10 ca lam sang 2017

Phosphalugel 1 g6inen khi dau Khdm lffm sirmg: Benh nhen fiEh, ti6p xuc t6t.. Sring ng?ry UIA\ benh nh0n vio bQnh viQn chd ktuim thi cim gi6c mQt mdi, ch6ng m{t, du-o.. Ca l6m shng 4PARK

Ca lflm sirng 1

LOET D4 DAY B-enh nhan nir 66 tu6i, cao 156 cm, n{ng 61 kg, o=i kh6m b0nh

thugmg vi 2 tuan

TiAn sfr b.6nh:

vi ph6n kh6, cimg, dau vung

- Vi0m dp ddy 10 aEm C6ch ddy 4 thangbi x#t huy€t da ddy IIP (+), d6 dusc k0 6m ph6c

ao oec.

- ' Thoai h6a khop co tay 6 n6m, kh6ng riO dau kh dung paracetamol

- Tdng huy0t 6p 15 ndm

- DAi th6o duong We 2 12 uAffi

: NhOi m6u co tim 6 nEm tru6c

- LoEng xucrng

Li6i stimg: u6ng 1 ly rugu nho mdi ngiy,.thucmg thric khuya do kh6 ngir Tpp th6 di:c ngodi c6ng vi0n gAn nhA m6i buOi sang 30 phui.

Thmdc damg sr? dqamg:

i Aspirin 81 mg 1 viCn/ngdy

2 Lisinopril 20 mg 1 vi6r/ngdy

3 Alendronat 70 ng 1 vi0i:/tuAn

4 Genfibrozil600 mg 1 viOn x2lAn/ngiry

5 Glybr:ride 5 mg %.vidnx}lfrn]rrgiry

6 Diclofenac 75 mg 1 r,t6n-x2 Ldn/agiry

7 LanzoPsazsl 30 mg 1 vi6n/ngdy

8 Phosphalugel 1 g6inen khi dau

Khdm lffm sirmg: Benh nhen fiEh, ti6p xuc t6t

- HuyiSt ap 150/90 mmHg

- Nhr.p tim 80 16n/phrit

C$m l6m sirng:

Na 141 mEq/I- (135 - i50)

K 4,6 mEqlL (3,5 - 5)

BtIi\ 2l mgldL (7 -20)

Creatinin 1,1 mg/dl (0,7 - 1,5)

Glucose 119 mg/dl (80 - 110)

IIb 7,2 glil- (12 - 15)

Hct 2t% (3s - 4s)

PLT 390 I?pL(200 - 400)

- Nhip thd 15 16r:/phrit

- Tliari nhi0t 36,3oC

- $IBC 7,}WtrtL(4-10)

- Retic 1,8 Yo (0,5 - 1,5)

- HbAls 6,9 Yo

- Chol TF 195 mg/dl (150 - 200)

: LDL-C 125 m{dl- (< 130)

- I{DL-C 39 mgldL (> 35)

- TG 195 mg/dL (< 165)

- TSF{ 2,93 F.Wr.rL (0,27 - 4,94)

X6t nghiQm tim ffiP:

- Testhuy6tthanh(+)

- CLO-test (-)

NQi soi d4 ddy: 2 v6t lodt ducrng kinh khoang 6 mm, c6 v6t m6u ci6ng cr bd cong nh6

ChAq dofre: Lodt d4 ddy

Ca lflm sirng 2 rANe suntr Ap Th0ng tin chung

- B-Cnh nh6n nt, pinh ndm 1958, cdn nflng 49 kg, chiAu cao 1,57 m

Lf do nhfp viQn: Ch6ng m4t

Di6n ti6n bQnh

Khoang 4 ngity nay, bQnh nhdn c6m gi6c m-Ot, tO mbi 2 chdn, huy6t 6p do duo c 2601rc0 mmHg t hi lr*nim b6c si tu Sring ng?ry UIA\ benh nh0n vio bQnh viQn chd ktuim thi cim gi6c mQt mdi, ch6ng m{t, du-o c dua vdo cdp cr?u.

Tidn sfr bQnh

- TEng huy6t ap tr6n 5 ndm, k*r6ng k*r6m vi di6u hi.

