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กกก กก กกกกกก กก ก . , . , .กกก (), Med, 002, ก 014, 074, 085, 095, 118, Lulu 126, 155 ก ก ก กก กก ^__^ ก 4707xxx Chiangmai Medical School

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�����������กก� ���� ��������ก�� ก��� ���ก����� ������ ������

������������ !"�������#�������ก$����ก�%�ก�������ก� $&�'"ก(��������ก����� )������������*#+��,$&����$����กก�����

��+��&$��$&����%��������-.�-ก,������+������ �����ก� ���������� �� �"+$&��ก� �.$*0) �1 . �1���, �.�.� 34565* *�.4��1, �.ก�กก�5�1 ��*����� (��� �1*�+����), *�+�%4 Med, �� 002, ��ก 014, @� 074, *��-� 085, ��)*� 095, � 4�E4F 118, �)G Lulu 126, ��5*� 155

�������!���4&��������@�ก, � #��4&���$��!)ก ������"&���%������#��@L����ก��� �� �* ��ก������������+����������$��% ก�� �-&������ ������-ก��6��&���ก� ��� ���������*��1����������� ����M���ก���-ก����� ��

����������� ����� ^__^

����ก�� 4707xxx Chiangmai Medical School

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1. 4) �ก6��1 �"ก!" SLE ��ก��+�-& �"+ก� % ������@P4��%4ก� ��+��*�����ก�� SLE ��ก��+�-&ก��#� anti-dsDNA

ก� % � ANA �� sensitivity �)�%�$���������*��ก�� SLE 2. 3) M)�@]���� Acute arthritis ���ก����$�� joint fluid �@L� septic profile (WBC > 50,000) ��� c/s �" ��@L� gram negative diplococci

intracellular ����$&�ก�� Gonococcal arthritis ��ก��+�-& Drug of choice �#� Ceftriaxone

1. !���@L� Hemorrhagic effusion �"ก!" trauma, coagulopathy, etc. 2. !��$����� Hemorrhagic effusion ��&)����@L� 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 �4�4��� Neurocysticercosis Cysticercosis ��ก��&�����ก� ��ก ��� generalized, CT �� multipled calcified cystic lesion

���@L� accidental host �"+ก4�$���� Taenia solium ����$@ ($����)�%��M�ก�&%��,) Toxoplasma immunocompromised, CT �� ring calcification, �� transplacental transmission

4. 3) ����� ����6��1&)�����-ก��ก���"ก!" TB ��ก��+�-& �%���#+��ก sputum AFB ���M� negative 3 � � "��ก$������ ��$���� %�&�4���������@L� TB ����� ��+�� ����#� bronchoscopy �*#+� R/O CA �* ���ก��ก� ��� CXR ��6�ก���@L� CA lung $&� Diagnosis of TB

1. :�ก��/:�ก����< : $�� # � � (> 3 wk) �������, $��@L���#�&, � �����ก�&, $��, ��#+���กก���#� 2. Chest X-ray: Not specific ��� Not prove active disease, Strongly suggest TB ��#+��@L���+ 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. tuberculosis 4. Culture: Gold standard, sensitivity �)ก������� AFB (detect $&���#+��� > 103 AFB/ml) 5. Bronchoscopy: ��������� �#� M)�@]��$������ !$�����������ก��$&�, R/O CA $��$&�, ����# ���@�&����������% �

�����$��*���# � � #�M)�@]�� massive hemoptysis �*#+���ก%��������+����#�&��ก 6. Tuberculin skin test: $��������� Dx, ��& infection $��$&���& disease, @|-�������+����#� ��&�����-ก�� TB ��

�-���, ������-�ก� �4�4��� TB ���&�ก, �����4�4��� extrapulmonary TB, ��� ��ก�-�����+���+%�������@}�ก��ก� %4&��# � 5. 2) Guillain-Barre syndrome

M)�@]���� weakness ��� quadriplegia � #� generalized weakness �"+���ก4&$&��ก CNS � #� motor unit ก�$&� !���ก CNS ��ก�� conscious/cognitive change, �� hypertonia, hyperreflexia ����)5���� sensation &��� ����!���@L� neuromuscular cause ��ก� normal mental function, muscle tone @ก%4� #��&�, reflex @ก%4� #��&� �� ���� "�����@L��ก neuromuscular cause (nerve, muscle, NMJ) $@����%����� 16. ���� (��ก��������)

Internal medicine

Joint fluid analysis

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6. 1) Constrictive pericarditis Neck vein engorgement, hepatomegaly = signs of right-sided heart failure �Diffuse ST-T change with low voltage� = pericarditis

Pericarditis ��ก� ��ก����� pericardium �"+�-�� myocardium ��)� �������ก4& myocardial injury �����+�, �ก4&�@L� diffuse ST-T change, Low voltage �ก�� pericardial effusion ���ก� � heart ก�� electrode

Pericarditis ��+�� Rt.-sided heart failure = Constrictive pericarditis 7. 1) Acute pancreatitis

Keyword: ก4����������, @�&����4 �@��, ���$@���, ����%��&��" � 8. 5) Varicella zoster infection 9. 1) S. aureus Pyomyositis ��ก�ก4&ก��ก������# ���5�,���� Quadriceps, Gluteus ��# � most common �#� S. aureus 10. 1) TIA �@L�%����#�ก�&�����+�@L� Transient neurodeficit ����#+��@L�����$������@��,ก���� 11. 3) Roxithromycin

Atypical pneumonia Clue ����� : ���-����, �� URI �����ก���, CXR: interstitial infiltration Organism: Mycoplasma pneumonia most common S/S: Insidious onset *��������� -�� M)���5�%��%��

Progress �ก URI �$@ LRI �����, viral infection ����ก� �*�����ก���� ��ก$���� �����ก����ก� ����#+� ���� headache, myalgia, nausea, vomiting,

diarrhea, fatigue, sore throat CXR: Diffuse interstitial (reticular) infiltration �KกL�: Macrolide (Erythromycin, Azithromycin, Clarithromycine), Doxycycline

12. 3) ����� M)�@]��ก4�� ����ก electrolyte %��,�� � hypo &��� ��4+��+�� %�&��ก�#� hyperK, hyperNa hypoNa ������� osmolality ����#�&%+�� � ��� shift ���� cell ���� ����1��� �������� brain edema ��� IICP %���� hypoK $����M�%�� consciousness "�"ก!"���� hypoCa ���&��� circumoral numbness, %�� 4� Acute gastric dilatation ��$ $�� )�?? SIADH !"���������� hypoNa �%�$�������ก�+����

13. Lead Lead poisoning: N�<, P�<��:, motor neuropathy

• Lead $@����� ���$��1 ferrochelatase ��� ∆-ala dehydratase ��ก ����ก� � �� heme ������M)�@]����&��� MCHC ��� PBS �� basophilic stippling

• �� Peripheral motor neuropathy (wrist drop, foot drop) • @�&���� # � � @�&��� • Renal tubule damage • Lead line ��+ gingival-tooth border

14. 10% Calcium gluconate ��3��� K �)��ก,� #��� advanced EKG change �4+��+�����5��+�-&�#�%�� �� protect heart ก���

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ก���KกL� HyperK 1. Protect heart : ��*����#+��� advanced EKG change � #� K > 6.5 mmol/L

��� 10% Calcium gluconate (��ก��E4F antagonist) 2. Move K �U�� cell : ��� Insulin + glucose, NB albuterol, (+ NaHCO3) 3. UKV K : ��� Kayexalate + sorbitol (+ Furosemide, Hemodialysis)

15. 3) Leptospirosis

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

Signs and symptoms

$���) @�&��#+�� RUQ pain, N/V

$�� P�<��: $���) P�<กZ����[\]: ([ :)

$�� $�� (:�`�Pa[ pattern)

Skin Rash, Petechiae Rose spot (rare) Rash (rare) Rash (rare) No rash Jaundice ��ก$�����#� ���ก���� ± ��Z\:b���Pa[

icteric type ���ก���� ± �Zcก[�:� d ��ก

%�� ���� eKVfe %������6% ± %������6% ± %������6% ± %������6% ± %���� �����#�

6%��+� $��6% *����� 6%��*����+ $��6%

%� %��& ���� subconjunctival hemorrhage

$����%��& e��< %��& $����%��&

Meningitis $���� rare Aseptic meningitis

Aseptic meningitis

$����

Lung Effusion ��*� infiltration (pulm hemorrhage)

Interstitial pneumonia

Pulmonary edema

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

��ก@ก%4 WBC↑, neutrophil �&��, plt↓

varies Anemia, WBC↑, neutrophil �&��, plt↓

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

Others i<�j[ Peyer�s patch ruptured → pneumoperitoneum

CPK↑↑↑↑ Hx Zk�[]l�

Eschar nP����<[ ���[e �<���

16. 2) Dermatomyositis Proximal muscle weakness (�" ����$&�����ก �-ก�����ก) 1. Nerve: �� sensory, reflex, autonomic involvement ��ก�@L� distal

• Acute autoimmune demyelination of peripheral nerve • ��$&�@ ���%4 recent Campylobacter jejuni infection, viral infection � #� influenza vaccination �����ก��� • �� weakness (���� CN involvement) ���ก�� sensation loss ��� glove and stocking (���!-�#�!-����),

hyporeflexia � #� areflexia, LP ��6@ %���)

Guillain-Barre syndrome

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• �ก(�: Plasmapheresis ��� IVIG ($���� role ��ก� ��� steroid ��)

• �ก4&�กก� ������ axon, ���*��E1ก�� 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: M#+� ��%�, shawl sign: M#+���+$��� �����ก������

������, V-sign: M#+����������# ��� V, Gottron�s sign: M#+���+����#�� 4��. bony prominent) • �ก(�: Steroid

• Insidious onset, �� Hx ��� steroid ���, ���� �@L� asthma, COPD, rheumatoid

• M)�@]����� ���-���� ����ก� ����� ��������%#+���� ��@ ���%4��#+������กก�������ก,� #�ก4����� �# ���5�

(high carbohydrate meal) • %�� weak ��� serum K �%+�� • �� ��� TFT �*#+���ก��4&

1) Familial !�����&��� AD, ��ก�� Family Hx, TFT @ก%4 2) Thyrotoxic ����ก� �� thyrotoxicosis � #� TFT �@L� hyperthyroidism

3. NMJ: ก�-���� ���#��ก�-�� muscle �%���� fluctuation (��ก� �" �,�,) ��� fatigability (%��� ก��� �4+����4+����� )

• Autoantibody %�� postsynaptic Ach receptor • ���*��E1ก�� 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 �*4+� > 12% FEV1 �*4+� < 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)

����%-������+6��1����������ก4&�ก Cardiac beriberi (ก4���������� → ��& Vitamin B1 (thiamine) → Cardiac beriberi) �KกL�: ��� Vitamin B1 (thiamine)

19. 1) Chigger mite �@L�*����� Orientia tsutsugamushi 20. 3) Neurogenic shock

��4& ����%- CO PCWP SVR ก� �ก(� Hypovolemic (volume �&�)

Trauma, blood loss, third space loss, burn ↓ ↓ ↑

��� isotonic solution � #���#�&

Cardiogenic (��#�&��ก�ก����$��$&�)

Tension pneumothorax, CHF, cardiac tamponade, arrhythmia, MI, structural heart disease

↓ ↑ ↑

�ก(�����%- Dobutamine, dopamine or NE

Distributive shock (vasodilate) ↑ ↓ ↓

Septic Bacteremia 6&���*�� gram neg.

��� fluid ��� ABO *4� .���� Swan-Ganz catheter ��� dopamine � #� NE

Anaphylactic

�*����� ��, M" %���

��� Diphenhydramine ��� 1:1000 epinephrine !�� -��

Neurogenic* Spinal cord injury * Loss of sympathetic activity = hypotension + bradycardia

CO Cardiac output PCWP Pulmonary capillary wedge pressure �����ก����&���� LV SVR Systemic vascular resistance

21. 1) Inhaled Salbutanol prn + inhaled corticosteroid

Day attack Night attack PEF � #� FEV1

Variability Treatment

Mild intermittent

< 1 /��@&��1 < 2 /�&#�� > 80% < 20% SABA ��#+�����ก�

Mild persistent

> 1 /��@&��1 > 2 /�&#�� > 80% 20 - 30% + Inhaled corticosteroid

Moderate persistent

�-ก��� �ก��ก�

���

> 1 /��@&��1 60 - 80% > 30% + LABA

Severe persistent

%��&���� limit activity

�� �#� < 60% > 30% + Theophylline � #� oral LABA � #� Leukotriene modifier � #� oral corticosteroid

Management of asthma

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22. ASA + Propanolol Subacute thyroiditis (de Quervain�s thyroiditis) ����@L���� ��� �#� 1. Thyrotoxic phase 2. Hypothyroid

phase ��� 3. Recovery phase M)�@]�����&�����ก� %���$� ��&16%������ (�� ���$@��ก $ก , �)) 6&���$&��� ��ก� ��� thyrotoxicosis ��� hypothyroidism ���������ก� �� URI �����ก���������@&��1 ������5�6 ��� ��ก��� �%�ก��������� turn �@L� hypothyroidism !��

ก���KกL� ��� Aspirin high dose � #� NSAIDs �*#+��&��ก� @�& !���@L���ก����� steroid ���&��� ������ก� �� thyrotoxicosis �����$&���� #�� ���$&�&��� β-blocker ($���� role ��ก� ��� antithyroid drug �� thyrotoxic phase)

23. 1) Simple goiter 24. 3) Thoracic area ����� �@L� UMNL, cord lesion �* ���� Hyperreflexia, loss of sphincter tone ����� level of sensation loss

�&����+�����@L�$@$&���ก��+�-&�#� Thoracic area �* ������!" �&����&#� (T10) 25. 1) Atropine

26. 1) Anti-HIV ���� oral candidiasis 27. Pacemaker ($������)

AV black 1st degree AV block PR prolong �����&��� (> 0.02 sec � #� 5 ���)

