bài giảng bệnh học nội khoa 1

TRUONG DAI
HOC
Y HA NOI
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CAC BO■ MON NOI
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BENH HOC N0IKHOA
TAP I

NHA XUAT BAN Y HOC
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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 do 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 khi hoc ly thuyet cung nhtf khi thiCc hanh
d benh vien.
Noi khoa la mot trong 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 nay mot so chiidng da diCOc siCa chiia va
bo sung de cap nhat cac kien thiic mdi cua y hoc.
Tuy nhien trong dieu kien so can bo con 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 trong cam (fn

TRl/ONG DAI HOC Y HA NOI
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Cac bo mon noi

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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, khi viem nhiem ca kin quan thi goi la viem khi
- 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 ra b bat ky ltia tuoi nao
nhtfng nhieu nhat la tre em va ngUdi gia.
Benh hay xay ra 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 khi
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
1. Viem phe quan cap do virus
Viem phe quan cap do 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).
2. Viem phe quan cap do vi khuan
Viem phe quan cap do vi khuan it gap hdn cac trUdng hdp viem phe
quan cap do virus. Trong so cac vi khuan gay viem phe quan cap thUdng
gap nhat la cac vi khuan trong te bao nhtf Mycoplasma, va Chlamydiae, cac
vi khuan gay mu hiem gap hdn. Cac triidng hdp nhilm khuan do Mycoplasma

pneumoniae bieu hien bang viem phe quan d 25 % cac trifdng hdp (viem mui

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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 do trif d cac trUdng
hdp viem phoi thi ngUdi ta khong lam cac huyet thanh chan doan, ngay ca d cac
nU6c phat trien. Viem phe quan cap do 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.
3. Hit phai hoi d oc
Khoi thuoc la, chlore, Amoniac, acid, dung moi cong nghiep, hdi doc
chien tranh.
4. Yeu to" di vfng
Viem phe quan cap xay ra cJ tre con giong nhif cdn hen phe quan, viem
phe quan cap cung hay xay ra tren ngtfdi hen, may day, phu Quinck.
5. Nguyen nhan thuan lOi
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Thay doi thdi tiet, nhiem lanh dot ngot.

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Cd the suy mon, coi xufdng, suy dinh difdng cJ tre em, suy giam
mien dich.

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ti dong phoi do suy tim.

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Cac benh cua phoi nhu lao phoi va ung thu phoi.

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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 khi 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 do 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 2 giai doan:

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1. Giai doan kho
Benh nhan thiidng co cam giac rat bong sau xtfdng \ic lien quan den
viem khi phe quan, cam giac nay tang len khi ho, dau ngiic nguon goc do cd

vi ho lien tuc. Ho khan, co khi 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 ngay. Giai doan nay keo dai 3-4 ngay thi
chuyen sang giai doan U6t.
2. 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 ngay va ran am, go khong thay vung due. Giai doan nay keo dai
4-5 ngay va khoang 10 ngay 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 khi
benh bat dau mot cach ram ro: sot cao, ho nhieu, ho ra mau... Neu d ngUdi
16n tuoi nghien thuoc la co ho ra mau can chu y tim ung thu phe quan bang
cach soi phe quan ke ca trong trUdng hdp X quang khong co bieu hien gi ro
ret. Dau hieu X quang: trong viem phe quan cap thUdng khong co gi dac
biet, co the thay thanh 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 nay.
V. CHAN DOAN
1. Chan doan xac dinh dvfa vao
1.1. Trieu chiing cua viem ditdng ho hap tren
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Nhe: viem hong do, chay nU6c mui.

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Nang: viem mui mu, viem xoang, viem amidan, viem tai giGa.

1.2. Trieu chiing cua viem ditdng ho hap ditai
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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.

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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.

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2. Chan doan phan biet
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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.

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O ngUdi 16n: nhieu benh phoi co bieu hien viem phe" quan nhif: lao
phoi v6i hang lao do vao phe quan, benh bui phoi, ung thu phoi.
Khong nghi den viem phe quan neu trieu chting nghe phoi chi 0
mot ben.

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U* dong b phoi trong trUdng hdp suy tim (co trieu chiing suy tim).