- Parkinson 1 n6m

Tidn s& gia tlinh: Cha mdt vi nh6i m6u cotim nEm 60 tu0i

Tiln sr? dirng thuiic

Madopar rc025 (Levodopa/ Benserazid) x 3 lfu:/ngdy

Vitamin 3B x 3l6r/ngdy

Khim bQnh

Sinh hiQu: Mpch 98 hn/ph; thdn nhiQt 37oC; HA: 2101130 rnneHg; Nhlp tho: 20 l&:/pie; Sp02 98%

BQnh nh6n tinh, ti6p xfc t6t, da ru6m h6ng, tim dAu, ptrdi trong, bqng rnAm, gan lich kh6ng sb clapm, kfiOng phr);lrtr6ng liQt klru tri.

Si6u 6m tim: HO tanZl6y4,EF tltdtxaiAtyo

C$n lAm sirng

Euong huyet dOi: 27t rrrgldL

Creatinin: 0,8 mg/dl (0,8 - 1,4)

Cholesterol W:232 mgldl, (150 -200)

HDL-C: 38 mg/dl (> 35)

AST: 12 UIL (9 -48)

RBC:4,65x!or2 lL (4,3 -5,3x1012)

HCT:35% (37 - 49)

MCH:26,2p9(25 -35)

Thu5c sr? dqng t4i bQnh viQm

Captopril 15mgngflm + Furosemid 20rng IV Yr dngx 3 Gn/ ngay

Mixtard 30 HM: SC 15 UI x 2 Bn/ ngdy

BQnh nhdn dugc theo d6i m4ch, huy€t 6p vd dudng huy0t thuong xuy6n

Huy€t 6p vdo bu6i sang: Ngdy 1: 2L0ll30 mmHg; Ngiy 2: 180/100 mmHg; Ngdy 3: 140/80 mmrHg

Thu6c s{r dgng khi xudt viQn

Lisinopril 10 mg x 2 6n

Bisoprolol2;5mgx I l6n

Metformin500mgx2l6n

Atorvastatin l0mgx I l6n

Levodopa/ Benserazid 100/25mgx 3 lfu/ ngdy

Chin tlofn

TEng huytSt 6p, ddithiio iluong typel,r0i lopn lipid m6u, parkinson

HbArc 70,8Yo (4,4 - 5)

Ure 38 mg/dL (20 - 40) Triglycerid : 292 mg/ dI- (< 1 65)

LDL-C: l24m{dL (< 130) ALT: 10 UIL(5 -49)

I{GB: 12,6 gldl- (13 - 16)

MCV:75,3tu (78-98) MCHC: 36,1ddL(32-35)

F,%i' \,'

#:5

Ca lAm slrng 3

GOUT Benh nhan nt.84 tu6i, n4ng 55 kg

?So Up* viQn sang nay vi bi srmg do vdr dau nhric dt dQi o c6c khdp ng6n ch6n phai vA

d6u g6i

Tidu sri b6nh

- Suy tim sung hriyOt

- TEng huy0t 6p

.- Suy thQn men

- Gout (trong rym r11taqua, c6 3 16n x6y ra con gout cap; du-oc chi dj-nh allopurinol rfumg

bQnh nhao !i nOi mAn dO vd phai oe*g str dpng B6c si o phdng kh6m kO rlsn cbielircrn "

1mg khoi dAu, sau d6 giam o,rOng iiAulOO pg)

T'hudc dalle sl? dunE

- Bumeta:nide 1 mg I ngity

- R.amipril 5 wg I ngiry

- Chgc dich khop, ph6t hiQn tinh^&A \.:1, urat

1.t

CAm I6m sbmE

- CreatininhuyOt

ESR

- Ac uric huy€t

ChAre do6ar

_,

Con gout cdp t6i ph6t

160 pmoUl

115 mmigib 745"pmollL

Ca l6m shng 4

PARKINSON

Thdng tiri chung: Benh nh6n nt, 82 tu6i, cao 153 cm, nflng 55 kg

Ly do nhflp viQn: BQnh nhdn bi cang cring.co khi van dQng vd run khi nghi ngoi

DiSn tiSn bQnh: Khoing ntra thang nay bdnh nhAn thAy run toirn thdn khi nghi ngoi, cdng cung co l&i di chuyAn vd mAt th[ng bdng Ngudi nha cho biOt bQnh nhdn co nhi6ri luc l5n l6n vd hay kho ngt viro ban d6m

