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ก 4707xxxChiangmai Medical School


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1. 4) ก ก SLE ก กก ก SLE ก ก anti-dsDNA

ก ANA sensitivity ก SLE2. 3) Acute arthritis ก joint fluid septic profile (WBC > 50,000) c/s gram negative diplococciintracellular ก Gonococcal arthritis ก Drug of choice Ceftriaxone

1. Hemorrhagic effusion ก trauma, coagulopathy, etc.2. Hemorrhagic effusion Inflammatory, noninflammatory septic profile

Noninflammatory Inflammatory Septic

WBC < 2,000 /µL WBC > 2,000 < 50,000 /µL WBC > 50,000 /µL, PMN > 75%(Gram stain/Culture positive, glucose )

Osteoarthritis, trauma crystal → Gout, pseudogout crystal → RA, seronegative Septic arthritis

3. 1) Taenia solium NeurocysticercosisCysticercosis กกก generalized, CT multipled calcified cystic lesion

accidental host ก Taenia solium ( ก)Toxoplasma immunocompromised, CT ring calcification, transplacental transmission

4. 3) กกก TB ก ก sputum AFB negative 3 ก TB bronchoscopy R/O CA กก CXR ก CA lung

Diagnosis of TB1.

ก/ก : (> 3 wk) , , ก, , กก2.

Chest X-ray: Not specific Not prove active disease, Strongly suggest TB upper zone (apical postr seg. of upper lobe, supr seg. of lower lobe), cavitation calcified shadow

3.

Acid-fast staining: detect > 104 AFB/ml, Not specific to M. tuberculosis4.

Culture: Gold standard, sensitivity ก AFB (detect > 103 AFB/ml)5. Bronchoscopy: ก, R/O CA ,

massive hemoptysis ก ก6.

Tuberculin skin test: Dx, infection disease, ก TB

, ก TB ก, extrapulmonary TB, ก กก 5. 2) Guillain-Barre syndrome

weakness quadriplegia generalized weakness กก CNS motor unit ก ก CNS ก conscious/cognitive change, hypertonia, hyperreflexia sensation neuromuscular cause ก normal mental function, muscle tone ก, reflex ก ก neuromuscular cause (nerve, muscle, NMJ) 16. (ก)

Internal medicine

Joint fluid analysis


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กก HyperK1. Protect heart : advanced EKG change K > 6.5 mmol/L

10% Calcium gluconate (ก antagonist)2.

Move K cell : Insulin + glucose, NB albuterol, (+ NaHCO3)3.

K : Kayexalate + sorbitol (+ Furosemide, Hemodialysis)15. 3) Leptospirosis

DF, DHF Enteric fever Leptospirosis Murine typhus,Scrub typhus Malaria

Signs andsymptoms

RUQ pain, N/V

ก ()

(pattern)

Skin Rash, Petechiae Rose spot (rare) Rash (rare) Rash (rare) No rashJaundice ก ก ±

icteric typeก ± ก ก

± ± ± ±

subconjunctivalhemorrhage

Meningitis rare Asepticmeningitis

Asepticmeningitis

Lung Effusion infiltration(pulm hemorrhage)

Interstitialpneumonia

Pulmonary edema

CBC Hct↑↑↑↑, WBC↓↓↓↓,Atyp.lymph↑↑↑↑,plt↓↓↓↓

กก WBC↑, neutrophil, plt↓ varies Anemia, WBC↑,neutrophil , plt↓

U/A RBC ±±±± RBC, WBC,proteinuria, cast

Others Peyers patchruptured → pneumoperitoneum

CPK↑↑↑↑ Hx

Eschar

16. 2) DermatomyositisProximal muscle weakness ( ก กก)

1.

Nerve: sensory, reflex, autonomic involvement ก distal

• Acute autoimmune demyelination of peripheral nerve• recent Campylobacter jejuni infection, viral infection influenza vaccination ก• weakness ( CN involvement) ก sensation loss glove and stocking (),

hyporeflexia areflexia, LP

Guillain-Barre syndrome


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• ก: Plasmapheresis IVIG ( role ก steroid )

• กกก axon, ก chronic hyperglycemia• Affect motor (mild weakness), sensory (glove and stocking), autonomic sensory

2.

Muscle: ก ก sensation loss ก hyporeflexia/areflexia

• Symmetric progressive proximal muscle weakness• muscle pain, serum CK • Dermatomyositis = polymyositis + skin involvement (Heliotrope: , shawl sign: ก

, V-sign: V, Gottrons sign: bony prominent) • ก: Steroid

• Insidious onset, Hx steroid asthma, COPD, rheumatoid

• ก กกกก (high carbohydrate meal)

• weak serum K • TFT ก

1) Familial AD, ก Family Hx, TFT ก 2) Thyrotoxic ก thyrotoxicosis TFT hyperthyroidism

3. NMJ: ก ก muscle fluctuation (ก ) fatigability (ก )

• Autoantibody postsynaptic Ach receptor• ก thymoma• Ptosis, Bulbar involvement • Fluctuation and fatigability

17. 5) PFT Asthma Pulmonary function test FEV1/FVC response bronchodilator

← Bronchodilator

Abnormal PFT

FEV1/FVC < 70% FEV1/FVC > 70% Restrictive lung disease

Obstructive lung disease

FEV1 > 12% FEV1 < 12% Asthma COPD

Myasthenia gravis

Hypokalemic periodic paralysis

Steroid-induced myopathy

Polymyositis/Dermatomyositis

Diabetic polyneuropathy


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18. 2) Thiamine signs CHF (Rt.-sided) + pulmonary edema, LV systolic failure (S3 gallop),cardiomegaly (Lt.-sided)

กก Cardiac beriberi (ก → Vitamin B1 (thiamine) → Cardiac beriberi)ก: Vitamin B1 (thiamine)

19. 1) Chigger mite Orientia tsutsugamushi 20. 3) Neurogenic shock

CO PCWP SVR กกHypovolemic(volume )

Trauma, blood loss, thirdspace loss, burn ↓ ↓ ↑

isotonic solution

Cardiogenic(กก

)

Tension pneumothorax,CHF, cardiac tamponade,arrhythmia, MI, structuralheart disease

↓ ↑ ↑

ก Dobutamine, dopamine or NE

Distributive shock(vasodilate) ↑ ↓ ↓

Septic Bacteremia gram neg.

fluid ABO Swan-Ganz catheter dopamine NE

Anaphylactic , Diphenhydramine 1:1000 epinephrine

Neurogenic* Spinal cord injury* Loss of sympathetic activity

= hypotension + bradycardia

CO Cardiac output

PCWP Pulmonary capillary wedge pressure ก LVSVR Systemic vascular resistance

21. 1) Inhaled Salbutanol prn + inhaled corticosteroid

Day attack Night attackPEF

FEV1 Variability

Treatment

Mildintermittent

< 1 / < 2 / > 80% < 20% SABA ก

Mild

persistent

> 1 / > 2 / > 80% 20 - 30% + Inhaled corticosteroid

Moderatepersistent

กกก

> 1 / 60 - 80% > 30% + LABA

Severepersistent

limit activity

< 60% > 30% + Theophylline oralLABA Leukotrienemodifier oralcorticosteroid

Management of asthma


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22. ASA + PropanololSubacute thyroiditis (de Quervains thyroiditis) 1. Thyrotoxic phase 2. Hypothyroid

phase 3. Recovery phase ก (กก, ) ก thyrotoxicosis hypothyroidism ก URI ก ก ก

turn hypothyroidism กก Aspirin high dose NSAIDs ก ก steroid ก

thyrotoxicosis β-blocker ( role ก antithyroid drug thyrotoxic phase)23. 1) Simple goiter24. 3) Thoracic area UMNL, cord lesion Hyperreflexia, loss of sphincter tone level of sensation loss

ก Thoracic area (T10)25. 1) Atropine

26. 1) Anti-HIV oral candidiasis27. Pacemaker ( )

AV black

1st

degree AV block PR prolong (> 0.02 sec 5 )

2nd degree AV blockMorbitz I PR ก block 1

Morbitz II PR ก ก block 1

3rd degree AV block Complete A-V dissociation p wave ก QRScomplex ก

• 1st degree 2nd degree Mobitz I ก กก supranodal block ก junctionalrhythm ( AV node ก) HR 45 (ก)

• ก 2nd degree Mobitz II กก infranodal block (his, bundle branch) ก turn complete heart block idioventricular rhythm (ventricle ก) HR 20 () Mobitz II 3rd degree AV block pacemaker

(complete heart block)

Bradycardia

Adequate perfusion Poor perfusion

• transcutaneous pacing• Atropine 0.5 mg IV 3 • Epinephrine Dopamine IV drip

pacer

• Observe, monitor

Conscious change, ก,BP drop, shock

Airway, O2, monitor EKG, IV


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28. 4) Influenza vaccine 29. 2) Pancarditis pericarditis กก Keyword rub (friction rub)

ก friction rub กก pleura pericardium กกก cardiac friction rub กกก pleural friction rub

30. 1) Cardiac siderosis ก deposit Thalassemia กกก ก hemochromatosis ก

ก ก → heart failure, → cirrhosis/liver failure, → DM, Pituitary gland → hypogonadism, growth retardation

. Choice 4) - -31. 1) Ibuprofen

กก Rheumatoid arthritis • Physical, occupational therapy periarticular muscle

• Drugs symptoms กกFirst line Aspirin / NSAIDs ก Second line Glucocorticoid (joint injection oral)

DMARDs ก First line Hydroxychloroquine, sulfasalazine, methotrexate active กSecond line Leflunomide, anti-TNF

Azathioprine, gold, D-penicillamine, cyclosporine, cyclophosphamide• Surgery severe functional impairment ก deformity

32. 1) Ceftriaxone IV Aminoglycoside Gentamycin กกTreatment of UTIAcute cystitis: 3-day therapy

TMP-SMZ Sulfa, ก fluoroquinolones ก

Acute pyelonephritisOPD: GPC amoxicillin

GNB fluoroquinolonesIPD: GPC ampicillin

GNB aminoglycoside, cephalosporin (ceftriaxone, ceftazidime), fluoroquinolone33. 2) Naloxone

ก Organophosphate poisoningOrganophosphate poisoning

• Irreversible inhibit AChE enzyme ก Ach overstimulation


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• Muscarinic effects: DUMBELS (Diaphoresis and Diarrhea; Urination; Miosis; Bradycardia, Bronchospasm,Bronchorrhea; Emesis; Lacrimation; and Salivation)

Cardiovascular - Bradycardia, hypotensionRespiratory - Rhinorrhea, bronchorrhea, bronchospasm, cough, severe respiratory distressGastrointestinal - Hypersalivation, nausea and vomiting, abdominal pain, diarrhea, fecal incontinenceGenitourinary - IncontinenceOcular - Blurred vision, miosisGlands - Increased lacrimation, diaphoresis

• Nicotinic effects ก muscle fasciculations, cramping, weakness, diaphragmatic failure• CNS effects: anxiety, emotional lability, restlessness, confusion, ataxia, tremors, seizures, coma• กก

GI decontamination, Activated charcoal

Antimuscarinic: Atropine 0.5 2 mg IV q 15 min complete atropinization (dry mouth)Pralidoxime (2-PAM) 1 2 g IV ก 8 nicotinic symptoms ก BDZ

34. 1) กก DM type II (Guideline 2551) 1.

