경희대학교 의과대학·의학전문대학원

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Department of Hematology & Medical Oncology

(HMO)

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종양혈액내과

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Prof. 김시영

• 前 한국호스피스완화의료학회 회장 • 前 대한암학회 부회장 보건의료심사평가원 비상근 전문위원 • 식약처 의약품심사부 전문가협의체 항암제분과 위원 국립암센터 암정복추진기획단 기획위원

• American Society of Clinical Oncology, active member • American Association for Cancer Research, active member • European Society of Medical Oncology, active member

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Prof. 백선경

• 한국임상암학회 정회원 및 윤리간사 / 기획위원 / 보험정책위원 • 한국호스피스완화의료학회 정회원 및 윤리간사

• 국민연금공단 장애판정의사

• American Society of Clinical Oncology, active member • European Society of Medical Oncology, active member

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Prof. 맹치훈

• 한국 임상암학회 정회원 및 보험정책위원 • 대한 항암요법연구회 정회원 및 홍보위원 • 한국호스피스완화의료학회 , 교육위원회 간사 • 한국호스피스완화의료학회 , 기획위원회 • 국민연금공단 장애판정의사 , 근로능력평가위원

• American Society of Clinical Oncology, active member • European Society of Medical Oncology, active member • American Association for Cancer Research, active member

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Prof. 한재준

• 대한 항암요법연구회 정회원 , 림프종연구회 간사

• _{American Association for Cancer Research, active member} • _{American Society of Hematology, international member} • European Hematology Association, junior member • American Society of Clinical Oncology, active member • European Society of Medical Oncology, active member

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Prof. 김홍준

• 대한암학회 전산위원

• 항암요법연구회 홍보위원

• 항암요법연구회 폐암 분과위원 ,

두경부 식도

암 분과 위원

• American Society of Colinical Oncology, a

ctive member

• American Association for Cancer Researc

h, active member

• European Society of Medical Oncology, ac

tive member

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임상 실습의 개요

• 종양혈액내과 질환을 중심으로 문진 ,

병력 채취 및 신체검사 등 임상의사로서 기본적인 사항

을 습득하도록 하는데 목표를 둔다 .

• 대상 질환

- 종양질환 : 위암 , 폐암 , 대장암 , 유방암 , 전립선암 , 두경부암 등 고형암 - 혈액질환 : 백혈병 , 림프종 , 다발성 골수종 , 골수질환 , 빈혈 , 출혈 질환 , 조혈모세포 이식

• 숙지 술기

- 임상술기센터 : 동맥혈 채혈 , 안전수혈술기 - 관찰술기 : 골수검사

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실습평가

1. 임상 종합평가 : 20

점

2. 실습점수 : 75 점

1)

실습 평가 : 40

점

-

실습평가 배점 :

교수 별 각 8

점 배점

2)

임상실습 필기시험 : 35 점

-

증례중심으로 출제함 :

각 교수님 당 5

점 씩 (7 x 5)

-

환자의 주 증상 (problem)

을 해결하는 능력을 평가함 .

-

단편적인 지식 평가 문제는 출제 안함 (

주관식으로 출제 )

3. 출석 : 5 점

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TEXTBOOK

1. 의과대학 강의교재

2. HARRISON’S Principles of Internal Medicine

3. 혈액종양내과

혈액학

1. 혈액학 3판 대한혈액학회

2. Williams Hematology 9th edition

3. Pathophysiology of Blood disorders 2nd edition

종양학

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Neoplastic Disorders

Hematopoietic Disorders

Approach to the Patient with Cancer Hematopoietic Stem Cells

Prevention and Early Detection of Cancer Iron Deficiency and Other Hypoproliferative Anemias Cancer Genetics Disorders of Hemoglobin

Cacner Cell Biology Megaloblastic Anemias Principles of Cancer Treatment Hemolytic Anemias

Infections in Patient with Cancer Anemia Due to Acute Blood Loss

Oncologic Emergencies Bone Marrow Failure Syndromes Including Aplastic Anemia and Myelodysplasia Cancer of the Skin Polycythemia Vera and Other Myeloproliferative Neoplasms

Head and Neck Cancer Acute Myeloid Leukemia Neoplasms of the Lung Chronic Myeloid Leukemia Breast Cancer Acute Lymphoid Leukemia Upper Gastrointestinal Tract Cancers Chronic Lymphocytic Leukemia Lower Gastrointestinal Cancers Non-Hodgkin's Lymphoma Tumors of the Liver and Biliary Tree Hodgkin's Lymphoma

Pancreatic Cancer Less Common Hematologic Malignancies Neuroendocrine Tumors of the Gastrointestinal Tract and Pancreas Plasma Cell Disorders

