Israel Medical Students Association

2014
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.
.

.36 60 ,
. .

33

31

 CT - .
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.
.

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.

.43 76
40 . , 82
! 76/42" ,
12- .
.
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. ) Acute Mitral
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.
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.37 ?
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. 4

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.

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?
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.
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. INR

. 110

.42 25
,
25 .
,
?
IV Calcium Gluconate .
IV Isoproterenol .
IV Magnesium Sulfate
.
IV Glucagon .
IV Atropine .

34

32

 23 ,
.3 ?
. LBBBs
. RBBBs
. VTs
.
.

.49 Intra Aortic Balloon Pump

?
.

.

.
. ) ,(VSD

.

.55 4?
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Paroxysmal Supra-Ventricular
.

.50
) PCI-percutaneous coronary intervention
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PCI .

.
.

CABG .
CABG .
) (LMCA

. PCI -

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Type-1 2nd Degree AV Block
Complete (3rd Degree) AV Block

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.51 73 3
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.
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.

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eluting stents
. LAD- Bare metal
stent
. Bare
metal stent

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.

,
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.

?
Hypovolemia .
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Acute Pyelonephritis .
Acute Tubular Necrosis .
Acute Glomerulonephritis .

.52 ,35
.170/90 ,
BHCG , 3 .

?
Captopril .
Losartan .
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IV Nitropruside .
.53 ,64
,30%
. Sustained
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.

?
.
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. Implanted
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.

.58 ,35
,
, ,
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.

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33

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.
.

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.

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.
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.

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.

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.

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.

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.

36

34

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.

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. TSI
.
.

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. Sick Euthyroid Syndromes

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.

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Membranoproliferative
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FSGS
IgA Nephropathy

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. FSGS

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.
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.
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CT
2.5 .
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.
. CT
. FNA
. MRI

.72 22 , ,
. -
178/102 ,
. - 68%
2.4 .%
C3 -+ ANCA ,
antiGBM . ?
Wegener's Granulomatosis .
Lupus Erythematosus .
Good Pasture's Syndrome .
Berger's Disease .
Microscopic Polyarteritis Nodosa .

.79 ,30 ,
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, .
mOsm/l180
?
.

.
.
.

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.
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.
, ?
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Acarbose .
Insulin
.
Repaglinide .
Rosiglitazone .

.74
?
ANA .
Anti-dsDNA .
Anti-Sm .
Anti-RNP .
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?
Minimal Change Disease .

.81 .
. ,26 .

37

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.
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.
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.
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35
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, ,
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.84

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.
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38

36

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. ?
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.
.
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CMV Pneumonitis .

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.

.92
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39

37


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40

38


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.

Chronic -
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.
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cystic fibrosis .
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.

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40% .
60% .
80% .
95% .

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.
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) (pulse steroid treatment"
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3
.
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. mycoplasma

Mycobacterium Tuberculosis .

.
HIV
. -

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.
.
.

primary ciliary dyskinasia

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41

39

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.
.
.
.

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Azythromycin
.
Carbapenem .

2 4
4 10
0.5
0.5 2 -

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.
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.
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.
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.

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.
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.
.

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.
. 10
, .
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.
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Acute Uric
?Acid Nephropathy
.
.
.
.
.

.16 25
, .
.
BHCG .
?
IM Penicillin + PO Rulid .
IM Ceftriaxone + PO Azithromycin .
IM Ceftriaxone + PO Doxycycline .
PO Ofloxacin .
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.
Amylase 500 U/L .Lipase 40 U/L 90/50 . 100
.
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Pancreatitis .
acute cholecystitis .
acute intestinal obstraction .
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.23 25 .


5
.
.
, 90/50 ,
.
.
, ,
LDH , .
?
. MRI

.
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.

. ?
Escherichia coli .
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Staphylococcus aureus .
Candida albicans .

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?Lithiums
. QT
. QT
. QRS

.

.24 ,27 6 . 8
4 .
42

40

 .
5 , -
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chloroquine .
proguanil .
quinine + doxycycline .
primaquine .

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.
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.
.
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, .
, .
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.

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320
"/ .

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.
.
.
.
. .

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.
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,
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.
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.

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.

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doxycycline 6-
.
phase II

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.

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. BISFERENS

.34 62 .
,
,
,

AMOXICILLIN .,
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?
.

.
. A2
.
3/6
.29 28 .
2/6
.

43

41

 .WBC= 15000, PLT=450000

. ?
.
. NSAIDs
Anti-TNF .
.
.

Penicillin g 1 .

lg Vancomycin . ,

Clindamycin 600 mg . ,

Trimethoprim-Sulfamethoxazole .
) (160/800mg ,

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82" , 1.71 - . BMI - ?
28 .
24 .
32 .
34 .

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HIV
) ,(copies/ml 10000 -B
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IgG .A
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C
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HlV-
. C
HIV -
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C

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120/80 80 .37
3+ .
urea=45, cr=2.8, albumine=2, .:
cholesterol=280 ,Urine protein/ 24h=3.8gr

. .

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.
.
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, ,
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;
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Staphylococcus aureus
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?
.
. Oxacillin Vancomycin -
. Ceftriaxone Vancomycins -
. Ciprofloxacin -
.

.41 55 ,Sjogren
.Renal Colic
. . Cl -
=.PH=7.28, HC03=12, Na=140, K=2,8 ,120
?
RTA I .
RTA II .
RTA III .
RTA IV .
.42 ,50 .K=3.0
. .
Urea=25, Creatinine-0.8, pH=7,47, =34
.HC03 - CT .
. ?
Liddle Syndrome .
Primary Hyperaldosteronism .
Barter Syndrome .
Gitleman Syndrome .
.Cushing Syndrome .

Vancomycins
Rifampin

.37
?C
. 35 .
. 48
.
. 58 ) (proteinuria
.
. 62 ST-T
...
. 54 , -
CSF .

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130/50
3/6 .
?
.
.
. Amyl Nitrite
.
.

.38 45 Crohn's 20 .

. .
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,
4 + . -
Albumin=2.1, Fibrinogen=340, ,10=Hb

.44 65 20 ,
.
.
, .

Cholesterol=300

44

42

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. 55 60%
,

,
.
90/50 - .30
A .
?
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.
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.
.

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7 ?
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2
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,

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,
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,
, ,48


.
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.
.
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.
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.
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.

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ACE
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.
.

. 60"
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.

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ACEi ,
.
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.

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. VT
.

.54 55 .9+10
?
.

.
A
. PULSE PRESSURE

.

.

.49
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90/60 , ,
.
. 65
) (EF .60%

45

43

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. ,Atenolol ,
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UREA=45 , CR
80%
. ?
. AMLODIPINE
. ACE-i -
ATENOLOL
.
. HYDRALAZINE -
. DILTIAZEM -

.55
?
. CARDIAC OUTPUT

.

.
.
.
.
.56
?
.

. NITRIC OXIDE

.

.
.

.61
?
Losartan .
Atenolol .
Amlodipine .
Hydralazine .
Methydopa .
.62 10- .

?2
ACEi .
ARBs .
Diuretics .
beta Blockers .
Ca Blockeres .

.57 75
.
,
.SICK SINUS SYNDROME
,
?
.
.
.
.
,

.63 ,
?
. 75 2.5
3 -
ACE-I

. 55 1.8 ,
,HB=9

. 45 4.5 200/120

. 20 1.8
90/50

.58
?
CLOPIDOGREL .
ACS

.

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.(I
.

. NO
.

.64 .58 ,150/85

,mg/dL2.5 2.8 .

?
.
.
.
.
.

.59 60 ,

30
. .90/50
.11
.
.
.
70/40 . 25
?
.
.
.
.

.65
?
Multiple Myeloma .
. AA
Light Chain Deposition Disease
.
.Waldenstrom Macroglobulinemia .
.
.66 .55
7 . CT
. CT
46

44

 . 5
anti-LKMl .
?
. C

.
2 ANA - anti
.smooth muscle
. D ,
B .D -
.

.
?
.
.
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.
.
.67 55

5 .
.
) (Livedo Reticularis .
.:
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.
?
. C
. RENAL FAILURE INDEX
.
.
. DTPA

.72
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.
.
.
.
MP-6 .
.73 ? IgA deficiency
.
.
.

.
. SLE

.68 45 Acute
Pyelonephritis .
.
KLEBSIELLA
. 48

.39.5 ?
.
.

. US
. 24
.

.74 ,30
. .
.
?
.
CT .
.
. T & B
.

.69 ?
Pentamidine .
AZT .
Lamivudine
.
Interferon .

.75 ?
.
.
. IVIG
. +
. +

.70 .55 .
.
.
vasopressin - 0.2
. .
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. ?
.
.
.
.
. LOSEC -

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.
.
.
.
.
Nesiritide .77?
.
BNP . IV
.
. +
. +

.71 55 .
,
20
.
.SGOT=105 SGPT=120
.

.78 40
) NYHA
.class 3 ,(PPH
, Bosentan -
?

47

45

.
.
.
.

.84 30 ,
.
.13
?
Follicular Lymphoma .
Burkitt's lymphoma .
Diffuse Large B-Cell Lymphoma .
Lymphoblastic Lymphoma .
.
.

.79 35
.
CT .

) (ILIAC ,
.Diffuse Large B Cell Lymphoma-
STAGE ?
I-A .
I-B .
B .II
IV-A .
IV-B .

.85 17 14
- .
?
. 14
. 15
. 16
. 17

.80 70 .CLL
.
14.3' ,% .
MCV ) 88( . .

, .
.Na-138 ; Plt-420,000 -WBC- :

.86 - .18
-
.
Cell
Lymphoma .Diffuse Large B
?
. ,

. ,

.
.
.

12500 ,Hb, 9.9-MCV-98 ,Bilirubin-2.9

.1050LDH ,Creatinine-1.1 ,Ca-7

?
. -

.
. B12
.
. Haptoglobin

.87 60
, .NYHA-4 :
10.2Plt-400,000 ,WBC-10500 ,MCV-79 ,Hb.
?
. -

. ,

.

.
Hemochromatosis
.

.81 40 Acute Myeloid

.Lukemia WBC-120,000:
90% ,Hb-12.5 . .45000

?
.
Allopurinol .
Tarivid . Resprim Forte
Fusid . Bicarbonate
. N-Acetylcystein
.82 25
) .(Gaucher
?
.
. X-Linked
.
Acute Chest Pain .

. .

.88 30 .
3
. 150/90
80 . 37.8 2
.
.
, 3+ .
HB=9, WBC 4.5=PLT=75000, UREA=35,
.CR=1.4, ALBUMINE=2.5,
.GLOBULINE=3500 .

.83 ,12 .25

?
. , - .
. .
.
. .

?
cANCA .
pANCA .
dsDNA .
ANA .
48

46

 .
.
?
.
.
.
.
.

anti-Ro .

.89 35 .29
3 ,

.
5
.
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.
.
. drug induced
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..
. .

.95
?
.
.
.
.
.96
ACETOMINOPHEN ?
.
.
.
.

.90 60
: ,
: ,
5 .

. -
.
?
NSAIDs .
.
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.
. COX-1

.97 45
.
,
.
.38.5 :
.

.
. :

.91
. 5
. .
.HB=9, MCV 2.5=albumine=95,
.B12

?
.
DPENICILLAMIN .
.
.
.

Hb=13.2, WBC=9300, CPK=2500, ESR

20/hr, ANA titer 1:1280, RF positive at 1:512

.
?
Azathioprine .
Methotrexate .
NSAEDs .
Plasmapheresis .
.Prednisone .
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.
) T4- 2.0 ) T3 - 3.3 ,(1.5 -0.8 -2.2
) TSH -2.3 ,(4.2 .(4-0.4
?
.
hjs -
METHIMAZOLE
.
.

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?
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.
.
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.42 ,30 15 .

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.

.36
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.43 ,22 .
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58

56

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glomerulonephritis
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glomerulonephritis Crescentie .
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glomerulonephritis

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59

57

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58

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.

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,
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61

59

 . ,
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.1
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.6
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.8
.9
.10
.11
.12
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.14
.15
.16
.17
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.19
.20
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.22
.23
.24
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.26
.27
.28
.29
.30
.31
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.33
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.36
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.40
.41
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.51
.52
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.66
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.76
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62

60


- 3009

63

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.19
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.26
.27
.28
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.32
.33
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71

69


- 3008
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. .
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Rractional excretion of Sodium . .1
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INSULIN .
ROSIGLITAZONE .
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.
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.

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13-14% .
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) .(PIPS +DIPS
2
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. .
. .
. PTH.

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.
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.
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.
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.

) (extensor .

.29 65 , , 38.5
, :
. 25% - .

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. .
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.

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.
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. D-DIMERS
.
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10 .

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. US

.
.

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?
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.
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.
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?
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CT . , .
CT . .
. .
. .

74

72

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, .
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.
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..
. .
. .
. .
. .

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. .
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?
. .
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Dry tap . .
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.33 ,78 STEMI

. .

.
. ?
.
.
. CT
.

.39
)"( ?
.
.MITRAL STENOSIS -
. "
.
.
.Primary pulmonary hypertension -
.
CHRONIC THROMBOEMBOLIC

.PULMONARY HYPERTENSION
.
.

.34 .

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. .

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,
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. .

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. -
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.
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. .HIV
. IIBIIIA glycoprotein
).(Gp
. .15/17

.41 AMIODARONE
?
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.

.

.

.

.36 33

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GBM .
?
IgA nephropathy .
Microscopic polyarteritis nodosa .
SLE .
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75

73

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.

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.
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.

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.
, .
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. ,
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.(herpetiformis
.

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.
.

T.

.43 ,

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. ,
.
.


.
.
.
.

.

.48

?
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.44 50 ,
,METFORMIN ,GLIBENCLAMIDE
.NIFEDIPIN

,6.2 1.8 % 58 .%
110
,PH 7.29 ,% 140 %
.20
?
. METFORMIN

. -

.49
?
Familial adenomatous polyposis .
Gardner's syndrome .
Peutz Jeghers syndrome .
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Streptococcus bovis bacteremia .

MINERALCORTICOIDS
. FUROSAMIDE -
. SPIRINOLACTONE -
. PSEUDOHYPERKALEMIA -

.45 40 12
.
, .

?
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5 .
.
. ,
, .
.

.
.
.
.
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48.

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.

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76

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.
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.
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.

.58 60 -
GLIBEMCLAMIDE ,
, 2.6
% 68 , %
?
.
. US
.
.
. CT

.53
ACARBOSE ?
.
.
SULFANYLUREAS

. IBD
. I

.59 pulsus
altemans
?
.
. 10
.
.
LSB .

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) .Mercaptopuriiie (6-MP
100 , .
38.2 , 10" /"
.
.
?
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Infliximab

.
.
pouch

.60 45 RHEUMATOID ARTHRITIS -

, ,
,2.5
320 ,% 24
3.7 .
, ?
MINIMAL CHANGE DISEASE .
MEMBRANOUS NEPHROPATHY .
FOCAL AND SEGMENTAL
.

.55 20
24- , .

, CT
,
. ,

, ?
.
.
.
US . ,
.

.
.

GLOMERULOSCLEROSIS
MEMBRANOPROLIFERATIVE
GLOMERULOPATHY
DIFFUSE AND NODULAR
GLOMERULOSCLEROSIS

.61 60 ,
.


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omeprazole
.
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.
.
.
. Methotrexates
NSAID's
.
.
NSAID's-
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.

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30 .
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30 .
15 . 15
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20 . 10 -
10 . 10 , 10
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.64 62 ,
,.PND ,

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120

).(CRT
.

.

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.

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RENAL TUBULAR -
) ,ACIDOSIS (RTA

?
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.
.
.
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.70
?
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..
.
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..

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78

76

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.
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. .
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?
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. LVH
. Q
. PR
.

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.

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?
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.
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. .. .
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79

77


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anti-HCV .
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HBeAG .

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/ ,
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. T4/T3

.

.
. 40-60

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.
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LDL ?
> 190
. LDL
> 160
. LDL
> 130
. LDL
> 100
. LDL
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.

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)?(infliximab

.
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100

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.
Psoriatic arthritis
.

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.

.87 , 35 , 15 ,

,
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..
..

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,
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,
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/( . 8"/
2/" .
,
,

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,H.pylori

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80

78

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.
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.H.pylori-b
. omeprazoles
.
.

. EUS

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.
. .
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.
50" .
.
-
. - 1.5 20
,BUN
.
?
.
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. antiproteinase 3 antibodies
. antimyeloperoxidase anti

.90 ,23
. , .
.
?
. .
. .
. .
. .
. .

bodies

. .
.95 ,54
, 10"
, 15
, 16 .
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pericarditis constrictm
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.

Pericardial knock .

.91 ,48 ,
, ,
, .
?
. 10"

. ST
upsloping mv 0.1

. false positive

. 95%
. .. CLBBB
ST

.96 ?dermatomvositis
.

.

.

.

.
.

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)?(IBD
.
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. 10-15:
50-60
.
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.

.
.

.97 80
.
?
. TSH
.

. CT
. QTC
. 12

.93 60
.
CT .
honeycombing
.GROUND GLASS
?
. .
. .
. .

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81

79

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10 . ?
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.
CT . US,
.
.

.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.11
.12
.13
.14
.15
.16
.17
.18
.19
.20
.21
.22
.23
.24
.25

.26
.27
.28
.29
.30
.31
.32
.33
.34
.35
.36
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
.47
.48
.49
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.51
.52
.53
.54
.55
.56
.57
.58
.59
.60
.61
.62
.63
.64
.65
.66
.67
.68
.69
.70
.71
.72
.73
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.76
.77
.78
.79
.80
.81
.82
.83
.84
.85
.86
.87
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.90
.91
.92
.93
.94
.95
.96
.97
.98
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82

80


- 3004
.1

50 , 110 ,
.

5 . ) goblet
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.
Intestinal metaplasia
Low grade dysplasia
?
. .
.

. proton pump inhibitors

.
.
6-12 .

.2

) (Exenatide-byetta?
.
)(sulfonylurea
. GLP-1 analogue) -1
(GLP
. )PPARy agonist
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.
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.3

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Syndrome of inappropriate ADH ) .

.6 82 .
,
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150/90 140 .
. -
. ?
.
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) (metoprolol,
, .
. ,
. .
) (Amiodarone " .
. ,
,,

.
.
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.8

14 .
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,
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/ ,400-AST ,4.0-INR ,
.
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. acute HBV
(infection) B
. Carbamezapine -
. )acute Budd-
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.9

,70 ,
10 . 3 ,

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.
Staphylococcus aureus
3 .
,
. .
?
.
)(Vancomycin
.
)(Gentamicin+Rifampicin
.

secretion (SIADH
Liver cirrhosis .
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.4

50 . 15-
,
,
.
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, ,NSAIDS
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. .
. )(eradication
.
.
.NSAIDS
.
.

.5

30 Autosomal dominant
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. -

. ?
MRI .
.
CT .
.

83

81

 .
.
?
.

.
.

.
.
.
.
.
,
.

.10 35
.

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Rheumatoid arthritis .
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Ankylosing spondylitis .
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.
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, low RBC
,mass
. B12.
?
. JAK2
. Flow cytometry (FACS) CD59-
CD55 -
. methylmalonic acid
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.
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. .
. .
. .

.12
. ,

.
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. .
12 TIPS -
. ) distal
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.17 27
3 .
:
Na- 127 mol/L, K- 4.5 mol/L, CI- 95 mmol/L

.HC03-10 mmol/L ,pH-7.21, pC02- 28 mmHg

?
.
. .
RTA type I .
.
.18 35
. 5-6
.
5 .

.NSAIDS P-ANCA,
(anti Saccharomyces cerevisiae Ab) ASCA-1
. ?
Crohn's disease .
Ulcerative Colitis .
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.NSAIDs-mduced colitis .

.13 75

ST .
, .
.jventricular Aneuysm
?
.
.
. .
. ST
).(PRINZMETAL

.19 57 3
,
-
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JAK2 ?
. JAK2-

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Post Infectious
?Glomerulonephritis
.
.
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.

polycythemia verao

.

. -
idiopathic myelofibrosis

. JAK2

.15 45
38.5 .
, , .

essential thrombocytosis

84

82

 .25 70
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. ,
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FVC-83% ,FEVl . :
.
.
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. .
.
.
.

.
.
.

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?
. ,60 -
) (PPD 11"
. 8
"
. HIV
10"
. 25
14
.21 55
.
. Wide -
.complex tachycardia
?
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. fusion beats
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LBBB
. .carotid massage

.26 41 ,type 1
3 .
.
,
.
?
Leishmaniasis .
Strongyloidiasis .
Cryptococcosis .
Mucormycosis .

.22 5,24
,C40 , ,
min/50
3 . ,
.
.
?
. pseudomembranous
colitis
. Enteric fevers

.

. Infectious
mononucleosis

.27 HCV 1A
?
. pegylated interferons
48
. pegylated interferons
24
. lamivudin^ pegylated
interferons 48
. pegylated interferons 48

.23 25

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.
?
.
).(systemic sclerosis
. 5-3
.
.
,
-.
. " 30
.

.28 60 gout
.
2.0" .%
colchicine
. ?
.
.
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NSAED) Non Steroidal Anti Inflammatory .
(Drug
Prednisone . ACTH.
.29 70
,110 28 ,115/70
, .91% .
CT
,
.
?
. .

)(.
.
)(.
.
.

.24 10 ,18 ,C38 ,.

, ,
.

.
?
.
.
. 10%
.

85

83

.34 ,41
C39 .
, ,
. ?
. , CT ,
,
CT . , , ,

. , , CT ,

. PCR ,
CT , ,

.30 74 ,
. : ,
- .
, .IgG, IgA ,IgM
stick
.
?
. monoclonal
gammopathy of undetermined
)significance (MGUS

.
.

polyclonal

.35 ?
. 30
.
.
.

hyperglobulinemia

.36 66 . 40
.
) (Hydrochlorothiazide" .
1.5" .
.
Polyclonal Gammopathy
, .
. PTH .
?
.
. Parathyroid
. .
. ). (Multiple Myeloma

.31 17 .
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,
, 3-
.
?
.
.
.
.

.37 28 ,
6 .
. . :
, FSH + LH,
.
?
.
. MRI
. ) nocturnal penile
(tumescence
.

.32 ,28 ,
,

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,
. ST
ST .AVF ,2,3
?
.
.
.
.
)(.
. .
. .

.

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-
.clindamycin+ciprofloxacin 3
4 .
,C38 10
, . 30,000
.
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.1 ?
. ,
) ,(Metronidazole .
. , -
(Clostridium difficile toxin) CDT
'
, CDT
.

. , CDT

.33 47 .Hodgkin
,
. PET
.
) ,(stage B-
?B
IIA .
IIB .
IIIA .
IIIB .

86

84

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.
, , .
25.
ASA-5 - .
CRP-1 ,70 5 .
?
. methotrexate .
. ) (cyclosporine
.
.
. Infliximab

.
.
.

