GESTROINTESTINAL
43/1)Mesenteric angina:SMA 의 atherosclerotic dis., 식후 30 분경 심한 midabdominal pain, vomiting, abd. Distension
small bowel infarction & large bowel 의 ischemic damagefibrosis & stricture; splenic flexure 에서 잘일어남
30/2) Acute mesenteric ischemia: sever abd pain due to spasm of the mesenteric a  followed by rapid emptying of the bowel
causing GI hemorrhage & hematochezia, but not to the extent seen in diverticulosis or angiodysplasia.
152/2) Carcinoid syn: secondary to metastatic carcinod tumor to the liver from a primary site in the small intestine
liver 의 metastatic nodule 에서 serotonin & oter chemical 을 분비.
Flushing(m/c symptom), pruritus(-)
156/2)Malabsorption
screening test- quantitative stool for fat(>6g/day)
localization study- D-xylose absorption test, radioactive bile breath test(bacterial overgrowth 를 detect)
fat-soluble vit A,D,E,K 의 결핍
Vit A 결핍 night blindness & squamous metaplasia of the respiratory tract(leading to infections)
Vit D 결핍 rickets & osteomalacia; excess bulidup of unmineralized osteoid secondary to hypoCa & hypoP
Vit K 결핍 hemorrhagic diathesis
Loss of protein hypoalbuminemia, VLDLhepatomegaly due to fatty change
Water-sol vitamine deficiency, hypoMg, iron,folate,VitB12, isotonic loss of sodium, hypoK, nl anion gap m. acidosis
INH hepatotoxicity
1. toxic & idiosyncratic, 첫 몇주동안 aminotransferase 상승.
2. alcholo & rifampicin 은 hepatotoxicity 를 촉진시킴.
3. slow acetylator 에서 hydrozine 생성 toxicity
acetaminophen hepatotoxicity
1. direct toxic type, intrinsic, dose-dependent
2. zonal necrosis(centrilobular necrosis)
3. glutathione 과 binding 함으로 detoxified
4. 악화요소: alcohol, phenobarbital, starvation
5. 복용후 4~12 시간후에 N/V, diarrhea, abd. Pain, 24~48 시간 뒤에는 liver injury 시작.
6. tx: gastric lavage, N-acetyl cysteine, supportive care
51/3) Hepatitis C : mc cause of post-transfusional hepatitis.
잠복기- 2weeks ~ 6months
대부분 anicteric, ALT>AST
alkaline phosphatase & r-glutamyltransferase cholestasis 를 의미
atypical lymphocytosis- viral hepatitis 에서 보일수있다.
106/3) Acute cholecystitis: stone impacted in the cystic duct(90%), E.coli 에의한 invasion
RUQ pain- 식후 15~30 분경에 나타남, vomiting 으로 완화되지 않음.
steady, aching, radiate to the rt scapula, Murphy’s sign(+)
febrile, jaundice, absolute neutrophilic leukocytosis, HIDA scan
72 시간내 대부분 수술
chemically induced inflammation of the GB: chronic cholecystitis
Biliary dyskinesia: RUQ pain, absence of stone
Hydrops of the GB: duct obs 으로 lumen 내 mucus 축적
69/4) Whipple’s dis: multiorgan systemic dis caused by a bacillus ( G(+) actinomycete Tropheryma whippeli)
- white, middle-aged men, malabsorption
- emaciation, polyarthritis, fever, lymphadenopathy, peculiar gray-brown pigmentation of skin
- tx: bactrim or procaine penicillin
CARDIOLOGY
51/1) Lidocaine- class IB, least cardiodepressant. MI 후 ventricular tachycarida 에 사용(procainamide 도 사용)
고농도에서 depress myocardial contractility & CNS excitation(hyperreflexia, seizure)
amiodarone & quinidine- torsades de points 유발.
flecainide-MI 후 예방적으로 사용시 mortality
Classification of Antiarrhythmic drug
Class I
Block of the inward Na current in tissue with fast response action potentialsVmax
A- quinidine, procainamide, dispyramide
B- lidocaine, phenytoin, tocinide, mexiletine
C- flecainide, propafenone, moricizine
Class II
Antisympathetic agents; propranolol, blockerSA nodal automaticity, AV conduction
Class III
action potential duration in tissue with fast response action potential; bretylium, amiodarone, sotalol
Class IV
Ca blocker- slow response action potential 조직에서 conduction, refractoriness;eg, verapamil, diltiazem
Cannot be classified Digitalis, adenosine
97/4) Quinidine- prolong the action potential, vagolytic effect  AV 전도 AF 때 ventricular response 를 증가시킴
digoxin: parasympathomimetic action  AV conduction ventricular rate
metoprolol: cAMPNa & Ca currentAV conduction ventricular response
Verapamil & diltiazem: depression of calcium current in tissue(AV node) refractory period conduction velocity
60/1) Cardiotoxic effects of digitalis: hyperCa.(thiazide 에의함), hypoMg.(loop diuretics 에의함), hypoK.에서 
K+- digitalis 와 Na,K ATPase 결합을 놓고 경합, 따라서 nl. K+ level 을 유지해야하지만,
hyperK+시는 re-entrant phenomena 에의해 arrhythmia
age, renal insufficiency, hypothyroidism, electrical cardioversion, quinidine 같은 약물 동시투여 digitalis 에대한 sensitivity
Na는 역효과 초래.
115/1)Atrial flutter.: ventricular rate 는 atrial rate 의 1/2 정도vagolytic properity 를 갖는 quinidine 같은 agents 로 atrial
rate 를 낮추면 ventricular rate 는 갑자기 증가할수 있다.
tx: DC-cardioversion
blocker, Ca antagonist, digitalis 로 AV nodal conduction후 class I or amiodarone 으로 sinus rhytm 으로 전환
재발방지- quinidine, flecainide, propafenone, amiodarone.
144/1)Variant angina: recurrent, prolonged attacks of severe ischemia,
caused by episodic focal spasm of an epicardia coronary artery. 3/4 에서 spasm site 의 1cm 이내에 fixed obstruction.
30~40 대, pain 은 rest,잠에서 깰때에 나타나고 multilead ST-segment elevation 이 특징.
- nitrates & Ca blocker(nifedipine) are more effective than  blocker
146/1) Cholesterol &HDL- best screen for primary prevention of CAD
LDL- carries most of the cholesterol., initial screen for 2 ndprevention & decide whether drug th. is indicated.
Oxidized LDL; more atherogenic than native LDL, 대식구의 LDL receptor 에의해 taken up foam cell 형성
ahterosclerotic process 에서 fatty streak 을 형성.
Antioxidant(Vit.A,C,E)- neutralize oxidized LDL
LDL=cholesterol-(HDL+TG/5) <130mg/dl(normal)
The goal of therapy in primary prevention of CAD- LDL<130mg/dl.
,but in 2nd prevention- LDL<100mg/dl.
148/1) Normal in the elderly:
mild glucose intolerance adipose tissue
Alkaline phosphatase degenerative arthritis
autoAb. secondary to a CD8 T cell
CcrGFR
Hgb concentrationmen 에서 testosterone 감소로 성인여성수치(12-16g/dl)정도로 떨어짐
세균뇨, PVC, 골밀도저하, 포도당내성이상등은 노인에서 비교적흔함
빈혈, 발기부전, 우울증 같은 증상들은 원인을 규명해야함
*노화의 특성(I): 구조적 변화
1. 육안형태학적 변화
(1) 근육체적의 감소
(2) 골부피의 감소
(3) 지방양의 감소
(4) 피부의 변화- 멜라닌 세포소실, 노출된 피부는 얇아짐
2. 조직의 변화
(1) 세포변화: 지방갈색소의 침착(mc), 불규칙하고 이상분엽의 핵, 공포화된 사립체, ER, 골지복합체변화
(2) 섬유물질의 변화: 양적으로 교원섬유증가보다 섬유 특성변화가 더 광범위.
3. 중요장기의 변화
(1) 중추신경계의 변화- 뇌의 선택적인 부위에서 신경원의 일부소실.
가. 핵주위 세포질의 변화- Nissl’s body 의 염기호성감소, 양도 감소. 지방갈색소 침착
세로이드는 병적상태에서만 관찰
neurofibrillary tangle, neuritic plaque 출혀
나. 수상돌기 신경연접 및 축삭의 변화- 수상돌기 가지와 극의 수가감소, 신경연접,연접틈새는 정상
(2) 심장순환계의 변화- 심근섬유증, 동맥벽은 비후되고 경화됨.
(3) 호흡기계의 변화- 폐조직은 탄성이 떨어지고 팽창됨.
*노화의 특성(II): 기능적 변화
- 예비능력이 감소하여 스트레스 상황에 대한 대처를 약하게함
1. 심맥관계의 변화- 기능저하가 가장 뚜렷.
(1) 심장의 변화- 이완기의 유순도가 감소, 최대심박수 & 최대일박출량이 감소
전부하증가로 concentric hypertrophy 초래, 나이가 들면서 eccentric hypertrophy 가 병발
(2) 혈관계의 변화- 저항혈관인 소동맥은 근원성에의해, 저장혈관이 정맥계는 신경성으로 긴장도유지.
내피세포에서 NO 의 분비능력감소, endothelin 에대한 반응성감소.
대동맥등 풀무혈관에서 맥파의 전도속도로 심실후부하증가 가장중요한 변화
저장혈관계에서 , 2-receptor 활동저하로 말초정맥계에 혈액저류,
압감수기활동저하로 기립성 저혈압이 흔함
(3) 동맥혈압의 변화- 75 세 전후로 동맥혈압의 증가 경향이 역전되어 수축기, 이완기혈압이 감소.
(4) 심맥관계의 대한 조절기전의 변화- NE, renin,
2. 호흡기계의 변화- Pco2, dead space, 호식용적, 호식 기류속도.
(1) 기계적성질- residual vol, functional RV, 폐유순도, closing vol, 흉벽유순도
(2) 환기 및 관류- closing vol>FRC, 폐확산능.
(3) 호흡조절기전- 말초 화학감수기는 산소에, 연수의 중추화학감수기는 탄산가스분압에 반응
3. 신장의 변화
(1) 사구체- GFR & 세뇨관기능, 전신근조직도 감소하므로 혈중 Cr는 없다. 주로 피질에서 신조직감소
4. 소화기계의 변화- 위액분비, 대장운동성 & 근육층 비후와 점막근층약화로 게실
혈중인슐린 but 인슐린 감수성감소로 비정상적 포도당 내성소견.
인슐린 감수성감소는 인슐린 파괴과정저하, 수용체감소, 유리감소등이 원인
5. 내분비계의 변화
6. 신경계의 변화- 밤중에 자주깨고, 1 단계수면, 3~4 단계수면, 기억력감퇴, 공간지각
*노화의 기전(I): 노화의 원인- genetic programme theories & theories of aging related to primary damage
151/1) -blocker bradycardia, hypotensioin, convulsions, bronchoconstriction, hypoglycemia
blocker: sinus rate, SA node recovery time, AV node 의 ERP,conduction
Ix.- slowing of ventricular rate during AF, Af; arrhythmias induced by exercise, hyperthyroidism,
polymorphic VT associated with congenital long QT syndrome.
156-8/1) Cardiovascular drug
Ca blocker: mild-to-moderate HTN & angina, AV 전도장애있는 경우 Nif >Verapamil.
Nif capsule 은 emergency treatment 에사용하지 말 것(MI or stroke 위험때문, 그러나 한두번은 가능)
Dihydropyridine 계열(Nif.)만 reflex tachycardia 초래.
negative inotropic action 이 있기 때문에 angina pectoris 환자에서 유용.
Diazoxide & minoxidil: potent arteriolar vasodilator
Diazoxide- hyperglycemia, hyperuricemia, Na retention 유발, but thiazide 와 같이사용할경우 이뇨효과증가
Hydralazine: potent vasodilator, 주로 arterial resistence 에 작용.
No direct effect on the heart, but severe reflex tachycardia 를 일으킬수 있다.
Procainamide: Na channel blocker, but K channal 도 block prolongation of the cardiac action potential
Bretylium & sotalol: prolong the duration of the cardiac action potential
165,6/1)Clonidine & trimethaphan; prejunctional site(2recepotr)에 작용하는 symphathoplegics activity 를 감소시킴.
Trimethaphan- ganglionic blocking drug, hypertensive crisis & 수술시 controlled hypotension 에 사용.
Phentolamine- nonselective -blocker, arteriolar level 에 작용.
Propranolol- nonselective blocker, heart & kidney 에 작용.
Cardiac output, renin 분비  smooth m relaxant 나 diuretics 와 같이사용할경우 효과적.
Hypoglycemic therapy 중인 DM 환자에서 hypoglycemia 에대한 교감신경반응을 억제하므로 주의
morbidity & mortality 를 감소시키는 drug: blocker, thiazide, ACEI
ACEI- hypertension & CHF 에 사용. Coughing 야기함baclofen, cromolyn, or methylxanthine 으로 완화.
109/3) Marfan syn: AD, defect in fibrillin I the connective tissue
eunucoid proportion(ie, span greater than height), arachnodactyly, lens dislocation, dissection aortic aneurysm
dissecting aortic aneurysm- 60~65 men, retrograde arteriography(gold standard for making dx)
Syphilitic aortitis vasculitis of the vasa vasorum aortic wall 의 ischemic damage AR 초래
Granulomatous inflammation Takayasu’s arterirtisdissection
86) RF 후 Mitral stenosis- squat position 에서 심잡음을 잘 들을수있다.
ENDOCRINOLOGY
Lung 의 small cell ca. with disseminated dis. adrenal gl 를 파괴 adrenal insufficiency
; loss of cortisol, mineralocorticoid, cathecholamine hypoglycemia, hypoNa, hypotension, hyperK, metabolic acidosis.
SIADH- hypoNa, hypoK, hypoCl, low bicarbonate
Primary aldosteronism- hyperNa, hypoK, hyperCl, metabolic alkalosis
Loop diuretics or thiazides- hypoNa, hypoK, hypoCl, metabolic alkalosis, renin & aldosterone, HTN(-)
Diarrhea- nl anion gap metabolic acidosis, hypoK
107/1)Primary aldosteronism- plasma vol + peripheral vascular resistance(effect of Na) HTN
“escape mechansim”;plasma volperitubular capillaries 의 hydrostatic prloss of Nano pitting edema
hypoK m weakness, ADH 에대한 tubule 의 resistantpolyuria, nocturia
Alkalosisionized Ca 의 bindingtetany
Dx: Salt-loading response (Na에도 aldosterone 분비억제가 안됨)
Batter’s syn- defect in Cl reabsorption in the ascending tubules, renin , HTN(-)
Liddle’s syn- aldosterone 에대한 tubule 의 sensitivity 증가. nl aldosterone, renin, hypoK, metabolic alkalosis
Hyporeninemic hypoaldosteronism- juxtaglomerular apparatus 의 destruction.low aldo, low renin, hyperK, metabolic acidosis
DM, tubulointerstitial dis(type IV RTA)관련.
175-180/1) Addison’s dis: fatigue, weakness, anorexia, gastric irritability, wt loss, hyperpigmentation, hypotension, hyponatremia,
hyperkalemia, BUN, hypercalcemia, ACTH, cortisol, eosinophilia
dx: ACTH stimulation test.
Hyperthyroidism: gold standard diagnostic criteris- TSH<0.3U/ml
DI: nephrogenic type- drug(lithium carbonate or amphotericin B) or hypoK 가 원인  water deprivation test
16/2) Ca, P, PTH malabsorption of vit D
Ca,P,PTH renal failure
97/2) MEN IIa: parathyroid adenoma, pheochromocytoma, medullary carcinoma of the thyroid
autosomal dominant,
MEN IIa > IIb(medullary ca, pheochromocytoma, mucosal neuroma)
medullary carcinoma- 10%에서 familial & MEN IIa or IIb 와 연관 serum calcitonin(best screen)
pentagastrin or Ca 이용한 provocative stimulation 으로 가족중에 위험한사람 구분.
TSH, T4 는 normal
Tx: total thyroidectomy & neck dissection
127-29/2) Cushing’s syn: neutrophilic leukocystosis, lymphopenia, eosinopenia
secondary polycythemia, 17-hydroxycorticosteroid,17-ketosteroid in 24hr urine.
Gluconeogenic effect of cortisol hyperglycemia
소견
갑상선 동통, 압통
URI hx.
ESR
AutoAb
Pathology
RAIU
T3,T4
Tx
Postpartum hx
Subacute thyroiditis
+
+
현저
-/+
Granuloma
저하
증가
Aspirin,
glucocorticoid,
propranolol
Painless thyroiditis
경미
+
Lymphocyte 침윤
저하
증가
Self limited
Propranolol
Grave’s dis
+
+++
증가
증가
Antithyoid drug
Radioactive iodine
+
+
38/3) In DKA, glucosuria loss of sodium, potassium, phosphate in the urine
DKA 의 치료로 insulin 을 사용할경우 P 는 glucose 와 함께 muscle & adipose tissue 로 들어감
glucose 는 phosphorylated 되고 glycolysis 에 사용됨 phosphate 가 고갈됨.
P<1mg/dl 일 경우 muscle 에서 ATP 생성장애 muscular weakness & paralysis respi failure 초래
Pathophysiology of DKA: hyperglycemia & ketogentsis(insulin 결핍, glucagon excess)
Clinical feature: anorexia, N/V, abd pain, tachypnea, dehydration, disorientation, hyperventilation, kussmaul ’s respiration,
odor of acetone in breathing, leukocytosis (,but fever suggest presence of infection)
Lab: metabolic acidosis(increased anion gap), K, Na,hyperTG, BUN, amylase
Tx: 1) insulin tx(regular insulin)- low dose, continuous IV, (human insulin 은 anaphylactic reaction 없다)
2) precipitatin factor 제거
3) fluid replacement
4) electrolyte replacement- Potassium; 일반적으로 renal perfusion & urine output 시작되면 potassium phosphate 투여
bicarbonate, phosphate
치료효과 판정: pH, anion gap
141/3) DM; microscopic nerve damage & vascular change, psychologic factor, poor metabolic control  erectile dysfunction,
but orgasm & ejaculation 은 영향을 안받음
144/3) Acromegaly : secondary to a benign pituitary adenoma- GH, somatomedin
generalized enlargement of bone, cartilage, soft tissue, cardiomegaly
cardimyopahty with CHF
diastolic hypertension
muscle weakness
peripheral neuropathies
DM from the gluconeogenic properties of GH
Headaches Y visual field defect
Hypopituitarism
Degenerative arthiritis
Lab: hyperglycemia
Inability to suppress glucose with an oral glucose tolerance test
Paradoxical increase in GH with TRH
No stimulation of GH release with L-dopa
 serum phosphate associated with growth sputs
enlargement of sella turcica
tx: transsphenoidal surger or octreotide
154~6/3) Insulin tx.; total dose= wt.0.7unit/kg, 아침에 2/3(NPH 를 2/3, regular 를 1/3), 저녁에 1/3
eg) 체중 68kg 의 경우, Total dose= 68kg0.7unit/kg=48unit/day 아침에 32unit(2/3), 저녁에 16unit(1/3)
AM: NPH2/332=22unit; Regular=10
PM: NPH2/316=10unit; Regular=6
*7am. glucose  pm. NPH insulin
12pm. glucose  am. RI
5pm. glucose  am. NPH
10pm. glucose  pm. RI
163,4/3) Statin: HMG-CoA inhibitors  LDLreceptorLDL uptake
atorvastatin- potent TG-lowering effect 도 갖는다
gemfibrozil- activate lipoprotein lipases in vascular endothelial cells VLDL cholesterol & plasma TG
atorvastatin, gemfibrozil homozygous familial hypercholesterolemia 에 사용.
¾) Hydroxylase deficiency : cortisol  ACTH  loss of vigor & appetitie, hypoglycemia
Deficiency Aldosterone Cortisol(17OHCS) Testosterone(17KS) Clinical Mx.
17