2nd degree AV block Morbitz I PR ����,�����ก � block $@ 1 � �

Morbitz II PR �������,ก�� �%���)�,ก� block $@ 1 � �

3rd degree AV block Complete A-V dissociation �#� p wave ก�� QRS

complex $�����*��E1ก��

• 1st degree ��� 2nd degree Mobitz I ��ก�@L���+�� ������ก4&�ก supranodal block ��ก�����@��+��$@��� junctional rhythm (��� AV node �@L�%��ก����4&$��}�) $&� HR @ ���. 45 (ก���6���)

• ��ก .� 2nd degree Mobitz II �ก4&�ก infranodal block (his, bundle branch) ��6�ก��� turn �@L� complete heart block �) �"+�������� idioventricular rhythm (ventricle �@L�%��ก����4&$��}�) HR @ ���. 20 ($����� �&) &��� � Mobitz II ��� 3rd degree AV block "%�� ��%4& pacemaker

(complete heart block)

Bradycardia

Adequate perfusion Poor perfusion

• %4& 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 �����������M)��)���- 29. 2) Pancarditis 4,����%�� pericarditis ��กก��� Keyword �#� �|$&� rub (friction rub)

ก� �|$&� friction rub ��&!"ก� ��ก����� pleura � #� pericardium !�������� ����*��E1ก��ก� �%��������ก������@L� cardiac friction rub !�����*��E1ก��ก� ����ก������@L� pleural friction rub

30. 1) Cardiac siderosis �#�3�������ก$@ deposit ��+���� M)�@]�� Thalassemia ��+%��$&���#�&����,���@ 4��.����ก�ก4��� ��ก�� �ก4&3��� hemochromatosis �"+����ก

��ก�$@������+������%��, $&��ก� �K�` → heart failure, eKV → cirrhosis/liver failure, eKV: :[ → DM, Pituitary gland → hypogonadism, growth retardation

@�. Choice 4) ��+�� �4&���+�� - -� 31. 1) Ibuprofen

ก���KกL� Rheumatoid arthritis • Physical, occupational therapy �*4+��������� �� periarticular muscle • Drugs

Z< symptoms �ZsZ<ก��:Kก��V First line Aspirin / NSAIDs ��ก��E4F� �� Second line Glucocorticoid (joint injection � #� oral)

DMARDs d �sZ:ก��<l��[�[f�t First line Hydroxychloroquine, sulfasalazine, methotrexate ������+6 � active ��ก, Second line Leflunomide, anti-TNF

�#+�, Azathioprine, gold, D-penicillamine, cyclosporine, cyclophosphamide • Surgery ��*4� .��� ����+�� severe functional impairment �ก deformity

32. 1) Ceftriaxone IV ����� 4,�� %�� Aminoglycoside ���� Gentamycin ��กก��� Treatment of UTI Acute cystitis: 3-day therapy TMP-SMZ �������������+�*� Sulfa, �&������ � 4+�&# �����ก�" � fluoroquinolones ����������&�ก�������� Acute pyelonephritis OPD: GPC amoxicillin GNB fluoroquinolones IPD: GPC ampicillin GNB aminoglycoside, cephalosporin (ceftriaxone, ceftazidime), fluoroquinolone

33. 2) Naloxone ����� ����$&�ก�� Organophosphate poisoning Organophosphate 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, hypotension Respiratory - Rhinorrhea, bronchorrhea, bronchospasm, cough, severe respiratory distress Gastrointestinal - Hypersalivation, nausea and vomiting, abdominal pain, diarrhea, fecal incontinence Genitourinary - Incontinence Ocular - Blurred vision, miosis Glands - Increased lacrimation, diaphoresis

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

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 ���� ��$&��-ก 8 ��+�6� � nicotinic symptoms ���$@ !����ก��� BDZ

34. 1) ����-����� ก���KกL� DM type II (Guideline ��$�� 2551) 1. FBG < 200 mg/dL ��� HbA1C < 8% → Lifestyle modification 1 � 3 �&#�� !����$��$&�%���@}����� ��� start �� 2. FBG 200 d 300 mg/dL → Lifestyle modification + start �� (%����ก(.�M)�@]��)

Metformin Sulfonylurea ��ก(.� Insulin resistance: • BMI ≥ 23 kg/m2 • BP ≥ 130/85 mmHg � #�$&����&

����&�� • TG↑, HDL-C↓

��ก(.���& Insulin: • BMI < 23 kg/m2 • ����ก� �ก� ��%������#�&�)��&�� • �&��� ��%������#�&�)��ก • Postprandial sugar �)

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

3. FBG > 300 mg/dL � #� HbA1C > 11% ���ก������ก� �ก� ��%������#�&�) → �� Insulin

�Px����� 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 Graveys disease �ก(�6 � + �&��ก� �KกL�f�t

1. Antithyroid drugs (PTU, Methimazole)

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• ��&���ก ����ก� organification (PTU inhibit peripheral conversion T4 → T3 $&�) • ☺ !)ก ��&�ก • � High recurrent rate, serious side effect: agranulocytosis • Indication: �<cก, t[��:��\:��[�Vke� (t���� PTU ��กก� �), Thyroid storm, ����������ก6 �$&��� ����+

��ก� $�� -�� , induce euthyroid stage ก��� RAI � #� Surgery, ����@L� long term �� ����+ recurrent hyperthyroidism �����������#+�$��$&�M�

• Methimazole: Half-life ���ก��� ก4������� � $&� • ��ก%���������������� 2 @� ��� � %����� L-thyroxine �����%��� ก

2. Radioactive iodine (I131) • ☺ High cure rate, safe & easy, ���&%������ก�, $����M���������ก ��� ���� infertility � #� develop CA • � Hypothyroidism, ������ ophthalmopathy ����, ���������ก4& severe thyrotoxicosis / thyroid crisis ��M)�@]��

uncontrolled hyperthyroidism (�� �����ก������ euthyroid) • Indication: �@L� First-line treatment ����@ ���', recurrent ����ก$&���� #�M��%�&, :��k��ก (��������-����!��

�ก4& hypothyroid �%��ก4���%����ก���) • Contraindication / precaution: ���/������-% , ���-����, Low radioiodine uptake, Severe hyperthyroidism,

Active ophthalmopathy, ���� CA thyroid, %�����5���ก,, poor compliance 3. Surgery (Subtotal thyroidectomy)

• ☺ ก����@L� euthyroid stage � �� • � Surgical complications (recurrent laryngeal n. injury, hypoparathyroidism), ��6�ก�� relapse $&���� • Indication: e :��z , ����ก� �ก%���$@ก&�������������, Severe Grave�s ophthalmopathy, :��k[�:�, ����

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

Z<:�ก�� → ββββ-blocker %������ก� ��#�ก��� A. Radioactive iodine, B. Antithyroid drugs, C. Surgery %���6% 50 ก ��, moderate hyperthyroidism, new case

%�����5� $������*�ก ��ก� hyperthyroidism -��

B (6&���+�$@�����ก���)

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

�@L�� ������ก �ก(�&����� �@L�� �����M��%�&$@���� ���-��ก ���-����

A, C A A B, C

36. 1) Free T4 (�����*4+��%4�� #+� thyrotoxic hypoK periodic paralysis ��� 16.) 37. 1) 2 wks 38. 5) NB salbutamol ( 4, iv steroid ก��� ���)

ก���KกL� Acute asthmatic attack 1. �� oxygen, keep O2 sat > 90% 2. �� bronchodilator

!���:Vn� �k[��

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�)& β2-agonist �ก nebulizer � #��ก MDI with spacer !���:V�k[�� (PEF < 50% � #� ���#+���*)&$��$&� � #���� accessory muscle) �)& anticholinergic ���ก�� β2-agonist

3. �� Steroid : ��� IV � #� oral steroid 4. �#+�, ���� ��� antibiotic !���� bacterial infection

39. 4) Oral itraconazole Treatment of Tinea unguium

Tinea unguium (Onychomycosis) �@L�6 ���+%�����ก� �ก(���� �@L�� ��$&����� *��������$������$&�M� %������@L���ก4� 6&���+�$@�����#��%�����%����$&�� ��ก����������� ����+���$&��ก� Oral griseofulvin, oral turbinafine, oral itraconazole

40. 1) Psoriasis • �@L�ก�-��M#+����-� (papulosquamous) �@L� well-marginated, erythematous plaque with silvery scale ��ก*�� 4��.

extensor surface, ���'� (� • Koebner�s sign positive �ก���+�#+�����M#+��" �, Auspitz sign positive �ก�������#�&��ก�4�, • Associated findings: psoriatic arthritis, nail change (oil spot, onycholysis, pitting nail, subungual thickening)

41. 3) Xanthelasma *��� hyperlipidemia 42. 5) Propanolol + Flunazine Propanolol = Beta blocker, Flunarizine = CCB

Migraine Drug Prophylaxis: ��#+�����ก� > 3 � � %���&#�� TCA, β-blocker, CCB, valproic acid, topiramate Treatment (Abortive Rx): 1. ASA, acetaminophen, caffeine, high-dose NSAIDs 2. Dopamine agonist: Metoclopramide IV,

prochlorperazine IM or IV 3. 5-HT1 agonists (�Triptan�) ���������M)�@]�� CAD 4. Ergotamine ������� ���& �����M)�@]�� CAD

43. 3) Subarachnoid hemorrhage Keyword: @�&�����ก����� + stiffness of neck

44. 4) Myasthenia gravis (&)��� 16.) 45. 5) Intravenous immunoglobulin ���� �@L� 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) ����� ���#������$&�ก�� Gout ��ก��+�-&��#+��ก *���ก��+�4 ����������� Joint fluid �@L���4& inflammatory ���*� Needle-shaped crystal ก� �@��+���@��� x-ray �$����������M4&@ก%4�� ���� ก , 6&���*��%��� soft tissue ��� ก �&)ก�@ก%4� #�������ก(.��������#+�� �"+�@L�ก� �@��+���@�%�����- �%��� �����+M)�@]���@L���ก����� tophi ก� % � x-ray ก�������@L� soft tissue mass � 4��.�� � ���ก����ก �&)ก�����"+�@L� punch out lesion, overhanging edge �� ����+�@L���ก�����!)ก������$@��& Gout

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

��*� Soft tissue calcified mass !���@L� chronic tophaceous gout • ก� �ก(�:

o Acute attack: NSAIDs, colchicines, steroid $���� �������+�& �&�� uric acid �* ���ก �%-�� attack

o �&� �����ก �&@|����+�*4+� uric acid (alcohol, diuretics, aspirin, �� #+���, ��&M�ก) o Maintenance: Allopurinol (Xanthine oxidase �&ก� � �� uric acid)

Probenecid (�*4+�ก� ��� uric acid ��$%) CPPD (pseudogout)

• Acute monoarthritis ��ก�@L���+�������� #������5�, • X-ray: �� Calcium deposit ��+ articular cartilage � ��ก chondrocalcinosis • Synovial fluid: ��*� CPPD crystal �@L������������)� � #� rhomboid � #� cuboid ��� weakly positive

birefringence 48. 3) M)�@]�� ���� ��&��� Acute monoarthritis �ก��ก(.���ก� ��+������� -�� �@L�� �� ��$�� ���&���6 ���+�4&!"$&�ก��� Crystal-

induced arthritis, Septic arthritis �@L�%�� ก� ������&) Synovial fluid �������ก� �4�4�����ก6 ��� ���� $&���ก��+�-& Differential diagnosis U: Acute arthritis

Monoarthritis Polyarthritis Pyogenic arthritis Acute rheumatic arthritis Crystal induced arthritis Pyogenic arthritis Acute rheumatic arthritis Seronegative arthritis Traumatic arthritis Viral arthritis Seronegative arthritis SLE Rheumatoid arthritis Rheumatoid arthritis

49. 3) ����� $������ �%��กก� ���!��M)� )��������������������@L� gout ��ก��+�-&

M)�@]�� ���� ��&��� Acute monoarthritis 6 ���+�4&!"$&�ก��� Crystal-induced arthritis, Septic arthritis, Rheumatoid arthritis (RA) ��#+�&)ก� %�����%�� NSAIDs *���� RA %�����$&�&���ก @ �ก��ก����ก�ก4&ก��������ก, ��กก��� "�4&!"

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����� ��ก .��� septic arthritis �� *� WBC > 50,000 ��� PMN > 75% �ก joint fluid profile "���#� gout ��� pseudogout ��ก .��� gout !���@L� ���� ก,�$��*�����M4&@ก%4�ก���1� ���� CPPD ��ก�%��*�����M4&@ก%4 (���1��@L�������"+��ก� Dx) "�"ก!" gout ��กก��� (����� $������ 4, -_-!)