Ti6n sfr bQnh: Parkinson - ETD type 2 - Trim cam - Huy€t kh6i tinh mach san

Ti6n sfr gia tlinh: Kh6ng ghi nhfn

Tiiin sfr dring thuiic:

- Fluoxetin 20 mg x 1 vi€n/ngdy

- Selegilin5 mgx 1viCn/ngdry

- Metformin 850 mg x 2 l6n/ngdy

- Sitagliptin 100 mg x 1 ldn/ngny

Khfm b$nh:

- Sinh hi0u: mach 80 lddphirt nhip thO 20 lArvphrit, huy€t ap l5Ol100 mmHg, thdn nhiQt 37oC

- Benh nhdn tinh, v6 mdt it cim xtc, da ni€rn nh4t

-l

- Tim d6u 16, phOi kh6ng ran, bung m0m

- Myerson (+), b6nh xe rdng cua (+)

- Babinski (-)

Cgn lflm slrng:

- Scr 1,8 mg/dl (0,7-1,5)

- BLIN 30 mg/dl (7-20)

- Glucose doi 170 mgldL (80-110)

- HbAlc 8,2o/o

ChAn dorin: BQnh chinh: Parkinson n{ng

Xfr tri: Bdnh nhAn dusc cho nhfp viQn khoa n6i thAn kinh

Thuiic sfr dgng t3i bQnh viQn: B6 sung

- Sinemet2sll}} mg 1 viOn x 3 16ra/ngiy

- SAt sulfat 325 mg I viOn x 3 lAn/ngdy

- C6c thu6c khdc, giir nguy6n

- Hb 10,3 g/dl (12-15)

- MCV 70 fL (80-100)

- MCHC 280 glL (310-370)

:';E- i;

't;F4*4=*"*J**:j

i& i,€1 ffi a E

,.-i

aBhi_

S 5L'5*

Ca l6m sane 5

T'HTEU MAU rffiU SAr, Th0ng tin chung

BQnh nhdn: Biri ML., nft

Tu6i:28

Dang mang thai drSa con dAu ti6n thang thtt Thai k! ph6t tri6n binh rhuong

Lf do khfm

lennlnan cdmthiv m9l va,flo 110 nelv :i kli lam nhftng vi6c nhe nhdng nhAt Trong qu6 trinh

thdm kh6m, bQnh nhdn cho bi6t thcm gAn d6'y hay b! ch6ng"m4i, cnJ-ot rirt,-thdm 6n nr"r6c d6 vi ciau

lu0i

Ti0n sfr bQnh

Khdng

Ti6n sti gia dtmh

Cha mg kh6e m4nh

t 6l s6mg

Kh0ng hrit thu5c, kh6ng uOng ruou

m.l

rrem str o! rrrnE

Chua ghi nhfln

Kh6m bQuh

Sinh hiQu: Mpch: 1i0 l6n/ phut "t+

Huy6t 6p: tZ0/80 mmHg

Thdn nhiQt: 37 oC.

Khdm tdng qudt:

Da, ni6m vd m6ng tay nhpt .'

Vi6m lu0i

Cfm l6mo sirmg

ChAm dotftm

Thi€u m6u thi€u s8t

Hb 8 e/dl, (11,5-16,5) MCV 70 fL (80-96) .Sdt huy6t thanh 40 mce/dL (40-150)

Hct28%(3343%) MCH 22ps(274a) Ferritin huy6t thanh 10 nglm1

g?-150)

Ti6u cAu 480 000/p,L

(3 1 0-370)

TIBC 450 mcs/dL (250-400)

HOng cdu ludi 0,3%

(0,5-2%)

RDW r8.4%(tt-14)%

- NTilrF,M TRuN*c -Arittffiiffl-rt ar rsAo

BusF{G Thdng tin chung

Penh nhen nam,67 tu6i, cen nflng g0 kg, chiAu cao 1,65 m

B-Onh nhdn dtin kli6m sric kh6e'di.iih tcyi,a co pha;rar;t,int oqng mAt ngu gAn d6y.