HTN, phenotype F,
no maturation
21



Masculinization,BP
11



Masculinization, HTN
Masculinizing ovarian tumor : 17KS, normal pregnanetriol
176~80/4) Hypoalbuminemia  low total Ca without affecting free ionized Ca or PTH concentraion
Long standing, untreated celiac dis: steatorrhea, multiple fat & water soluble vit deficency
- hypovitaminosis D  hypoCa & secondary hyperparathyroidism
Renal adenoca; ectopic secretion of a PTH-like peptide  hyperCa & PTH
Addison’s dis, tetany, hypoCa, mucocutaneous candidiasis has autoimmune hypoparathyroidism
 type I polyendocrinopathy deficiency syn.과 연관
type II: adrenal insufficiency, type I DM, Hashimoto’s thyroiditis
Primary hyperPTH
- Ca  gastrin release  gastric acid  peptic ulcer
- Ca  urinary Ca  Stone
Epigastric pain with radiation into the back, (+) stool guaiac, long history of renal ston formation
 posterior penetrating duodenal ulcer with extension into the pancrease
KIDNEY
Thiazide- hypercalcemia(Ca 의 tubular reabsorption)
Carbonic anhydrase inhibitor(acetazolamide), loop diurteics- hypocalcemia
Mannitol- hypercalcemia, hypernatremia
161-4/1)Urinary cast kidney 의 pathological process 를 의미
NS- fatty cast
WBC cast- kidney 에서만 생김. acute pyelonephritis 를 의미
Waxy cast- acellular cast, cellular cast 의 progressive degeneration  marker for end-stage chronic renal dis.
RBC cast- glomerulonephritis
Renal tubular cast- acute tubular necrosis secondary to ischemic or nephrotoxic damage, oliguria 와도 관련
hyaline cast- most common overall cast, Tamm-Horsfall mucoprotein 으로 불림.
37/2) Salicylate intoxication: mixed blood gas disorder  primary metabolic acidosis & respiratory alkalosis
따라서 pH 는 normal 이됨.
110/2) Acute drug-induced interstitial nephritis: fever, sudden onset of oliguria, proteinuria, skin rash, eosinophilia, eosinophiluria
primary type IV hypersensitivity reaction
reversible cause of renal failure
methicillin(prototypical drug), ampicillin, penicillin, cephalosporin, thiazide, furosemide, NSAIDs
치료에 glucocorticoid 의 효과는 not established
Drug-induced immune complex glomerulonephritis- nephrotic syn.(membranous GN)
Acute pyelonephritis- lower UTI 에서 시작, costovertebral angle pain, WBC cast & pus in the urine, neutrophilic leukocytosis
Endotoxic shock- E.coli septicemia, acute cystitis 보다 PN 와 연관
nephrotoxic acute tubular necrosis- renal tubular cast 와 연관, rash or eosinophilia 는 없다.
133/2) adult polycystic kidney: hematuria, hypertension, AD inheritance pattern
association with cysts in liver, berry aneurysms of the circle of Willis, diverticulosis
tx: long-term hemodialysis or renal transplantation
IgA nephropathy: mc glomerulonephritis associated with hematuria
Common in young men, URI infection 후 며칠내 microscopic hematuria
전자현미경상 mesangium 에 IgA 침착
hematuria, RBC cast, proteinuria
corticosteroid 는 치료에 도움이 안됨.
Goodpasture’s syn: young men 에 common, 초기에 객혈로 나타남.
Crescentric GN & linear pattern of immunofluorescence
Plasmapheresis is useful, cyclophosphamide, 신장이식
Staghorn calculus: magnesium ammonium phosphate(struvite)에의해 만들어짐
urease-splitting organism(Proteus), alkaline pH 와 연관
Alport’s syn: genetic diseas, boy 에서 더 흔하고 심함,
nerve deafness & glomerulonephritis
139/2) Renovascular hypertension
affected kidney 의 vein 에서 renin(정상인쪽보다 1.5 배이상)
만약 양쪽에서 renin 이 증가되있으면 “normal” kidney 에서 nephrosclerosis with small vessel dis 의미.
이런경우 “norma”kidney 제거하고 involved kidney 의 renal a.를 repair.
18/3) Renal stone - renal colic abrupt onset in the flank, abdomen & groin 으로 radiation
urinary frequency, dysuria, hematuria 와 연관
- idiopathic hypercalciuria[not hyperuricemia]; mc metabolic abn
- Ca oxalate(60%): Crohn’s dis 에서
- low urine citrate level, urine volume, incomplete distal renal tubular acidosis(phosphate stone in children)에서 stone
- Ca 를 포함하는 stone 만 radiopaque, however uric acid, xanthine,ammonium nitrate 는 radiolucent
- Lab work-up:
a. urinalysis(pH check)
b. urine culture(urease splitter increase stone formation)
c. serum calcium &serum phosphate(R/O primary hyperparathyroidism
d. serum uric acid(R/O hyperuricemia)
e. electrolyte( metabolic acidosis due todistal RTA)
f. a flat plate of the abd
g. IV pyelogram
h. 24-hr urine for Ca.
i. 24-hr urine for uric acid
j. 24-hr urine for citrate
k. 24-hr urine for sodium(NaCa)
l. 24-hr urine for phosphate
-general tx:
hight fluid intake,
Ca, oxalate, Na restriction
UTI control
-hydrochlorothiazide; TOC of hypercalciuria
alkalinizing the urine pH; useful in the tx of uric acid, oxalate, cystin stone
struvite stone(staghorn calculi); antibiotics 만으로는 치료가 어렵다, 수술로 제거
152,3/3) Salicylate poisoning: increased anion gap, acidosis
GI distress, hearing loss or tinnitus, hyperventilation with possible respi alkalosis
Tx: activated charcoal orally with a cathartic, hemodialysis(salicylate level>100mg/dl 일경우만)
urine acidification 은 부적절
forced alkaline diuresis 에의해 salicylate 의 배설이 빨라짐.
HEMATOLGOY
1/1) Congenital spherocytosis; AD, RBC 막에 spectrin 결핍.  hypotonic sol.에 매우 취약;osmotic fragility test
Young pt., gallstones, anemia, splenomegaly  extravascular hemolytic anemia; spleen 의 대식세포에 의해파괴
Hemeunconjugated bil.jet-black Ca. bilirubinate stone(pigment stone)cholecystitis.
Tx.: splenectomy
154,5/1) Polycythemia: Hct>55%
Condition
RBC mass
Plasma volume
SaO2
Polycythemia rubra vera


N
Hypoxemia(COPD)

N

Ectopic EPO

N
N
Smoker’s polycythemia


Variable
Stress polycythemia
N

N
Dehydration
N

N
Chronic hypoxemia- COPD, restrictive lung dis, cyanotic CHD, high-altitude
Stress polycythemia- obese, male hypertensive 에서.
EPO




N
N
167-9/1) AIHA- Coombs’s test: gold standard, IgG,C3 를 detect.
Cold type:IgM & C3, intravascular or extravascular hemolysis,
Mycoplasma pneumoniae, IM, malignant lymphoma, CLL
Tx- alkylating agent
Warm type:IgG with or without C3, extravascular destruction of RBC
Splemomegaly WBC, platelets 파괴.
CLL, drugs, Hodgkin’s dis, viral infection, collagen vascular dis(SLE)
Tx- corticosteroid, splenectomy, immunosuppressive therapy.
2/2) von Willebrand’s dis : ristocetin cofactor assay.
56/2) Thalassemia: microcytic anemia, defect in globin chain syn.
60/2) ESR : anemia, temporal arteritis.
: polycythemia, sickle cell anemia,
169-71/2) chemotherapy of Hodgkin’s dis- adriamycin(doxorubicin), bleomycin, vinblastine, dacarbazine (ABVD)
doxorubicin- cardiotoxic, hematotoxic
dexrazoxnae: free radical scavenger anthracycline 의 cardiotoxicity 로부터 보호
Cyclophosphamide: liver enz 의 bioactivation 을 필요로함.
대사산물이 acrolein 은 hemorrhagic cystitis 를 유발 mercaptoethane sulfonate(mesna)로 보호.
Paclitaxel & vinblastine – spindle poison, hematotoxicity, paclitaxel 은 peripheral neuropathy
Vinblastine(plant alkaloid): bind to tubulin to prevent formation of the mitotic spindle(M phase specific)
Paclitaxel(synthetic taxene): M-phase specific, preventing disassembly of the spindle
Bleomycin- G2 phase 에 작용, cytotoxic via free radical formation
Methotrexate- inhibitor of dihydrofolate reductase, S-phase specific
7/3) Aseptic necrosis secondary to sickle cell dis: hip joint involve(mc)
Salmonella osteomyelitis- sickle cell dis 와 동반
acute onset of bone pain- osteomyelitis & ischemic necrosis of bone 을 d/d
Combined technetium & gallium scan- uptake in osteomyelitis,
반면 bone infarction 은 painful joint 근처에 avascularity 를 보임
pathological bone fr: defect in the bone & discontinuity in the periosteum
Legg-Calve-Perthes dis: avascular necrosis of the femoral head, 4~10 세 소아에서 호발.
insidious development of a limp, pain in the groin, ant thigh or knee.
Self-limited
58/3) MM 에서 hypercalcemia: EEG 상 short QT, personality change, confusion, depression, acute psychosis, coma
Cardiovascular - hypertension, potentiation of cardiac glycoside, shortening of the QT
GI – nausea, constipation, peptic ulcer, acute pancreatitis
Pseudogout, nephrocalcinosis, polyuria, natriuresis, problem with urine concentration
PULMONARY Medicine
17/1) Primary pul. Hypertension: middle-aged women, progressive onset of dyspnea(m/c), fatigue, chest pain, syncopal episodes
Secondary PH: emphysema, chronic hypoxemia, chronic respiratory acidosis, recurrent pul. Emboli;
Lt-sided heart disease(MS, Pul. Venous dis), lt-rt. Shunt(VSD,PDA), polycythemia rubra vera.
Accentuation of P2, RVH(lt. Parasternal heave), JVP, CO(syncopal episode, chest pain,carotid pulse)
V/P mismatch(hypoxemia)
Pickwickian syn.; obesity associated with repi. Acidosis
149/1) Restrictive & obstructive lung diseases D/D
Restrictive type- compliance, elasticity TLC
Obstrictive type- compliance, elasticityTLC,
64,5/2) acute episodes of bronchial asthma: 2selective agonist via aerosol + O2 & parenteral glucocorticoid; acute management
aerosolic form 의 glucocorticoid or a mast cell stabilizer 를 예방적으로 사용
“Quick relief” drugs: inhaled -agonist, inhalational forms of muscarinic blocking agent, oral steroid
methylxanthine 의 사용에서 tolerance 는 발생하지 않는다.
zileuton(a lipoxygenase inhibitor) & zafirlukast(a leukotriene antagonist)- bronchial hyperactivity 를 감소시킴.
149/3) Comparison Between Obstructive & Restrictive Lung disease
Parameter
Obstructive
Restrictive
TLC