FBG < 200 mg/dL HbA1C < 8% → Lifestyle modification 1 3 start 2.

FBG 200 300 mg/dL → Lifestyle modification + start (ก )

Metformin Sulfonylureaก Insulin resistance:• BMI ≥ 23 kg/m2 • BP ≥ 130/85 mmHg

• TG↑, HDL-C↓

ก Insulin:• BMI < 23 kg/m2 • กก • ก• Postprandial sugar

ก: Glitazone, Repaglinide, α-glucosidase inhibitor, DPP-4 inhibitor(ก FBS 250 350 mg/dL HbA1C > 9% 2 ก)

3.

FBG > 300 mg/dL HbA1C > 11% กกก → Insulin

FBG 70 110 mg/dL HbA1C < 6.5%BP < 130/80 mmHg LDL < 100 mg/dL ( CAD keep < 70 mg/dL)

ก: keep FBG < 130 mg/dL, HbA1C ≈ 7% 35. 3) PTU

Treatment of Graves disease ก + ก ก

1. Antithyroid drugs (PTU, Methimazole)


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• กก organification (PTU inhibit peripheral conversion T4 → T3 ) • ☺ ก ก• High recurrent rate, serious side effect: agranulocytosis • Indication: ก, ( PTU กก), Thyroid storm, ก

ก, induce euthyroid stage ก RAI Surgery, long term recurrenthyperthyroidism

• Methimazole: Half-life ก ก • ก 2 L-thyroxine ก

2. Radioactive iodine (I 131 )• ☺ High cure rate, safe & easy, ก, ก infertility develop CA• Hypothyroidism, ophthalmopathy , ก severe thyrotoxicosis / thyroid crisis

uncontrolled hyperthyroidism (ก euthyroid)

• Indication: First-line treatment , recurrent ก, ก ( ก hypothyroid กก)• Contraindication / precaution: /, , Low radioiodine uptake, Severe hyperthyroidism,

Active ophthalmopathy, CA thyroid, ก, poor compliance3. Surgery (Subtotal thyroidectomy)

• ☺ ก euthyroid stage • Surgical complications (recurrent laryngeal n. injury, hypoparathyroidism), ก relapse • Indication: , กกก, Severe Graves ophthalmopathy, ,

CA thyroid, 2nd trimester• Contraindication: previous neck surgery, severe systemic i llness, lack of well-qualified surgeons

ก → ββββ-blocker กก A. Radioactive iodine, B. Antithyroid drugs, C . Surgery 50 ก, moderatehyperthyroidism, new case

กก hyperthyroidism

B ( ก)

A, CB, ( A)B then A, C

กก ก

A, C A A B, C

36. 1) Free T4 ( thyrotoxic hypoK periodic paralysis 16.)37. 1) 2 wks38. 5) NB salbutamol ( iv steroid ก)

กก Acute asthmatic attack1.

oxygen, keep O2 sat > 90% 2.

bronchodilator


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β2-agonist ก nebulizer ก MDI with spacer (PEF < 50% accessory muscle)

anticholinergic ก β2-agonist3.

Steroid : IV oral steroid 4. antibiotic bacterial infection

39. 4) Oral itraconazoleTreatment of Tinea unguium

Tinea unguium (Onychomycosis) กก ก ก ก Oral griseofulvin, oral turbinafine, oral itraconazole

40. 1) Psoriasis• ก (papulosquamous) well-marginated, erythematous plaque with silvery scale ก

extensor surface,

• Koebners sign positive ก , Auspitz sign positive กก• Associated findings: psoriatic arthritis, nail change (oil spot, onycholysis, pitting nail, subungual thickening)41. 3) Xanthelasma hyperlipidemia42. 5) Propanolol + Flunazine Propanolol = Beta blocker, Flunarizine = CCB

Migraine DrugProphylaxis: ก > 3

TCA, β-blocker, CCB, valproic acid, topiramateTreatment (Abortive Rx): 1. ASA, acetaminophen, caffeine, high-dose NSAIDs

2. Dopamine agonist: Metoclopramide IV,prochlorperazine IM or IV

3. 5-HT1 agonists (Triptan) CAD4. Ergotamine CAD

43. 3) Subarachnoid hemorrhageKeyword: ก + stiffness of neck

44. 4) Myasthenia gravis ( 16.)45. 5) Intravenous immunoglobulin Guillain-Barre syndrome ( 16.)46. 1) Aspirin

Secondary prevention of STEMI• Smoking cessation• Aggressive lipid lowering• Control of hypertension and diabetes• Prophylactic use of aspirin, beta-blockers, and ACE inhibitors


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47. 5) ก Gout ก ก ก Joint fluid inflammatory Needle-shaped crystal

ก x-ray ก ก soft tissue กกกก ก ก tophi ก x-ray ก

soft tissue mass กกก punch out lesion, overhanging edge กกGout

• Acute monoarthritis ก 1st MTP joint, midfoot, , , กก • Chronic: Tophi (urate crystal deposit)• Joint fluid: Needle-shaped, negatively birefringent crystal• X-ray: Bone erosion with overhanging edge

Soft tissue calcified mass chronic tophaceous gout•

กก:o Acute attack: NSAIDs, colchicines, steroid

uric acid ก attacko ก uric acid (alcohol, diuretics, aspirin, , ก)o Maintenance: Allopurinol (Xanthine oxidase ก uric acid)

Probenecid ( ก uric acid )CPPD (pseudogout)

• Acute monoarthritis ก • X-ray: Calcium deposit articular cartilage ก chondrocalcinosis

• Synovial fluid: CPPD crystal rhomboid cuboid weakly positivebirefringence

48. 3) Acute monoarthritis กกก ก Crystal-induced arthritis, Septic arthritis ก Synovial fluid กก ก Differential diagnosis Acute arthritis

Monoarthritis PolyarthritisPyogenic arthritis Acute rheumatic arthritisCrystal induced arthritis Pyogenic arthritisAcute rheumatic arthritis Seronegative arthritisTraumatic arthritis Viral arthritisSeronegative arthritis SLERheumatoid arthritis Rheumatoid arthritis

49. 3) กก gout ก

Acute monoarthritis ก Crystal-induced arthritis, Septic arthritis, Rheumatoidarthritis (RA) ก NSAIDs RA ก กกกกกก กก


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ก septic arthritis WBC > 50,000 PMN > 75% ก joint fluid profile gout pseudogout ก gout กกก CPPD กก ( ก Dx) ก gout กก ( -_-!)

50. 2) Acute fever ก RUQ pain Infection Inflammation กก Malignancy ก

ก, LFT ALP , Ultrasound Hyperechoic mass ก ก Amebicliver abscess กก HCC ก Bile duct dilatation ก CCA

51. 2) กกก ก Esophagus ก (Rupture) กBoerhaaves syndrome content ก กก breath sound Mallory-Weiss Upper GI bleed กกก mucosa กก

52. 3) ก Lower GI bleeding alcohol ก Hemorrhoidsก ก กก กก กกก ก fiber

53.

1)Pellagra

กกก Niacin (Vit. B3) alcohol ก กก ก 4Ds ก Diarrhea, Dermatitis,Dementia, Death ก pigmented scaling กกกก

Nutrient Clinical Finding Contributing Factors to Deficiency Thiamine Beriberi: neuropathy, muscle weakness and wasting,

cardiomegaly, edema, ophthalmoplegia, confabulationAlcoholism

Riboflavin Magenta tongue, angular stomatitis, seborrhea, cheilosis Niacin Pellagra: pigmented rash of sun-exposed areas, bright red

tongue, diarrhea, apathy, memory loss, disorientationAlcoholism, vitamin B6 deficiency, riboflavindeficiency

Vitamin B6 Seborrhea, glossitis convulsions, neuropathy, depression,confusion, microcytic anemia

Alcoholism, isoniazid

Folate Megaloblastic anemia, atrophic glossitis, depression, ↑ homocysteine, Alcoholism, sulfasalazine, pyrimethamine,triamtereneVitamin B12 Megaloblastic anemia, loss of vibratory and position sense,

abnormal gait, dementia, impotence, loss of bladder andbowel control, ↑ homocysteine, ↑ methylmalonic acid

Gastric atrophy (pernicious anemia), terminalileal disease, strict vegetarianism

Vitamin C Scurvy: petechiae, ecchymosis, coiled hairs, inflamed andbleeding gums, joint effusion, poor wound healing

Smoking, alcoholism

Vitamin A Xerophthalmia, nightblindness, Bitôt spots, follicularhyperkeratosis, impaired embryonic development, immunedysfunction

Fat malabsorption, infection, measles,alcoholism, protein-energy malnutrition

Vitamin D Rickets: skeletal deformation, rachitic rosary, bowed legs;osteomalacia

Aging, lack of sunlight exposure, fatmalabsorption

Vitamin E Peripheral neuropathy, spinocerebellar ataxia, skeletalmuscle atrophy, retinopathy

Occurs only with fat malabsorption, or geneticabnormalities of vitamin Emetabolism/transport

Vitamin K Elevated prothrombin time, bleeding Fat malabsorption, liver disease, antibiotic use

54. 6.