50. 2) M)�@]����&��� Acute fever ���ก���� RUQ pain �4&!" Infection � #� Inflammation ��กก����� Malignancy % � ��ก��*�%��6% ก&���, M� LFT *������ ALP �)�" �, ��� Ultrasound �@L� Hyperechoic mass ก����&��� ���&��5� ����$&�ก�� Amebic liver abscess ��กก��� HCC ��+$��������%��6% ก&��� �����#+�$���� Bile duct dilatation ก��4&!" CCA ����

51. 2) ��ก� ����ก4&�����*���%�������������ก %�������ก4&&�������"�4&!" Esophagus ��+��ก��& (Rupture) ��+� ��ก��� Boerhaave�s syndrome ����� � #� content ��ก���"+�E4�����ก� ������ก� ��+ breath sound �&�$&� �.���+ Mallory-Weiss ���&��� Upper GI bleed ��#+��ก��ก� ��ก��&��*�� mucosa $��$&���ก��&�-ก�� �

52. 3) �-� �����#�&@��%�$���@L���# ��&���ก�� �4&����@L� Lower GI bleeding �� ���� ��@ ���%4&#+� alcohol &��� �"ก!" Hemorrhoids ��ก��+�-& �%���#+��ก��$���������������%-�กก� &#+��- � 4� #�$�� ก� �ก(���+��������*#+��&��ก� !����@L���#�&"�@L�ก� �ก(���# �%��$@ก����#���� ��@ �������� ��+�� fiber �)�*#+����!����-� ����

53. 1) Pellagra �ก4&�กก� ��& Niacin (Vit. B3) *���M)���+&#+� alcohol ��ก ��ก� ���ก, ก��#� 4Ds $&��ก� Diarrhea, Dermatitis, Dementia, Death ��ก(.�M#+���@L� pigmented ��� scaling ����� ����

e�����<:�ก��กKV:�ก����<U:ก��U�<��e���[��{�l�tKz���:�|��s��{:�`�Pa[����ek Nutrient Clinical Finding Contributing Factors to Deficiency Thiamine Beriberi: neuropathy, muscle weakness and wasting,

cardiomegaly, edema, ophthalmoplegia, confabulation Alcoholism

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

tongue, diarrhea, apathy, memory loss, disorientation Alcoholism, vitamin B6 deficiency, riboflavin deficiency

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

Alcoholism, isoniazid

Folate Megaloblastic anemia, atrophic glossitis, depression, ↑ homocysteine,

Alcoholism, sulfasalazine, pyrimethamine, triamterene

Vitamin B12 Megaloblastic anemia, loss of vibratory and position sense, abnormal gait, dementia, impotence, loss of bladder and bowel control, ↑ homocysteine, ↑ methylmalonic acid

Gastric atrophy (pernicious anemia), terminal ileal disease, strict vegetarianism

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

Smoking, alcoholism

Vitamin A Xerophthalmia, nightblindness, Bitôt spots, follicular hyperkeratosis, impaired embryonic development, immune dysfunction

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

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

Aging, lack of sunlight exposure, fat malabsorption

Vitamin E Peripheral neuropathy, spinocerebellar ataxia, skeletal muscle atrophy, retinopathy

Occurs only with fat malabsorption, or genetic abnormalities of vitamin E metabolism/transport

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

54. &)��� 6.

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55. 5) M)�@]���� clinical �� Acute Pulmonary edema ���ก���� Hypertension �%��� ���� $���)��ก��ก "��$��%�� ���&����&�� ก� �ก(���+��������� ���� �#�ก� ��� Morphine �"+�@L� Transient venodilator �����& Preload ����������& Afterload �� ����+�� Hypertension ���&��� ��ก�ก�� �������&��ก� Dyspnea, Anxiety, Stress, Catecholamine level, Tachycardia &��� * ����� �กก� !��M)� )� ��ก���$������ ����� morphine � #� nitroprusside

56. 1) ��ก� ���#+��, N/V, ��#+����� , ��������M4&@ก%4 �@L���ก� ���*���� Digoxin intoxication ��+��ก�$กก� �ก4&*4(�ก3��� Hypokalemia �4+M)�@]�� ���� $&� ���� Furosemide �"+���M������� Hypokalemia ����ก�� ������$@�)�ก� �ก4& Digoxin intoxication %��������+�-&

57. 3) ��%-M�%����� 56 ��#+��ก4& Digoxin intoxication ก�%����-&��&�ก���� 58. 2) 3��� True Hyponatremia ��+ Urine Osm < 100 ��4&!" Primary polydipsia, Beer protomania, Reset osmostat !�� > 100

"��"ก!" SIADH (����ก��� ADH �� function &���)�) 59. 2) Coxsackie B virus �@L� virus ��+�������ก4& Dilated cardiomyopathy �"+ Systolic function $��&� ���$@�)�ก� �ก4& Congestive

heart failure ����+�-& 60. 1) M)�@]���� Platelet < 100,000 ���ก�� Coagulopathy (prolonged PT, aPTT) �4&!"3��� DIC ก� % � D-dimer ��@ �6���1��

ก� �4�4��� (��ก����%-��+�����) ����4�4�����ก6 ��� ����

61. 1) HbH disease �� genotype �@L� - - / - α (Heterozygous α-Thal-1 / α-Thal-2) &��� ��)ก%��$&� �� gene - - ก�� - α �ก*�����

��� ��#+�&)�กM���#�&����*����*���� MCV %+�� (@ก%4 80 - 100) ��&����� RBC %�����ก "�����@L� Thalassemia minor �#�����+�� - - gene (- - / αα) �������ก���� - α �%� MCV �����$��%+�� �4&��������@L� Carrier (- α / αα) ��กก���

62. 1) ก4�������!#+�� �4&!" Methanol intoxication $������ (����� 6��1$������ก� ���*������$� �) ��ก� �������ก��������ก Metabolic acidosis �"+ Methanol �������ก4&$&� 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 ก� �ก(���+����������&��� ก�#�ก� ��� Defibrillation 64. 2) Key point �#� ��� ��@�ก� �"+�@L���ก� ��+�������"ก!" Tetrodotoxin (��&�����@��@|ก�@}�� ��#&M����)���@�� �����#����+���

�@L�������+3�������) 65. 4) ($������) M)�@]�� ���� �� Candiduria (Candida �� urine) ���� Bladder thrush �� ����+�� Foley�s catheter ������ Bladder

irrigation &��� Amphotericin B !��$��$&���� Foley�s ��� oral Fluconazole ��� 66. 1) M)�@]����@ ���%4��กก����ก���������กก���� (��ก��ก��� ) �������#&�@L��� �-.�3)�4�) �� signs �� dehydration �4&!"

Exertional heat stroke ��ก��+�-& (3��� dehydration ���� !ก �%-������ก4& Heat stroke $&�)

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67. 4) MAHA blood picture �4&!" DIC, HUS, TTP M)�@]���� Platelet < 100,000 ���ก�� prolonged PT, aPTT �����@ ���%4��+�@L�����%-�� DIC $&�ก��#��� Sepsis �ก Bed sore "�4&!" DIC ��ก��+�-&

68. 2) ��ก�-�� HMG CoA reductase inhibitor (ก�-�� Statin) ��@ ��4�E43�*��ก��+�-&��ก� �& LDL ����������& Triglyceride $&���

�&����"+

Drug Major Indications Mechanism Common Side Effects HMG-CoA reductase inhibitors (statins)

Elevated LDL-C

↓ Cholesterol synthesis, ↓ hepatic LDL receptors, ↓ VLDL production

Myalgias, arthralgias, elevated transaminases, dyspepsia

Cholesterol absorption inhibitors (Ezetimibe)

Elevated LDL-C ↓ Intestinal cholesterol absorption Elevated transaminases

Bile acid sequestrants (Cholestyramine)

Elevated LDL-C

↑ Bile acid excretion and ↑ LDL receptors

Bloating, constipation, elevated triglycerides

Nicotinic acid Elevated LDL-C low HDL-C elevated TG

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

Fibric acid derivatives (Gemfibrozil, Fenofibrate)

Elevated TG, elevated remnants

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

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

69. 5) ���M)�@]���ก4& Myocardial infarction ����$���ก4� 3 ��+�6� ก� ��� Thrombolytic agent ���� Streptokinase, Tissue

plasminogen activator (tPA) �����@ �6���1��)� �%�!��!����� ก� �ก(���+���������+�-&�#���$ ก�%��%�� PCI ��)�&�

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70. 2) M)�@]����+��&��� Diarrhea ��������� ก� �� Stool examination ��@ �6���1��ก� �4�4��� �������� ���� �� underlying �@L�

Cirrhosis �4&!" Spontaneous (Primary) bacterial peritonitis $���� DDx. &���ก�%�� �"+�%����� Abdominal paracentesis �*#+�ก� �4�4��� �%�M)�@]����ก���&���$�� @�&�����กก��� "�4&!"������� ����

71. 4) M)�@]��������-$����ก ��@ ���%4�)��-� �+ �� Cyanosis @����4 � % �*� Radial pulse �&��%� Brachial pulse @ก%4 ����ก!" distal vessels M4&@ก%4��กก��� proximal vessels �4&!"6 � Thromboangiitis obliterans (Buerger�s disease) �"+�@L� Small to Medium-sized vascular disease

72. 2) M)�@]����&��� Acute monoarthritis ��$�� ���&��� ��ก(.� Synovial fluid �@L� Septic group (Group III) "�4&!" Septic arthritis �� ����+*� WBC �� Synovial fluid 50,000 /mm3 �" �$@���� ��$��������ก(.���ก�����ก���� !��� Empirical

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Antibiotics $&���� ���� �� ���� ����@L� Gonococcal arthritis ก�$&��* ��*���+������� �� WBC 50,000 �" �$@ PMN �&�� �����ก������ #��*����# �$������$&�

73. 4) *��E4 Capillaria philippinensis ������ ��#&�@L�*��� 74. 3) M)�@]��������� ก&��� ��@ ���%4��+ !���, $������$&������4&!" DVT ��#+�����ก� ������#+�� ����ก �%��| Breath sound

@ก%4 "�4&!" Pulmonary embolism 75. 2) % � ��ก���� Hepatosplenomegaly ����ก���M)�@]����6 �� # � ���)�ก�������6&���*�� Hematologic disease ��#+�&) CBC

*���ก(.� Microcytic anemia �"+6 ���+����������ก(.�&�ก�������%������6%ก��#�ก�-�� Thalassemia & Hemoglobinopathies ��"+���� ��#� HbH disease ����ก� ��& ���#� �"ก!"3��� Acute hemolysis �ก4&%�����$�� �"+�@L� Stress ����ก4&3���&�ก�����" ���6 ���

76. 4) M)�@]���� clinical ����$&�ก�� Hypertensive crisis ���� �#� BP > 180/120 ������&�@L� Hypertensive emergency &��� �* ��� 4+���������������������� %���&����&��6&�� ����+�-&

77. 1) ก� �ก(� Anaphylactic shock �#���� Adrenaline 1:1,000 ���& 0.3-0.5 ml Intramuscular (IM) %��������+&���+�-&�#� Vastus lateralis muscle % %����

78. 1) M)�@]������ก� �ก4&�" ����������& ��ก� ����� �� ������������ ���-&�����5�#��� pupil ���ก � ��ก Pin-point pupil �@L���ก(.��� Pontine hemorrhage ��������ก� @�&������� �&4��� �*�$&��� Cerebellar hemorrhage �%���ก� ��������ก���(�@L���+�6�) $���� pin-point pupil

79. 4) ��ก(.������5�#� �����ก� ��� 4��.M#+�� ���M#+� ������, "�"ก!" Leprosy (6 �� # ��) �� ����

80. 4) ($������) Diastolic rumbling murmur ����� Opening snap �4&!" Mitral valve stenosis (MS) ��#+�&)�ก%����#�ก@ �ก��ก�����-M)�@]������ �"ก!" Calcification %����#�ก�#+���ก4& Regurgitation ��กก���

81. 1) ��ก(.� clinical ��� CXR �� Cavity ��+�� Air-fluid level ����$&�ก�� Lung abscess ��ก��+�-&

82. - M)�@]�� ���� �� Hypokalemia (&)�ก%����#�ก��@L� Renal loss) ���ก�� Hypertension ����%-��+�@L�$@$&� �#� Diuretics, Hyperaldosteronism, Renal a. stenosis, Cushing�s syndrome �"+ก� &) plasma aldosterone/plasma renin activity (PA/PRA) ratio �����$&� 6&�!�� > 20 ��4&!" Primary hyperaldosteronism �%��� ���� ����)�$���*��*���+���ก Primary hyperaldosteronism ก�� Renal a. stenosis $&�

83. 1) M)�@]����@ ���%4��� Penicillin ������ Diarrhea *���ก(.��� Antibiotic associated colitis (AAC) �4&!" Pseudomembranous enterocolitis �ก Clostridium difficile ก� �ก(��#���� Metronidazole �@L� Drug of choice (*�������� PO !��$��$&�"��� IV) ����� Vancomycin ก�$&� �%� ����*

84. 4) M)�@]������ก(.���& ���ก�����#� �4&!" Hemolytic anemia �"+M)�@]��������ก�������6%��#+��ก�@L����������� RBC �%��� ���� %������$��6% 6 ���ก�-���� ��+����$��6%��"ก!" G-6-PD deficiency ก� ��% ���+�������"�@L� G-6-PD screening

85. 2) ����� %����ก�* ���@L�ก� �ก(���+���@L��� 2 %����#�ก ���$��� ��3�����M)�@]�� �� �� �� DKA ���� ก%����� IV fluid �&��� Intra & Extravascular volume �@L�������+�����5��+�-& �ก�� �"��� Insulin ��� �&��� ��%���&� 50-70 mg/dL/hr ����#� 200 mg/dL

86. 1) ��M)�@]�� DIC ��+�� prolonged Pt, aPTT ��&�����ก� ��& coagulation factor "�� ��� FFP �� �� ก� ��� FFP � #� Platelet ���@ �6���1��#+�M)�@]������#�&��ก� #����+��)��+���#�&��ก �%�ก� �ก(� DIC ��+�����5��+�-&�#� ก���KกL�����ek $���ก�% �� ก�$����� ��#+���&)%����#�ก��+�� Antibiotics (ATB) &��� �&����6��1������� ���� �ก4& DIC �ก Sepsis ก� �ก(���+�������"�@L� Antibiotics

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87. - 4, %����������� Sustained VT PVC %4&ก�� 3 %�� � ��ก Triplet PVC !��%4&ก�� 4 %���" �$@�� ��ก Nonsustained VT �%�!���� PVC %4&%��ก���ก4�ก��� 30 �4����"�� ��ก Ventricular tachycardia (VT)

88. 1) ก� �ก(� Complete heart block &������#� Atropine ��� Isoproterenol IV �*#+��*4+� HR ��+�� ������$&�M���#+��@L� block ��+ AV node �%�ก� ��� Pacemaker implantation �@L�ก� �ก(� AV conducting system disease ��+&���+�-& 6&�������#+��� Indication

89. 1) ��ก� $����, �@L� Side effect �� Enalapril �"+�@L� ACEI Drug Class Other Indications Contraindications/Cautions

Diuretics Thiazides (HCTZ)

Diabetes, dyslipidemia, hyperuricemia, gout, hypokalemia

Loop 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, sinus tachycardia, ventricular tachyarrhythmias