Tidu sfr bQnh

+ D6i th6o tlucrng typeZ (15 n6m), ki0m so6t k6m

+ Da.timg lodt bdn chen trii di6n (3 n6m)

+ Tr0m c4m (diOu tri du_o c 1 th6ng)

IYI-m-*!i* 1]-rt tti,1oc, udng rusu BN thuong qu€n uSng thu6c vd kh6ng rio dulng

huyet thuong xuy€n theo chi dinh cria b6c sL

Ti6n sir gia tlinh

1 Slr ilt T benh nh6i m6u co tim, o'6i th6o ciuorig Wpe Z,tang huy6t 6p

+ IVIe mat vi ung thu vfi

Ti6n sir ili rrlrng: su_lfaraid vd ampicillin

Ti6m sfr dtrng thu6c

Novolin 70130 60 tim vi sang vd chi6u

Metfgmin 1000mg .10nS x}lfrrntngiry

Aspirin 81 mg uOng t l6r:ingay

Lisinopril 20 mg- u6ng 1 lan/ngdy

Atowastatin 20 mg u0ng 1 lAri/ngay

Fluoxetin 20 mg uOng 1 lAd ngay

Khr6m bQaah

sinh SpOzglYo hiQu: M4ch 78 dri/pn; than .,.:, nhi€t: 37,4oc; HA: 140/90 mmllg; Nhip tho: zz larJph;

BN tinh, ti€p xtic tot Thara fcfrafi tri6v c6 v€t lo6t sung, h6, s6u kho6ng z c1;t 6gan bdn ch6n

tr6i tr6n vct lo6t de hnh fru6c d6, c6 ri d!ch EN khong trean eau vJ fiuore"uj6??u i"er oe n6n npng hon

C$n Iflm sdarg

Creatinin: 1,3 mgldL (0,8 - 1,4)

Cholesterol TP: 240 me/ dL (1 50 - 200)

IIDL-C: 4LmgldL (> 35)

AST: 20 U/L (9 -48)

Hgb: 14,i g/dl, (13 - tO

WBC: 16,3 x 103/ mm3 (3,9 - g,g)

Lymphs: L7% (20 -25)

IIIeq I lo,/ **, (4s0 - 4W)

MCII: 26,2p9(25 -35)

ChSn dodm

Lo6t bdn chdn tniil dai th6o ducrng WeZ

HbArc: 1l,8Yo (4,4 - 6)

Ure: 30 mg/dL (20 - 40) Triglycerid: 183 mgldl (< i65)

LDL-C: 163 mgldl, (< 130) ALT: 1,7 UlL (5 - 49) klct: 42,3%o (37 - 49) FMNs: 78% (50 - 60) Monos: 5% (5 -7)

ESR: 73 mm/h VICHC: 36,1 g/dl (32 -35)

Ca 16ma sdng 7

SEIY TIM, BSI{TT TIM TETIEU MAU CUC BO Th0ng tin chung {Genera! information)

T0n: LO Vdn T

-Cdn ngng: 76 kg

Gi6t: Nam

{4,1-6,1 mmol/L) (<40 u/L) (135-150 rnEq/L) (20-40 ms/di,) (150-200 ms/dl) (<165 mg/dl)

Tudi: 68

ChiAu cao 7,62 m

Lf ito glp DSIBS - Lf do viro viQn (Ckief comptaint)

Eau nggc, mQt m6i ntriOrr kh6 thO

Di6n bi6n b$nh (EPl- Eistory of Present lilness)

tit vai nEm nay, b-Cnh nhan thinh thoang c6 nhtng con dau nguc li6n quan gang $tc, ccm khoang 5-10

phtit, giam khi nghi ngoi Vdi ngdy nay, benh nhAn.dau ng.uc nhiAu hon, ron tEo aai nori rc p*t,Z-Z cgn/.ngay XgaY4r0p viQn, bQnh nhfrn than dau nggc nhiAu kdm kh6 tho, ch6ng mpf k1idng gr3.* rOi trinilroglycerin Cn{G) dang 4t.