RV


TV


VC


FEV1


FVC


FEV1/FVC


PaCO2

nl to 
38/4) lung abscess: due to aspiration of infected material from the oropharynx
 G-stain 상 mixture of aerobic & variable-staining anaerobic organisms; G(+) cocci, gram(+)(-) rods with tapered ends
common anaerobes; Bacteroids melaninogenicus(faint G(-) rods), anaerobic streptococci(small G(+) cocci),
Fusobacterium nucleatum(G(-) rods with tapered ends)
G(+) diplococci in sputum: S. pneumonia, community-acquired pn 에서 mc
Fat gram-negative rods with capsule: K. pneumoniae, abscess 는 lobar consolidation area 내에 위치
G(+) filamentous & branching bacteria in sputum : Actinomyces or Nocardia
Actinomyces- anaerobe, sulfur granule 내에 존재
Produce pleuropulmonary dis with sinus tracts draining pus out to the skin
Nocardia- strict aerobe, partially acid-fast
Primary pul dis with abscess: most commonly seen in immunocompromised host, 특히 심장이식 환자
INFECTION
23/1) Endotoxic shock(septic shock): G(-) septicemia(m/c E.coli)에의함. cell wall 에서 endotoxin(LPS)분비
complement pathway 활성화anaphylatoxin C3a,C5a vasodilationwarm skin, venous returen, CO
C5a 는 potent chemoattractant for neutrophil & mononuclear phagocyte
macrophage & monocyte 자극TNF,IL-1endothelial cell 손상endothelial cell 에 neutrophil adhesion,
pheripheral neutrophil count
lung 에서 내피세포손상 ARDS, DIC
neonate: GBS, E.coli,
children: H.inf., Pneumococcus, Meningococcus
adult: G(+) cocci,
IV drug user: S. aureus
Asplenic pt.: Pneumococcus, H. inf., Meningococcus
G(+) shock: secondary to fluid loss, exotoxin 에 의함. staphy. & streptococcus.
PE: fever(or hypothermia), tachycardia, tachypnea, hypotension, shock.
Warm skincool skin 으로진행, Petechiae or ecchymoses; DIC 의미.
IL-1: stimulate release of TNF-, IL-6, IL-8, PAF, PG
Stimulate T & B cell
Induces skeletal m proteolysis
Causes fever
Promotes acute-phase protein production & release
expression of adhesion molecules
endothelial procoagulant activity
IL-2: stimulates releas of TNF- & INF-r
Causes hypotension
Enhance T-cell proliferation & cytotoxic T-cell function
IL-6: stimulates acute-phase protein production and release
Promote T-& B-cell activation
Cause fever
Enhances neutrophil activation & accumulation
TNF-: stimulates release of IL-1, IL-6, PAF, PG
Promotes activation of neutrophils, eosinophils, monocytes
expression of adhesion molecules
activates complement & coagulation cascades
Increases vascular permeability
Causes hypotension
Causes fever
GCSF: stimulates growth of granulocyte
GM-CSF: stimulates growth of granulocyte, eosinophil, macrophage
IFN-r: stimulates release of TNF-,IL-1,IL-6
Promotes macrophage activation & function
67/1)AIDS- HIV1: RNA retrovirus, reverse transcriptase 포함.
reversing the CD4 helper T-cell/CD8 suppressor T-cell ratio <1/2
normal cellular immunity(type IV hypersensitivity, impaired cellular immunity)
anergy, abnormal phytohemagglutinin assay(potent T-cell mitogen)
EBV,CMV- potent polyclonal stimulators of B cell polyclonal gammopathy(hypergammaglobulinemia)
88/2) Traveler’s diarrhea: caused by bacterial enteropathogens; ETEC(50~75%)
; Enterotoxin cAMP 를 활성화 secretory diarrhea
; No mucosal damage
; 후진국여행시 24 시간내, diarrhea, low grade fever, N/V, abd cramps, urgent stool
; Doxycycline, bactrim, fluoroquinolones, bismuth subsalicylate
Toxin-induced damage of the mucosa: operative in pseudomembranous colitis, C.difficile
Invasion on the bowel: C. enteritis, low-volume type of diarrhea,
Bacterial invasion of the bowel blood,mucus, inflammatory cell 이 stool 에존재.
stool smear fo leukocyte 로 invasive 와 secretory or osmotic diarrhea 를 D/D
102/2) Toxic shock syn(TSS): staphylococci-producing toxin(epidermal exfoliative toxin)
164-6) G6PD deficiency 에서 hemolysis 유발- chloroquine, primaquine, INH, nitrofuran, sulfonamide
17/3) Coccidioides immitis: soil saprophyte, airborne fungus, endemic to dry regions of the southwest US
infection of the lungs- often asymptomatic, influenza-lke illness
tx- fluconazole, 그러나 lung lesion 있거나 disseminated dis.인경우만 치료.
erythema nodosum, painful leg nodules delayed hypersensitivity response; favorable px.
Produce cavitary lesion in the lower lobes, pleural effusion.
Serologic test are useful in screening, but skin test 는 덜 유용.
sputum culture 로 organism 을 isolate
primary pul lesion 은 자연히 소실됨
35/3) histoplasmosis: mc systemic fungal dis, but rarely found in the dry climat
association with bird and bat droppings in moist soil
erythema nodosum
serologic test & culture 로 확진
61/3) acute cystitis: suprapubic pain, dysuria, urinary frequency + urinary sediment findings of clumps of neutriphil, scattered RBC
bacteria without the presence of casts or fever
: E. coli 가 주원인  dipstick nitrite(+) / neutrophil leukocyte esterase(+)
86/3) Tx of Gonorrhea: first choice- ceftriaxone(IM) or cefixime(perorally)
Oral administration of single doses of ceficime & azithromycin
133/3) herpes simplex keratoconjunctivitis: corneal involve 는 topical corticosteroid or sys corticosteroid tx 로 촉진됨.
tx- idoxuridine, vidarabine, trifluridine
topical EM & sulfacetamide  bacterial conjunctivitis 에서 사용.
7/4) CMV pneumonitis: basophilic intranuclear inclusion.
Organ transplantation 환자(특히 BM allogragt recipients) & AIDS 에서 흔하다
Ganciclovir: 예방 및 치료
12/4) AIDS 에서의 combination tx.
Nucleoside reverse transcriptase inhibitor: lamivudine(3TC) & zidovudine(AZT)  additive action against HIV
protease inhibitor(indinavir) reverse transcriptase inhibitor 와 synergystic action
AZT 의 hepatic metabolism 을 억제하므로 AZT 용량을 줄여야함
no activity against herpes
fluconzole: esophageal candidiasis 의 DOC
very effective prophylactically in the AIDS pt against cryptococcal meningitis
43/4) RM spotted fever: tick(Dermacentor andersoni)- carrying Rickettsia rickettsii
Triad- rash, fever, history of exposure to a tick
잠복기 2~12 일
rash-손바닥, 발바닥에서 시작하여 trunk 로 spread (cf, 다른 rickettsial organism 은 centrifugal fashing)
smallvessel 의 endothelial cell 을 침범하는 vasculitis  petechial lesion 을 produce
Oklahoma & North Carolina- highest incidence of RM spotted fever
Dx- indirect immunofluorescent technique
rather than the outdated Weil-Felix reaction Proteus vulgaris OX-2, OX-19 reaction (+)
tx: Chloramphenicol(TOC)
Murine typhus: vector- flea
Disease causing agent- Rickettsia typhi
Host- mice & rat, southern California & Texas
Plague: vector- flea
Disease causing agent- Yersinia pestis
Host- rat, ground squirrel
Epidemic typhus: vector- body louse
Disease causing agent- Rickettsia prowazekii
Human to human 으로 전파됨, via the louse
Mites- rickettsial pox 를 운반, primary host 는 mouse
Causative agent: Rickettsia akari, pruritic conditions 을 초래
scrub typhus: chigger 에의해 전파,
disease causing agent- Rickettsia tsutsugamushi, Oceania & the Far East.
71/4)Pasteurella multocida: cat bite 후 24 시간이내일경우 mc.
- Amoxicillin 에 반응, 24 시간 후의 감염은 cephradine or dicloxacillin 에 반응
Bartonella henselae: cat-scratch fever 초래, granulomatous microabscesses in LN
88/4) influenza A; vaccination 후 항체생성까지는 2~4 주 소요됨. 따라서
그이전에 노출될경우는 amantadine or rimantadine 투여
119/4) PCP prophylaxis: TMP-SMX(DOC)….. sulfonamide 에 allergy 있는경우 pentamidine, dapsone.
그외 pyrimethamine-sulfadiazine, primaquine+clindamycin
Toxoplasmosis prophylaxix: pyrimethamine-sulfadiazine
Candidiasis tx: nystatin
ONCOLOGY
9/1) Lung Ca.
smoking,wt. loss, clubbing finger, hemoptysis, hilar adenopathy primary bronchogenic ca. (SCCa. or oat cell ca.)
cough(m/c sx.)>wt. loss>hemoptysis.
bronchitic component- cough, rhonchi, wheeze, dilated tubular shadows(thickened bronchial wall)
emphysematous component- AP diameter, distant heart sound, flattened diaphragm.
Evaluation; CXR, CT, Bronchoscopy with biopsy or FENA
Cytology-gold standard test.;
Papanicolaou’s stain 상 eosinophilic-staining cytoplasm, irregular, hyperchromatic nucleiSCCa.
small, lymphocyte-sized, basophilic-staining cell Small cell ca.
Paraneoplastic syn.;
Small cell- Cushing, SIADH, peripheral neuropathy, Subacute cerebellar degeneration, Myasthenia(E-L syn.)
SCCa.- Hypercalcemia, HPOA /
Large cell- gynecomastia /
Adenoca- thrombophlebitis, verrucouse endocarditis
All- Dermatomyositis, anemia, DIC, eosinophilia, thrombocytosis, Acanthosis nigricans, erythema gyratum repens
36/1) ca. of the head of the pancreas: >50,M 에서 m/c.
jaundice, wt. Loss, postprandial epigastric pain(leaning forward 로 완화), diarrhea, palpable GB(Courvoisier’s sign)
smoking, chronic pancreatitis 와 연관.
Conjugated hyperbilirubinemia(direct bil.>50%), bilirubinuria, urobilinogen(-),clay-colored stool
ALK, GGTT- markers for cholestasis
5/3) Oncologic emergency
With a hx of prostatic ca, weakness of both legs, sensory loss from T10, barely able to move his leg
 Oder emergency myelogram after bolusing with IV steroid, MRI 를 delay 하면안됨
8/3) Renal adenoca: smoking is a predisposing factor
hematuria(mc), pain, palpable mass, fever, “Cannon-ball”metastases to the lung
fever 는 infection 때문이 아니고 tumor 에서분비하는 chemical 때문
ectopically secrete- EPO, Pathhr-like peptide, renin, gonadotropin, cortisol
진단: CT 가이드하에 needle aspiration, angiogram 에서 vascular pattern
치료: radical nephrectomy
92/4) Benign intracranial hypertension (Pseudomotor cerebri)
- progressive visual loss; enlarged blind spot
- sixth nerve palsy; 일시적.
- herniation syn; rare
153/4) Adult T-cell leukemia : HTLV-1 과 연관
- epistaxis, skin rash, generalized lymphadenopathy, hepatosplenomegaly, lytic bone lesion, hypercalcemia
- Japan 에 흔함.
- Skin 에 T cell infiltration
- 대부분 진단 1 년내에 사마
154/4) 24 세, ecchymoses,lymphadenopathy, hepatosplenomegaly, hypergranular blast cell with Auer rod
 acute progranulocytic leukemia(M3)
- DIC; PT & PTT, fibrinogen, postive D-dimer test
- T(15;17) translocation
- Tx: High dose of Vit A
155/4) 65 세, arthritis, palpable purpura(a vasculitis), hepatosplenomegaly, absence of lymphadenopathy, pancytopenia
 Hairy cell leukemia
- splenomegaly; neoplastic cell 들이 spleen 에서 증식  splenectomy 필요
- malignant B cell; positive tartrate-resistant acid phosphatase(TRAP)stain
- splenectomy 후 -interferon therapy & pentaostatin(blocks adenine deaminase)필요.
- Lytic bone lesion
156/4) 45 세, hypermetabolic state(i.e. fever, wt loss, sweating, hyperuricemia, LDH), epistaxis, generalized lymphadenopathy,
massive hepatosplenomegaly  CML
- cell 의 과다증식 folate deficiency macrocytic anemia & hypersegmented neutrophil
- thrombocytosis, peripheral blood basophilia & eosinophilia
- LAP, Ph(+)
- 대부분 3 년후 blast crisis
157/4) AML(M5) : monoblast
- gum 에 침착 swollen gum,
- nonspecific esterase(+), Auer rod(-)
RHEUMATOLOGY
62/1) Ankylosing spondylitis: seronegative, HLA B27
sacroiliac areadmlsclerotic change- 1st radiographic evidence., Schober test
restrictive-type lung dis, iridocyclitis, aortitis with valve insufficiency, reactive amyloidosis
Indomethacin- DOC
110/1)RA- ulcer; rt 5th MCP joint 에 존재, lower leg 의 ulcer 는 rheumatoid vasculitis 때문 RA factor
pannus: synovial tissue 에서부터 inflammation 시작, fusion(ankylosis)
RA in neck- atlatoaxial joint 를 involve vertebral a.를 압박 vertebrobasilar insufficiency
Baker’s cyst; knee 를 involve 시 popliteal fossa 에 synovial cyst 형성.
tx.- NSAID(1st), methotrexate, gold salts, antimalarial(hydroxychloroquine), penicillamine
physical th.가 중요.
42/2) Systemic sclerosis, localized scleroderma- CREST syn 으로서 Raynaud’s phenomenon 동반.
cold temperature & stress 는 손가락의 color change 를 유도: blanchcyanoticred.
Mechanism- vasospasm & thickened digital vessel
CREST syn: calcinosis of the digit, Raynaud’s phenomenon, esophageal motility disfunction, sclerodactyly of the fingers,
telangiectasia over the digits and under the nails.
: anticentromere Ab.가 50%에서 (+)
Systemic sclerosis: degenerative & inflammatory change  collagen tissue deposition in various tissue
Esophageal motility problem dysphagia for solid & liquid
Arthritis, renal involvement(onion skinning of the vessel), pericardial effusion, pulmonar y fibrosis, restrictive lung dis,
renal crisis
anti-Scl-70 Ab(specific)
Penicillamine may improve
Raynaud’s phenomenon 의 다른원인들- buerger’s dis, cryogloulinemia, cold agglutinins with Ig M, ergotiamine poisoning.
67/2) Contact dermatitis: allergic contact dermatitis, irritant contact dermatitis, contact photodermatitis, contact urticari a
Allergic contact dermatitis- type IV hypersensitivity reaction;
Antigen phagocytized by Langerhan’s cells LN 로 transportT cell 에서 cytokine 분비
Irritant contact dermatitis- local toxic effect of the chemical on the skin
Contact photodermatitis- tx: wet compresses with Burow’s slo, steroid cream.
Contact urticaria- wheal & flare reaction, type I hypersensitivity(IgE-mediated) or nonimmunologic reaction
mast cell degranulation histamine 분비vessel permeability, swelling, inflammatory reaction
Arthus reaction: localized immune complex disease(type III); complement sys.활성화, anaphylatoxin 생성.
; farmer’s lung
Antibody-dependent cell-mediated cytotoxicity(ADCC): type II
; Warm autoimmune hemolytic anemia, with destruction of Ig G antibody-coated RBC by macrophage in the spleen
immune complex dis: type III, serum sickness
84/2) Ig A deficiency: mc immunodeficiency, IgA 분비결핍으로 mucosal problem sinopulmonary infection, allergies, diarrhea
autoimmune dis
수혈로인해 IgA 에 sensitize  IgA 에대한 Ab.형성. IgA 에 재노출시 anaphylactic reaction.
159-61/2)serum protein electrophoresis(SPE)
Sarcoidosis- noncaseating granuloma, perihilar adenopathy,
polyclonal stimulation of B cell(IgG, polyclonal peak), albumin
cf) polyclonal gammopathy: tuberculosis, autoimmune dis, cirrhosis of the liver
Alcoholic cirrhosis- _gamma bridge(IgG & IgA), hypoalbuminemia
Panacinar emphysema- 1antitrypsin 결핍(1-globulin curve 의 main globulin)
Acute inflammation- albumin 만 감소(염증반응으로 acute-phase reactant 생성이 증가하기때문)
21/3) Dermatomyositis- PM+skin rash
proximal lime 의 m weakness(symmetrical)- hip & thigh, 식도 침범, 레이노, pul abnormality
ocular m 은 침범하지 않음
Lab: muscle enz 상승(CK, aldolase, LDH, AST/ALT)
ESR, myoglobin, ANA(+), RF(+), Anti-Jo-1(mc)
EMG-low amplitude, polyphasic, abn early recruitment, insertional activity)
Muscle biopsy- perivascular inflammatory cell infiltraion
Skin rash: erythema, masculopapular eruption, eczematoid dermatitis
Eyelid, nose bridge, cheek,elbow, knee& knuckles, nailbed 주위에서 발생
tx: 고용량의 steroid., cytotoxic drug.
Polymyalgia rheumatica: proximal aching, but m enzyme 상승 & EMG 상 myopathic feature 는 없다.
Hereditary angioedema due to C1 esterase inhibitor deficiency: AD pattern
C4 & C2 의 excessive stimulation histamine & other vasodilator vessel permeability, swelling of soft tissue
Recurrent swelling of the face, upper airways, & extremities along with abd cramp from sub mucosal edema
Mc cause of death- edema of the upper airway
Best screen- C4 complement assay(감소됨, C2 도 감소, C3 는 정상)
Confirm- C1 esterase inhibitory assay
Tx- 기도유지, FFP, e-aminocaproic acid, androgen
98/3) type I allergic reaction: urticaria, anaphylaxis, angioedema
노출된지 수분내에 나타남. IgE-mediated (type II,III IgG or IgM)
cephalosporin 보다 penicillin 에서 흔함.
type IV: mediated by cell, occur 24~72 hours after exposure
59/4) insect sting: type I hypersensitivity reaction; 이전에 sensitized pt. IgE Ab 를 생산
- local wheal & flare reaction, pain, hives, flushing, wheezing, rhinitis, conjunctivitis, fever
- 심할경우 hypotension, diffuse urticaria, laryngeal edema, bronchospasm, diarrhea with abd cramping, arrhythmia
- tx: subcutaneous ad of aqueous epinephrine 1:1000, 0.1mg/kg, maximum dose 는 0.3~0.5ml (20~30 분마다 반복)
- subcutaneous 로 반응안할경우 1:10000 epi 를 IV
- nebulized 2 agonist(albuterol) or IV aminophylline; bronchospasm 에 사용
- sting site 는 knife 로 scraping
73/4) Disseminated gonococcemia: gram(-) coffee-bean-shaped diplococci N. gonorrhoeae
- Septic arthritis; knee, wrists, ankle 을 involve 또는 tenosynovitis-dermatitis syn
- Tenosynovitis 는 C5 through C8 complement 의 결핍과 연관
- Reiter’s syn ( seronegative spondyloarthropathy ) ; urethritis, conjunctivitis, HLA-27(+) arthritis.
i.
Mycoplasma, Yersinia, Salmonella, Shigella 감염과 연관
C3 결핍: 심한감염과 연관.
102/4) SLE: low C4 & normal factor B  alternative pathway 이기때문
- Musculoskeletal dis: mc sx, arthralgia & myalgia, morning stiffness
- 소수에서만 RF(+) ; 특히 ANA(-)인경우
- (+) band fluorescence test in a biopsy of grossly nl skin(50%), Discoid lupus 는 involved skin 에서만(+)
- serositis: pericarditis 가 mc; effusion 은 exudate, monocyte & lymphocyte 가 predomint
- renal involve: mc cause of death, 대부분 nephritic, “lumpy-bumpy” immunofluorescent pattern
145/4) Stress fracture of the tibia: junction of the middle & distal thirds of the tibia 가 mc site
Chronic exertional compartment syn: no localized bony tenderness
Overuse myositis: tenderness over the muscle-tendon,
Anterior tibialis tendinitis: pain over the dorsum of the feet,
tenderness, swelling over the anterior tibialis tendon
NEUROLOGY
2/1)Status Epilepticus; 30 분이상, 반복적인 발작.
원인- anticonvulsant withdrawal/noncompliance, EtOH/ sedative withdrawal or drug intoxication, metabolic
disturbance(eg,hypoNa.), trauma, infection
Evaluation- pulse oximetry, CBC, electrolytes, Ca, glu.,ABGs, LFT, BUN/Cr, ESR, toxicology screen,
환자가 안정될때까지 EEG, brain imaging 은 연기.
Tx.- ABCs, IV BZD, phenytoin, 발작이 계속될겨우 phenobarbital.
발작이 계속될경우 IV midazolam or pentobarbital 고려.
11/1)Acoustic neuroma;
tinitus, N/V, vertigo, nystagmus, 8 th-n deafness
cerebellopontine angle 에서 발생trigeminal n.를 involveface 의 sensory change
neurilemoma(schwannoma, m/c)- benign, encapsulated tumor.
Neurofibromatosis 에서 발생
Untreated mastoiditis; erodes through boneacoustic n. damage (rare)
Cerebellar tumors & vertebrobasilar a. insufficiency ataxia,
Glioblastoma multiforme; adult 에서 m/c primary malignancy of the brain, frontal bone.
18/1) acute onset of dysarthria, rt.-side Horner’s syn, rt. Ataxia, hiccoughs, sensory loss rt-face & lt-body, intact cognitionstroke