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55. 5) clinical Acute Pulmonary edema ก Hypertension กก กก ก Morphine Transient venodilator Preload Afterload Hypertension กก ก Dyspnea, Anxiety, Stress, Catecholamine level, Tachycardia

* กก ก morphine nitroprusside56. 1) ก , N/V, , ก ก Digoxin intoxication กกกกก

Hypokalemia Furosemide Hypokalemia ก กก Digoxinintoxication

57. 3) 56 ก Digoxin intoxication กก58. 2) True Hyponatremia Urine Osm < 100 Primary polydipsia, Beer protomania, Reset osmostat > 100

ก SIADH (ก ADH function )59. 2) Coxsackie B virus virus ก Dilated cardiomyopathy Systolic function กก Congestive

heart failure 60. 1) Platelet < 100,000 ก Coagulopathy (prolonged PT, aPTT) DIC ก D-dimer ก (ก ) ก

61. 1) HbH disease genotype - - / - α (Heterozygous α-Thal-1 / α-Thal-2) ก gene - - ก - α ก ก MCV (ก 80 - 100) RBC ก Thalassemia minor

- - gene (- - / αα) ก - α MCV Carrier (- α / αα) กก62. 1) ก Methanol intoxication ( ก) กกกMetabolic acidosis Methanol ก Causes of High-Anion-Gap Metabolic Acidosis

• Lactic acidosis• Ketoacidosis: diabetic, alcoholic, starvation• Toxins: ethylene glycol, methanol, salicylates, propylene glycol, pyroglutamic acid• Renal failure (acute and chronic)

63. 1) Ventricular fibrillation กก กก Defibrillation

64. 2) Key point ก ก ก Tetrodotoxin (ก )

65. 4) ( ) Candiduria (Candida urine) Bladder thrush Foleys catheter Bladderirrigation Amphotericin B Foleys oral Fluconazole

66. 1) กกกกก (กก) signs dehydration Exertional heat stroke ก ( dehydration ก ก Heat stroke )


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67. 4) MAHA blood picture DIC, HUS, TTP Platelet < 100,000 ก prolonged PT, aPTT DIC ก Sepsis ก Bed sore DIC ก

68. 2) ก HMG CoA reductase inhibitor (ก Statin) ก ก LDL Triglyceride

Drug Major Indications Mechanism Common Side EffectsHMG-CoA reductaseinhibitors (statins)

Elevated LDL-C ↓ Cholesterol synthesis, ↓ hepaticLDL receptors, ↓ VLDL production

Myalgias, arthralgias, elevatedtransaminases, dyspepsia

Cholesterol absorptioninhibitors (Ezetimibe)

Elevated LDL-C ↓ Intestinal cholesterol absorption Elevated transaminases

Bile acid sequestrants (Cholestyramine)

Elevated LDL-C ↑ Bile acid excretion and ↑ LDLreceptors

Bloating, constipation, elevatedtriglycerides

Nicotinic acid Elevated LDL-Clow HDL-Celevated TG

↓ VLDL hepatic synthesis Cutaneous flushing, GI upset,elevated glucose, uric acid, andliver function tests

Fibric acid derivatives(Gemfibrozil, Fenofibrate)

Elevated TG, elevatedremnants

↑ LPL, ↓ VLDL synthesis Dyspepsia, myalgia, gallstones,elevated transaminases

Omega 3 fatty acids Elevated TG ↑ TG catabolism Dyspepsia, diarrhea, fishy odorto breath

69. 5) ก Myocardial infarction ก 3 ก Thrombolytic agent Streptokinase, Tissueplasminogen activator (tPA) กก ก PCI


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70. 2) Diarrhea ก Stool examination ก underlying Cirrhosis Spontaneous (Primary) bacterial peritonitis DDx. ก Abdominal paracentesis

ก ก กก 71. 4) ก Cyanosis Radial pulse Brachial pulse ก กdistal vessels กกก proximal vessels Thromboangiitis obliterans (Buergers disease) Smallto Medium-sized vascular disease

72. 2) Acute monoarthritis ก Synovial fluid Septic group (Group III) Septicarthritis WBC Synovial fluid 50,000 /mm3 กกก Empirical


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Antibiotics Gonococcal arthritis ก WBC 50,000 PMN ก

73. 4) Capillaria philippinensis 74. 3) ก DVT ก ก Breath sound

ก Pulmonary embolism75. 2) ก Hepatosplenomegaly ก ก Hematologic disease CBC

ก Microcytic anemia กกกก Thalassemia & Hemoglobinopathies HbH disease ก ก Acute hemolysis ก Stress กก

76. 4) clinical ก Hypertensive crisis BP > 180/120 Hypertensive emergency

77. 1) กก Anaphylactic shock Adrenaline 1:1,000 0.3-0.5 ml Intramuscular (IM) Vastus

lateralis muscle 78. 1) กก ก pupil ก ก Pin-point pupil ก Pontine hemorrhage ก Cerebellar hemorrhage กก( ) pin-point pupil

79. 4) ก ก ก Leprosy ( )

80. 4) ( ) Diastolic rumbling murmur Opening snap Mitral valve stenosis (MS) กกกก ก Calcification ก ก Regurgitation กก

81. 1) ก clinical CXR Cavity Air-fluid level ก Lung abscess ก

82. - Hypokalemia (กก Renal loss) ก Hypertension Diuretics,

Hyperaldosteronism, Renal a. stenosis, Cushings syndrome ก plasma aldosterone/plasma renin activity(PA/PRA) ratio > 20 Primary hyperaldosteronism ก Primaryhyperaldosteronism ก Renal a. stenosis

83. 1) Penicillin Diarrhea ก Antibiotic associated colitis (AAC) Pseudomembranousenterocolitis ก Clostridium difficile กก Metronidazole Drug of choice ( PO IV) Vancomycin ก

84. 4) กก Hemolytic anemia ก ก RBC ก ก G-6-PD deficiency ก G-6-PD screening

85. 2) กกก 2 ก DKA ก IV fluid Intra & Extravascular volume ก Insulin 50-70 mg/dL/hr 200 mg/dL

86. 1) DIC prolonged Pt, aPTT ก coagulation factor FFP ก FFP Platelet ก ก กก DIC กก ก ก ก Antibiotics (ATB) ก DIC ก Sepsis กก Antibiotics


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87. - Sustained VTPVC ก 3 ก Triplet PVC ก 4 ก Nonsustained VT PVC กกก 30ก Ventricular tachycardia (VT)

88. 1) กก Complete heart block Atropine Isoproterenol IV HR block AV node ก Pacemaker implantation กก AV conducting system disease Indication

89. 1) ก Side effect Enalapril ACEIDrug Class Other Indications Contraindications/Cautions

Diuretics Thiazides (HCTZ) Diabetes, dyslipidemia, hyperuricemia,

gout, hypokalemiaLoop diuretics(Furosemide)

CHF,renal failure

Diabetes, dyslipidemia, hyperuricemia,gout, hypokalemia

Aldosterone antagonists(Spironolactone) CHF, primary aldosteronism Renal failure, hyperkalemia

K+ retaining (Amiloride,Triamterene)

Renal failure, hyperkalemia

Beta blockers Cardioselective (Atenolol,Metoprolol)

Angina, CHF, post-MI, sinustachycardia, ventriculartachyarrhythmias

Asthma, COPD, 2nd or 3rd degree heartblock, sick-sinus syndrome

Nonselective(Propranolol)Combined alpha/beta

(Labetalol, Carvedilol)

? Post-MI, CHF

Alpha antagonists Selective (Prazosin,Doxazosin, Terazosin)

Prostatism

Nonselective(Phenoxybenzamine)

Pheochromocytoma

Sympatholytics Central (Clonidine,Methyldopa, Reserpine)ACE

inhibitors (Captopril,Lisinopril, Ramipril)

Post-MI, CHF, nephropathy Renal failure, bilateral renal artery

stenosis, pregnancy, hyperkalemiaAngiotensin IIantagonists (Losartan,Valsartan, Candesartan)

CHF, diabetic nephropathy, ACEinhibitor cough

Renal failure, bilateral renal arterystenosis, pregnancy, hyperkalemia

Calcium antagonists Dihydropyridines(Nifedipine)

Angina Heart failure, 2nd or 3rd degree heartblock


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Nondihydropyridines(Verapamil, Diltiazem)

Post-MI, supraventriculartachycardia, angina

Direct vasodilators Direct vasodilators

(Hydralazine, Minoxidil)

Severe coronary artery disease

90. 2) Chronic oligoarthritis ก Crepitus ก Osteoarthritis91. 1) Uncomplicated UTI ( underlying structural/neurological disease, pregnancy upper UTI

UTI Complicated UTI) กก Co-trimoxazole (Bactrim) ก Fluoroquinolone3 ก

92. 4) Hypercalcemia (Dx. Ionized Ca > 4.5 Corrected Ca > 10.5 mg/dL) Ca ก 12mg/dL ก Neuro, KUB ( ), Heart GI กก Fluid กก Ca ก ก Loop diuretics

93. 2) Migraine headache กกกก ก 4 choices ก 1 choice ( 42. )94. 1) 5)


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1. 1) EBV tonsilar patch, splenomegaly with cervical node enlargement

ก ก กก/ก

Diphtheria(Pharyngealdiphtheria)

- ก -ก-กก-- dyspnea

-Mild pharyngeal injection-Uni/bilateral tonsillar grayish- pseudomembrane (Bleedingif scrape) and may extendedwildly to uvula, pharynx,larynx, trachea, bronchus etc.-Cervical lymphadenopathy(Bullneckก)

Specific tx.-Antitoxin in 48 hr-Penicillin G iv × 14dPrevention-DTaP or DT

-Complication:Myocarditis, polyneuritis,bronchopneumonia-Droplet transmission-Bull neck = prog.

