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Arch Surg. 1981; 116(5):645-650. doi:10.1001/archsurg.1981.01380170121022 BỆNH ÁN NGHIÊN CỨU CỦ ĐỀ TÀI “NGHIÊN CỨU ỨNG DỤNG PHẪU THUẬT NỘI SOI CẮT LÁCH ĐIỀU TRỊ XUẤT HUYẾT GIẢM TIỂU CẦU MIỄN DỊCH Ở TRẺ EM” Mã câu hỏi C u hỏi T ời Số TT Mã số hi u Mã BA Bệ h số: Mã HS Mã h sơ: A HÀNH CHÍNH A1 H ê ệ h h A2 Tuổi ( ươ g h) A3 Giới Nam 1 N 2 A4 H ê ha mẹ A5 a hỉ A6 iệ hoại A7 Email A8 Ng y o iệ // A9 Ng y mổ // A10 Ng y a iệ // B TIỀN SỬ B1 Số ăm mắ XHGTC ( ăm) B2 SLTC ú mới ệ h (x109/L) B3 SLTC uy ( hườ g xuyê ) (x109/L) B4 SLTC h h (x109/L) B5 SLTC ướ hi đi u g TC ại iệ huy h B6 Xu huy g Không 0 Có 1 B7 T iệu h g xu huy g ( hi u a h ) Xu huy iêu hóa 1 Xu huy ão 2 B8 Thuố đa g đi u Corticoid 1 Co i oi huố h 2 B8i1 Li u Co i oi <1mg/kg 0 ≥1mg/ g 1 B9 T uy iểu ầu Không 0 Có 1 B9i1 Tầ su ( h g/ ầ ) B9i2 Khối ư g (đơ / ầ ) B10 Ti sử ệ h hối h Viêm gan B 1 Viêm gan C 2 Mổ ũ 3 Bệ h h 4 (ghi rõ) C LÂM SÀNG C1 Toàn thân C1i1 Chi u ao m C1i2 C g g C1i3 BMI C1i4 Huy m hu (mmHg) C1i5 Huy m ươ g (mmHg) C1i6 Nhiệ độ (độ C) C1i7 Mạ h ( ầ / hú ) C2 HC Cushing Không 0 Có 1 C3 Xu huy Không 0 Có 1 C4 T iệu h g xu huy ( hi u a h ) Xu huy ưới a 1 Xu huy iêm mạ 2 C5 Xu huy g Không 0 Có 1 C6 T iệu h g xu huy g ( hi u a h ) Xu huy iêu hóa 1 Xu huy ão 2 C7 Hội h g hi u m u ê m s g Không 0 Có 1 C8 Lách to Không 0 Có 1 C9 M độ h o ộ 1 1 ộ 2 2 ộ 3 3 ộ 4 4 C10 Hội h g hiễm g Không 0 Có 1 C10i1 i u h g si h Không 0 Có 1 C11 T iệu h g h ( u h g ó đi 0) D CẬN LÂM SÀNG TRƯỚC MỔ D1 Siêu âm D1i1 K h hướ h (cm) D2i2 L h hụ Không 0 Có 1 D2i3 Siêu m h hiệ hườ g h Không 0 Có 1 Ghi rõ D2 C g h m u D2i1 H g ầu (T/ ) D2i2 Hemoglobin (g/ ) D2i3 Hematocrit (%) D2i4 Bạ h ầu (G/ ) D2i5 Tiểu ầu D2i6 MPV (fL) D2i7 PCT D3 g m u D3i1 Tỷ ệ o h om i (%) D3i2 APTT (gi y) D3i3 Fibrinogen D4 Sinh hoá máu D4i1 Glucose (mmo / ) D4i2 Urê (mmo / ) D4i4 Acid uric (µmo / ) D4i5 GOT (U/ ) D4i7 GPT (U/ ) D4i8 CRP (mmo / ) D4i9 Vss ( hú ) E Phẫu huậ E1 T uy iểu ầu gay ướ mổ Không 0 Có 1 E2 Tổ g hời gia mổ ( hú ) E3 Chi u i đườ g ạ h a h Z ( m) E4 L h hụ Không 0 Có 1 E4i1 V h hụ E5 Cách iểm so mạ h uố g h g hời 0 ộ g mạ h ướ , ĩ h mạ h sau 1 E6 Số ư g m u m .................. ml E7 T uy m u Không 0 Có 1 E7i1 Số ư g m u uy m E8 hêm o a : Không 0 Có 1 E9 Mổ mở Không 0 Có 1 E10 Bi h g o g mổ Rách bao lách 1 Ch y m u ừ độ g mạ h