외래진료 매뉴얼 - 근거 중심의 2vol. 1set > Family Medicine

절판도서입니다

진료실에 한 환자가 찾아왔습니다. 47세 남자였고, 3개월 전부터 왼쪽 가슴이 조여오는 듯이 아프다고 하였습니다. 동시에 왼쪽 어깨도 쑤시는 듯이 아프다고 하였습니다. 운동을 할 때 특히 심해지는지는 알 수 없다고 했지만, 일상생활 중 신경이 쓰일 정도로 통증이 심하다고 하였습니다. 환자는 이상지질혈증과 고혈압으로 동네 병원에서 약을 타다 먹고 있었으며, 환자의 아버지가 급성 심근경색으로 급사한 가족력이 있어서 본인의 증상에 대해 매우 불안해하였습니다. 이미 다른 3차 병원의 전문과를 방문하여 관상동맥조영술, 위내시경검사를 비롯한 여러 검사를 받았으나 이상이 없다는 말과 함께 걱정하지 말라는 의사의 이야기를 듣고 온 상태였습니다. 하지만 그 후로도 증상은 지속되어서 매우 불안해하고 있었습니다. 진찰결과 왼쪽 흉늑관절(costosternal articulation)을 따라 압통이 있었으며 왼쪽 승모근(trapezius)을 촉지하였을 때 유발점(trigger point)이 발견되었습니다. 환자에게 흉통의 원인은 늑연골염(costochondritis)이며 왼쪽 어깨 통증의 원인은 근막통증증후군(myofascial pain syndrome)이라고 설명한 후안심시켰으며, 왼쪽 승모근의 유발점 주사 요법(trigger point injection)을 시행함과 동시에 비스테로이드성 소염진통제를 처방하였습니다. 몇 번 더 진료실을 방문하여 유발점 주사요법을 받은 이후에 증상은 많이 호전되었고 환자는 만족해하였습니다.

     일차의료현장은 3차 병원의 환경과 많이 다릅니다. 교과서의 지식이 일상생활 환경과 부딪히는 영역이기에 때로는 교과서의 논리적이고 과학적인 접근 방법이 통하지 않는 곳이기도 합니다. 그래서 예술(art)로서의 의학이 가장 힘을 발휘할 수 있는 곳이기도 합니다. 하지만 일차료에 대한 충실한 기초가 없다면 임기응변식의 진료를 보기 십상인 곳이기도 합니다. 일차진료현장에서는 입원 환자의 진료를 통해 배운 질병에 대한 진단과 처방 방법뿐만 아니라 일차의료환경에서 흔히 발생하는 질병에 대해 넓고 깊게 알아야 합니다. 이 책은 한 대학병원에서 두 명의 전공의가 그와 같은 고민을 하면서 시작하게 되었습니다. 입원 환자 중심의 주치의 생활을 마치고 외래 환자를 보려다 보니 막히는 부분이 많았습니다. 흉통 같은 경우를 예로 들면 병동이나 응급실에서 본 흉통 환자는 급성 관상동맥증후군 환자가 제일 많았지만, 외래에서 본 환자는 대부분 근골격계질환이 원인이었고 위식도 역류질환이나 정신적인 원인의 흉통도 많았습니다. 급성 관상동맥증후군이 아니더라도 환자에게 무엇인가를 해주고 싶었지만 마땅히 참고할만한 자료는 많지 않았습니다. 기존에 한글로 나온 책들은 대부분 입원 환자를 대상으로 한 매뉴얼이었으며, 외래 진료를 위한 책이 몇 권 있기는 하였으나 그 내용의 근거를 찾기 힘든 경우가 많았습니다.