EBV infection(Infectiousmononucleosis)

- (>39°C)-Nausea, notvomiting

-Tonsilar exudates or patch-Splenomegaly-Generalizedlymphadenopathy (esp. post.Cervical)-Atypical lymphocytosis

Supportive tx.(hydration,acetaminophen)- ampicillin amoxicillin กrash

- Hepatomegaly

GAS (Group AStreptococcalpharyngitis)

-Fever (>38°C)-Odynophagia-ก - ก GI

-Tonsilar yellow blood-tingedexudates-Enlarged/tender anteriorcervical lymph nodes

Specific tx.-Amoxicillin × 10d-Erythromycin ( penicillin) × 10d

-Gold standard กDx throat swab C/S

Measles -3C(conjunctivitis,cough, coryza)-ก

-Inflamed buccal mucosa-Erythematous, nonpruritic,maculopapular rash-Koplik spot (white/bluishlesions with an erythematoushalo)-Cervical adenitis

Supportive tx.Prevention-MMR

-ก / confluent- ~ 4d -AOM, croup,pneumonia:complications

2. 2) Pityriasis albaPityriasis alba hypopigmented lesion ก round or oval, macular of slightly elevated patched

fine adherent scale ก , , proximal portions ก ก ก mild form eczema กก vit iligo, tineavesicolor tinea corporis ก lubricant ก

Vitiligo กก immunologic abnormalities antibody melanocytes 2 generalized localized กก18 ก generalized form symmetricpattern of white macules and patches with hyperpigmented margin vitiligo ก autoimmune disease

Pediatrics


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DM ก topical steroid, topical tacrolimus ก narrow-band UVB(UVB311)

Pityriasis vesicolor tinea vesicolor กก chronic fungal infection stratum corneum กMalassezia furfur normal flora ก , กก, plasma cortisol ,

immunosuppression, malnourishment ก hypopigmented macules, covered with a finescale KOH ก ก Spaghetti and meatball ก Selenium sulfide susp., imidazole orterbinafine cream ketoconazole/itraconazole PO

Tinea facialis กกก กก dermatophyte (Trichophyton, Microsporum, Epidermophyton) ก dry, mildly erythematous, elevated scaly papule or plaque กก clear central annular lesion KOH filamentous fungus กKetoconazole/clotimazole topical Terbanafine, griseofulvin PO ก Tinea

Contact leukoderm chemical leukoderma ก vitiligo ก ก

satellite lesion กก melanocyte กก melanocyte ก vitiligo ก 3. 3) foreign body aspiration ก FB rt. Main bronchus common site for bronchial

foreign body aspiration ก กก acute onset ก aspiration ก partial LRT obstruction (rhochus 2 sibilant rhonchus = wheezing sonorous rhonchus

= rhonchus ก ) กก ก 3 ก 1-3 ก

ก (Stable patient) Plain chest film Resp. tract obstruction

(segmental atelectasis) opaque foreign body ก inspiratory and expiratory film กplain CXR ก ก partial obs. ก ball-valve (insp.=air , exsp.=air กก airtrapping) hyperinflation ก, mediastinal shift ipsilateral diaphragm ก กก fluoroscope bilateral decubitus chest film ก bronchoscopy lateral film ก

4. 2) + 5) Hypoglycemia newborn plasma glucose lv. < 40 mg/dl ( 45 mg/dl ก wholeblood glucose


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5. ก Turner syndrome (45, XO) ก webbed neck, short stature, cubitus valgus, short neck, 1°

amenorrhea multiple congenital anomalies in phenotypic females ก ovarian development X chromosome ก ovary Turner syndrome ก ovary

streak ovary stromal cell 1° amenorrhea ก low estrogen and low progesterone gonadotrophin GnRH ก amenorrhea

6. 4)? Henoch-Schönlein Purpura กก small vessel vasculitis กก palpable purpuric rash

ก waist buttocks; arthritis ก knees ankles; abdominal pain กก vasculitis GItract glomerulonephritis hematuria proteinuria ก prognosis U/A กก renal involvement ก chronic hypertension CRF

7. Polyarteritis nodosa? ( ก ก ก) necrotizing vasculitis small medium sized arteries 9

กก URI, Group A Strep. Infection chronic hepatitis B กกก mesenteric a. inflammation renovascular arteritis purpura, edema and linear erythema wih palpable, painful nodule arteries ก กneuro, cardio ก biopsy skin lesion ก oral/IV corticosteroid

8. 5) กกก pathological jx. jx. ก 24 hr. ก; jx unconj.bili. > 12.9 mg/dl term > 15 mg/dl preterm; conj.billi. > 2 mg/dl; bili. lv > 5 mg/dl/d jx. ก 1 wk term ก 2 wk preterm pathological jx.

กก ABO incompatibility ก O, jx. 1st 24 hr กก

anemia ก hemolytic anemia ก ก sepsis jx. 1st

24 hr ก anemia ก ก sepsis sign jx. ก ( 4 hr PROM prolong risk infection)

Jx. of prematurity ก 3-4 ( physiologic jx.)ก G6PD def. ก mutation promoter region UDP-glucuronyl transferase-1 ก

กกก G6PD def. jx. ก hemolysis Thalassemia neonatal jaundice

9. 10. 2) 1 ( Diphtheria patch กก tonsil) candidiasis ก white

plaque immunocompromised host11. 5) ก asthma exacerbation ก severe exacerbation ก

dyspnea, retraction, accessory muscle use, tachypnea, mental status change, poor air entry. กก O2 supplement inhaled bronchodilator SABAs (Short-acting inhaled β2 agonist- albuterol, salbutamol, levalbuterol)ก 20 1 กก ก 1st inhaled β-agonist inhaled ipratropium ก SABA ก expiratory wheezing ก inhaledipratropium systemic corticosteroids


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กกก intramuscular injection of epinephrine β-agonist Mucolytics, chest physical therapy spirometry asthma exacerbation ก severe

bronchoconstriction 12. 3) ก splenectomy ก ก parasite encapsulated bacteria ก

ก ก opsonized (กก complement C3b ก ) กกก กก Ab T cell-independent antigen polysaccharide capsule

ก Pneumococcal vaccine (S. pneumoniae), meningococcal vaccine (N. meningitides) H. influenzae type B vaccine กก 2 กก postsplenectomy sepsis meningococcal vaccine serotype B (serotype ) Pneumococcal vaccine H. influenzae vaccine

Oral penicillin V prophylaxis ก 2 ก splenectomy

13. 1) abdominal tumors ก ( 14)14. 1) Wilms tumor ก abdominal mass, abdominal pain, hematuria vomiting 15-25

Hydronephrosis กก obstructive uropathy ก recurrent UTI pyuria

TUMOR AGE CLINICAL SIGNS LABORATORY FINDINGSWilms Preschool

(1 - 5 yr) Unilateral flank mass, aniridia,hemihypertrophy

Hematuria; bone scintigraphy (clearcell sarcoma)

Neuroblastoma Preschool(median age 2 yr,

almost < 5yr

GI/GU obstruction, raccoon eyes,myoclonus-opsoclonus, diarrhea, skinnodules (infants), mass may crossmidline

Increased VMA;increasedHVA;increased ferritin; stippledcalcification in mass.Bone marrow positive

Non-Hodgkin lymphoma > 1 yr Intussusception in >2-yr-old ↑ urate; bone marrow positiveRhabdomyosarcoma All GI/GU obstruction, sarcoma botryoides,

vaginal bleeding, paratesticular massGerm cell/teratoma Preschool, teens Girls:abdominal pain, vaginal bleeding

Boys:testicular mass, new-onsethydroceleSacrococcygeal mass/dimple

Increased hCG;Increased AFP

Hepatoblastoma Birth 3 yr Large, firm liver Increased AFPHepatoma School age, teens Large, firm liver; hepatitis B, cirrhosis Increased AFP

ก Nelson Textbook of Pedriatric, 18th

ed.15. 1) ก anemia jaundice lab NCNC RBC reticulocyte count กก hemolytic anemia 2 ก ก Corpuscular hemolytic anemia (Membranedefects, enzyme defects, Thalassemia and hemoglobinopathies) extracorpuscular hemolytic anemia (Immunehemolytic anemia, mechanical hemolytic anemia, direct toxic effect on RBC) กก Coombstest negative positive


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Inclusion test supravital stain inclusion bodies HbH กก HbH disease (--/-α) Coombs test negative ก กก hemoglobintyping, G6PD def. screening

bone marrow aspiration ก bone marrow response (RC ) bone marrow defect ก investigation ก anemia bonemarrow aspiration ( algorithm ก 5 anemia in children)

16. Adrenaline (Epinephrine) anaphylaxis กกก potent active mediator ก mast cells basophils

ก (urticaria, angioedema, flushing), (bronchospasm, laryngeal edema), CVS(hypotension, arrhythmias, MI) GI (nausea, colicky abdominal pain, vomiting, diarrhea) IgE mediated immuneresponse ก exposed antigen ก กก ก IM epinephrine ก IM or IV H1 and H2 antihistamine antagonists,

oxygen, IV fluids, inhaledβ

-agonists corticosteroid biphasic anaphylaxis 4 hr observe 4 hr ก D/C ก ER17. 2) ก sepsis ( SIRS + suspected/proven infection) ก DIC (low platelet with

prolong PT and PTT with clinical bleeding) ก shock ก management DIC กก antibiotic ก ก ก ก septic shock ก fluid resuscitation management ก FFP, platelet conc. PRC clinical bleeding plt. conc. → FFP → PRC ( control bleeding ก) clinical bleeding กmanagement ก control DIC กก sepsis กกก control bleeding

SIRS systemic inflammatory response syndrome 2 ก 4

• Core temp. >38.5 °C < 36 °C (ก, ก, ก central catheter)• Tachycardia (mean heart rate > 2SD above normal for age) กก 1 persistent

bradycardia ก ½ hr (mean heart rate 2SD above normal for age or acute need for mechanical ventilation (not related to Neuromuscular

disease or GA)• Leukocyte count elevated depressed for age >10% immature neutrophils

18. Idiopathic Vit K def. of infant ก ecchymosis coagulopathy กก ก vit K ก

vit K 1 mg IM ก vit K ก vit K def. กกก 3

• Classic hemorrhagic disease of the newborn ก 1 -14 กก vit K ก vit K

ก กกก กก ก vit K2 ก sterile กก ก vit K กกกก Vit K 1 mg IM

• Late VKDB (Vit K-def. bleeding) ก 2-12 ก 6 ก ก vit K cholestatic liver disease


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• ก ก ก warfarin, phenobarbital, phenytoin กกก vit K

ก vit K def. GI bleeding, mucosal and cutaneous bleeding, bleeding umbilical stump post-circumcision site Intracranial bleeding ก

19. 1) ก nephrotic syndrome (ก nephritic syndrome heavy proteinuria: >3.5 g/d > 40 mg/m2/hr, hypoalbuminemia:


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LTBI = Latent tuberculosis infection ก ก, TT ก, CXR ก (ก TB ก) (ก HIV ) LTBI กก TB 1-2 host ก 5 ( < 2 ), ก, ก กก

Isoniazid 6-9 ก LTBI ก

1. กก กก 5 , TT reaction > 15 mm. BCG2. Immunocompromised hosta. Severe malnutrition TT ≥ 10 mm.b. Steroid therapy TT ≥ 10 mm.c. HIV infection - TT ≥ 5 mm.