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Hen phe quan tang tiet dich: sau cdn hen thi het cac trieu chiing.

P.

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y

ty

ty

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VI. TIEN TRIEN, BIEN CHIING
1. 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 trong 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.

2. 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 do virus, sU viem va hoai tU nghiem
trong 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 khi tac nghen nang, khong hoi phuc v6i thuoc gian phe
quan cifdng P2 hoac corticoid. Tien lufdng khong biet trU6c dUdc, thUdng
nang, doi khi cai thien tam thdi v6i corticoid hoac thuoc lie che" mien dich.

CJ ngUdi 16n sau nhiem trung do virus hiem khi 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 do
dung thuoc (dieu tri bang D-penicillamine).

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2.2. Chiing tang tinh phan ting phe quan
Tang tinh phan ting phe quan va/hoac roi loan thong khi tac nghen
thoang qua co the gap trong moi trUdng hdp viem phe quan cap, ngay ca d
nhting ngUdi trU6c day khong he bi cac benh ho hap. Cac roi loan nay,
thUdng thay sau khi bi viem phe quan do virus hoac do mycoplasma, co the
bien di d 40 % cac trUdng hdp trong vong 2 thang sau ddt viem khdi phat.
Vi vay can chd sau thdi gian nay 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 khi 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 trong 5 den 7 ngay), thuoc
giam dau thong thUdng, cac thuoc giam ho nhu sirop Codein khi ho khan
nhieu va co the dung cac thuoc gian phe quan cUdng P2 dUdng phun hit khi
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 trong viem phe quan cap la: ho keo dai va khac ddm mu tren 7 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 trong nhom penicillin A hoac macrolid
nhtf erythromycin l,5g ngay trong 10 ngay, Rulid 150mg x 2 lan/ngay.

Viec ngting hut thuoc la mot thanh 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
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Loai bo ye"u to klch thlch: khong hut thuoc, tranh khoi bui trong
nha, moi trUdng o nhiem.

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Giti gin stic khoe, giti am nhat la mua lanh.

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Gay mien dich bang tiem chung vacxin chong virus, vi khuan.

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BENH
PHOI TAC NGHEN MAN
TINH
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1. Dinh nghia
Benh phoi tac nghen man tinh la tinh trang benh co roi loan thong
khi tac nghen khong co kha nang hoi phuc hoan toan. Su can trd thong khi
thUdng tien trien tti tti va lien quan den phan ting viem bat thufdng cua
phoi do cac phan tti hoac khi doc hai.
2. Dich te hoc benh phoi tac nghen man tinh
Theo WHO, nam 1990, ty le bi mac benh phoi tac nghen man tinh
tren toan the gi6i U6c tinh khoang 9,34/1000 0 nam va 7,33/1000 0 nti. Tuy
nhien, nhting U6c tinh nay bao gom 0 mm ltia tuoi va chtfa phan anh dung
ty le benh phoi tac nghen man tinh thifc ci ngiidi cao tuoi. Ty le mac benh
phoi tac nghen man tinh cao nhat d nhting nuf6c da va dang thinh hanh
viec hut thuoc trong khi ty le mac benh phoi tac nghen 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 nghen man tinh hien la nguyen nhan

gay tti vong hang thti 4, va dtf bao con tang len trong nhting nam t6i. C) My
ty le chet do benh phoi tac nghen man tinh rat thap d tuoi du6i 45 nhufng
sau do tang dan theo tuoi. Benh phoi tic hghen man tinh tr3 thanh nguyen
nhan dting hang thti tii hoac thti nam gay tti vong d tuoi tren 45.
3. Cac yeu to" nguy cd gay benh phoi tac nghen man tinh
3.1. Thuoc la

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La nguyen nhan chinh cua benh, va tti vong do benh phoi tkc
nghen 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 nghen man tinh.

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80- 90% cac benh nhan benh phoi tac nghen man tinh deu co hut
thuoc.

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Hut thuoc la thu dong: tre em trong gia dinh co ngUdi hut thuoc la
bi cac benh difdng ho hap tren vdi ty le cao hdn tre em trong gia
dinh khong co ngtfdi hut thuoc.