H v tn: Hong Th Kim Ngn

Lp: Y2012D Nhm: 9

KHOA H HP BV NHI NG 2
I. HNH CHINH:
H tn bnh nhi: Phan Trung Dng
Gii tnh: nam
Nm sinh: 21/9/2012 (42 thng tui)
a ch: Thun An, Bnh Dng
Ngy nhp vin: 21h30 10/4/2016
Ngy lm bnh n: 20h 11/4/16
II. LI DO NHP VIN: St + ho m
III. BNH S: bnh 8 ngy, m l ngi trc tip chm sc b khai bnh
Ngy 1-3, b st 390C, khng ho, khng s mi, khng tiu chy, khng ni nht -> khm bc s t
c chn on nhim siu vi, cho thuc ung khng r loi, c p ng thuc h st
Ngy 4-5, b cn st nh (khng r nhit ), ho m, khng s mi
Ngy 6-8, b ht st, cn ho m, kh kh, i sau ho ra thc n ln m trng trong, th nhanh, mt
-> nhp vin Nhi ng 2
Sut qu trnh bnh, b chn n, khng tiu lng, phn vng khng nhy mu, tiu kh, nc tiu
vng trong.
Tnh trng lc nhp vin:
- Sinh hiu: Mch: 120 ln/pht
Huyt p: khc
Nhp th: 40 ln/pht
Nhit :370C
- B tnh
- Da nim hng, chi m, mch r, khng du mt nc
- Tim u. Th rt lm ngc nh. Phi rale m
- Bng mm
Din tin t lc NV n lc khm:
11/4/16, 8h:
B tnh. Khng st. Ho m trng trong, khng s mi. i sau n ra m trng trong.
Mi tm/kh tri. SpO2: 88-89%. Mch r: 135 ln/pht
Th co lm ngc 56 ln/pht. Phi th, rale m, n lan ta 2 ph trng.
-> 13h30: chuyn cp cu, th oxy qua canula 3 l/p, phun kh dung-> gim kh th, mi hng

IV. TIN CN:

1.

Bn thn:

a. Bnh l :
- Cha ghi nhn tin cn d ng thuc hay thc n
- Cha ghi nhn bnh bm sinh
- Kh kh ti i ti li nhiu ln
b. Sn khoa :
- Con 1/1, phu thut do con to, u thng, cn nng lc sanh l 3.9 kg, sau sanh khc ngay,
khng ngt, PARA(1001)
- Pht trin tm thn vn ng bnh thng
- Chch nga y u theo lch tim chung m rng
2.

Gia nh:

Khng ai hen, lao hay bnh l khc bt thng khc

3.

Dch t :
- B c i nh tr, khng r b khc b tng t
- M ni tr, nh chm sc b

V. LC QUA CC C QUAN:
Tai mi hng: khng s mi
H h hp: ho m
H tim mch: khng tm ti
H tiu ha: khng i, khng tiu lng, khng to bn, phn vng khun, khng ln nhy mu
H tit niu sinh dc: Tiu c, khng gt but, tiu vng trong
H vn ng: khng sng cc khp, khng gii hn vn ng
H thn kinh: khng yu, lit cc chi, khng nut sc.
VI. KHM:
a. Sinh hiu:
Mch: 108 ln/pht
Nhp th: 36 ln/pht
b. Tng trng tri gic:

Nhit :370C
SpO2: 97%/kh tri

B tnh, ti

Cn nng: 14kg, chiu cao: 99cm -> bnh thng theo tui

Da nim hng, chi m, mch r

Hch ngoi vi khng s chm

Khng du xut huyt, khng du mt nc

c. u mt c:
2

Kt mc mt khng vng

Nim mc mi hng

Hng sch, khng lot, amidan khng sng

Khng c dch bt thng tai

d. Ngc:
-

Cn i, di ng u theo nhp th, th co lm ngc nh

Tim u, T1,T2 r, khng m thi bnh l

Phi ran m 2 ph trng

e. Bng
-

Bng cn i, di ng u theo nhp th

Bng mm, gan lch khng s chm

f. Thn kinh: khng du thn kinh nh v, c mm

VII. TM TT BNH N:
B nam, 3 tui 3 thng, NV v st + ho m, bnh 8 ngy
- St 390C, hin khng st
- Ho m trng trong, kh kh
- Th nhanh, co lm ngc, phi rale m, n
- SpO2 88%
- p ng th oxy
VIII. T VN :
B nam, 3 tui 3 thng, NV v st + ho m, bnh 8 ngy
Hi chng nhim trng h hp di (st, ho m, th nhanh, co lm ngc, rale n)
Suy h hp 2 (p ng th oxy, nhp tim nhanh, th nhanh)
IX. CHN ON S B:
Suy h hp 2 - Vim phi nng
X. CHN ON PHN BIT:
Suy h hp 2 td Suyn cn nng bi nhim bc 1
XI. BIN LUN LM SNG:
B nam, 3 tui 3 thng, NV v st + ho m, bnh 8 ngy:
3

- Vim phi: b c hi chng nhim trng ng h hp di, khng c hi chng tt nghn ngh
nhiu nht n vim phi, ngh cy m, chp x quang phi cung c chn on
- Suyn: b c kh kh ti i ti li m cha ghi nhn bnh bm sinh, tui ny t ngh tro ngc
d dy thc qun, khng hi chng nhim lao chung, kh th p ng vi ventolin nhng khng c
hi chng tt nghn, gia nh khng ai hen, vim mi d ng, vim da nn t ngh.
- B c suy h hp 2 v hi chng nhim trng h hp di nn ngh n l vim phi nng.
- Suyn cn nng bi nhim bc 1: SpO2 <90%, nhp tim, nhp th tng, kh th c khi ngh ngi
ngh cn suyn nng sau nhim trng h hp, trn nn cha c cn kh th trc ngh bc 1
XII. CN LM SNG NGH:
- Cng thc mu, CRP, glucose, AST, ALT, creatinin mu
- Kh mu ng mch
- Ion
- Cy m
- X-quang ngc thng
XIII. KT QU CN LM SNG
a. Cng thc mu:

BC
Neu %
Lym %
HB
HCT
MCV
MCH
MCHC
RDW
PLT

Khong BT
4-10
37-80
10-50
12.5-16
35-50
83-92
27-32
32-35.6

8,3
32,4
45,0
14,3
37.6
82.7
24.5
29.6
12
236

130-400

b. X-quang phi:

n v
K/l
%
%
g/dl
%
f/L
pg
g/dl
%
K/l

Hnh
chnh
K thut

Tn
thng

Tn bnh nhi
Ngy chp
T th
Ht vo
Tia
Phim cn i
M mm
Khung xng
Trung tht
Bng tim
Phi
Mng phi

Phan Trung Dng

Gii tnh: nam Nm sinh: 21/9/2012 (42 thng tui)
11/4/2016
AP (khng c bng hi d dy, xng b vai nm trong
ph trng , tun hon phi trn di nh nhau
B ht u su (cung sn sau s 10 ct vm honh)
Cng (thy 8 t sng ngc u tin)
Cn i (2 u xng n i xng qua ng gia)
Khng trn kh di da, khng u bu
Khng gy xng, khoang lin sn khng gin
Khng trn dch hay trn kh
Khng to (ch s tim lng ngc <0,6)
Thm nhim 2 rn phi, xa m b tim
Khng trn dch hay trn kh

XIV. BIN LUN CLS:

- WBC khng tng, Neutrophile khng chim u th tuy nhin X-Quang gi vim phi, km lm
sng ph hp => xc nh vim phi
XV. CHN ON XC NH:
Suy h hp 2 - Vim phi bnh vin nng