Asthma, COPD, 2nd or 3rd degree heart block, 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, hyperkalemia

Angiotensin II antagonists (Losartan, Valsartan, Candesartan)

CHF, diabetic nephropathy, ACE inhibitor cough

Renal failure, bilateral renal artery stenosis, pregnancy, hyperkalemia

Calcium antagonists Dihydropyridines (Nifedipine)

Angina Heart failure, 2nd or 3rd degree heart block

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18

Nondihydropyridines (Verapamil, Diltiazem)

Post-MI, supraventricular tachycardia, angina

Direct vasodilators Direct vasodilators (Hydralazine, Minoxidil)

Severe coronary artery disease

90. 2) M)�@]���@L� Chronic oligoarthritis �@L���ก�" ���������� �� Crepitus ����$&�ก�� Osteoarthritis 91. 1) M)�@]�� ���� �4&!" Uncomplicated UTI (!���� underlying structural/neurological disease, pregnancy � #��@L� upper UTI

���� UTI ���*'����&�@L� Complicated UTI) ก� �ก(��� ���� ��� Co-trimoxazole (Bactrim) � #�ก�-�� Fluoroquinolone 3 ���ก�*�

92. 4) ���� �4&!"3��� Hypercalcemia (Dx. ��#+� Ionized Ca > 4.5 � #� Corrected Ca > 10.5 mg/dL) ��#+� �&�� Ca �)ก��� 12 mg/dL �� 4+�����ก� �� Neuro, KUB (��� ���� ), Heart ��� GI ก� �ก(����$&� Fluid �&�������ก��#�ก� � ���� Ca ��ก6&������ก�-�� Loop diuretics

93. 2) ���� �4&!" Migraine headache ����� ����!����@}�ก����กก����� �ก(� �* �� �@L��� �ก(� 4 choices �@L���@}�ก�� 1 choice (&)��� 42. �*4+��%4�)

94. 1) � #� 5) $�� )�

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

f�t :�ก�� :�ก����< ก���KกL�/Px:กK[ :\{[� Diphtheria (Pharyngeal diphtheria)

-��$��� #�$��ก�$&� -������ก����� -ก�#������ก -������� -�� dyspnea

-Mild pharyngeal injection -Uni/bilateral tonsillar grayish - pseudomembrane (Bleeding if scrape) and may extended wildly to uvula, pharynx, larynx, trachea, bronchus etc. -Cervical lymphadenopathy (Bullneck�!���@L���ก)

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

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

EBV infection (Infectious mononucleosis)

-$���) (>39°C) -Nausea, not vomiting

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

Supportive tx. (hydration, acetaminophen) -!����� ampicillin � #� amoxicillin ��ก4& rash

-��*� Hepatomegaly

GAS (Group A Streptococcal pharyngitis)

-Fever (>38°C) -Odynophagia -$����&�)ก� #�$� -$������ก� GI

-Tonsilar yellow blood-tinged exudates -Enlarged/tender anterior cervical lymph nodes

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

-Gold standard ��ก� Dx �#� throat swab C/S

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

-Inflamed buccal mucosa -Erythematous, nonpruritic, maculopapular rash -Koplik spot (white/bluish lesions with an erythematous halo) -Cervical adenitis

Supportive tx. Prevention -MMR

-$��ก��� ����M#+�� 4+���+����) $@����� ���%�� �]��#�/���� ����� confluent -$����� ~ 4d ���M#+��" � -AOM, croup, pneumonia: complications

2. 2) Pityriasis alba

Pityriasis alba � �@L� hypopigmented lesion ��ก(.� round or oval, macular of slightly elevated patched ����� fine adherent scale ��ก*���+ ������, ���%�, ���%����������� proximal portions ����� ��ก�$����� $��� ������%-��6 ��� �%���@L���ก�" ���กM4���� ������&����@L� mild form �� eczema $&� 6 ��� ��ก!)ก�����M4&����@L� vitiligo, tinea vesicolor � #� tinea corporis �ก(�6&���� lubricant ��ก�&��" ��%����������������&#��

Vitiligo ��$��� ������%-��+�����& �%���#+�����ก4&�ก immunologic abnormalities �"+� �� antibody %�� melanocytes ���$&��@L� 2 ��4&�#� generalized ��� localized ��ก*�ก������-18 @� ������ก�@L� generalized form �"+�*� symmetric pattern of white macules and patches with hyperpigmented margin *���� vitiligo ���������*��E1ก�� autoimmune disease

Pediatrics

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����6 � ��!" DM &��� �ก(�&��� topical steroid, topical tacrolimus �� ����+�@L���ก����� narrow-band UVB (UVB311)

Pityriasis vesicolor � #� tinea vesicolor �ก4&�ก chronic fungal infection �� stratum corneum �ก Malassezia furfur �"+�&����@L� normal flora @|�����+��#� ��ก� ��� �# �, ��#+���ก��ก, plasma cortisol �), immunosuppression, malnourishment *���������� -�� ����$����ก*��@L� hypopigmented macules, covered with a fine scale ��#+�% � KOH �*���ก(.���+� ��ก��� �Spaghetti and meatball� �ก(�6&� Selenium sulfide susp., imidazole or terbinafine cream � #� ketoconazole/itraconazole PO

Tinea facialis �ก4&�กก� %4&��# ���M4�����ก ���*�ก dermatophyte (Trichophyton, Microsporum, ���Epidermophyton) ��ก*��@L� dry, mildly erythematous, elevated scaly papule or plaque �"+��* ��ก% ก��$@ 6&��� clear central �����������@L� annular lesion ��#+�% �&��� KOH �*� filamentous fungus �ก(�6&� Ketoconazole/clotimazole topical � #� Terbanafine, griseofulvin PO ��ก .��� Tinea ��+M��������

Contact leukoderm � $����������#� chemical leukoderma � ��ก(.����#�� vitiligo ��ก*���+�#�ก��� ����� satellite lesion $@��� 4��.��+$��6&��� ���� �ก4&�ก melanocyte �&��������� 4��.�� �, ����%-�กก� ���M���� ������+������ melanocyte �ก(����#�� vitiligo ������ก���+��� ������ �,

3. 3) �4&!"3��� foreign body aspiration ��ก��+�-& 6&� FB ��)���+ rt. Main bronchus �"+�@L� common site for bronchial

foreign body aspiration ����%-��+�"ก!"3����� ��#+��ก��ก� �@L� acute onset �������ก� ��$��"+��&!" aspiration ���

����ก� ��&�� partial LRT obstruction (rhochus� �� 2 ��4& �#� sibilant rhonchus = wheezing ��� sonorous rhonchus

= rhonchus ������������+���ก����+�$@) @ �ก��ก��M)�@]���@L��&�ก���- 3 @� �"+*�3����� �������&�ก���- 1-3 @� ���ก�������

�� �&�ก���-�3�*&�%��&

��{��{t��� �V\]:e�[[���[�] (Stable patient) �#� Plain chest film �*#+�&)����� Resp. tract obstruction $��(segmental atelectasis) � #�&) opaque foreign body ����ก� ��� inspiratory and expiratory film ��*4� .����%�� ��ก plain CXR @ก%4 ��#+��ก�� partial obs. ��ก4&3��� ball-valve �" � (insp.=air ����@�&$&�, exsp.=air ��ก$��$&��ก4& air trapping) �*#+�&) hyperinflation ��@�&!)ก�-&%��, mediastinal shift ��� ipsilateral diaphragm ���#+������� �������&�ก��+���ก��ก � #�$�� ����#� ����� fluoroscope � #� bilateral decubitus chest film $&� ����ก�� �*4� .� bronchoscopy ���� lateral film $���4�������ก .���

4. 2) + 5) 3��� Hypoglycemia �� newborn �#��� plasma glucose lv. < 40 mg/dl (�������� 45 mg/dl � ��ก�@L� whole

blood glucose <50 mg/dl �* �� WBG. < PG. 10-15 mg/dl ��ก�����ก DTX ����� plasma glucose confirm &���) �ก4&�ก

sudden withdrawal of transplacental glucose supply 6&���ก�%+���-&�� 1-3 hr. of life ������ 12-24 hr. of life ��*�

hypoglycemia $&���ก�* �� gluconeogenesis ��� ketogenesis ��� 45$��&� @|������ 4��#� preterm, �� DM mother, ��

erythroblastosis fetalis, �� asphyxia ����� SGA

�KกL�f<� !��� ! D#�ก�&��� feeding !�� D#�ก�& (apnea, hypotonia, irritability, irreg. respiration, tremors, eye rolling, seizures, etc.) ��� IV 10%

glucose 2 ml/kg (rate1 ml/min) �ก������ก�� seizure ����� 4 ml/kg $&����� maintain &��� IV fluid with GPR 6-8 mg/kg/min (3.6-4.8 ml/kg/h of D10W) recheck �-ก 15-30 ���� 6&�@ ���*4+� rate/concentration $&�

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5. $�������!)ก M)�@]�� Turner syndrome (45, XO) ����ก(.��#� webbed neck, short stature, cubitus valgus, short neck, 1° amenorrhea ��� multiple congenital anomalies in phenotypic females 6&��������M4&@ก%4�� 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� �)�" ���¡� 16������4&�� $���������%-�� amenorrhea

6. 4)? $���������%�� Henoch-Schönlein Purpura �ก4&�ก small vessel vasculitis ����ก� �����ก� ��&�#� palpable purpuric rash

��ก*���+ waist ��� buttocks; arthritis ��ก�@L���+ knees ���ankles; abdominal pain �ก4&�ก vasculitis ��������#�&�� GI tract ��� glomerulonephritis �"+��&��� hematuria � #� proteinuria $&� ก� ��% ���+����@ ���4� prognosis ��+�����5��+�-&�#� U/A ��#+��ก��ก*������ renal involvement ��*�����������ก4& chronic hypertension � #� CRF %����$&�

7. Polyarteritis nodosa? ($��������ก, ��#+��ก6��1�������)�������ก) �@L� necrotizing vasculitis �� small ��� medium sized arteries ���-����+���+*��#� 9 @� $��� ������%-��6 � �%�

��ก*�����ก4&%����� URI, Group A Strep. Infection ��� chronic hepatitis B M)�@]������&�����ก� $��6&�$��� ������%-ก�����ก� �#+�, %���� ��*� mesenteric a. inflammation ������@�&��� ��� renovascular arteritis ����������&��6��4%�) *� purpura, edema and linear erythema wih palpable, painful nodule %�� arteries ��+��ก��� ��*���ก� �� ��� neuro, cardio ���&��� ก� �4�4������$&�6&� biopsy skin lesion �ก(�6&� oral/IV corticosteroid

8. 5) �� ก� ก�ก4&��+��%�����#� ���������� pathological jx. ��#+� jx. �ก4&�� 24 hr. � ก; jx ��+ unconj.bili. > 12.9 mg/dl �� term � #� > 15 mg/dl �� preterm; conj.billi. > 2 mg/dl; bili. lv �*4+� > 5 mg/dl/d ��� jx. ���ก��� 1 wk �� term ���ก��� 2 wk �� preterm &��� ���M)�@]�� ���� ��3��� pathological jx.

����%-��+�"ก!"��ก��+�-&�#� ABO incompatibility ��#+��ก �� &�����)�6��4% O, �� jx. �� 1st 24 hr @ �ก��ก����3��� anemia �"+�������"ก!" hemolytic anemia ��ก��+�-& ����%-�#+�, ��+���"ก!"$&��#� sepsis �"+��*� jx. �� 1st 24 hr $&�����ก�� ��3��� anemia $&�����ก�� �%���#+��ก sepsis ��+�� sign �*����� jx. �����&����� �*�$&�������ก "�4&!"����� (@ ���%4� ���&4� 4 hr ���� &� �&����@L� PROM ��+$�� prolong "$���*4+� risk %�� infection)

Jx. of prematurity ��ก�*��������+ 3-4 6&�%��%�&6 ��#+�, !"��4�4���3����� (!#�����@L� physiologic jx.) ก� �� G6PD def. ���ก���� mutation �� promoter region �� UDP-glucuronyl transferase-1 ��ก�@L�����%-��+������

�� ก� ก�ก4&��+��3��� G6PD def. �� jx. 6&�$���ก4& hemolysis &��� �"�4&!"������� ���� ���� Thalassemia $��*�����@L�����%-�� neonatal jaundice

9. $������ 10. 2) ��%-M�%����� 1 (!���@L� Diphtheria 6��1��������� patch $@��+�#+���ก�ก tonsil) ���� candidiasis �*���ก(.� white

plaque ����*��� immunocompromised host 11. 5) M)�@]���&�ก��+��&��� asthma exacerbation �� @ ���4����� -�� ��6 � 6&���ก�@L� severe exacerbation �*���ก(.��#�

dyspnea, retraction, accessory muscle use, tachypnea, mental status change, poor air entry. ก� �ก(��#� ��� O2 supplement ������ inhaled bronchodilator �#� SABAs (Short-acting inhaled β2 agonist- albuterol, salbutamol, levalbuterol) �-ก, 20 ���� �@L����� 1 ��+�6� ��� ��ก��ก� $��&��" ���ก� ��� 1st inhaled β-agonist ��*4� .���� inhaled ipratropium �"+��M)�@]�� ���� ����ก��� SABA ������ก� &��" ���� �%����� expiratory wheezing ��)� "�� �ก(��*4+�&��� inhaled ipratropium ���� systemic corticosteroids ��*4� .����$&�!�����@L�

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��ก��ก� �@L���ก ��*4� .���� intramuscular injection of epinephrine � #� β-agonist %���#+�, Mucolytics, chest physical therapy ��� spirometry $���� ����� asthma exacerbation �* ��������ก4& severe

bronchoconstriction $&� 12. 3) ก� ��� splenectomy ��������*4+��������+���ก� %4&��# ���ก�-�� parasite ���encapsulated bacteria ��ก�" � �* ����#+�%�&

�������� �$������ !ก���&������ ����+!)ก opsonized (ก ����ก� ��+ complement 6&���*�� C3b $@��ก����# �6 �) ��ก�กก �����#�& �����ก* ����ก� � �� Ab %�� T cell-independent antigen ���� polysaccharide ��+��)��� capsule �������� ��$&�

����� 4ก�����������������& Pneumococcal vaccine (S. pneumoniae), meningococcal vaccine (N. meningitides) ��� H. influenzae type B vaccine ก���ก� M��%�& 2 ���4%�1 �*#+��&ก� �ก4& postsplenectomy sepsis �%���@ ���'$�� meningococcal vaccine serotype B (serotype ��+*�������$��) $���������@ ���'$�� &��� ���$��"�����������& Pneumococcal vaccine ��� H. influenzae vaccine

������������ Oral penicillin V �*#+� prophylaxis %����ก 2 @�����ก��� splenectomy �%��� ����+���������+��) ��*4� .����%���!"���M)���5�

13. 1) &)%� �� #+� abdominal tumors ���&�ก (��� 14) 14. 1) Wilms tumor ���� !��&�����ก� abdominal mass, abdominal pain, hematuria ��� vomiting $&� ����� 15-25 ����

Hydronephrosis �"+�ก4&�ก obstructive uropathy ��ก��� recurrent UTI ���&��� �"+������ pyuria ���&���

TUMOR AGE CLINICAL SIGNS LABORATORY FINDINGS Wilms Preschool

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

Hematuria; bone scintigraphy (clear cell sarcoma)

Neuroblastoma

Preschool (median age 2 yr, almost < 5yr

GI/GU obstruction, raccoon eyes, myoclonus-opsoclonus, diarrhea, skin nodules (infants), mass may cross midline

Increased VMA;increased HVA;increased ferritin; stippled calcification in mass. Bone marrow positive

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

vaginal bleeding, paratesticular mass

Germ cell/teratoma

Preschool, teens

Girls:abdominal pain, vaginal bleeding Boys:testicular mass, new-onset �hydrocele� Sacrococcygeal mass/dimple

Increased hCG;Increased AFP

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

�ก Nelson Textbook of Pedriatric, 18th ed.