     Queen Mary, University of London의 General practice and primary care 담당 교수인 Trisha Greenhalgh는 그의 저서『Primary health care, The Theory and Practice』에서 일차의료의사의 자질에 대해 언급하고 있는데 그 중‘지식을 발견하고 평가하고 요약하고 병합하고 공유하는 지식을 관리하는 능력’인 이른바‘지식 관리(Knowledge management)’에 대해 강조하고 있습니다. 인터넷이 발전하면서 우리는 넘쳐나는 지식과 정보 속에서 믿을 만한 것을 가능한 한 신속하게 얻어내야만 하는 숙제를 안고 있습니다. 특히 의학지식은 근거중심의학으로 급격히 패러다임이 바뀌고 있고 그 교체주기도 빨라지면서 지식의 근거가 더욱 중요시되고 있습니다. 따라서 범람하는 지식의 홍수 속에서 소극적인 자세로 출처가 불분명한 내용을 믿고 받아들이기보다는 인터넷으로 인해 이전보다 비약적으로 높아진 의학정보에 대한 접근성을 이용하여 각종 의학정보와 권위있는 저널의 내용을  적극적으로 평가하고 잘 요약하고 병합하여 진료 현장에 적용하는 능력이 중요해졌습니다. 지식 관리의 측면에서 본다면 인터넷 시대에서는 아는 것이 힘일 뿐만 아니라‘어디에 있는지를 아는 것’또한 큰 힘이라는 뜻입니다.

     이 책은 일차의료현장에서 흔한 질병에 대한 전문가가 되자(Primary care specialist)는 취지로 약 2년 동안 국내외 유명 저널의 리뷰 논문 약 2,000편을 참고로 하여 만들어졌습니다. 모든 내용에는 인용 논문이나 인용 도서의 출처를 표기하여 내용의 근거를 분명히 하였습니다.
  
     이 책은 역동적인 과정에 체계적으로 접근하기 위해 크게‘증상/징후/검사소견별 접근방법’과 ‘질환별 접근방법’으로 구성되어 있습니다. 전자는 대부분 증상이나 징후, 검사소견을 바탕으로 대략적인 진단을 내리기 위한 과정이며, 후자는 개별적인 질환의 구체적인 진단방법과 치료방법을 확인하는 과정입니다.
     각 파트에는 각 주제의 내용을 실제적으로 적용하는 데 도움이 될만한 검사의 해석방법이나 약물에 대한 리뷰를 추가하였습니다. 각 주제의 시작에는 골격이 될만한 중요 참고문헌(Key references)을 언급하였고, 그 주제를 가장 잘 설명할 만한 환자 증례(Case vignette)를 제시하였습니다. 질환을 이해하는데 도움이 될만한 교과서적인 내용도 되도록이면 모두 언급하려고 했습니다. 그렇기에 다소 산만해질 수 있는 구성을 보완하기 위해 실제 진료에 적용할 수 있는 각 주제의 핵심을 요약해서(Practice key-point) 함께 제시하였습니다.
     이 책을 디딤돌로 삼아 모두 경쟁력 있는 일차진료의(Primary care specialist)가 되길 기원합니다.


2011년 2월
전문의로서 첫 발을 내딛으며
이 상 봉 / 정 세 영

Part 01 ｜의학적 의사결정/건강증진 Medical decision making/Health promotion

1. 의학적 의사결정 ························ 2
2. 통증관리 ····························10
비암성 만성 통증 관리 ··················10
암성 통증 관리 ·····················16
3. 금연 ······························27
4. 음주 ······························36
5. 비만 ······························45
6. 건강검진 ····························51
7. 예방접종 ····························56
성인예방접종 ······················56
소아예방접종 ······················67
8. 여행자의학 ···························79

Part 02 ｜전신 및 감염성 문제 Systemic & Infectious problems

증상/징후/검사소견별 접근
1. 만성피로 ····························86
2. 체중감소 ····························93
3. 발열 ······························99
4. 임파선 비대 ························· 108

질환별 접근
5. 후천성면역결핍 바이러스 감염 ················· 116
6. 말라리아 ··························· 128
7. 가을철 열성질환 ······················· 140
참고 8. 항생제 사용의 실제 ······················ 146

Part 03 ｜심혈관 문제 Cardiac problems

증상/징후/검사소견별 접근
1. 흉통 ····························· 204
2. 실신 ····························· 217
3. 심계항진(두근거림) ······················ 229
4. 부정맥 ···························· 237
질환별 접근
5. 고혈압 ···························· 243
6. 허혈성 심질환 ························ 268
7. 정맥 혈전색전성 질환 ····················· 293
8. 심부전 ···························· 300
9. 심방세동 ··························· 314

