Bệnh học nội khoa tập I -Y Thái Nguyên

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TRNG I HC Y KHOA THI NGUYN B MN NI

BNH HC NI KHOATp 1

NH XUT BN Y HC H Ni - 2006

CH BIN: BS. CKII. Doanh Thim Thun

THAM GIA BIN SON: 1. BS. CKII. Doanh Thim Thun 2. BS. CKI. Bi Duy Qu 3. BS. CKI. Nng Minh Chc 4. BS. CKII. Nng Th Minh Tm 5. ThS. Nguyn ng Hng 6. TS. Dng Hng Thi 7. TS. Trnh Xun Trng 8. ThS. Nguyn Vn Tha 9. ThS. Nguyn Trng Hiu 10. ThS. V Th Hi Yn 11. ThS. Nguyn Tin Dng 12. ThS. L Th Thu Hin 13. ThS. Phm Kim Lin

TH K: BS. Trng Vit Trng

LI NI U nng cao cht lng o to sinh vin Y khoa, to iu kin cho sinh vin ang hc trong trng c ti liu hc tp v sau khi ra trng c th c li, tham kho nhng vn hc khi cn thit. Tp th ging vin B mn Ni Trng i hc Y khoa Thi Nguyn bin son tp Bnh hc ni khoa. Ti liu ny l nhng vn c bn v ni khoa, c chia lm 2 tp. Bao gm 54 bnh l ni khoa v hi sc cp cu. y l nhng bi ging v cc bnh l thng gp ti bnh vin tuyn c s v tuyn tnh. Hai tp Bnh hc ni khoa ny c bin son da vo cc ti liu theo quy nh ca V Khoa hc v o to, B Y t, da trn nhng mc tiu v ni dung trong khung chng trnh c thng nht, c cp nht nhng thng tin kin thc mi, gip cho sinh vin nng cao kin thc cng nh thc hnh v t lng gi. Tuy nhin, trong qu trnh bin son, khng th trnh khi nhng thiu st. Chng ti rt mong c cc bn ng nghip v cc c gi ng gp kin ln ti bn sau ni dung cun Bnh hc ni khoa s c hon chnh hn. Xin trn trng cm n! T/M BAN BIN SON TRNG B MN NI

BS. Chu. Doanh Thim Thun

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MC LCTp 11. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.TNG HUYT P............................................................................................................. 3 HP VAN HAI L ........................................................................................................... 15 H VAN HAI L............................................................................................................. 24 H VAN NG MCH CH ........................................................................................ 29 HP VAN NG MCH CH ...................................................................................... 35 IU TR SUY TIM ........................................................................................................ 40 IN TM NG DNG TRONG LM SNG ..................................................... 44 HEN PH QUN ............................................................................................................. 57 VIM PH QUN CP, MN ....................................................................................... 64 VIM PHI THY .......................................................................................................... 70 P XE PHI..................................................................................................................... 74 LOT D DY T TRNG........................................................................................... 80 XUT HUYT TIU HA CAO.................................................................................... 86 VIM KHP DNG THP ............................................................................................ 91 XUT HUYT GIM TIU CU................................................................................ 100 I THO NG...................................................................................................... 104 BASEDOW..................................................................................................................... 115 BU GIP TRNG N THUN ........................................................................... 126 CHN ON V IU TR THN H TH PHT................................................ 132 TM PH MN............................................................................................................. 138 X GAN ......................................................................................................................... 144 P XE GAN DO AMP.................................................................................................. 150 CP CU NGNG TUN HON............................................................................... 157 IN GIT .................................................................................................................... 163 NGT NC ................................................................................................................. 167 RN C CN ............................................................................................................. 171 NGUYN TC X TR NG C CP .................................................................... 174 NG C BACBITURIC ............................................................................................. 179 NG C LN HU C............................................................................................. 182 NG C THUC CHUT T TRUNG QUC ....................................................... 186

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TNG HUYT P1. I CNG 1.1. nh ngha Theo T chc Y t Th gii, mt ngi ln b tng huyt p thc s khi huyt p tm thu trn hoc bng 160mmHg v huyt p tm trng trn hoc bng 95 mmHg. - Huyt p tng gii hn khi huyt p tm thu t 140 - 160 mmHg v huyt p tm trng 90 - 95 mmHg. nh ngha ny n gin nhng c nhc im l tr s huyt p khng hon ton n nh v huyt p thay i theo gii, tui... 1.2. Dch t hc Tng huyt p l mt triu chng ca nhiu bnh, nhiu nguyn nhn nhng c th l mt, bnh tng huyt p nu khng tm thy nguyn nhn. 1.2.1. Th gii cc nc chu u - Bc M t l tng huyt p chim 15 - 20% ngi ln. C th: Hoa K 6 - 8% Thi Lan 6,8%; Chi L 19 - 21%. 1.2.2. Vit Nam T l tng huyt p chung l 11% (B Y t Vit Nam, 1989 T l ny gia tng ng quan tm v trc nm 1975 t l ny min Bc Vit Nam ch c 1 - 3% (ng Vn Chung - 1971). 2. NGUYN NHN V CC YU T THUN LI 2.1. Tng huyt p nguyn pht Chim gn 90% trng hp tng huyt p (theo Gifford - Weiss). 2.2. Tng huyt p th pht 2.2.1. Bnh thn Vim cu thn cp, vim cu thn mn, thn a nang, vim i b thn mn do nc, m i b thn, u thn lm tit renin, hp ng 2.2.2. Bnh ni tit - Bnh v thng thn nh: hi chng Conn, hi chng Cushing. - Bnh tu thng thn: u tu thng thn (hi chng Pheochromocytone). 2.2.3. Bnh tim mch - Bnh hp eo ng mch ch, h van ng mch ch. - Vim hp ng mch ch bng ch xut pht ng mch thn. 3

