bài giảng bệnh học nội khoa 1

TRUONG DAI HOC Y HA NOI ■ ■ ■ CAC BO■ MON NOI ■ B a i g i a n g BENH HOC N0IKHOA TAP I NHA XUAT BAN Y HOC ■ TRUONG DAI HOC Y HA NOI CAC BO MON NOI BAI GIANG BENH HOC NOI KHOA TAPI (Tai ban Ian thiC chin co siia chiia va bo sung) NHA XUAT BAN Y HOC HA NOI - 2004 Tham gia bien soan: PGS.TS NGUYEN THjMINH AN GS TS TRAN NGOC AN PGS TS PHAM THI THU HO TS NGO QUY CHAU GS PHAM KHUE GS PHAM GIA KHAI PGS BS NGUY§N VAN THANH GS TS TRAN OCfC THO GS TS NGUY6N KHANH TRACH TS DO TH| LIEU GS TS NGUY§N LAN VIET GS TS NGUY§N VAN XANG TS CHU VAN Y Thir ky bien soan: GS TS TRAN NGOC AN PGS TS PHAM TH| THU H6 LDfl NOI DAU Bai giang benh hoc noi khoa can bo giang day cac bo mon noi thuoc TrUbng Dai hoc Y Ha Noi bien soan nham cung cap mot so tai lieu de sinh men cac Ictp Y3 - Y6 theo chtfdng trinh cai cach mdi dung de hoc tap va tham khao hoc ly thuyet cung nhtf thiCc hanh d benh vien Noi khoa la mot nhiing mon hoc chinh cua cac Tritilng Dai hoc Y Noi dung can ditrfc sita doi bo sung cho phii help uc'fi sit tien bo khong ngitng cua y hoc Lan tai ban mot so chiidng da diCOc siCa chiia va bo sung de cap nhat cac kien thiic mdi cua y hoc Tuy nhien dieu kien so can bo it oi, thdi gian han che cuon sach khong tranh khoi thieu sot nhat dinh, mong ban doc gop y de lan tai ban sau cuon sach dit(lc hoan thien hdn Xin tran cam (fn TRl/ONG DAI HOC Y HA NOI ■ ■ Cac bo mon noi ■ C H lfO N G I HO HAP VIEM PHE QUAN CAP I DAI ClTdNG VA DINH NGHIA Viem phe quan cap la tinh trang viem nhiem niem mac cua phe quan 16n va phe quan trung binh, viem nhiem ca kin quan thi goi la viem - phe quan Viem nhiem lan den tieu phe quan tan va phe nang thi goi la phe quan-phe viem Viem phe quan cap co the xay b bat ky ltia tuoi nao nhtfng nhieu nhat la tre em va ngUdi gia Benh hay xay ve mua lanh va dau mua xuan Trieu chiing lam sang chmh la ho va khac ddm nhay - mu Benh tien trien lanh tfnh sau khoi khong de lai di chiing Viem phe quan la mot van de siic khoe cong dong quan trpng lam nhieu ngUOi phai nghi viec hoac nghi hoc di kham benh va dung cac thuoc khang sinh II NGUYEN NHAN Viem phe quan cap virus Viem phe quan cap virus chiem 50 t6i 90% cac trtfcing hdp viem phe quan cap Ngifdi ta da ghi nhan co tren 180 virus gay benh Cac virus thiidng gap nhat la cac myxovirus (virus cum va virus a cum), cac rhino''irus, coronavirrus, virus dai thUc bao dUdng ho hap (Respiratory Syncticial Virus), Adenovirus, enterovirus (coxsackie va echovirus) va mot so"chiing herpes virus (CMV, varicellae) Viem phe quan cap vi khuan Viem phe quan cap vi khuan it gap hdn cac trUdng hdp viem phe quan cap virus Trong so cac vi khuan gay viem phe quan cap thUdng gap nhat la cac vi khuan te bao nhtf Mycoplasma, va Chlamydiae, cac vi khuan gay mu hiem gap hdn Cac triidng hdp nhilm khuan Mycoplasma pneumoniae bieu hien bang viem phe quan d 25 % cac trifdng hdp (viem mui hong dOn thuan chiem 60%, viem phoi chi chiem 5% Mycoplasma pneumoniae