Part 04 ｜호흡기 문제 Respiratory problems

증상/징후/검사소견별 접근
1. 기침 ···························· 322
2. 호흡곤란 ·························· 341
3. 흉막삼출 ·························· 351
4. 객혈 ···························· 357
5. 고립성 폐결절 ························ 363

질환별 접근
6. 급성 기관지염 ························ 367
7. 지역사회획득 폐렴 ······················ 372
8. 기관지 천식 ························· 382
9. 만성 폐쇄성 폐질환 ····················· 395
10. 폐결핵 ··························· 409
11. 자발성 기흉 ························· 420
참고 12. 폐기능 검사 ························· 426
13. 호흡기 약물 ························· 432

Part 05｜소화기 문제 Gastrointestinal problems

위장관계

증상/징후/검사소견별 접근
1. 복통 ···························· 458
2. 소화불량 ·························· 466
3. 설사 ···························· 472
4. 변비 ···························· 492
5. 구역/구토 ·························· 502
6. 연하곤란(삼킴곤란) ······················ 508
7. 위장관 출혈 ························· 514

질환별 접근
8. 위식도역류질환 ······················· 530
9. 소화성 궤양 ························· 541
10. 기능성 위장장애 ······················· 550
11. 헬리코박터 파일로리 감염 ·················· 569
12. 급성 충수돌기염 ······················· 575
13. 게실염 ··························· 580
14. 항문질환 ·························· 584

간/담/췌

증상/징후/검사소견별 접근
15. 간기능검사의 해석 ······················ 596
16. 황달 ···························· 606
17. 복수 ···························· 612

질환별 접근
18. 급성간염 ·························· 618
19. 만성 B형 간염························ 631
20. 만성 C형 간염 ······················· 645
21. 지방간 ··························· 652
22. 알코올성 간질환 ······················· 661
23. 간경변증 ·························· 667
24. 담석증 및 담낭염 ······················ 678
25. 담도염 ··························· 688
26. 담낭 용종 ·························· 691
27. 급성 췌장염 ························· 694
참고 28. 소화기 약물 ························· 701

Part 06 ｜내분비 문제 Endocrinologic problems

증상/징후/검사소견별 접근
1. 갑상선 검사의 실제 ······················ 736

질환별 접근
2. 당뇨병 ···························· 737
3. 이상지질혈증/대사증후군 ··················· 775
4. 골다공증 ··························· 797
5. 갑상선 결절 ························· 815
6. 갑상선 기능항진증 ······················ 826
7. 갑상선 기능저하증 ······················ 845
8. 남성갱년기 ·························· 856

Part 07 ｜혈액 문제 Hematologic problems

증상/징후/검사소견별 접근
1. 빈혈 ····························· 864
2. 출혈 ····························· 869
3. 적혈구 수의 이상: 빈혈/적혈구증가증 ·············· 873
4. 백혈구 수의 이상: 백혈구감소증/백혈구증가증 ·········· 876
5. 혈소판 수의 이상: 혈소판감소증/혈소판증가증 ·········· 886

질환별 접근
6. 철결핍성 빈혈 ························ 900
7. 만성질환에 의한 빈혈 ····················· 913
8. 거대적혈모구빈혈 ······················· 917

Part 08 ｜신장 문제 Nephrologic problems

증상/징후/검사소견별 접근
1. 소변검사의 해석 ······················· 924
2. 혈뇨 ···························· 930
3. 단백뇨 ··························· 941
4. 부종 ···························· 948

질환별 접근
5. 요로감염 ·························· 956
6. 급성 신부전 ························· 964
7. 만성 신부전 ························· 971

Part 09 ｜비뇨생식기 문제 Genitourinary problems

증상/징후/검사소견별 접근 
1. 하부요로증상 ·························· 2

질환별 접근       
2. 성매개질환··························· 8 
3. 매독  ·····························17 
4. 외음부질염  ··························22 
5. 요석······························28 
6. 양성 전립선 비대증 ·······················33 
7. 과민성방광 ···························38
8. 발기부전  ···························46


Part 10 ｜부인과 문제 Gynecologic problems

증상/징후/검사소견별 접근 
1. 비정상 자궁출혈 ························54
 2. 급성 골반통 ··························58
 3. 월경통  ····························63
 4. 유방종괴  ···························69

