PT(chng) TCK (APTT) TCK chng APTT (BN)/APTT (chng) Fibrinogen

1.17 1.12 36.8s 30.0 1.23 6.49

(<1.2) (<1.3) (1.5-4.0 g/L)

XIII. Chn on xc nh: XIV. Hng iu tr: Dng thuc gim tiu cu XV. Tin lng
D dt

Tng tiu cu nguyn pht ET.