MAU LAM BENH AN THEO THAC BO HANH CHANH Tén: Duong Gia K. Gidi: Nam Sinh ngay: 23/05/2022 Tudi: 1 tudi 5 thang (17 thing) Dia chi: Ap Ci Doi Nho, xd Nguyén Viét Khai, huyén Pha Tan, tinh Ca Mau Ngay nhfp vign: 12h28” ngay 14/11/2023 Buéc 1: Khai thc bénh sir va tim trigu chirng lm sang dic higu Ly do nhép vién: Co giat Bénh sur: NI: t6i bé 61 5 - 6 lan, 6i dich sita. N2: ha s gu chay 5 Kin/ngay, dich xanh vang, t6i > nhap vign BV Binh Duong t 38,5 d6 C c6 dap tng voi thudc N. sau con bé ngii, khéng (6i co giat (khGi phat toan thé, tron mit, tim mdi, co cimg toan thin, con 2-3phut ) N4: sang bé co gift (con tuong tyr lac truéc)—> nhfp vién ND2 Trong qua trinh bénh ly: bé an udng duge. Tién can: - Sétco gidt 1 lan hic 6 thang tudi, 43 diéu tri, chua do dién nao - San khoa: con thir 1, PARA 1001, sinh du thang, sinh m6, can nang lic sinh 3,2 kg, - Phat trién tam than van déng: + Van d6ng thé: Di ving. + NgOn ngit: Néi tir don. - Khéng di tmg, thie an. - Tiém chung chua day du theo lich tiém ching mé réng ctia bé y té (thiéu viém nao Nhat Ban)~ Gia dinh: chua ghi nhan tién can dong kinh, co giat Nghi dén Ly do Triéu chtrng dac hiéu can HOI thém va bénh KHAM LNhiém Co giat + sét - Dau higu mang nao: Cé guong, Kernig, tring hé 6i Brudzinski. than kinh trung uong. 2. Nhiém Co giat +s6t - Kham dau mat nuée tring ngoai hé | ; - Kham bung TK TW: NT Tiéu chay, 61 - Tinh chat phan: Mau/ mii/ hrong/ mau dudng tiéu hoa 3. Réi loan chuyén hoa Co giat + sét Tiéu chay, 61 - Bam dudng huyét mao mach - HaK: Nghe tim - Ha Na: Danh gia tri gide 4.DOng kinh Co giat lan 3 - Kham bat thong dau, chéng so - Kham bat thudng chtte nang nao:Tri gidc, phat trién tam van - Denver II tric no: Do vong Bu’éc 2: Bién luan chén doan lam sang va chan doan phan biét Dat van dé: - Con co giat - cé sét - tinh cht phitc tap - c6 yéu td kich goi - tai phat lan 2. - Tiéu chay - Oi - Tién can: Sét co giat hac 6 thang tudi Chan doan: Sét co giat do nhiém tring dudng tigu hod.a tri cho chin Kham: (néu céc trigu chtmg duong tinh hoa doan, chan doan phan biét) Bénh Yéu té pha hop Yéu t6 khéng phi hop (gém trigu churng co’ nang va thre thé) 1. Nhiém = TCCN: sét co - Cémém tring TKTW gidt, 61 - Khéng dau mang nao - TCTT: khong = Chua tim viém nao Nhat Ban 2.R6i loan = TCCN: sétco - Tré 4n uéng binh chuyén hoa giat, 6i, tiéu thuong chay, 6i - Tim déu, tan sé: 130 1an/ph - Tinh, tiép xuc tot, Glasgow: 15 3.Déng - TTCN: co giat - Vong dau: Kinh - - Danh gia Denver IL 1. Ca nhan - xa hi: Tiét muc sit dung thia dia 75% ~ 17,5 thang, DQ= 98,3% => Binh thuong 2. Van d6ng tinh té thich img: Xép chéng 4 khdi 50% ~ 22 thang, DQ= 123,6% => Binh thudngthong nhay 7 thurng 3. Ngén ngit: Noi cau 2 tir 25% ~ 17,2 thang DQ=96,6% =>Binh 4. Van dong thé: Chay ~17,8 thing , DQ=100% => Binh Bue 3: D8 nghi xét nghiém Cae xét nghiém can lam Ly do cho xét nghiém va két qua mong dgii Phan tich két qua Choc dé DNT Ly do: Co KQ mong dgiz Mau: tring trong . Dung 50-60 mg% Dam < 0.4g/l ctase <3 mmol TE bao bach cdu < 5 lympho phite tap yk Chua ghi nhan két qua. Dién giai dé Ly do: Co giat , sot, tigu chay, 6i - KQ mong doi: 1. Na binh thudng 2. K binh thudng Na giam rt it, K va Cl binh thuéng. -> phii hop véi bénh canh 6i (N1) va tiéu chay (N2), hién khéng tiéu chay, 6i ,bé an udng duge.-> loai trir duge Joan chuyén hod. Céng thite mau Ly do: Tim dau nhiém tring KQ mong doi: Bach cau ting. CRP Ly do: Tim dau nhiém tring KQ mong dgi: CRP ting CRP ting > gi y 4 nhiém tring Sigu am bung XQ bung KSS Ly do: tim 6 nhigm tring tigu hod, loai tri NN ngoai khoa KQ mong di: hinh anh goi ¥ nhiém tring tiéu hoa va hoi, day thinh dong tam cdc quai rudt ving bung ‘trai #3mm. > goi y nhiém tring dudng tiu hoa Dién nao do Ly do: loai trir bénh dong kinh Chua ghi nhan oe két qua. KQ mong doi: tim bat thudng. Buréc 4: Bign luan va chin doan xac dinh Bénh Cac yéu t6 phi hop Cac yéu t6 khong phi hopSét co gidt do nhiém tring dudng tiéu héa. - Co nang: sét, co gidt, 6i, tiéu chay - Thue thé: bung mém, khong co dau mang nao. - CLS: + BC ting nhung neu khéng ting + CRP: 6,5 mg/l => ting nhe => nghi nhiém sigu vi + SA bung: céc quai ruét nhieu dich va hoi, day thanh déng tam cée quai rugt ving bung trai #3mm => hinh anh goi y nhiém tring tiéu hod