3. Old fibrotic scar ก (TT ≥ 10 mm.)4. Recent converter (TT กก 6 mm.)


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ก TB criteria กก ก ก 2

1. ก 2. ก

3. กกก4. ก ก AFB ก

22. 2) ก ketoacidosis ก ก electrolyte HCO3 กกketone กก ketoacidosis กก (ก ก starvation, alcohol DM) DKA กก กก IV fluid กก poor perfusion ก 10-20 ml/kg IV bolus 0.9% NaCl or LRS ก volumeexpansion ก Insulin drip at 0.1U/kg/hr 1 g/kg IV push for cerebral edema 2 กก hypokalemia ก Potassium กกก ก HCO

3 pH < 7.0

23. 2) delivery room ก term infant with meconium staining hypopharyngeal suction กก กกก distress ( hypoxia, bradycardia, fetal acidosis or apnea) ก endotracheal intubation suction endotracheal tube meconium กก ก preterm infant < 34 wk ก IUGR , meconium purulent fluidก infection bile stained กก proximal intestinal obstruction

24. 3)? 18 anemia jaundice bulging of AF intracranialbleeding ก sepsis SIRS SDH ก seizure

25. Rubella

ก Congenital infection MANIFESTATION PATHOGENIUGR CMV, Plasmodium, rubella, toxoplasmosis, Treponema pallidum, Trypanosoma cruzi, VZV Congenital Anatomic DefectsCataracts RubellaHeart defects Rubella (esp. PDA)Hydrocephalus HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosisIntracranial calcification CMV, HIV, toxoplasmosis, T. cruzi Microcephaly CMV, HSV, rubella, toxoplasmosisNeonatal Organ InvolvementEncephalitis CMV, enteroviruses, HSV, rubella, toxoplasmosis, T. cruzi, T. pallidum Hepatitis CMV, enteroviruses, HSVHepatosplenomegaly CMV, enteroviruses, HIV, HSV, Plasmodium, rubella, T. cruzi, T. pallidum Hydrops Parvovirus, T. pallidum, toxoplasmosisRetinitis CMV, HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis, T. pallidum Late SequelaeDeafness CMV, rubella, toxoplasmosisMental retardation CMV, HIV, HSV, rubella, toxoplasmosis, T. cruzi, VZV

ก Nelson Textbook of Pedriatric, 18 th ed.


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26. 1) กก hypoxic spells (Paroxysmal hypercyanotic attacks) ก TOF ก ก 4 ก TOF cyanosis ก cyanosis ก ก progressive pulmonary stenosis ก pansystolic murmur at lt. parasternal border* TOF lt. lower parasternal border (ก TOF murmur ก SEM at lt. upper parasternal

border)Hypoxic spells กก 1-2 กก ก ก

ก กก กกก already compromised pulmonaryblood flow (ก infundibular spasm) ก systemic hypoxia metabolic acidosis

กก Knee-chest position peripheral vascular resistance ก O2 MO ก 0.2 mg/kg sc. infundibular spasm NaHCO3 metabolic acidosis systemic vascular resistance phenylephrine, levophed ketamine กก β-blocker กก ก palliative Sx. modified Blalock-Taussig shunt ก definitive Sx.

Breath-holding spells ก 6 2 ก กกก กก กก 30 กกก กกก cyanosisก

Asthmatic attack severity ก asthma wheezing cyanosis ก murmur pulmonary embolism U/D condition adventitious sound กก murmur

* ก PSM @ Lt. parasternal border cyanotic heart

Tricuspid atresia ก 1 , truncus arteriosus กก ก 1 VSD PSM 27. 5) Retropharyngeal abscess 1-6 กกก ( ก

กก foreign body) กกก mixed organism ก irritable, fever, ↓food intake ก ก ก (muffled voice) กก drooling airway obstruction กก posterior pharyngeal wall ก lat. neck film retropharyngeal space ( C2 >7mm, or C6 > 14 mm) กก IV antibiotic (3

rd gen. Cephalosporin + ampicillin-sulbactam or clindamycin)± surgical drainage

Acute tracheitis (Bacterial tracheitis) กก Viral URI laryngotracheitis (croup) กกก

S. aureus life-threatening condition ก airway obstruction 5-7 ก typical brassy cough, high fever toxicity with respiratory distress purulent secretion drooling dysphagia กก epinephrine ก clinical กก epiglottitisกก IV antibiotic O2 supplement intubation

Acute epiglottitis ก 2-7 กกก H. influenzae type B (Hib) กก S. pyogenes, S. pneumoniae, S. aureus กก Hib ก typical ก


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fever, irritability, sore throat, drooling, muffled voice, rapidly progressive stridor, respiratory distress ก erythematous and swollen epiglottis thumb sign กก ก secure airway ก ก ก IV line placementก ก secure airway ก IV antibiotic

Viral Croup (Laryngotracheobronchitis Laryngotracheitis mild form croup) กก 1-3 กกกก parainfluenza virus type 1-3 กกก ก 1-3 กก upper airway obstruction ก barking cough, hoarseness inspiratorystridor ก coryza, normal-mod. Inflamed pharynx slightly ↑RR กก dyspnea, marked↑RR, cont. stridor, cyanosis, hypoxia, pallor กกก airway management

กกก กกก กกก ก NPO กกก O2 humidificationก Nubulized epinephrine กก moderate-severe croup (stridor at rest, possible need for intubation,respiratory distress and hypoxia) ก constriction precapillary arterioles β-adrenergic receptors กresorption interstitial space ก laryngeal mucosa ก oral corticosteroids ก ก ก antibiotics croup

Acute laryngitis ก กก (ก diphtheria) ก ก UTI sore throat, cough ก ก กก ก ก pharyngealinflammation inflammation vocal cord subglottic tissue laryngoscope

28. 3) กก 1 ก ก ก 1 DTP4, OPV4, JE

กก 2 m 4 m 6 m 9 m 12 m 18 m 2-2½yr 4-6 yr 12-16 yrBCG,HBV1

DTP1,OBV1,HBV2

DTP2,OPV2

DTP3,OBV3,HBV3

MMR1 DTP4,OPV4

JE3 DTP5,OPV5,MMR2

dT ก10

JE1JE2 ก 1-4 wk

29. 2) preterm GA 32 wk dyspnea ก RDS ก กกก surfactant กก ก surfactant ก dipalmitoylphosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins cholesterol กก กก type II alveolar cell surfactant surface tension alveoli กก collapse

small air spaces กก ก dipalmitoylphosphatidylcholine lecithinกก RDS DM, C/S delivery, precipitous delivery, asphyxia กก

ก PAH PIH, heroin, PROM ก steroidprophylaxis

30. 1) 131. 1) 21


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32. >


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with insidious onsetcharacterized by fever,headache, constipation,malaise, chills, and myalgia;diarrhea is uncommon, andvomiting is not usually severe.

contaminated raw fruitsand vegetables (alfalfasprouts, melons). S.typhi epidemics areoften related to fecalcontamination of watersupplies or street-vended foods.

not indicated unless thereis extra-intestinal spread,or the risk of extra-intestinal spread, of theinfection. Considerampicillin, gentamicin,TMP-SMX, or quinolonesif indicated. A vaccineexists for S. typhi.

Shigella spp. Abdominal cramps, fever, anddiarrhea. Stools may containblood and mucus.

47 days Food or watercontaminated withhuman fecal material.Usually person-to-person spread, fecal-oral transmission.

Ready-to-eat foodstouched by infectedfood workers, e.g., rawvegetables, salads,sandwiches.

Supportive care. TMP-SMX recommended inthe U. S. if organism issusceptible; nalidixic acidor other quinolones maybe indicated if organism

is resistant, especially indeveloping countries.

Staphylococcusaureus (preformedenterotoxin)

Sudden onset of severenausea and vomiting.Abdominal cramps. Diarrheaand fever may be present.

2448 hrs Unrefrigerated orimproperly refrigeratedmeats, potato and eggsalads, cream pastries.

Supportive care.

Vibrio cholerae (toxin) Profuse watery diarrhea andvomiting, which can lead to

severe dehydration and deathwithin hours

37 days.Causes life-

threateningdehydration.

Contaminated water,fish, shellfish, street-

vended food typicallyfrom Latin America orAsia

Supportive care withaggressive oral and

intravenous rehydration.In cases of confirmedcholera, tetracycline ordoxycycline isrecommended for adults,and TMP-SMX forchildren (


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primarily in older children andyoung adults. May have ascarlitiniform rash or erythemanodosum with Y.

pseudotuberculosis.

water. Infection hasoccurred in infantswhose caregivershandled chitterlings.

antibiotic therapy withgentamicin or cefotaxime(doxycycline andciprofloxacin alsoeffective).

Rotavirus Vomiting, watery diarrhea, low-grade fever. Temporary lactoseintolerance may occur. Infantsand children, elderly, andimmunocompromised areespecially vulnerable.

48 days Fecally contaminatedfoods. Ready-to-eatfoods touched byinfected food workers(salads, fruits).

Supportive care. Severediarrhea may require fluidand electrolytereplacement.

33. 4) croup - 2734. 1) ก 33.35. 3) ก Neonatal mastitis ก term 2 3 กก swelling,

induration tenderness erythema warmth purulentdischarge ก nipple กกก S. aureus, coliform bacteria (included anaerobes), group B streptococcus กกก subcutaneous tissue ก systemic infection

กก ก กก (mild cellulitis, no fluctuation) C/S nipple discharge antibiotic sensitivity ก cloxacillin + aminoglycoside cefotaxime ก ก admit ก fluctuation drainage

36. 1) ก antibiotic-associated diarrhea กก overgrowth C. difficile กก ก

ก ampicillin, clindamycin cephalosporin กก ก metronidazole PO 7-10 37. 4) กกก primary hemostasis กก

(epistaxis, menorrhagia, petechiae, ecchymoses, occasional hematomas, and less commonly, hematuria andgastrointestinal bleeding) กกก secondary hemostasis hemophilia กก ก ก (ecchymosis, extensive hematoma)

ก primary hemostasis ก 2 ก vessel (Henoch-Schönlein purpura, vit. Cdef., collagen disease, etc.) ก platelet ก (quantitative) (qualitative) กCBC กก PBS ก confirm CBC plt.

ก กก กก function ก bleeding time กก primary hemostasis ก กก plt. vessel

ก ก ITP ก ITP ก viral infection ก 1-4 wk ก clinical bleeding ( กก immune reaction) กกกก hepatosplenomegaly, lymphadenopathy กก leukemia กก ITP CBC series ก plt. (ก bleeding ก

ก Nelson Textbook of Pediatric, 18h ed.


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anemia ) ก PBS blast cell platelet ก bone marrow series ก megakaryocytes

กก ITP ก IVIG, Prednisolone, IV anti-D ( Rh +ve) severe life-threatening acute ITP Chronic ITP plt. < 30,000/mm3 ก 1 กก

ก clinical bleeding plt. < 20,000 /mm3 ก plt. contraindication ITP ก life-threatening bleeding

DHF petechiae, ecchymosis clinical course DHF ก fever phase 4-6 shock or hemorrhagic phase (1-2 d) ก shock convalescent phase (1-3 d) convalescent rash

APDE Acquired platelet dysfunction with eosinophilia ก ก กกก กก ecchymosis CBC eosinophilia กก prolonged bleeding time ก ก parasite กก antiparasitic drug ก

38.