,
.
CT , PET
,
anti ,endomysial, ASCA
.IgA
ERCP,
.

.44 ,60 ,
.
. .
8 .
.2 ?
.
.
6 -.
.
.
.
acid fast ,
.
. ; , ,
LDH .

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) ,(giibenclamide )(simvastatin
.
.
30" . % ?
.
.
.
.

.45 35 ,

. ,
,
.
C-ANCA , .
?
.
CHOP -
.
. DIC -
E. coli-
- ) Hemolytic-uremic
.(syndrome
.

.
.
Wegenr's granulomatosis
.

.41 ,74 .
- ) (mid-systolic
, ,
. ,
. .101/86
0.8 ,
45" .
- ,
.35% -
.
?
. ,
3 ,
.
. 3 ,
ACE
.afterload .

.50%
. .
.

.46 25 ,

3 .
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(descriminant factor .40
?
DF . ,
.
. .
. .
. TNF
.

.42 ,16 ) .rheumatic fever (RF

?
.
.
.
Strep.A.
.
.Jones
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.
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20- .
- .

,
. /
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. FVC--69% .
100% FEVl/FVC ,FEV1-78% .
?

87

85

.
.
.
.

.

.

.
,

.
.
.
.

.48 38 6
.
130 .
, ,BMI 32- 160/94"
,
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1" . ,
.
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.
.
. 24.
. ACTH .
. MRI .

CT
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. mg/dl 95 LDL -
. mg/dl 170 LDL -

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98

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.5 ,37 ,
,
.

, .
?
.
.
. .
,
.

.11 .72 .

.

117

115

 35)," ( .
, ) (Ejection Fraction .55%
?
.
.
.
, 55% .
. ,
,
.
.
.

.
.
.
.

.

.
.
.

.17 34 .
. .
- 8 - .
140/ )
.(135-145 ) water
,(deprivation test 148 -
/ . ,
.
) Antidiuretic hormone
(vasopressin ,
.
?
. .
Nephrogenic diabetes insipidus .
Central diabetes insipidus .
Primary polydipsia .

.12
?Bone Mineral Density
. 60
.
. 60 .
. 60 .
. 60
L4 .
.13 40 , .

, ,
4- .
3 , 2-
.
?
TSH .
. H. pylori. -
. HIAA- 5 -
. .

.18
, ?
. Pyelonephritis
,
.
. ,
.
.
10
.
Pseudomonas Aeruginosa .

.

.14 30 - ,
, , .
.
?
Acute Ihyroiditis .
Subacute Thyroiditis .
Grave's Disease .
Hashimoto's thyroiditis .

.19
?Ankylosing Spondylitis -
. .40
.
.
MRI .

.15 ,18 .

. c40 ,
,80/40 )
( .
.
?
. .IV acyclovir
. .IV doxycycline
. )(.
.
.
.

.20 .60 /
.
12 . . .II
Simvastatin + Amlodipine -
.Metformins +
?
.
.
. .Metformins
. .Amlodioines
.21 .60
10
" , . -
,
. . )
,(35 80/40" .

.16 20
.
. ,Ampicillin-
.
.
?

118

116

 . US -
. :
.
100 ."
10 ."
100 ." ,
.22

.WBCs/hpf, many pigmented casts

?
. -
.
Rhabdomyolvsis
.
HIV nephropathy .

?
.
.
.
. .

.28 Crohn's Disease

?Ulcerative Colitis
. ASCA
. .
. - .
. .

.23 30
Hepatitis .:
IGG positivenegative - HBs-Ag , ANTI HBc
,Anti-HBs - Ag positive .
?
. HBV.
. .HBV-
. .HBV
. .HCV

.29 ,16 , :
" ; ).AST - 18 IU/L (Normal 5-43
)Total Bilirubin - 40 mol/l .ALT - 21 (5-60
)- Alk. Phosph .Direct bilirubin - 4 mol/l (1-5
.LDH-280 IU/1 , 260 IU/L
?
.
/.
. Primary Biliary Cirrhosis -
.AMA -
.
.Ultrasound
. .

.24 ?
. .
.
. .
.

.30 71
) FFP ( . -
.
- .
.
.TRALI ?
. HLA
.
.
).(leukoreduced
. Anti-
platelet antibodies.
. ) Washed
(FFP.

.25 86 .
.
.Ramus pubis -
. ?
. .
. D
. D.
. ,D
.
.26 , ?
,
.

.
24
.

.

.
.

.
.

.31 ,50 ,
. : 100/60"
.:
Blood:Na:130 mmol/L (Normal 135-145), K6.8 mmol/L (3.5-5). glucose: 9 mmol/L (4.46.5) Urine: Na: 50 mmol/L (135-145), K: 34
) .mmol/L (high

?
. .
. .
. Anti-Diuretic Hormone -
.

.27 .21
. ,38.8
.
" 175/100" . 110 . .38.8
:

.32 75
.

.Alendronate -

Creat: 350 mmol/L (Normal 60-110), BUN: 15

)mmol/L (3.5 - 7.2), K+: 6.0 mmol/L (3.5- 5
Urine: SG: 1.010 pH: 5.0, protein: trace,
Urine sediment: 1-3 RBCs/hpf, 1-3 +blood: 4

119

117

 .
?
. .
. .
. .
. .

.
.

.38 74 Multiple
,Myelomas
.
, . .:
,
. : 57 -/ ) ,(60-84
30"/ ) ,(35-50
.
. ?
. . ,.
.
.
.
.
. .

.33 .19 .
. ?
. 10
.
. .
. Human rabies immune globulin
.
. Post exposure prophylaxis
.
.34 55 39 3
.
.
24 . 98 . 106/72
.88%
.
,BAL
BAL .
?
Amphotericin .
Piperacillin/Tazobactam .
rimetoprin/Sulfamethoxazole .
Penicillin .

.39 IgA
,Nephropathy ?

.
.
.
.

.20

.
IgA

.40 ?RA
.
. RA- DIP -
. ) (Baker's Cyst
.
. RA- -
.

.35 50 II 15
.
100 ,
20" .

. ?
.
.
.
.
.
.
.
.

.41 ?
. ,

.
.

.
.


.
. "
.

.36 ,17 10
. ?
cANCA ..
. C3
. .C4
. .IgA

.42 68 prosthetic valve endocarditis

Streptococcus viridans-
) ,(MIC=0.01 + Gentamicin -
Penicillin 10 .
, ,

S.viridans .
?
.
.

.37 50 .
. - ,RBC-casts
C-ANCA .
Necrotizing Vasculitis
?
Systemic Steroids and Septrin (Co.
.

.Systemic Steroids and Thalidomide

.Systemic
Steroids only

)Trimoxazole
.Systemic Steroids and
Cyclophosphamide

120

118

.
.
.

?
NSAID - (Naproxen) .
. Allopurinol .
.Prednisone
.
probenecid .

10 -".

.43 .
.160\90

?
.
.
.
(Anti-Centromer Ab) .

.48 50 .
.
)k=3.0 /1
,meq 5 .(3.5
.
.
.3
?
.
QT .
.
.

,
. ,
.

.44 60
.II :
150/ ) ,(60-110
+4 ,
. 10 - .

. ?
.
10
.
.
3-4 .
.
.
. < 500
/
5-10.

.49
?
.
.
.
.
.50 - 6 22
.
?
. .
. .
. Direct anti-globulin
. Soluble transferrin receptor

.45 45 , 3 .
,c38 .
.
.
, CT -
.L 1,3-4
?
Echinococcos
.
.Lymphoma
.
.Endocarditis
.
Brucellosis
.

.51 80
.
, .

. .
.4
?
. .
. .
. ).(AICD
..
.
.

.46 ,32 ,
. :
PT , PTT ,.

.PTT
?
DIC .
. VIII
. .
. .K

.52 17
,c38.5 ,
.
5 .
, .
?
. )(Infectious mononucleosis
. )(measles

.47 .70 .
.:
200\ ) .(60-110
7\" ) CRP ,(3-8 .
.
.2
121

119

.
.

)(chickenpox
)(Rubella

.53 30 .
(Mantoux) PPD
14' . .

. ?
. PPD 15-
.
.
9.
.
.
.
. .

.59
) (AML
) (cytogenetics?
.
.
.
.
.
.
.
.

.55
Sickle cell -
?anemias
Extramedullary hematopoiesis .
.
. -

.60 .30
.
. - , .

.
.50
?
. ESRD
.70
. .
. .
. .

Parvovirus

.58 ,30 .

.

. .
) ( -
,
. ?
. 3
, .
.

.
.
.
).(LABA

.54 14 .
) D(Rh) - :( . .
.D-
?
. D+ D
.
. ,
.D+
.
D.anti
. D+
D.anti

.
.

RF.
ANTI-CCP
RF.

.

.

.56 ,47
.
. -
. . -
, ,
.
?
. .Direct anti-globulin
. HCV-- . HBV
. Schilling .
. .

.61
?(Primary Hyperaldosteronism) Conn
.
.
Adrenocortical -
.
.Hyperplasia

.

.
.

.57 . ,30

.:
.:
, .
CRP : RF ,,
ANA ANTI-CCP , . ?
. OVERLAP SYNDROME

.62 .
?
27 ,HIV
.
" . .

122

120

 .
HRCT .7
/?
.
.
.
.
.
.
.
.

. ,50 .

. ,47 , ,
.
. ,20
.

.63

Disseminated Intravascular Coagulation

) (DIC ?

.
.
FDP .
aPTT .
.64

.
.
.
.
.65

.
.
.

.
.
.
.
.67

,34 ,
.
.5mm X 6mm
CT .
?
,
) ,Broncho-Alveolar Lavage (BAL
.
.CT
PET
.
CT 3-6.

.69 ,
?
. .
. -.
. .
. .

22
DVT .
DVT .
?

.
DVT
.

.

.

.66

.68 19 ,c39
5
.
tache -
) noire( . ?Penicillin .
Resprim (Co-Trimoxazole) .
.Quinine .
.Doxycycline .

.70 ,75 7 Ceftriaxones

. ,
.
,c39 .
) microliter/39,000 .(4,000 - 10,000
?
. , Metronidazole
.
. , .
. Vancomycin
.
. ,
.

:
- ,80 55 ,
135\' ) .(60-110
- ,50 55 ,
135\' ) .(60-110
Glomerular Filtration Rate -
?
GFR -
.
,
GFR-n
.
' GFR '.
GFR -
.

.71 50
.
.

.
?
Membranous Glomerulopathy .
Focal and segmental glomerulosclerosis
.
IgA Nephropathy .
Minimal Change Disease .
.72 53 ,
.(NSTMI) ST
.
, .
.
?
.
.

60
. :
FVC 55% FEVI-50% . ,
) FEV1/FVC-0.82 ( TLC . 53%
, DLCO .40%
123

121

.
.
.

.
.
.
.

.
.
.

.78 35 ,Ulcerative Colitis-

) .Aminosalicylic acid (5-ASA
,
. : ,38.5 ,110
. .8
?
. .
. .
. .
.
. .

.73 EBV (Epstcin -

?(barr virus

.
.
.
.

)Pneumocystis Jirovecii (Carini

Mycobacterium Tuberculosis
Streptococcus Pneumonia
Klebiella Pneumonia

,
.
.
.

.

.74 ,54 -
,Hepatocellular carcinoma
,HBV
.
- .
.
.
Optalgin (Dipirone) - 1
4 , ) Oxycod (Oxycodone
. ?
. ,NSAIDS
Ibuprofen 6 ,
.
. ) Oxycod
( - 6.
. Oxycontin
) ( ) Oxycod
(.
.

.

.79 .19 .
. .
. : .120 - .90/70
24
.
. .
500) %
120 (%
?
. ANION GAP.
. ANION GAP.
. ANION GAP.
. ANION GAP
.
.80 ,66 , .
) 305 ,
( , . ,
.145/89 -65
.LDL ?
. .
. .
.
.prehypertension
.
.LDL
. LDL
.120/75
. . LDL
.130/80

.75 ,60
) .(38%
,
.
?
. .Angiotensin Converting Enzyme
..
Aldospirone
.
. ).(Furosemide
.76 ,70
) .(Aortic Stenosis = AS:
, .
AS .
.
. ?
. , ,ACE
.
.
.
. .
.
.

.81 .50 Ulcerative Colitis

)AminosalicyIic acid (5-ASA 5
) ,Imuran (Azathioprine 3
, ,
.
.
,
,
.

?
.Ibuprofen .
.Allopurinol .
.Probenecide
.
.Prednisone .

.77
?AIDS

124

122

 .87 Digoxin-

.82 67
.
.
. ST
.
.
" "ballooning ,
. ?
. .

) (spasm
.
. .tako-tsubo
.
. ST
.
) (NSAIDS
.
. Post Traumatic
Stress Disorder ) .(PTSD

.

?
Phenytoin (Dantoin) .
.Quinidine (Quiniduran) .
).Amiodarone (Procor
.
.Verapamil (Ikacor) .

.88
) Amiodarone (Procor ?
. , .
. .
. .
. .
.89 - ) IADL (Instrumental
Activities of Daily Living ,

?
.
.
.
.

.
.
.
.

.90
.
) .(Familial Mediterranean Fever (FMF
?
.
MEFV
. .
. .
.
.

.83
) ,(cardiac arrest 7-8 .
?
. J300
VT . VF
. .
. .
. .
.84
(Systemic Lupus Erythematosus) SLE ?
Arthralgia
.
Pericarditis
.
Discoid rash
.
Lymphopenia
.

.91
COPD ?
. ) (DLCO
.
. .Residual Volume (RV)-
. FEVl - .FEV1/FVC
. ) Total Lung Capacity (TLC

.85 ,86 .
.
, .

?
.).(Calcium
. ).(Sodium
.).(Potassium
.).(Glucose

.92 ) Celiac
(disease ?

.
.
.
.

.86 50 .
, ,.
- 48% , )Normal 60-100%
.(PT .

?
Ag . - Hbs HBV-surface
Anti-HCV . .HCV
IgM-HAV . .HAV
) Anti Smooth-Muscle Ab .
(

.
Diabetes Mellitus Type 1
.

.93 ,
?
..
. .
..
. .
.94 A
, ?
Ventricular Tachycardia .

125

123

.
.
.

Complete Heart Block

Atrial Fibrillation
.Tricuspid Stenosis

.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.11
.12
.13
.14
.15
.16
.17
.18
.19
.20
.21
.22
.23
.24
.25

.95 70

.
?
. .
. 24.
. .
. .
.96 60
.
. .
.
?
. .
. CPK .
.
.
.
.
.97 ,40 , ,
.

?
. ).(GERD
. .
..
Post-Nasal Drip .
.98
?
NSAID. .
.Bisphosphonates .
Beta-Blocker. .
.Anti-Platelets .

126

124

.26
.27
.28
.29
.30
.31
.32
.33
.34
.35
.36
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
.47
.48
.49
.50

.51
.52
.53
.54
.55
.56
.57
.58
.59
.60
.61
.62
.63
.64
.65
.66
.67
.68
.69
.70
.71
.72
.73
.74
.75

.76
.77
.78
.79
.80
.81
.82
.83
.84
.85
.86
.87
.88
.89
.90
.91
.92
.93
.94
.95
.96
.97
.98


- 3000

Na+: pCO2: 40, HCO3:17, Cl: 100 / ,7.20

.K+: 2.7 mmol/L ,135 mmol/L

?
.
.
. , ,

. ,

.1 ,20 " ,
.
.

20
" , .
.
?
. .
. FNA .
. US .
. .
.2

.7 "
" . -
Fludrocortisone
?Hydrocortisone
. .
. .
. nonfunctioning pituitary
macroadenoma.
. .

,30 ) Ulcerative
(Colitis 5- . -
.(Rafasal (Mesalamine

. .
, .
Alkaline Phosphatase 600

.8
?
. T .
. ST .up-sloping
. .
. .

IU/L (normal 20-140) Gamma-GT 560

.(IU/L (20-75
.
?
. -
.Rafasal
.Primary Biliary Cirrhosis (PBC) .
.Primary Sclerosing Cholangitis (PSC) .
. A ).(HAV

.9 35 ,

.
. " ,
. .
?
Insulinoma .
Glucagonoma .
Gastrinoma .
VIPoma .

.3
?Legionella pneumophila -
. .hypernatremia
. 90%.
. .
.
.

.10 40
3 . -
,
. - .50
. , 4 + -
1.5 24 . RF - -
ANA . ?
. .
. .Methotrexate-
. ).ACPA (anti CCP
. .Cyclophosphamide-

.4 ,30 ,
.
5"
4 .
?
. .
. .ASCA
..
CT ..
.5

:
,FVC= 82% predicted ,FEV1/FVC = 0.54

.11 75 )"(.
[ (Atenolol (Normiten --]
[ (Amlodipine (Norvasc - ].
Amitriptyline -
)[ (Elatrolet -] .
.
?
. Amitriptyline
.
. Atenolol
.

= FEV1= 60% predicted, post broncodilator

.TLC= 180%, RV= 190% ,+6%

?
.
.
(Idiopathic Pulmonary Fibrosis (IPF/UIP .
rheumatoid arthritis associated ILD .
.6 60 , , ,
.pH: :
127

125

.
.

.
?
.
.
.
.
. .
. 5-7.

Amloipine
.
).Oxybutynin (Novitropan

.12 -
?Pancreatitis
Prednisone .
Metformin .
Simvastatin
.
Azathioprine .

.18 ,
,
.
.
.acute HIV syndrome -

?
.p24 antigen levels .
. .CD4
. HIV -.ELISA -
Western Blot ..HIV -

.13
ampicillin
?
. ,20 .
. 45
5.
. 45
.
. .30

.19 47
.
5-" ,
.
Polycythemia vera ?
. .MCV
. .JAK2
. .B12
. .

.14 30
.
.
, .
.

?
Staphylococcus saprophyticus .
Enterococcus faecalis .
Chlamydia trachomatis
.
Borrelia burgdorferi .

.20 ,73 - .
."
106 .
rhythm
.control
.
?
. 80
.lone atrial fibrillation
.
.
.
.
. .

.15 )Exenatide (Byetta

?
.
.
. .
.
.
.
.
.16 30 .

) .(ICS

,-
.
. ?
. - 3
, .
. -
.
.
) ,(LABA .ICS
. ICS-
).(LABA

.21 35
.
.C39.8
,
. -

?
Campylobacter jejuni .
Shigella sonnei .
Salmonella non typhi
.
Entamoeba histolytica .
.22 29 ,
, .
, .

.17 15
. 3

128

126

 . .

, ) x,y
(descents .
?
.Cirrhosis .
Nephrotic Syndrome .
Left-sided heart failure
.
Constrictive pericarditis .

Hemoglobin 6.3 g%, MCV 100, WBC

.13,000, Haptoglobin 0%, PltNormal

?
. B12 .
. .
. .
. .
.23 65 ,20 ,
.
CT
2.5" .RLL

?
. .
..
..
. .

.28 ?Acute Interstitial Nephritis

. 3
.
.
.
. ,
.
.
.

.24 70 .
.
.-
, .
. ) (
.
?
. HLA-
.
. -NSAID-
). (allopurinol
. ,
.
.
.

.29 ,30
Hepatitis
.anti-HBs antibodies- :
.negative, HBsAg-positive, anti-Hbc-positive
.
?
. HBV-.
. .HBV-
. HBV-.
. .HCV
.30 ,84 .
.
, .
,38 , .
.60" ,
.40 , TSH .
?
. .
. ,
.
. ).(EPS
.
.TSH

.25 ) anion
(gap?

.
.
.
.

.
.Metformin
.
.

.26 ,39 Acute

.Myeloid Leukemia : ,

, .
Na+: 136 mmol/L (Normal 135 - :
pH: K+: 8.9 mmol/L (Normal 3.5-5) (145

.31 .
PPD 13 .
PPD- 6 . ,
. ?
. .
. .
.
. . PPD
15 .
. .

4 .

)7.35, Creatinine: 65 mmol/L (Normal 60-110

)ECG: normal sinus, .BUN: 3 mmol/L (3.5-7.2
.no ST/T/QRS rhythm changes

?
. .
. .
. Kayexalate .
. .

.27 ,76 .
.
.106/87 ,
, ,
, .
, ,shifting dullness -

.32 ,25 .

, " .
,

129

127

 " .
.
?
US ..
. .
. .
....

,
. ,CRP<0.5 .16
?
. .
.(Azathioprine (Imuran .
. .TNF
. .

.33
?Staphylococcus aurous
. 1-8
.
. .
.
.
Staphylococcus aureus .
.

.39 40 .
Shirmer
.

?
pANCA .
anti LA ( SSA) .
dsDNA
.
anti centromer .

.34 36 .
.
Schober .
?
. .
.HLAB51 .
. .
. .NSAID

.40 ?Delirium
.

.
.
.
.
.
. ,
.

.35 ,79 .
.
) (Nasogastric tube .
?
. ''.
.
).(Suctions
.
.
.
).(PEG

.41 .
) (...
.Mycobacterium tuberculosis
.
?
.
).Tuberculin Skin Test (TST
.
.
.
.
. Isoniazide
.

.36 78 .
.

.
?
Aspirin .
Aspirin + Plavix .
Coumadin
.
. .

.42
?COPD
.

.
.
.COPD-
.
COPD
.
.
COPD
.

.37
?
Cystic fibrosis .
Usual Interstitial Pneumonitis (UIP) .
Eosinophilic Pneumonia
.
Emphysema .
.38 ,42 )(Crohn's Disease
20 .

. 5-
. .RLQ-CT-
20"

.43 -
?Diffuse large B-cell lymphoma
. rituximab
.cure-

130

128

.
.
.

) (relapse
.

.8;14
80%-
.

Clostridium difficile diarrhea

.49 ) (increment
6
, ?DIC
2000 .
5000 .
50000
.
10000 .

.44
)< (50% ?DVT
. .
. .
. .
. ".

.50 ,30
.HBV- ,

. HBV-DNA
600 ) ( ,
) AST (ALT- .
?
. .
. .Lamivudine-
. .Interferon alpha -
. .Tenofovir-

.45 54 ,
. - LV
LVEF .32%
.ACE
?
.Spironolactone (Aldacton) .
.Beta-blocker or Verapamil (Ikacor) .
Beta-blocker and Spironolactone
.
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. .

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132

130


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.65 22
.
. :
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(K+: 2.7 mmol/L (Normal 3.5-5
)pH: 7.30, HCO3:17 mEq/L (Normal 18-24
( Cl: 110 mmol/L (Normal 98-108
Urine electrolytes: Na:5 mmol/L, K:10
.mmol/day ?

.
.
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. ACTH 7-8.
. MRI .

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.
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)
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Cerebral toxoplasmosis .
CNS Cytomegalovirus (CMV) infection .
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. ?
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.
.
.

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) .(14
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..
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.

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.

134

132

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. ).(Pleuritis
. .
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?
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.
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. Enterococcus
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. Bartonella
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.87
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.
-.
. -.
.
-.
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.95 ?
.
.
.
.

