NGUYN PHC M

Y2011B
T 3 Nhm 7
I HC Y KHOA PHM NGC THCH

BNH N KHOA THN KINH

I.Hnh chnh
H tn bnh nhn: NGUYN HONG T NH
Gii tnh : N
Ngy sinh: 25/08/2010 (4 tui)
a ch : Q. Bnh Thnh, TPHCM
H tn m : NGUYN MINH TUYT
Ngh nghip : Ni tr
Ngy nhp vin : 21h ngy 20/12/2014
II.L do nhp vin
St ngy 3
III.Bnh s : bnh ko di 3 ngy
Sng ngy 18/12, b st 1 cn 380C , p ng thuc h st, khng km co git, li b,
l m, lnh run km theo ho m xanh lng nhiu, 15-20 cn / ngy, khng kh th,
khng kh kh.
Ngy 19/12 : b khng st, ho m xanh tnh cht nh trn
Ngy 20/12: 17h b st 400C, p ng h st, sau 2 gi th b vn cn st 390C th
b ln cn co git khi b ang ngi th bt nga ra sau, km trn mt, tm mi, trong
cn b mt thc, gi khng p ng, cn trong 5 pht, gim khi m lau mt cho b,
sau cn khong 5 pht th b tr li bnh thng, m thy b mt nn a nhp vin
Nhi ng 2.
Sut qu trnh bnh : b khng nn i, n ung c, i tiu bnh thng, nc tiu
vng trong, i tiu phn vng, st 1 ln/ ngy.
Tnh trng lc NV:
Mch 120l /ph, nhit : 37.7 0 C, nhp th: 20l /pht, huyt p : 90/60 mmHg
B tnh, mi hng, chi m, mch r, tim u, th u, phi khng rale, bng mm,
hng sch, Petechie (-), tiu tiu bnh thng.
iu tr : Cefixim
100mg
1g
x2 (u)
Hapacol
150mg
1.5 gi x4 (u)
Vancomua
100mg
2 gi x2 (u)
Sp Motilium 100mg

1 mg/ml x 3(u) trc n 15 pht

Din tin bnh phng: b cn st, ho m xanh nhiu, khng s mi, khng kh kh,
n ung c, tiu tiu bnh thng.

IV.Tin cn
Gia nh
Cha ghi nhn bt thng
Bn thn
Sn khoa :
Con th 1/1, sanh thng, sanh thng
PARA 1001
Cn nng lc sanh : 2.8 Kg
Bnh l : tin cn Vim Ph Qun/ st co git nm 2012 nhp BV Nhi ng 2 1 ln.
D ng : cha ghi nhn d ng thuc, thc n
Pht trin tm thn : 1 nm ni bp b

Pht trin vn ng : 16 thng bit i

1.
2.

Dinh dng : 12 thng cai s m hon ton, n dm sau

Tim chng: chng nga Lao, vim gan B, Ho g, un vn, bch hu, bi lit.
V.Khm : 9h 21/12/2014
1. Tng trng :
B tnh, tip xc tt
Sinh hiu :
Mch : 120 ln/pht
Nhp th : 20 ln/pht
Nhit : 37.8oC
Huyt p: 100/60 mmHg
Mi hng, chi m
Mch quay r
Khng du xut huyt, ban tay chn ming.
Cn nng : 16.5 kg
2. u mt c
Ming: khng sang thng, khng lot
Hng: sch
Tai : khng sng, khng chy dch
Mi : khng sng, khng chy dch
Mt : khng nhn l, khng nhn m
Kh qun khng lch

C mm
3. Lng ngc
Cn i di ng theo nhp th
Khng u, khng so m c, khng c p bt thng
Th u 20 l/pht , khng co lm ngc , khng co lm hm c , hm trn c
m ph bo th, khng nghe rale
Nhp tim u 120 ln / pht
4. Bng
Cn i, di ng theo nhp th
Bng mm
Khng im au khu tr
Gan, lch khng s chm
5. T chi
Khng yu lit chi , xng khp khng bin dng , khng gii hn vn ng
6. Thn kinh:
Kernig: m tnh, Brudzinski: m tnh, khng du thn kinh nh v.
VI.Tm tt bnh n
B n 4 tui , nhp vin v st, co git
Tin cn : i khm bnh vin Nhi ng 2 vi chn on vim ph qun, st co git
cch y 2 nm
Sau khi hi v khm pht hin : _St cao khng lin tc 3 ngy
_Co git ton th, n gin, thong qua 1 ln
_ Ho m xanh nhiu, khng kh th.
`
`
_Tim u, Phi th, Bng mm, Gan lch
khng s chm.
_Khng ni ban xut huyt
_ Hng sch.
_Khng co git, khng yu lit, khng du thn kinh
nh v
_Tin cn st co git 1 ln (lc 2 tui)
* t vn :
St cao khng lin tc
Co git ton th, n gin, thong qua, sau cn tr v bnh thng
Hi chng nhim trng h hp
Tin cn st co git ( lc 2 tui).

VII.Chn on s b
Vim Phi, st co git lnh tnh
Chn on phn bit: Vim phi, ng kinh

VIII.Bin lun
B n 4 tui c st co git:
u tin loi tr cc nguyn nhn chn thng v xut huyt v b khng c du hiu
chn thng, khng du thn kinh nh v, khng au u.
K tip loi tr cc nguyn nhn chuyn ha nh h ng huyt, ri lon in gii v
b khng c du hiu mt nc, khng nn i hay tiu chy.
Cn co git xy ra 1 ln, thi gian khong 5 pht, km st >390C, sau cn b tr v
bnh thng, tin cn st co git lc 2 tui, ph hp tui nn ph hp vi tiu chun
chn on cn st co git lnh tnh.
B c hi chng nhim trng h hp di: ho m xanh lng nhiu, th nhanh, phi
th nn ngh nhiu l Vim Phi.
=>Do ngh nhiu nht l Vim phi, st co git lnh tnh.
Phn bit vi ng kinh v c th st khng phi l yu t kch gi co git, v b c
cn co git ti pht nhng khng ngh nhiu v b ch mi co git 1 ln trc y, gia
nh cha ghi nhn tin cn ng kinh, sau cn b tr v bnh thng.

IX. ngh cn lm sng

Tng phn tch t bo mu bng my m laser, CRP, Xquang phi , ion , in no
.
X.Kt qu cn lm sng
*Tng phn tch t bo mu
WBC

22.98

4,0-10,0 K/uL

%NEU

83

37-80%

%LYM

9.9

10-50%

RBC

3.86

3,9-5,8 M/uL

HGB

10.1

12,5-16 g/dL

HCT

30.6

35-50 %

MCV

79.2

83-92 %

MCH

26.18

27-32 pg

PLT

382.5

130-400 K/uL

*Sinh ha:
CRP

63 mg/l

Na:

136 mEq

3.9 mEq

Ca

2.72 mEq

Ca total

99 mEq

Mg

24 mEq

*X quang phi:
Thm nhim 2 y phi xen k l tn thng ph nang.
*Bin lun :
Huyt ghi nhn WBC tng cao km %Neu chim u th km CRP tng cao gi
tnh trng nhim trng. X quang gi tnh trng vim phi. .
Ion trong gii hn bnh thng.
=> khng cho thy tnh trng ri lon in gii.
Chc d dch no ty khng c ch nh.
Cn lm sng gi Vim phi.
XI. Chun on xc nh
Vim Phi, st co git lnh tnh.