Acute onset of focal neurologic deficitsischemic or hemorrhagic stroke.
Risk factor: DM, HTN, smoking, AF, cocaine.
M/c etiology: atherosclerosis of the external vessel
PE: MCAaphasia(dominant), neglect(of contralateral limbs), hemiparesis, gaze preference, homonymous hemianopsia( 반대편)
Dressing difficulty(nondominant)
Dominent hemisphere 의 angular gyrus area 병변시 acalculia, finger agnosis, lt-rt disorientation, agraphia
ACALeg paresis(반대편), akinetic mutism, slowness, lack of spontaneity, gait apraxia, mental impairment
PCAHomonymous hemianopsia & sparing of macular vision, memory defectprosopagnosia, simultagnosia,
posterior cortical infarction in dominant hemisphere  naming colour & object 에 장애.
- midbrain syn : III nerve palsy with contralateral hemiplegia Weber’s syn
- thalmic syn : chorea or hemiballismus with hemisensory disturbance, intension tremor, spontaneous pain & dysestheias
Basilar arteryComa, cranial nerve palsies, apnea, cerebellar sign
- Sup.cerebellar artery syn : disturbed gait, limb ataxia, ipsilateral Horner’s syn, contralateral sensory loss-pain/temperature
- AICA syn : ipsilateral limb ataxia, Horner’s syn, sensory loss(pain/T of face), facial weakness, paralysis of lateral gaze,
contralateral sensory loss(pain/T of limbs of trunk)
- PICA syn : lateral medullary syn
i.
Cerebellum- dysarthria, ipislateral ataxia, vertigo & nystagmus
ii.
Brain stem- Horner’s syn, sensory loss(pain/T of face), pharyngeal & laryngeal paralysis, contralateral sensory
loss(pain/T of limbs & trunk)
Lateral medullary syn(Wallenberg’s syn)
- contralateral: impiared pain sensation over half the body
- ipislateral: Horner’s syn, impaired sensation over half the face, ataxia of limbs, falling to side of lesion, dysphagia,
hoarseness, paralysis of vocal cord, diminished gag reflex, loss of taste (8,9,10 번 뇌신경장애)
- other: nystagmus, hiccup
Lacunar strokePure motor or sensory stroke, dysarthria-clumsy hand syn., ataxic hemiparesis.
Initial lacunar infarction 후 HTN 조절이 중요.
Aspirin 은 recurrence 에대한 protective 효과없다.
TIA: Transient neurologic deficit that lasts<24hours
Tx.: Heparin & aspirin for embolic strokes/ brain swelling, IICP, herniation 을 경계
Thrombolysis, neuroprotective agents
Prevention: aspirin, carotid endarterctomy, anticoagulation. HTN 조절.
30/1)Adrenoleukodystorphy:
X-linked dis. Young male(7-8 세), CNS 의 demyelination(hemisphere 의 post. Area)
very-long-chain fatty acid 가 축적됨. 뇌의 백질변성.
adrenal insufficiency, mental deterioration, aphasia, apraxia, dysarthria. 1/3 에서 visual loss
MRI 검사, 혈장의 hexacosanoic acid 상승
MS: CNS-demyelinating dis., ventricle 주위.
편측근력약화, 운동실조, 두통, 시각장애, 감각장애, 배뇨장애,
호전, 재발을 반복
진단- 뇌간,척수,뇌실주위 등에 다발성의 plaque 가 보임.
치료-보존요법, 급성기 부신피질제제.
Metachromatic leukodystrophy: weakness& reflexes.
- 백질대사의 장애, arylsulfatase A 의 감소 cerebroside sulfate 가 CNS 와 PNS 의 백질과 수초에 침착
- toluidine blue 염색상 적갈색으로 염색됨
- 처음에는 보행장애로 시작, 사지의 경직성 마비, ankle jert 감소,지능장애, 말도못함.
- 요의침전물에서 toluidine blue 로 metachromatic material 을 증명, 말초신경의 전달 속도가 저하, 척추액의
단백이 증가, 말초신경생검
- tx: 골수이식.
Creutzfeldt-Jakob dis.: spongiform encephalopathy, prion. Adult 에서 dementia.
- slowness in thinking, difficulty concentrating, impaired judgment, memory loss, mood changes, emotional lability
Subacute sclerosing panencephalitis: visual dis, measles virus.
45/1)CT- immediately shows any blood present; anticoagulated & new neurologic deficit.인경우 pressing concern
MRI- acute bleed 에 덜 민감, 응급상황에서는 별로 유용하지 않다.
57/)Wilson’s dis.- AR, lenticular nuclei(globus pallidus and putamen) & liver 의 disorder.
Positive, spotty family hx, MRI 상 hypodense basal ganglia bilaterally.
Acute mental status changes, abd. Pain, ascending paralysis
59/1) lesion of inf. Chiasm bitemporal quadrantanopia (eg, pituitary tumor)
ant. chiasm blindness in the lt. eye
parietal inf. Quadrantanopia
behind th chiasm contralateral deficits
Rt. occipital lt. Homonymous hemianopia
IICP enlarged blind spot
68/1) Bell’s palsy- acute, PNS 에 안면신경마비 loss of taste(chorda tympani br.), hyperacusis(stapedius m.의 br)
전신적 virus 감염(EBV)후 2 주이내 나타남.
증상- 동측이통(전구증상), 마비된 측의 구각이처지고, 눈물이 감소되고 눈을 감을수 없음.
자연치유됨
D/D- 중심성 안면신경마비 이마 밑부위만 마비가옴
Brain-stem glioma & parotid tumor- facial n. weakness, but not acute
122-4/1) Temporal arteritis-temporal a 부위에 headache, fever, malaise, jaw claudication, leukocytosis, ESR, blindness or diplopia
palpation 시 thickened, tender, nonpulsatile artery.
major Cx: central retinal a thrombosis
tx: IV stroid
15/2) Myasthenia gravis.
Crisis: Cholinergic crisis- overdose of pyridostigmine, 부교감신경자극증상, 호흡근마비, miosis인공호흡, atropin 투여
Myasthenic crisis- not taking an adequate dose,약제의 급격한중지, 월경, 임신
호흡장애, meiosis  혈장교환 or neostigmine 투여
감별- small dose of edrophonium 투여후 증상개선 inadequate dose of pyridostigmine
증상악화excessive dose
21/2) Subgaleal hematoma: blood collecting subadjacent to the galea, after minor injury, can be very alarming
not associated with loss of consciousness
ts: leave it alone, (aspiration 은 감염일으킬수도…)
Epidural hematoma: blood collecting within the cranial cavity, middle meningeal a 의 tear 후, temporal bone 의 fracture line 보임.
Lucid interval, IICP sign(headache, vomiting, loss of consciousness, 동측의 pupil size, 반대측의 hemiplegia)
subdural hematoma: intracranial hemorrhage, fracture 는 없을수 있다.
comatose from the time of injury, evidence of cerebral injury, px 는 poor
lipoma: benign soft tissue tumor, 갑자기 발생하지는 않는다.
59/2) Vasculopathic third nerve palsy: rotation outward form medial rectus we akness & ptosis from levator palpebrae weakness
normal pupilary size(nonemergent 의미)
intranuclear ophthalmoplegia: interruption of the medial longitudinal fasciculus 6th nerve palsies & spared medial rectus fx.
146/2) Leopard syn: AD.
lentigines, ECG abn, ocular hypertelorism, pul stenosis, abn genitalia, growth retardation, sensorineural deafness
Pendred’s syn: AR , deafness, goiter
Usher’s syn: deafness, MR, seizures, retinitis pigmentosa, cataracts
Waardenburg’s syn: AD, white forelock, patches of hyperpigmentation, defective hearing, lateral displacement of the inner canthi.
52/3) Syringomyelia: dissociated sensory loss- preserved posterior column, absent spinothalamic tract
Horner’s syn- suggest intrinsic disease of upper thoracic spine
Cf) spinal stenosis or herniated cervical disc 에서도 weakness & sensory loss 가 가능하지만,
extrinsic process 이므로 dissociated loss or Horner’s syn 과는 관련없다.
67/3) Cluster headache: striking young men in the nocturnal hours
nasal congestion on rt. & rt conjunctival injection 과 연관
tx: nasal oxygen, intranasal lidocaine
예방: PDS, lithium, ergotamine
83/3) Sterile subdural effusion- common in H. influenzae meningitis, CT 로 진단
H.influenzae 에의한 뇌막염(48%)- sinusitis, epiglottitis, pneumonia, otitis media, head trauma with cerebral fluid leak, DM,
alcoholism asplenic state, immne deficiency 에서 증가
N.meningitidis- children & young adult, epidemics 에서 흔히 발생
S.pneumoniae- 30 세이상에서 mc, mortality
S.aureus- mortality
105/3) Dx of neurophaty: nerve conduction velocity & EMG
54/4) Neurofibromatosis: multiple café-au-lait macule + family history
- AD, variable penetrance
- >5 café-au-lait macules or 5cm 이상, 겨드랑이와 서혜부의 주근깨
- multiple neurofibromas dispersed on or in the body
- pigmented iris hamartoma ; Lisch nodules
- meningioma, optic nerve glioma, acoustic neuromas of the 8 th nerve, pheochromocytomas, sarcomatous degeneration of
neurofibromas involving large nerve trunk
- massive distortion of the skin & soft tissue (“elephant man”)
Dysplastic nevus syn: malignant melanoma, irregular border, various shades of black, tan, red.
- 100 nevi scattered over thir body
Sturge-Weber syn: port wine colored hamangioma, 한쪽안면의 삼차신경분포지에 생김
경련, 반신마비, 뇌석회 침착과 지능장애; 경련은 혈관종있는 안면 반대쪽에서 나타남
우안, 녹내장이 관찰될수있다
ipsilateral AV malformation in the leptomeninges, MR
두개골 X 사진상 double contour or rail-road track 모양의 석회화.
예후는 뇌 및 눈의 침범정도와범위에따라 결정됨.
Tuberous sclerosis: 경련, 지능장애, 피지선종(adenoma sebaceus), AR 유전
rhabdomyomas of the heart, angiomyolipoma of the kidney, periungual fibromas, intracranial calcification, skin nodule
depigmented nevi, shagreen patch
어린영아에서 infantile spasm, 안저의 harmatoma
부모에게 뇌 CT, MRI, 복부 초음파, 피부 및 안저검사해야함.
Tinea versicolor: dermatophytosis, many macular patchs( 모양, 크기가 다양)
기타
31/4)Torn meniscus  pain on ratary or flexion motion, swelling, locking, giving way
joint-line tenderness, effusion, positive McMurray’s test
Discoid meniscus; 보통 lateral side, plain X-ray 상 widening of the lateral or medial joint space
Patellofemoral pain syn: ant knee pain
Osgood-Schlatter dis: apophysitis due to mechanical stress & excessive tension at the patellar tendon insertion
Ant. & Post. Cruciate ligament tear
144/4) Epidermolysis bullosa: skin break down & form blister, usually after minor trauma
stretching the skin 으로도 유발  확진
Osteogenesis imperfecta: osteopenia
Type I: blue sclera, brittle bone, deafness
- 사춘기 이전에 multiple fracture, premature postmenopausal osteoporosis
- deafness; conduction type
- blue sclera; 98%
Type II: 자궁내에서 죽음
Type III: not have blue sclera, X-ray 상 bone density, photon or x0ray absorptiomentr 로 확진
164~7/4) Rt-Lt disorientation  damage to the dominant parietal lobe
Broca’s aphasia  damage to the dominant frontal lobe
Transcortical aphasia: can repeat phrase, but speech & comprehension are impaired
 damage to the temporal-occipital-parietal junction
Dyscalculia  damage to dominant parietal lobe
OBGY
3/1) Nagele’s rule: months-3 & days+7(28 일 주기)
12/1) transverse-appearing external osmultiparous
absence of scarringnulliparous
retrated s-c junctionpostmenopausal women
28/1) 1st stage of labor- latent: cervical effacement & early dilation.
Active : cervical dilation>4cm.
 acceleration phase
 maximum slope
 deceleration phase
2nd stage: sign- bearing down sensation,
bloody show 의 sudden increase,
defecation sense,
buldging of perineum, dilation of anal orifice
34/1)Vasa previa- fetal originfetus 의 exsanguination 초래
<Abn of Cord insertion>
1. Velamentous insertion: umbilical cord 가 placenta 의 margin 에서 떨어져 cord vessel 이 membrane 에 붙어있는 것
A. 합병증- 태아기형, vasa previa 를 유발
2. Vasa previa
A. velamentous insertion 의 scar
B. membrane 에 붙어있는 fetal vessel 이 insernal os 부위를 지나거나 태아 선진부 앞에 놓인 상태
C. membrane ruptur 시 혈관이 rupture 되어 infant 의 blood loss 초래APT test 로진단.
44/1)PIH 에서 seizure 예방; magnesium sulfate cf. Mg gluconate 는
<PIH 의 pathophysiology>
1. vasospasm of arterioles
2. hypersensitivity to AT II
3. organ perfusion(kidney, liver, uterus, not brain) urine vol
4. Na retention
5. blood vol
6. irritability, reflex, clonus
7. catabolic state(negative nitrogen balance)
predisposing factor- Nulliparity, family hx, Multiple fetus, DM, chr vascular dis, renal dis, H mole, teenage, 35 세 이상.
46/1)HBV: main route of neonatal inf.- vaginal delivery
Can be transmitted through breast milk, fulminant & lethal
52/1)Recurrent genital herpes- congenital malformation 위험을 높이지는 않는다. Labor 시작후 분만 route 를 결정.
protective Ab.를 갖고있기 때문에 viremia 는 없다. no risk of transplacental viral passage
breast lesion 이 없다면 안전하게 breast-feed 가능.
56/1) GBS- female genital tr.의 normal flora., not normally a pathogen. / labor 시 potential significant adverse impact.
(+) culture 여성에서 uninfected infant 가능.
(-) culture 라고해서 delivery 시 R/O 할수없다.
carier treatment 는 ineffective.
preterm, PPROM, prolonged rupture of membrane, intrapartum fever and a previous neonate with GBS infe ction 에서
presumtively treat
61/1)Alcohol 만 임신에대한 영향이 밝혀짐IUGR, CNS effect, facial anomalies; short palpebral fissure, epicanthal folds,
flat midface, hypoplastic philtrum, thin vermillion border.
*Smoking  spontaneous abortion, 저체중아(mc), 주산기 사망증가, placental abruption, confined placental mosaicism.
66/1)HIV in preg.: mode of delivery not affect maternal-neonatal transmission. Preg.not accelerate HIV.
Perinatal transmission 의 비율- 30%
passive maternal Ab 가 18 개월까지 존재하기 때문에 검사에 지장
effective immunization for neonates- nothing, contaminated fluid 에 노출된경우(eg 주사바늘) Zidovudine
progression in neonate & infant > in adult
69/1)Gestational DM- macrosomia, traumatic delivery, delayed fetal lung maturity, respiratory distress syn of the neonate,
congenital anomalies, intrauterine fetal death 와 관련.
Diabetogenic state 관여인자: HPL, steroid H(estrogen, progestrone), cortisol, insulinase
*fasting>105, PP1>190, PP2>165, PP3>145 2 개이상 비정상시 GDM.
신생아에대한 영향: preterm delivery, birth injury, RDS, hypoglycemia, hypoCa, predisposition to DM
모체에대한 영향: Preeclampsia, infection, macrosomia, c-sec, hydramnios
Class A1: nl fasting & abnl postprandial diet alone tx.
Class A2 이상은 insulin tx., oral hypoglycemic agents 는 금기.
Pregnant DM Cx.- preeclampsia, polyhydramnios, hypoglycemia, ketoacidosis, diabetic coma,
typical end-organ involvement of diabetes
79/1) Presentation
81/1) Terbutaline: 2-agonist, relaxes the smooth m. , glycogenolysis glucose,
tocolysis Ix- multiple gestation, placenta previa
severe preeclampsia- tocolysis is inappropriate
88/1)Folic acid deficiency- Maternal megaloblastic anemia & fetal congenital mal.(neural tube defect, anencephaly)
placental abruption, PIH, Abortion.
anticonvulsant tx(phenytoin)의 rare complication.
99/1) Evaluating gestational age(2 nd trimester)- HC, BPD, AC, FL
102/1) Puerperal sepsis- 원인: PROM(mc), manual placental removal, retained productis of conception, cesarean delivery
121/1) IUGR: symmetric- 태아기형, 선천감염, 산모의 영양장애, 흡연
Trisomy 18, rubella inf, renal agenesis, toxoplasmosis
asymmetric- 태반기능부전;chronic hypertension, 진행된 DM, renal dis, cardiopul dis,
진단- fundal height, 내분비검사(E3,HPL), US(most diagnostic)
142/1)Apgar score: 5 parameter-skin color, heart rate, respiration,grimace, muscle tone.
4/2) septic pelvic thrombophlebitis  tx : IV heparin
17/2) Cystic teratoma- Calcification
24/2) Ovarian cancer- 부인과 악성종양의 25%, key feature 는 ascites.
- 위험인자: 미혼, parity, 초경이 빠르거나 폐경이 늦은경우, Talc, Asbestos,
- familial & genetic factor
i.
Hereditary breast/ovarian familial cancer syn(BRCA1 gene)
ii.
Hereditary nonpolyposis colon ca syn(Peutz-Jeghers 증후군)
iii.
Lynch II syn
- 종류
i.
serous tumor> mucinous> endometroid> clear cell
ii.
serous cystadenoma: epithelial ovarian tumor 중 mc
iii.
serous cystadenocarcinoma: ovarian cancer 중 mc
- 증상 : 대부분 증상없이 진행, palpable mass, heavness, pain, fullness, ascite, hypercalcemia
- tumor markcer: CA125, CA19-9, OCAA, NB/70K, AFP, hCG
악성종양 large(>6cm), multilocular, thick septa, mixed echogenicity, solid area, ascites(++), low blood flow pattern, 저항
36/2) 임신시 lab.변화- cholesterol, renal plasma flow, BUN, plasma vol, Hb, ALP
- Fat metabolism:  total lipid, cholesterol, phospholipid, neutral fat, lipoprotein, FFP
- Ablumin, A/G ratio
- GFR(early), RPF, serum creatinine 과 BUN 감소, 임신시 glycosuria 는 정상
- TBG, T3 & T4, T3RU
63/2) Septic pelvic thrombophlebitisprolonged PROM & emergency cesarean delivery: puerperal sepsis 의 유발인자
iv heparin 에 반응
68/2) Puerperal fever, unresponsive to appropriate antibiotic therapy pelvic abscess 를 먼저 R/O
91/2) Endocrinology functionong ovarian tumor:
Granulosa-theca cell tumor; feminizing sign & symp.
- 5th &6th decade(폐경후 여성)
- pelvicor abd pain, palpable mass, Abn uterine bleeding
- 현미경상 coffee-fean shape, Call0Exner bodies
- tx: unilateral oophorectomy
Sertoli-Leydig cell tumor; virilizig sign & symp.
- stage of defeminization: amenorrhea, atrophy of the breast, loss of the subcutaneous fatty deposits
- stage of masculinization: hypertrophy of the clitoris, hirsutism, deepening of the voice, “Adam’s apple”발달
- testosterone, urinary 17KS
106/2) Pregnant woman infected by parvovirus- asymptomatic or nonspecific symptom
그러나 fetus 에게 transplacental passage of the virus stillbirth & nonimmune hydrops fetalis(<5%)
infection 는 2nd trimester 에 most sensitive
parvovirus 는 teratogen 이 아니며, typical syndrome 과 관련이 없다.
chorioretinitis & microcephaly  congenital toxoplasmosis
111/2) diameters of the pelvic plane- post sagittal diameter<10cm, 가장 적다.
123/2) Tx of deep venous thrombosis in preg.- Heparin(not cross the placenta, TOC )
Coumarin- small molecule 로 fetus 에 teratogenic syn.일으킴
aspirin, dipyridamole, streptokinase 는 임신시 사용안함.
141/2) Hyperemesis gravidarum: weight loss & ketonemia, hypokalemia, hemoconcentration
hypochloremic alkalosis
144/2) twin gestation; perinatal mortality , morbidity 가 높은 이유? Preterm labor
155/2) MSAFP: - trisomy 21(Down) , trisomy 18/ -신경관 결손
- 검사시기 : 16~18 주
- : Neural-tube defect, pilonidal cyst, intestinal obstruction, liver necrosis, cystic hygroma, teratoma, abd wall defect,
renal anomalies, osteogenesis imperfecta, congenital skin defect, cloacal exstrophy, low birthwight
i.
증가되면 반드시 재검  US  aminocentesis 비정상시 high resolution US, acetylcholinesterase
ii.
unexplained MSAFP : 태아사망, 주산기사망, 태반조기박리
- : trisomy 21(Down), gestational trophoblastic dis, fetal death
i.
낮게측정되면 재태연령측정위해 US 시행 재태연령일치하면 양수천자로 핵형분석
양수천자: 16~18 주에 시행- 세포유전학적검사, 효소, DNA 분석, surfactant, AFP, acetylcholinesterase, bilirubin
융모막 융모검사: 9~11 주.
20/3) leiomyoma
- submucosal myomata; Sx & Cx 이 가장 많다
i.
Abn bleeding, ulceration, bleeding
ii.
Sarcomatous change, infection, suppuration, necrosis, radian resistant
- intramural(interstitial) type: mc
- subserous(subperitoneal) type
- 임신중 자궁근종의 Red degeneration
i.
abd. Pain & tenderness, 미열, moderate leukocytosis
ii.
tx- 진통제 투여하며 관찰
- 내과적 치료: GnRH agonist, progesterone 제제
- 외과적 치료: 근종절제술
32/3) Genital condylomata acuminata- caused by HPV(6,11)
oral contraceptive 는 external lesion 을 증가시킴
tx: podophyllin 국소도포(임산부,유아에선 금기), cryotherapy, interferone
53/3) Complete mole: vaginal passage of grape-like vesicles hydropic avascular villi
- 질출혈, 거대자궁, preeclampsia, hyperemesis gravidarum, hyperthyroidism, trophoblastic embolism, theca luteal cyst
- 대부분 46,XX– both X chromosomes parternally
- no fetal RBC
Incomplete mole: triploid karyotypes. 69XXX, 69XXY, 69XYY…