Bronchiolitis Obliterans organizing

.pneumonia
.Pulmonary Langerhans cell histiocytosis
.Adenocarcinoma of the bladder
.Desquamative interstitial pneumonia

.88
, ?
Prostacyclins .
ACE inhibitors .
.Phosphodiesterase-5 inhibitors .
.Endothelin antagonists .

.96
?
Cataract .
Hyperkalemia .
.Myopathy .
Osteoporosis .

.89
?
. 50 .
. 38 .
. 19 ,
.
. 30 - ,,
7 .

.97 H. Pylori-
?
Gastric Ulcer .
Gastro-Esophageal Reflux Disease .
MALT Lymphoma .
Gastric Carcinoma .
TIMI-risk score .98 Non-ST elevation acute
coronary syndrome

.90
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,
.

, ?
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. .
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?
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.
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. - .
. .
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.
.
.
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.
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133


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.16 .41
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.51
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136

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MCV .88
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. .
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Anti endomesial antibodies .

.2

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,
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methicillin susceptible Staphylococcus
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methicillin resistant Staphylococcus
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methicillin susceptible staphylococcus
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Methicillin resistant Staphylococcus
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viral load , , CD4 .150
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.
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Herpes simplex type II .
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.10

137

135

91 .
.

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.
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.

.15 28 38.5 ,

.

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Shigella -
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Shigella flexneri .
Shigella boydii .
Shigella sonnei .
Shigella dysenteriae .
Shigella suiss .

.11 30 .
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.
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. .
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mononeuritis multiplex .
glomerulonephritis .
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Subcutaneous nodules .
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. 0.7 ,
, 70,000
,,

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. 1000 ,
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anti-smooth body antibodies .
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.
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.
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.
138

136

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.
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. VIII
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.
.
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, .
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, 1.6
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.
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Non-Hodgkin lymphoma .
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.26
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. .
. . 160/100" .
. .
..
. .
.27 40
, ,
210/127" .-
1.7"/" , 8.7/"
87,000 .

?
angiotensin converting enzyme inhibitors .
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prednisone .
cyclophosphamid .
anti-TNF .

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. octreoscan -
. PH
MRI ..

.28
?
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Bleomycin . .
Melphanan . .
Cyclophosphamide .
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.23 28

.
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,
139

137

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.
.

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chorea .
erythema marginatum .
arthritis .
subcutaneous nodules .
group A streptococcus infection .

.31 ,80 , ,
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.
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.
Cyclophosphamide, daunorubicin .
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.38 60
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, PND-
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.40 ,
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140

138

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.
.
.
.

. .

4.5".
BICUSPID AORTIC VALVE
5.3".
MARFAN
4.5".

.
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. CT
.

resistant Staphylococcus aureus

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Enterococcus faecalis

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139

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5 ,
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SIADH .
.

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?
FEV1/FVC . RV , FRC ,.
FEV1/FVC . RV , FRC ,
FEV1/FVC . RV , FRC ,
FEV1/FVC . RV , FRC ,
.

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AST . ALT-
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spider angioma . .
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.
.
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. Direct Coombs test
. rapidly progressive
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. ADAMTS-13

.57 sickle cell

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.
.
.
.

.

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parvo B19 virus
.
acute chest syndrome
.
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.58
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142

140

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.

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clarithromycin

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clarithromycin cefuroxime -
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ceftriaxone - -
azithromycin

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ceftriaxone - -

.68 , 56
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azithromycin

.

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143

141

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PML-RAR fusion protein .

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.
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, RBC , 700"
. .
?
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.
anti-GBM disease .
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.
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.
..
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.

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.87 DIGOXIN ?
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.
.
Unstable angina .

.18 Acute
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.
.
.
.
.

.26
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.
.
.
.

.27 ,75

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.
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. ,8 PTH ,2.2

. ?
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. D
PTH .
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.22 ,55 ,
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. - ,
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. ?
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.
.
.
.

:
Amiodarone .28
Heparin .29

.
.
.
.32
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P02< 60 .
Cor Pulmonale .
Cor Pulmonale + P02< 60 .
Polycythemia + P02 <65 .
PC02 >45 + P02< 75 .

.21 ?
.
.
.
. 6

236

 .

.
.

.31 ,65
?
.
.
.
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.42 ,
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.
.

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.
.
.

.33 (
)?
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.

.42
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.
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.

.34 ?
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Ca .

.43 ,57 ,
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,
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?
.
.
.

.35 ,
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.
.
.
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.36 ?Hepatorenal syndrome

Non Oliguric RF .
.

.

.45 ,76 ,
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.
.
.
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.37 NIDDM 1/2-

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,UREA=33 ,Ca=0.8 ,HbAlC=6,5 ?
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. 120/80
.
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SVC SYNDROME .
.
.

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237

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.

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.
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.

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.

.54 .
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.
.
.
.

.61 TB?HIV -
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Load
.

.55
.
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.78 ?
.

.

238

.
.

,
HIV

.62 ?barret esophagus

. PPIs
.

.
.

30

AVF^ ST, 2,3

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.

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. 40 70
. 55 ,
.
. 60
. 70 Hb=10.7, MCV=107

.72-71 ?
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.
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.
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.64 40 .
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.
. US-
.

.71 __ -
.72 __ -

.73
, ?
.
.
.
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.65 ,
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PTT .
.
.
.66 .45 ,.
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.
.

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. ,

.

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.
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. whole blood
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.

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.

.69 ,18 ,
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.
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.
.

.78
?
.
.
.
.
.

.70 ,50 ,
, , .

.79
?

239

.
.
.
.
.

30

.
.
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DIP
Radioulnar carpal

.87 30
PCP .PC02=36 ,P02=56 :
?
. +
.
.

.80
?
.
.
.
.
.

.88 43 , , .
?
.
CPAP .
.
.

.81 36
: ,+++ ,0
,0 .0 ?
IgA nephropathy .
Membranous proliferative .
MCD .
Wegener .
Goodpasture .

.89 25 ,50 .
anterior uveitis . ?
psoriatic arthritis .
reactive arthritis .
ankylosing spondilitis .
.
Rheumatoid arthritisGoodpasture .

.82 SLE
4
.
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. ,
.
. ACE
.

.90
?
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.
. 72
.
. 89%

.83 , .
?
.
.
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.
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.91 2 .IHD
?IHD -
.
. . . 140/90
IHD
.

. THD

.84 ,25 , .

. -
,
.
?
.
CT .
.
.
.

.92 ?Prinzmetal angina

.

.
.
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.93 ,85 T
( ,)V1-V4 QRS
?
Isoprel .
.
calcium gluconate .
.

.85
, ?
.
.
.
.
. CT

.94 60 DKA
, mg%180

.86 RA
?
MTP .
MCP .
240

, 3.6 ?
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 .
DVT .
DVT .

.
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.102 ,46 .

.

.
.20% ,
. ,110/70
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. -

135
136

4.1
4.3
BUN
60
96

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5.7

+1
+1

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?
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.
.
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.
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?
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. DVT
.
.

?
.
Prerenal Azotemia .
.
.
Allergic Interstitial Nephritis .

.98
,HP?
. ,

.

.
. MALT -

.103 -
( 400") ,
140/85 .90 .
?
. CT , ,

.
.

Lymphoma

.104 -
HbSAg antiHbS , antiHbc ,,
antiHCV . ?
. B C
. antiHDV
. ,B
, C

.99 ,NIDDM, HTN ,60 ,

, ,
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?
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.
.
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.

.105
?
.
.
.
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.

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:

130
140

4.3
4.6

1.1
3.1

28
35

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. , ,

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US .
.
.
. ACE
.

.107 24
.
,
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.
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.

.101 LMWH ?

241

 ,90%- .60%-
?
CABG .
. Prox LAD -
.

. X-Linked

.108 ?
SLE .
APLA .
.
Wegener Granulomatosis .
PAN .

.117 55 .
.
(,D-DIMER ,PTT ,PT
- ) .
Packed Cells ,FFP - .
?
TTP .
DIC .
ITP .
. vWF
.

.109
?CRF-
.
.
.
.
.110 ,

. :
. ?
. ACTH
.
. ACTH

.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.11
.12
.13
.14
.15
.16
.17
.18
.19
.20
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.22
.23
.24

.111 Complete AV
,block Ml , ,

?
. DDD

.
.
.112 Temporal Arteritis
. ?
PPD .
.
.
.113 .
.INR=-5.6 -
?
FFP .
VitK + FFP .
VitK PO .
VitK IV .
.114 23 .
. 5
24 , : ,126 -
,25 - .83 -
?
SIADH .
Compulsive Drinker .
Central DI .
Nephrogenic DI .
.115 T
?
.
. 70
. 30
.116 -
Marginal Artery Proximal LAD ,70%-
242

.25
.26
.27
.28
.29
.30
.31
.32
.33
.34
.35
.36
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
.47
.48

.49
.50
.51
.52
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.56
.57
.58
.59
.60?
.61
.62
.63
.64
.65
.66
.67
.68
.69
.70
.71
.72

.73
? .74
.75
.76
.77
.78
.79
.80
.81
.82
.83
.84
.85
.86
.87
.88
.89
.90
.91
.92
.93
.94
.95
.96

.97
.98
.99
.100
.101
.102
.103
.104
.105
.106
.107
.108
.109
.110
.111
.112
.113
.114
.115
.116
.117

- 2003 '
.1 ?
Quinidine .
Vincristin .
Daunarubicin
.
Heparin .
Clopidogrel .

.9

.2 LIFE LVH
?
.

CVA
.
.

20 2 .
3
,

80 , 120
6

?Pure AR
S1 .
.
. ( )
.

.10 ? S2
LBBB .
.
ASD .
.11 ,
B12 . D
, ?
.
. 40% - Anti ASCA
Pentasa -
.

.3 (
) ?
. 50
Morbid Obesity .
. HIV
Portal Vein Thrombosis .
.

.12 HCV .
,
, "
, . :
, 110 .
Hb : , 16000 ,
,200 - LDH ,78 - ALT ,112- AST ,
Alk. Phos ... .
, ?
.
.
CT .
.

.4 ?
.
. 2
.
.5
AR - , ?
. , -

. 6-
.

.13 , -
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?
.
.
.

.6
, .TTE
.Strep. Bovis -
.2.. . PR (st 1
.)Degree AV Block ?
. 6-4-
. 3-
.

. TEE
. TEE

.14 90 .Ml 6
.
?
.
.
.
.
Staph. Aureus .

.7 .
2/3 .
?
.
.
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.
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.15 .
,PPD=15
,Latent TB - ?
.
. 4-3-
.

.8 ?
.
50

01

243

 .23 47 10-
. .110\60
.. . ST .
?
.
. tPA
Primary PTCA .

.16 , ?
. LDH<0.4 PE
. pH=7.3 ,LDH>0.7

. TB - ,50%-

. ,TB

?
__ - TPN .24
__ - Halotan .25
__ - Chlorpromasin .26

.17 ,
Levofloxacin -
. 5
( LUL ).
?
.
.
.
.

.
.
.
.
.

.18 ,
ACE ,
(.)perihilar adenopathy
?
.
Open Lung Biopsy .
CT .
.

.27 ,70 50 ~ .2
.
?
. CCT 50
. CCT 20
.
.
CCT -

.19 ,Hb=8.5 ,
, ,12.4
.
?
.
.
.
.

.28
, .Brisk -
, .. . LVH.
?
AS .
Hypertrophic Cardiomyopathy .
.

.20 80 .
.
?
. +
. +
.
.
. +

.29 ?Small Pox

.

.
Disseminated Variolla -
. ,

.21 27 1100 ,
1900 .
?
.
.
SAT 89% .
PC02=32.4 ."
P02=95.5 .

.30 ?
.
.
. ACE
.
.31 AntiJo1 .
?
.
.
.

.22 . 20
.
?
.
.
.
.
. .

244

Intrahepatic Cholestasis
Hepatic Stenosis
Toxic Reaction
Idiosyncratic Reaction
Toxic & Idiosyncratic Reaction

.32
. Q
Fever ,Doxillin 3

. ?
. Candida Esophagitis -

00

.
.

TEE

.40 ?
. O
.
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.
.

.33 ,
,
. .
?
.
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.
. 36

.41 ?
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55
.
.
.
.

.34
. ,
DLCO . ?
.
.
.
.
.

.42 38 ,,
IgM , ANA ,AntiKLMl ,

, .
?
.
Ursodeoxycholic Acid .
.

.35 '
.

. ?
PC02=48 .
. P02 -
.

.43 Waldenstrom -
,macroglobulinemia ,IgM
?
.
.
.
.

.36 .
?
.
IgE .
RAST
.
.
.

.44 48 RBBB . -
150. ...Wide .
Complex Tachycardia ,RBBB
?
Dcacor IV .
Adenosine IV .
Procor IV
.
.

.37 ,

. ?
.
.
. + -

.45 ?Torsades de Pointes -

.
.
.
.
.

Monteleukasto

.46 .. . QT -.
..?.
.
. 3.5
Digoxin . 3.2
TSH . 100
CPK .

.38 65 Small Bowel Resection

. . 3
. : ,153
BUN 120 ,350 .
, ?
Central DI .
Nephrogenic DI .
Osmotic Diuresis
.
Hyperalimentation .

.47 ,120
,
?
.
.
. 3
. TEE
.

.39 .56
()
.
?
. Paget -
.
.

02

245

 .55
?
Acetyl Cysteine .
.
.
.
.

.48 ? CVA
. 10-12%
.
. 50-
,40%

.

.56 TPN
, ....
.
?
.
.
.

.49 80 ,
. ....
35 . ?
.
.
.
.

.57 Crohn's ,
.
?
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.50 .
.
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. .3 -
?
. Barter
.
.
.

.
.
.
.

.58
.
. 8 ,
.
?
.
. antiDNA ANA -
Open Lung Biopsy .

.51 48 , ,85\55
, . 240
?
Autoimmune Polyglandular Failure .
Hypothalamic Adrenal Insufficiency .
AIDS
.
.52 ,27
, ,
.
?
.
.

Meloidosis -
.
. 36

.59
?
.
.
.
.
.60 ?Polycystic Kidney Disease
. ESRD 30 20
.

.53 ?Mitral Valve Prolapse

.

.
.
.

.61 . US -
.
?
IgA Nephropathy .
Membranous Glomerulonephritis .
Membranoproliferative Glomerulopathy .
FSGS .
Amyloidosis .

.54 ,74
.
. 3 .
.Oxycontin 80mg 4xD
.
= 64 ,PC02 = 84
,P02 ?
.
. Andexate IV
Naloxon IV
.
CT .
. Dexamethasone IV

246

Cyclophosphamides
IV
Cyclosporine
Infliximab IV
Leflunomide +

.62 ?
.
.
.
.
.

03

 .70 , .
ELISA .HIV-
?
. Acute HIV
. Viral Load

. CD4

.63 ,,
TSH .
?
.
CT .
FNA .
.
.65
,syndrome ?
BCL2 .
p53 .
fas .
XIAP .

Li fraumeni cancer

.71
.
. ?
. +
.
.
.

.64 .
?
. 8
. ( )ACTH
.
. 24

.72 , .
Indomet .
.
. , ,
?
.
.
.

.65 6 ,
.
.
.
?
Secretin Test .
.
.
.

.73 ?HCV
. ALT
. RNA HCV
.
.
.74

.
,
?
.
HAM Test . CD59
.
. G6PD

.66 ?
.
.

.
.67 ,37
, ,
. ?
.
CT .
.
.

.75
, ,Hb=9.6 ,
,220 - MCV ,80
. ?
.

.
.

.68 .
.
.17-15 ?
.
.

. antiCD 20
.

.76 ,
C3 pANCA . .
.
?
AntiGBM Disease .
Wegener Granulomatosis .
FSGN .
IgA Nephropathy .

.69
, antiHBs AgHBs Ag ,
antiHBe IgM , , HCV.
?
.
.
Lamivudin .
. Acute Hepatitis B

.77 8 .
. .270

04

247

 80 .40
?
SIADH .
.
DI .
DI .

Small Cell Carcinoma .

Adenocarcinoma .
Bronchial Adenoma .

.85 ?Barrett's Esophagus

. 10

.
.

.78 PTT - 120 PT-.

,
?
APLA .
.
. 8
. 9
. von Willebrand Factor

.86 .
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?
.
.
.

.79 9- ,
?
. RNP
APLA .
AntiSm .

.87
. ?
. .
. .
. CT

.80
?Rheumatic Fever
. ,
.
Migratory Arthritis .
Huntington Chorea . .

.88 ,
.
?
.

.

.
.

.81 6
,
.
.
,
.
?
.
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. TSH
.
.

.89 ,60
.
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.
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.
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. .


. ?
.
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. "

.82 .
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.162 70 .
?
10 .
4 .
6 .
2 .

.91 ?
.

QT .
. "

.83 , , .
?
. ,
48
.

. 24
. 5% 48-

.92 ?ARBs
.
. ESRD
.

. LIFE

.84 ,12
.
?
Squamous Cell Carcinoma .
248

05

 . Saline
.
.

.93 ?
.
.
Dilated Cardiomyopathy .
.94 ?
.
.

.102 .
,
,
, .
?
.
.
.

.95 Viability
?
.
.
.

.103 ,
,
. .P02=89, PC02=30 -
?
. PEEP
.
.

.96 ?Hypertrophic Cardiomyopathy

.
.

. , Afterload

.104 .

PTH . ?
.
. PTH
.

Reduction

.97 ,
.
.10- 10 ,7
?
.
.

.
.

.

.105 ?HBV -
.
.
.
.
.106 ,
27 .
.
. ,
.
Peptide - .C
, ?
. 72
CT .
.

.98 35 .
.
.
.
?
.
. TPO
. T3
.99
.
. ,
?
.
.
.
. , D
RF .

.107 Traveler Diarrheal?

.
.
Rotavirus .
.108 ?Traveler Diarrheas
.
.
.

.100 Rheumatoid Arthritis ,

DLCO , ,
?
.
.
.

.109 ?
. 15
. , 9
. ,
6

.101 , -
BUN ,
, .
?

.110 , ,3
, ,2+ 5.6-
,6.3 . . ?
.

06

249

 .
.
.

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6
.
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.
.
.

.111 , ,
, .
?
.
.
.

.119
, . :
4- .:
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,1.6 .
?
. US
. ,
.
. Dubin Johnson
.

.112 COPD ,
.

. ,
. 100 . ?
.
.

.
.

.120 ?
. , ,

.
. 3

. .

.113 ,
?
.
JVP .
.
.
.

.121 ,
. ,
. ?
.
.
.

.114 58 ,
,
150\90
. .
?
.
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. INR 5-4
.

.122 ,17 ,1.60 50 ,

. 11
, 12
, ,
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.
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.

.115 CRF
, , .
. ?
.
. , 0.6
, LDL 130
. ,
1.3 - " , LDL 70 -

.123 ?
.
.
.

.116 LDL -
?100
. Ml 65
.
.
.
. HDL -.

.124 , .
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.
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.
.
.

.117
?
.
.
.
. 80
.

250

.125
, , ,
.
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. IV

07

 . IV
.

.134 . C-Peptide

.
?
.
.
.

.126 , . ,
.
50000 . ?
.
.
. ,

.135 ,67 , .

. ?
.
.
.

.127
, ?
.

MRI .

.136 ,50 ,
1 , ?
.
FNA .
.

.128 ?
.
.
.
.
.

.137 , ,
, .
, ?
.
.
.

.129 30 .
?
.
.
N
. N

.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.11
? .12
.13?
.14
.15
.16
.17
.18
.19
.20
.21?
.22
.23
.24
.25
.26
.27
.28
.29
.30

.130 SLE , .
,
NS AID ,
, ?
. NS AID
. +
.
. + A
.131 ?CRF
.
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.
.
.132 . 3-
.Staph. Aureus
?
. G
.
.
.
.133 ?
.
.
.

08

251

.31
.32
.33
.34
.35
.36
.37
.38
.39
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- 2004 '

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sulfasalazine .
gold .

.65 .
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FSGN .
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24

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26

259

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.116 ?thyroid storm -

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.
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.117 24 , ,
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carpal tunnel syndrome .

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27

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28

261


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262

29


- 2005 '

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Cushing Syndrome .
Liddle Syndrome .
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700 .
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IgA Nephropathy .
RPGN .

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32

265

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Klebsiella Pneumonia .
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272





106
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108

2005  
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102
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.

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. 45 - .110
?
.
.
.
.
.
RTA 4 .
.91 20
, ,
.
?
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.83
?Pre renal azotemias
. > 10
. < 40
Specific gravity . > 1.01
.
. 500
.
NaFE<l% .

279

45

.
.
.
.
.
.
.

AntiGBM .
pANCA .
. anti-dsDNA + ANA
ASOT .

.92 4
3 ,
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. GBM -
cANCA .

CT

.99 .
?
.
.

Nasogastric tube
.
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CT .
.

.93 , ,
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.

.100 ,54 ,
.
( .)9
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.
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.94 ,24
. RBC ,4+
.
?
membranous glomerulopathy .
minimal change disease .
RPGN .
FSGS .
MPGN .

.101 ?UC-
.
.
.
.
.
.

.95 40 10000
. .
?
.
.

.
.
.

.102 ?hepatorenal syndrome

.
.
.
.

.96 ,FMF- ?
.
.
.
.
.

.103 70
.
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500/ .
?
.
.
.
PE .
.
.
.

.97 ,23 .
anti HAV IgM : HBs Ag ,,
anti-HCV . ?
. B
HCV . C
anti HAV IgM .
A
. anti HBC IgM
. D

.104
?
.
.
.
.
IBS .

.98 20

.
. ?
PH .

46

280

.
.

.111 ,
, . ?
:
. TMJ
. 20
. .. TMJ-
. 60

. NSAIDs
.

Collagenous sprue

.105
?
. 50
. UC
.
. 80 ,
40
.
.106
. PPI - .
, ,
.
?
. H2
. Hi
.
.
.

.112 ,40
,
.
" .
?
Anti-Ro .
Anti-dsDNA ,ANA .
)anti SCL 70) Scl-70 .
Anti-La .
RF .
ANCA
.

.107 17 3 .
. -
.
, ?
. B12 -
.
.
.

.113 , COPD
,
.
, .
?
.
.
.
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.
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.
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.
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.

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.
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.115 ?
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( : )
.

ANCA 3 90%

.110 ,
() , .
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?
IGF-1 .
. / Congo red
.
GH .
.

281

.116 . ?
.
.
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47

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.117 28 B27
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.123 RA . NSAlDs +PPl

, 3 .
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.118 .
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.
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.
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.
.

.119 40 ,
PCKD , ,2
, .
8 .%
. ?
. IV
.
. 40 ACTH
X1 Diclofenac 50mg3 . 3
. 1 X3
NSAID
.

.126 , Ramipril -
,5mg/d ,
KCL . .150/80
.3.1 : ,45 .110
- ,140 ,2.8 12,27
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.
.
.
.
.

.120 36 "
.
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PTH .
PTHrP .
.
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).
.