Ti6n sfr bQnh (PMH - Past Medical History)

: Suy tim NYHA II - E6i th6o dulng type} (1 n6m nay)

- R5i lo4n lipid m6u

cha mdt ndm 70 tu6i vi bi nh6i m6u co tim

f.iii siing {SH - Soctgl ltristory'1

Htt 30 di0u/ngdy, udng t chai bia/ngA.y

Benh nhan hay quQn u6ng thuOc vdr it do tiuong huy€t

A'spirin 81 mg bao tan t?i ruQt, uong I lAr/ngdy omeprazol 20 mg,m5i sang

Nicorandil 10 mg, udng2l6n/ngity- Isosolbid mononitrat SR 6dmg, uong rn6i si:ig Atenolol

f 00 mg, uong m6i ngdy simvastatin za mg,uong m6l #i

TNG xiJ duoi lu0i khi c6n Clopidogretr 75 m!,uOu! m6i ngay

TiAm sfr d! rlme (ALL - Allergiclz kg6ng

Khdm Q€mh (FE - Playsical Eiawaiwtutton)

I{lldm t6ng qudt

BN tinh, ti6p xiic tOt, Fh6i c6 ti6ng ran, bqng mdm

Kh0ng vdng d4 phir chi duoi (+;, tinh m4ch canh n6i

Sinhhigu:

Mpch 100 tAUpUut ThAn nhiet 37oC

C$m l6m snmg (L,48"91

Huy€t 6p 155/90 mmHg Nhip tteO 27lbnlphlfr Sinh kda rmdu:

Glucose

AST

Na+

Urea

Cholesterol TF

Triglycerid

ffi mi6n dlck

HbAr

N,{ kuydt kgc:

7,zYo (4,4-6%)

RBC 4,65 (3,8-5;5 M/uL) HGB !3,2 (12-15 gldL) \

MCH 28,2 (26,7-30,7 pG) MCHC 33,2 (32-35 gtd}

PLT 278 (200-400 tVuL)

ECG: ST ch6nh xu5ng khoing 1 mm khi dau nguc vd hOi phpc khi khong co tri€u chring

si6u 0m tim: EF 35Ya, rdi loqn chiic n6ng t6m thu trrat trai, day *6tnai

ChAn ttorf,n

Nh6i mau cotim ktr6ng ST ch6nh l€n, suy tim j\nT{A III

9 31 1,37

27

277

90

ALT 35 (< 40 U/L)

K+ 4,2 (3,5-5,0 inEq/L) Creatinin 67 (70-123 Fnxoll[,) LDL-C 155 (<i30 mgldL)

I{DL-C 32 (> 35mg/dn ) Troponin-T hs 0,025(<0,0i4 ng/mx,)

BQnh nh6n nam, 68 tuOi, nflng 4l- t_g, dang dugc ch6m s6c o viQn diAu duoiig sau khi bitai bit5n mpch

m6u nflo vd b! liQt r"? *gYd-, tr6i ,!o tinh trpng dinh duOmg kdm, hai thgng gAn a'ay bQnh nla6n ougc nu6i duong.qurmQt

Qoq ilor_q.*!i-dg day Hai ngdy ,uy, U.coa nhan sot, j<f,6 tho: ho kh4c dam

s'-oi ngQtnqng dAn, tem tfran Ui6n d6i n€n du-oc nhflp viin.