- partial, fetal RBC(+), abn fetus
- no trophoblastic proliferation
high risk metastatic group: hCG>40000, 4 개월이상의 기간,
liver or brain metastasis, previous chemotherapy 실패, full-term delivery 후
임신성 융모 상피암: develop after full term delivery, abortion, or hydatidiform mole / 융모는 없다
104/3) Osteoporosis risk: fair-skinned, slender, white women with a positive family hx, Cigarette, alcohol, nulliparity
: low in animal protein, high body mass index, multiparity, exercise
tx: 골흡수억제제: Ca+vit.D, estrogen, calcitonin, bisphosphonate
골형성촉진제: NaF, low dose PTH, anabolic steroid(androgen)
thiazide
108/3) Postmenopausal women: FSH(),LH(), GnRH(), Estrogen(, 대부분 E1), sex hormone binding globulin()
혈중 E2 는 대부분 ADD 에서 전환된 E1 에서 유래된 것
E1,2 농도는 나이와 관계없이 체중과 깊은 관련.
Testosterone- 폐경후 난소에서 주로 생산됨.
132/3) perimenopause:  LH & FSH
142/3) HRT contraIx: chronic hepatitis (estrogen 은 간에서 대사되고 배출되므로.)
임신, abd uterine bleeding, active thrombophlebitis, GB dis, liver dis
168~174/3) Cancer of Fallopian tube,or oviduct,: malignancies, no official FIGO staging criteria
Cervical ca: only clinically staged (모든 부인과적 종양은 surgical staging)
- 방사선 검사: IVP, 바륨관장, 흉부 X 선검사, 골격 X 선검사.
- 조직검사: 자궁경부생검, 원추형생검, 자궁경 내막 소파술, 질확대경, 자궁경, 방광경, 직장경
175~180) CA 125 – serous, mucinous, endometrioid adenoca.
Gonadal-stromal tumor : Sertoli-Leydig cell tumor, lipid cell tumor, gynandroblastoma produce testosterone
Dysgerminomas: LDH 와 관련된 유일한 gonadal-stromal tumor
Common ovarian neoplasm(청소년, 임신동안); 월경이상없음 9hormonally intat)
Most radiosensitive
Localized dis unilateral SO, TAH+BSO
전이, 재발 RTx
Endodermal sinus tumor produce AFP, unilateral,평균 19 세; 반드시 chemotx + 일측난소절제술.
가장흔한 증상은 abd. Pain.
schiller Duval body;신장 사구체와 유사
Embryonal ca: AFP(+), hCG(+), CEA(+), precoccious puberty
Nongestational chorioca. -HCG 생산
Granulosa cell tumor & thecoma  produce estrogen
Brenner tumor: 측정할 수 있는 tumor marker 가 없다.
2/4) Polycystic ovary syn: tonically elevated LH absence of nl menstrual hormone fluctuation
BMI
hirsutism(not virilization), ovary 에서 andorgen production
amenorrhea, infetility, DUB, 하복부 동통
불임증치료: clomiphene citrate, bromocriptine, cortisone acetate, wedge resection
14/4) Genuine urinary stress incontinence: loss of the urethral/vesicle angle, 복압증가시 요의 유출
No change occurs in voiding flow rate, residual urine, bladder compliance
kegel exercise, -adrenergic drug, estrogen, 전기자극.
Urge incontinence: 갑자기 압박감과 통증 때문에 배설, 신경서
- 방광내압 과 요방광 잔류량 증가
- 치료: anticholinergic drug
Dyssynergic bladder: 긴장이나 배뇨의사없이, 어느정도 이상 방광내 소변이 충만되면 스스로 배뇨됨
- 원인: 정서적 결여
17/4) Endometriosis: dysmenorrhea, dyspareunia, dyschezia, infertility
surgery- only definitive tx.
Early reproductive year 에 발생
mc site: ovary, 그다음 cul-de-sac, uterosacral lig…
endometriod ca 와 관련이 없고, malignant transformation 은 드물다
24/4) Endometrioid tumor: psammoma bodies, high malignant potential
32/4) Primary amenorrhea: breast 발달 & palpable uterus 의 유무로 4 group 으로 나눔
nl breast develop & without a uterus testicular feminization syn or congenital uterine absence
- testicular feminization syn: congenital lack of androgen receptors, nl male level of testosterone
- nl female hormonal status congenital uterine absence 와 관련, low level of testosterone
FSH primary amenorrhea with absent breast but uterus present 의 원인 감별에 도움이됨
FSH; absence of functional follicles
FSH; hypothalamic-pituitary problem
LH fluctuate 하므로 도움이 안됨
Amenorrhea D/D:
① Prolactin 측정 상승시 TSH 측정
② Progesterone challenge test
③ Estrogen-progesterone challenge test
④ FSH/LH 측정 상승시 원발성난소부전 염색체 검사, 저하 or 정상시 CT scan of sella turcica,GnRH 검사
40/4) DM 환자에서 Candida vaginitis: pruritic, whitish, cheesy vaginal discharge
dx: KOH prep, Sabouraud’s 배지에 배양, Whiff test(-)
tx: topical Azole 약제- clotrimazole
55/4) lichen sclerosis: atrophic skin description- stenotic vaginal introitus, thin, wrinkled, parchment-like
TOC- testerone cream
Fluorinated corticosteroid- indicated for hyperplastic dystrophies of the vulva.
<외음부의 백색병변>
 absence of pigmentation – leukoderma, vitiligo
 Hyperkeratosis
 Dystrophies(Leukoplakia)
 Lichen sclerosus atrophicus
 Hyperplasia; tx- corticosteroid
 Mixed dystrophy; tx- corticosteroid + testosterone
 CIS
 Invasive cancer
64/4)Primary dysmenorrhea: nl pelvic exam finding, excessive PG-induced myometrial contraction
- progesterone withdrawal bleeding 있을때 PG-induced spiral arteriolar spasm excessive myometrial contraction
- tx: 증상치료, 배란억제(estrogen, oral pill(, aspirin, indomethacin, tocolytics(alcohol, terbutaline, nifedifine)
104/4) cervical ca: 유일하게 surgical staging 안함.
- laparoscopy, exploratory laparotomy, lymphangiogram, lymphadenectomy 는 staging 에 도움안됨.
118/4) Disseminated gonococcemia: joint effusion, fever, skin rash in a sexually active young woman
Secondary syphilis: middle stage of a STD – fever, maculopapular rash, but not joint effusion
Lymphogranuloma venereum: STD, painless genital ulcer, fever, inguinal adenopathy,
but not joint effusion or extremity rash
Reiter’s syn: triad- arthritis, nongonococcal urethritis, conjunctivitis
Fever, joint sx, but not a rash
Hepatitis B: sexually transmitted DNA virus, can cause fever & abd pain & joint pain, but no extremity rash
(168~75/4) Hydatid cyst of Morgagni : paraovarian cyst
- thin-walled, pedunculated, benign cyst attached to the tubal fimbria
- paramesonephric origin
- small( 10cm 까지 커질수있다), very mobile
Theca-lutein cyst: excessively high HCG 에대한 normal ovary 의 반응
- bilateral, fluid-filled, growing to massive size
- HCG 의 원인을 제거하면 사라짐
Corpus luteum cyst of preg: placenta 가 progesterone 생산의 기능을 대신하면 사라짐, unilateral
29 세, LMP 9weeks, 9~10cm soft midline pelvic mass, morning nausea  normal preg
Precocious puberty with the unilateral pelvic mass  hormonally functional ovarian tumor producing estrogen; granulosa cell tumor
Postmenopausal woman, virilization, unilateral pelvic mass hormonally functional ovarian tumor producing androgen
; Sertoli-Leydig cell tumor
SURGERY
4/1) trauma 없는 골절 pathologic fr. ; m/c 는 metastatic bone dz. & primary dz. of bone
primary tumor site- breast>lung(small C.Ca)>thyroid(follicular ca.)
primary hematologic mal. of bone- MM; osteoclast activation factor 분비 pathologic fr.
13/1)Boerhaave’s syn.: full thickness rupture of the distal thoracic esophagus or stomach
vomiting or retching 과 관련
20/1)Plummer’s dis.: hyperthyroidism associated with a multinodular goiter
Graves’s dis: diffuse goiter 와 연관된 hyperthyroidism
Hashimoto’s thyroiditis: hypothyroidism, diffusely enlarged gl.
26/1)Hirschsprung’s dis.(CMC): Down syn. & Chagas’s dis(Trypanosoma cruzi)와 연관
m/c cause of death- necrotizing enterocolitis
fecal soiling, bleeding, excessive mucus 와는 관련 없다.
33/1)Gynecomastia; normal in the neonate, pubertal boy, elderly  hyperestrinism
adolescent- bilateral, 2~3cm, 1 년내에 subside. > 5cm or 16 세이상 지속시 subcutaneous mastectomy
adult- adrenal or testicular tumor(HCG), Klinefelter’s syn.에서 hyperplastic Leydig’s cell, liver cirrhosis 에서
estrogen 대사 , androgen activity(cimetidine, spironolactone), marijuana, digitalis)hyperestrinism;
senescent gynecomastia- 생검필요없다.자연치유됨,
한쪽만 invalve, 압통,
50 세이상에서,
원반모양의 mass, areolar 밑에 대칭적으로 분포
38/1)asymptomatic woman, no hx of bone pain, hypercalcemia 1’ hyperparathyroidism(m/c-benign adenoma in inf. Parathyroid )
: hyperCa, hypoP., hypoMg, parathormone, renal stone(m/c), osteititis fibrosa cystica, bone pain, constipation, polyuria..
: hyperchloremic metabolic acidosis
hyperCa. in hospitalized pt. cancer(m/c- breast ca.); PTHr-like peptide 분비 activate osteoclast., parathr.은 감소.
Thiazide: Ca. renal absorption & osteoclastic activity
41/1)modified radical mastectomy(Patery technique)=radical(Halsted) – pectoralis major m.
49/1)Acute arterial occlusion- popliteal a.가 most susceptible ; pain, absence of the pulse, parestheias, paralysis, pallor
Herniated disc- whole leg 을 involve , deep tendon reflex , various motor & sensory sign
Superficial thrombophlebitis- pain, tenderness
Deep venous insufficiency- superficial varicose vein, stasis dermatitis.
Hypovolemic shock- generalized pallor & cold, clammy skin
54/1) breast skin edema with dimpling- “peau d’orange”; infiltrating ductal ca.에의한 subcutaneous lymphatics 의 obstruction.
 almost pathognomonic of cancerous involvement of the breast.
Breast ca.의 m/c Sx.- hard painless mass, upper outer quadrant 에 위치. but, inflammatory ca.는 painful.
Invasive ductal tumor( 90%, 10%는 breast lobules 에서 arising.)
- lymphatic spread,
- multiple satellite mass, calcification(hard), central necrosis,
- Ca cell 이 주위 stroma 에 퍼져있다.
Lobular Ca
- Calcification(), distant meta 가 쉽다, bilateral involve
- Poor px
- Mammo 상 detect 어렵다크기가 작고, 석회화없고, 커지기전에 전이되므로.
Bloody nipple discharge- 40 세 이하에서는 intraductal papilloma, 50 세이상에서 malignancy.
그외, dimpling of the skin on movement of the arm
vascular engorgement overlying the breast
diffuse “inflammation”of the breast(inflammatory ca.)
nipple erosions(Paget’s dis.)
>50, mass with axillary node enlargement
Risk factor: Genetic- family hx in a 1stdegree relative, personal hx of breast or ovarian cancer
Hormonal- Nulliparity, 1stPreg.>35 세,early menarch, late menopause, older age
Dietary-High fat intake
Morphologic- Fibrocystic change with cellular atypia.
Prognosis; better- older, estrogen receptor(+)  favoral type: mucinous ca, medullary ca, adenoid cystic ca, secretory ca.
Poor- axillary lymph node involve  unfavorable type: inflammatory ca.
50 세이후 annual mammography 필요.
Paget’s dis.- intraductal ca., main excretory duct 를 involve.
Crusting erosion of the nipple.
진단당시 extent.가 예후와 관련.
Intraductal papilloma
- menopause women
- ductal wall 의 lesion, centrally beneath the areola
- bloody nipple discharge, fern like projection, small & palpable mass
65)Supracondylar fr of the humerus- entraps the brachial a. & median n. Volkmann’s ischemic contracture in the forearm m.
Greenstick fr- convex side 는 break, concave side 는 intact.
Pott’s fr- bimalleolar fr. foot 이 eversion & abduction.
Colles’s fr- falling on an outstretched hand radius 의 distal end(suprastyloid level), ulnar 의 styloid process 의 fr. ‘dinner fork’
Femoral neck fr- avascular necrosis, nonunion. Osteoporosis 가 m/c cause
Intertrochanteric fr- avascular necrosis 의 위험 낮다.
76/1)Finkelstein test- de Quervain’s dis: chr stenosing tenosynovitis pain in the region of the radial styloid process.
Schober test- AS
McMurry test- rotate 시켰을때, click is felt along the posteromedial margin medial meniscus tear
Click is felt along the posterolateral margin lateral meniscus tear
Ortolani- CHD
Anterior draw sign- tear in the ant. Cruciate lig.
85/1) femoral hernia- F>M, femoral a 내측, strangulation & infarction
indirect hernia- mc, small bowel extends into the scrotal sac, strangulation 은 femoral 보다 덜함. Recurrent 는 rare.
성인에서 bassini repair.
Direct inguinal H.: abd musculature 의 weakness, Hesselbach’s triangle, internal inguinal ring 의 medial 에서 촉지됨.
Strangulation 은 rare, recurrent 는 frequent
Surgical repair: post wall repair- Ferguson
Ant repair- Bassini, Halsted, Andrew, McVay, Shouldice
신경손상- iliohypogastiric n suprapubic area 의 sense
ilioinguinal n penile base 및 인접 scrotum 일부의 sense.
Genitofemoral n.
Ventral hernia: incisoinal h high recurrency, high complication
Incarceration 은 흔하나 stracgulation 은 드물다
Pantaloon hernia
Sliding h.: hernia sac 의 일부가 intraperitoneal organ 으로 이루어짐 rt.은 cecum, lt.는 sigmoid colon 이 mc
Richter’s h: hernia sac 내 intestine 의 antimesenteric wall 의 일부가 stragnulation (without int. obstruction)
Litter’s h: Meckel’s diverticulum 을 포함하는 sac.
92/1)Acute conjunctivitis-purulent eye discharge, matting of the eyelashes, mild photophobia
normal pupillary reaction to light, nl intraocular pressure.
S.aureus, S.pneumonia, H.aegypti(pink eye)
Topical polymyxin B, neomycin, bacitracin
Acute ant uveitis-uveal tr(iris,ciliary body, choroid)의 염증
Sarcoidosis, AS 가 원인
Blurred vision, no conjunctival discharge, moderate pain, severe photophobia, ciliary flush, constricted irregular pupil
Nl intraocular pressure, poor pupillary light reflex.
Topical corticosteroids
Acute glaucoma
Optic neuritis- Tb,syphilis,multiple sclerosis,glaucoma 에 2 차적으로발생.
sudden unilateral loss of vision, pain on eye movement,
optic disk swollen, flame-shaped pericapillary hemorrhage
IV & oral steroid tx.
Central retinal a occlusion- 한쪽눈에 sudden, complete, painless loss of vision. Elderly pt.
Pallor of the optic disc, edema of the retina, cherry-red fovea, bloodless a, constricted arterioles, “boxcar” in the retinal v.
Surgical decompression of the ant chamber(1 시간내)
Central retinal v occlusion- sudden, painless, unilat loss of vision.
In pt of hypercoagulable state(polycythemia rubra vera), DM, glaucoma
Swelling of optic disc, venous dilatation, tortuosity widespread retinal hemorrhage, cotton-wool exudate.
120/1) Acute glaucoma- tonometer pr. >21
defect in Schlemm’s canal
Open-angle glaucoma: sudden onset, blurry vision, pain, minimal photophobia, ciliary injection, streamy appearing cornea,
absent pupillary light reflex, pupil- mild dilated, fixed, irregular
No discharge,
Tx.; Glycerin, pilocarpine,mannitol, acetazolamide, iridectomy(peripheral or laser)
Hyphema- blood in the ant chamber, acute visual loss
Corneal erosin- blurry vision, pain, moderate photophobia, watery discharge, mild-to-moderate conjunctival injection, a hazy cornea,
a (+) fluorescein stain, nl or constricted pupil, poor-to-nl pupillary light reflex, nl intraocular pressure
Papilledema- IICP, venous stasis, prominent disc vessel, swollen disc with blurred margins, absence of the physiologic cup.
98/1) Acute surgical parotitis(sialadenitis)- elderly pt.에서 수술후 1 주일경 발생. Pooly dental hygene & have been intubated
S. aureus(m/c), surgical drainage & antibiotics 필요
acute & chronic sialadenitis- sialolithiasis(submandibular gl 로 drainage 되는 Wharton’s duct 의 calculi) 때문.
Parotid gl enlargement- Sjogren’s syn, collagen vascular dis 와 연관immunologic destruction of minor salivary gl
Mumps- viral parotitis 의 common cause
104/1)Zinc deficiency- alopecia, aculopapular rash around the mouth and eyes, tast & smell abn., wound healing 에 문제.
Essential fatty acid deficiency- eczematous rash & thrombocytopenia
Selenium deficiency- muscle pain, cardiomyopathy
Mg deficiency- resistance to activity of parathormone hypoCa & tetany, muscle weakness, irritability, delirium, convulsion
Alcoholism(mc cause)
Copper deficiency- IDA 와 연관, dissecting aortic aneurysm, kinky-hair syn.
106/1) Rupture of the spleen- 자동차사고후 lt lower ribs 에 point tenderness & hypovolemic shock
PE 상 peritoneal irritation sign, referred pain to Lt.shoulder, 자세에따른 dullness 변화,
Phrenic n. irritation 에의한 neck pain, LUQ 의 bruising, ecchymosis, Lt. Multiple rib fr.
dx: radionuclide scan, CT, peritoneal lavage, immediate surgical intervention(∵shock 의심)
125-7/1)Pulmonary embolus- pul angiography(gold standard), perfusion scan
chest Xray: 50%에서 비정상소견, Hampton’s sign(wedge shaped), Westermark’s sign(hypovascularity, atelectasis)
fluid analysis: exudate with RBCs, neutrophils, protein(>3g/dl)
dyspnea, pleuritic chest pain, hemorrhagic pl effusion, fever, sinus tachycardia, wheezing, hemoptysis, cough, P2,
136/1)inhalational anesthetic
Blood:gas partition coefficient: low- act rapidly & time to recover is short.
Minimum alveolar concentratin: 50%를 마취시키는 양, potency 와 관련.
170-4/1)Twisting injury to the lateral aspect of the ankle torn lateral ligament
5th metatarsal 의 base 부분에 avulsion fr & talus 의 fr.와 동반 가능.
unable to walk on this leg if there were ecchymosis on the dorsolateral aspect of the ankle
Tear of the Achilles tendon- pain behind the ankle, dificult walking on tiptoe, tear 된 부분에서 gap 을 촉지
plantar flexion is weak, calf m.을 압박시 no pain. X ray 는 불필요
Tear involving m fiber of the plantar flexors(eg, gastrocnemius & soleus)- pain in the calf, ecchymosis, Xray 는 불필요
Calf m 압박시 pain(+), plantar flexion is normal, 손상부위에서 gap 이 촉지 안됨, can walk on tiptoe.
Falling on both feet calcaneus 의 fr., lumbar vertebra 의 compression fr(X-ray 필요)
Compartment syn. & necrosis of the skin 일어날수있다.
March fracture- involves the shafts of the metatarsal(2 nd,3rd), pain in the foot, not become worse with walking.
Tenderness over the point of fr, fr 는 X 선상에서 안보임.
½) 수술후 overzealous fluid resuscitation vol overload ; 수술후 CHF, SIADH 의 mc caus. Tx: loop diuretic & 수분제한.
18/2) Pleomorphic adenom: mixed parotid tumor): mc salivery gl tumor, essentially benign
malignancy- sudden  in size, pain, infiltration into the facial nerve.
Adenolymphoma( Warthin’s tumor): 주로 parotid gl 에 위치, cystic,
middle-aged or elderly male
1 개이상의 tumor 가 발견됨
Mucoepidermoid ca.: mc malignant tumor of the parotid gl, 분화와 성장이 다양, swuamous component 많을수록 예후 poor.
Local invasion 은 제한됨 facial n paralysis 는 보통없다. local LN 로 전이도 드물다.
Adenoid cystic ca: mc malignant tumor of minor salivery gl, perineural tissue 로 invade
 pain, paralysis of muscle, involved skin 의 anesthesia
bone 을 invade 할수도 있다
acinic cell ca: rare malignant tumor, F>M, slow growing, tends to be soft, locally invasive, metastasis.
38/2) Wound infection: 수술후 5~10 일경 발생
 risk: located in the abdomen, 2 시간이상 지속된 수술, 수술중 contamination,
key factor 는  O2 tension in the tissue
49/2) Gallstone ileus: elderly women, chr inflamed gallbladder(adhere to the bowel)
emergency laparotomy & enterotomy, but fistula 는 자연적으로 막힘.
Cholecystectomy should be undertaken at a later date
62/2) Intraductal papilloma: bloody nipple discharge in a woman under 50 years of age, located in the lactiferous duct.
Can be multicentric or involve the contralateral breast
Segmental resection of the lactiferous duct is recommended.
Bloody nipple discharge in a woman older than 50 years of age & in a male malignancy
Subareolar abscess: S.aureus, purulent nipple discharge