.
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.127 22 .
HBV + HCV ,
. : 84 AST , - 92 ,1.2 -
. - ALT ,162 - Alk P
Gold standard?
. (
)
.
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.122 25
. -

.128
?

human oral mucosa antibodies

48

282

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.
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.

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126" %
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200" % ,
75

.
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.
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. 30

.129
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.
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MRI .
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.

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.
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.

.
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.
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?
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.
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. TSH

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. ACTH
.

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283

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49

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. 35
. "
.

Brain Natriuretic Peptide

.141
?
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. ,
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. BMI , LDL ,30
. LDL , BMI , 30
LDL . ,

.148 60 5
INR .3 -2
Staph
.aureus ,
. INR .1.4
?
.
.
.
.
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. K
. K
.
INR -

.142 25 , 2"
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. ?
.
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.
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.143
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.
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.
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CSF ,
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?
.
.
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.
.
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?
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.
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.151 65 5 ,
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. LP

.152 , ACE
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.146 ?
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.

51

284


.1 .32
.2 .33
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.8 .39
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.94
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286

2002,2009
On- 
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212

2041-2044

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1994

2020 ,2023

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319

The physical examination is remarkable for signs of anemia; about 20% of

patients have splenomegaly. Some unusual skin lesions, including Sweet's
syndrome (febrile neutrophilic dermatosis), occur with MDS. Autoimmune
syndromes are not infrequent.

:  20%-   

Most symptomatic patients complain of the gradual onset of fatigue and weakness,
dyspnea, and pallor, but at least half the patients are asymptomatic and their MDS is
discovered only incidentally on routine blood counts. Previous chemotherapy or
radiation exposure is an important historic fact. Fever and weight loss should point
to a myeloproliferative rather than myelodysplastic process. Children with Down
syndrome are susceptible to MDS, and a family history may indicate a hereditary
form of sideroblastic anemia or Fanconi's anemia .

: 
Idiopathic MDS is a disease of the elderly; the mean age at onset is 68 years.
:

   
RAEB1- ;5%-    MDS-  
    
94-5 
(  40%   RAEB1/2) 10-19%  RAEB2-   5-9% 

Polyuria .1
.   
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: 211  ,16  .7
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CF ,  , 
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clubbing        , ' .clubbing-  
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. 
  -   
:(      ,  ) 94  ,16    .10
MYELODYSPLASIA
DEFINITION
The myelodysplasias (MDS) are a heterogeneous group of hematologic disorders
broadly characterized by cytopenias associated with a dysmorphic (or abnormal
appearing) and usually cellular bone marrow, and consequent ineffective blood cell
production. A clinically useful nosology of these entities was first developed by the
French-American-British Cooperative Group in 1983. Five entities were defined:
refractory anemia (RA), refractory anemia with ringed sideroblasts (RARS),
refractory anemia with excess blasts (RAEB), refractory anemia with excess blasts
in transformation (RAEB-t), and chronic myelomonocytic leukemia (CMML). The
World Health Organization classification (2002) recognizes that the distinction
between RAEB-t and acute myeloid leukemia is arbitrary and groups them together
as acute leukemia, notes that CMML behaves as a myeloproliferative disease, and
separates refractory anemias with dysmorphic change restricted to erythroid lineage
from those with multilineage changes (Table 94-5).

2006  
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: 
 
Most patients die as a result of complications of pancytopenia and not due to
leukemic transformation; perhaps one-third will succumb to other diseases
unrelated to their MDS
:90  ,16  .12
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.ADULT FANCONY SYNDROME :  
   
  " "     (
)     
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 + "
       
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: 
  16  .16
Most patients with CML52 in chronic phase have a rapid hematologic response to
imatinib therapy. In the initial studies with imatinib in patients with chronic-phase
CML who were intolerant to IFN53-a, 95% of patients achieved complete
hematologic remission, and 60% achieved major cytogenetic remission, with a
complete cytogenetic remission rate of 41%.
Maintenance of the hemoglobin level at
140 g/L in men and
120 g/L in women is .17
mandatory to avoid the thrombotic complications. Thrombosis due to
erythrocytosis is the most significant complication of this disorder. Phlebotomy
serves initially to reduce hyperviscosity by bringing the red cell mass into the
normal range. Periodic phlebotomies thereafter serve to maintain the red cell mass
within the range of normal and to induce a state of iron deficiency, which prevents
an accelerated reexpansion of the red cell mass. In most polycythemia vera
patients, once an iron-deficient state is achieved, phlebotomy is usually required
only at 3-month intervals. Although both phlebotomy and iron deficiency, in
addition to the disease itself, tend to increase the platelet count, thrombocytosis is
not correlated with thrombosis in polycythemia vera, in contrast to the strong
correlation between erythrocytosis and thrombosis in this disease.
Anagrelide, a quinazolin derivative and platelet antiaggregant that also lowers the
platelet count, can control thrombocytosis and is preferable to hydroxyrurea or
IFN-
. A reduction in platelet number may be necessary in the treatment of
erythromelalgia if salicylates are not effective or if the thrombocytosis is
associated with migraine-like symptoms.

320


    - () 526- (
) 525  16  .18
  
    
 . 
     

 
      
 .(1751 ' 16 )  
.(
     ,525) ... 
 aplastic anemia     (

   )    .21
!
Factor XI deficiency .23
In the absence of prophylactic antiretroviral therapy to the mother during .28
pregnancy, labor, and delivery, and to the fetus following birth (see below), the
probability of transmission of HIV from mother to infant/fetus ranges from 15 to
25% in industrialized countries and from 25 to 35% in developing countries. These
differences may relate to the adequacy of prenatal care as well as to the stage of
HIV disease and the general health of the mother during pregnancy. Higher rates
of transmission have been reported to be associated with many factors; some of
these are well proven by a number of studies, while others are considered to be
potential factors since various studies may have given divergent results. The bestdocumented factor that is associated with higher rates of transmission is the
presence of high maternal levels of plasma viremia. Low maternal CD4+ T cell
counts have also been associated with higher rates of transmission; however, since
low CD4+ T cell counts are often associated with high levels of plasma viremia, in
one study using multivariate analysis including plasma viral load and CD4+ T cell
count, only the level of plasma HIV RNA was significant.
: 
     
     
  HAART

        HIV   
 .
 C/I       
  
 ( )   
.     
   ,

    .
 Thyphoid Fever-   
 .29


  - (...ROSE SPOTS) 
    .  
....       ,   
     (150-4  ) 964-965 '  " .    

 .30
  "Low risk"     
  
 TB     
   .  9  
      " 15  
       
      
. 
 

: 
The cutoff for a positive skin test (and thus for treatment) is related both to the
probability that the reaction represents true infection and to the likelihood that the
individual, if truly infected, will develop tuberculosis (Table 150-4). Thus positive
reactions for close contacts of infectious cases, persons with HIV1 infection,
persons receiving drugs that suppress the immune system, and previously untreated
persons whose chest radiograph is consistent with healed tuberculosis are defined
as an area of induration =5 mm in diameter. A 10-mm cutoff is used to define
positive reactions in most other at-risk persons. For persons with a very low risk of
developing tuberculosis if infected, a cutoff of 15 mm is used. Treatment should be
considered for persons from tuberculosis-endemic countries who have a history of
.BCG46 vaccination

321

289

Complete oral
Primaquine
absorption; active
compound not
known; t1/2: 7 h

Pharmacokinetic
Drug(s)
Properties

322

falciparum

Radical cure;
eradicates
hepatic forms
of P vivax
and P ovale;
kills all stages
of gametocyte
development
of P

Antimalarial
Activity

323

Nausea, vomiting,
diarrhea, abdominal
pain, hemolysis,
methemoglobinemia

Minor Toxicity

1232 
Primaquine (0.5 mg of base/kg or 30 mg, daily adult dose) has proved safe and
effective in the prevention of drug-resistant falciparum and vivax malaria in adults.
Abdominal pain and oxidant hemolysis, the principal adverse effects, are not
common as long as the drug is taken with food and is not given to G6PD-deficient
persons. Primaquine should not be given to pregnant women or neonates.
, ,   .  4- 2   
    .32
   "Koplick's spots"  , (    ) .  '

.     
        
.     
.744 '  () 745 ' ,(  ) 743 ' - 110  ,16  .33
!  B  -
   , 6-30% -HBV , 1.8% -HCV   -'  .34
     .      , low gradient   .35
   

 
   , 50% . 
      70% 
   
 
  .
     .HCC  
. ( , ) 
  
       - , 
     .40
. 
   
     
 .100>LDL  
.TG   
.41
Beta-Adrenoceptor Blockers
While the abrupt administration of large doses of beta-adrenergic receptor blockers
can intensify HF, especially acute HF, the administration of gradually escalating
doses has been reported to improve the symptoms of HF, and to reduce allcause death, cardiovascular death, sudden death, rehospitalization for HF, and
pump failure death in patients with chronic heart failure already receiving ACE
inhibitors (Table 216-3). These drugs are indicated in patients with moderately
severe HF (classes II and III), but are not indicated with unstable HF, in hypotensive
patients (systolic pressure < 90 mmHg), in patients with severe fluid overload, in
patients who have required recent treatment with an intravenous inotropic agent, and
in patients with sinus bradycardia, atrioventricular block, or a bronchospastic
disorder.
Three beta-adrenergic blockers (metoprolol, bisoprolol and carvedilol) have been
shown to improve survival in patients with HF. The first two are selective and block
only
1 receptors, while the third blocks both
1 and
2 receptors as well as

receptors, thereby causing mild vasodilation. Carvedilol also appears to exert
antioxidant activity.
Before commencing beta-blocker therapy, patients should be stabilized on an ACE
inhibitor, diuretics and possibly digoxin. They should be begun in very low doses,
e.g., carvedilol 3.125 mg bid or metoprolol XL 12.5 mg qd and titrated upward
slowly every 2 to 4 weeks. During titration, the patients should be observed closely
for hypertension, bradycardia, and worsening HF. Approximately 15% of patients

Massive
hemolysis
in subjects
with severe
G6PD
deficiency

Major
Toxicity

195-7  ,195  ,16  .31

TABLE 195-7 Properties of Antimalarial Drugs

 ,
"    ,         .43
.   
Shock Secondary to Right Ventricular Infarction 255  ,16  .46
 
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EXTENSIVE RV INFARCTION   -
     
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    ADEQUATE RV PRELOAD 
" , 
 - 
. 

   
    
   - 
  
. INTRA- AORTIC    
    .WPW   AF-    
   .53
.  
.54
MALIGNANT HYPERTENSION
In addition to marked blood pressure elevation (usually diastolic blood pressure >
130 mmHg) in association with papilledema and retinal hemorrhages and exudates,
the full-blown medical emergency of malignant hypertension may include
manifestations of hypertensive encephalopathy, such as severe headache, vomiting,
visual disturbances (including transient blindness), transient paralyses, convulsions,
stupor, and coma. Cardiac decompensation and rapidly declining renal function
are other critical features of malignant hypertension. Oliguria may, in fact, be the
presenting feature.
The pathogenesis of malignant hypertension is unknown. However, at least two
independent processes
dilation of cerebral arteries and generalized arteriolar fibrinoid
necrosis
contribute to the associated signs and symptoms.
Many patients also show evidence of a microangiopathic hemolytic anemia; this
secondary phenomenon could contribute to the deterioration of renal function.
:1346 ' .55
In patients in whom cardioversion is unsuccessful or in whom AF has recurred or
is likely to recur despite antiarrhythmic therapy, it is probably wisest to allow the
patient to remain in AF and to control the ventricular response with calcium
antagonists, -adrenergic blockers, or digitalis glycosides. Since such patients are
always at risk of systemic embolization, particularly in the presence of organic
heart disease, chronic anticoagulation must be considered (Table 214-3). Chronic

cannot tolerate beta blockade, and an equal number cannot tolerate target doses
(carvedilol 25 mg bid and metoprolol XL 200 mg). In the latter, low-dose betablocker therapy is preferred to no therapy.
Once a maintenance dose has been achieved, administration of the beta blocker
should be continued indefinitely. If treatment of a patient on a beta blocker with a
positive inotropic agent is required, a phosphodiesterase III inhibitor (see below)
should be used.

290

325

    

       a  .60
   cannon a waves .   "  
atrioventricular   )     ( junctional   )  
(complete heart block    dissociation
)      "      .61

    
 
   
 
   .( 


.    
,  .            
           
  
"    
 
  .(LVEDP)       
.(1.2  
)  E:A 
    

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.  
. 

 
 
 5 
 MI         .63
!!  ASD    RBBB /   
     .66

    GI 
    :    
 .69

  

      ! 
 
   ,      
  ,  
."    ,
   ,...    , ' , 


 . CURB  PORT  
  

 .

     .70
  )   

   
    
      

 90   " ,30   
,125

        
  
 
   .(
,           .     
  
   
 .     
   -     .DRSP 
 
 

.
     
.     ,    
  .    48      HAP .72
, 
  ) 
 
   HAP    
  .(  

  (  70%-)ARD  ,



  .HAP   -  1.5% :
 
.   
    HAP   6-20   
   
  :  (!)  
    , 

64%" .HAP        MRSA    ,"
,
 ,(21%) 
 
 ,     

         " . 

S. pneumoniae, H. influenzae, S. aureus, and enteric gram-negative bacilli :
   .((i.e., E. coli, Klebsiella spp., Proteus spp., and Serratia marcescens
. 
 
     
 
      :failure to improve  : 
  2  .74
     PE ,    

  
   . 
 

      
 


.    ,  ,   
     


   "
   .CT     ,    
....' 
 
   ,  
   
          

   
.
  
  " 1         
   " 1     
 - 1536  17   : 
.
.   
  ,   " -
  .75
  )       +       .80
(C/I      "    
:  .81
In the acute setting, bilateral obstruction may mimic prerenal azotemia. However,
with more prolonged obstruction, symptoms of polyuria and nocturia commonly
accompany partial urinary tract obstruction and result from impaired renal
Absent
Present
Absent
Present
All patients

<65
6575
>75

Warfarin[target INR 2.5 (range 2.53.0)]

Aspirin or warfarin
Warfarin[target INR 2.5 (range 2.03.0)]

Aspirin
Warfarin[target INR 2.5 (range 2.03.0)]

Recommendations

324

:1347 '
Atrial flutter is usually less long-lived than is AF, although on occasion it may
persist for months to years. Often, if it lasts for more than a week, atrial flutter will
convert to AF. Systemic embolization is less common in atrial flutter than in AF.
Although atrial flutter is associated with a slightly lower risk of embolization than
AF, the same precautions should be followed in regard to anticoagulation as are
used with AF.
:   special considerations   230  16  .56
Diabetes Mellitus
The diabetic patient with hypertension is particularly challenging to treat because
multiple agents are usually needed to achieve goal blood pressure and because many
of the agents used to lower blood pressure can affect glucose metabolism adversely.
ACE inhibitors or angiotensin receptor blockers should be first-line therapy in
hypertensive individuals with type 2 diabetes. They have no known adverse effects
on glucose or lipid metabolism and minimize the development of diabetic
nephropathy by reducing renal vascular resistance and renal perfusion pressure
the
primary factor underlying renal deterioration in these patients (Chap. 323). Metaanalyses of clinical studies have demonstrated that setting a lower blood pressure
goal in diabetic patients is ideal to prevent progression of end-organ disease, with
current recommendations shifting from 130/85 mmHg downward to 130/80. The
average hypertensive diabetic patient will require at least three medications to
achieve appropriate control.
1353  ,16  .58
 60-120    ,slow VT  
Accelerated idioventricular rhythm
 ,  
 ,-  ,     .
  
   ,   ,  , 

  
 )     .   . 
  
  .       
  
.(   "  
slow ,AIVR) Accelerated idioventricular rhythm - 1456 ' ,16  :
    . 60-100      (ventricular tachycardia
    .-    25%-  ,STEMI
.      ,   
:1418   .59
This disorder results when the healing of an acute fibrinous or serofibrinous
pericarditis or a chronic pericardial effusion is followed by obliteration of the
pericardial cavity with the formation of granulation tissue. The latter gradually
contracts and forms a firm scar, encasing the heart and interfering with filling of the
ventricles.

Risk factors are prior transient ischemic attack, systemic embolus or stroke,
hypertension, poor left ventricular function, rheumatic mitral valve disease,
prosthetic heart valve, congestive heart failure.

Risk Factorsa

Age, years

Table 2143. Recommendations for Long-Term Anticoagulation in

Patients with Chronic Atrial Fibrillation

anticoagulation is particularly important in the elderly, where the attributable risk

of AF for stroke approaches 30%.

291

concentrating ability. This defect usually does not improve with administration of
vasopressin and is therefore a form of acquired nephrogenic diabetes insipidus.
Disturbances in sodium chloride transport in the ascending limb of Henle and, in
azotemic patients, the osmotic (urea) diuresis per nephron lead to decreased
medullary hypertonicity and hence a concentrating defect. Partial obstruction,
therefore, may be associated with increased rather than decreased urine output.
Indeed, wide fluctuations in urine output in a patient with azotemia should always
raise the possibility of intermittent or partial urinary tract obstruction. If fluid intake
is inadequate, severe dehydration and hypernatremia may develop. Hesitancy and
straining to initiate the urinary stream, postvoid dribbling, urinary frequency, and
incontinence are common with obstruction at or below the level of the bladder.
      (! 50% ) 
 . IgA nephropathy   .82
. 

1.018 < SG - Pre-renal ARF- .83
.FSGS   264-4  1686  .85
  

   FSGS - 264-1  1675 ' 16  : 


  ( Charcot Marie Tooth ,   , ,HIV , ) 

(  

 ' )
   ,  5-10%    
 801 " .88
   
     " .     
.   
     .
 20-30% ,muddy brown    
   .ATN 1646 "
,  ,
 - 
)          . 
.(  ,  . , , 

   

7-10   .    ,10-30%   "  

.  
 , "   .  "    
- 
.          ,   ,  
,  ,ACE -  ,MM , " :    -1645-1647  .89
/      -1328 ' ;2176 ' -  ; 

               

.
 
 .    
    HCV - 
    .91
,MPGN , ,- - 
  "   
.
        .
 - SBE
. C4 - 
C3 - post-strep - 
 .92
...    ,TTP -    
  .93
FMF   
   .96
.FMF -         , 
  -  .1
 
     FMF  90%  -    .2
     
     
 .

-  ,
   , 
,        
   .  
 
    CT . 
, 
    
  ,   
.
 .         
   .  ,    
  " - 
   .3
  
 thoracentesis ;    
.        ,     . 


   ,  , ,  ,  
 "- FMF arthritis .4
     .   ,    
      . 
      , 

,     
 .  
  
, 
.   FMF  5% -  
    
  
 ,HLA-B27 
   FMF -    
 
.  

,erysipelase-like erythema  FMF -   
 
  -
 .5
, ,          ,   
.   ,pleurisy ,      ,
   

326

   ,FMF -  

 (nonfebrile)  "   .6
.      febrile myalgia  
      ,
  

  .7
.    
. 
  
 
         
 .8
.  
     ,     .9
 periarteritis nodosum - henoch-schonlein purpura  , .10
.FMF -   
,   
   
         .98
     
 
 
      

.'    
:GI '     ,16  .100
GI Bleeding Hemorrhage may develop from any gut organ. Most commonly,
upper GI bleeding presents with melena or hematemesis, whereas lower GI
bleeding produces passage of bright red or maroon stools. However, briskly
bleeding upper sites can elicit voluminous red rectal bleeding, while slowly
bleeding ascending colon sites may produce melena. Chronic slow GI bleeding
may present with iron-deficiency anemia. The most common upper GI causes of
bleeding are ulcer disease, gastroduodenitis, and esophagitis. Other etiologies
include portal hypertensive causes, malignancy, tears across the gastroesophageal
junction, and vascular lesions. The most prevalent lower GI sources of
hemorrhage include hemorrhoids, anal fissures, diverticula, and arteriovenous
malformations. Other causes include neoplasm, IBD1, ischemia, infectious colitis,
and other vascular lesions.
:  
Anemia and Occult Blood in the Stool Iron-deficiency anemia may be
attributed to poor iron absorption (as in celiac sprue) or, more commonly,
chronic blood loss. Intestinal bleeding should be strongly suspected in men
and postmenopausal women with iron-deficiency anemia, and colonoscopy is
indicated in such patients, even in the absence of detectable occult blood in
the stool
 
   ,      
  
! 
  -
)   
    UC-    .101
.( 
 8-10  
  0.5-1%-
.    ,1867 ' , 289   .102
Hepatorenal syndrome is a serious complication in the patient with
cirrhosis and ascites and is characterized by worsening azotemia with avid
sodium retention and oliguria in the absence of identifiable specific causes
of renal dysfunction. The exact basis for this syndrome is not clear, but
altered renal hemodynamics appear to be involved. There is evidence for
inappropriate intense renal vasoconstriction, perhaps in response to the
splanchnic vasodilation accompanying cirrhosis. The kidneys are
structurally intact; urinalysis and pyelography are usually normal. Renal
biopsy, although rarely needed, is also normal, and in fact, kidneys
from such patients have been used successfully for renal transplantation.
   T CELL LYMPHOMA    -   ,   .104
MALT           , B  .(     ) lymphoma
.
      ,gastric outlet obstruction   
  .106
(

 ) IM  (
 ) SC ,1:1000 ," 0.3-0.5 
  -
  .108
.   20   

   
  ,  (
)  
 ,    

  
.          


 .
     ABC       ,

 
  (  )     (  

)    
   90  "  )    
 . 
.()       ( 120

327

292

329

Anticentromere antibodies react with protein antigens located in the kinetochore

region of chromosomes and are present in 40 to 80% of patients with limited
cutaneous scleroderma or CREST syndrome. Anticentromere antibodies are
found in only about 2 to 5% of patients with diffuse cutaneous scleroderma and
rarely in other connective tissue diseases. They are found occasionally in
patients with only Raynaud's phenomenon and may indicate subsequent
development of limited cutaneous disease.
- (Anti-Nucleolar) SSc   



 ,   SSc-  5-40%-  Anti-Polymerase I, II, III
SSc-  14%-  Anti-Th RNP .      
95--  ,   SSc-  5-10%-  Anti-U1 RNP .  
(anti-fibrillarin) Anti-U3 RNP .(MCTD)  -    100%
     ,    SSc-  5%- 
SSc-  25%-  Anti-PM/Scl ;  "   ,
.
Antinucleolar antibodies are relatively specific for SSc and are present in 20 to
30% of patients. Several antinucleolar antibodies have been associated with SSc:
Anti-RNA polymerases I, II, and III are found in patients with diffuse cutaneous
SSc who have a higher prevalence of renal and cardiac involvement. Anti-Th
RNP has been found in patients with limited cutaneous SSc, and anti-PM-Scl,
formerly referred to as anti-PM1, along with anti-Ku, may be found in a subset
of patients with overlapping features of limited cutaneous SSc and polymyositis.
Anti-U3 RNP (anti-fibrillarin) is also highly specific for SSc and may be
associated with skeletal muscle disease, bowel involvement, and pulmonary
arterial hypertension. Anti-U1 RNP is found in 5 to 10% of SSc patients and in
95 to 100% of those patients with the overlap syndrome of MCTD. The titers in
MCTD are usually high. Anti-SS-A (Ro) and/or anti-SS-B (La) are present in
those patients with overlap syndrome of SSc and Sj
gren's syndrome.
hypertrophic Osteoarthropathy .113

   .OA -          .114
 )   
          ,

  .