Ti6n sfr bQnh

Ddi th6o ducrng php thuQc insulin tu n6m 30 tu6i

Tai bi0n mpch mdu ndo c6ch ci6y 5 nam

Nhi6ry ffirng ducrng ti6u cach day I th6ng do E coli vit duo;c o'iAu tri bing sulfamethoxazoV trimethoprim i60/8b0 mg ducrng uSng trong i0 ngdy

Ti6n sfr dirng thudc

Insulin

- Famotidin 20 mg m6i ngdy

Ca i6m shag I

vffi,na pE[Gr

Huy€t 6p 147187 mmllg ThAn nhiQil 39"C

SpO282% (h'ong kliOng khi phdng)

Khrflm l6m shmg

SinhhiQu:

Mpch: 110 nhiy' phtt

Nhi.p tho: 28 nhip/phrit

Khrtrn fing qudt:

T0ng trqng gid yOu, hay b6n ch0n lo lEng

Eiu kh0ng ch6n thuocg, c6 rnAm.

c Kh6m thinh ng.uc thdy rmnO O'ptiOi gifia vd pli6i phii tr6n

C$m lf,m simg

Sinh hda mdu:

Glucose 168 (80-110 mg/dL) :Albumin 3,0 g/dL (3,6-5

Ure 19 (20-40 mgldl,) s/dL)

Creatinin 1,0 (0,7-1,5

ms/dL)

Xdt nghiQm hlryiit hqc;

WBC 14,5 (4-10 K/uL)

ToNEU 81,7 (45-75%)

NEU 8,17 (4,5-7,5)

LYM% 6,3 (20-35%)

LYM 0,63 Q-3,5)

MONO% 5,03 (4-L0Yo)

MONO 0,49 (0,4-1,00)

Xdt nghi(m hinh anh:

X-quang nggc: th6m nhi6m phOi thiry tron vd gira phOi ph6i, c'Ong tipc thny ph6i

Xdt nghiQmvi sinh:

Dich.hut khi quan.cluoc 6y vd dua o=i nhuQm Gram vd cAy ph6n lgp (bQnh nh6n tuong dOi knOng hgp

tric vd k*rOng th€ khAc ddm)

KCt qui nhuQm Gram cho flrdyn'.uc khuAn Gram 6m vdi khoang 4Yoneutrophil Dang chd k€t qu&b6y

phdn lflp

ChAn dofn

Suy h6 h6p.

Vi6m ph6i nghi do vi khuAn Gram 6m.

E6i th6o duong type l/ Di ch:ung tai bi6n mach m6u n6o.

Di6u tri

Benh nien duo c cl{t nQi khi quan vd dung m6y th0

Bgnh nhan dugc truy€n dlch d6 duy tri tJqmg nu6c ti€u 50 ml/gid.

Khang sinh chi dinh trudc khi c6 rct qua ki,ing sinh dd : Cefoiixone 1g ti6m tinh mpch, ngdy 1 6n

GOT/ASAT 37 (<40UIL)

GPTALAT 32 (<40UtL)

Na- 135 (135-150 mEq/L) EASYI6,23 (1-8%) EOS 0,59 (0,1-0,8) BASO% 1,73 (0-2%) EASO 0,t7 (0-0,2) RBC 3,8 (3,8-5,5lzVuL) h\db t2,3 (12-15 ddl) Hct37,6Yo (35-45W

K* 3,6 (3,5-5 mEq/L)

Cl- 99 (98-110 mEq/L) Calci 4,5 (4,5-5,5 mEq/L) CRP 680 (0-50 nmotr/L) HbAlc 8.2% (4-60/o) N{CV 76 (78-100) MCH 24.4 (26,7-30,7) MCHC 3t,2 (32-35) RD$/ 14,0 (t2-20%) PLT 240 (200-400ITuL) MPX/ 8,38 (7-12tu)

Ca l6m shag 9

OAT TNAO DUCT.IG

BQnh nhan nam'54

t6i.!* 1,78m, npng.i00kg, toinlrOng lchdm d.akhoa vi kh6ng ki6m soatffi i:f?f1trSl;^r*._Yf**:*.H,::g"jITg"6",y6,:gfif"r:er ,ins F.,,e binh h 100mg/dl vit tdas

ren khoing 200 mg/dLtronghAn qua Bgnh or,6, rr,o ri6i"*i#ft;;A;ilifr ; ffi?# va LdttB

MQt th6ng tru6o, theo sg tu v6n cria bdc si dinh duong, bgnh nh6n d6 c6 gi6m c6n vd c6i thi6n mu*c duong trong miiu bing c6ch di bQ m6i ngal,l.5_qhr1t T"uyilil;, bpnh nhan'r.rron! irra budc nhanh vi vi€m tlau khop, triQu chrmg nay gi6m den-g kc khi b6c si cr-io dtrng piedniron