va Chlamydiae pneumoniae la nguyen nhan cua 25 % cac trvfOng hdp viem phe quan cap Tuy nhien ty le mac benh chfnh xac kho xac dinh trif d cac trUdng hdp viem phoi thi ngUdi ta khong lam cac huyet chan doan, ca d cac nU6c phat trien Viem phe quan cap phe cau va hemophillus influenzae thifdng it gap d ngUdi 16n, hay di kem v6i sot va cac dau hieu ngoai dtfdng ho hap Xet nghiem vi khuan thUcing am tmh ci 80 den 95 % cac trtfdng hdp viem phe quan cap Hit phai hoi d oc Khoi thuoc la, chlore, Amoniac, acid, dung moi cong nghiep, hdi doc chien tranh Yeu to" di vfng Viem phe quan cap xay cJ tre giong nhif cdn hen phe quan, viem phe quan cap cung hay xay tren ngtfdi hen, may day, phu Quinck Nguyen nhan thuan lOi - Thay doi thdi tiet, nhiem lanh dot ngot - Cd the suy mon, coi xufdng, suy dinh difdng cJ tre em, suy giam mien dich - ti dong phoi suy tim - Cac benh cua phoi nhu lao phoi va ung thu phoi - Moi trUdng song am thap nhieu khoi bui III GIAI PHAU BENH LY Vi tri ton thifdng: ton thUdng giai phau thay d phe quan goc, phe quan thuy co the ca quan va phe quan tan Nhiing ton thifdng thay diidc: niem mac phe quan bi phu ne, sung huyet, cac mach mau gian to, co 16p dich nhay, mu bao phu, xam nhap bach cau da nhan, te bao bieu mo bi bong va co cho bi loet, cac tuyen nhay cang va tang tiet IV TRIEU CHtTNG Viem phe quan cap virus bat dau dien hinh bang viem long dUdng ho hap tren v6i h^t hdi, so mui va/hoac viem mui hong Ton thifdng viem lan xuong dUdng ho hap du6i bieu hien trtfcic tien bang ho khan, ho tiing cdn, ho ong ong va dau Day la luc benh toan phat gom giai doan: Giai doan kho Benh nhan thiidng co cam giac rat bong sau xtfdng \ic lien quan den viem phe quan, cam giac tang len ho, dau ngiic nguon goc cd vi ho lien tuc Ho khan, co ho ong ong, ho tifng cdn, khan tieng Trieu chiing toan than: thtfdng sot vtifa, khoang 38°C Nhtifc dau, met moi, dau minh may, bieng an Kham phoi luc dau binh thUdng, sau co the thay rai rac co ran rft va ran Giai doan keo dai 3-4 thi chuyen sang giai doan U6t Giai doan tfdt Cam giac dau rat bong sau xUdng lie giam dan roi het han, kho thcf nhe, ho khac ddm nhay, ddm nhay mau hoac ddm vang-mu Nghe phoi co the co ran va ran am, go khong thay vung due Giai doan keo dai 4-5 va khoang 10 thi khoi h&n C) mot so" trufdng hdp ho khan keo dai nhieu tuan le (tang tfnh phan ling phe quan sau nhiem trung) Doi benh bat dau mot cach ram ro: sot cao, ho nhieu, ho mau Neu d ngUdi 16n tuoi nghien thuoc la co ho mau can chu y tim ung thu phe quan bang cach soi phe quan ke ca trUdng hdp X quang khong co bieu hien gi ro ret Dau hieu X quang: viem phe quan cap thUdng khong co gi dac biet, co the thay phe quan day Xet nghiem: cong thtic bach cau va mau l4ng tang vtfa phai Cay ddm: thay nhieu loai vi khuan nhUng ft co gia tri de chan doan va thong thUdng khong co chi dinh lam xet nghiem V CHAN DOAN Chan doan xac dinh dvfa vao 1.1 Trieu chiing cua viem ditdng ho hap tren - Nhe: viem