15. 1) M)�@]���&�ก��&��� anemia ��� jaundice % � lab *� NCNC RBC ��� reticulocyte count �) 3�����+�"ก!"��ก��+�-&�#� hemolytic anemia �"+���� !�������%-$&��@L� 2 ก�-�����ก, �#� Corpuscular hemolytic anemia (Membrane defects, enzyme defects, Thalassemia and hemoglobinopathies) ��� extracorpuscular hemolytic anemia (Immune hemolytic anemia, mechanical hemolytic anemia, direct toxic effect on RBC) �"+�� ������%-�� ��กก��6&���� Coomb�s test �"+����M� negative ��� positive %�����&��

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Inclusion test ��������!" supravital stain ����*� inclusion bodies �"+�@L� HbH ��+%ก%�ก�������&��#�&�& *��� HbH disease (--/-α) �"+�� % � Coomb�s test �������M� negative ก���"*4� .���� �����&���ก��ก� ��� hemoglobin typing, G6PD def. screening

���� bone marrow aspiration ��$���� ����� ���� ��#+��ก�� bone marrow response ��+&� (RC �)) "��$���4&!" bone marrow defect �%���ก investigation � ��-ก, ����������$������ !�E4��� anemia $&� ��*4� .���� bone marrow aspiration (��&) algorithm ������#��&�ก @� 5 � #+� anemia in children)

16. Adrenaline (Epinephrine) 3��� anaphylaxis �ก4&�กก� ���+ potent active mediator �ก mast cells ��� basophils �������������& ����������ก� %�� ���%��, �#� M4���� (urticaria, angioedema, flushing), ������� (bronchospasm, laryngeal edema), CVS (hypotension, arrhythmias, MI) ��� GI (nausea, colicky abdominal pain, vomiting, diarrhea) �@L� IgE mediated immune response �"+%���@L�ก� exposed %�� antigen � � ��+���@L�%��$@ 3����� �&�@L�3����-ก��4� %��$&� ��ก� �ก(������ �&��� ����+%������@L����&��� ก�#� IM epinephrine ���#+�, ��+���$&��ก� IM or IV H1 and H2 antihistamine antagonists, oxygen, IV fluids, inhaled β-agonists ��� corticosteroid ��*����M)�@]���� biphasic anaphylaxis $&�3���� 4 hr "�� observe �������� 4 hr ก��� D/C �ก ER

17. 2) �ก6��1*����M)�@]����3��� sepsis (�� SIRS + suspected/proven infection) ���ก���� DIC (low platelet with prolong PT and PTT with clinical bleeding) 6&�$������ก� shock ก� management ��+�����5��+�-&�� DIC �#� ก� �ก�����%- "�� ��� antibiotic �*#+��ก�$�����%-ก��� ��#+��ก�� ���� ��$������ก� septic shock ก� ��� fluid resuscitation "��$����� management ��+�����5��+�-&���.��� ก� ��� FFP, platelet conc. ��� PRC �� ��� *4� .������#+��� clinical bleeding 6&���� plt. conc. → FFP → PRC (%�� control bleeding ���$&�ก���!"�����#�&) �"+�� ���� �� clinical bleeding 4�%�ก� management ��+�����5��+�-&���.��� �#�ก� control DIC ��+�ก4&�ก sepsis ��กก���ก� control bleeding

SIRS � systemic inflammatory response syndrome �#�3�����+�� 2 �ก 4 ���%��$@�� • Core temp. >38.5 °C � #� < 36 °C (��&����� ���ก, ก ��*��@|�����, ���@�ก � #� central catheter) • Tachycardia (mean heart rate > 2SD above normal for age) � #����&�ก���-����ก��� 1 @� �� persistent

bradycardia ���ก��� ½ hr (mean heart rate<10th percentile for age) • RR > 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 �4&!"�����3��� coagulopathy 6&��ก@ ���%4*�����&�ก���������+���ก� ��& vit K �#��ก4&

��+���� ��$��$&� �� vit K 1 mg IM ������& ���$&�ก4�������"+ vit K %+�� "���ก4& vit K def. $&� ���&�ก� ก�ก4&�� 3 )@��� �#� • Classic hemorrhagic disease of the newborn �ก4&��#+� 1 -14 ���������& �ก4&�ก vit K ��+������������#+��ก vit K M��

� ก��$&�$������&� ��������� ก������&�&�กก4�$&�$��&� ��ก�ก�� ���$����ก� � �� vit K2 ��#+��ก���$���� sterile ����%-�����5�#� ก� ก4������ ��#+��ก vit K ������������� &��� ��&�ก� ก�ก4&�-ก��"%��$&� Vit K 1 mg IM

• Late VKDB (Vit K-def. bleeding) �ก4&��#+� 2-12 ��@&��1������& ������ก4&$&�!" 6 �&#��������& ����%-�#�ก4������ 6&���@|�����+��#� ก� &)&�"� vit K $��&� ������ cholestatic liver disease

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• �ก4&������.����& � #�����ก���&$����� ��#+��ก�� &������ ���� warfarin, phenobarbital, phenytoin �"+M��� ก$&���� �ก��ก� ������� vit K

��ก� �#+�, �� vit K def. �#� GI bleeding, mucosal and cutaneous bleeding, bleeding ��+ umbilical stump � #� post-circumcision site ���� Intracranial bleeding �� �*�$&��%�$����ก

19. 1) �ก6��1 M)�@]��������3��� nephrotic syndrome (ก� �4�4��� nephritic syndrome �#� �� heavy proteinuria: >3.5 g/d ��M)���5� � #� > 40 mg/m2/hr, �� hypoalbuminemia: <2.5g/dl, edema ��� hypercholesterolemia) ��#+��ก�� proteinuria, edema ��� hypercholesterolemia (&)$&��กก� ��+�� oval fat body �ก UA) ����%-�� edema �� nephrotic syndrome ��$�������� -@��+�����& �%���+�@L�$@$&���ก��+�-&�#� �� massive urine protein loss �������ก4& hypoalbuminemia ������ plasma oncotic pressure �&� ������ fluid �ก IV compartment $@�� interstitial space

20. 5) �ก6��1�$&����M)�@]��������3��� Reflex syncope � #� Neurocardiogenic syncope �"+�ก4&�กก� �*4+��� peripheral sympathetic activity ��� venous pooling �"+��������ก4& myocardial contraction of a relatively empty lt. ventricle �"+�ก �%-�� myocardial mechanoreceptor ��� vagal afferent nerve fiber ����������� sympathetic activity ก �%-�� parasympathetic activity ���

Syncope ��4&�� *�$&��ก4�� "+���� ��& ������ก4&� ���" �$&� ����%-ก �%-���#� �3�*�4+��&������+����& � #� ���, ���ก�¡��1, extreme fatigue, severe pain, hunger, prolonged standing, emotional or stressful situations

����%-��+�"ก!"3����� ��ก��+�-& �* �� M)�@]����@ ���%4��+����$&� ��&�%4$����� ��#+���&�%4�������� !�¤¥�$&��� $������ก� ��กก �%-ก % � ��ก��@ก%4 "��$�����@L�%����% ��*4+��%4� ก� % � EKG ������#+�% � ��ก�� � #�@ ���%4��������� arrhythmia �����&���ก��ก� %4& Holter monitor ���� blood sugar �� ���*4� .������ก���� hypoglycemia ����M)�@]��$��$&��%4ก����#����� ��@ ���%4�@L� DM �-�&���������4& � #� insulin �@L�%��

21. *4� .�%�������%��$@�� (&�&�@��ก�M�ก� @ ��-�M)����+����56 �%4&��# ����&�ก ���ก���.6 �; 6 ก.*. 2551�)

��ก Harrison�s Principle of Medicine, 17th edition.

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6&� LTBI = Latent tuberculosis infection �#� ก� %4&��# ���.6 ���+$������ก� , TT ���M���ก, M� CXR @ก%4 (�ก��������@L� TB ��ก���) ���M��*����# ��@L��� (�ก����M)�@]�� HIV �� ��) 6&� LTBI ��6�ก���-ก����@L� TB $&��)�-&�� 1-2 @����%4&��# � ����� host ��+���-����ก��� 5 @� (6&���*�������4+ < 2 @�), ��3)�4�-��ก���&�, ����# ���.6 ���ก ก� �ก(����$&�6&���� Isoniazid 6-9 �&#��

� �ก(� LTBI ���&�ก��+$����@ ���%4���M��6 �%����#+� 1. �&�ก@ก%4���� &� ���-����ก�������ก�� 5 @� , TT reaction > 15 mm. 6&������& BCG 2. Immunocompromised host

a. 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 �@��+���ก���@L���ก ����*4+��" � 6 mm.)

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ก� �4�4��� TB ����� criteria �#� ����ก� �����ก� ��&����.6 � ���� $�� # � � � �����ก�& ��$�� ���ก�����%��$@�� �������� 2 ���

1. ��@ ���%4���M����.6 ��กM)���5� 2. M��&�����M4�����@L���ก 3. ������M4&@ก%4�กก� % �3�* ���@�& 4. ก� % ��#+�, ������-����� ก� % ������ AFB ���M���ก

22. 2) �ก6��1 �4&!"���M)�@]����3��� ketoacidosis ��ก��+�-& ��#+��ก��#+�% � electrolyte *���� HCO3 %+�� @ �ก��ก��% �*� ketone ��@|����� ��������%-ก� �ก4& ketoacidosis �� �$������ !��ก$&��ก����)���+����� (�ก4&$&��� �ก starvation, alcohol ��� DM) �%�����%-��+�����@L�$@$&���+�-&�#� DKA ก� �ก(�����# �%����+�� ����#��@L����&��� ก�#�ก� ��� IV fluid ��#+��ก% � ��ก��*������ poor perfusion 6&�����+�6�� ก��� 10-20 ml/kg IV bolus 0.9% NaCl or LRS �*#+�����ก4& volume expansion ���� �&� �� �����*4� .����� ��$&� ก� ��� Insulin drip at 0.1U/kg/hr � #� 1 g/kg IV push for cerebral edema �� � �� 4+��������+�6���+ 2 �*#+��&ก� �ก4& hypokalemia ����ก� ��� Potassium �� �ก�������� � �������ก �����#�&ก��� "�*4� .���� ���%��@|�������ก&� ���� HCO3 �*4� .������#+� pH < 7.0

23. 2) �� delivery room ��ก*� term infant with meconium staining �� ��� hypopharyngeal suction �-ก ��ก������&$��� �4+��+�� *4� .�%�����#� �&�ก� ก�ก4&��3��� distress � #�$�� (���� hypoxia, bradycardia, fetal acidosis or apnea) ��ก���� *4� .���� endotracheal intubation ����� suction M��� endotracheal tube �*#+���� meconium ��ก�ก���&4����� �%���ก�@L� preterm infant < 34 wk �� �4&!"��� �&�ก��3��� IUGR � #�$��, � ��� +���@L� meconium 4� #�����@L� purulent fluid �ก infection � #� � ��� +���� bile stained �"+�ก4&�ก proximal intestinal obstruction

24. 3)? %����%-M���� 18 %��6��1��+�����M)�@]����3��� anemia 6&�$���� jaundice ����� bulging of AF ���4&!"3��� intracranial bleeding ��ก��+�-& ���� sepsis �� � ���� $���� SIRS "�4&!"����� ���� SDH M)�@]����������ก� ���� seizure �@L�%��

25. Rubella ��ก� �� Congenital infection ��+*�������&���

MANIFESTATION PATHOGEN IUGR CMV, Plasmodium, rubella, toxoplasmosis, Treponema pallidum, Trypanosoma cruzi, VZV Congenital Anatomic Defects Cataracts Rubella Heart defects Rubella (esp. PDA) Hydrocephalus HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis Intracranial calcification CMV, HIV, toxoplasmosis, T. cruzi Microcephaly CMV, HSV, rubella, toxoplasmosis Neonatal Organ Involvement Encephalitis CMV, enteroviruses, HSV, rubella, toxoplasmosis, T. cruzi, T. pallidum Hepatitis CMV, enteroviruses, HSV Hepatosplenomegaly CMV, enteroviruses, HIV, HSV, Plasmodium, rubella, T. cruzi, T. pallidum Hydrops Parvovirus, T. pallidum, toxoplasmosis Retinitis CMV, HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis, T. pallidum Late Sequelae Deafness CMV, rubella, toxoplasmosis Mental retardation CMV, HIV, HSV, rubella, toxoplasmosis, T. cruzi, VZV

&�&�@��ก Nelson Textbook of Pedriatric, 18th ed.