' o '' B0nh nhdn cho biOt hrit thuoc 16 khoang i g6i/ ngdy rir khi 20 tu6i Thinh thoang u6ng i ly rugu vdo

bta 6n

Tiin sft bQnh

E6i rh6o tluong We2

TEng huydt 6p

COPD

Vi0m ktiop

ROi lopn lipid huy6t

Ti6w s# gia ffink

cha vd anh bi bQnh ri6i th6o a*uong ,-ype z.Mg ch6t khi bgnh nhdn g tu0i

Di {nag tlawdc: Chua ghi nhfln

Sink kdQat

Huy€t ap

145190 mmHg

Nhip tim

.80 dhi.p/phrit

Nhip tho

tS Br/ phfrt

Thfln ahiQt

a4 a^

)t v rc& qradxet ng&aiQwa

Sinh hda rndu (nhin d6i 12 qid)

Na* 135 mEqll

J

K 4.0 mEq/L

BLIN 2l mgldL

SCr 0,9 mg/dl

Tkw6c dang d{arag

1 Glyburide 10 mg

2 Atorvastatin 10 mg

3 Amlodipine 5 mg

4 Albuterol MDI

5 Frednisone 10 mg

6 Aspirin 8l mg

.' Glucose 230 mg/dL cholesteror todn pt,an

2rzmgldT-HbAlg 6.9% LDX,-C fiO

S9mg/dT-Triglycerid 100 mgldtr

2ldn/ngity

1 lar/ngay (mdi dtrng 3 thilng.gAn d6y, kh6ng ghi nhAn duu *o hay titc dpng php ndo cria thu6c)

I 6n/ngdy

1 lddngny (2 tuan gAn ddy vi bQnh vi€m khcrp do th6p bQc p.!i6t).

(t.u y dung theo loi khuy6n cria gia dinh)

Xdt nghiarn nudc tiiiu: Microalbumin niQu (rnicroalbunnin 200 mcg/mg creatinin).

Ca l6m sderg tr0 RGI n-OAN LrPm naAu

,/-,?tu*{J*, ld gq

%\ry,,? -.n -.1\

g-\

Thdng tin chuug

T€n: Cao Thi L.

Tu0i: 50

Cdn npng: 50 kg

Gioi: Nt

ChiAu cao: im60

Lf do khfm

Khdm sric kh6e dinh ky

Ti6n sfr b6nh

Cao huyOt'rip

Ti€n sfr gia dinh

Ong ngopi binhOi mdu cotim 16c 56 tu6i, m6t

-4 ,.

IJOfl S@nng

Hrit thuOc 20 g6i-nEm, tQp th6 dqc 4 Gr:/tuan, cli6 ilQ 6n fr ,,ki,tbeo

Thar6c damg d&mg

Enalapril lOmg/ngdy

*.1

rrem sw dl mg

I(hdm bQuah

Sinh hiQu: tuI4ch: OS An/ phtt.

Huy€t 6p t35l15 mmHg

Thdn nhiQr 3T-oC.

" Nhip th6: 12 nhip/ phrit

Khd:m t6ng qudt

Chrlc ndng gan binh thuinig

KhAm tim, phi5i, btmg ktrdng c6 gl b6t thumrg.

C$m lf,m siurg

Na': 138 n'iEqfu (135-145)

Ca'- : 1,2 mmoVl (1, 1 3- 1,3 5)

BUN: l,2mgldL(8-20)

Cholesterol toan ph6n: 230 mf,dL (< 200)

IIDL-C:45 mg/dl (> 50)

ALT: 11 unit/L (< 40)

Ch6u dodm

ROi logn lipid huy€t

If: 4,0 mEq/L (3,5-5,2) Cl-: 98 mmoVl (95-105)

Cr huy0t tuong 1,0 mg/dl (0,8-1,2) Triglycerid: 180 mg/dl (<150) Glucose: 96 mf,dL (S5-110) AST: 8 unit/L (< 40)