Intraductal papillomatosis: ductal hyperplasia in fibrocystic change
Plasma cell mastitis: mammary duct ectasia  green brown niple discharge in a premenopausal woman just before menstruction
Galactorrhea(milky discharge): prolactinoma, primary hypothyroidism, birth control pills, chlorpromazine
Birth control pills clear, serous, milky discharges, 특히 mense 시작 직전.
85/2) AV fistula: result of a penetrating injury(mc),
congenital cause, erosion of an arterial graft or aneurysm into a subjacent vein, Paget’s dis
: Branham’s sign- mass 를 compression 시 pulse rate
: MRI, angiography.
107/2) Inflammatory ca of the breast: painful breast mass,
edema, warmth, erythema due to plugging of the dermal lymphatics by the tumor
most malignant type
metastasis occurs early, prognosis is extermely poor.
Paget’s dis of the breast : mc in elderly women, scaly, eczematous rash usually involving the nipple
Extramammary Paget’s dis- vulva 를 involve, breast variant ; underlying ca.와 연관
Cystosarcoma phyllodes: mc malignant stromal tumor of the breast, massive breast enlargement
Stroma is hypercellular, but the epithelial elements are benign
Rarely metastasize to the axillary nodes
Tx: simple mastectomy
Erysipelas: brawny cellulitis, GAS 와 연관
breast abscess: mc associated with breast-feeding
125/2) mc Cx after a carotid endarterectomy- acute MI
131/2) Zollinger-Ellison syn.: malignant islet cell tumor 와 연관
gastrin, acid, peptic ulcer, diarrhea(acid 가 pancreatic enz 를 억제하므로)
BAO>20mEq/hr, MAO>60mEq/hr.
Secretion challenge tset- paradoxica increase in gastrin secretion, 확진.
tx: resection of the tumor, omeprazole
Menetrier’s dis(giant hypertrophic gastritis): giant rugal hypertrophy,
secondary to the collection of protein-rich fluid in cyst in the submucosa & glandular epithelium
loss of protein-rich fluid  hypoalbuminemia
glucagonima: malignant islet cell tumor, DM, migratory necrolytic erythema
gastric adenoca: achlorhydria 와 연관
135/2) Hyperacute rejection of transplants: mismatch in ABO group or presence of anti-HLA Ab
ABO mismatch type II hypersensitivity reaction, proper ABO match 가 가장 중요
tests that determine the compatibility of the HLA loci useful in preventing cellular rejection(type IV)
그러나 HLA compatibility is not as critical for graft survival as ABO compatibility and the absence of anti-HLA Ab in the recipient
Hyperacute
Acute rejection
Chronic rejection
1. 시기
수분~수시간
수개월내
수개월~수년
2. 기전
Antidonor Ab.(+)
humoral+cellular immunity
cellular immunity
3. 증상
Kidney swelling, cyanotic, no malaise,fever,tenderness,wound 신기능점차하강,단백뇨,혈뇨
urine
swelling,oliguria,HTN,신기능
4. 빈도
Rare
rejection 중 최다
5. 진단
percutaneous needle Bx.
6. 치료
removal
PDS,ALG,OKT3
no specific tx, BP, 재이식.
158/2) Breast ca: mc ca in adult women
risk- a family hx of a 1stdegree relative with breast ca or mother with breast cancer
previous hx of contralateral hreast ca
early menarche & late menopause
low-fiber, high-fat diet
nulliparity
a hx of endometrial ca
age(가족력이 없는 경우 가장중요)
174-80/2) Ant dislocation of the shoulder: mc fracture
shoulder joint 는 inferior aspect 가 약하기 때문에 humoral head 가 subcoracoid position 으로 dislocation 잘됨
axillary nerve 와 가까이 있기 때문에 shoulder 의 측면에서 hypesthesia 를 test 하는것이 중요
musculocutaneous n.- 손상시 forearm 의 측면에서 hypesthesia
shoulder 는 external rotation 됨.
Reduction- Kocher’s method
Post dislocation of the shoulder: rare, seizure 에의해 초래됨.
arm cannot be externally rotated
tangential view X-ray 로 확진
Subluxtion of the radial head: supination 으로 reduction 됨. Immobilization 은 필요 없다
Supracondylar fracture of the elbow: neurovascular trauma 와 연관- medial nerve & brachial artery.
Swelling around the elbow
Reduction 하면서 radial pulse 를 촉지해야함.
kept immobilized in a Dunlop traction
Volkmann’s ischemic contracture
Positive fat pad sign- capsule 뒤에 있는 fat 이 뒤로 더 밀려감.
Positive sail sign- 앞쪽에 있는 fat 이 앞으로 밀려서 삼각형을 이룸
Monteggia’s fracture: shaft of the ulna is fractured & head of the radius is dislocated
Proximal & distal joint 손상여부를 X-ray 로 확인하는 것이 중요
Galeazzi’s fracture: fractured radius with dislocation of the radioulnar joint at the wrist
proximal & distal joint 손상여부를 X-ray 로 확인하는 것이 중요
1/3) Deep veonus insufficiency- stasis dermatitis & superficial varicosities
stasis sermatitis: rusty discoloration of the skin, ( rupture of vessels around the an kles skin 에 hemosiderin 침착)
located around the ankles
superficial varicosities: hydrostatic pressure
superficial thrombophlebitis- pain, erythema along the course of the superficial saphenous vein.
Not associated with stasis dermatitis
100/3) Distal splenorenal shunt(Warren shunt): most physiologic  reduce portal pressure in cirrhosis
maintain portal blood flow, selectively decompresses esophageal varices, controls bleeding from varices in 90%
Total portosystemic shunts  reduce portal pressure but deprive the liver of portal blood flow hepatic encephalopathy 를 악화
End-to-side & side-to-side shunts decompress sinusoidal pressure in the liver & relieve ascites
Mesocaval shuntJ anastomoses between the SMV & vena cava, portal vein & vena cava, mesenteric vein & renal vein
Emergency procedure for active esophageal bleeding resistant to therapy.
5/4) Small bowel infarction: occur in elderly pt with atherosclerotic dis.
Sudden occlusion of the SMA by thrombosis(mc), embolism, vasculitis(uncommon) ….aortic aneurysm repair, dissection
25%는 nonocclusive infarction- vasospasm, hypovolemia hypotension
SMV occlusion(25%): hypercoagulable state- antithrombin III deficiency, protein C & S deficiency)
Secondary bacterial penetration, generalized peritonitis
Sudden onset of severe abd pain with vomiting & abd distenstion
Bowel sound, peritoneal sign 은 후기소견
striking neutrophilic leukocytosis with lt shift., serum amylase, barium studies 에서 “thumbprinting”
surgery, embolectomy, intra-arterial vasodilator
10/4) Anal fissure: sentinel pile, fissure, hypertrophied papilla
tx: stool softner, internal sphincterotomy
16/4) Esophageal ca: SCCa(95%)
smoking, alcohol, lye stricture, Plummer-Vinson syn, diverticular dis, nitrosamine, achalasia
mid-esophagus 가 mc site
Diffuse esophageal spasm: dysphagia, chest pain, “corkscrew”esophagus
Nitroglycerin 으로 호전
Zenker’s diverticulum: hallitosis, 수술로 제거
Plummer-Vinson syn: elderly women with iron deficiency
Esophageal web, spoon nail, achlorhydria
23/4) loss of CSF secondary to basilar skull fr
CSF: chloride, protein, glucose,WBC than serum
70/4) Spondylolysis: nondisplaced stress or traumatic fracture of the pars interarticularis
- sport with hyperextension maneuver (gymnastics)에서 위험
- lumbar spine extension 으로 증상악화
- oblique X-ra of the lumbosacral spine 으로 “scotty dog”확인.
89/4) Breast Ca.의 예후인자
- LN status: important prognostic index
- Estrogen & progesterone receptor assay
- Flow cytometric analysis; S-phase fraction 을 측정  높을수록 예후안좋다
- location of the tmor; axial LN 에 가까이 있을경우 예후않좋다
- tumor size
99/4) Gardner’s syn: adenomatous polyp, colon involve
- 95%에서 colorectal ca.발생
- retinal pigmentation; osteoma of the mandible, skull, long bone; supernumerary teeth; thyroid & adrenal tumor
- 모든 환자에서 colectomy
Turcot-Despres syn: adenomatous polyp, malignant glioma 와 brain tumor 와 연관
113/4) Pseudocyst tx.: internal drainage with cystogastrostomy or cystojejunostomy 가 선호됨
6 주이내의 immature cyst 인경우 external drainage
120/4) MEN2: thyroid tumor 는 100%동반, 예후는 thyroid ca 의 course 에 달려있다
liver 의 metastatic lesion 는 thyroid origin
133/4) Ductal carcinoma: worst prognosis
Adenoid-cystic ca: never metastasizes
146/4) Torsion of the test
- left ; counterclockwise 방향으로 꼬임  rotate in a clockwise direct
- right ; clockwise 방향으로 꼬임  counterclockwise 방향으로 detortion
148/4) “Unhappy triad” : 무릎에 sudden valgus stress 를 받을경우
 rupture of the medial meniscus, medial collateral lig, anterior cruciate ligament.
151/4) Compartment syn  Volkmann’s ischemic contracture, myoglobinuria, renal failure, hyperkalemia, loss of limb 초래
; 증상 – pain in the finger or toes on movement, paresthesia, 초기에 pulse 는 정상
; tx – cleaving
152/4) Neurogenic shock : hypotension & bradycardia
sympathetic paralysis vasodilation  hypotension, 상대적으로 부교감신경항진되므로 bradycardia.
Hypertension & bradycardia  epidural hemorrhage 로인한 IICP 의미
Hypertension & tachycardia  acute severe pain
114/2) Lobular carcinoma: mc malignancy of the terminal lobule, palpable mass 로 detect 하기가 어렵다.
치료하지 않을경우 20~30%에서 invasive
high degree of bilaterality
estrogen & progestrone receptor (+)
chest wall involvement 는 uncommon
PSYCHIATRY
5/1) Depense mechanism
Undoing: symbolically reverse
Rationalization: distortion of reality so that the event seems to be desirable
39/1)Displacement: simple phobia 의 psychodynamic defense mechanism
progjection
dissociation
conversion
resistance
71/1)Splitting- psychological separation of all good & all bad.; 특정인에대한 양가감정때문.
Children & borderline personality
Conversion- transformation of psychological stressor into physical complaints.
Involuntary loss of function
No apparent external incentive
Idealization- the exaggeration of an individual’s qualities by an admirer.
Projection- the attribution of one’s feeling to another.
Symbolization- the selection of a particular object to represent other meaning
21/1)Schizophrenia
1%, M(15-25 세)=F(25-35 세), 자살율
winter month, temperate region 에서 발생위험
D/D: schizoaffective,major depression,bipolar,substance-induced,drug withdrawal,seizure,CNS tumor,Cushing,SLE
Px.: premorbid level of functioning 과 밀접, sudden onset 에서 good. MRI change 는 심한
임상증상과 연관.
Paranoid 에서 best overall px.
27/1) Conversion disorder: loss of motor control or sensory function psychological conflict
emotional blandness”la belle indifference”
specific phobias, obsessive-compulsive dis., hypochondriasis anxiety 와 연관
50/1) Depression 유발- antihypertensive, steroids, hypnotic med., psychostimulants 의 withdrawal 시.
58/1) Depression
77/1) Vit. B12 deficience- neurodegeneration & dementia.; strict vegetarianism, alcholism, pernicious anemia
Mg deficiency- rare, cognitive change, weakness.
Lecithin deficiency- hereditary absence of the enz lecithin-cholesterol acyltransferase anemia, renal failure
86/1) Tardive dyskinesia- long term treatment 에서 choreoathetoid movement, finger & tongue 에서 시작
105/1) Manic episodes in bipolar dis- CNS neurotransmitter
mood-stabilizing med.의 작용은 unknown.
Family hx.(+) heritable, but Chromosomal abn; rarely detected
113,4/1) Generalized anxiety disorder
tx- Buspirone;특히 cognitive fn 에 sensitive 한 경우.
118/1) mild mental retardation- idopathic, no clear physical or social pathology
severe MR- known physiologic lesion(eg, genetic or chromosomal abn)
129/1) Learned helplessness- behavioral theory of depression: reaction to a perception of one’s inability to improve a situation
Faulty cognitive framework- cognitive theroy of depression
Object loss- psychodynamic theory of depression
Inadequate exposure to light – biologic theory of depression
Double-blind communication – family dynamics in schizoprenia
132/1)Alzheimer’s dis: gradual onset of memory impairment & absence of forcal neurologic dis.
Old age 에서 mc cause of dementia
Alcoholic dementia
Cerebrovascular dis: sudden onset, forcal neurologic impairment or other vascular dis
Depression: difficulty concentrating, but agnosia or short term memory 의 장애는 없다.
143/1) Sedation & sialorrhea- common untoward effect of clozapine  WBC count 필요.
5,6/2) Mania- bipolar 에서 일생중 another episode 의 chance 는 90%
14/2) Schizophrenia 에서 neuroimaging-  metabolic activity in the prefrontal cortex,  cerebral asymmetry,
size of the corpus callosum, size of the lateral ventricles
41/2) Drug dependence- 다른 mental disorder 가 동반될 확률이 50%: mood disorder, anxiety disorder,psychotic disorder
cocaine dependence 에서 alcohol dependence 는 흔히 동반됨.
cocaine dependence 의 psychological effect 는 금단후 몇주간 지속.
48/2) Opioid dependence: time-limited, lasts less than one decade
more commonly associated with sociability than with isolation & loneliness
rarely cause psychosis, / deviant behavior is common
53/2) Autistic disorder: strongly associated with intrauterine infection( mc rubella)
encephalitis, errors of metabolism(eg, tuberous sclerosis)
57/2) Dissociative identity disorder- childhood sexual abuse 에서
61/2) Fragile X syn: associated with MR & autistic sym
Cri du chat syn: associated with sever MR
Klinefelter’s syn: cognitive & emotional difficulties
Down syn: associated with MR & Alzheimer’s dis
Turner’s syn: associated with cognitive, social, behavioral problem.
74/2)Adjustment disorder: duration- quite brief,
stressor 가 사라지면 해결됨.
83/2) Separation anxiety dis 성인이되어 pannic disorder 흔함.
89/2) BZD withdrawal- anxiety, insomnia, psychosis, seizure
opioid withdrawal- anxiety, malaise, pain, diarrhea, rhinorrhea, yawning, piloerection, sleep disturbance
cocaine withdrawa- anxiety, sleep disturbance, depression
LSD, cannabis 는 특별한 금단증상이 없다
99/2) Memory impairment  cognitive disorder( delirium or dementia)
101/2) Opioid-induced delirium: common in hospitalized, elderly individuals.
Develops rapidly & has a short clinical course(<1 month)
103/2)delusion of reference: assignment of personal significance to neutral events.
130/2) Schizoid personality disorder: emotional aloofness, indifference to praise or criticism, absence of any bizarre thinking
Schizotypal personality disorder: withdrawn & aloof, peculiar thinking
Paranoid personality disorder: unwarranted suspiciousness
Narcissistic personality disorder: 대부분의 사람들을 경멸, 그러나 소수는 극히 이상화
Avoidant personality disorder: need for human contact & feels lonely.
136/2) construction apraxia: nondominant parietal lobe 의 damage.
Damage to the dominant frontal lobe expressive(Broca’s) aphasia
Damage to the dominant temporal lobe receptive(Wernicke’s) aphasia
Damage to the nondominant frontal & temporal lobes problem of mood, orientation, concentration, memory
154/2)DT:
tx- chlordiazepoxide
hypomagnesemia- alcoholic 에서 common, hypocalcemia 로인해 tetany 발생
thiamine deficiency- alcololic 에서 common, 이때 glucose 를 IV 투여시 Wernicke’s encephalopathy 촉진
ICU syn: typical ICU environment of bright light, noise, sleep deprivation 등과 연관,
confusion, subsequent development of delirium
Postoperative psychosis: 대부분 이전에 기분장애를 갖고있따. stress, drugs, -endorphin 이 contributing factor
Hypoglycemia: adrenergic sign & symptom without hallucination
Reaction to anestheitc drug- 수술직후 나타남.
162,3/2) Diazepam- stage 4 sleep  sleep terror & sleepwalking 치료시 사용
BZD rebound- sleep latency
Major depressive dis- early morning awakening
Barbiturate- REM suppression
2/3) Transvestic fetishism: paraphilia, obsession with cross-dressing for the purpose of the sexual arousal
Exhibitionism: exposes his genitals to others
Frotteurism: sexual pleasure by rubbing his genitals against an unsuspecting person
Gender identity disorder: wearing the clothes of the opposite sex, but it is not done for sexual pleasure
Feel more comfortable with the opposite gender identity
4/3) Hypochondriasis: brief psychoteraphy 통해 life problem 을 exploration 함으로써 증상완화
placebo 는 일시적인 도움을 주고, BZD 는 별 도움이 안됨
34/3) Dementia: commonly present with psychotic symptom
delusion, mood change(eg. anxiety, depression), thought disturbance(eg,perservation)
56/3) delirium: disturbance of awareness or attention, cognitive problem, rapid onset, fluctuation in severity
hallucination, persecutory ideation.
Possible physiologic causes: L-dopa, anticholinergic toxicity, alcohol withdrawal.
Alcohol-induced or due to Parkinson’s dis 에의한 dementia 흔히 cognitive problem 의 hx 있다.
90/3) Schizotypal PD: social withdrawal, peculiar ideation, absence of any hx of psychosis
antipsychotic med 는 peculiar ideation 을 감소시킴.
Family hx of schizophrenia
94/3) Oppositional defiant: problems in relating to authority figures
get along well with peers & have no other problem of conduct or development
Conduct disorder: violation of age-apropriate social norms, fighting, runaway behavior, theft, destruction of property
Childhood disintegrative disorder: 정상 발달기간이후 social, communicative, cognitive function 의 발달장애,
135/3) lithium-induced  hypothyroidism, wt gain, acneform skin eruption, tremor, leukocytosis, polyuria
no reported hepatotoxicity, low incidence of renal toxicity
Routine monitoring- plasma lithium, CBC, BUN, creatinine level, TFT
1601/3)
Erik Erikson: psychosocial development- series of stage, or epigenetic cycles
각각의 단계에서 특별한 “task”를 달성해야함.
Trust vs. mistrust, Autonomy vs. shame,Initiative vs. guilt, Industry vs. inferiority
Identity vs. identity confusion, Intimacy vs. isolation, Generativity vs. stagnation, Integrity vs. despair
Jean Piaget: cognitive development  sensory-motor, preoperational-operational, formal operational
각각의 단계는 “assimilation” & “accommodation”을통해 달성되고, 사고과정의 reorganization 을 필요로함
Melanie Klein: Paranoid-schizoid & depressive position
Margaret Mahler: “psychological hatching”- Autism disorder, symbiosis, differentiation
4/4) Antisocial behavior : young men 에서 발생, 40 세이후에 급격히 감소
사춘기이전에 발병
chaotic family setting
not fluctuate in intensity, 장기간 constant personality trait
36/4) Bipolar disorder: 25%에서 lithium 에 반응안함. 이경우 lithium 용량을 늘리는 것은 unwise, valproate 를 사용
thioridazine, haloperidol 도 psychotic thinking & excessive motor activity 를 감소시키지만,
bipolar dis 를 조절하는데는 lithium 이나 valproate 보다 덜 효과적
51/4) Somatization disorder: long history of physical complaints from multiple organ system
- generalized malaise, GI symptoms, neurological symptoms, sexual symptom
- analgesic & sedative-hypnotic abuse,
- 여성에 흔함.
90/4) Dissociative fugue: sudden travel away from home
- inability to recall one’s past
- disturbance of identity
- occurs during the course of severe stress
96/4) Pain disorder: psychological factor.에의한 pain. Underlying physical lesion(+), 실제병변부위와 Sx 일치않함