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26. 1) �ก��ก� ��M)�@]�� �4&!"3��� hypoxic spells (Paroxysmal hypercyanotic attacks) �ก TOF ��ก��+�-& �* ����ก� ������@L�%� �%����- 4 �&#�� �"+����$&�ก�� TOF �"+�������$���� cyanosis �����������& 6&���ก��� cyanosis 3����@�� ก������& ��#+��ก�� progressive pulmonary stenosis % � ��ก��$&� pansystolic murmur at lt. parasternal border* �"+���|$&��� TOF ��+ lt. lower parasternal border (%��@ก%4 TOF murmur ��ก��@L� SEM at lt. upper parasternal border)

Hypoxic spells ��ก*�����ก4&��������- 1-2 @� M)�@]����ก�����ก� ����� �� �������ก�" � �������&�%4$&� ��ก��ก4&���������� #�*"+%#+���� � #�����ก ��$��������ก ����%-�ก4&�กก� �&��� already compromised pulmonary blood flow (�ก infundibular spasm) �"+�������ก4& systemic hypoxia ��� metabolic acidosis %����

ก� �ก(��#� ��������� Knee-chest position �*#+��*4+� peripheral vascular resistance ��������#�&$@@�&$&���ก�" � ��� O2 ������ MO $���ก4� 0.2 mg/kg sc. �*#+����M)�@]����� ����������& infundibular spasm *4� .���� NaHCO3 �*#+��& metabolic acidosis ��*4� .�������*#+��*4+� systemic vascular resistance ���� phenylephrine, levophed � #� ketamine �@L�%�� ก� �ก(� �������� ��� β-blocker �*#+��-���ก� ���E�%-����ก�*#+� �ก(�3�����& �����*4� .���� palliative Sx. �#� modified Blalock-Taussig shunt ก���*4� .���� definitive Sx.

Breath-holding spells ��ก*���������- 6 �&#�� � 2 @� �ก4&��#+��&�ก ��$���ก����6ก E � #���� 6&��&�ก��ก� ��$�� -�� ������ ����� �� %��&���ก� ��-&�������������ก ��������$@$����������������3���� 30 �4���� �����ก�������������%��@ก%43����$��ก�+���� �"+������ก�&�ก��ก����-�3�*���� &� $����6 �@ ���%�� "$�������� cyanosis ก���������+� ��$������ ����

Asthmatic attack ��*����M)�@]�������$&� �%����&����� severity ��ก �%��� asthma �����|$&� wheezing ���$�������� cyanosis �����ก�����������&#�� ��!"$�������|$&� murmur ���� pulmonary embolism �� �M)�@]�������� U/D � #� condition ��+����������!" ��������|$&� adventitious sound ��+@�&��กก����|$&� murmur

*#�RR,SRTUVWX, )YZ[#$R�ก\�)]"(*#$ PSM @ Lt. parasternal border TD[ D cyanotic heart &!+ ,�+UTD['X,�_$�,�'Z# Tricuspid atresia `_[$ aกRb)*DU+c�UdY 1 ),Z#Y, truncus arteriosus `_[$ aกRb)*DU+� ! �ก efb aกRb]a+dR+�Uc�UdY#�U( 1 ),Z#Y \!+Y VSD Rbhi PSM TD["j�e]Y!$YDk�,�e"!Rb� !)*DU+ l Wm�)nfU

27. 5) Retropharyngeal abscess *�������������- 1-6 @� ��ก�ก4&%�����ก� %4&��# ����&4����������� (��M)���5���ก�ก4&�ก foreign body) ��ก�ก4&�ก mixed organism ����ก� irritable, fever, ��� ↓food intake ��#+��@L���ก�" ������ก� ����� �������ก� ��� %��������������� (muffled voice) ก�#������ก drooling ����� airway obstruction $&� �กก� ��� �� posterior pharyngeal wall ��ก������ �� lat. neck film �*#+�&)��������� retropharyngeal space (��+ �&��C2 > 7mm, or C6 > 14 mm) ก� �ก(����$&�6&���� IV antibiotic (3

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

Acute tracheitis (Bacterial tracheitis) ��ก�ก4&%����� Viral URI 6&���*�� laryngotracheitis (croup) ��ก�ก4&�ก��# � S. aureus !#�����@L� life-threatening condition �������ก4& airway obstruction $&� ���-����+���+*��#� 5-7 @� ��ก(.� typical �#� brassy cough, high fever ��� toxicity with respiratory distress �� purulent secretion 6&�M)�@]������ !��� ��$&� $���� drooling ���$���� dysphagia ก� �ก(�&��� epinephrine $��$&�M� �4�4����ก clinical ���ก� $��*���ก(.��� epiglottitis ก� �ก(����$&�6&���� IV antibiotic ��� *4� .���� O2 supplement ��� intubation

Acute epiglottitis *���ก�����- 2-7 @� ��ก�ก4&�ก��# � H. influenzae type B (Hib) �� ����+$��$&� �������� ������ ����+$&� ��������*�����ก4&�ก S. pyogenes, S. pneumoniae, S. aureus �����*�����ก4&�ก Hib $&� ��ก� ��+ typical ���&�ก

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�#� fever, irritability, sore throat, drooling, muffled voice, rapidly progressive stridor, respiratory distress 6&�M)�@]�����+���% 6���%��$@��&������� % � ��ก��*� erythematous and swollen epiglottis % ��� ���*� thumb sign ก� �ก(���+�����5�#� ก� secure airway 6&�$���� �����%!ก� �&, ��+�������&�ก%#+�ก���� #��@L����% ������ IV line placement � #�����&�ก��)��������� �ก���� secure airway $&� ����" �ก(�&��� IV antibiotic

Viral Croup (Laryngotracheobronchitis � #� Laryngotracheitis �� mild form croup) ��ก*����&�ก���- 1-3 @� ������ก�ก4&�กก� %4&��# � parainfluenza virus type 1-3 M)�@]����ก����ก� �����$�����&�����ก��� �#� ��� ���)ก ����� $� $��%+��, 1-3 ���ก��������ก� �� upper airway obstruction �"+���&��ก� �#� barking cough, hoarseness ��� inspiratory stridor % � ��ก��*� coryza, normal-mod. Inflamed pharynx ��� slightly ↑RR ��ก�@L���ก��*� dyspnea, marked ↑RR, cont. stridor, cyanosis, hypoxia, pallor � #��"�� �"+��ก����ก� ��ก�� *4� .� airway management

ก� �ก(���ก��)���+���� ��������&$�� �)&$�� �� ��ก��ก� �@L�$����ก �%���ก��ก� �@L���ก�� �����*��*��1 �����#+�!"6 *����� �� ������&$�� $��*�����ก��M)�@]�� ��*4� .� NPO ��ก����ก� ��ก ��� O2 ��� humidification ����ก� ��� Nubulized epinephrine �@L�ก� �ก(� moderate-severe croup (stridor at rest, possible need for intubation, respiratory distress and hypoxia) ��ก��E4F6&� constriction precapillary arterioles M��� β-adrenergic receptors ��������ก� resorption ���������� interstitial space ����&ก� ����� laryngeal mucosa ����ก� ��� oral corticosteroids ���� !�����&ก� ��)�6 *����� ��� ���������ก� ��)�6 *�����&��� $����ก� ��� antibiotics �� croup

Acute laryngitis �ก#���� ��&�ก4&�ก��# �$� �� (�ก���� diphtheria) ��ก� � 4+�� ก���#�� UTI �#� sore throat, cough ���������� ��ก� 6&���+�$@$�����ก �ก������������ก�����+�� ��@L���ก, % � ��ก����*� pharyngeal inflammation $&���� inflammation �� vocal cord ��� subglottic tissue ��*�$&���#+�&)M��� laryngoscope

28. 3) ����������+%�������กก��� 1 � � ��ก���$&� ������������� ���$���� ��� � %��$@%��ก����&��& ���� !���������� � %��$@$&� 6&�$��%��� 4+�%������ &��� � ���&�ก ���� $&� ��������� �!"���- 1 @� ��������+�� ���%��$@�#� DTP4, OPV4, JE %��%� �%��$@��

��ก�ก�< 2 m 4 m 6 m 9 m 12 m 18 m 2-2½yr 4-6 yr 12-16 yr BCG, HBV1

DTP1, OBV1, HBV2

DTP2, OPV2

DTP3, OBV3, HBV3

MMR1 DTP4, OPV4

JE3 DTP5, OPV5, MMR2

dT �-ก, 10 @�

JE1�JE2 ���ก�� 1-4 wk

29. 2) M)�@]�� preterm GA 32 wk ��&���� #+� dyspnea 3�����+�4&!"��ก��+�-&�#� RDS �"+����������%-��+�������ก4& ����%-��"+�ก4&�กก� ��& surfactant ��+@�&�กก� � ����+�&� ���ก� ���+��+�&� �"+ surfactant ������@ �ก���� dipalmitoyl phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins ��� cholesterol � ��%�����&���ก��ก$@���� 6&��!)ก� ���ก type II alveolar cell 6&�������+�� surfactant �#��& surface tension �� alveoli �������@}�ก��ก� collapse �� small air spaces �.��4 ��-&��ก� ������ก &��� ���M)�@]�� ���� �� ��+������&��ก��+�-&�#� dipalmitoyl phosphatidylcholine � #� lecithin

����������ก� �ก4& RDS �#� �� &��@L� DM, C/S delivery, precipitous delivery, asphyxia ���������)ก��ก���, �@L� ����@|����+�&�������+�$&��ก� � 31��+�� &��@L� PAH � #� PIH, �� &���� heroin, PROM ���ก� ��� steroid prophylaxis

30. 1) ��%-M�%����� 1 31. 1) ��%-M�%����� 21

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29

32. $������ ><� ���������)�� #+� diarrhea ��� Congenital Lactase deficiency �@L�3�����+*�$&���ก��ก ������ก��ก��@L� primary adult type hypolactasia � #�

secondary lactose intolerance ��กก����"+ก .������ก�ก4&%����� small bowel mucosal damage �����ก celiac disease � #� rotavirus infection ��ก�!����-� ��@L�� ��������ก, ���%" ��ก���@L�*�ก, ������ก����#+��-� � �-� ���ก�4+���� ���*� ��, )��� ��ก� ��ก�����M4����$&�

Antibiotic-related diarrhea �ก4&�กM���������� antibiotic �"+$&��ก� amoxicillin, ampicillin, amoxicillin-clavulanate, cefepime, clindamycin, doxycycline, erythromycin �"+���������������$&� ��ก�ก�� � ก� ��� antibiotic ���, 6&���*��ก�-����+�@L� broad spectrums ���������ก4&����$����&-��������� �������$�� ��������� C. difficile �ก4& overgrowth ����������ก� diarrhea $&� �� �����+$���� pseudomembrane �������+� ��ก��� psuedomembranous colitis

ETIOLOGY SIGNS AND SYMPTOMS DURATION OF ILLNESS

ASSOCIATED FOODS TREATMENT

Bacillus cereus (preformed enterotoxin)

Sudden onset of severe nausea and vomiting. Diarrhea may be present.

24 hr Improperly refrigerated cooked or fried rice, meats

Supportive care

Campylobacter jejuni Diarrhea, cramps, fever, and vomiting; diarrhea may be bloody.

2�10 days Raw and undercooked poultry, unpasturized milk, contaminated water

Supportive care. For severe cases, antibiotics such as erythromycin and quinolones may be indicated early in the diarrheal disease. Guillain-Barré syndrome can be a sequela.

Enterohemorrhagic E. coli (EHEC) including E. coli O157 : H7 and other Shiga toxin�producing E. coli (STEC)

Severe diarrhea that is often bloody, abdominal pain and vomiting. Usually, little or no fever is present. More common in children <4 yr old.

5�10 days Undercooked beef especially hamburger, unpasteurized milk and juice, raw fruits and vegetables (e.g., sprouts), salami (rarely), and contaminated water

Supportive care, monitor renal function, hemoglobin, and platelets closely. E. coli O157 : H7 infection is also associated with hemolytic uremic syndrome (HUS), which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS.

Enterotoxigenic E. coli (ETEC)

Watery diarrhea, abdominal cramps, some vomiting

3 to >7 days Water or food contaminated with human feces

Supportive care. Antibiotics are rarely needed except in severe cases. Recommended antibiotics include TMP-SMX and quinolones.

Salmonella spp. Diarrhea, fever, abdominal cramps, vomiting. S. typhi and S. paratyphi produce typhoid

4�7 days Contaminated eggs, poultry, unpasteurized milk or juice, cheese,

Supportive care. Other than for S. typhi and S. paratyphi, antibiotics are

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with insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is not usually severe.

contaminated raw fruits and vegetables (alfalfa sprouts, melons). S. typhi epidemics are often related to fecal contamination of water supplies or street-vended foods.

not indicated unless there is extra-intestinal spread, or the risk of extra-intestinal spread, of the infection. Consider ampicillin, gentamicin, TMP-SMX, or quinolones if indicated. A vaccine exists for S. typhi.

Shigella spp. Abdominal cramps, fever, and diarrhea. Stools may contain blood and mucus.

4�7 days Food or water contaminated with human fecal material. Usually person-to-person spread, fecal-oral transmission. Ready-to-eat foods touched by infected food workers, e.g., raw vegetables, salads, sandwiches.

Supportive care. TMP-SMX recommended in the U. S. if organism is susceptible; nalidixic acid or other quinolones may be indicated if organism is resistant, especially in developing countries.

