CHUYN

C XNG KHP
H Ni, ngy 16/03/2012

Thng tin bnh nhn

Bnh nhn: Nguyn Th A, N, 61 Tui a ch: H Ni Ngh nghip: Gio vin mm non Ngy vo vin: 1/3/2012 L do vo vin: au khp gi phi

Bnh s
T 2008 (Cch y 4 nm):
au mi khp gi P, tnh cht c hc, tng t, thnh thong sng nh, khng nng Khm v iu tr nhiu t vi C: Thoi ha khp ti BV Xanh Pn:
Diclofenac 50mg/ngy, mi t khong 10 ngy Tim khp gi P 1 ln cch y 2 nm Glucosamin 1g/ngy, ung ko di

Bnh s (tip)
Thng 1/2012 (Cch 2 thng):
Khp gi P: au: VAS 60/100, tnh cht c hc Sng Khng nng C du hiu kt khp Khp gi T khng sng au Khng st, khng gy st cn. Khm v iu tr ngoi tr ti BV Bch Mai bng gim au chng vim, gin c Kt qu: Bnh nhn t, cn du hiu kt khp Vo vin.

Tin s
1. TS bn thn
- Sinh l: Mn kinh nm 54 tui (7 nm). 4 con. - Bnh l: RL Lipid mu, iu tr khng thng xuyn - Khng c tin s chn thng 2. Tin s gia nh: Khng c g c bit

Khm bnh
Ton thn:
Tnh, khng st Chiu cao: 150 cm; Cn nng: 60 kg; BMI: 27 M: 80 ln/ pht; HA: 120/80mmHg Da, nim mc hng Khng xut huyt di da Khng ph. Hch ngoi vi khng s thy

Khm bnh (tip)

Khm khp gi:
- Khp gi P:
- Sng nh, khng nng - Bp bnh xng bnh ch m tnh - au khi vn ng, khng hn ch vn ng cc ng tc - C kn Baker vng khoeo, kt 1 x 5cm

- Khp gi T:
- Khng sng nng, khng au - Vn ng bnh thng

Khm bnh (tip)

Khm cc khp khc:
Khng bin dng Khng sng nng au Khng hn ch vn ng

Khm bnh (tip)

- Khm cc b phn khc
Tim mch: T1, T2 r, nhp tim u: 88l/p
H hp: RRPN r, khng ral

Tiu ha: Bng mm, gan lch khng s thy

Thn kinh: Khng lit, khng ri lon c trn

Cc b phn khc cha pht hin g c bit

Tm tt bnh n
BN n 61T, vo vin v sng au khp gi P Tin s: Ri lon m mu. Hi chng, triu chng chnh:
Sng au khp gi P, kiu c hc, khng nng VAS 60/100 C du hiu kt khp khp gi P Kn Baker khoeo P Cc khp khc khng sng au, khng hn ch vn ng Ton trng khng bin i

CHN ON S B
TD Thoi ha khp gi phi c du hiu kt khp

Chn on nguyn nhn

Thoi ha khp gi P c tn thng sn? U xng sn mng hot dch khp gi phi? Vim khp dng thp th mt khp?

Cc xt nghim
1. Xquang: Khp gi 2 bn thng, nghing. 2. Siu m khp gi 3. Bilan vim : CTM, Mu lng, CRP. 4. Sinh ha mu : Ure, Creatinin, Glucose, Acid uric, GOT/GPT, Lipid mu, in gii mu, calci, Yu t dng thp 5. Tng phn tch nc tiu 6. o mt xng ton thn

Kt qu xt nghim
2/3/2012 Hng cu 4.5 T/L

Hemoglobin
Tiu cu Bch cu Trung tnh Mu lng 1h Mu lng 2h

137 g/L
233 G/L 6.64 G/L 52.9% 20 mm 40 mm

Kt qu xt nghim (tip)

Ure Creatinin
Glucose Calci TP

6.1 mmol/l 49 umol/l

5.7 mmol/l 2.42 mmol/l

Acid uric Triglycerid

HDL-C

313 umol/l 2.88 mmol/l

1.51 mmol/l

Cholesterol 6.45 mmol/l

GOT/ GPT
CRP

27/34 U/l
0.2 mg/dl

LDL-C
RF

3.63 mmol/l
m tnh

Kt qu SA khp gi
Kn khoeo P

Kt qu SA khp gi phi
C rt t dch Ti cng trn ngoi c nhiu nt vi ha, mt s nt tp trung thnh m di 1.25cm, mt s nt tri t do trong dch khp, khi BN thay i t th cc nt vi ha cng di chuyn Ti cng di gn c t u i c nt vi ha 2.21cm Kn Baker khoeo P, kt 1.37 x 5.27 cm Gai xng khe i chy trong v ngoi bn P Phn mm quanh khp khng thy bt thng

Kt qu XQ khp gi

Gai xng

Kt qu XQ khp gi

Kt qu o mt xng ton thn

CT SNG THT LNG

Kt qu o mt xng ton thn

C XNG I

Chn on
Thoi ha khp gi 2 bn - TD U xng sn mng hot dch khp gi 2 bn/ Ri lon m mu

Ni soi khp gi
BN c ch nh ni soi khp gi phi Mc ch: - Chn on nguyn nhn (kt khp do rch sn chm, bong mnh xng- sn; sinh thit mng hot dch, PCR lao) - iu tr: Ra khp bng dung dch Natriclorua 0.9%, ly b t chc di vt

Kt qu ni soi khp gi
Dch khp: t, snh, mu vng trong Mng hot dch: tn thng vim tng sinh mch mu, tng sinh hnh lng mc nhiu Tng sinh fibrin rt t

Kt qu ni soi khp gi (tip)

Sn khp b mt sn thoi ha 3, nhiu ch l xng di sn, c ch sn tn to C 1 mnh t chc cng,mu trng, kt 2.5x2cm, gn vo b trn xng bnh ch C nhiu mnh t chc cng,mu trng, kch thc 3-5mm, c cung gn trn b mt MHD Sn chm v 2 dy chng cho bnh thng

M bnh hc
Kt qu sinh thit: t chc xng v sn Mng hot dch vim mn tnh PCR lao: m tnh.

Kt qu ni soi khp gi (tip)

Kt qu ni soi khp gi

Kt qu XQ khp gi phi (sau m ni soi)

Chn on xc nh
U xng sn mng hot dch th pht do thoi ha khp gi 2 bn/ Ri lon m mu

iu tr
iu tr ni khoa
Chng vim: Etoricoxib(Arcoxia) 60mg/ ngy Gim au bc 2: Paracetamol+Tramadol(Ultracet) 3vin/ngy

Gin c: Myonal 50mg 2vin/ngy

Chng thoi ha khp: Diacerein 50mg 2v/ngy Glucosamin sulfat 1500mg 1 gi/ngy

iu tr (tip)
iu tr ni khoa (tip)
B sung Calci PPI: Omeprazol Khng sinh d phng nhim khun (ni soi khp) Chc ht kn khoeo gi phi

Kt qu iu tr
Sau 12 ngy iu tr: BN au khp gi phi VAS 20/100, sng nh, khng nng Khng hn ch vn ng khp gi

Vt m kh, ang lin, ct ch

BN ra vin iu tr ngoi tr.

K hoch iu tr khi ra vin

Gim au, chng vim Thuc chng thoi ha khp ung ko di Tp vn ng khp gi trnh cng khp, dnh khp sau m. Gim cn, tp luyn nh nhng gim chu ti cho khp gi.

Cu hi tho lun

Xin trn trng cm n!