    ,-tramadex   (  

  .         

.OA -       
 

1962 ' ,10%-    .115
     ;1962 ' , 
   X- 
45  >  
 50       ;1963, 
/          ;1963-4 ,  

1964 ,
.116
Vascular Occlusions
The prevalence of transient ischemic attacks, strokes, and myocardial infarctions is
increased in patients with SLE. These vascular events are increased in, but not
exclusive to, SLE patients with antibodies to phospholipids (aPL). Ischemia in the
brain can be caused by focal occlusion (either noninflammatory or associated with
vasculitis) or by embolization from carotid artery plaque or from fibrinous
vegetations of Libman-Sachs endocarditis. Appropriate tests for aPL (see below)
and for sources of emboli should be ordered in such patients to estimate the need for,
intensity of, and duration of anti-inflammatory and/or anticoagulant therapies. In
SLE, myocardial infarctions are primarily manifestations of accelerated
atherosclerosis. The increased risk for vascular events is as much as 50-fold in
women with SLE <45 years old compared to healthy women. Characteristics
associated with increased risk for atherosclerosis include older age, hypertension,
dyslipidemia, aPL, repeated high scores for disease activity, and high cumulative
doses of glucocorticoids. When it is most likely that an event results from clotting,
long-term anticoagulation is the therapy of choice. Two processes can occur at
once
vasculitis plus bland vascular occlusions
in which case it is appropriate to
treat with anticoagulation plus immunosuppression.

328

:303-4  +  

40%- SSc-  20%-  (anti-Scl-70) Anti-Topoisomerase 1 


.   SSc  

Antitopoisomerase 1, originally called anti-Scl-70, recognizes the nuclear
enzyme DNA topoisomerase 1, a nuclear enzyme involved in the unwinding of
DNA for replication and RNA transcription. These antibodies are found in 20%
of all SSc patients and in 40% of those with diffuse cutaneous SSc. They are
associated with diffuse cutaneous involvement, interstitial pulmonary disease,
and renal and other visceral organ involvement. A very high frequency of these
antibodies has been reported in Choctaw Native Americans in association with
diffuse cutaneous SSc. They are seldom present in other disorders or in
conjunction with anticentromere antibodies.
.   SSc   60-80%-  Anti-Centromere 


    
    () 
 
. 
      .VENULAR LEAKAGE
 ,
    I.V 
   
    
.     "  , 
   

/ 
-           
  
 ,          ,  / 

.     
  
 :  .110
   ,  

    

) . 
    , 
   ,
  
, 
     ,    .(     
.    ,
GRANULAR   ,    
   -  
.      .     SPARKLING
.()     "   


.   
      ,  2B  
      ,. 

   
    
 .
   

   

 .    
. 
  
 ,     ,
    "     

       CONGO RED   . 
. 
   "     .       .111
.      
- 303  ,(    ,  ) 13  ,On-Line  .112

 ()  
:(303-3  +) 
 

   ,(SSc)    95-100%-  
 
 .(Limited Cutaneous)     (Diffuse Cutaneous) 
    .  
  80%-  (  
 )  
  ;     40%-   SSc   35%-
         anti-Scl-70  

  SSc
   ,   
  "   
 .
 
 .       .  
  
 (30%)   
  , -    
.(1%- ) 
Patients with diffuse cutaneous involvement who have antitopoisomerase 1
antibodies are particularly at risk of developing severe pulmonary fibrosis.
    
  ,       ,  ,  
     ,   " 
    (10%>)  
. 
  ,
  "   , 

  ,  
   
 
     

.(Anti-Topoisomerase 1) anti-Scl-70   

POST CAPILLARY

293

330

331

       

 A1C      

       .   
 
 
   )          

Cardiac Manifestations
Pericarditis is the most frequent cardiac manifestation; it usually responds to antiinflammatory therapy and infrequently leads to tamponade. More serious cardiac
manifestations are myocarditis and fibrinous endocarditis of Libman-Sachs. The
endocardial involvement can lead to valvular insufficiencies, most commonly of
the mitral or aortic valves, or to embolic events. It has not been proved that
glucocorticoid or other immunosuppressive therapies lead to improvement of lupus
myocarditis or endocarditis, but it is usual practice to administer a trial of high-dose
steroids along with appropriate supportive therapy for heart failure, arrhythmia, or
embolic events. As discussed above, patients with SLE are at increased risk for
myocardial infarction, usually due to accelerated atherosclerosis.
. Ankylosing Spondylitis -  .117
( 
  
)    : .118
            
  
,     
 
  , 

 
        . 
  


     , 
 ,  :       
.  

      
   
  
    
.  2-4   
  
 -            
.  
 -  .   , 
  
.              CNS  
,  ,            "
.   
 , :   

  2022   

.  
,
 ,    , . 
  
, .  4-6  " " 1 
 
 "    
  
.  2-3    "


       .       '- ' .119
,    (
 ) NSAIDS-    ,GI 
   
 .GI   
    , 
 
  ACTH     .   PO ,IV   
. NSAIDS   
-
  
  .120
, 


 
    
    '
.121
! sinus vein thrombosis  ,    ,      
.   
   
 '    


  "   
" ,          .122
 :      , ( ' 
 , )   
.   
  IV - III
 
   
   
 
 .124


 .     
 . 

 .         
 

.(     )    30  
...
 . '' ,  ,    - 

     IV   :       . 


 
        .flu like    
 !! 
       , 
    
) 
  ,     ! GI  :  
-   .    
   , ,(
 
 :         

jaw necrosis -  
    ... 
   
. MM -   
         
,(2142  ,321-7   
) 
 
 "    .125
   )      TB     
. 

 
    
 
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 , " , 


 :2139 ' .126

  ,  ,     ,
    
. 
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  - 1697 ' .  
 
   
- 2135 ' .  
"   ,   
 

 - 1707 ' .150/90  " ,  , , 
' ACEi  

.   " ,  
  

- "  ,     , :260 ' 
 " .1474
. 
  <

    .129
.        ( )  


  
 
  , 

    . 
   10-14  
      " ,(    ) "
. 
      
 ACE  ,   
.  
.Familial hypocalciuric hypercalcemia   .130
:
  .131
.
       

   -
 
.          ,   
. ,HRT  ,        .132
 ) TT4       
     
.    TSH   .(2108    
.136
.    35 mg/dL    A1C- 1%   x
 A1C  ADA- "  ,        x
.  

 , 
     (  3 )     x
.1       

    , 
 ,  
    x
.(  
 ,  
)  
 A1C   
;             x
   , 
   2-3-      

.  120 
     
      (A1C-   )   
 x
            
    .        
   ,       ,  :
 
    , 
      ,  
    ,         
    (       ,)
.  

   ,   

 
(
 
 
) ADA-
-
       
:323-9 

 


7%>
A1C
180 mg/dL>
Peak postprandial plasma
*glucose
90-130 mg/dL
Preprandial plasma glucose
.   10-15%-    *

294

>1.7 mmol/L (>150 mg/dL)

<1.3 mmol/L (<50 mg/dL)

130/ 85 mmHg

>6.1 mmol/L (>110 mg/dL)

Blood pressure

Fasting glucose

333

. 
              .142
          -    

.( 
 
 
 )    
The most important viruses causing sporadic cases of encephalitis in .144
immunocompetent adults are HSV-1, VZV and, less commonly, enteroviruses.
 
   .   
      HSV1 ... 
.CSF - RBC - ,
 EEG ,   
  
 
   
       :    .145
     .  
    

 
        , 
 ,

.LP 
 MRI  CT   ,      

      
    "
 
. LP-  
   
NSAIDS . 
   
  1646  .146
  ,  

 
 
 
.     
.      

   ,1869 '
(
   ) 
  802    
.            
.692   16  .INR     

   .148
.149
Side effects include the potential for an increased risk of serious infections.
Particularly notable is the capacity of TNF blockade to increase the risk of
developing reactivation of dormant tuberculosis. It is prudent to carry out
tuberculin skin testing and, if necessary, further evaluation with chest radiographs
before beginning therapy with an anti-TNF agent to limit the chance of inciting

Overweight and obesity are associated with insulin resistance and the metabolic syndrome.
However, the presence of abdominal obesity is more highly correlated with the metabolic
risk factors than is an elevated body-mass index (BMI). Therefore, the simple measure of
waist circumference is recommended to identify the BMI component of the metabolic
syndrome.
b
Some male patients can develop multiple metabolic risk factors when the waist
circumference is only marginally increased, e.g., 94102 cm (3739 in.). Such patients may
have a strong genetic contribution to insulin resistance. They should benefit from life-style
changes, similarly to men with categorical increases in waist circumference.

<1.0 mmol/L (<40 mg/dL)

Men

Women

HDL cholesterol

>88 cm (>35 in.)

Women

>102 cm (>40 in.)

Triglycerides

Men (waist circumference)b

Abdominal obesitya

Table 2253. Clinical Identification of the Metabolic SyndromeAny Three Risk

Factors
Risk Factor
Defining Level

 
 225  , -   8  ,Online   .141
:225-3  ,  

332

 
 2         .(  
.
  "  
 335  ,  

 14  ,-    .137
: 
 
HMG-CoA reductase inhibitors are well tolerated and can be taken in tablet form
once a day. Potential side effects include dyspepsia, headaches, fatigue, and muscle
or joint pains. Severe myopathy and even rhabdomyolysis occurs rarely. The risk
of myopathy is increased by the presence of renal insufficiency and by
coadministration of drugs that interfere with the metabolism of HMG-CoA
reductase inhibitors, such as erythromycin and related antibiotics, antifungal
agents, immunosuppressive drugs, and fibric acid derivatives. Severe
myopathy can usually be avoided by careful patient selection, avoidance of
interacting drugs, and by instructing the patient to contact the physician
immediately in the event of unexplained muscle pain. In the event of muscle
symptoms, the plasma creatine phosphokinase (CPK) level should be obtained to
document the myopathy, but serum CPK levels do not need to be monitored on a
routine basis as an elevated CPK in the absence of symptoms does not predict the
development of myopathy and does not necessarily suggest the need for
discontinuing the drug.
,Atorvastatin ,HMG-CoA reductase inhibitors  
 (Link)   
:Interactions 
The risk of developing myopathy during therapy with HMG-CoA reductase
inhibitors ('statins') such as atorvastatin (CYP3A4 substrate) [5460] is
increased if coadministered with CYP3A4 inhibitors [5506]. Examples of
CYP3A4 inhibitors include but are not limited to: clarithromycin, erythromycin,
fluconazole, imatinib, STI-571, itraconazole, ketoconazole, troleandomycin, and
voriconazole.[4718] Itraconazole increases the AUC of atorvastatin by 2.5-fold,
which is substantially less than the effect of itraconazole on the AUC of simvastatin
and lovastatin (increased 19-fold and 20-fold, respectively).[5790] [5791] [5792] [5793]
Coadministration of atorvastatin with erythromycin increases atorvastatin
plasma concentrations by about 40%.[5460]
HMG-CoA reductase 
    : 
 .138
  .VLDL   LDL R   "  
 
.
   .   
  ;    ,  ,  , : 
 ,    "   , 
"  
,      
  .  
 , 

      .   
  CPK    

 
      
 
 
     CPK
 ,   

   . - 
" . 
.  6    8
 .

        
 

 .139
 .       ' 24       
    )       
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334

reactivation of tuberculosis. TNF-neutralizing therapy can also induce the

development of anti-DNA antibodies, but rarely is there associated evidence of
signs and symptoms of systemic lupus erythematosus. Other side effects include
infusion or injection site reactions and rarely the development of demyelinating
central nervous system disease.
 
        .  
   .151
.
 
    .154
:377-4  ,377  ,    
 ,  16  ,Online  : 
Mechanism - Methanol causes ethanol-like CNS depression and increased
serum osmolality. Formic acid metabolite causes AGMA and retinal toxicity.
Clinical Features - Initial ethanol-like intoxication, nausea, vomiting,
increased osmolar gap. Delayed AGMA, visual (clouding, spots, blindness) and
retinal (edema, hyperemia) abnormalities. Coma, seizures, cardiovascular
depression in severe cases. Possible pancreatitis.
Specific Treatment - Gastric aspiration for recent ingestions. Sodium
bicarbonate to correct acidemia. High-dose folinic acid or folate to facilitate
metabolism. Ethanol or fomepizole for AGMA, visual symptoms, methanol
level > 6 mmol/L (20 mg/dL), and for ethanol-like intoxication or increased
osmolal gap if level not readily obtainable. Hemodialysis for persistent AGMA,
lack of clinical improvement, and renal dysfunction. Hemodialysis also useful
for enhancing methanol elimination and shortening duration of treatment when
methanol level > 15 mmol/L (50 mg/dL).


- 2007 '

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306

266

125 
The UKPDS demonstrated that each percentage point reduction in A1C was associated
with a 35% reduction in microvascular complications. As in the DCCT, there was a
continuous relationship between glycemic control and development of complications.
Improved glycemic control did not conclusively reduce (nor worsen) cardiovascular
mortality but was associated with improvement with lipoprotein risk profiles, such as
reduced triglycerides and increased HDL.
One of the major findings of the UKPDS was that strict blood pressure control
significantly reduced both macro- and microvascular complications. In fact, the

The possibility of lymphoma must be considered whenever a patient with celiac sprue
previously doing well on a gluten-free diet is no longer responsive to gluten restriction
or a patient who presents with clinical and histopathologic features consistent with
celiac sprue does not respond to a gluten-free diet

90 
Failure to Respond to Gluten Restriction
The most common cause of persistent symptoms in a patient who fulfills all the criteria
of the diagnosis of celiac sprue is continued intake of gluten. Gluten is ubiquitous, and
significant effort must be made to exclude all gluten from the diet... About 90% of
patients who have the characteristic findings of celiac sprue will respond to complete
dietary gluten restriction. The remainder constitute a heterogeneous group (whose
condition is often called refractory sprue) that includes some patients who (1) respond
to restriction of other dietary protein, e.g., soy; (2) respond to glucocorticoids; (3) are
"temporary," i.e., the clinical and morphologic findings disappear after several months
or years; or (4) fail to respond to all measures and have a fatal outcome, with or without
documented complications of celiac sprue, such as development of intestinal T cell
lymphoma.

83
898-900 
TYPHOID FEVER.   , :

265

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20 
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    "
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should be employed as the first line treatment to control bleeding acutely

11 
   
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15 
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MRI.       -CT          ,     
           
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Allogeneic SCT is currently the only curative therapy

for CML and, when feasible, is the treatment of choice

73 
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Patients with silicosis are at greater risk of acquiring Mycobacterium tuberculosis
infections and atypical mycobacterial infections.

2007 
 
 
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64 
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65-70             .      
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51
: most laboratory tests for toxins   .760-762 16    
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lack sensitivity thus if the first specimen is negative and diarrhea presists,testing of
additional stool spicimemens increase the likklihood of diagnosis. empirical treatment
is appropriate if CDAD is strongly sespected on clinical grounds
....            


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MRI .

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antinuclear antibody .
anti dsDNA .
anti SM .
anti RO .
anti phospholipids .

.9 Limited
Cutaneous Systemic Sclerosis
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CHF .
Pulmonary fibrosis .
Pulmonary arterial hypertension .
Scleroderma renal crisis .
. anti topoisomerase 1

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Salmonella Parathyphi .
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.

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WBC ,10 ,
PHOS-ALK , .

?
.
.
.
.
.

LMWH

.31
.32
MCH ,HB-12 , MCV-70RDW ,
. ?
.

.
.
. 2

.39
,
,
?
.
.
.

.32
?
.
.
.
Severe aortic stenosis .
Severe hypertension .

.40 47 ,
, .

. IBS
?
.
.
.
.
US .

.33 RA ,
?
adenocarcinoma .
Diffused large B cell lymphoma .
.
.
.34 ?BIPAP-
.
.
.
.
. 40

.41
.
3
?
.
. 45"
.

.
.

.35 ,68 .
high pitched
3
. ?
Hypokinetic pulse .
Dicrotic pulse .
Bisferiens pulse .
Parvus pulse .
Pulsus alterans .

.42 ?
TLC .
FEV1/FRC .
FEV1/FRC .
RV .

.36 ,25 ,
.
. : ,120/80
,100 .39 .
?

.43
?B
HBsAb . HBsAg

64

309

 HBsAb . HBsAb
HBsAb . HBsAg
HBsAb . HBsAg
HBsAb . anti HBc

.50 ,73 , :
68% 28,000
cd22, cd21 low grade -
.diffuse b cell lymphoma ?
.
.
.
( )chlorambucil
.

.44 ?
.
. Ca -Adeno
.
.

.51 , 40 100
120/80 32 - 91%
?
. 32 -
. 12,000
.
. 91%

.45 23 ,
.
,
.3
, . ?
. ,

. ,

.
.
.

.52 60
.

. ,80 .
.EF=30 ,
?
fusid, digoxin, spironolactone .
enalpril, atenolol, clopidogrel .
digoxin, fusid, Coumadin .
enalapril, fusif, hidralazine .
enalapril, fusid, spironolactone, carvedilol .

.46 , 24 ,
. .
?
.
.
.
.
.

.53
.38 300 ,
. ?
. ,

. +
. CT-

.
. G-CSF

.47
.
?
.
.
Sturvite .
.
.

.54 ?
. 63

. 55
. ,38 ^ ulceratice

.48 " ,
. , ,140/90 ,100
,1.1 INR ,10,000 WBC .1.1
, . ?
.
. , 6
.
.
. 24

colitis

. ,47 10

. ,45 70
.55 55 ,
.

,
. .
, , .
?
.
PH . 24 - GERD
.
. -
. -

.49 ?FMF
.

.

.

.

. FMF

310

65

.
.
.

.56 17
. =MCV ,Hb = 8.3 :
,77 , .
. 66 ?
.
RBC .
. IV
.
. PO

.
.

.64
?
.
.

.
.

.57 19 .
.
12,000 12% ,
. , RBCs 1 .
?
Renal Tubular Acidosis .
.
.
Acute Glomerulonephritis .
Allergic interstitial nephritis .

.65 ,
. -
?
.
PH = 7 .
.
LDH .
.

.58 ,80 , ,
.
, ( PTH 160) ,
, 20 24,
,0.9 .50 PTH -
?
."
.
. D
.
. " '

.66 3800
42% . ,
. -
. ?
G-CSF .
G-CSF .
GM-CSF
.
.
.67 ,
, .
?
.
.
. HLA b27
.

.59 ?
.
.
.
.
.60 ,
. . ?
.
.
.

.68 ,75 OA HEBERDEN

.NODES CRP ,20 ANA .RF .

. ?
. SLE
. ,OA RA
. RF 20%10
,
. RA
. Generalized

.61 .
, -
, .
. .
?
proximal RTA .
.
Conn's syndrome .
.

Erosive Osteoarthritis

.69 ,60 US .
2.8" . ?
. FNA
.
.
. 6

.62
?
.
.
.
.
.

.70 ,68 , .
, . :
, . ,WBC=1300
, . ?
.

.63 ?

66

311

. ,
.
.

.78 ARDS
?Near-Drowning

.71 ,
. .1 ?
AVNRT .
ATRIAL FLUTTER .
WPW
.
.

.
.
.
.
.

.72" ?
. +
.
.
. +

Inverse Ratio Ventilation

Nitric Oxide

.79 ,
,4.4: 560 ,240 -
123 ?
.
.
.
.
10%
.

.73
.FEV1=95%,DLco=50% ,fev1/fvc=85%:
?
.
.
.
.

.80 " ?
.
. CNS
.

.74 ,
,
, .

.
?
.
.
.
.
.

.81 , .
?
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.
.
.82 ?UC
.
.
.
.

.75
.
?INR
.
. ,
. ,
. ,
. ,

.83 ,65
. , ,
.
, ramipril
. ?
.
.
.

REFLUX .

.76 .
, friction
,rub ?
Losartan .
Furosemide .
Thiazide .
Hydralazine .
Diazoxide .

.84 AML ,
.
?
. 0.9% ,
.
.
.

.77 ,68 Rheumatoid Arthritis

.
. : ,38.2 ,
, . :
.65%=PMN ,WBC=12000
?
. ,

.

312

Prone
Tidal Volumes

.85 .Na=158
12 ?
152 .
146 .
125 .
132 .
137 .

67

 . FNA-
. ?
.
.
.
.
. FNA

.86 ,75 .
10 .E-Coli
?
.
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.
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.

.95 HOCM .
,
. 60"
. ?
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.
.
.

.87 ?
.
.
.
.
.
.88 ?
.

.
15-20
. 2-5

.

.96 54
. ,
.S3.. Q V1-V4
ST .
?
.
.

.
.
.

.89 , ?
. IV
.
.

.97 72 3 38.6
.
: ESR ..
: .T12 :
. ?
staph aureus .
group B strep .
E. coli .
salmonella typhi .
pseudomonas aeruginosa .

PH .90 , ,P02=85 , C02=40 ,

. ?
.
.
.
.
.91 23 ,
. .PR ?
.
.
.
.

.98 55 3 ,
, ,209/110" .
ST . ,
. ,
, ,?
. ,
. ,
.
.

.92 80
, ,
0.7?
. ,

. ()
.

.99
, ,130/90
,90 .
.
ST .
?
.
. ,
.
.
.

.93 ,23 , ,
.. . T .
?
.
.
.
.
.

.100 PT ? PTT
. 7
DIC .

.94 ,40 3".

,
. .

68

313

.
.
. A

.107 ?
.

.

APLA

.101 ,
.
.
. ?
.
.
.
. PPI-
.

.108
?20
.
.
.

.102 Kaposi's Sarcoma ? HIV

. (30% )
HHV8 .
. CD4
. HSVs

.109
?
.
.
.
.
.

.103 24 . : ,
. :
.
. ,2
?
congenital lipodystrophy .
hairy cell leukemia .
myelodysplastic syndrome .
gaucher disease .
aplastic anemia .

.110 30 ,
,
LH+FSH . . MRI -
2.5 -" . ?
. ,

. .


. MRI

. DOPAMINE AGONISTs
MRI ,
. DOPAMINE AGONISTs
MRI

.104 ,60 ,
.
.grand mal CT .LP-
200 30% ,
100 .
?
. CSF Herpes Simplex
PCR . (HSV) Herpes Simple CSF
.
. HSV-I
. HSV-ll

.111
,
. ?
.
.
.
SVC .

.105
?
.

.

.

.

.