Staphylococcus aureus (preformed enterotoxin)

Sudden onset of severe nausea and vomiting. Abdominal cramps. Diarrhea and fever may be present.

24�48 hrs Unrefrigerated or improperly refrigerated meats, potato and egg salads, cream pastries.

Supportive care.

Vibrio cholerae (toxin) Profuse watery diarrhea and vomiting, which can lead to severe dehydration and death within hours

3�7 days. Causes life-threatening dehydration.

Contaminated water, fish, shellfish, street-vended food typically from Latin America or Asia

Supportive care with aggressive oral and intravenous rehydration. In cases of confirmed cholera, tetracycline or doxycycline is recommended for adults, and TMP-SMX for children (<8 yr).

Vibrio vulnificus Vomiting, diarrhea, abdominal pain, bactermia, and wound infections. More common in the immunocompromised, or in patients with chronic liver disease (presenting with bullous skin lesions). Can be fatal in patients with liver disease and the immunocompromised.

2�8 days Undercooked or raw shellfish, especially oysters, other contaminated seafood, and open wounds exposed to seawater

Supportive care and antibiotics; tetracycline, doxycycline, and ceftazidime are recommended.

Yersinia enterocolytica and Y. pseudotuberculosis

Appendicitis-like symptoms (diarrhea and vomiting, fever, and abdominal pain) occur

1�3 wk, usually self-limiting

Undercooked pork, unpasteurized milk, tofu, contaminated

Supportive care. If septicemia or other invasive disease occurs,

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primarily in older children and young adults. May have a scarlitiniform rash or erythema nodosum with Y. pseudotuberculosis.

water. Infection has occurred in infants whose caregivers handled chitterlings.

antibiotic therapy with gentamicin or cefotaxime (doxycycline and ciprofloxacin also effective).

Rotavirus Vomiting, watery diarrhea, low-grade fever. Temporary lactose intolerance may occur. Infants and children, elderly, and immunocompromised are especially vulnerable.

4�8 days Fecally contaminated foods. Ready-to-eat foods touched by infected food workers (salads, fruits).

Supportive care. Severe diarrhea may require fluid and electrolyte replacement.

33. 4) �@L� croup - ��%-M�%����� 27 34. 1) �����&���ก����� 33. 35. 3) �ก6��1�4&!"3��� Neonatal mastitis ��ก*��� term 6&���*�������4%�1��+ 2 � 3 ������& ��ก� ��ก���&��� swelling,

induration ��� tenderness ���%���������+�@L� 6&���*� erythema � #� warmth ���&���$&� ���� ����*� purulent discharge �ก nipple ��ก�ก4&�ก��# � S. aureus, coliform bacteria (included anaerobes), � #� group B streptococcus ��ก �ก(�������-ก���$@��+ subcutaneous tissue ������������ก4& systemic infection $&�

ก�&&aกp� ��ก .���+����ก� $����ก (mild cellulitis, no fluctuation) �� C/S ������� nipple discharge ������� antibiotic %����# ���+*������@��+��%�� sensitivity ��+$&� �%���ก$��*���# � �� ����@L� cloxacillin + aminoglycoside � #���� cefotaxime ��ก .���+����ก� -�� �� ��� admit ��ก����$&� fluctuation �� drainage &������� ���& ���

36. 1) �ก6��1�������M)�@]����3��� antibiotic-associated diarrhea �"+�ก4&�ก overgrowth �� C. difficile �"+��ก*�����ก�+�����ก��ก� ��� ampicillin, clindamycin ��� cephalosporin ก� �ก(��#� ����� � �������-&�����%���&4� ��ก�@L�$@$&� �%�!���@L�$@$��$&�����*4+� metronidazole PO 7-10 ��� �������� � ���&���

37. 4) �ก6��1�$&�����&�ก������M4&@ก%4�� primary hemostasis �* ������ก� ��#�&��ก���%# � � 4��.M4���� �����#+��- (epistaxis, menorrhagia, petechiae, ecchymoses, occasional hematomas, and less commonly, hematuria and gastrointestinal bleeding) �"+��%ก%��ก������M4&@ก%4�� secondary hemostasis ������ hemophilia ��+��ก�����#�&��ก����# ���#+��"ก ������ก������# �� #���� (ecchymosis, extensive hematoma)

����M4&@ก%4�� primary hemostasis �� ����$&����ก, 2 �����#� �ก vessel (Henoch-Schönlein purpura, vit. C def., collagen disease, etc.) ����ก platelet �"+��M4&@ก%4��+@ 4��. (quantitative) � #� �-.3�* (qualitative) �"+ก� % � CBC �������ก���������M4&@ก%4��@ 4��.� #�$�� PBS �@L�ก� % ��*#+� confirm CBC ��� plt. %+�� 4� #�$�� �����������ก� @ ���4����& ���ก� %4&�����ก �&��#�& �"+��กM4&@ก%4����&!" function ��+M4&@ก%4$&� ���� bleeding time ������ก���������M4&@ก%4�� primary hemostasis ������ � ��ก$��$&�����ก4&�ก plt. � #� vessel

��M)�@]�� ���� 6��1$�����) .1�* ��$��� ������@L����&���������$ ก�����6 *����� �%�6 ���+�����@L�$@$&���ก��+�-&�#� ITP ��#+��กM)�@]�� ITP ��ก��@ ���%4�� viral infection �����ก��� 1-4 wk ก�����+��� clinical bleeding �" � (��#+�����ก4&�ก immune reaction) @ �ก��ก��ก� % � ��ก���"+$��*� hepatosplenomegaly, lymphadenopathy �"+��ก*���ก(.�������� �� �4&!" leukemia ��กก��� ITP ��#+��� CBC �� *���� series �#+�, @ก%4 ���*�� plt. ��+%+�� (�ก���� bleeding ��ก��

()(*+,-��ก Nelson Textbook of Pediatric, 18th ed.

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�� anemia ��+�E4���$&�) ��#+�&)�ก PBS %��$��*� blast cell ��� ��*� platelet �����&��5��" �$&� �ก bone marrow �*���� series �#+�, @ก%4 ��� megakaryocytes ���*4+�������" �

ก�&&aกp� ITP ���$&�6&�ก� ��� IVIG, Prednisolone, IV anti-D (���$&���*�� Rh +ve) � #�%�&�����"+������#+��@L� severe life-threatening acute ITP � #� Chronic ITP ��+ plt. < 30,000/mm3 ���ก��� 1 @���+$��%�����%��ก� �ก(� 6&�� �ก(���#+��� clinical bleeding � #� plt. < 20,000 /mm3 ����ก� ��� plt. �� �!#��@L� contraindication �� ITP �ก������� life-threatening bleeding

DHF ����&��� petechiae, ecchymosis $&��%� clinical course �� ���� $�����#�� DHF �"+�� �����+����#�&��ก��+M4������@L� fever phase �"+$����)��� ��� 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$�� ��&��� ����#�&%��%�� ��#�&ก���&�$�� % � ��ก����ก$��*�����M4&@ก%4�#+�, ��ก�ก ecchymosis % � CBC *� eosinophilia �ก �&��#�&�����@ก%4 �%�����%4&��� ��� prolonged bleeding time ��#+�����ก�+�����ก�� parasite �ก(�&���ก� ��� antiparasitic drug ��ก*�*��E4

38. 1)? �� ก��+��@|5��� #+� seizure %����ก3�����+$����� seizure ��กก������� jitteriness �"+�ก �%-ก �%���#+�����#����������-& � #�3��� non convulsive apnea �"+%��������%-���� sepsis �%���ก�@L���ก� ��ก�ก �ก �%-ก 4���� ���� �����4&!"����@L� seizure 4 ����%-�� seizure ��$&���������%-���� hypoxic-ischemic cerebral injury, Intracranial hemorrhage, neonatal cerebral infarction, metabolic abnormalities (Hypoglycemia, hypocalcemia, hypoMg, HypoNa, hyperNa), infection, inborn errors of metabolism ¨�¨ �4+��+�� ���%��$@�#� rule out hypoxia 6&�&)�ก clinical �����ก@ก%4�� % �&) glucose level �ก DTX ��ก��3��� hypoglycemia �� ��� plasma glucose lv. �*#+� confirm

(�� ���� $��������� C/S &��� indication ��$ ���� fetal distress? CPD? Fail V/E or F/E?; � �����ก� ก���&����$ �@L� macrosomia $�� � #��@L� IUGR $�� �"+��ก$&�@ ���%4 2 ������ ������ guide ����%-$&���ก�" �)

39. RDS �� newborn ����%-�� dyspnea ��+�����5$&��ก� a. RDS � #� Hyaline membrane disease �@L�����%-��+*�������+�-& ��ก*��� preterm ��#+��ก��& surfactant @ �ก��

ก�� chest wall compliance �� preterm ��$��&�*� �*�$&���ก�" ���#+� GA �&� �� ก������ก� ���������ก�������������& � #� 2-4 ��+�6�� ก�ก4& (��ก�ก4&��� 6 ��+�6�$������ก4&�ก RDS) ��ก� ��@L���ก�" ��� 48 ��+�6�� ก ��ก$&� ��ก� �ก(���+����������$����6 ��� ก���� ��ก� ��ก�&��" ���� 48 ��+�6� ��CXR �*� diffuse reticulogranular pattern with superimposed air bronchograms, hypoaeration with loss of lung volume ��ก�@L���ก������ lung density ���#�� heart density � ��ก��� white-out lung ��#+���� lung haziness �ก4&�ก diffuse atelectasis ��� pulmonary edema ก� ��� prenatal corticosteroid ���� &�ก������& �����&�-��%4ก� .1������� -�� ��6 �

b. Transient tachypnea of the newborn (TTNB) ��#+��������%-�ก4&�ก delay lung fluid clearance �กก� $����ก� ��� �&%��ก������& ��ก*��� term, near term ��+��� C/S � #��� precipitate labor, M>F ��ก� 6&���ก$�����ก ��ก&��" ��� 2-3 ��� CXR *� lung fluid ��ก �� ����*� pleural effusion � #���*� sun burst appearance �ก� ����+$��ก����� lymphatic vessel

c. Meconium aspiration syndrome (MAS) *�$&� 15% ���� ก��+�� meconium stained AF �@L�3�����+%��ก� ก� &)��������.����& 6&�ก� ��� ET intubation ��ก� dyspnea ��ก�ก4&3���� 6 ��+�6�������& ��ก!��� meconium �����ก��� 2-3 ��+�6�ก������& ��� meconium stained %��M4����, ���� �����&#� 3����� *�$&���ก�" ��� post-term, IUGR ��#+� CXR �*� diffuse coarse density, area of hyperinflation, air trapping ��*� pneumothorax ���$&�

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d. Persistent pulmonary hypertension (PPHN) ���� ก��+��@|5�� severe and prolonged hypoxia ��������ก4& met. acidosis ���������� pulmonary vessel constriction ����ก4& pulmonary hypertension ��������#�&����@�&$@��ก�@��+��ก����&� 6&���� hypoxia ������$��%�����%�� FiO2 ��+�*4+�

40. 5) ��M)�@]����+��&��� drowning management ��# �%���#� ABCDE ��M)�@]�� ���� *�������� respiratory insufficiency ���ก�� drowsiness "�� *4� .� intubation ������ positive end-expiratory pressure ��#+��ก�� pulmonary edema ($������������������� steroid � #� diuretics ��ก .��� )

41. ITP? %����� 37. 42. 2) Guillain-Barré syndrome (GBS) �@L� postinfectious demyelinating polyneuropathy ��ก� ��6 ���ก�%�����

nonspecific viral infection @ ���. 10 ��� � #����ก4&%�����ก� %4&��# ��� GI (esp. C. jejuni) � #��� respiratory tract (esp. M. pneumoniae) ��ก� typical ��6 ��� �#� ��ก� ����� � 4+��ก lower extremities �����@L����" �� #+��, ���ก� ����� �� trunk, upper limbs ��� bulbar m. �"+� ��ก pattern �� ��� Landry ascending paralysis ��ก� involve proximal & distal m. ����, ก�� onset ��6 ����@L���� � #���@&��1 ���� ����*���ก� �� ���&���

ก� % � lab ��+�����#� CSF study �*� protein �)ก���@ก%4��กก��� 2 ����, glucose lv. @ก%4 ���$���� cell ��กก���@ก%4 % � motor nerve conduction velocity *������&�������ก ���� sensory nerve velocity ���&�$&� EMG �*���ก(.� acute denervation of muscle ก� ��� muscle biopsy $�����@L����� ��ก� �4�4���

ก� �ก(���+��*���#���� IVIG, plasmapheresis � #� immunosuppressive drug (steroid ���$��$&�M�) �4+�����5�#� Supportive care 6&���*�� respiratory support etc. ��ก� ��ก���$&�3���� 2-3 wk ���ก������กก����#����ก#����& DTR �ก���������-&

Beriberi �#�6 ���+�ก4&�กก� ��& vitamin B1 �� 2 forms �#� wet beriberi (undernourished, pale, edematous, dyspnea, vomiting, tachycardia, waxy skin) ��� dry beriberi (fat, pale, flabby, unenergetic, dyspnea, tachycardia, hepatomegaly) ก� %���ก6 ��� ��ก������%-�ก cardiomegaly ���ก�� EKG ��+*� ↑QT interval, inverted T waves, low voltage �"+��ก$�� �ก(� ��ก4&�@L� high-output cardiac failure $&� ��ก�ก�� ���*� peripheral neuropathy ��*�������� ��� DTR↓

43. 2) %��%� ������� �4&!" organophosphate ��ก��+�-& (6��1�����@L� diaphoresis $����� dysphoresis)

Toxidrome Representative Agent(s)

Most Common Findings Additional Signs and Symptoms

Potential Interventions

Opioid Heroin

Morphine

CNS depression, miosis, respiratory depression

Hypothermia, bradycardia. Death may result from respiratory arrest, acute lung injury

Ventilation or naloxone

Sympathomimetic Cocaine

Amphetamine

Ephedrine

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

Seizures, rhabdomyolysis, myocardial infarction

Death may result from seizures, cardiac arrest, hyperthermia

Cooling, sedation with benzodiazepines, hydration

Cholinergic Organophosphate Salivation, lacrimation, Bradycardia, Airway protection and

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insecticides

Carbamate insecticides

diaphoresis, nausea, vomiting, urination, defecation, muscle fasciculations, weakness, bronchorrhea

miosis/mydriasis, seizures, respiratory failure, paralysis

Death may result from respiratory arrest from paralysis, bronchorrhea, or seizures

ventilation, atropine, pralidoxime (only in Organophosphate poisoing)

Anticholinergic Scopolamine

Atropine

Altered mental status, mydriasis, dry/flushed skin, urinary retention, decreased bowel sounds, hyperthermia, dry mucous membranes

Seizures, dysrhythmias, rhabdomyolysis

Death may result from hyperthermia and dysrhythmias

Physostigmine (if appropriate), sedation with benzodiazepines, cooling, supportive management

Salicylates Aspirin

Oil of wintergreen

Altered mental status, respiratory alkalosis, metabolic acidosis, tinnitus, hyperpnea, tachycardia, diaphoresis, nausea, vomiting

Low-grade fever, ketonuria

Death may result from acute lung injury

MDAC, alkalinization of the urine with potassium repletion, hemodialysis, hydration

&�&�@��ก Tintinalli's Emergency Medicine, 6th ed.