hong do, chay nU6c mui - Nang: viem mui mu, viem xoang, viem amidan, viem tai giGa 1.2 Trieu chiing cua viem ditdng ho hap ditai - Nhe: ho, khan tieng, thci kho khe va dau hieu cua viem dtfdng ho hap tren, nghe phoi co the co ran ngay, ran rft - Nang: ngoai jihting trieu chijfng tren, kho thd ro ret, co keo long ngtic, tfm, nhip thd nhanh tren 30 lan/phut Nghe phoi co ran rft, ran bot d vung day phoi phfa sau lifng Chan doan phan biet - C) tre em neu trieu chiing viem phe quan keo dai, can nghi den hach d trung that, chen ep phe quan, di vat phe" quan hoac gian phe quan - O ngUdi 16n: nhieu benh phoi co bieu hien viem phe" quan nhif: lao phoi v6i hang lao vao phe quan, benh bui phoi, ung thu phoi Khong nghi den viem phe quan neu trieu chting nghe phoi chi mot ben - U* dong b phoi trUdng hdp suy tim (co trieu chiing suy tim) - Hen phe quan tang tiet dich: sau cdn hen thi het cac trieu chiing P ^ ^ y ty ty ^ VI TIEN TRIEN, BIEN CHIING Tien trien trvfdc mat Tien ltfdng gan cua viem phe quan cap noi chung la tot Tuy nhien tien trien trU6c mat co the dang lo ngai hdn b mot so" cd dia nhu suy ho hap man tinh, hen phe" quan, hoac suy tim va trufdng hdp viem tieu phe" quan b tre nho O ngufdi 16n tuoi, tinh trang suy yeu he thong mien dich bao ve, va cac bien doi ve giai phau tai cho co the lam cho benh de lan t6i cac tieu phe quan tan va cac phe nang dan den benh canh viem phoi cap vdi tien ltfdng nang hdn Tien trien lau dai Phan 16n benh khoi hoan toan khong de lai di chiing Benh tai phat nhieu lan co the dan den gian phe quan hoac viem tieu phe" quan bit tkc, nhat la d tre em 2.1 Viem tieu phe quan bit tac C) tre em sau viem tieu phe" quan virus, sU viem va hoai tU nghiem bieu mo phe" quan co the dan tdi tang sinh rat manh cac te" bao bieu mo phu tieu phe quan gay bit tic long phe" quan bdi to chiic xd seo Benh canh lam sang bieu hien bang suy ho hap man tinh v6i kho thd, ho va tieng bat thUdng dac trUng nghe thay d thi hit vao Ve chtic nang ho hap thUdng co ro"i loan thong tac nang, khong hoi phuc v6i thuoc gian phe quan cifdng P2 hoac corticoid Tien lufdng khong biet trU6c dUdc, thUdng nang, doi cai thien tam thdi v6i corticoid hoac thuoc lie che" mien dich CJ ngUdi 16n sau nhiem trung virus hiem xuat hien viem tieu phe" quan bit the va neu co thi phai tim xem benh nhan co bi cac benh he thong (xd ciing bi, viem da kh6p dang thap) hoac mot so nguyen nhan dung thuoc (dieu tri bang D-penicillamine) 2.2 Chiing tang tinh phan ting phe quan Tang tinh phan ting phe quan va/hoac roi loan thong tac thoang qua co the gap moi trUdng hdp viem phe quan cap, ca d nhting ngUdi trU6c day khong he bi cac benh ho hap Cac roi loan nay, thUdng thay sau bi viem phe quan virus hoac mycoplasma, co the bien di d 40 % cac trUdng hdp vong thang sau ddt viem khdi phat Vi vay can chd sau thdi gian mcii nen ket luan la co tinh trang tang tinh phan ting phe quan hoac co hen phe quan VII DIEU TRI (3 ngUdi binh thUdng