1)? ก seizure ก seizure กก ji tteriness กก non convulsive apnea sepsis กกกกกก seizure seizure hypoxic-ischemic cerebral injury, Intracranial hemorrhage, neonatalcerebral infarction, metabolic abnormalities (Hypoglycemia, hypocalcemia, hypoMg, HypoNa, hyperNa), infection,inborn errors of metabolism rule out hypoxia ก clinical กก glucoselevel ก DTX ก hypoglycemia plasma glucose lv. confirm

( C/S indication fetal distress? CPD? Fail V/E or F/E?; กก macrosomia IUGR ก 2 guide ก )

39. RDS newborn dyspnea ก

a. RDS Hyaline membrane disease ก preterm ก surfactant กก chest wall compliance preterm ก GA กกก 2-4 กก (กก 6 กก RDS) กก 48 กกกก ก กก 48 CXR diffusereticulogranular pattern with superimposed air bronchograms, hypoaeration with loss of lung volume กก lung density heart density ก white-out lung lung haziness กก diffuse atelectasis pulmonary edema ก prenatal corticosteroid ก ก

b. Transient tachypnea of the newborn (TTNB) กก delay lung fluid clearance กกกก ก term, near term C/S precipitate labor, M>F กกก ก 2-3

CXR lung fluid ก pleural effusion sun burst appearance ก กlymphatic vessel

c. Meconium aspiration syndrome (MAS) 15% ก meconium stained AF กก ก ET intubation ก dyspnea กก 6 ก meconium ก 2-3 ก meconium stained , ก post-term,IUGR CXR diffuse coarse density, area of hyperinflation, air trapping pneumothorax


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d. Persistent pulmonary hypertension (PPHN) ก severe and prolonged hypoxia ก met.acidosis pulmonary vessel constriction ก pulmonary hypertension ก ก hypoxia FiO2

40. 5) drowning management ABCDE respiratory insufficiency กdrowsiness intubation positive end-expiratory pressure ก pulmonary edema ( steroid diuretics ก )

41. ITP? 37.42. 2) Guillain-Barré syndrome (GBS) postinfectious demyelinating polyneuropathy กก

nonspecific viral infection 10 กก GI (esp. C. jejuni ) respiratory tract(esp. M. pneumoniae) ก typical ก ก lower extremities ก trunk, upper limbs bulbar m. ก pattern Landry ascending paralysis ก involve proximal &distal m. ก onset ก

ก lab CSF study protein กกกก 2 , glucose lv. ก cellกกก motor nerve conduction velocity ก sensory nerve velocity EMGก acute denervation of muscle ก muscle biopsy ก

กก IVIG, plasmapheresis immunosuppressive drug (steroid ) Supportive care respiratory support etc. กก 2-3 wk กกกก DTRก

Beriberi กกก vitamin B1 2 forms wet beriberi (undernourished, pale, edematous,dyspnea, vomiting, tachycardia, waxy skin) dry beriberi (fat, pale, flabby, unenergetic, dyspnea, tachycardia,hepatomegaly) กก กก cardiomegaly ก EKG ↑QT interval, inverted T waves, low

voltage กก ก high-output cardiac failure กก peripheral neuropathy DTR↓

43. 2) organophosphate ก ( diaphoresis dysphoresis)

Toxidrome RepresentativeAgent(s)

Most Common Findings Additional Signs andSymptoms

Potential Interventions

Opioid Heroin

Morphine

CNS depression, miosis,respiratory depression

Hypothermia,bradycardia. Death mayresult from respiratoryarrest, acute lung injury

Ventilation or naloxone

Sympathomimetic CocaineAmphetamine

Ephedrine

Psychomotor agitation,mydriasis, diaphoresis,tachycardia, hypertension,hyperthermia

Seizures,rhabdomyolysis,myocardial infarction

Death may result fromseizures, cardiac arrest,hyperthermia

Cooling, sedation withbenzodiazepines, hydration

Cholinergic Organophosphate Salivation, lacrimation, Bradycardia, Airway protection and


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insecticides

Carbamateinsecticides

diaphoresis, nausea,vomiting, urination,defecation, musclefasciculations, weakness,bronchorrhea

miosis/mydriasis,seizures, respiratoryfailure, paralysis

Death may result fromrespiratory arrest fromparalysis, bronchorrhea,or seizures

ventilation, atropine,pralidoxime (only inOrganophosphatepoisoing)

Anticholinergic Scopolamine

Atropine

Altered mental status,mydriasis, dry/flushed skin,urinary retention, decreasedbowel sounds,hyperthermia, dry mucousmembranes

Seizures, dysrhythmias,rhabdomyolysis

Death may result fromhyperthermia anddysrhythmias

Physostigmine (ifappropriate), sedation withbenzodiazepines, cooling,supportive management

Salicylates Aspirin

Oil of wintergreen

Altered mental status,

respiratory alkalosis,metabolic acidosis, tinnitus,hyperpnea, tachycardia,diaphoresis, nausea,vomiting

Low-grade fever,

ketonuriaDeath may result fromacute lung injury

MDAC, alkalinization of the

urine with potassiumrepletion, hemodialysis,hydration

ก Tintinalli's Emergency Medicine, 6th ed.44. 3) Congenital diaphragmatic hernia ก respiratory distress (tachypnea, grunting, accessory muscles

usage, cyanosis) ก ก (honeymoon period) 48 scaphoidabdomen, increased chest wall diameter bowel sound decreased breath sounds bilaterally (oripsilaterally) PMI CXR with nasal gastric tube confirm dx. กก

respiratory support (ET intubation, sedation, probably paralysis) hyperventilation PaCO2 45-60 mmHg(permissive hypercapnia), pH >7.3Situs inversus abdominal organs, lung lobation atrium ก dextrocardia

กTE fistula ก ก VACTERL syndrome กก frothing bubbling กก

, respiratory distress ก feeding ก ก กก regurgitation ก aspiration gastric content distal fistula ก pneumonitis

early-onset respiratory distress ก NG OG tube pass ก Esophageal atresiaก polyhydramnios ก CXR with NG/OG tube coiled feeding tube in esophageal pouch

air stomach ก ก TEF กก prone position กgastric secretion distal fistula intermittent esophageal suction ก aspiration ก blind pouch ET intubation with mechanical ventilation

45. 4) Eisenmenger complex (syndrome) ก VSD partially totally right to left shunt ก pulmonaryvascular disease ก (กก ADS, AVSD, PDA left-to-right-shunt anomaly ) ก ก ก right heart failure edema, hepatomegaly ก


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RV impulse PSM RV LV ก P2 ก Diastolic rumblingmurmur left upper sterna border ก PR ก Graham Steels murmur

Pulmonary embolism U/D lung adventitious sound (localizedcrackles) sign of dyspnea, diaphoresis, chest pain

AR diastolic rumbling murmur upper and mid left sternal border radiation to the apex and theaortic area ก

Hypoxic spell: 26.46. 2) nonbilious vomiting Hypertrophic pyloric stenosis ก 2-8

ก ก progressive nonbilious emesis กก RUQ mass peristalsis epigastrium กกก ก chronic malnutrition dehydration with hypochloremic alkalosis ก

Duodenal atresia complete obstruction of duodenal lumen ก maternal polyhydramnios, bilious

projectile emesis abdominal distension ก 24-48 ก plain abdomen double bubble sign47. 4) กก hyperthyroid กก Graves disease lab ก TSH↓, FT4↑

antithyroglobulin กก กก (methimazole, PTU)48. 2) Chickenpox or varicella incubation period 2-3 wk 48 ก vesicular rash

vesicles กก49. 1) 2250. 4) 1251. 2) ก meningitis ก กกก bacteria กกก

ก ก กก ก ก กtense and bulging fontanel ก ก

ก signs of meningeal irritation stiff neck (>1 yr), Kernigs sign Brudzinskis sign sign of IICP ก LP CSF กก signs of IICP etc.

ก Neonatal: gram negative bacilli GBS1 2 m: gram negative bacilli (Salmonella, E. coli ) Ampi + genta, ampi + 3rd gen cephalosporin2 12 m: H. influenzae, S. pneumoniae, Salmonella Ampi + 3rd gen ceph1 3 yr: H. influenzae, S. pneumoniae, N. meningitidis Ampi + 3rd gen ceph

3 15 yr: S. pneumoniae, H. influenzae, N. meningitidis PGS or 3rd gen ceph. + Vanco typical appearance purpuric rash ก

meningococcal septicemia (embolic phenomenon) ก ก CFS กก กกก post-exposure antibiotic rifampicin กก contact N. meningitidisกก ก 4 contact ก H. influenzae

52. 4) 5


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53. 2) 454. ? subdural hematoma กก กก subdural hematoma leukocytosis

with neutrophilia infection induced DIC?55. 4) ก acute bacterial rhinosinusitis ( foreign body obstruction ก

2 ) กกก กก กก กก 5-7 ก 10 ก ก ก /ก ก กก กกก 10 ก ก 14

กก 1st line Amoxicillin 45- 50 MKD PO bid ก drug resistance S. pneumoniae ( antibiotic 1-3 , daycare < 2 ) 80-90 MKD PO bid ก amoxicillin cephalosporin 2nd gen. cephalosporin (cefuroxime, ceprozil) ก cephalosporin erythromycin,clarithromycin, azithromycin cotrimoxazole

2

nd

line ก Amoxicillin/clavulanate, 2

nd

gen. cephalosporin, 3

rd

gen cephalosporin (cefpodoxime, cefdinir) ก amoxicillin cephalosporin clarithromycin, azithromycin ก ก ก

กก 1st line antibiotic ก ก 3-7 ก 7 ก 2nd line

2 ก 1-5 response compliance (ก clinical ก) ก PNS film กกก กกก ก

ก bacterial rhinosinusitis ก 3 speculum

examination ก foreign body (ก foreign body ก )56. 3)

Motor Adaptive Language Social2 m ก Social smiles4 m ก, 6 m , กก ก12 m ก ก ก ก (10 m.) 18 m 3 10 ก 2 yr ก ก

3 yr , ก กก ก4 yr ,

กกกก ก 1 กก

ก

5 yr ก ก 4 6 yr ก กกก

57. 3) 36.


