Ca lflm sirng 1
LOET D4 DAY
B-enh nhan nir 66 tu6i, cao 156 cm, n{ng 61 kg, o=i kh6m b0nh
vi ph6n kh6, cimg, dau vung
thugmg

vi 2 tuan.

TiAn sfr b.6nh:
Vi0m dp ddy 10 aEm. C6ch ddy 4 thangbi
ao oec.

:
-

'

x#t

Thoai h6a khop co tay 6 n6m, kh6ng riO dau
Tdng huy0t 6p 15 ndm

huy€t da ddy IIP (+), d6 dusc k0 6m ph6c

kh

dung paracetamol.

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

Nhip thd 15 16r:/phrit
Tliari nhi0t 36,3oC

C$m l6m sirng:

Na
K
BtIi\

Creatinin

Glucose
IIb

Hct
PLT

141 mEq/I- (135

-

i50)

4,6 mEqlL (3,5 - 5)
2l mgldL (7 -20)

mg/dl (0,7 119 mg/dl (80 -


1,1

7,2

glil-

(12

1,5)
110)

- 15)

2t% (3s - 4s)
390 I?pL(200 - 400)

:
-

$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

TG
TSF{

X6t nghiQm tim ffiP:


-

39 mgldL (> 35)
195 mg/dL (< 165)

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

Testhuy6tthanh(+)

CLO-test (-)
NQi soi d4 ddy: 2 v6t lodt ducrng kinh khoang 6 mm, c6 v6t m6u ci6ng
ChAq dofre: Lodt d4 ddy.

cr

bd cong nh6.


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;
BQnh nh6n tinh, ti6p xfc t6t, da ru6m h6ng,
kfiOng phr);lrtr6ng liQt klru tri.

Si6u 6m tim: HO

HA: 2101130 rnneHg; Nhlp tho: 20 l&:/pie; Sp02 98%
tim dAu, ptrdi trong, bqng rnAm, gan lich kh6ng sb clapm,


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

HbArc

- 5)
Ure 38 mg/dL (20 - 40)

-

-200)

70,8Yo (4,4

Triglycerid : 292 mg/ dI- (< 1 65)
LDL-C: l24m{dL (< 130)

HDL-C: 38 mg/dl (> 35)
AST: 12 UIL (9 -48)
ALT: 10 UIL(5 -49)
RBC:4,65x!or2 lL (4,3 -5,3x1012)
I{GB: 12,6 gldl- (13 - 16)
HCT:35% (37 - 49)
MCV:75,3tu (78-98)
MCH:26,2p9(25 -35)

MCHC: 36,1ddL(32-35)
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
Nifedipin LA20 mg x 2 l6n
)
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


/F

Ca lAm slrng 3

F,%i'
\,'
#:5

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 urat
\.:1,


1.t

I6m sbmE
- CreatininhuyOt
. ESR
- Ac. uric huy€t
CAm

ChAre do6ar
_,

Con gout cdp t6i ph6t

pmoUl
mmigib
745"pmollL
160
115


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

-

Hb 10,3 g/dl (12-15)
MCV 70 fL (80-100)
MCHC 280 glL (310-370)

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
mg I viOn x 3 lAn/ngdy
C6c thu6c khdc, giir nguy6n

SAt sulfat 325


:';

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

Ca l6m sane 5
T'HTEU MAU

rffiU

Th0ng tin chung
Biri ML., nft
Tu6i:28
Dang mang thai drSa con dAu ti6n thang thtt .Thai

SAr,

i&
,.i,€1 ffi.
aE i
aBhi_
S 5L'5*

BQnh nhdn:

Lf

khfm

lennlnan cdmthiv

k!

ph6t tri6n binh rhuong.

do

m9l va,flo
nelv
kli lam nhftng vi6c nhe nhdng nhAt. Trong qu6 trinh
110
thdm kh6m, bQnh nhdn cho bi6t thcm
gAn d6'y hay b! ch6ng"m4i, cnJ-ot rirt,-thdm 6n nr"r6c d6 vi ciau

:i

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

Hb 8 e/dl, (11,5-16,5)

Hct28%(3343%)

Ti6u cAu 480

000/p,L

(1s0.000-4s0.000)
HOng cdu


MCV 70 fL (80-96)
MCH 22ps(274a)