hiem can dieu tri viem phe quan cap Khi co chi dinh chi dieu tri trieu chting vdi nghi ngdi tai giUdng, cho du lifdng nUcic uong, cac thuoc chong viem khong phai corticoid hoac mot ddt ngan corticoid dUdng uong (prednison: 0,5 mg/kg/ngay den ngay), thuoc giam dau thong thUdng, cac thuoc giam ho nhu sirop Codein ho khan nhieu va co the dung cac thuoc gian phe quan cUdng P2 dUdng phun hit co dau hieu co that phe quan Chtfa co nghien ctiu nao chting minh hieu qua cua cac thuoc long ddm Khong can dung khang sinh cho viem phe quan cap d ngUdi binh thUdng Cac thuoc khang sinh khong lam thay doi tien trien cua benh va gay tang chi phi dieu tri Cac khuyen cao lien quan den viec dung khang sinh viem phe quan cap la: ho keo dai va khac ddm mu tren ngay, cd dia viem phe quan man tinh hoac co viem mui mu, viem amidan, viem VA, viem tai gitia phoi hdp Trong cac trUdng hdp nay, khang sinh dUdc khuyen cao la dung mot loai thuoc nhom penicillin A hoac macrolid nhtf erythromycin l,5g 10 ngay, Rulid 150mg x lan/ngay Viec ngting hut thuoc la mot phan cd ban cua dieu tri d nhting ngifdi nghien thuoc la, thuoc lao Dieu tri cac nguyen nhan thuan ldi neu co VIII PHONG BENH - Loai bo ye"u to klch thlch: khong hut thuoc, tranh khoi bui nha, moi trUdng o nhiem - Giti gin stic khoe, giti am nhat la mua lanh - Gay mien dich bang tiem chung vacxin chong virus, vi khuan BENH PHOI TAC NGHEN MAN TINH • • Dinh nghia Benh phoi tac man tinh la tinh trang benh co roi loan thong tac khong co kha nang hoi phuc hoan toan Su can trd thong thUdng tien trien tti tti va lien quan den phan ting viem bat thufdng cua phoi cac phan tti hoac doc hai Dich te hoc benh phoi tac man tinh Theo WHO, nam 1990, ty le bi mac benh phoi tac man tinh tren toan the gi6i U6c tinh khoang 9,34/1000 nam va 7,33/1000 nti Tuy nhien, nhting U6c tinh bao gom mm ltia tuoi va chtfa phan anh dung ty le benh phoi tac man tinh thifc ci ngiidi cao tuoi Ty le mac benh phoi tac man tinh cao nhat d nhting nuf6c da va dang thinh hanh viec hut thuoc ty le mac benh phoi tac man tinh thap nhat d nhting nU6c it hut thuoc hdn hay co ty le tieu thu thuoc la tren moi ca the thap Tren toan the" gicii benh phoi tac man tinh hien la nguyen nhan gay tti vong hang thti 4, va dtf bao tang len nhting nam t6i C) My ty le chet benh phoi tac man tinh rat thap d tuoi du6i 45 nhufng sau tang dan theo tuoi Benh phoi tic hghen man tinh tr3 nguyen nhan dting hang thti tii hoac thti nam gay tti vong d tuoi tren 45 Cac yeu to" nguy cd gay benh phoi tac man tinh 3.1 Thuoc la 10 - La nguyen nhan chinh cua benh, va tti vong benh phoi tkc man tinh Ngting hut thuoc lam giam cac yeu to" tren Khoang 15% so nhting ngufdi hut thuoc co trieu chting lam sang cua benh phoi tac man tinh - 80- 90% cac benh nhan benh phoi tac man tinh deu co hut thuoc - Hut thuoc la thu dong: tre em gia dinh co ngUdi hut thuoc la bi cac benh difdng ho hap tren vdi ty le cao hdn tre em gia dinh khong co ngtfdi hut thuoc