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58. 4) ก ก Cushing syndrome กก moon facies, generalized/truncal obesity, purplish striae, , delay pubertal development, , , , , hyperglycemia, กก hirsutism, , enlarged clitoris delayed or amenorrhea

cushing syndrome bilateral adrenal hyperplasia, hypersecretion of corticotrophin

(Cushing disease), ectopic secretion of ACTH, exogenous ACTH or steroid, tumor, etc.Lab cortisol lv. (ก cortisol ก cushing syndrome

circadian rhythm) urine cortisol 24-hr single-dose dexamethasone suppression plasma cortisol lv. bone age delayed bone age

electrolyte ก serum calcium lv. ก (glucocorticoid action ก serum calcium กก hypercalcemia ก PTH response serum calcium ก) hypokalemia,hypochloremia metabolic alkalosis กก ectopic production of ACTH

59. 5) ก pancytopenia investigation bone marrow aspiration

ก ก serum ferritin iron-def. anemia, bleeding time ก primaryhemostasis, screening coagulogram ก secondary hemostasis, reticulocyte count erythropoietic activity

Pancytopenia ก aplastic anemia, bone marrow infiltration with leukemic cells, paroxysmalnocturnal hemoglobinuria, SLE, B12 or folate deficiency, etc.

60. 4)? ก postprandial regurgitation ก GERD ก aspiration pneumonia GERD ก respiratory symptoms กก refluxed gastric content ก respiratory tract (ก aspiration, laryngeal penetration microaspiration) กก reflux ก vagal /neural reflex กairway resistance airway reactivity ก wheezing wheezing infant ก

bronchodilator ก wheezing bronchodilator กกก61. Benign rolandic epilepsy (Benign focal epilepsy of childhood or benign epilepsy with centro-temporal spikes)

ก กก idiopathic partial epilepsy กกก 3-13 กก ก ก ก 1-2 ก กก ก กกกก

Epileptic syndromes ก Childhood absence seizure generalized epilepsy syndrome 4-10 กก ก 4-20 กก ก absenceseizure automatism ก 10-200 GTC ก Valproic acid ethosuximide

West syndrome - triad infantile spasms (sudden extensor/flexor trunk movements) psychomotorretardation EEG hyparrythmia (disorganized high-voltage slow waves, spikes and sharp waves) กก 3 กก 1 ก ก ก tuberous sclerosis

62. 3) กก secondary hemostasis ก bleeding time ก PTT prolong กก intrinsic factor ก factor VIII factor VIII deficiency (hemophilia A)


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Secondary hemostasis 2 pathway ก intrinsic pathway extrinsic pathway pathway กก coagulation factors cascade intrinsic pathway ก HMWK, PK, FXII, FXI, FIX FVIII extrinsic pathway ก FVII pathways กก FX กก common pathway FX, FV,prothrombin (FII) fibrinogen (FI) fibrin กก FXIIIa stabilized fibrin clot

กก coagulation factors pathway aPTT ก intrinsic common pathway PT ก extrinsic common pathway

Lupus coagulopathy ก prolonged PTT clinical SLE กก bleeding tendency Factor VII def. (hemophilia B or Christmas factor def.) isolatedprolonged PT ก present thrombosis กก

von Willebrand factor def. prolonged PTT ก prolonged bleeding time ± decrease plt. countกก superficial bleeding, epistaxis, postop bleeding, menorrhagia, etc. Hereditary plateletdysfunction prolonged bleeding time

63.

Iron def. anemia? ก anemia hypochromic microcytic RBC ก ก PBS Lab ก

Iron def. ก ½ -3 , ,hookworm, menses, chronicblood loss, pica, koilonychias

Mild -mod.Anisopoikilosis,↓ or ↔ RC,Pencil-shaped RBC

↓SI, ↑TIBC,SI/TIBC < 16%

Fe supplement

Thalassemia Hepatomegaly, splenomegaly, jaundice, failure to thrive,

thalassemic facies, Fam. Hx,gallstone, hemosiderosis

Mod. - markedanisopoikilosis

Target cellsTeardrop cellsSchistocytes

Abnormal Hbtyping

- Transfusion- Iron chelation

- Splenectomy

Lead poisoning /, battery, ก,, lead band longbone X-ray

- Basophilic stripingRBC

Screening urinecoproporphyrin,whole blood lead

- Supportive- Chelation dimercaprol EDTA

64. 5) Caput succedaneum diffuse edematous swelling soft tissues suture line กก ก prolonged vaginal delivery ( hematoma ก minimal bleeding) กกsubgaleal hemorrhage ก

Subgaleal hemorrhage (hematoma) กก aponeurosis ก subcutaneous tissue ก firm fluctuant mass, increases in size after birth suture line 2-3 กก ก Vacuum-assisted delivery


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Cephalhematoma subperiosteal hemorrhage suture line ( surface one cranial bone ) กก firm tense mass with palpable rim localize over 1 area of skull 2 3 calcification

Epidural hematoma subdural hematoma signs of IICP

65. 3) ก acute renal failure ก intrinsic renal cause signs volumeoverload pulmonary edema furosemide ก

66. 1) ก acute bronchiolitis กก ก 2 กก respiratory syncytial virus ก ก ก กก 2-4 ก กกก ก กก ก กsigns of dyspnea, ก hyperresonance, diminished vesicular breath sound ก wheezing fine crackles CXR hyperinflation

กก Supportive treatment O2 (keep O2 sat. > 95%), NPO ก ก,salbutamol/terbutaline NB (controversy), epinephrine, ribavarin ( )

ก O2 supplement67. 2) pneumonia ก cellulitis กก S. aureus pneumonia ก กกก

hematogenous spreading ก CXR localized or diffused bronchopneumonia lobar pneumonia ก กก necrotizing pneumonitis, pneumatocole pneumothorax ก ก

68. 3) APDE ( 37.)

ก Nelson Textbook of Pediatric, 17h ed.


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y1. 4) Surgery

: ก กก ก Inguinal

hernia Inguinal hernia 2 1. Indirect inguinal hernia hernia sac กก internal ring lateral deep epigastric artery2. Direct inguinal hernia hernia sac กก opening medial deep epigastric artery

inguinal hernia 5 5 กกก ก กก กกก Incarcerated hernia content ก complication ก obstruction strangulation ก incarceration hernia ก strangulation Obstructive hernia irreducible hernia content intestine ก obstruction ก ก

colicky pain tenderness hernia site ก strangulated herniaTreatment : Immediate surgery closed loop intestinal obstruction

Strangulated hernia content sac impaired blood supply กก hernia sac progress colicky pain ก hernia sac ก ก sac sepsis Treatment : Immediate surgery ก

obstructive hernia กก immediate surgery

1) ก กก ก complication 2) ก ก sign incarcerated hernia กก ก

ก 3-4 3) ก กก observe 5) ก กก complication ก

Surgery

Inguinal hernia History : ก กก Diagnosis : Get above sign negative ก mass testis

ก (positive) sac ก silk sign Ddx : กก internal ring ก indirect

กกก ก internal ring direct กก medial กก external ring ก indirect ก ก direct ก

Tx : กก กกก strangulation ก Direct Indirect กกก


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2. 1) Plain abdomen : acute abdomen plain film กก ก

Perforated hollow viscus, Intestinal obstruction, paralytic ileus, กกก gas forming organism, abnormal calcification, abnormal intraabdominal mass, ascites, abdominal

abscess, foreign body GI tract, bowel infarctionPlain abdomen ก 3 ก 1. Plain abdomen กก ก กก

2. Plain abdomen กก ก gut obstruction

paralytic ileus3. Chest ก free air 1-2 . !!! Plain abdomen กก Acute abdominal series

2) 5) ก ก ก 3) ก ultrasound กกก ก GI perforation 4) ก abdomen series ก plain abdomen supine & upright CXR

ก Acute abdominal series Plain abdomen 3. 2) Fibroadenoma

: fibroadenoma ก 20-30 most common benign solid tumor breast กก ก rubbery firm, discrete mass non tender, extremely mobile ก calcification

กก : Excisional biopsy ก capsule กก

1) ก Fat necrosis ก chest wall breast trauma ก needle biopsy lipid material ก mammogram กก carcinoma กก

3) ก Fibrocystic disease ก 30 ก ก cyclic mastalgia ก painful and tender breast with nodularity nipple discharge ก ก lactiferous duct ก palpable cyst

4) ก กก ก

ก กก irregular, hard, ill-defined margin, not tender Skin dimpling Nipple retraction Skin involvement ulceration, skin edema(peau dorange), satellite nodule Axillary lymph node


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5) ก ก intraductal papilloma กก bloody nipple discharge serous mostcommon cause in bloody nipple discharge กก focal area of necrosis hemorrhage papilloma

4. 1) Villous adenoma : Polyp ก ก mucosa (pedunculated)

ก (sessile) ก 2 ก ก 1. ก ก Benign lymphoid polyp , inflammatory polyp, metaplastic polyp, Juvenile polyp, Peutz-

Jeghers polyp ก2. ก ก rectum sigmoid colon 20

60 3 ก 2.1) Tubular adenoma (adenomatous polyp) กกก 2.2) Villous adenoma rectum กก 2.3) Tubulo-villous adenoma กก ก

ก TubularTubulo-villous

Villous

5%20%40%

5. 1) Reduction : inguinal hernia 1 clinical strangulation reduction

reduction ก herniorrhaphy 2-3 ก 1. 2) ก ก clinical ก 3) ก ก strangulation

4) ก กก inguinal hernia 5) ก กกก กก (irreducible)

ก ก reassure6. 1) Orchitis

: ก U/S ก increase vascular bloodflow torsion torsion ก ก ก ก torsion กก ก torsion ก ก () ก กกก ก Orchitis ก Epididymitis ก ก กก Orchitis ก Epididymitis Epididymis testis


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7. 4) Internal drainage : pseudocyst complication กก Acute pancreatitis

Pseudocyst collection fluid enzyme กกก pancreatictrauma ก ก lesser sac กกก fluid กก

ก fluid ก pseudocystกก pseudocyst กก 2 ก pseudocyst

pseudocyst Body, Head, stomach posterior wall stomach internaldrainage cystogastrostomy cystojejunostomy

pseudocyst distal pancreas Distal partial pancreatectomy ก pseudocyst front of pancreas 4) Internal drainage