Chronic , physiologically mediated physical pain- pain disorder 와 마찬가지로 physical lesion 찾기 어려움
Personality pathology, good response to biofeedback th, 경제적 & 법적 문제연관.
106/4) psychotherapy: specific explanation for the genesis of pathological behavior
147/4) Cognitive psychotherapy effective in Major depressive disorder, single episode, without psychosis.
PEDIATRICS
6/1) Bacterial vulvovaginitis; prepubertal pt.에서 nonvenereal infectious vulvovaginitis 은 common.
- due to a primary respi. or skin pathogen.
- Group A beta-hemolytic streptococcus; 인두염, scarlet fever 와 관련.
- perineal area 에 burning, dysuria, erysipelas 와 비슷한 erythema
- serosanguinous or grayish-white vaginal dscharge.
Strep. pneumoniae, H. influenzae URI 와 함께 purulent aginal discharge
소아에서 N. gonorrhea, Chlamydia 발견시 sexual abuse 의심.
10/1) HSP; arthritis, GI & renal sx, lower extremities 와 buttocks 에 purpuric rash.
C3 치는 정상, 신부전이 15%정도이나 대부분 완전회복가능.
Poor px.: 신증후군과 혈뇨동반, 고혈압, GFR, 사구체에서 반월체 관찰.
Corticosteroid- 관절통, 복부증세완화시키지만 신질환의 예후에는 영향못끼침.
RM spotted fever rash 가 periphery 에서 시작, 온몸으로 퍼짐.
ITP pressure point(eg, elastic band)에 rash,
16/1) Mastitis: not CIx to breast-feeding, infant 는 not become ill, 그러나 mother 는 anti.와 analgesics 로 치료
frequent nursing 으로 breast 가 engorge 되는 것을 방지 breast abscess 로 진행을 억제.
22/1) Moro reflex: loud noise or sudden motion 에의해 유발 abd. & extension of the extremities, elbows followed by flexion
출생시 나타나서 4 개월에 사라짐.
Asymmetric tonic neck feflex(ATNR): 2 주째 나타나서 6 개월째 사라짐. fencer position
Parachute reflex: 9 개월째 나타나서 지속됨
Grasping reflex: 출생시 나타나서 3 달째 사라짐.
Protective equilibrium reflex: 4 달째부터 나타나서 지속. 한쪽으로 밀면 힘을 받은쪽은 구부리고 반대쪽 팔을 폄.
 Rooting, sucking, Moro, grasp, placing reflex- 3 개월에 사라짐
 Trunk incurvation, crossed extension reflex- 1~2 개월에 소실
 Stepping reflex- 1 개월에 소실
 Tonic neck, placing reflex- 3~4 개월에 소실.
 Landau reflex- 1~2 년에 소실.
25/1) protein: Cow’s milk 에 많다. Kidney 에 solute load 1 세이하에서 lethargic, dehydrated.
모유>우유- 지질, 유당, 단백질중 Whey:casein 비, 불포화지방산:포화지방산비.
우유>모유- 단백질,회분, 무기질
Fe 는 우유와 모유가 같다.
모유는 알칼리성, 우유는 산성.
32/1)Foreign body aspiration: history of chocking.
건강한 3 세 소아에서 m/c cause of recurrent pneumonia, 폐구조상 rt.-side 에 더 흔함.
Immunodeficiency dis.- recurrent inf. 흔히 opportunistic organism, failure to thrive.
Cystic fibrosis- failure to thrive, malabsorption, clubbing, 폐렴은 Pseudomonas 에 의함.
Chediak-Higashi syn.-AR, neutrophil 내 giant granule 과 연관, skin, mucous membrane, respi tract 에 recurrent inf.
Albinism, 중추 및 말초 신경이상증 발생,ADCC 와 NK 세포기능저하로 종양발생
혈소판 응집력 장애혈소판 수는 정상이나 출혈시간은 연장.
Pancytopeniarecurrent inf사망;EBV 와 관계.
Sx.: photophobia, 안구진탕, red reflex,안면 백색증, 치은염 반복, 구강점막궤양
성인이되면 운동실조, 근무력증, 운동신경전달 장애, 경련.
Congenital lung abn.- earlier stage 에 나타남.
42/1) neat pincer grasp- >10month.
53/1) iron toxic ingestion 후 hematemesis, hypotension, lethargy  deferoxamine
serum iron level>TIBC, serum iron>300ug/dl.
Dimercaprol, CaEDTA- lead poisoning 에 사용
응급해독제 요법
Acetaminophen N-acetylcysteine
Atropine physostigmine
BDZ Flumazenil
blocker Atropine, isoproterenol, Glucagon
Cyanide Amyl nitrite
Digoxin Fab(Digibind)
INH Pyridoxine
Mercury,arsenic, goldBAL(dimercaprol)
Nitrite Methylene blue
Organophosphate Atropine, Pralidoxime
Niotinic efect; fasciculation, twitching, weakness, areflexia, tachycardia, HTN  Pralidoxime
Muscarinic effect; salivation, lacrimation, urination, defecation, abd cramp Atropine
Symptathomimetic phentolamine, blocker
Lead BAL, Ca-EDTA
63/1)Reye’s syn.: vomiting, lethargy, confusion- progress quickly, liver enz. & ammonia
tx.: IICP control, 예후는 disordered cerebral fx. 기간에 달려있다.
Infectious mononucleosis- EBV, fatigue, fever, sore throat, generalized lymphadenopathy.
splenomegaly lt. Upper quadrant abd. Tenderness.
Symptomatic hepatitis or jaundice; uncommon., mononuclear lymphocytosis with atypical-appearing lymphycotes
Pharyngitis- 발병첫주에 나타남, gray-white membrane, 인두부 종창, 편도비대 동반, 입천정에 점상출혈..
피부발진(faint morbiliform 발진, 24~48 시간지속), 안와부 부종
비정상 간기능- 간비대, 간효소치 상증(발병 2~3 주에 시작해서 5 주에 정상으로됨)
EBV 특이 항원에 대한 항체검사
i) VCA IgG- 발병초에 최고치, 평생지속
ii)VCA IgM- 진단적 가치
iii)EA- 바이러스증식과 연관
iv)EBNA IgG- 잠복감염조정, 가장늦게 나타나 영구히지속, 초감염과 재감염감별에 지표가됨.
합병증- 비장파열, 신경계, 심근염, 간질성 폐렴, 용혈성 빈혈, 혈소판 감소성, 자반증, 재생불량성 빈혈, 인두부,
기도폐쇄, 췌장염, 이하선염, 고환염, 레이증후군
Gilbert syn.- inherited, benign, unconjugated hyperbilirubinemia, AD
Hyperbilirubinemia; mild, fluctuate, jaundice 는 intermittent.
Liver bx., LFT 는 normal
70/1) Measles: 전구기(catarrhal stage)- 전염력이 가장 강함, cough & coryza & conjunctivitis, Koplik 반점.
발진기(eruptive period)- 홍반성구진상 발진이 귀뒤에서~ 첫 24 시간에 얼굴, 목,팔, 몸통상부~ 2 일째는
대퇴부~3 일째는 발까지 퍼진 후 역순으로 소실, 발진이 융합되며 때로 점상출혈반 나타남
회복기(convalescence)- 발진소실되며 색소침착, 손발은 벗겨지지 않으며, 합병증이 잘생김.
Cx.: Otitis media- mc.,
mesenteric node involve- appendicitis 와 비슷한 pain.
Subacute sclerosing panencephalitis- rare, 성격,행동변화, 지능저하, 경련, 간대성 근경련, 혼수, 사망
Interstitial pn.- measles virus 로인함, immunocompromised pt.에 더 흔함. Multinucleated giant cell 보임
Bronchopn.- pneumococcus 에의함. Interstitial pn. 보다 흔함.
Keratoconjunctivitis- asymptomatic
수동면역: 예방접종 못한 소아가 홍역환자와 접촉한 경우 감마 글로불린을주사.
Tx: 세균성 합병증의 경우 항생제, giant cell pn 의경우 대량의 감마 글로불린, 뇌염합병지는
75/1) Vaginal bleeding(pseudomenses)- newborn female 에서 nl.- 10 일정도 지나면 좋아짐. only reassurance.
78/1) Neonatal conjunctivitis
Chemical injury- silver nitrate 에의해, 1~2 days
Bacterial etiology(S. pn, H.inf, N.gonorrhea) topical preparations
Gonococcal ophthalmia- 21 days if prophylaxis is given, 2~3 days after birth. hospitalization & ceftriaxone
Pseudo.- 5~18 일.
Chlamydial conjunctivitis- mc, acuqired during delivery. 5~10days oral EM 으로 chlamydial pn 예방.
Herpes simplex conjunctivitis- delayed by 2 weeks.
Viral conjunctivitis: 유행성 눈병
Adenovirus type 8,19- epidemic keratoconjunctivitis
Enderovirus type70- acute hemorrhagic conjunctivitis
결막 출혈, 동통, 눈물 흘림, 이물감, 눈부심, 심한 누곱, 이전 림프절 종창
치료- 1~3 주지나면 자연치유
84/1) Erb-Duchenne paralysis- brachial plx injury, C5-6 involved. C4 involve 시 ipsilateral diaphragmatic paralysis
Klumpke’s paralysis- C7-8,T1involve. “claw hand”
Clavicular fr- asymmetric Moro reflex, clavicle 에서 crepitus.
Todd’s paralysis- focal seizure 후 hemiparesis, 24 시간내 회복.
spinal cord injuries- in the lower cervical, upper thoracic vertebrae with breech presentation.
, and at the 4thcervical vertebra in cephalic presentation. 1 주일내에 나타남.
87/1) Phrenic n injury with ipsilateral diaphragmatic paralysis- abdomen does not bulge. US or fluoroscopy 로 진단
RDS- preterm, cyanosis, tachypnea, grunting respiration. Mother 에서 difficult delivery 의 hx.
Chest X ray: ground glass appearance
Choanal atresia- cyanotic newborn(feeding or rest), relieved by crying, 코로 catheter 통과 못함.
91/1) werdnig-Hoffman dis: spinal muscular atrphy, AR.
Symptomatic at birth; spearing of the extraocular m & sphincter. 근력저하, 근긴장 저하, 근위축, 심부건반사 소실,
Fasciculation; best seen in the tongue
“frog-leg” posture. 하지가 상지보다 더 강하게 침범.
심근장애는 보이지 않으며 지능도 정상.
CK 정상, 근전도와 근생검에서 신경원성의 변화
Neonatal form of myotonic dystrophy- motonic dystrphy 있는 모체에서 태어남, clubfoot & contracture.
약한 태동, 양수과다증의 산과력, 포유와 호흡곤란, 내반족, 삼각형얼굴, 벌린입, 안면마비
정신지체동반. 생후 8~12 주가되면 호전됨.
진단: 근전도.
Congenital Myotonic Dystrophy
Myotonia Congenita
Myotonia
없다.
흔하다
:골격근의 지속적 수축
EMG 상 약간있다
EMG 에서 현저
Hypotonia
흔히 있다
없다
Weakness
심하다
경하거나 없다
Muscle bulk
형성부전
정상 또는 비대
MR
흔히 있다
없다
유전
AD,어머니는 거의다 이환
AD or AR
Infantile myasthenia gravis- fasciculation(), extraocular m spare()
Duchenne’s muscular dystrophy- rarely at birth
병형
Duchenne 형
지대형(Limb-girdle) 안면견갑상완형(FSH)
악성형(duchenne) 양성형(Becker)
성
남자
남자
남자, 여자
남자,여자
유전양식
반성열성
반성열성
AR
AD
발병시기
2 세이전
6~19 세
10 세이후
소아기~성인
근위축순서 요대,견갑근
요대,견갑근
견갑,요대근
안면,견갑,요대근
가성비대
80%
때때로
드물다
드물다
진행성
급송
완만
급속~완만
완만
변형구축
관절구축
적음
말기에 본다
드물다
CK 변화
상승(고도)
상승(고도)
정상~상승
정상
예후
불량, 10 년내사망 비교적양호
중년이후 악화
양호
기타
지능장애
결혼가능,
transverse smile
여아는 모두보인자
Botulism
*식품매개성(식중독)- 대칭적인 뇌신경 손상, 하향성 마비, N/V, 타액분비감소, 두통, 변비, 요정체
Infant botulism- 2~6 개월에 peak.; 변비, 젖빨기가 약해짐, 약하게 울고, 힘이 약해져 목을 가눌수 없으며,
전신적 근긴장저하, 젖을 삼키지 못함., 뇌신경증상, 대칭성 하행마비
식품매개성 botulism- 12~36 시간의 잠복기, 대칭적인 뇌신경손상과 하향성으로 나타나는 마비 증상.
N/V, 탈력감, 쇠약감, 현기증, 타액분비감소, 구갈, 두통, 변비, 요정체, 복시, 시력불선명, 수명,
고정확장된 동공, 안구진탕, 발성 장애, 구음장애, 연하 장애
Wound botulism- 외상후 1~14 일
100/1) Tinea capitis- dermatophyte inf., multiple patches of alopecia & severe itching
dermatophytoses- tinea or ring worm, invad dead tissue(stratum corneum, hair, nails)
scalp inf.은 contagious & children 에서 잘생김.
Tinea corporis(body), tinea cruris(“jock itch”),Tinea pedis(“athlete’s foot”), Tinea unguium(nail), Tinea capitis(scalp)
Trichophyton, Microsporum, Epidermophyton 세종류가 dermatophyte inf.일으킴
Trichophyton tonsurans(mc): not fluoresce, “black dot ringworm”의 scalp pattern,
Circular patches of alopecia with hairs broken off close to the follcle
Microsporum canis(2nd): bright blue-green fluorescence
Epidermophyton: invade the intertriginous skin, not the scalp.
Epidermophyton floccosum tinea crusis 의 원인균
Tx.: topical antifungals(miconazole, clotrimazole) or oral antifungals(griseofulvin)
103/1) Blood in the stool of a newborn- mc 은 swalled maternal blood  Apt test.
위장관 출혈; 24 시간내 위십이지장 내시경시행.
Meckel 게실의 진단- Tc99m pertechnate scan
 안될경우 Tc99m sulfur colloid scan(0.1ml/min 의 출혈도 찾아냄,매우 예민, but 실제출혈있어야발견)
혈관조영술- 내시경, 동위 원소 스캔 등의 소견이 음성일 때 적응, 출혈속도가 0.5ml/min 이상이어야함.
*토혈- 신생아 토혈; 출산시 흡인된 모체의 혈액을 토해내는 경우
영유아의 토혈; 십이지장이나 위궤양의 출혈, 최근 화상입거나(Curling’s ulcer), CNS 손상, 감염있는 환자에서
*혈변과 직장출혈
-신생아: 분만시에 흡입된 모체의 혈액, 신생아기 출혈성 질환, 난산 혹은 패혈증, 뇌막염등
-영아기: 항문열상(mc, 변비있는경우가 많다)
-학동전: 연소성 용종(건강하게보이는 아동에서 소량의 선홍색 변)
Meckel 게실(건강하게보이는 환아에서 다량의 혈변)
-학동기: 궤양성 장염, 크론병
109/1) Anemia of prematurity- low birth wt 에서 1~3 개월에 발생, RBC 수명, growth, frequent phlebotomy
feeding problems, tachypnea, tachycardia, pallor
Megaloblastic anemia of infancy- deficiency of folic acid, 4~7month
irritable, poor wt gain, chr diarrhea
심한 창백과 간비종대, 호흡기 감염, 점상 출혈반.
Newborns with sickle anemia- 5~6month, acute sickle dactylitis(painful swelling of the hands & feet)
agar gel electrophoresis 나 microcolumn chromatography 를 이용해 진단
vasoocclusive crisis: 하부 국소빈혈, 통증, 마비
sequestration crisis: : 순환허탈
aplastic crisis, hyperhemolytic crisis.
간기능저하, 황달, 담석, 신기능저하,잦은 패혈증, 뇌막염, 골수염등 중증 감염(폐렴구균, 살모넬라균)
비장은 초기에 커져있으나 funtional hyposplenism, 후기에는 아주작게됨(autosplenectomy)
target cell, poikylocyte, Howel-Jolly bodies, 유핵적혈구, ESR
sodium metabisulfite 처리후 겸상적혈구를 더 현저히 관찰할수 있다.
Thalassemia- heritable, hypochromic anemia
-T: chain 의문제severe progressive hemolytic anemia,
T. minor(-thalassemia trait): poikylocytosis, ovalocyte, basophilic stippling, target cell, Hgb A2
T.major(Cooley anemia, homozygous): 장기적 수혈로 심장의 위험부담을 줄여야함.
Medulla 와 extramedulla 조혈의 증가로 뼈가 얇아지고, 병적골절 증가, 얼굴과 머리의 골형성이 특이,
X 선상 hair-on-end 소견, 간비장종대, 혈청증
당뇨,심장 질환등이 합병되어 20 대에 주로 사망.
134/1)Bronchiolitis- small airway 의 inflammatory obstruction. Inflammation 은 2 살이내에 나타남(6~12 개월이 peak)
모유수유를 하지 않으며 여러명과 함께거주하는 3~6 개월의 남아에서 호발.
basic pathology: 폐쇄성 폐기종, 작은산발적 무기폐, bronchial edema, exudate
RSV, parainfluenzae, influenzae…
URI 로 점진적으로 시작, 발병 수주전에 가벼운 호흡기 질환을 가지 환자에 노출된 병력.
Tachypnea, nasal flaring, rales, wheezes, retraction, hyperresonance to percussion, liver & spleen palpable
구토나 설사 같은 전신증상은 대개 없다.
Tx: 항생제 사용은 효과없고, corticosteroid 도 효과없다. 진정제는 금기
adequate hydration, nebulizers, oxygen
ribavirin:초기투여시 경과호전, methylxanthine 계열은 투여금지.
합병증없으면 72 시간후에 회복됨.
Croup- brassy, barking cough. URI history.
Laryngotracheitis: croup 의 가장 흔한 형태, parainfluenza virus 가 common
seasonal outbreak.
Harsh, barking cough, hoarseness, inspiratory stridor, but Drooling is not common
Neck Xray:모래시계모양.
Tx: oxygen, nebulized epinephrine, steroids
Epiglottitis- older children, high fever, severe respiratory distress, drooling, strider. Sudden respi obstruction rapidly fatal
,but barking cough 는 없다.
원인균: H.influenzae type b
lean forward with neck extension(“sniff”position) improve breathing
lateral neck films: “thumbprint sign”, visualization of a red, swolen epiglottis: diagnostic
medical emergency, 즉시 입원 & intubation, IV cephalosporin
하열후 24 시간내 extubation, 발관후 postextubation croup 예방 dexamethasone 4~8mg 정주.
예방: 2 개월이상 아기는 H.inf 백신을 접종.
Cystic fibrosis- recurrent pul infection, chr lung obstruction 때문에 rt sided HF 가능
135/1) Childhood developmental landmarks
2m: lifts head to 45degrees, Eyes follow to midline(물체를 90 도까지 따라옴), Vocalizes(able to babble, coo), Smiles,
State of half-waking consciousness
4m: Lifts head to 90degrees, Eyes follow past midline, Laughs, Regards own hand, Slight awareness of caregiver
6m: rolls over, Grasps rattle, Turns to voice, Feeds self, Separates world into “Mom” & “not Mom”
12m: sits without support, Pincer grasp, Babbles, Indicates wants, Stranger anxiety
stand momentarily, say”dada”&”mama”, bang two cubes held in his hands
18m: Walks well, Makes tower of two blocks, Says three words, Uses spoon & cup, Temper tantrums
2yr: Runs, Climbs steps, Makes tower of four blocks, Combines words, Removes clothes, Develops concept of object permanence
3yrs: 세발자전거, 원과 십자를 보고 그린다, toilet trained, play interactive games, give their 1 st&last name,
4yrs: balances on one foot for 2secs, Copies a circle, 사각형을 보고그림, Explains pictures, speech can be understood, dresses self,
Magical thinking, Egocentric, symbolic play, catch a bounced ball
5yrs: 삼각형을 보고그림.
6yrs: Balances on one foot for 6secs, Draws a person with six parts, Defines words, Knows opposites, Prepares cereal,
Logical thinking, Understands conservation of mass and volume
학설
0~1(영아기)
2~3(걸음마)
3~6(학령전기)
6~12(학령기)
12~20(사춘기)
Freud:psychosexual
구강기
항문기
오이디푸스기
잠복기
사춘기
Erikson:psychosocial Basic trust
Autonomy –
Initiative - guilty
Industry
- Identity –
shame & doubt
Inferiority
Identitiy diffusion
Piaget:cognitive
Sensorymotor
조작전기
구체적조작
형식적조작
137/1)Pneumavax 의 Ix
:>2 세에서, high risk for acquiring sys pneumococcal infection or increased risk of serious dis if they become infected
 sickle cell ds, functional asplenia, NS,CRF, immunosupression, HIV(+), CSF leakage
140/1) Petit mal, or absence,seizure: stops abruptly, blank stare with fluttering of the eyelids
No postictal stage
Hypsarrhythmia infantile spasm
Interictal slow-spike wave  Lennox-Gastaut syn
Centrotemporal spike benign partial epilepsy
Four-to six-per-second irregular spike-and-wave juvenile myoclonic epilepsy
<경련성 질환>
*연령에 따른 원인
출생후~6 개월 출생시 손상(hypoxia) - 첫 24 시간이내는 산소결핍, 그후는 저혈당증과 저 Ca 혈증
생후 2 주이후는 감염이나 유전성 대사질환등이원인
~24 개월 급성열성경련
~6 세 CNS 의 급성 감염
~16 세 특발성 간질.
*열성경련: 전신성, 15 분이내, 열이내린후 EEG 정상—단순 열성경련
항경련제투여 Ix – 1 세이하, 신경학적 or 발육이상, 복합열성경련, 가족중 간질환자.
*영아 테타니: 혈청 Ca<7mg/100mL., 미숙아, 당뇨병모체, 일과성인 기능적 hypoparathyroidism
수족경련, 후두경련, 경련, Chvostek 증상, Erb 증상, Trousseaus 증상, 비골증상
*부분발작-focal, Jacksonian seizures:발작시 의식장애없다, 전조,
-복잡부분발작(측두엽,정신운동발작): 발작시 의식장애,
1 분이상지속, 초점성 간질파, 발작후 졸음, 자동증
-CBZ
Benign rolandic epilepsy: benign partial epilepsy of childhood.
발달장애가 없는 소아에서 발생, 사춘기가 되면 없어짐.
수면중 특히 아침에 일어나기전 , 잠든직후에 일어남
입언저리, 목, 얼굴등에 국하도니 경련과 감각이상
EEG- centrotemporal, Rolandic area 에 고진폭의 극파가 일측 또는 양측에 나타남(수면중)
tx- anticonvulsant.
전신발작-결신발작(Absence):5~10 세, 전조없이 의식이 잠깐동안 소실, 발작후 졸음이없다.
Hyperventilation 으로 3Hz spike-wave 소견.
ESM,VPA
-근간대성발작(Myoclonic): 사지나 몸통근육이 갑작스런 불수의적 수축
-강직,간대,강직-간대발작:의식을 완전히 잃고 쓰러짐, 청색증, 대소변실금, 발작후 깊은잠
-탈력발작(Akinetic): 갑자기 전신의 근긴장이 소실, 아침혹은 잠에서 깨어난 잠시후에 흔히.
-Infantile spasm(West syn): 3~8 개월, 갑작스런근수축으로 머리,몸통 및 사지가 일시에 굴곡, Jackknife 발작
발작 전후에 배아픈듯 울기도하고 웃기도함, 하루에 수십회이상 나타남, 잠에서 깬직후에 많다.
고진폭의 서파가 불규칙하게 뇌전역에서 출현(hypsarrhythmia), 80~90%에서 MR
2~3 세가 지나면 없어지고 다른형의 경련나타남(Lennox-Gastaut 증후군)
ACTH/steroid
141/1)Symptomatic HIV-infected children- measles 에 노출될경우 IG(0.5ml/kg), Asymptomatic 일경우는 0.25ml/kg
만약 3 주이내 IG 투여할경우 no additional IG required
symptomatic HIV 환자는 passive immunoprophylaxis 필요.
severe measles 에서 low serum vitamin A
145/1) External otitis,”swimmer’s ear”- caused by excessive moisture in the ear canal,  loss of protective cerumen & chr irritation
eari pain, erythematous & edematous ear canal, otorrhea.
P. aeruginosa(mc), Neonate 에서는 S.agalactiae
147/1) Immunizations
11/2) Von Gierke’s dis: glycogen storage dis, G6P 결핍.
enlarged kidney & liver, hypoglycemia, “doll face”, 키가작고 정신발달은 정상.
tx: corn starch, 자주 식사.
Tay-Sachs dis: CNS involve, defect in the lysosomal enz -hexosaminidase
지능과 운동발달퇴화, 날카로운 소리에 깜짝 놀라는 반응, 눈썹이 길고, 피부가 창백, 인형 같은 얼굴표정
머리가커지며, cherry red spot 이 황반에 나옴, 경련발작, 건반사 항진, 무감각, 시력소실, 청력소실
진단은 hexosaminidase A 활동도를 혈청 또는 백혈구에서 측정.
Gaucher’s dis: one of the lipidosis, or lysosomal lipid storage dis, as is Niemann-Pick dis
-glucosidase 결핍 glucocerebroside 축적
I 형- mc, 비종대, 간종대, 뼈에침착(rarefaction 와 골조송증), 혈소판 감소, 빈혈, 키의 성장안되고, 체중
Niemann-Pick: sphingomyelin 침착
A 형- 생후 수개월이내 간비종대와 정신운동 발달지연, 시력이 서서히 소실,황반에 cherry red spot, 근무력증.
Hurler’s syn: mucopolysaccharidoses
Deficiency of -L-iduronidase leads to mucopolysaccharide-engorged lysosome
지능저하되나 경련발작은 없다, 청력소실, leptomenngeal thickening, arachnoid cyst, 뇌수종, 각막혼탁,
망막변성으로 시력 소실, 키가작고, 얼굴모양이 조악(gargoly like), 간비종대, 관절변형, dysostosis multiplex,
척추 후만, 제대 및 서혜부 탈장, 상기도 감염이 흔하며, 승모판 및 대동맥 판막의 침윤으로 심근기능
장애
39/2) PKU: blond(피부가 희고, 눈이 파란), vomiting, mental retardation, musty & mousey odor of phenylacetic acid
검사는 72 시간후 protein 먹인후 실시
초기에 low phenylalanine diet 실시가 뇌손상을 예방
PKU 여성은 임신전 저 pheylalanine 식이를 실시하고 임신기간내내 <10mg/dl 유지유산과 birth defect 예방
10mg/dl 이상인 여성의 infant 는 MR, microcephaly, congenital heart anomaly
46/2) Congenital syphilis: Early- fever, anemia, snuffles, maculopapular rash, failure to thrive, hepatomegaly
pseudoparalysis of Parrot(painful osteochondritis 로인해 안움직임)
Late- saber shins, saddle nose, Hutchinson’s teeth, rhagades(perioral fissure in the skin
52/2)Kawasaki syn.(mucocutaneous lymph hode syn): febrile vasculitis of large coronary blood vessel of children
Criteria- unexplained fever of 5 day’s duration
Blateral nonpurulent conjunctivitis
Changes of the mucosa of the oropharynx(dry, cracked lips; strawberry tongue)