h 2 Ch y m u ừ ĩ h mạ h h 3 Ch y m u ừ độ g mạ h gắ 4 Th g òm ho h 5 Tổ hươ g ạ y 6 Tổ hươ g đại g 7 Tổ hươ g đu i uỵ 8 Khác 9, ghi õ ( ) E11 Tử o g o g mổ Không 0 Có 1 Ghi ại guyê h E12 ẫ ưu ổ ụ g Không 0 Có 1 F THEO DÕI SAU MỔ F1 Số g y ằm iệ sau mổ ( g y) F2 Số g y đ h hơi ở ại ( g y) F3 Tha g điểm VAS (Visual Analog Scale) F3i1 iểm VAS sau mổ 6 giờ F3i2 iểm VAS sau mổ 24 giờ F4 Loại huố gi m đau Paracetamol 1 Thuố h 2 F5 Số g y g gi m đau ( g y) F6 Bi h g sớm sau mổ Không 0 Có 1 F6i1 Loại i h g sớm sau mổ T h m g hổi 1 Tụ h hố h 11 2 Ch y m u o g ổ ụ g sau mổ 3 Nhiễm huẩ mổ 4 Ch y m u mổ Huy hối 5 Viêm hổi 6 Khác 7 Ghi rõ F7 T uy m u sau mổ Không 0 Có 1 F8 Tử o g sau mổ Không 0 Có 1 Ghi ại guyê h F9 XN m u sau mổ 24 giờ F9i1 H g ầu (T/ ) F9i2 Hemoglobin (g/ ) F9i3 Hematocrit (%) F9i4 Bạ h ầu (G/ ) F9i5 Tiểu ầu x109/L) F9i6 MPV (fL) F9i7 PCT F10 Xé ghiệm CT m u sau mổ g y 7 F10i1 H g ầu (T/ ) F10i2 Hemoglobin (g/ ) F10i3 Hematocrit (%) F10i4 Bạ h ầu (G/ ) F10i5 Tiểu ầu (x109/L) F10i6 MPV (fL) F10i7 PCT Theo dõi sau xa sau mổ T iệu h g m s g sau mổ T1 Xu huy ưới a Không 0 Có 1 T2 Xu huy iêm mạ Không 0 Có 1 T3 Xu huy g Không 0 Có 1 T4 Hội h g Cushi g Không 0 Có 1 T5 Tắ uộ Không 0 Có 1 T6 Nhiễm huẩ huy Không 0 Có 1 T7 Huy hối Không 0 Có 1 T8 Tử o g Không 0 Có 1 Nguyên nhân T9 Xé ghiệm g h m u hời điểm 6 tháng T9i1 H g ầu (T/ ) T9i2 Hemoglobin (g/ ) T9i3 Hematocrit (%) T9i4 Bạ h ầu (G/ ) T9i5 Tiểu ầu (x109/L) T9i6 MPV (fL) T9i7 PCT T10 h gi m độ h i ò g a ố mẹ ới sẹo mổ heo ha g điểm Li e Hoàn toàn không hài lòng 1 Không hài lòng 2 B h hườ g 3 Hài lòng 4 Hoàn toàn hài lòng 5 h gi sẹo mổ heo ha g điểm S a Cosmesis Assessme a Ra i g (SCAR) Scale T11 B sỹ đ h gi T11i1 ộ ộ g sẹo Gầ hư h g h h y 0 Mỏ g hư đườ g ú h 1 Sẹo mở ộ g hẹ, ễ hậ h y u hú ý quan sát 2 Sẹo mở ộ g u g h, sẹo õ 3 Sẹo mở ộ g ghiêm g 4 T11i2 Ba đỏ Không 0 H g hẹ, ó hể ó giã mao mạ h 1 ỏ, hi u mao mạ h giã 2 ỏ đậm ho m 3 T11i3 Rối oạ sắ ố (Bao g m ă g gi m sắ ố) Không có 0 Có hiệ iệ 1 T11i4 D u ho h u Không có 0 Có hiệ iệ 1 T11i5 Ph đại/ eo Không 0 Nhẹ: ó hể sờ h y hầu hư h g h h y h đại eo 1 T u g h: h h y õ h đại eo 2 Nghiêm g: h đại ho eo õ g ho h h h h sẹo i 3 T11i6 Ấ ư g hu g Sẹo mo g muố 1 Sẹo h g mo g muố 2 T12 Bệ h h đ h gi T12i1 Bạ ó hó h u ởi g a ừ sẹo o g 24 giờ ua? Không 0 Có 1 T12i2 Bạ ó h y hó h u o đau ừ sẹo o g 24 giờ ua? Không 0 Có 1