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Procalcitonin, Calcium, and Magnesium in Patients with Febrile Seizure during One-Hour Attack. Br J Med Med Res, 6 (6 ), 617- 624. PL.1 PHỤ LỤC 1: BẢNG ĐIỂM SOFA Điểm Cơ quan 0 1 2 3 4 Hô hấp PaO2/FiO2 ≥ 400 < 400 < 300 < 200 (thở máy) < 100 (thở máy) Đông máu Tiểu cầu (G/l) ≥ 150 < 150 < 100 < 50 < 20 Gan Bilirubin TP (µmol/l) 204 Tim mạch HATB ≥ 70 HATB< 70 Dopa <5/ Dobu (bất kỳ) Dopa 5,1-15/ Nor ≤ 0,1/ Adre ≤ 0,1 Dopa 5,1-15/ Nor ≤ 0,1/ Adre ≤0,1 Thần kinh Điểm Glasgow 15 13-14 10-12 6-9 <6 Thận Creatinin (µmol/l) Nước tiểu (ml/24h) < 110 110-170 171-299 300–440 <500 >440 <200 Liều thuốc vận mạch tính theo µg/kg/phút, dùng kéo dài ít nhất 01 giờ Dopa: Dopamin, Dobu: Dobutamin, Nor: Noradrenalin, Adre: Adrenalin SOFA: Sepsis-related Organ Failure Assessment score (đánh giá suy chức năng cơ quan) PL.2 I. HÀNH CHÍNH Mã NC: Số hồ sơ: 1. Họ và tên: 2. Tuổi: 3. Giới: 4. Khoa: 5. Vào viện: 6. Ngày chẩn đoán: 7. Ra viện: 8. Kết quả điều trị 30 ngày: 9. Ngày tử vong: 10. Thời gian đến khi TV (ngày): 11. Thời gian sống 30 ngày (ngày): 12. Chẩn đoán xác định: 13. Bệnh lý kết hợp: Đái tháo đường: Đột quị não: Bệnh tim mạch mạn tính: Bệnh phổi mạn tính: Bệnh gan mạn tính: Bệnh thận mạn tính: Ung thư: Khác: BỆNH ÁN NGHIÊN CỨU II. LÂM SÀNG 1. Ngày bệnh khi vào viện: 2. Lý do vào viện: 3. Đường vào (ổ nhiễm khuẩn tiên phát): Tiêu hóa Tiết niệu Phổi Thần kinh trung ương Cơ, mô mềm Xương khớp Mũi xoang Khác: 3. Ổ di bệnh (Ổ NK thứ phát): Tiêu hóa Tiết niệu Phổi Thần kinh trung ương Cơ, mô mềm Xương khớp Mũi xoang Khác: 4. Triệu chứng lâm sàng: Sốt: Cơn rét run: Đái buốt: Đái rắt: Máu mủ: Đái máu: Đau đầu: Nôn: Đau bụng: Ỉa lỏng: Ho: Đau ngực: Khó thở: Nhịp thở(Lần/phút): Thở ô xy: Thở máy: FiO2: Ngày thở máy: Cai được máy thở: Ngày cai máy thở: Nhịp tim(lần/phút): HA tâm thu (mmHg): HA tâm trương (mmHg): Sốc nhiễm khuẩn: Ngày xuất hiện sốc: Thuốc vận mạch Noradrenalin µg/kg/phút Adrenalin µg/kg/phút Dopamin µg/kg/phút Dobutamin µg/kg/phút Thoát sốc: Ngày thoát sốc: Thời gian dùng vận mạch (ngày): Glasgow(điểm): SOFA(điểm): Khác: III. XÉT NGHIỆM 1. Các xét nghiệm cơ bản: Xét nghiệm sinh hóa Các xét nghiệm sinh hóa Khi (+) NKH Ghi chú Glucose (mmol/L) Urea( mmol/L) Creatinin( µmol/L) SGOT(U/L) SGPT ( UI/L) GGT (UI/L) Bilirubin TP(µmol/L) Bilirubin TT(µmol/L) Protid (g/L) Albumin (g/L) CRP (ng/L) PCT (ng/L) Prothronbin (%) Na+ (mmol/L) K+ (mmol/L) Ca2+ pH PaO2 (mmHg) PaCO2 (mmHg) Lactat (mmol/L) HCO3- (mmol/L) Xét nghiệm huyết học Các xét nghiệm huyết học Khi (+) NKH Ghi chú 1. Bạch cầu WBC (G/L) Neu (%) 2. Hồng cầu (T/L) 3. HGB (g/L) 3. Tiểu cầu (G/L) 4. Prothrobin (%) 5. INR Xét nghiệm vi sinh Cấy máu: Kết quả: Cấy đờm: Kết quả: Cấy nước tiểu: Kết quả: Cấy dịch não tủy: Kết quả: Cấy dịch vết thương: Kết quả: Khác: Kết quả: PCR máu: Kết quả: PCR dịch (ghi rõ): Kết quả: Chẩn đoán hình ảnh và chẩn đoán chức năng Siêu âm: Xquang: Cắt lớp vi tính: MRI: 2. Xét nghiệm định lượng vitamin D, Fe, Mg, Zn huyết tương Tại thời điểm T1 Tại thời điểm T3 Vitamin D (ng/mL) Sắt (µmol/L) Magiê (mmol/L) Kẽm (µg/dL) IV. Điều trị 1. Kháng sinh ban đầu (ghi rõ): 2. Sử dụng kháng sinh ban đầu phù hợp (so với KSĐ) Có Không 3. Lọc CRRT Có Không Lọc trước thời điểm lấy mẫu T1: Có Không Lọc máu trước thời điểm lấy mẫu T3: Có Không 4. Truyền máu và các chế phẩm máu: Có Không Truyền máu và các chế phẩm máu trước thời điểm lấy mẫu T1: Có Không Truyền máu và các chế phẩm máu trước thời điểm lấy T3: Có Không 5. Bổ sung vitamin D trong quá trình điều trị: Có Không Bổ sung sắt trong quá trình điều trị: Có Không Bổ sung magiê trong quá trình điều trị: Có Không Bổ sung kẽm trong quá trình điều trị: Có Không Hà nội, ngày ..... tháng ...... năm ..... Người lập phiếu