Changes of the peripheral extremitis(edema, erythema)
Polymorphous rash
Cervical lymphadenopathy
Palm & sole 의 desquamation 은 late finding(2~3 주)
Thrombocytosis- 2~3 주에 나타남, leukocytosis, CRP, ESR
Scarlet fever: strawberry tongue, maculopapular rash, Pastia’s lines, circumoral pallor
Acute rheumatic fever: Jones criteria
DLE: cardiac involvement 와 관련
Periarteritis nodosa: necrosis & inflammation of small & medium sized arteries
55/2) ACHA recommendation for prematriculation immunization- MMR, DTP
79/2) Meningitis- headache(쉬거나 누울때심함), photophobia, vomiting, giddiness, fever, stiffness of the neck
98/2)
112/2) Panniculitis: secondary to cold injury to fat, / indurated lesion.
Erysipelas: acute, well-demarcated infectin of the skin with lymphangitis
Ill, fever, vomiting,irritability
Cellulitis: distinct margin, tender, indurated, warm to touch
119-22/2)Cystic fibrosis: recurent pul infection, malabsorption, failure to thrive
elevated sweat chloride level.
infection- sputum 에서 S.aureus, P.aeruginosa(+)
이차적으로 Vit D 결핍(fat-soluble vitamine 의 흡수장애때문)
H.influenzae type B- meningitis, pneumonia 유발
C.trachomatis pn.- 1~3 개월사이, 임신시 chlamydia infection 된 mother
Persistent cough, low-grade fever, tachypnea, eosinophilia
Streptococcus agalactiae(GBS)- neonate, vertical transmission, horizontal transmission in the nursery, transmission form adults
L.pneumoniae- alveolar filling infiltrate, adult 에서 rapid onset of fever, pleuritis, chest pain, dyspnea
Tx: EM with or without rifampin
132/2) Pertussis(whooping cough)- extremely contagious respiratory dis., caused by Bordetella pertussis
1 살이하에서 주로 발생
catarrhal stage- URI 증상, thick nasal discharge, conjunctivitis
paroxysmal stage- spasm of forceful coughing ending, inspiratory whoop, vomitng, facial redness, cyanosis
convalescent stage- cough & vomiting gradually subside
cough 는 몇 달간 지속될수있다., petechiae, conjunctival hemorrhage.
Otitis media- common cx., CBC 상 leukocytosis(predominantly lymphocyte)
Bronchiolits: normal WBC count & diff count.
Chlamydia pneumonia: cough, tachypnea, lack of fever, eosinophilia
RSV pneumonia: WBC, lymphocyte predominance
137/2) Infant botulism: honey & corn syrup, soil & house dust 에있는 C.botulinum spore 를 삼켜서 생김.
progresses quickly, ventilatory support 필요.
afebrile & previously healthy, costipation, feeds poorly, weak cry, hypotonia, loss of head control, descending paralysis,
Gray syn: chloramphenicol 사용과 관련
Hypothyroidism & Werdnig-Hoffmann dis: hypotonia, earlier in life 에 보임, slow progression
Hypomagnesemia: hypocalcemia + tetany.
138/2) ROP: vasoproliferative retinopathy
Stage I
Demarcation line between vascular & avascular retina
II
Thickening of the demarcation line; formation of an intraretinal ridge
III
Extraretinal, fibrovascular proliferation forms on ridge; hemorrhages
IV A Detachment is extrafoveal
IV B Detachment involves the fovea
V
Total funnel-shaped retinal detachment
147/2) Osgood-Schlatter dis: overuse injury- physically active boys around puberty 에서 more common.
Pain & swelling of the tibial tubercle
Tx: reductioin of the activity, 몇주내 상태는 좋아짐
Legg-Calve-Perthes: gradual limp, stiffness, pain in the groin, hip, thigh or knee
4~8 세 소년에서 흔함, femoral head 의 avascular necrosis
leg is shorter on the affected side
radiograph- increased density in the femoral head
Slipped capital femoral epiphysis: overweight adolescent boy(9~15 세)에서 생김
Chronic condition 은 hypothyroidism 같은 endocrine abn 와 연관.
septic arthritis: joint space 내 염증, pain & limitation of motion, 진단은 관절액 검사
chondromalacia patellae: undersurface of the medial side of the patella may be crepitant & tender.
153/2) E.coli sepsis- galactosemia 와 밀접.
Classic galactosemia: galactose-1-phosphate uridyltransferase 의 결핍 liver, kidney, brain 에 침착
Cataract, jaundice, hepatomegaly, hypoglycemia, vomitting, aminoaciduria, failure to thrive
Early detect 해서 식이요법하는 것이 중요.
11/3) Visceral larva migrans: infection with Toxocara larvae
1~4 세, 특히 pica & contact with dogs and cat 의경우 발생증가
fever, hepatomegaly, wheezing, pul dis, eosinophilia
Loffler’s syn: eosinophilia, wheezing, hepatomegaly
Splenomegaly is absent
Strongyloides stercoralis(strongyloidiasis): mild & pass unnoticed,
그러나 immunosuppressed & malnourished children 에서 massive with S.stercoralis;
 generalized abd pain, fever, shock due to gram-negative sepsis.
44/3) GBS(Streptococcus agalactiae); mc cause of neonatal meningitis, followed by E.coli L monocytogenes
common inhabitant of the maternal GU tract
vertical transmission
early onset sepsis
late onset meningitis
54/3) Klinefelter’s syn: mentally retarede, tall, slim, underweight, long-legged, gynecomastia, atrophic testes, azoospermia
testicular biopsy after puberty- hyperplasia of the Leydig’s cell, fibrosis of the seminiferous tubules
Barr body(+)
Gonadotropins, testosterone
55/3) Rett syn: only in female, 6~18month 까지는 정상발육
dementia 와함께 microcephaly, lose purposeful movement of their hands
ataxia, seizure, scoliosis, loss of gross motor skill, 양손을 비비며 손을 씻는 모양의 운동이 나타남.
Russel-Silver syn: short status, triangular facies with downturned corners of the moth, clinodactyly, large head
Turner’s syn: short stature, webbed posterior neck, broad chest with widely spaced nipples, carrying angle of the arm
Williams syn: depressed nasal bridge, epicanthal folds, prominent thick lips with open mouth, short stature
Autism: regression of language, play without loss of motor skill.
79/3) Breast-feeding jaundice
82/3) Metachromatic leukodystrophy: myelin metabolism 의 disorder arylsulfatase A activity 결핍.
gait disturbance, hypotonic extremitis, deep tendon reflexes 소실, slurred speech, nystagmus
feeding & swallowing are impaired
death from bronchopneumonia
CSF- protein, cell & glucose는 정상,
Metachromatic granules in urine
Infant with Frabbe’s dis: hypertonic, white matter에 globoid histiocyte가 보임
fabry’s dis: X-linked recessive, adolescence에 증상 나타남.
skin reuption around the navel & buttocks
PKU: fair skin, blue eye, eczematoid or seborrheic skin rash, musty odor
Adrenoleukodstrophy: X-linked recessive, long-chain saturated fatty acid 의 침착  skin, adrenal, white matter of CNS의 dysfunction
3가지 phenotype이 소아에서 나타남 hyperactivity,impaired auditory discrimination, visual disturbance, seizure..
89/3) Subdural hematoma & retinal hemorrhage- common sign of fatal child abuse(“shaken baby syn”
 contact the state agency that deals with this problem
128/3) Vitamin D-resistant rickets: familial, X-linked dominant hypophosphatemia, mc form of rickets
defects in the proximal renal tubular reabsorption of phosphate
bowing of the leg, waddling gait, short stature
Calcium level은 정상
tx: phosphate supplement.
Calcium-deficient rickets: tetany, myopathy, rachitic rosary, Harrison’s groove(pectus deformity)
131/3) child abuse: old healed fr, belt marks, bruises on the buttocks or lower back, SDH, rupture of internal organ
hot-water-drnking burn circular burn restricted to the buttocks
sexual abuse- genital or anal trauma, STD, UTI
134/3) Fragile X syn: mental deficiency, prominent jaw, large ears with soft cartilage, macro-orchidism.
Trisomy 18: prominent occiput and low-set, posteriorly rotated, malformed auricles
Clenched hand with overlapping fingers, rocker-botton feet
Trisomy 21: epicanthal folds, Brushfield’s spots, simian crease, wide space between the 1st & 2nd toe, short 5th finger, small ear
Klinefelter’s syn: hypogonadism, long extremities, decreased intelligence, behavioral problem
Prader-Wili syn: narrow face, almond-shaped eyes, thin upper lip, hypoplastic gonad, truncal obesity
이런 환자들은 또한 slow motor development, delayed puberty, behavioral problem을 갖는다
143/3) osteomyelitis: puncture후 foot의 osteomyelitis의 mc cause는 P.aeruginosa.
`
pseudomonas가 puncture후 cellulitis 를 초래하는경우는 드물다
S.aureus: puncture후 cellulitis 와 관련된 mc pathogen
151/3) Ewing’s sarcoma: teenage 에서 mc
radiographic feature- diffuse, mottled, lytic lesion medullary cavity & cortical bone 을 affect
“onionskin”
Osteosarcoma: mc malignant bone tumor in children
Cortical destruction, sclerosis, “sunburst”pattern of new periosteal bone formation, calcified, soft tissue extension
Chondrosarcoma: rare in children, pelvis 에 잘발생
Eosinophilic granuloma: painless or mildly painful swelling in the skull,long bones, ribs, pelvis, vertebra
Lytic lesion with well-defined border
Osetomyelitis: femur & tibia
Radiograph 는 정상
6/4) Severe asthma 에서 becoming sleepy & less responsive 의경우 tiring & retaining CO2
 ABG 를 즉시실시
theophylline toxicity: nausea, irritability, tremor, seizure, cardiac arrhythmia
11/4) Posterior fossa tumor of childhood: astrocytoma (mc), ataxia, nystagmus 등의 증상이 동반됨.
Childhood 에서는 infratentorial tumorrk 가장흔하고, 성인에서는 supratentorial 이 가장흔함
2 살이하의 infant 나 adolescent 는 종양의 위치가 성인에 가깝다
Cerebellar vermis 의 tumor : truncal ataxia, Romberg(+), tandem gait 장애, IICP 증상(두통, papilledema)
예후는 뇌종양중 가장 좋다
Craniopharyngioma: short stature or other endocrine abn.
Optic n., pons, 3rd ventricle compress
Medulloblastoma: 2nd mc post fossa tumor
뇌척수액로를 통해 전이
짧은 병력,
IICP 증상(두통,구토, 유두부종, 학업저조, 외선신경마비, 복시, 경부강직, 사경, 의식장애, cerebellar fit)
정중선 소뇌징후, 뇌신경징후, 편측소뇌 증후
Pontine astrocytoma: 3rd mc,cranial nerve symptom, pyramidal tr abn
Colloid cyst of the 3rd ventricle: 뇌압상승증상
Brainstem glioma: intrinsic, diffuse pontine hypertrophy, 좌우 및 전후 직경증대되고 상하로 파급
① 다발성 뇌신경장애: dysarthria, dysphagia, 사시, 안면신경마비
② long tract sign: 반신부전마비
③ 소뇌징후: 운동실조성 보행
tx: 방사선, 항암화학요법.
예후는 뇌종양중 가장 불량
18/4) allergic rhinitis: eosinophil on nasal smear  substantiate the diagnosis
RASTdtermine Ag-specific IgE concentraion in serum
less sensitive than direct skin testing
19/4) Sturge-Weber dis: port-wine nevus
Tuberous sclerosis: ash-leaf spot
Mees’s line: arsenic poisoning
Duchenne’s & Becker’s muscular dystrophy:pseudohypertrophy of the calves
Chartcot-Marie-Tooth dis: “stork legs”
Tay-Sachs dis: cherry-red spot on the macula
33/4) Congenital rubella syn: hepatosplenomegaly, thrombocytopenia, hepatitis, jaundice , cataracts, “blueberry muffin” rash,
neurologic depression
cf) rubeola, measles 는 선천성기형과 관련없다
congenital varicella: 1 st half of preg.때 감염될경우, limb hypoplasia, microcephaly, seizure, cataracts
last 3weeks 에 감염될경우, mild or fever & pneumonia
congenital toxoplasmosis: chorioretinitis, hepatosplenomegaly, jaundice, convulsion, cerebral calcification
congenital syphilis : hepatospelnomegaly, generalized lymphadenopathy
1 주일 후에 snuffles(a purulent & blood-tinged nasal dischage)
34/4) homocystinuria: methionine 대사장애, AR trait
thromboembolic dis, failure to thrive, developmental delay, lens dislocation, astigmatism, glaucoma, cataracts,
MR, seizure, marfanoid, fair skin, blue eyes, marar rash
몇환자는 vit B6 에 반응
46/4) Roseola infantum( Exanthema subitum): human herpesvirus type 6
sudden onset fever, febrile seizure 가능, child looks quite well
3~4 일째 fever 내리고 macular or maculopapular rash erup, 몸통에서 시작하여 사지로 퍼짐
rash of rubeola(measles): fever 와 함께 발생. 목, 얼굴에서 시작하여 밑으로 내려감
rash of Erythema infectiosum: erythematous maculopapular rash 로 시작, arm 을 involve, trunk & leg 으로 퍼짐.
Rash 가 사라지면서 lacy appearance 를 남기며 2~3 주 지속됨
Rash of Rubella: 얼굴에서 시작하여 매우 빨리진행(within 24hr), 얼굴의 rash 는 trunk 로 전파되면서 사라지기시작
둘째날 pinpoint appearance
57/4) Juvenile RA: chronic synovitis + extra-articular manifestations
-Systemic JRA: high fever, rash, hepatosplenomegaly, pleural & pericardial effusion, anemia, ESR
-Acute rheumatic fever: carditis, transient migratory arthritis
-Lyme dis: erythema chronicum migrans, tick bites, careful history & PE 으로 감별.
58/4) Cavernous sinus thrombosis: sinusitis 의 cx.
-ophthalmoplegia, loss of accommodation
Hand-Schuller-Christian dis: skeletal abn, skin lesion, exophthalmos, hepatosplenomegaly, pituitary dysfunction
93/4) Craniopharyngioma: mc supratentorial tumor of children
- plain skull film 에서 calcification
- short stature, bitemporal field defect, 3 rd ventricle 을 압박해서 hydrocephalus, papilledema, polyuria
Astrocytoma of the 3rd ventricle: IICP 증상 & seizure
Pinealoma: CSF pathway 의 destruction, IICP, Parinaud’s syndrome,
paralysis of upward conjugate movement, Poorly reactive pupil
Chromophobic adenoma of the pituitary : short stature, DI
103/4) Tuberculosis meningitis: recently infected individuals, infnat & children
- 3 stage; prodromal – seizure – coma
- CT of the head : periventricular lucencies, edema, infarction, hydrocephalus
- CSF : WBC 약간증가, 대부분 lymphocyte, glucose<40, protein 약간증가, Chloride
Cryptococcal meningitis: protein, hypoglycorrhachia, mononuclear peocytosis(>300cell/mm3)
Subacute sclerosing panencephalitis: CSF- nl cell content, nl protein, gamma-globulin
Eastern equine encephalitis:
Meningococcal meningitis: CSF 에서 원인균 동정.
110/4) Ataxia-telangiectasi: AR, mc degenerative ataxia
- ataxia: 2 살때 시작해서 사춘기때 완전 상실
- telangiectasia: eye, bridge of the nose, ears, exposed surface of the extremities, loses elasticity of skin
- frequently sinopulmonary infection, IgA & IgE, AFP
- risk of lymphoreticular & brain tumor
Wiskott-Aldrich syn: XR, atopic dermatitis, thrombocytpenic purpura, infection
Rendu-Osler-Weber dis: hereditary hemorrhagic telangiectasia
- angiomas of the skin, mucous membrane, GI tract, liver,
- Pul AV fistula
Friedreich’s ataxia: 10 세이전, progressive ataxia, dysarthric speech, nystagmus, skeletal abn
Cerebral palsy: static encephalopathy, nonprogressive disorder of posture & movement
- MR, epilepsy, auditory, verbal, visual, behavioral abn
134/4) Chlamydia in a 15year old girl must obtain informed consent form the patient & treat her infection
reportable STD – syphilis, gonorrhea, AIDS
143/4) Optic glioma: neurofibormatosis 의 15%에서 동반, 진단의 criteria 가됨.
-  visual acuity, pale disc
Cryopharyngioma: short status, bitemporal visual field defect
Cavernous sinus thrombosis: venous engorgement of the lid & orbital tissue, ptosis, ophthalmoplegia, loss of accommodation
PREVENTIVE Medicine
7/1) Sensitivity=TP/(TP+FN)100
Specificity=TN/(TN+FP)100
15/1) case-fatality rate
29/1)US 의 leading cause of death: heart dis>cancer>stroke, stroke 는 여성이 많고 heart dis.는 남성이 많다.
40/1)Perinatal mortality rate
48/1)Odds ratio: case-control study 에서 relative risk 를 평가. ad/bc.
64/1) Mean(평균), median(중앙치), mode(최확수)
74/1) Hemophilia A- sex-linked recessive dis
87/2) Durable power of attorney: an individual designates a legal representative to make decisions concerning health care in the event
that the individual can no longer do so.
58/3) Student’s t-test: two group 사이를 비교할 때
three group analysis of variance
correlation coefficient assesses the strength of association
chi-squared test assesses differences between groups of categorical variables
Logistic regression assess a categorical outcome for a continuous predictor.
87/3) Validity: how well a study measured what it was disigned to measure
Association: degree to which two things are related
Reliability: results of a test can be reproduced
Relative risk: strength of a cuase-and-effect relationship
P-value: probability of obtaining a given result by chance
102/3) Double blinding investigators: measurement bias 를 prevent
157~9/3) Toxic syndrome
TCA(amitriptyline) Cardiotoxicity, Convulsion, Coma
Dilated pupil, nystagmus, hot & dry skin, bowel sound, confusion, hallucination, seizure,
tachycardia, QRS prolongation, hypotension, cardiac arrhythmia
tx: activated charcoal
acidosis 교정 bicarbonate
cardiotoxicity  phenytoin
seizure control  IV diazepam or lorazepam
Iron: 1st 6hr severe necrotizing gastroenteritis  shock
Next 48hr coagulopathy, seizure, coma, cardiovascular collapse
그후 jaundice, renal insufficiency, severe metabolic acidosis, fibrosis 로인한 obstructive GI cx.
Tx- supportive tx of shock, fluid loss, metabolic acidosis
Parenteral deferoxamine
SSRI(fluoxetine, sertraline) “Serotonin syndrome”
Diaphoresis, diarrhea, myoclonus, tremor, confusion
심할경우 seizure, marked hyperthermia, possible ventricular arrhythmia
다음약제와 동시사용시 상용량에서도 발생할수있다
; MAOI, levodopa, meperidine, lithium, dextromethorphan
Acetaminophen
Diazepam
Scopolamine
Heroin
Amercury
Lead
Phenobarbital
Physostigmine
Trifluoperazine
165~7/3) Preferred provider organization(PPO): 3rd-party payer, insurance company or union trust fund, contracts with physicians
and hospital to provide medical care to its subscribers
Intermediate-care facility: nursing home provides only limited nursing care, typically restorative nursing, assistance with self-care
Health maintenance organization(HMO): paid a yearly salary to provide medical services to a group of peo ple
Who have voluntarily enrolled and paid a yearly premium in advance
20,1/4) Mercury : Acute poisoning- GI & renal symptom
oral intake stomatitis, abd pain, N/V, explosive, bloody diarrhea, kidney damage
CNS sx- ataxia, slurred speech, visual & hearing impairment
Tx: correction of fluid & electrolyte imbalance, gastric lavage,
BAL,dimercaprol
Penicillamine- BAL 에 부작용있는경우
Iron: cause a hemorrhagic gastroenteritis, but renal failure is not common
2~4 일후 liver involvement manifests 나타남
Arsenic poisoning: abd pain, N/V, delirium, coma, death, ATN but not ataxia
Lead poisoning: chronic, 혈중 level 이 >80g/dl 일경우 intestinal sx 나타남
lethargy, convulsion, death
tx: EDTA & BAL
48/4) Top five causes of death in US: Heart dis> Ca> cerebrovascular dis> COPD> accidents
67/4) Medicaid eligibility : mean-tested program, determined by the presence of financial hardship
- require an individual to expend personal resource fo health care before Medicaid can be used.
- Cover the cost of her medication & the cost of long-term care(Medicare 와 다른점)
- not dependent on prior payment into the system or on reaching a particular age(Medicare 와 다른점)
115/4) Random allocation: hallmark of clinical trial.