MCHC 300
(3 1 0-370)

ludi 0,3% (0,5- RDW r8.4%(tt-14)%

2%)
ChAm dotftm

Thi€u m6u thi€u s8t

.Sdt huy6t thanh 40 mce/dL (40-150)

Ferritin huy6t thanh 10

g?-150)
slL TIBC 450 mcs/dL (250-400)

i;

nglm1


-

-Arittffiiffl-rt


NTilrF,M TRuN*c
ar rsAo BusF{G
Thdng tin chung
g0 kg, chiAu cao 1,65
m.
Penh nhen nam,67 tu6i, cen nflng
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)
tti,1oc, udng rusu. BN thuong qu€n uSng thu6c vd kh6ng rio dulng
huyet thuong xuy€n 1]-rt
theo chi dinh cria b6c sL
Ti6n sir gia tlinh
benh
1
Slr mat viT ung thunh6i m6u co tim, o'6i th6o ciuorig Wpe Z,tang huy6t 6p
+ IVIe
vfi
Ti6n sir ili rrlrng: su_lfaraid vd. ampicillin
Ti6m sfr dtrng thu6c
Novolin
60 tim vi sang vd chi6u
Metfgmin
.10nS x}lfrrntngiry
Aspirin 81
uOng t l6r:ingay
Lisinopril 20

u6ng 1 lan/ngdy
Atowastatin 20
u0ng 1 lAri/ngay
Fluoxetin 20
uOng 1 lAd ngay
Khr6m bQaah
sinh hiQu: M4ch 78 dri/pn; than nhi€t: 37,4oc; HA: 140/90 mmllg; Nhip
tho: zz larJph;

IYI-m-*!i*
ilt

70130
1000mg
mg
mgmg
mg

SpOzglYo

.,.:,

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
IIDL-C: 4LmgldL (> 35)

-

-

200)

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)
(4s0 - 4W)

IIIeq
I lo,/ **,
MCII: 26,2p9(25

ChSn dodm
Lo6t bdn chdn

tniil

-35)

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
SEIY

16ma

sdng 7

TIM, BSI{TT TIM TETIEU MAU CUC BO

Th0ng tin chung {Genera! information)
T0n: LO Vdn T. Gi6t: Nam
Tudi: 68
Cdn ngng: 76 kg
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)
- Dau thit
- T6ng huy€t ap
: Suy tim NYHA
- E6i th6o dulng type} (1 n6m nay)
- R5i lo4n lipid m6u

nglrc
II

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,
Isosolbid mononitrat SR 6dmg, uong rn6i si:ig
Atenolol 00 mg, uong m6i
simvastatin za mg,uong m6l #i
f
TNG xiJ duoi lu0i khi
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
Huy€t 6p 155/90 mmHg
Nhip tteO 27lbnlphlfr
C$m l6m snmg (L,48"91
Sinh kda rmdu:
Glucose
9
CK-MB <3yo (<3%)
{4,1-6,1 mmol/L)
AST
(<40
31
u/L)
ALT 35 (< 40 U/L)
Na+
(135-150 rnEq/L)
1,37
K+
4,2 (3,5-5,0 inEq/L)
Urea
(20-40 ms/di,)
27
Creatinin 67
(70-123 Fnxoll[,)
Cholesterol TF 277
(150-200 ms/dl)

LDL-C 155 (Triglycerid
(<165 mg/dl)
90
I{DL-C 32 (> 35mg/dn )
ffi mi6n dlck
HbAr.
7,zYo (4,4-6%)
Troponin-T hs 0,025(<0,0i4 ng/mx,)
N,{ kuydt kgc:
4,65 (3,8-5;5
(12-15
\
4s,3
(78-100 fi,)
28,2 (26,7-30,7
(32-35 gtd}
74,3
(4-10 K/uL)
9,6
(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

udng2l6n/ngityngdy
c6n

RBC

59_I
MCH
RDU/
PLT

M/uL)
pG)
(12-20%)

(35-4s%)

278

HGB !3,2
MCv ss,z
MCHC 33,2
WEC

gldL)


Ca i6m shag

I

vffi,na pE[Gr
BQnh nh6n nam, 68 tuOi, nflng 4l- t_g, dang dugc ch6m s6c o viQn diAu duoiig
sau

khi bitai bit5n mpch

tinh
trpng
dinh
duOmg kdm, hai thgng gAn a'ay bQnh nla6n ougc
,!o
nu6i duong.qurmQt
day. Hai ngdy ,uy, U.coa nhan sot, jQoq ilor_q.*!i-dg
m6u nflo vd b! liQt

r"?