.112 ?AF
. 65
HTN .
DM .
CHF .
.
.113 .
.
. ?
.
.
.
PCP .

.106 19 . 130/80
90 . 37.8
." .?
anti venom .
.
. 48
IV .
. P0

314

69

.
.
.

.114 ,80 PAF ,HTN-

-
, ,140 .
?
. ,

. ,

. ,

. ,

. ,

RV
FEVI

.122 ,80 110"/",

,
, 9% .
3 .
?
.
. BJ
.
.123 GRAVES ,
. .
TSH .T4 + ,
T3 . .
?
.
. GRAVES
.
SUBACUTE THYROIDITIS .

.115 32 12 150/100
- ?
.
.
.
.
.
.116 -60 ?
.
Neisseria Gonorrhea .
.

.124 48
, 6 .
.
ANA ,2.1 . -
.Necrotizing pauci immune GN
?
Churg strauss .
Goodpasture .
HSP
.
Sarcoidosis .
Wegener's .

.117 19 . ,50
, 5
. ?
.
.
.
.
.

.125 ,18 '

' .
.
?
.
.
.
. circle of williss
.

.118 ,
. ,38
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.3 ?
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.
ARDS .
.
.

.126 , CHILD SCORE C

. UGI BLEEDING
.
?
TIPS .
.
.

.119
INR=1.8 . ?
.
.
.120 , BMI=32 ,40 2
.TYPE
.
.116-123 ?
. TYPE 2 MNT

. IFG MNT
. IFG
. TYPE 2
NOMONORM

.127 ,27 . .
,38
, .
: 10"/" .
, .
?
.
.
. .

. .
. .

.121 ?
TLC .

71

315

Severe HTN .

.128 ?Iga nephropathy

.
.
.
.
ACE-I .

.136 ?
.
.

. PCP - HARRT-

. CD -
. CD4 200

.129 130/90
. ?
.
BETA BLOCKER .
CALCIUM CHANNEL BLOCKER .
THIAZIDE .
ARB .

.137
. .
?
.

.
. -

.130 26 .
.
.
11 . 0.9
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.138 23
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.
.

.131
?
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.

.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.11
.12
.13
.14
.15
.16
.17
.18
.19
.20
.21
.22
.23
.24
.25
.26
.27
.28
.29
.30

.132 ,60 "

. .
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.
.
.
.
.
.133 ,30 ,
.
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.134 45
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. VVIR
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.
.
.
Severe AS .
316

70

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? ?

.31
.32
.33
.34
.35
.36
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
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.48
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.91
.92
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.99
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.102
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.114
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317

199

:neuromuscular abnormalities  - 1659 ' -   

Central, peripheral, and autonomic neuropathy, as well as abnormalities in muscle
composition and function, are all common complications in CRD. Retained
nitrogenous metabolites and middle molecules as well as PTH all contribute to the

preparation for renal :    1662 ' , 

   - ' : .28
:replacement therapy
Over the past 40 years, renal replacement therapy using dialysis and transplantation
has prolonged the lives of hundreds of thousands of patients with ESRD. Renal
replacement therapy should not be initiated when the patient is totally asymptomatic;
however, dialysis and/or transplantation should be started sufficiently early to prevent
serious complications of the uremic state. Clear indications for initiation of renal
replacement therapy include pericarditis, progressive neuropathy attributable to
uremia, encephalopathy, muscle irritability, anorexia and nausea that are not
ameliorated by reasonable protein restriction, evidence of protein-energy malnutrition,
and fluid and electrolyte abnormalities that are refractory to conservative measures.
The latter include volume overload unresponsive to diuretic therapy, hyperkalemia
unresponsive to dietary potassium restriction, and progressive metabolic acidosis that
cannot be managed with alkali therapy. Clinical clues indicating the imminent
development of uremic complications are a history of hiccupping, intractable pruritus,
morning nausea and vomiting, muscle twitching and cramps, and the presence of
asterixis on physical examination. In addition, the patient whose follow-up and
compliance with conservative management are questionable should be considered for
earlier initiation of renal replacement therapy, lest potentially life-threatening uremic
.complications or electrolyte disturbances supervene
Since there is considerable interindividual variability in the severity of uremic
symptoms and renal function, it is ill-advised to assign a certain usual level of blood
urea nitrogen, serum creatinine, or GFR to the need to start dialysis. Nevertheless, in
the United States, the Health Care Financing Administration has assigned levels of
serum creatinine and creatinine clearance to qualify for reimbursement from Medicare
for patients receiving dialysis. Serum creatinine must be 700 mol/L (8.0 mg/dL)
and the creatinine clearance must be 10 mL/min. Recent controlled studies have
failed to show a survival advantage for early initiation of renal replacement therapy
prior to onset of clinical indications

1998 ' ,' : .27

2161-2162  323   .26

1662 ' ,' : .25

      
    " .(  ,372 ) 2565 ' ,'
: .23
IV 
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. 

 

   .CNS   

"if PBP is suspected and multiple organisms :750  112  ,' : .22
including anaerobes are recovered from the peritoneal fluid, the diagnosis must be
reconsidered and source of secondary peritonitis sought"
          

         
.    

198

2210 " 17  ,' : .21

2303 ' ,+ : .20

1995 ' , : .18

1472 ' ,
: .16

       

 214-6     1346  .
: .15
   
   !%40   EF 
   
,   
 .AF
.   
 
 LVEF < 40% and/or CHF

RF     (  ) 1976  (   ) 1973 '.' : .14
.   
     
   
   

1552 ' -'  .13

2455 ' 17  -   .12

1656 ' ??
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2007 ' , : .10

(303-2 ) 1980 ' '  .9

 

 " .(40-4    
319 ) 2099 '  : .8

  
  .      DI   


      

.
   

"         .(follow up 239 )   1536 '

: .7
       .
 
         
 
     
  
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. "  


     .   "    1480 '    .   .

: .6
.    
    1478 

1704 ' , : .5

2143 ' ' : .4

1724 '  : .3

1964 ' .'



  .2

1687 ' , : .1

16        ,   

 *

 

318

201

    
 
 SCLC-      .566  ,': .44
.  
       ,('    ) 
 

 ?   ,   ...  

   , , )   .   ,'   
:(...           
Excessive and unregulated production of hormones such as ACTH, PTHrP, or
vasopressin can lead to substantial morbidity and can complicate the cancer treatment
plan. Moreover, the paraneoplastic endocrinopathies are sometimes the presenting
feature of underlying malignancy and may prompt the search for an unrecognized
.tumor

1833  285-3  ,' : .43


      .
     - 1500 ' ,' : .42
.  
  FEV1/FRC ,RV- ,TLC-  

     

    .(  ,214 ) 1345 ' ,' : .41
      
      .        
    3  1.8 INR    
 
.     
   
. 48-     
  
 

  
. 
     
  
 
 48-

.40<          
     :1791 ' ,'
: .40

The most important complication of celiac sprue is the development of cancer. An

increased incidence of both gastrointestinal and nongastrointestinal neoplasms as well
as intestinal lymphoma exists in patients with celiac sprue. For unexplained reasons
the occurrence of lymphoma in patients with celiac sprue is higher in Ireland and the
United Kingdom than in the United States. The possibility of lymphoma must be
considered whenever a patient with celiac sprue previously doing well on a glutenfree diet is no longer responsive to gluten restriction or a patient who presents with
clinical and histologic features consistent with celiac sprue does not respond to a
gluten-free diet. Other complications of celiac sprue include the development of
intestinal ulceration independent of lymphoma and so-called refractory sprue (see
above) and collagenous sprue. In collagenous sprue, a layer of collagen-like material
is present beneath the basement membrane; patients with collagenous sprue generally
do not respond to a gluten-free diet and often have a poor prognosis.

The most common cause of persistent symptoms in a patient who fulfills all the
criteria for diagnosing celiac sprue is continued intake of gluten. Gluten is ubiquitous,
and significant effort must be made to exclude all gluten from the diet. Use of rice in
place of wheat flour is very helpful, and several support groups provide important aid
to patients with celiac sprue and to their families. More than 90% of patients who
have the characteristic findings of celiac sprue will respond to complete dietary gluten
restriction. The remainder constitute a heterogeneous group (whose condition is often
called refractory sprue) that includes some patients who (1) respond to restriction of
other dietary protein, e.g., soy; (2) respond to glucocorticoids; (3) are "temporary"
(i.e., the clinical and morphologic findings disappear after several months or years);
or (4) fail to respond to all measures and have a fatal outcome, with or without
documented complications of celiac sprue, such as development of intestinal T cell
lymphoma.

200

:1772 ' ,'

: .39

2009 ' , : .38

  

50-   E-coli ,17  
 816 "  " , '
: .36
.    
   

high  
 
:aortic regurgitation  
 
 
 . : .35
    ,decrescendo ,(...    ?) blowing ,pitched
.(1400  16  
)   
  
 3- 

2       bisferiens pulse    ,16  
 1305     
.(HCM ) aortic regurgtaion  
      

;    
:  
 .(- 242 ) 1554 ' ,' : .34
  ;    
  ;    
  
 ;    ;  
 
 
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 )  
.

1972 " ,' : .33

       

,   

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. 

.

   
  
 
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 MCV-   RDW-  .(      ) 
   
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'
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) 

       .(LMWH 103 ) 689 ' ' 

'
: .30
 
   AT3     
  ,AT3   
 
  


         ;     LMWH , .AT-  

     , ;     
 
 LMWH    
.60%-  LMWH

pathophysiology of neuromuscular abnormalities. Subtle clinical manifestations of

uremic neuromuscular disease usually become evident beginning at stage 3 CRD.
Early manifestations of central nervous system complications include mild
disturbances in memory and concentration and sleep disturbance. Neuromuscular
irritability, including hiccups, cramps, and fasciculations/twitching of muscles,
becomes evident at later stages. Asterixis, myoclonus, and chorea are common in
.terminal uremia, which may also be associated with seizures and coma
Peripheral neuropathy usually becomes clinically evident when the patient has been at
stage 4 CRD for >6 months, although electrophysiologic and histologic evidence of
peripheral neuropathy occurs earlier. Initially, sensory nerves are involved more than
motor nerves, lower extremities more than upper, and distal portions of the
extremities more than proximal. The restless legs syndrome is characterized by illdefined sensations of discomfort in the legs and feet requiring frequent leg movement.
If dialysis is not instituted soon after onset of sensory abnormalities, motor
involvement follows, including muscle weakness and loss of deep tendon reflexes.
Accordingly, evidence of peripheral neuropathy is a firm indication for renal
replacement therapy. Some of the central nervous system and neuromuscular
complications of advanced uremia resolve with dialysis, although nonspecific
electroencephalographic abnormalities may persist. Successful transplantation may
reverse residual peripheral neuropathy

319

203


.  

 .  
 .(311 ) 2027 ' ,'
: .60
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.       
   

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  " .( 103 ) 692 ' ,' 
'
: .59
  
      
.              

 
  
     
   
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.  


   ,  PTH- D     .(331 ) 2248 ' ,' : .58
- .PTH-        (  )        

 "
   
 .  "
  "     
 HPT
    '
 .PTHrP   PTH-  
 .  "

.  

   
  PTH-  
     
"

1705  266  ,: .57

  
         .590-591 ' , : .56
        
        - ' .  
 .          
          .RBC
.    ,
    
     ,     
     ,  

  ..    
.PO  
       

:        

           38 
For motor esophageal dysphagia, barium swallow, esophageal manometry,
esophageal pH, and impedance testing are useful diagnostic tests.
Esophagogastroscopy is also often performed in patients with motor dysphagia to
exclude an associated structural abnormality.

Manometry shows the basal LES pressure to be normal or elevated, and swallowinduced relaxation either does not occur or is reduced in degree, duration, and
consistency. The esophageal body shows an elevated resting pressure. In response to
swallows, primary peristaltic waves are replaced by simultaneous contractions (Fig.
286-3). These contractions may be of poor amplitude (classic achalasia) or of large
amplitude and long duration (vigorous achalasia). Cholecystokinin (CCK), which
normally causes a fall in the sphincter pressure, paradoxically causes contraction of
the LES (the CCK test). This paradoxical response occurs because, in achalasia, the
neurally transmitted inhibitory effect of CCK is absent and the direct excitatory effect
of CCK remains unopposed. Endoscopy is helpful in excluding the secondary causes
of achalasia, particularly gastric carcinoma.

A chest x-ray shows absence of the gastric air bubble and sometimes a tubular
mediastinal mass beside the aorta. An air-fluid level in the mediastinum in the upright
position represents retained food in the esophagus. Barium swallow shows esophageal
dilation, and in advanced cases the esophagus may become sigmoid. On fluoroscopy
with barium swallow, normal peristalsis is lost in the lower two-thirds of the
esophagus. The terminal part of the esophagus shows a persistent beaklike narrowing
representing the nonrelaxing LES (Fig. 286-1, panel 4).


 
   
  

      
  
 286 
: 

202

:

:286  17    
   
 .' : .55
Achalasia affects patients of all ages and both sexes. Dysphagia, chest pain, and
regurgitation are the main symptoms. Dysphagia occurs early with both liquids and
solids and is worsened by emotional stress and hurried eating. Various maneuvers
designed to increase intraesophageal pressure, including the Valsalva maneuver, may
aid the passage of the bolus into the stomach. Regurgitation and pulmonary aspiration
occur because of retention of a large amount of saliva and ingested food in the
esophagus. Patients may complain of difficulty belching. The presence of
gastroesophageal reflux argues against achalasia; in patients with long-standing
heartburn, cessation of heartburn and appearance of dysphagia may suggest
development of achalasia, peptic stricture, or carcinoma on top of reflux esophagitis.
The course is usually chronic, with progressive dysphagia and weight loss over
months to years.

   50    

 .(screening  272 ) 1737 ' ,' : .54
;  3-5      /  
 : 
    .    '

)     
  

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: .53
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1372-1375 ' ,: .52

,      " .(   ,239 ) 1532 ' ,'
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Nondiagnostic biopsies occur for many reasons, including a fibrotic reaction with
relatively few cells available for aspiration, a cystic lesion in which cellular
components reside along the cyst margin, or a nodule that may be too small for
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is repeated. Ultrasound is also increasingly used for initial biopsies in an effort to
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TREATMENT
MCD is highly steroid-responsive and carries an excellent prognosis. Spontaneous
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Documentation of two major criteria, of one major and three minor criteria, or of five
minor criteria allows a clinical diagnosis of definite endocarditis

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Membranous glomerulonephritis .
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thiazide .
hydralazine .
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325

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sacroileitis .
uveitis
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erythema nodosum .

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prostate cancer .
factitious .
adult still's disease .

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metabolic acidosis .
metabolic alkalosis .
mixed metabolic acidosis with respiratory .

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CT .
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alkalosis
mixed metabolic acidosis with metabolic .
alkalosis

.53 gold standard Renal

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contrast arteriography
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.
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AP=110, AST=40, ALT=38, .

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LDH=660, t.BILIRUBIN=3, DIRECT=0.5

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CLL .
polycytemia vera .
autoimmune hemolytic anemia .
megaloblastic anemia .

.60
3 INR=2.5 .

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. 75

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statins .
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.

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.

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CT .
.
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.
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.
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nitroglycerin .
captopril .
metoprolol .

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.
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.
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.
.

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?
.
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apirin+enoxapirin+clopidogrel .

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, . 3

.128 .
.
.
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81

331

 .
CT .
D-DIMER .

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.
.
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.
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strep pneumonia .
legionella .
staph .

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.

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TTP .
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TIDAL VOLUME .
DLCO .

.142 ,H.pylori - ?
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.
.

.135 , 3
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?
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.

.

.

.
332

80


.1
.2
.3
.4
.5
.6
.7
.8
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.10
.11
.12
.13
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.15
.16
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.18
.19
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.21
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.31
.32
.33
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.41
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.91
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.134
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.136
.137
.138
.139
.140
.141
.142

82

333


- 2010 '

.
.

.1 ?AIDS
.
HEP A .
.
HEP B .
Tetanus .
.2

60 24

( .)halithosis -
70 68 -" . ?
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Cyclophosphamide
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84

337

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338

ATN
Prerenal
Postrenal
Renal Artery Stenosis
Allergic Interstitial Nephritis

85

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US . -
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. ?
CT .

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Paracetamol .

.41 ?allopurinol
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SQUAMOUS CELL CARCINOMA

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40 SQUAMOUS
PET -

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86

339

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. TB
. TB

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.47 HIV .
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.56
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340

.
.
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PAN
WEGENERS
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protracted diarrhea

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.

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anti-Ro .
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.65 55
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.72 diverticulosis

?73
.

88

341

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CT .
.

.

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.

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342

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MI
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amyloidosis

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right heart

89

.
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.
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,


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91

343



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Mycoplasma Pneumoniae
Mycobacterium Tuberculosis
Legionella
Pseudomonas Aureginosa

.98 COPD" ?GOLD criteria

.
.
. 6 -
.
RV .
FEV1
FEV1/FVC

.104 UTI -
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.

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( 200 ) .

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.
.

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PO 40

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.
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-

.108 70 , ,
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.
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.

.102
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. CT
.

.109 -
ABVD ?

.
.103 ,68 ,2 ,
, 4,
, :
= 6.8= ,PTH=1200 7 =4

344

TSH

.
.

90

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.
.
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Milk alkali syndrome .

.
.
.

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Total cholesterol- 348, HDL- 38, LDL- :
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TSH .
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. ?
.

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. LDL

.123 .
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92

345

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.
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. PO
. IV
. IV

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?
.
.
.
.
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. PTH 900 .
?
.
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-1.5 . T score -
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.

.131 ?FSGN
.
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.
.
.132
. ,
,
.
' :
88 -
20 -
39 -
60\90 -
86%
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131 -
4.4 -
15 -

.125 , ,105
,220 ,300
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.

Normal saline

. +
. +
.126 .74 , ..

. .LBBB ?
.
.
.
.
.

PCO2-42

90 -
90 -
PH - 7.25

- ?
.
.
.
.

.127 HIV
. ?

.133
?
.Triemterene +
. +
+ ACEI .
. ACEI +

.
.
. HIV-
Analgesic nephropathy
FSGS

.128 inferior wall MI

.PCI +PTCA " ,
. ARF
. ?

.
.
.
.

.134 20
.
,
3 . ?
.

.

.

.

ATN
Contrast glomerulopathy
GN
Interstitisal nephritis

.129 .IgA nephropathy ?

.
. =

50% . ESRD 20
.
20
. HUS
.
346

93

 .135
?
.
.
.

.
.

.142 29 .
.
- .
?
.
.

.136 honeymoon?
.
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. 1


. ,1

. 2
.

.
.

IgA Nephropathy
UTI

.143
, ?
.
.
.
.
.

.137 ,80 39
, , .
wbc=14,000 : 90%
.
.
?

.
.
.
.
.

I.V 1 mg
P.O 5 mg

.144 .
3 , 9.2 - 9-
?
.
.
.

Enterococcus Faecalis
Staph. Aureus
Peptostreptococcus
Strep. Bovis
Strep. Viridans

.145 ,70
. 30,000
" .-
. ?
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. 300"
. 10"
NSAIDS .
.

.138 ,80 , ,
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. : ,,8000-
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. PO
.
.
.139 ?
.
.
.
.
.140

?
.
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, .
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. () P.O
. 0.3" S.C

94

347


.1
.2
.3
.4
.5
.6
.7
.8
.9
.10
.11
.12
.13
.14
.15
.16
.17
.18
.19
.20
.21
.22
.23
.24
.25
.26
.27
.28
.29
.30

.31
.32
.33
.34
.35
.36
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
.47
.48
.49
.50
.51
.52
.53
.54
.55
.56
.57
.58
.59
.60

.61
.62
.63
.64
.65
.66
.67
.68
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Allergic Interstitial Nephritis
MM
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CML
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acute myelofibrosis
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.

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HIV AIDS?
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358

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.
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.

ICD

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G6PD disease

.132 UA
. 90% -
proximal LAD 100%- .RCA-
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Mycoplasma pneumoniae

. 18000
.

LAD

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LAD

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, .
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.133 flutter 80 ,
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. INR 2-3 -
.
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) .
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.
.
.

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. US- .DVT
-
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016

359

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. Enalapril -
.
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.
.
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.
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.
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,
. -CT .15

?
RV . TLC , VC ,FEV1/FVC ,

RV . TLC , VC ,FEV1/FVC ,

RV . TLC , VC ,FEV1/FVC ,

.143 GLP-1
, ?
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.
.
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MRI .
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.138 RBC.
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?
.
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.

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.

CT .
.
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.
.
.
.
.

.141
?renal crisis
.
. 2
360

Pericardial effusion
Pneumothorax
Acute MI
Aortic dissection
Pulmonary embolism

017

Familial Hypocalciuric Hypercalcemia

MM
Parathyroid Adenoma
Sarcoidosis
Slow growing breast cancer


.31
.1
.32
.2
.33
.3
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.4
.35
.5
.36
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.15
.46
.16
.47
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.48
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.49
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.20
.51
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.52
.22
.53
.23
.54
.24
.55
.25
.56
.26
.57
.27
.58
.28
.59
.29
.60
.30

.61
.62
.63
.64
.65
.66
.67
.68
.69
.70
.71
.72
.73
.74
.75
.76
.77
.78
.79
.80
.81
.82
.83
.84
.85
.86
.87
.88
.89
.90

.91
.92
.93
.94
.95
.96
.97
.98+
.99
.100+
.101
.102
.103
.104
.105
.106
.107
.108
.109
.110
.111
.112
.113
.114+
.115
.116
.117
.118
.119
.120

.121
.122
.123
.124
.125
.126
.127
.128
.129
.130
.131
.132
.133
.134
.135
.136
.137
.138
.139
.140
.141
.142
.143
.144
.145
.146

018

361

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. US
.
.

.37 , CT- ?
+ FFP . K
. + K
6 . K
.

.30 ) 2 ( , , '
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.
. R -

.38 ,mg/dl17 .
?
2 jak .
.
.
.

.31 , , . TSH , .
, . . ?
.
NSAIDs .
.
.
.PTU /

.39 ?
ITP .
TTP .
. 12B

.32 40 . -
3fT 4fT , TSH , . ?
.
. central-

370

MDS .
.

.
.
.
.

.40 , 0.6 - monoclonal peak , .8%

, , . ?
multiple myeloma .
smoldering myeloma .
monoclonal gammopathy of undetermined significance .
waldenstrom macroglobulinemia .
POEMS .

.43 66 3 , , .18.000 WBC , - .

?
. )(9;22
.
. INR , PTT ,
.
. CMV-

.41 , , : LDH,

.44 MM ) ( , ?
. paraprotein
. RBC
.
.
.

?
.
CT .
PET-CT.
.
.
.42 ) - ( , 9.8=WBC=13.2, Hb ,112000
?

.45 49 , , . ,60,000 -
. 6" .
R-CHOP .
. ARA-C
.
.
imatinib mesylate .