2.2.4. Do thuc Cc hormon nga thai, cam tho, corticoid, ACTH, cht gy chn n, cht chng trm cm vng... 2.2.5. Cc nguyn nhn khc - Ng c thai nghn: hi chng albumin niu. - Bnh cng gip, bnh Beriberi, bnh a hng cu, hi chng carcinoid, toan h hp, tng p lc s... 2.3. Mt s yu t thun li: c lin quan n tng huyt p nguyn pht l: 2.3.1. Yu t di truyn, tnh gia inh 2.3.2. Yu t n ung n nhiu mui, ung nhiu ru, ung nc mm t Ca+, Mg+, K+, n t protid. iu ni bt c tha nhn l s lin quan gia con Nay v tn sut bnh tng huyt p. ton Na+ lm tng huyt p qua trung gian gia tng th tch mu v qua s co thi mch mu. 2.3.3. Yu t tm 1 x hi, tnh trng cng thng stress thng xuyn 3. C CH BNH SINH CA TNG HUYT P NGUYN PHT Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh lin quan n h thn kinh giao cm, thn, Renin, angiotensin v c ch huyt ng, th dch khc. 3.1. Bin i v huyt ng 3.1.1. Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch phn b li mu lu thng t ngoi vi v tim phi. Do sc cn mch mu cng tng dn. Tim c biu hin tng hot ng b tr v dn n dy tht tri, huyt p v sc cn ngoi bin ton b tng dn. Lu lng tim v lu lng tm thu gim, cui cng dn n suy tim. 3.1.2. Trong cc bin i v huyt ng, h thng ng mch thng b tn thng sm v ton b. - Ti thn, tng sc cn mch thn, gim lu lng mu ti thn. Chc nng thn suy gim. - Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh thi k c tng huyt p r. - Khi huyt p tng, sc cn ngoi vi tng th tch huyt tng c xu hng gim cho n khi thn suy, th tch dch trong mu tng c th dn n ph. 3.2. Bin i v thn kinh 4

thi k u h giao cm nh hng s tng tn s tim v tng lu lng tim. S hot ng ca h thn kinh giao cm cn biu hin lng catecholamin trong huyt tng nh: Adrenalin, No-adrenalin cc cht ny rt thay i trong bnh tng huyt p h thn kinh t ng giao cm c iu khin bi h thn kinh trung ng hnh no - tu sng v c hai h ny lin h nhau qua trung gian cc th cm p lc. Trong tng huyt p cc th cm p lc c iu chnh n mc cao nht v vi ngng nhy cm cao nht. 3.3. Bin i v th dch 3.3.1. H Renin - Angiotensin - Aldosteron (RAA) Hin nay c chng minh c vai tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ng no gy tng huyt p qua cc th th Angiotensin II. Angiotensin II c tng hp t Angiotensinogne gan v di tc dng ca Renin s to thnh Angiotensin I ri chuyn thnh angiotensin II l mt cht co mch rt mnh v lm tng tit Aldosteron. S phng thch Renin c iu khin qua 3 yu t. p lc ti mu thn - lng Na n t ng ln xa v h thn kinh giao cm. S thm d h RAA da vo s nh lng Renin trc tip huyt tng hay gin tip phn ng min dch v Angiotensin II nhng tt nht l tc dng ca cc c ch men chuyn. 3.3.2. Vasopressin (ADH) c vai tr kh r rng trong c ch bnh sinh tng huyt p c tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm thn kinh trung ng i vi phn x t xoang ng mch cnh v quai ng mch ch) tc dng ngoi vi co mch (trc tip v qua hot ha cc si adrenergic). 3.3.3. Cht Prostaglandin tc dng trung ng lm tng huyt p, tc dng ngoi vi lm gim huyt p. 3.3.4. Ngoi ra cn c vai tr ca h Kalli - Krein Kinin (K.K.K) trong bnh tng huyt p v mt s h c vai tr cha r nh: H angiotensin trong no v cc encephalin, h cng dopamin bin i hot ng th cm p lc. Mt c ch iu ho lin quan n cc th cm p lc. Mt c ch iu ho lin quan n cc th th Imidazol trung ng v ngoi bin c ghi nhn t nhng nm 80 vi s xut hin thuc huyt p tc dng ln th cm Imidazole gy gin mch. 3.3.5. C ch sinh bnh ca tng huyt p th pht: Tu thuc vo nguyn nhn gy bnh. 4. TRIU CHNG HC 4.1. Lm sng 4.1.1. C nng a s bnh nhn b tng huyt p khng c triu chng g cho ti khi pht hin ra bnh. 5

- au u vng chm v hai bn thi dng. - Cc triu chng khc c th gp nh: hi hp, mt, kh th, m mt...nhng khng c hiu. - Mt s triu chng khc ca tng huyt p tu thuc vo nguyn nhn tng huyt p hoc bin chng ca tng huyt p. 4.1.2. Thc th, ton thn * o huyt p: l ng tc quan trng nht c ngha chn on xc nh. Khi o cn phi m bo mt s quy nh. - Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun tr