질환별 접근       
5. 요실금  ····························76
 6. 폐경 및 폐경 후 호르몬 대체요법 ················81
참고       7. 임신과 수유기의 약물요법 ····················93


Part 11 ｜근골격계 및 류마티스 문제    Musculoskeletal & Rheumatologic problems

증상/징후/검사소견별 접근 
1. 경부 통증 ·························· 102
2. 허리 통증 ·························· 107
3. 고관절 통증 ························· 114
4. 어깨 통증 ·························· 119
5. 팔꿈치 통증 ························· 135
6. 손과 손목의 통증 ······················· 142
7. 무릎 통증 ·························· 161
8. 발목 통증 ·························· 171
9. 발 통증 ··························· 179

질환별 접근/전신성    
10. 골관절염 ·························· 192
11. 류마티스관절염 ······················· 198
12. 통풍 ···························· 214
13. 섬유근통증후군 ······················· 226
14. 근막통증증후군 ······················· 234

질환별 접근/척추     
15. 척추관협착증 ························ 240
16. 추간판탈출증 ························ 246

질환별 접근/상지     
17. 수근관증후군 ························ 252


Part 12 ｜신경계 문제 Neurologic problems
 
증상/징후/검사소견별 접근 
1.  두통  ···························· 258
2.  어지럼(증)/현훈 ······················· 295
3.  떨림 ···························· 321
4.  발작 ···························· 326
5.  근육쇠약 ·························· 332

질환별 접근       
6.  뇌졸중 ··························· 340
7.  치매 ···························· 351
8.  파킨슨병 ·························· 364
9.  안면신경 마비 ························ 370
10. 삼차 신경통 ························· 377


Part 13｜정신적 문제 Psychiatric problems

1. 수면장애 ··························· 384
2. 불안장애 ··························· 397
3. 우울증 ···························· 407


Part 14｜눈 문제 Opthalmologic problems

증상/징후/검사소견별 접근 
1. 안구 충혈  ·························· 420
2. 비충혈성 안구통증 ······················ 431
3. 안구건조증 ·························· 437


질환별 접근       
4. 다래끼 ···························· 445
5. 결막염 ···························· 450
참고    6. 안과 약물 ·························· 456
 

Part 15 ｜ 귀, 코, 인후, 구강, 경부 문제   Ear, nose, throat, mouth and neck problems
 
귀
증상/징후/검사소견별 접근 
1. 귀통증 ···························· 460
2. 난청(청력소실) ························ 467
3. 이명 ····························· 475
4. 귀지색전(귀지떡) ······················· 482

코
질환별 접근       
5. 외이도염 ··························· 485
6. 중이염 ···························· 489

증상/징후/검사소견별 접근 
7. 코피 ····························· 498

질환별 접근       
8. 비염 ····························· 502
9. 급성 부비동염 ························ 514
10. 쉰소리 ··························· 519
11. 구강건조증 ························· 524
12. 구취(입냄새) ························· 529
13. 경부종괴 ·························· 533
14. 급성 상기도 감염  ······················ 541
15. 급성 인두염 ························· 548
16. 흔한 구강질환 ························ 553
17. 구강 작열감 증후군  ····················· 563


Part 16 ｜피부 문제 Dermatologic problems

증상/징후/검사소견별 접근 
1.  피부질환의 기술 및 접근 방법  ················ 570
2.  습진의 일반적인 치료 ···················· 573
3.  두드러기 ·························· 575
4.  가려움증 ·························· 585
5.  급성 피부창상의 관리 ···················· 592

질환별 접근       
6.  아토피 피부염 ························ 601
7.  접촉성 피부염 ························ 615
8.  지루성 피부염 ························ 622
9.  건선 ···························· 629
10. 피부진균증 ························· 637
11. 피부 및 연조직 감염   ···················· 646
12. 대상포진 ·························· 659
13. 옴 ····························· 666
14. 여드름 ··························· 671
15. 탈모 ···························· 680
16. 주사(장미증) ························· 689
17. 피부종양  ·························· 696
참고     18. 외용 스테로이드의 사용 ··················· 703


찾아보기 ······································· 710