8. 2) Explore wound at OR : Neck injury Zone II Sternal notch mandible ( .ก

) กก 2) Explore wound at OR

9. 4) Ultrasound ก ก 6 : ก กก กกกก

ก กก Breast imaging evaluation ultrasound ก 35 35 mammogram

Penetrating neck injuryก 3 zone ก

1. Zone I กก (clavicle) กก cricoid ก vertebral carotid

2. Zone II กก cricoid ก angle of mandible ก jugular vertebral carotid common, internal external ก

3. Zone III angle of mandible base of skull ก pharynx jugular vertebral internal carotid

กก• ก expanding or pulsatile hematoma กก

ก neck exploration • ก zone I zone III กกกกก กก

• ก zone II ก ก กก 2

1. neck exploration ก กก platysma

2. ก กก panendoscopy


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solid mass กกก ก (tissue histologic diagnosis) ก กกก 60-85% ก ก fine needle aspiration, core needle biopsy open surgical biopsy ก กก ก ก

กก ก ก clinical examination → imaging → FNA (Triple assessment) benign

กก กกก 2 cm. ก 1 ก ก 3-4 ก ก 6 กกก core biopsy excision ก ก 2 cm. excision 1) ก choice ก ก ก 2) ก ก 3) ก ก

5) ก 16 mammogram 35 breast tissue fat ก10. 3) Acute pancreatitis

: suggest acute pancreatitis ก • ก • ก ก 5 ก 12 48 ก• Tender at epigastrium , decreased bowel sound

กก pleural effusion ก fluid retroperitoneal space dehydration, tachycardia, hypotension hemorrhagic necrotizing pancreatitis

(Cullens sign) (Grey turners sign) กก retroperitoneum11. 3) Hemorrhoidectomy

: hemorrhoid ก internal hemorrhoid กกdentate line ก ก hemorrhoid ก dentate line squamous epithelium กexternal hemorrhoids

internal hemorrhoids 4 1. Grade I Bleeding without prolapsed2. Grade II Prolapsed with spontaneous reduction

3. Grade III Prolapsed with manual reduction4. Grade IV Incarcerated, irreducible prolapsed

role ก ก Indications for surgery ก • Prolapsed thrombosed hemorrhoids• Incarcerated hemorrhoids• กก ก ก


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1. Fail conservative treatment sclerotherapy, rubber band ligation2. hemorrhoids กก ก3. hemorrhoids grade III-IV กก4. กก ก กกก

grade III hemorrhoidectomy 1) ก ก grade I-II 2) ก ก grade I-II 4) ก ก กกกก 5) ก กก ก dietary life style modification กก

กก 12. 1) Ceftriaxone + Metronidazole

:•

Ceftriaxone : Streptococcus, enterococci, GNR• Metronidazole : Anaerobes (including B. fragilis) above the diaphragm• Clindamycin : Gram positive (except enterococci) & anaerobes (including B. fragilis) below the diaphragm• Gentamicin : Some enterococci, GNR, no activity against anaerobes• Ampicillin : Exteded-spctrum penicillin GPB and GNR (E.coli , H.influenzae, enterococci)• Cetazidime : Same as Ceftriaxone and Pseudomonas

ก peritonitis ก secondary peritonitis กก bowel perforation Streptococcus, enterococci, gram negative anaerobe ก Ceftriaxone ก GNR Metronidazole (anaerobes below diaphragm)

2) กกก clindamycin Gentamicin ก Gram positive negative 3) cover กก Gram positive negative ( ก broad spectrum ก) anaerobe clindamycin ก infection abovediaphragm ก 1)

13. 1) Pleural tapping : tension pneumothorax (classic triad deviation trachea , cyanosis,

distended neck vein, , breath sound ) life-threatening conditions role ก thoracentesis pleural tapping 2nd ICS MCL ก tubethoracostomy

14. 2) Pericardiocentesis : cardiac tamponade (Becks triad ก BP drop, CVP , distant heart sound) ก

กก stab wound anterior chest wall กกก needle aspiration ก pericardial sac subxiphoid approach 45 ก inferior angle left scapula ก emergency thoracotomy


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15. 2) Acute subdural hemorrhage : ก CT scan crescent shape ก subdural hemorrhage/hematoma

hyperdensity area acute phase (0-7 ) ก isodensity area subacute phase (3-14 ) ก hypodensity area chronic phase (>21 )

กกกก bridging vein cerebral cortex venous sinus 1) acute epidural hemorrhage ก temporal temporoparietal กกกก

ก middle meningeal CT scan high density mass ก biconvex shapeก skull fracture

3) , 4) , 5) CT isodensity lesion ก subacute phase16. 2) ET intubations

: severe head injury (GCS 3-8) ก management ก • Oxygenation ก Oxygen administration, Endotracheal intubation in ALL

• Blood pressure ก maintain SBP > 90 mmHg• Intravenous fluid ก Isotonic crystalloid, keep euvolemia• Ventilation ก Keep PaCO2 35-40 mmHg , Hyperventilation in severe IICP• Hyperosmolar therapy ก mannitol, glycerol• Antiepileptic drug

17. 3) Thoracic cord : ก (paraplegia) ก T10 ( level ) ก

cord lesion Thoracic cord 18. 4) 340 mL/hr ??

: Thermal injury suggested fluid resuscitation (modified Parkland formula)

second degree burn first degree กก ก ก กก 50 kg ก

Total volume for 24 hours = 4 x 50 x 27 = 5400 cc 24 hr 2700 cc 8 ก 337 cc/hr 340 cc/hr

Day 1 (Hour 0 = Time burn occurred) (hour 0-24)Lactated ringers solution

Total volume for 24 hours = 4 cc/kg/% burn Give ½ of total volume in 1st 8 hrGive ½ of total volume in 2nd 15 hr

Adjust infusion rate as necessary to keep urine output :Adult : 30-50 cc/hr

Children : 1.0 cc/kg/hr


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19. 2) Esophageal rupture : Esophageal rupture esophagus ก tear tear lung

(decreased breath sound Lt. lung) tear ก tender with guarding 1) ก hiatal hernia ก

3) ก 5) ก ก 4) ก Mallory-Weiss tear ก กก

lung20. 2) Carotid cavernous fistula

: Carotid cavernous fistula (C-C fistula) internal carotid artery กcavernous sinus กกก internal carotid artery ก cavernous sinus aneurysm กกก

ก clinical features ก

1. Pulsating exophthalmos2. Chemosis3. Veleorbital pain4. Dyslogia

5. 6. Ophthalmoplegia7. Bruit

ก cerebral angiography กก ก Embolization, Embolization with internal

carotid artery ligation, Occlusion of C-C fistula, Direct repair, Cavernous sinus occlusion21. 5 Rabies vaccine and Rabies Ig

: ก กก ก ก

WHO category IWHO category II

WHO category III

ก กก1. ก 2. กก3. ก กก1. ก ก2. ก ก ก ก

RIG

กก 2 x 1 cm (ก) grade III ก ก RIG22. 5) BPH

ก BPH กกกกก กกกก ก• ก • ก • • กก• กก• ก


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• ก กก urinary retention

hydronephrosis กกก กก rubbery23. 4) Tracheostomy

: loss of laryngeal prominence , subcutaneous emphysema cervical กlaryngeal injury indication ก tracheostomyIndication of tracheostomy ก

• Acute laryngeal trauma• Age under 12 (cricothyroidotomy is not recommended)

24. - : acute cholangitis กก antibiotics ก mild form 5-7 ก hemoculture positive 10-14 ก กก ก antibiotics ก respond ก ก

24-48 ก drain ก penetrate organ biliary drainage (decompression) +/- endoscopic spincterotomy semi-elective ( ) 72 ก ERCP, PTBD Surgical biliary drainage ()

antibiotics ก biliary drainage 3 ก 14 ก ก 3 drain + remove CBD stone remove gallstone กกก กก ก (LC) 1) ก ก 14 ก drain ก 2) ก ก LC remove gallstone กกก

3) ก กก ก (surgical biliarydrainage) กก 72 ก 6 wk

Biliary drainage (decompression) ERCP +/- spincterotomy PTBD Surgical biliary drainage ก 72

25. 2) Emergency surgery : ก acute abdomen tender at RLQ rebound tenderness acute

appendicitis ก กกกก กก

กกก ก ก ก กก กก ก กกกกก ก acute appendicitis กก generalized peritonitis กก morbidity

กก ก ก ก กก delay ก ก ก pathology ก ก GI tract ก diagnosis ก

26. 1) Diaphragmatic hernia : Diaphragmatic hernia ก 2 1. Congenital กก ก


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2. Acquired กกกก กกกกกกกกก

กก ก progressive dyspnea, cyanosis apparent dextrocardia กกกก กกกก กก

กกก กก mediastinum กก barium meal aspiration

27. 2) Local flap : ก Graft ก Flap ก• Graft ก epidermis dermis กก

(donor) ก ก (Recipient site)• Flap ก skin graft

flap ก skin subcutaneous tissue ก ก ก Graft flap

Skin graft Skin flap1. Facial wounds2. Flexor surfaces ก 3. ก ก4. กกก skin flap FTSG5. mucosa ก pharynx vagina

6. dura, pericardium, pleura peritoneum7. overgrafting unstable scars, tattoos

non-hairy pigmented nevi

1. poor vascular avascular bed2. structure nerve artery joint3. ก 4. bony prominence padding

pressure sore

5. กก 6. ก sensation7. tissue reconstruction

Graft FlapSkin graft Skin flap

1. Split-thickness skin graft (STSG) skin graft ก epidermis

dermis ก ก • Thin STSG• Intermediate STSG• Thick STSG

2. Full-thickness skin graft (FTSG) skin graft ก epidermis

dermis

operative technique ก

1.

Local skin flap skin flap ก ก defect skin กกrecipient color texture hair thickness , กก distantflap, กก distant flap2. Distant skin flap ก

skin flap กกก defect


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ก flap bedsore ก bony prominence ก localskin flap กกก distant skin flap

28. 2) U/S : Approach to jaundice patient ก liver function test Direct hyperbilirubinemia

( DB กก 30% TB) กก ALP ก Post-hepatic cause ก cholestatic jaundice กก

1. Benign causes , 2. Malignant causes investigation ก ultrasound ก

1) ก ก investigation 3) ก ก

4) ก ก invasive กก กก 5) ก ก U/S กก 29. 3) C-spine protection

: ก ก Trauma ก A B C D ก A กC-spine protection

30. 5) Surgery : inguinal hernia 1. ก 1

strangulated hernia กกก ก hernia sac progress colicky pain ก

hernia sac ก ก sac กก (ก)

ก Surgery 1) ก reduction strangulated hernia 2) ก ก ก ก acute abdomen

ก ก ก กก กกก acute abdomen �

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