371

 .
.
.
.50 19 . , .Amoxicilline -
. , , .38
,130,000 BUN 30, CPK ,1.6 .145 .
,1.015=SG ,++++ . .
US- , , .
?
prerenal azotemia .
. IgA nephropathy
.
.
.51 , , . ?
FeNA . 1%
. 10
. 300
. 40
.

.46 "" ?
. gpII/III
. ADP
cox inhibitor.
.

.52 ,70 " ,160 . .CT -

80% . ?
.
. ACEI
.
.
.

.47 ?dabigatran
. protein C
.
. Xa
. 4-5
. INR

.53 ,60 - , . /
. ?
.
.
.
.
.

.48 ) (HRT . ,DVT-

5 . " . ?
HRT .
HTR .
HRT . 1.5-2 INR-
. INR 2-3 HRT-
. HRT

.54 ,70 . : , .HCV- :" ,90/60

, . : ,147 - ,5 - ,109 - ,320 - ) 3 -
( , .7.02 - PH ,10 - ,1.03 - specific gravity : trace ,
. . ?
.
diabetic nephropathy .
2RTA .
. " HCV
.

* DBCL ?R_CHOP-

- ADPKD .49 , ?
.
.

372

 .55 1DM , - .DKA ,360 .

190 ,5.6 . ?
. IV
. IV
.
.

.
. 0.9%
.62 60 ,ACE INH , . ,hypertensive retinopathy II
5" .:
145
-
2.2
total protein 8
?HB 12
, , . 24 5 .
?
diabetic nephropathy .
.
MM.
membranous nephropathy .

.56 ) ( ampicillin SBE-

, 3- , , , ,+++ RBC
, . ?
ATN .
Interstitial Nephritis .
.
. -
.57 ?
Minimal change disease .
Focal Segmental .
MembranoProliferative .
Membranous .
Focal proliferative .

.63 8 , , > .0.9" .130/80 ?

IGA NEPHROPATHY .
ALPORT .
LUPUS GRADE IV .
MEMBRANOUS .

.58 17 , ?
.
.
. 24
CT.
. CPK

.64 , ,IHD ,MM- CT . ?

.
. CT
. 12
. CT
. .

.59 , US - )?( . -
. ? .
?
.
.
.
.
. PH - .7.5

.65 ?
.
.
.
.
. .
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. .150 ?
.
.
RTA .
DKA .
.

.60 ,AS 4C3, C , ANCA , ANA . ?

Wegner's Granulomatosis .
Culture-Negative SBE .
Lupus Nephritis .
Membranoproliferative GN .
Anti-GBM syndrome .

.67 ) , ,(6.7
) . ( . ?
) NSAIDs . ?(
.

.61 21 ) ,(110 . ) ,(250 ) (600 60 .

?
. 3%
.

373

. 35 , .
. ,65 .

.68 .
. ,5 .60
?
.
.
.
. .

.73 , . ?
.
.
.
.
.

.69 -contrast nephropathy ?

. .
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. 3-5

.74 HIV- -
.
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. 40
.

.75 MR 14" ,TTE- % 40=EF

.
.
. TEE
.
.
.

.70 ,60 3 . " , , .37.8

: . 3 . ?

.76 , MSSA
. + oxacillin +
. + +
. + +
.77 ,43 2-3 . 3- ,38 LDH . 2
. 4200 3800.
3 . .
.
.
.
.
carcinomatous lymphangitis .

.
.
. ++
. , ,
.
.71 PPD ?
. HIV-
.
. 65 ,
.
. ,60 40

* 2 )
, ) (
( , . , ,
.78 major ?Duke Criteria-
.
.
Roth's spots .
.

.72 asymptomatic bacteriuria ?

. 80 .
. 60 .
. 60 .

374

 .79 , , . .
. 39 ,70 . ?
. .
Ceftriaxone .
.
. , .IV
.

.
.
GCSF .
.
.86 ,73 8 . 3 .
. - , , , .
- 40" 70,000 , " . .
. - ,8000 -WBC ,11 - .110 ?
.
NSAID .
.
.
.

.80 " MRSA

.
.
.
.
.
.81 ,72 , , MRI ,
?
.
GBS .
.
.4 .
.5

.87 71 . 33 , , .. 90/60 ?
.
.
.
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.88 )? VAP( ventilator associated pneumonia
PPI.
AB .
.
.
.

.82 ,23 , .
?
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.
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.83 73 38 . .
, - 12,500-WBC , 80% . . ?
.
.
. +
.+
ACYCLOVIR.

.89 ,48 , , . , 170/110" , 38.0 .

, ANA .8 . ,
, . ?
.HIV .
.HBV .
.HCV .
.HAV .
.90 RA " 3 ) ,,( , , 37.7
, MTP , ?
.
. Uric Acid
US .
.

.84 . 10
WBC- 13000 . . , ?
. PO
. PO
. IV
. IV
.+ PO

.91 ,35 .1+ . SLE 13 ,

. .18 - ,37 .88 - , .
- . - ." ST . VT .VF
. ?

.85 , . 150
. . 3 350 ,38.5 ,
. ?
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375

 .98 ,35 . . , ,
, ?
MRI .
US .
.

. .
. .
..
. .
Libman-Sacks Endocarditis . .LAD-

.99 ,65 , . 13 .:
, 4C , , ?
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.
MM .
RA .
.

.92 RA , . . .102 Hb 10.1, MCV -

, ?
NSAIDS .
..
..
. .TNF
..

.100 ,RA / NSAID . ,DMARD-

.7 ?
.
. TNF
.
.

.93 anti TNF

.
.
.
.
.94 ,52 30 , 2" ,
.CT- . 15 ) ( . ?
CT .
. PPD
.
.
.

.101 STEMI RCA - PCI- , .

, ,120 ] . :" [ . ?
. MR-
.
AR .
.

.95 " , + . ,
. ?
3C . 4C-.
ANA ..
..
Anti-histone Ab .
RF .

.102 :
.
.
. "
.
.

.96 ?
. D
. ACE
.
. PTHrP

.103 ,40 ) 50 ( 8 ,
. 0.8 ST" , ?
. 6
. stress-Echo
.
.

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.
. 3
. 20"
.

.104 , . . "
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. 30'
.

376

.
. ICD
. ACE inhibitor

.105 ,76 , ." .90/60 ."

140 - . ?
. J200
.
. IV
. "

.110 " . ) JVP( . ? ).. -

ST-elevation ST-depression , ST-elevation , .V2, V3,V4-
(R
.Early Repolarization Pattern .
.
. -
.

.106 ..

."
. O
RF.ANA-
.

.111" . ,30 8 .

.107 " ?50

."
.
.
.
.108 ?DCM
..
.
.
.
. .
NSAID .
.
.
.

.109 68 " ,ACE inhibitor - " " .,

, , . " . ?

.112 . ,, ACEI , .slow-K -

? " " P QRS-.
. .
.
.
.113 " ?
. 5 NSAIDs -
. - .
. " .
.
.
.

377

.
. CCB FP -
.
.
. (
.119 MVR-
. 40%=EF LVEDV=50
. 50=EF=70%, LVEDV
. " 30
. 38 38% EF63 LVEDV
.120 49 . , . ,
2S ,2P ,
. "
MS . "
."
.
ASD . ) (
.121 60 , , ,
2 , :
.
VSD .
MS .
PS .
HOCM .

.114 ,55 . 3-4 , .

." ,120/80 ,66 ," . ?
. , ,
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.
.

.122 severe MS
. PAF
. CVA
. TEE
. 1".
. AF

.115 BNP ?
. BNP-
. BNP-
. BNP-
. BNP-
. BNP-

.123 " ?30=EF

.
CCB .
.
.

.116 " "?

. 3 .
. 50" .
. .
. " 60 .

.124 ?Drug Eluting Stent

.
.
. neointimal proliferation

.117 - ":
Sulfonylurea .
.
acarbos .
rosiglitasone .

.125 ,62 " . STEMI . 6 .

CPK . ?
ACE .

.118 ,30 ) ,(160/110 CCB- ,3.6=K , ?

378

 .
.
.
.

.130 ,50 FVC - 90%, FEV1-89%. .90%

.
.
.
COPD .
.
. ) (

.126 ,36 . ., ." .120+

?
MS .
MR .
AR .
AS .
. "

.131 62 . ?
.
.
.
.
.

.127 ?NSCLC-
.
. 10%
.
..

.132 60 .COPD . . , .
. .PO2=60, PCO2= 65, 17=HGB ?
.
.
.
.
.

.128 } . {CT ?
Ciprofloxacin .
Metronidazole .
Clindamycin .
Doxycycline .

.133 ,19 . , ,
. ?
.
.
.134 19 , - ?
. COPD-
.
. HBV
.
.135 -ARDS - ?
. TV
.
. 100 120-
.
.

.129 ,50 = BMI ,COPD ," 5

. . ?
102=2PCO .
PO2=89 .
2pO .
. 40%

.136 ?
. +
+ SABA .
+ N-acetyl cysteine .
+LABA .
. +
.137 ?

379

 .
.

. 2PCO-
.
2PCO .
2PO ." 90

.144 . ?
.
. CT
. CA PNEUMNIA-

.138 ,28 , . - ,
) ," ( ," ,90/60 . ?
.
.
.
.
LMWH .
)(
.139 .
?
.
.
.
ezetimibe .
.140 DVT Coumadin ,Enoxaparin- .
?
. Antithrombin-III
.
.
). ( Enoxaparin-
.141 ,60 . - .
. .48 ?
. ?
.
. INR .
.
. .
.142 .
CAD , .FAP- .2-2.5 INR
.
.
.
.
.143 .150,000 -CPK .
. 30%=EF , ?
.
IVIG .
.

380


.6 - MALT ,H. Pylori- . ?
. PPI
.
. PPI-
.
:

.1 ) (?
.
.
.
.
.
:

.7 " ?
UC.
.
.
IBS .
:
subacute thyroditis

.2 , .90/40 ?
.
.
.
CT .
:

.8 ?
-N . 24
. 4-
.
.
. ,
: " arterial blood lactate levels among such patients with acute liver failure may distinguish
" patients highly likely to require liver transplantation '? ! )(
.? ' .' .
305-1 , Acetaminophen- Predictable and Dose-Related Toxicity, -
' - . ) ( ,
) ) .dose-related ' ' -
?! !!!
) ( " .

.3 ?
. .
. ) (.
. .
. .
. - .
: )(848-849
.4 38.5 . .
. ) 126 () ,
,(10 , ) ? 150 ?(
. ,
. 5%.
. 200 3%" 4
. FFP-
. + 5%
:?

.9 BMI ) 90 ,(1.72 , . - ,
,80 AST 60, ALT HBsAG. anti HBcAG & anti HBs , ? AST
,60 ALT .150/90 .
.
. ) )B
.
. US- , ,, -
.
-: HBV , US- )( ) (
NASH- US- .

.5 ,42 , , . .
. . ,
. ?
.
.
. Loperamide (Imodium
.
.
:
In those aged >40 years, an air-contrast barium enema or colonoscopy should
also be performed.

.10 ,35 , PPI- 20"

. . , NSAID- ?
. PPI
.
.
. MEN
. PH 24?

381

 : , - ZES ,2455 , , .erosive esophagitis

Metronidazole .
Fluconazole .
Ganciclovir .
.PPI -
:

.11 87 " ,80/60 AF ) ,( PVD

, \ , , ,Pneumatosis Intestinalis
?
.
.
.
.
US .
: .

.15 50 , , . . B,C.
.
:
ANA,
AST ALT 2

4
3" "

.12 , , RUQ , . "

) " (90/60 .
.
ERCP .
. ) (
MRCP .
...US .
:
Charcot's triad of jaundice, abdominal pain, and fever is present in about 70% of
patients with ascending cholangitis and biliary sepsis. These patients are managed
initially with fluid resuscitation and intravenous antibiotics. Abdominal ultrasound
is often performed to assess for gallbladder stones and bile duct dilation.
However, the bile duct may not be dilated early in the course of acute biliary
obstruction. Medical management usually improves the patient's clinical status,
providing a window of approximately 24 h during which biliary drainage should be
established, typically by ERCP. Undue delay can result in recrudescence of overt
sepsis and increased morbidity and mortality rates.

?
.
.
.
.
. TNF
:) ? 90% (
' . ,42-1 figure- . -
) ANA,SMA,LKM,SPEP ( , .
, . '.
, "" ,
,
.
, . .
.
) :(301
Strict diagnostic criteria have not been developed for most liver diseases, but liver biopsy
plays an important role in the diagnosis of autoimmune hepatitis, primary biliary cirrhosis,
nonalcoholic and alcoholic steatohepatitis, and Wilson's disease
) :(301-1
Liver biopsy in acute liver disease: Reserved for patients in whom the diagnosis remains unclear despite
medical evaluation.

.13 12000 , ) ,(1200 , ) 3 ?5

) 100%) (5 5() . ?
. -
.
.
H2 receptor antagonists .
US .
: )' (2640
In most patients (8590%) with acute pancreatitis, the disease is self-limited and subsides
spontaneously, usually within three to seven days after treatment is instituted. Conventional
measures include (1) analgesics for pain, (2) IV fluids and colloids to maintain normal
intravascular volume, and (3) no oral alimentation.
There is currently no role for prophylactic antibiotics in either interstitial or necrotizing
pancreatitis

.16 , HCV( , - ,40 IHD )

) ,(.. - ,3 ,1.5 - ) . 2.8
'( ?
.-
.
.
.
.

.14 ,80 , . 10
, , ?
Acyclovir .

382

 , , 50 15-25
, , ,
. '
... ,

: ) . (2.5 .
) ,1.1>SAAG - . ,2.5 - " - ,? ." -
'( ,. .
,
, ?
. .

.19 - , .3-5TSH -5.5, T4-14, T : ?

/ .
US .
MRI .
.
thyroid stimulating hormone binding inhibitor immunoglobulin .
:? , TSH 3T 4T .

.17 - ?HBV -
. 40
.
. HDV
. HBeAG
. ALT AST-
-

.20 27 ,28 BMI ?

52=HDL .
.
.
. 130/80
. 2
:

:- , 2- , 4- 3
Certain clinical and laboratory features suggest progression of acute hepatitis to chronic hepatitis: (1) lack
of complete resolution of clinical symptoms of anorexia, weight loss, fatigue, and the persistence of
hepatomegaly; (2) the presence of bridging/interface or multilobular hepatic necrosis on liver biopsy
during protracted, severe acute viral hepatitis; (3) failure of the serum aminotransferase, bilirubin, and
globulin levels to return to normal within 612 months after the acute illness; and (4) the persistence of
HBeAg for >3 months or HBsAg for >6 months after acute hepatitis.
- , AST- ALT- ...
'
- ' . .

.21 ,45 -2.6 -2.8 -" PTH . .

.
. Vitamin D, TSH, Cortisol
. )?(
. ) (

:?
' )' 3126 (
3126 , " " ,
, -
...
OP PTH PAGET ' ?

.18 80 ,30% = EF , .
. . -
T3, T4 - normal. TSH 6.5
?
.
. 60" .
. " "
.
. } {O5 .
: , .
There are no universally accepted recommendations for the management of
subclinical hypothyroidism, but the most recently published guidelines do not
recommend routine treatment when TSH levels are below 10 mU/L.
?
TSH 4T
.
, ,
. ...30%=EF ?EF-
, EF-
.

.22 ,29 , . MRI- 7" ,

. . ?
. MRI 6.
. .
. .
. ) cabergoline- (.
: ) () (
) (
- .
.23 ... ) ?screening- 50 . ,,
(
.
. 1"
.

383

. ACTH
CRH test.
:

.27 ,57 , - ,140-150 ,220-240

HbA1C = 8.9%,
,250 = LDL = 130, HDL = 55, TG" ,130/80 , ? )
,110/70 Ace , (
. + + ACE
. Bezofibrate-
Losartan .Bezofibrate-
.
: . 40 \ . ACE
. .

.24 ,33 .
C-peptide . ?
.
. 2
.
factitious hypoglycemia .
Nonislet cell tumor .
:

.28 52"/" ) ? ) ) ,
, " 130/80 140/85 .
.
.
. CCB
.
: ? (: (:

.25 " , . .
4.5" , )( .CT ?
. CT 6.
. .
. CT
.
: - , , )??(
, ,
... ? ' .
- ' - ) (342-12
, 342-12 ,adrenal incidentaloma .
- , 4":
However, size alone is of poor predictive value, with only 80% sensitivity and 60%
specificity for the differentiation of benign from malignant masses when using a 4-cm cutoff.
- 4 , " ..
" , ! .. .
.
,
- .
.
,CCB - - .

- .. /
.
CT . ,
) , - 4 6" .
(.
? -' 342-12 '.
.26 28 ,106 ,200 .45 HDL ,108 ?
. 3
.
.
.
.

.29 2" TSH , . ?

FNA .
. US
.
.
:
.30 ) 2 ( , , '
.PTU /
.
. R -
:
.31 TSH .. . ?
) - , , . TSH , .
, . . ?(
.
NSAIDs .
.
.
.PTU /
: - 2
/PTU . grave's . .,
.grave's
PTU
...thyroid storm-

384

.32 40 . -
3fT 4fT , TSH , . ?
.
. central-
.
US.
.
:

.34 - . , ,Hodgkin's lymphoma- ?

. ABVD
R-CHOP . mantel
.
.
:
.35 , CT- ?
+ FFP . K
. + K
. 6) ?... (K
.
:

.33 ,11.0 pth ,1.2 .?

. D
. -.
. .
. .SQUMOUS CELL CA
: - , PTHrp , ,
? - , .
?

? :
Patients with serious bleeding need more aggressive treatment. These patients should be given
10 mg of vitamin K by slow IV infusion. Additional vitamin K should be given until the INR is in the
normal range. Treatment with vitamin K should be supplemented with fresh-frozen plasma as a
source of the vitamin Kdependent clotting proteins. For life-threatening bleeds, or if patients
cannot tolerate the volume load, prothrombin complex concentrates can be used.
??? PROTHROMBIN COMPLEX CONCENTRATE
, 8 PCC , C 2,7,9,10 .S- .

** ,42 ) 11.2 1 ( PTH , , 3.5- T score- ?

.1
....2 24
.3 (CT (
4. PET
.5 1MEN
:? , .

.36 ,mg/dl17 .
?
2 jak .
.
.
.
:) . ? HIGH CO ?( ,
?

40 " ,165/90 .III .3.6

, ) ( .160/85
. ?
. .
. .
. .
. ) . - (
:
Diagnostic screening for mineralocorticoid excess is not currently recommended for all
patients with hypertension, but should be restricted to those who exhibit hypertension
associated with drug resistance, hypokalemia, an adrenal mass, or hypertension before the
age of 40 years (Fig. 342-11). The accepted screening test is concurrent measurement of
plasma renin and aldosterone with subsequent calculation of the aldosterone-renin ratio
(ARR) (Fig. 342-11); serum potassium needs to be normalized prior to testing. Stopping
antihypertensive medication can be cumbersome, particularly in patients with severe
hypertension. Thus, for practical purposes, in the first instance the patient can remain on
the usual antihypertensive medications, with the exception that mineralocorticoid receptor
antagonists

.37 ?
ITP .
TTP .
. 12B
MDS .
.
:
.38 , - monoclonal peak , .8%
, , . ? ) gr 0.6
8% (
multiple myeloma .
smoldering myeloma .
monoclonal gammopathy of undetermined significance .
waldenstrom macroglobulinemia .
POEMS .

385

 : )(

41. ,(?) 60 , WBC , ) ( , , -

) .( smudge cells ?
. )(9;22
.
. - ???DIC INR , PTT ,
.
. CMV-
: ) (927

.39 , , , : LDH

?
.
CT .
PET-CT.
.
. ) - - )
:
) - ? CT ?(
, CT .
) ( + + <- .

.42 MM ) ( , ?
. paraprotein
. )RBC(
.
.
. ?
: ? Normocytic and normochromic anemia occurs in 80% of -
myeloma patients. It is usually related to the replacement of normal marrow by
expanding tumor cells, to the inhibition of hematopoiesis by factors made by the
tumor, and to reduced production of erythropoietin by the kidney
" , " ,paraprotein
-

.40 ) - ( , 9.8=WBC=13.2, Hb ,112000

?

.
.
.
.
. ] ]

43. 66 3 . 180,000 , .
? CLL
. )t(9,22

386

 .
INR . PTT ,?
.
.
:
) (41

cox inhibitor.
.
:
.46 ?dabigatran
. protein C
.
. Xa
. 4-5
. INR
:

.44 49 ,60,000 - ....

R-CHOP.
. ARA-C
.
.
imatinib mesylate .
: , ,160000 , , .
6" , CML .
) : CML - .
CML 60000
.CML
2 - 60000 180000
60,000 ,CML- 180,000
) AML- ?APL \ DIC ?(
. 180,000- AML-

.47 ) (HRT . ,DVT-

5 . " . ?
HRT .
HTR .
HRT . 1.5-2 INR-
. INR 2-3 HRT-
. HRT
:
* DBCL ?R_CHOP-

- 48. ADPKD , ?
.
.
.
.
.
:
.49 19 . , .Amoxicilline -
. , , .38
,130,000 BUN 30, CPK ,1.6 .145 .
,1.015=SG ,++++ . .
US- , , .
?
prerenal azotemia .
. IgA nephropathy
.
.
:
.50 , , . ?
FeNA . 1%
. 10
. 300
. 40

.45 "" ) (?
. gpII/III
. ADP

387

 .
diabetic nephropathy .
2RTA .
. " HCV
.
:
" " ,
?

.
:?? ) . -' , , .500
300 (...500 .
' ) ( ,- .500 350- .
, ATN
. ,500-
300- -' . ...
44
The prerenal urine sediment is usually normal or has occasional hyaline and granular casts
300
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. ,50 ," LBBB
. ,19 ,"

.53 ?
. ,60 , LBBB "
. ,45 - ,
. ,65 4 ,"
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. ,35 ,

.57 ?
. ,80 , .
. ,20 .
. ,27 .
. ,47 VT.
.5 ,16 .

.54 pulse pressure 75 "?

.
.
. RAAS
.
.

.58 NSTEMI .
. )3
?( .STEMI ?
restenosis . " warfarin
restenosis . "
.
in stent thrombosis . "
in stent thrombosis . " warfarin

.55 ,72 ," ,70/50 .86

, , " ." - ] 6 "

.59 DM-2 " . . ACE-I-

.ARB- ARB .,
, .190/100 ?
. - ARB-

404

 . ACE-I
. NON DIHYDROPYRIDINE CCB
.
.
.60 30 , , , " ,
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. .
CT ..
.
.61 ,58 .ACE
, . .
?
.
.
.
.
.62 ?
. .
.ACEi .
..
..
.63 NSTEMI :TIMI
. 7- .
. .
. .
. < 55

.66 STEMI .
, .
" ?

.64 75 . " .
?
Aspirin 325 mg/d .
Aspirin 325mg + Clopidogrel 75mg .
Clopidogrel 75mg.
Coumadin .
. -
.
.
.
.
.

