BỆNH VIỆN ĐA KHOA TỈNH THANH HÓA

CA LÂM SÀNG
Doctor: LÊ THỊ PHƯỢNG
 INFORMATION
• Full name: LÊ KHẮC VIỆT
• Sex: Male
• Age: 80
• Hospitalized date: 22/11/2022
• Reason for admission: Stomachache
 MEDICAL HISTORY
• 5 hours before admission, the patient began to have
epigastric pain, not spreading, intensity keep raising,
no increase or decrease factors.
• The patient had mild epigastric distension, no
heartburn, sour belching, no vomiting, no cough, no
shortness of breath, and no heaviness in the chest.
Abdominal pain continuously increasing. During the
day, the patient defecated with yellow molded stools,
yellow urine.
 MEDICAL HISTORY

• Has a high blood pressure: taking medication

regularly
• No history of peptic ulcer disease was recorded
• Do not drink alcohol
• No history of gallstones
 MEDICAL EXAMINATION
1. BODY FEATURES
• Patient still awake but tired
• Mucous skin is normal, not has jaundice
• Hands and legs still warm, clear blood vessel
• No edema
2. CIRCULATORY SYSTEM

• Regular, clear heart rate

• Heart rate: 80l/min, blood pressure: 140/80 mmHg
3. RESPIRATORY SYSTEM
• Balanced chest
• Rì rào phế nang 2 phổi rõ, respiratory rate 18l /min
• Vibrating the sound evenly on both sides,
percussion throughout the lungs
4. DIGESTIVE SYSTEM
• Stomach distended
• Epigastric lnterstitial hernia reaction (+)
• Cullen Point (-), Gray Turner Point (-)
• No collateral circulation
• Không dấu hiệu rắn bò
• Liver and spleen not palpable
5. OTHERS
Examination showed no abnormality

6. PROGRESSION AFTER HOSPITALIZATION

After 4 days of treatment
• Patient has reduced abdominal pain
• The epigastrium is slightly irritated
• Normal defecation and urination
• Tender stomach
CẬN LÂM SÀNG
 CASE SUMMARY
An 80-year-old male patient with a history of high
blood pressure was admitted to the hospital
because of acute epigastric pain at the 5th hour.
When the patient is admitted to the hospital:
• Epigastric pain is continuous, does not spread,
the intensity gradually increases, there is no pain
relief position
• Slight epigastric distention
• No vomiting
• Abdominal CT: image of Acute pancreatitis
• XN: Amylase: 1870 U/L Lipase 1617 U/L
 DIAGNOSE

• Day 1: Acute pancreatitis, due to gallstones

- Grade: Medium-Serious
• Hypertension

• Level: Serious
 TREATMENT
Day 1
• Temporary fasting: Inserting a gastric tube
• Paracetamol 1g * 1 infusion bottle 60g/min
• Ringer lactate 500ml * 6 infusion bottles 60g/min

• Glucose 10% 500ml * 2 infusion bottles 40g/min

Metronidazole 500mg/100ml * 2 chai truyền
60g/ph 8 giờ- 20 giờ
Ceftizoxim 1g * 4 lọ, tiêm tĩnh mạch chậm
8 giờ- 20 giờ
Atimezon( Omeprazole) 40mg * 1 lọ
tiêm tĩnh mạch chậm
Bn điều trị 4 ngày, bn ổn định, cho ăn trở lại
Đã chuyển BV đại học Y hà Nội điều trị tiếp
Xin chân thành
cảm ơn !