Renal Cell Carcinoma Amyloidosis

Cancer of the Bladder and Urinary Tract Transfusion Biology and Therapy

Benign and Malignant Diseases of the Prostate Hematopoietic Stem Cell Transplantation

Testicular Cancer

Disorders of Hemostasis

Gynecologic Malignancies Disorders of Platelets and Vessel Wall

Primary and Metastatic Tumors of the Nervous System Coagulation Disorders

Soft Tissue and Bone Sarcomas and Bone Metastases Arterial and Venous Thrombosis

Carcinoma of Unknown Primary Antiplatelet, Anticoagulant, and Fibrinolytic Drugs Paraneoplastic Syndromes: Endocrinologic/Hematologic

Paraneoplastic Neurologic Syndromes and Autoimmune Encephalitis Late Consequences of Cancer and Its Treatment

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PART 1. The Practice of Medicine

• When a patient poses challenging clinical problems, an effective physician must be

able to identify the crucial elements in a complex history and physical examinatio

n; order the appropriate laboratory, imaging, and diagnostic tests; and extract the

key results from densely populated computer screens to determine whether to tre

at or to “watch.” …….. This combination of medical knowledge, intuition, experien

ce, and judgement defines

the art of medicine, which is an necessary of the practi

ce of medicine as is a sound scientific base.

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Diagnosis

Symptoms &

Signs

발열

쉽게 멍이 듦

황달

피로

빈혈

…...

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PART 2. Cardinal Manifestations and Presentatio

n of Diseases

• _{Section 9 Hematologic alterations}

– Interpreting Peripheral Blood Smears – Anemia and Polycythemia

– Disorders of Granulocytes and Monocytes – Bleeding and Thrombosis

– Enlargement of Lymph node and Spleen

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Case 1

• 여자 /53 세

• 162 cm/72 kg

• 활력징후 : 120/80 mmHg – 72 회 /

분

–

20 회 /

분

–

36.1℃

•

53 세 자영업자로

멍이 쉽게 들어서

병원에 왔다 . 3

개월 전부터 고지혈증으로 약제를 복

용하고 있었으며 다른 병력은 없었다 .

일주일 전부터 본인도 모르게 전신에 멍이 들어있

었으며 부딪히거나 다친 기억은 없다고 하였다 .

멍은 주로 양쪽의 팔과 다리에 다발성으

로 관찰되었으며 이전에는 이렇게 멍이 든 적은 없다고 하였다 .

1. ‘

멍이 쉽게 들어서 의 원인을 알아보기 위해 필요한

’

병력청취

내용은 ?

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Peripheral Blood Finding

• Hb-WBC-PLT

– 12.6g/dL-3270/μL-59K/μL

• RBC : normocytic normochromic

• WBC : mildly decreased in number

– (seg. 72%, lympho. 19%, mono. 7%, eosi. 2%)

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Differential Finding

• Total count : 500

Blast

0.6 %

Eosinophil

1.2 % Histiocyte

0.0 %

Promyelocyte

4.2 %

Basophil

0.4 % Pasma cell

2.8 %

Myelocyte

14.8 %

Prono.

2.6 % Lymphocyte

15.0 %

Metamyelocyte

9.0 %

Baso.

3.0 % Monocyte

0.6 %

Band

9.8 %

Poly.

10.6 % Atypical lym.

0.0 %

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BM Aspiration

• _{Shows normocellular marrow particles}

• The granulocytic series and erythroid elements are normal in number an

d show good maturation sequences

• The estimated M:E ratio is approximately 2.11:1

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Clot Section & Biopsy Section

• _{The biopsy sections are fragmented}

• Cellularity cannot be estimated

• Hematopoietic cells are similar to those seen in aspiration smears

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Medical Decision-Making

• Occurs at each stage of the

diagnostic

and

therapeutic

process

– Involves the ordering of additional tests – requests for consultations

– decisions about treatment

– predictions concerning prognosis

• Requires an in-depth understanding of the pathophysiology and natural history of

disease

– Application of the scientific method (hypothesis formulation and data collection) is esse ntial to the process of accepting or rejecting a particular diagnosis.

• Decisions should be

evidence-based

whenever possible

– Despite the importance of EBM, much medical decision-making still relies on good clinic al judgement

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Progress in evidence-based medicine:

a quarter century on

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Research in HMO

Publications

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What is Research?

• _{We do research whenever we gather information to answer a question t}

hat solves a problem.

– Problem: 급성골수구성백혈병은 어떻게 진단하나요 ? – Research: 처방된 오더를 찾아보고 그 결과들 중에서

급성골수구성백혈병의 진단을 뒷받침하는 것들을 정리한다 .

• Writing is Thinking!

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