*gYd-, tr6i.

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 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
Khrflm l6m shmg
SinhhiQu:
Mpch: 110 nhiy' phtt.
Huy€t 6p 147187

ThAn nhiQil 39"C.
Nhi.p tho: 28 nhip/phrit.
SpO282% (h'ong kliOng khi phdng).
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
K* 3,6 (3,5-5 mEq/L)
Ure 19 (20-40 mgldl,)
s/dL)
Cl- 99 (98-110 mEq/L)
Creatinin
(0,7-1,5
GOT/ASAT 37 (<40UIL)
Calci 4,5 (4,5-5,5 mEq/L)
ms/dL)
GPTALAT 32 (<40UtL)
CRP 680 (0-50 nmotr/L)
Na- 135 (135-150 mEq/L)
HbAlc 8.2% (4-60/o)
Xdt nghiQm hlryiit hqc;
WBC 14,5 (4-10 K/uL)
EASYI6,23 (1-8%)
N{CV 76 (78-100)
ToNEU 81,7 (45-75%)
EOS 0,59 (0,1-0,8)
MCH 24.4 (26,7-30,7)

NEU 8,17 (4,5-7,5)
BASO% 1,73 (0-2%)
MCHC 3t,2 (32-35)
LYM% 6,3 (20-35%)
EASO 0,t7 (0-0,2)
RD$/ 14,0 (t2-20%)
LYM 0,63 Q-3,5)
RBC 3,8 (3,8-5,5lzVuL)
PLT 240 (200-400ITuL)
MONO% 5,03 (4-L0Yo)
h\db t2,3 (12-15 ddl)
MPX/ 8,38 (7-12tu)
MONO 0,49 (0,4-1,00)
Hct37,6Yo (35-45W
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

I

-

mmllg.

1,0

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.


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
va LdttB
tdas
.,ins F.,,e binh h 100mg/dl vit

i:f?f1trSl;^r*._Yf**:*.H,::g"jITg"6",y6,:gfif"r:er
ren khoing 200 mg/dLtronghAn qua. Bgnh or,6,
rr,o ri6i"*i#ft;;A;ilifr

;

ffi?#

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!
'----o irra budc nhanh vi
vi€m tlau khop, triQu chrmg nay gi6m den-g kc khi b6c si cr-io
''
dtrng piedniron..
B0nh nhdn cho biOt hrit thuoc

bta

16

khoang

6n

Tiin sft

i

g6i/ ngdy rir khi 20 tu6i. Thinh thoang u6ng

i

ly rugu vdo

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

mmHg

145190

rc& qradxet

Nhip tim

Nhip tho

Thfln ahiQt

.80 dhi.p/phrit

tS Br/ phfrt

a4 a^

)t v

ng&aiQwa

Sinh hda rndu (nhin d6i 12 qid)

Na*
K
--J

135

mEqll

4.0 mEq/L

BLIN 2l

mgldL

0,9

mg/dl

SCr

.'

mg/dL
HbAlg 6.9%
Glucose

230

cholesteror todn

LDX,-C
I{DL-C
Triglycerid

pt,an

2rzmgldTfiO mgldlS9mg/dT100 mgldtr

Xdt nghiarn nudc tiiiu: Microalbumin niQu (rnicroalbunnin 200
mcg/mg creatinin).
Tkw6c dang d{arag

1.

2.

Glyburide 10 mg
Atorvastatin 10 mg

2ldn/ngity

3.
4.
5.
6.

Amlodipine 5 mg
Albuterol MDI

I 6n/ngdy

bT

Frednisone 10 mg

1 lddngny (2 tuan gAn ddy

Aspirin 8l mg

(t.u

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

1.

2 nh6t m6i 6 gid khi

can.
vi

\

bQnh vi€m khcrp do th6p bQc p.!i6t).

y dung theo loi khuy6n cria gia dinh).


,/I

,?tu*{J*,
.ld gq

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

Ca l6m sderg tr0

g-\

RGI n-OAN LrPm naAu
Thdng tin chuug
T€n: Cao Thi L.

Gioi:

Tu0i: 50
Cdn npng: 50 kg

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. S@nng
IJOfl

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

Chua ghi

mg

nh4n

...,

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)