.65 " . ?.
.
.
.
.
.

.67 ?
. S2
. S2
S3 .
.
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405

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?
.
.
.
.
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. . .
. ST mV0.01 .
. ST 6' .
. .circumflex-
.70 ,28 - .
?
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? .
. .CT
.71 . .
" ). ( ..
,120 135 .252
.690
?
.
.
. 50
.

?
SOTALOL .1
VERAPAMIL .2
BB .3
AMIODARONE .4
PROCAINAMIDE .5

.72 75 . 7.27-PH 17-HCO3 7.1- .

" .35
?
.
K OXALATE . .
. .
. .

.75 , ST 1.5" .
, ?
.
.
.
.

.73 ?WIDE COMPLEX TACHY

.LAHB .
.AF.
.SVT.
.Orthodromic WPW.

AR .76 ,E/F = 60% .LESV = 40- ?

.
. afterload
. , EF -
. Afterload"

.74 ) ( , " ) .(A

, " .B

.77 65 , ,EF=65% , 55" .".AF -

?

406

 .82 ,26 3 , . CT
. ?

.
.
.

.78 ,40 ) (BMI=40 obesity hypoventilation

.syndrom ?
PCO2 . A-a gradient ,
PCO2 . A-a gradient ,
PCO2 . A-a gradient ,
PCO2 . A-a gradient ,
PCO2 . A-a gradient ,
.79 50 , ,COPD ?
FEV1/TLC .
. FEV1 .
FVC .
RV .
.80 27 . ,
. , .
?
. .PO
PPI .
.
. LABA
.

.
PET-CT .
.
.
. C-ANCA -
.83 50 .
, ,70/40 ? PE
. ?
IVC FILTER .
.
. )(
?coumadin+clexane .

.81 .COPD .PCO2=80, PO2=80, pH=7.1= 35 ,

. .pH=7.5 ?
. 100%
.
.
.
.

.84 ,72 3 , . .COPD

.LABA .70/50 , .65 : ,12
,WBC 8K ,K212 ,128 .ph 7.38 ,5.7 ,
. ?
.
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. IV
.
.85 ,70 , , .
?
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407

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.
RA .
FMF .

. .4.5

.86 , ,
. ?
.
.
.
.

.91 ,23 .
. , ?
Plaquenil .
Cyclophosphamide.
NSAIDS .
.

.87 ,75 . . . .38.5 70,000 -

90% . . ?
.
.
.
.

.92 ,65 , , ,
. -
)( . ?
.
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.
.

: , . , ,
. . . ?
. .
. IV PO
. IV
) . (...

.93 35 .
: - ." 180/98
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.
ACE-I .
. , IV
. IV
. IV

.88 ?ANCA
.
.'
. '
IgA nephropathy .
.89 ?ANTI-TNF
Mantoux test .
HBs Ag .
HAV .

.94 70 , ,
ANA . , . ?
.
.
.

.90 20 ,,
? :

.95 ,38 10 , 3 ,levido reticularis ,

: .90000 -PLT ,11000-WBC ,13.4- ?
.
. COOMBS
. APL
. TXA2

408

.96 ,43 .
. ANA , DLCO .
?
.
.
CCB .
ACE-I .
.
.97 , ?

 .
.

. .
. .
.

.104 ,17 , 3 ,
, ,Amoxicilin ,4+
, .
?
(
( Amoxicilin
( IgA nephropathy
( Post streptococcal glumerulonephritis

.98 , .DVT ?
..
. .IVC
..
. +
.99 PIP , RF .
CCP , . ?
NSAIDS .
.
anti TNF .
.

.105 ,50 , . ,
. ?
.
.
. .
. , .

.100 , . .
?
.
..
..
. .PO
dipyrone .

.106 ,39 . .:
.PH-7.38, HCO3-16, PCO2-21, NA-144, CL-110, K-3.7 ?
.1
.2
.3
.4

.101 1.8 ?GFR 36

.
.
.
.

.107 ,67 3 .
) ?( . 3 , .:

.102 ,58 10- , .18-

. ?
. congo red
. ,
GlumeruloSclerosing .
.
.103 MM , . , , ."
.130/78
Na Serum - 128
Na Urine - 60
Plasma osm - 260
Urine osm -300
?
. -
.

409

-" .170/95 - .+++ RBC ,+++ ?

anti-Ro .

 . .
..

C3 .
PSA .
.

.115 ,128 .240

. ?
. 50 55
. 660 .160
. 260 26
. 164 16

.108 SIADH
. .
. .
.
."

.116 ,75 . . ,
) . , : (140
.PCO2=68 pH= 7.21 HCO3=25 ?
.
.
.
.

.109 50 .
. . .
.4+ . ?
wegnaer .
good pasture .
IgA .
(Mambranous nephropathy) Membranous glomerulonephritis .

.117 ?
." ) .102 ,CURB 65-- (90
. .71
. .
. % 90

.110 . .
AG ) ( . , ) (.
.5 - .10 - ?
.
.
.
.

.118 .
?
C. Difficile .
.
.
.
.

.111 .
. ?
Goodpasture syndrome .
Wegener's granulomatosis .
Churg-Strauss .
.
.112 ,PEG ,
160 ' " . 90/60 ?
. PEG
. 0.9%
. 0.45%
. 5%
.113 ,
280 , 137 117 ,PH 7.25 10 .5.8" .120/80
?
.
.
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RTA4 .
.114 ?
..
K ..
..

.119 ?
. ) (
.
. N95
.120 35 38.5 , .
, , ,
" . - .Na- 136,K- 4.7, -
.WBC- 8000, PLT- 128,000, AST- 60, ALT- 60 ?
. .
. .ZN
. .PCP -
. .
. .

410

.121 ?Acute HIV syndrome

.

 . . ?

.
. ,
.
CNS .
.122 50 . 39 . .
. IV .
. ?
.
.
.
.
CT.
.123 ,70 . 39 ' ." ,' .
" lobar pneumonia- . ?
group A streptococcus .
pseudomonas .
mycoplasma pneumonia .
Staph aureus .
legionella .
.124 ,40 " , .
,
?
. - -
. , Amoxicillin-Clavulanate
. , Macrolides
.
. )(PCP

) , (
.
.
.
.
. .
.127 ,28 " , .'
. ,120/60 30 .110 , 85% .
.PH=7.42, PO2=40, PCO2=30 - .
?
.
.
PCP .
ARDS .
Cardiogenic pulmonary edema .

.125 ,45 . ?
. .
. US + ,- .
. . .
. .
. .

.128 HIV ,Antiretroviral Therapy- 8

" . ?
.1 . 10" - .
.2 10 . - 4-.
.3 4- .
.4 . - .
.5 IGRA - Interferon-Gamma Release Assay
.

.126 58 " . 4" .

.

.129 ?
. ,70 , 100 .
. ,
E.COLI 100.000.
.
. .
.130 10 ?

411

Jarisch-Herxheimer reaction .
.
.
.

. " .
.
. .acute rheumatic fever-
. .
. 10- .3-4-

.136 ,55 .COPD - .

, . .
" .
. ?
S.aureus .
GAS .
Pseudomonas .

.131 80 , , . 8
. . WBC 13000 . . ?
. PO .
. PO .
. IV
. IV
. .

.137 50 , .
?
B ..
..
..
..

.132 23 ,39 . .ICP LP ,

, ,20 .120 ?
.
.
TB .
.

.138 58 , . ,
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, .
?
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. .
.
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.133 .55 .
. 4 6 .Staph. Coagulase negative
?
. ,
.
. ,
.
.

.139 ?CO
.
Hb-CO . ) " CO-
" (
.
.

.134 18 .39.5 3 . ,
." ,70/40 .140 - :
. ?
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.
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.
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,40 , 125" 70/54 . ?
.

.140 ?
CO . SVR
CO . SVR.
CO . SVR.
CO . SVR.

412

.141 30 ?
. 100-120
. .
.
. 7 .

 2013 '
.142 ,45 " . . .70/40
.85% ?
.
CT .
.

.1
.2
.3
.4

:
**
, ' .
. - .

** Anti CCP
?
MTX ?** .. friction-rub ,
.
.
. .
.

.5
.6
.7
.8
.9

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. , ?
. -

413

.10
.11
.12
.13

.14
.15

.16
.17
.18
.19

: . ' , .MELD
...

? ... . .
. ,?

" 2565
The administration of oral contraceptive combinations of estrogenic
and progestational steroids leads to intrahepatic cholestasis with
pruritus and jaundice in a small number of patients weeks to months
after taking these agents .

:? ?
B ? HBc IgM " HBsAg" anti HBs B.
-Infrequently, in15% of patients with acute HBV infection, levels of
HBsAg are too low to be detected; in such cases, the presence of IgM
anti-HBc establishes the diagnosis of acute hepatitis B

: ' - / , ... '.

. ?
... ) .
(.march hemoglobinuria ,106
: .Table 344-2 Criteria for the Diagnosis of Diabetes : ,Mellitus .6.5-
.HBa1c - 3 - . ' ...
) (200

Chapter 341:

In AIT (Amiodarone induced thyrotoxicosis), the drug should be

stopped ,if possible, although this is often impractical because of the
underlying cardiac disorder. Discontinuation of amiodarone will not
have an acute effect because of its storage and prolonged half-life .
High doses of antithyroid drugs can be used in type 1 AIT but are
often ineffective .In type 2 AIT ,oral contrast agents ,such as sodium
ipodate (500 mg/d) or sodium tyropanoate (500 mg, 12 doses/d),
rapidly reduce T 4and T 3levels, decrease T 4to T 3conversion, and
may block tissue uptake of thyroid hormones. Potassium perchlorate,
200 mg every 6 h, has been used to reduce thyroidal iodide content.
Perchlorate treatment has been associated with agranulocytosis,
though the risk appears relatively low with short-term use.
Glucocorticoids, as administered for subacute thyroiditis, have modest
benefit in type 2 AIT .Lithium blocks thyroid hormone release and can
also provide some benefit. Near-total thyroidectomy rapidly decreases
thyroid hormone levels and may be the most effective long-term
solution if the patient can undergo the procedure safely.
' )
.(
! TBG - .(BHCG - ) :
.
?
BHCG , guidelines ?
+ TSH
. .TPU . , ,

.28
.29
.30

.31
.32
.33

? :?NSAID? ? ,"B12"
.
?-

? :-Chapter 115. Disorders of Platelets and Vessel Wall:

Initial treatment in patients without significant bleeding symptoms,
severe thrombocytopenia (<5000/L) or signs of impending bleeding
(such as retinal hemorrhage or large oral mucosal hemorrhages) can
be instituted as an outpatient using single agents .
- ... ' - single agent -
-
/large oral mucosal
-

.20

? : , "1 ,? .
. .0.5
! !! , " " - , "1 .


" 2- ,ACTH "-" 1
.

414

.21
.22
.23
.24
.25
II .25
.26
.27

Table 1111 Clinical Features of Multiple Myeloma

Clinical Finding Underlying Cause and Pathogenetic Mechanism
Hypercalcemia, osteoporosis, pathologic
fractures, lytic bone lesions, bone pain
Tumor expansion, production of osteoclast activating factor by tumor
cells, osteoblast
inhibitory factors
Renal failure- Hypercalcemia, light chain deposition, amyloidosis,
urate nephropathy, drug toxicity
)nonsteroidal anti-inflammatory agents, bisphosphonates), contrast
dye
Easy fatigue/anemia Bone marrow infiltration, production of inhibitory
factors, hemolysis, decreased red cell
production, decreased erythropoietin levels
Recurrent infections Hypogammaglobulinemia, low CD4 count,
decreased neutrophil migration
Neurologic symptoms Hyperviscosity, cryoglobulinemia, amyloid
deposits, hypercalcemia, nerve compression,
antineuronal antibody, POEMS syndrome, therapy-related toxicity
Nausea and vomiting Renal failure, hypercalcemia
Bleeding/clotting disorder Interference with clotting factors, antibody to
clotting factors, amyloid damage of
endothelium, platelet dysfunction, antibody coating of platelet,
therapy-related
hypercoagulable defects

.(AML ? ) :?2272
Hyperleukocytosis and the leukostasis syndrome associated with it is
a potentially fatal complication of acute leukemia (particularly myeloid
leukemia) that can occur when the peripheral blast cell count is
/100,000<mL .
At such high blast cell counts, blood viscosity is increased, blood flow
is slowed by aggregates of tumor cells, and the primitive myeloid
leukemic cells are capable of invading through the endothelium and
causing hemorrhage. Brain and lung are most commonly affected.
Patients with brain leukostasis may experience stupor, headache,
dizziness, tinnitus, visual disturbances, ataxia ,confusion ,coma, or
sudden death .
Plasma exchange remains the mainstay of treatment of : .
TTP
. . :
:
Chapter 245. ST-Segment Elevation Myocardial Infarction: "Pump
failure is now the primary cause of in-hospital death from STEMI"

.44
.45
.46

.47

.48
.49
.50

.51
.52
.53

.34

+ .5.5 + ? :.O .
. " , ,90/60 ..
30 " .? ?...
O- " ,
".
. 100/60
- - 45 )
- O - (

.
. ,60 -O ? ? :: . " Warfarin inhibits the vitamin K-dependent synthesis of biologically
active forms of the calcium-dependent clotting factors II ,VII ,IX and
X",
, K - ' -- . ," ' " .
.. -
: CKD - ' One example is warfarin anticoagulation for atrial fibrillation: the
decision to anticoagulate should be made on an individual basis in the
CKD patient, as there appears to be a greater risk of bleeding
complications.

6.5 ? . :
..... -
CD 20 . . . - .
. . .
? AML- MDS- LDH- 3-
.
. ,? ,
.
,T- PA- ,B12 .

.35

.36
.37
.38

.39
.40

.? .ATN - ? . .
.IGM ,10% MM VWD ,
:

415

.41
.42
.43

.54

.60

:? ?
Hypertensive patients have stiffer arteries, and arteriosclerotic
patients may have particularly high systolic blood pressures and wide
pulse pressures as a consequence of decreased vascular compliance
due to structural changes in the vascular wall. Vascular endothelial
function also modulates vascular tone. The vascular endothelium
synthesizes and releases a spectrum of vasoactive substances,
including nitric oxide, a potent vasodilator. Endothelium-dependent
vasodilation is impaired in hypertensive patients
) , . - -(.. !
: . . V5 V6 ! V2 V3 - . -
" , ...
?? :?
":
Contraindications to exercise stress testing include rest angina within
48 h, unstable
rhythm ,severe aortic stenosis ,acute myocarditis, uncontrolled heart
failure, severe pulmonary hypertension, and active infective
endocarditis .
AS AS . +'
..
" :2004

.55

.56

:.
? "?
" -
-
.
!!
, -
" , .

.61
.62
.63
.64

.65
.66

: . CHADS .
, .
= - / .
" , .
" .SAH
.(?RBBB +) AIVR .
LBBB .
:.
? A2 .

.67

.68
.69
.70

.71
.72
.73

? - ? CT -
?28
.
-? ) . (

! "
.57
.58
.59

:? ARB .
? ACEI
ARB CCB, BB '
.

- ARB

? ? ?

416

.74

.75

: QRS ) (. : SVT SVT !

SVT AF . http://www.cardiophile.com/wolf-parkinson-white-wpw- :syndrome
) :(2
SVT in WPW syndrome can be orthodromic or antidromic .
Orthodromic tachycardia has a narrow QRS complex and is the
commonest variety accounting for 90%. The remaining 10% is
antidromic and has a wide QRS.
' ) AF (ABERANCY SVT AVRT- AVNRT- )
( .
, AF ,SVT .
233-4 AF - ,SVT
.
. .
- .

fatigue. A randomized, placebo-controlled, prospective trial has shown

that withdrawal of hydroxychloroquine results in increased numbers of
disease flares. Hydroxychloroquine reduces accrual of tissue damage
over time. Because of potential retinal toxicity, patients receiving
antimalarials should undergo ophthalmologic examinations annually.
A placebo-controlled prospective trial suggests that administration of
dehydroepiandrosterone may reduce disease activity. If quality of life
is inadequate in spite of these conservative measures, treatment with
low doses of systemic glucocorticoids may be necessary. Dermatitis
should be managed with topical sunscreens, antimalarials, and topical
glucocorticoids and/or tacrolimus. Since recent data show that
mycophenolate mofetil, and belimumab (added to background
therapies of glucocorticoids-plus-antimalarial-plus
immunosuppressive) reduce disease activity in nonrenal
manifestations of SLE, it is reasonable to consider these interventions
in patients with persistent disease activity despite standard
therapies.Azathioprine or methotrexate may also be considered for
such patients (Table 319-5).
.? .
- . OA .
. .
.

.76
.77
.78

.79
.80
.81
.82
.83

.84
.85
.86
.87

.88
.89
.90
.91

[2184 '? ]. - obesity hypoventilation . syndrome

. , PCO2
, . , ? .obesity hypoventilation syndrome
. PaO2 -

.?? ? ?? PE . ? -- .
- CI
.
,( ' ) . - " : ... ,

.92

?. ? ) , : .133-3 .(1.4 ) ,(
,] . .""
. "
-Goodman & Gilman's The Pharmacological Basis of Therapeutics,
12e, Chapter 43:
Renal failure is another common comorbidity reported in patients
having lactic acidosis associated with metformin use, and decreased
glomerular filtration rates are thought to increase plasma metformin
levels by reducing clearance of drug from the circulation. There are no
consensus guidelines for renal contraindications for metformin use;
It is important to assess renal function before starting metformin
and to monitor function at least annually. Metformin should be
discontinued preemptively in situations where renal function could

.93
.94
.95
.96
.97
.98
.99
.100

:
" - ? MRSA ?
?

-( 314)
: , ,
Among patients with fatigue, pain, and autoantibodies of SLE, but
without major organ involvement, management can be directed to
suppression of symptoms. Analgesics and antimalarials are
mainstays. NSAIDs are useful analgesics/anti-inflammatories,
particularly for arthritis/arthralgias. However, two major issues
currently indicate caution in using NSAIDs. First, SLE patients
compared with the general population are at increased risk for NSAIDinduced aseptic meningitis, elevated serum transaminases,
hypertension, and renal dysfunction. Second, all NSAIDs, particularly
those that inhibit cyclooxygenase-2 specifically, may increase risk for
myocardial infarction. Acetaminophen to control pain may be a good
strategy, but NSAIDs are more effective in some patients. The relative
hazards of NSAIDs compared with low-dose glucocorticoid therapy
have not been established. Antimalarials (hydroxychloroquine,
chloroquine, and quinacrine) often reduce dermatitis, arthritis, and

.101

417

decline precipitously, such as before radiographic procedures that use

contrast dyes and during admission to hospital for severe illness.
, .
.102
.103

.104
.105

.114
.115
.116

. ) (.


2 BUN 260 . .
) ( , - ....

.106

.107
.108
.109
.110

.111
.112

.113

. .anion gap )
( .

? ) (.? ) .(CO2 . 102 , .CURB , CURB CURB "

90 , 102 . 92% ,
102-
? .. ? 86-4 ,neutropenic fever .
http://cid.oxfordjournals.org/content/34/6/730.long .figure 1
: . :N95 , - 131... transmissible pathogens are based on probable routes of
transmission: airborne, droplet, or contact, for which personnel don at
a minimum N95 respirators, surgical face masks, or glove and gown...
. . ) / .(...PCR /

.117

.118

:285Once lithium-associated nephropathy is detected, the discontinuation

of lithium in attempt to forestall further renal deterioration can be
problematic, as lithium is an effective mood stabilizer that is often
incompletely substituted by other agents. Furthermore, despite
discontinuation of lithium, chronic renal disease in such patients is
often irreversible and can slowly progress to end-stage kidney
disease. The most prudent approach is to monitor lithium levels
1> frequently and adjust dosing to avoid toxic levels (preferably
meq/L). This is especially important as lithium is cleared less
effectively as renal function declines. In those cases that develop
ACEIor ARB treatment should be initiated ,significant proteinuria.
. - . . PH . . 7.38- -

.119

.120

.121
.122
.123
.124
.125

.
Routine baseline hepatic ALT testing based solely on an age of :
<years is optional and depends on individual concerns. Monthly 35
treatment is indicated for isoniazid biochemical monitoring during
patients whose baseline liver function tests yield abnormal results and
for persons at risk for hepatic disease, including the groups just
.mentioned
, ) ?( .
' ,
...
.
? ' - ,
US ..

47-5 ,' .causes of non-anion gap acidosis ,368 > 15

.GI:
"K +excretion of <15mM is indicative of an extrarenal cause of
"hypokalemia
, TABLE 45-4 Causes of Hypokalemia .45-4 -B2c ....
? .0.9%<Harrison's Online < Chapter 45. Fluid and Electrolyte Disturbances
normal saline is usually inappropriate in the absence of very severe
hypernatremia, in which normal saline is proportionally more
hypotonic relative to plasma, or frank hypotension.
: 150 ????. . AG. , AG - ) ( ,

.126
.127
.128

418

? - HIV 2. , .
- HIV


, :In HIV-infected persons ,isoniazid may be administered concurrently
with nucleoside reverse transcriptase inhibitors, protease inhibitors, or
NNRTIs.
) (..
...
HIV 9 6..129
.130
.131
.132
.133
.134

.135
.136
.137
.138
.139

..
""shifting the oxyhemoglobin dissociation curve to the left" - '' .
, ) (dissociatntion.
' , . shifting the oxyhemoglobin dissociation curve to the "" :
,""left ) ( ,

.140
.141

. " !!"... TSS , ... .

- , / - .
...
, ,

. !!! !!CO
. 2 , , . , ,
" ... ".
.
-The pathophysiology of carbon monoxide exposure is incompletely
understood. CO binds to hemoglobin with an affinity more than 200
times that of oxygen, and this not only directly reduces the oxygencarrying capacity of blood, but further promotes tissue hypoxia by
shifting the oxyhemoglobin dissociation curve to the left.
CO" : 200 ,
,
"
" . , , -
. ?
, CO
.
.
)( . , ' ,
!

.142

419

.
: ) (:)The ADA suggests these glycemic goals for hospitalized patients: (1
;in critically ill patients: glucose of 7.810.0 mmol/L or 140180 mg/dL
(2) in noncritically ill patients: pre-meal glucose <7.8 mmol/L (140
mg/dL) and at other times BG <10 mmol/L (180 mg/dL).
:http://www.ncbi.nlm.nih.gov/pubmed/19509383
:271
Erythrocyte transfusion is generally recommended when the blood
hemoglobin level decreases to 7 g/dL, with a target level of 9 g/dL in
adults
:More recently, a randomized clinical trial that compared vasopressin
plus norepinephrine with norepinephrine alone in 776 patients with
pressor-dependent septic shock found no difference between
treatment groups in the primary study outcome, 28-day mortality.
:Meta-analyses of recent clinical trials have concluded that
hydrocortisone therapy hastens recovery from septic shock without
increasing long-term survival.
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