44. 3) Congenital diaphragmatic hernia �����ก� �� respiratory distress (tachypnea, grunting, accessory muscles usage, cyanosis) �"+���ก4&�����������& � #������$������ก� (honeymoon period) $&�!" 48 ��+�6� ���*� scaphoid abdomen, increased chest wall diameter ���|$&� bowel sound ��� decreased breath sounds bilaterally (or ipsilaterally) %������ PMI �����#+��$@��+�#+�, CXR with nasal gastric tube ����*#+� confirm dx. ก� �ก(����� �%�����$&�6&���� respiratory support (ET intubation, sedation, probably paralysis) $���� hyperventilation �� ��� PaCO2 45-60 mmHg (permissive hypercapnia), pH >7.3

Situs inversus �@L�3�����+ abdominal organs, lung lobation ��� atrium ��)��������ก�� ���� dextrocardia ����!" ������)���������� ��ก

TE fistula ��������"+��+�ก�+�����ก�� VACTERL syndrome M)�@]����ก����ก� frothing ��� bubbling ��+@�ก����)ก������& ���� $�, %������� ��� respiratory distress ก� feeding �ก �%-����ก� ������� ��#+��ก�ก4& regurgitation ������ก4& aspiration gastric content M���$@�� distal fistula �������ก4& pneumonitis

�� early-onset respiratory distress ��ก ��� NG � #� OG tube ���� pass $��$&���ก��&!" Esophageal atresia ��!"ก� ��+�� &���3��� polyhydramnios ��ก��� CXR with NG/OG tube �*� coiled feeding tube in esophageal pouch 6&����� air �� stomach � #�$��ก�$&� ��ก�����&!" TEF ก� �ก(���# �%�����$&�6&��&��� prone position �*#+�@}�ก�� gastric secretion ����$@�� distal fistula ����� ��� intermittent esophageal suction �*#+��&ก� aspiration �ก blind pouch ���� ET intubation with mechanical ventilation $���� ���

45. 4) Eisenmenger complex (syndrome) �#�ก� ��+M)�@]�� VSD �� partially � #� totally right to left shunt �ก pulmonary vascular disease ��+�ก4&�" � (���ก4&ก�� ADS, AVSD, PDA � #� left-to-right-shunt anomaly �#+�,) ��ก� ��+*��#� M)�@]�������ก� ����� ��ก� ���������+������&��" � �%�%������� right heart failure �#� edema, hepatomegaly % � ��ก������$&�

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RV impulse � �" � PSM ������* ������&���� RV ��� LV *�, ก�� ���� P2 �&���ก ��$&��4� Diastolic rumbling murmur ��+ left upper sterna border �ก PR $&� � ��ก3����� ��� �Graham Steel�s murmur�

Pulmonary embolism M)�@]�������� U/D �#+�, ��+�������4&!" ��#+��| lung ����$&� adventitious sound (localized crackles) ����� sign of dyspnea, diaphoresis, chest pain

AR ��|$&� diastolic rumbling murmur ��+ upper and mid left sternal border 6&��� radiation to the apex and the aortic area �%��$������ก� �����

Hypoxic spell: &)��� 26. 46. 2) �� ���� �4&!"����@L� nonbilious vomiting �"+�4&!" Hypertrophic pyloric stenosis ��ก��+�-& *���������- 2-8 ��@&��1 ����

����*�����@&��1� ก ����ก� progressive nonbilious emesis �"+��ก��@L���������ก4����� ������$&� RUQ mass ���*� peristalsis ��+ epigastrium *��������� ก�*'�����กก����54 M)�@]����ก��� chronic malnutrition ����� dehydration with hypochloremic alkalosis ����������ก� �"��$&�

Duodenal atresia �@L� complete obstruction of duodenal lumen ��ก�*� maternal polyhydramnios, bilious projectile emesis ��� abdominal distension 6 ��� ��ก�*��� 24-48 ��+�6�������& ��ก��� plain abdomen �*� double bubble sign

47. 4) �&�ก��&�����ก� �� hyperthyroid % � ��ก������$&�ก�� Grave�s disease % � lab *���ก(.���+����$&��#� TSH↓, FT4↑ ���% �*� �&�� antithyroglobulin �) ก� �ก(���+���������&�ก�#�ก� ����� (methimazole, PTU)

48. 2) Chickenpox or varicella �� incubation period 2-3 wk M)�@]������ !�* ���# �$&�%� �%� 48 ��+�6�ก����� vesicular rash �!" vesicles �� ��&������%ก���ก�&

49. 1) &)��� 22 50. 4) &)��� 12 51. 2) �ก6��1�4&!"3��� meningitis ��ก��+�-& ����%-6&���ก�ก4&�ก bacteria ��ก� �����ก� ��&��ก$����*����� ���

�" �ก�����-M)�@]�� ���� ก ����&�ก���ก ����&���$�� �"�� ��ก ���������ก ���#� $��&)&�� ������ % � ��ก����*� tense and bulging fontanel �������&�ก6%����&��� $�� @�&'� (� ������ �"�� � #��-&�4&����ก

% � ��ก����*� signs of meningeal irritation �#� stiff neck (>1 yr), Kernig�s sign � #� Brudzinski�s sign ��% �*� sign of IICP $&� ��ก .���+������ ��� LP �*#+�% � CSF �-ก ����ก$����������� ���� signs of IICP etc.

��# ���+*�������5���" �ก�����- �#� Neonatal: gram negative bacilli ��� GBS

1 � 2 m: gram negative bacilli (Salmonella, E. coli) � Ampi + genta, ampi + 3rd gen cephalosporin 2 � 12 m: H. influenzae, S. pneumoniae, Salmonella l Ampi + 3rd gen ceph 1 � 3 yr: H. influenzae, S. pneumoniae, N. meningitidis l Ampi + 3rd gen ceph 3 � 15 yr: S. pneumoniae, H. influenzae, N. meningitidis l PGS or 3rd gen ceph. + Vanco �����*� typical appearance ����# �����4& ����*� purpuric rash �"+���@L���ก(.���&��

meningococcal septicemia (embolic phenomenon) ����$ ก�%�� ก� % � CFS �����������5��ก� ��ก��4&����# � �*#+�������ก� %�&�4�����ก� �ก(� ���� post-exposure antibiotic ������������ rifampicin ก���-ก����+ contact �� N. meningitidis ������ก���&�ก%+��ก��� 4 @���+ contact ก�� H. influenzae

52. 4) &)��� 5

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36

53. 2) &)��� 4 54. ? 6��1$��� � ���$�������� subdural hematoma �* ���&�ก&)��&�ก4�$@��+��ก4&�ก subdural hematoma ��� �� leukocytosis

with neutrophilia &��� "���@L� infection induced DIC? 55. 4) �ก6��1 ��������@L� acute bacterial rhinosinusitis (6��1��+$&��� ���������@L� foreign body obstruction ��ก�@L����

�&��� �%� ���� �@L� 2 ���"�4&!"$&������) �"+$&��ก�ก� ��ก��������*�����$���� �"+�ก4&�ก��# ������� �� �������M)�@]����+����ก� ���)ก �����ก� ��������ก�@L�$�����&����3���� 5-7 ��� � #��@L�$�����&����ก4� 10 ��� �������ก� �����&������"+%��$@�� �#� � ���)ก ��&�)ก @�&/ก&���� 4��.������ � ���)ก$����� ก� $&�ก�4+��&� $�� $� @�&���#��@�&�|� �)�# � ���&�ก%������ก� ���ก��� 10 �������@L���ก�" �� #+��, � #� ����ก� �������� 14 ������$����������&��" �

ก� �ก(� 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

2nd line $&��ก� Amoxicillin/clavulanate, 2nd gen. cephalosporin, 3rd gen cephalosporin (cefpodoxime, cefdinir) %�����&�� ��ก�*� amoxicillin � #� cephalosporin *4� .���� clarithromycin, azithromycin �%���ก���$@��� � � ก����$��&��" ����@ "ก(��*��1��*����

ก� �ก(����� 1st line antibiotic ก��� ����&)��ก� �� 3-7 ������&��" �� #�$�� !��&��" ������%��$@��ก 7 ��� ��ก$��&��" ����*4� .� 2nd line � #���%��$@��M)����+����5

�� ���� ��$&����*�� 2 ����� �&) ����ก 1-5 �������� response � #�$�� ���@ ���4� compliance &��� (��ก clinical �#+�, @ก%4&�) ����ก� �� PNS film ������#+�M)�@]������ก� ����$&�ก��6 �$������ก��� �%�ก� % �3����6* �)ก$��*����������M4&@ก%4*���+��4�4���$&�����@L�6 �$������ก���

�%���ก6��1�@��+���@L� �� bacterial rhinosinusitis ����&������ �ก(� 3 �������$����� �� ��� speculum examination &)��ก� � �*#+�&)����� foreign body � #�$�� (���&�ก�����#�� #+� foreign body �-ก� � )

56. 3) :��k Motor Adaptive Language Social 2 m ����� ก���#�����, ����������� Social smiles 4 m ���������@�ก, ��+�� &)%���4+�� ���� �����&� ������&�������������� 6 m ��+��������, ��+$&� �@��+�������#�$&� ก������@�ก���� ���������� ��ก 12 m �ก�� �#� �&4� ��4������ก&����4 ��#� � ��ก*������ #�*)&���6&& 6�ก�#� (10 m.) %��#� 18 m �&4����� �4+�" ����$& ��������$&� 3 �� � *)&�@L���� 10 ��� ก4����� ��$&� 2 yr �&4��" ����$& �%����$&� ��ก����% *)&@ �6���� �, $&� ��ก����@|����� 3 yr �" ����$&��������,

��+�ก ��������� ��ก����ก�� )��*' ����#+� ��� ������%������# �$&� $��

@|����� &��+���%��ก���#� 4 yr �&4�����$&��������,

ก �6&&�����&��� ��ก���ก�ก��� ��ก��$&� 1 � #���กก���

���*�$&� � 4+�����ก�-��

5 yr �����)ก��� ��&�������+�� ��ก��$&� 4 �� �����������#�$&� 6 yr ����%��#����&���$&� ��&�����������# �M�� *)&���ก� ��$&���& )�������� ��กก�����ก���#�$&�

57. 3) ��%-M����#����� 36.

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37

58. 4) ��ก� ��M)�@]������$&�ก�� Cushing syndrome �"+��ก����ก� �#� moon facies, generalized/truncal obesity, purplish striae, %���%� �, delay pubertal development, ����� , @�&'� (�, �� �.1�@ @ ��, ����&��6��4%�), hyperglycemia, ก �&)ก* -� ��M)��54��*� 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. �*4+��)�" � (@ก%4 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%4 (glucocorticoid �� action ��ก� �& serum calcium �����ก� �ก(� hypercalcemia �%���#+��ก���� PTH response ������ �&�� serum calcium @ก%4) �������� � ��*� hypokalemia, hypochloremia ��� metabolic alkalosis $&�6&���*����+�ก4&�ก ectopic production of ACTH

59. 5) �ก6��1M)�@]����&��� pancytopenia �"+"�� investigation &��� bone marrow aspiration "���������+�-&�*#+�ก� �4�4��� ����ก� % � serum ferritin �����#+����� iron-def. anemia, bleeding time ��#+���������M4&@ก%4�� primary hemostasis, screening coagulogram �����#+���������M4&@ก%4�� secondary hemostasis, reticulocyte count ����*#+�&) erythropoietic activity

Pancytopenia ���&�ก�� �4&!"6 � aplastic anemia, bone marrow infiltration with leukemic cells, paroxysmal nocturnal hemoglobinuria, SLE, B12 or folate deficiency, etc.

60. 4)? M)�@]������ก� postprandial regurgitation �����"+�@L���ก� �� GERD �"+���������ก4& aspiration pneumonia $&� M)�@]�� GERD ������ก� �� respiratory symptoms $&��กก� ��+ refluxed gastric content ���M��ก�� respiratory tract 6&�% (�ก aspiration, laryngeal penetration � #� microaspiration) � #��กก� ��+ reflux ก �%-�� vagal /neural reflex �������ก4& airway resistance ��� airway reactivity �������ก4& wheezing $&� �"+ wheezing �� infant �� � 6&�������ก�%�����%�� bronchodilator &��� �ก� ��+ wheezing ���$@���$&� bronchodilator $��$&���ก����ก4&�ก����%-��$

61. Benign rolandic epilepsy (Benign focal epilepsy of childhood or benign epilepsy with centro-temporal spikes) �@L�6 �����ก��+*�$&�������+�-&���&�ก��ก�-�� idiopathic partial epilepsy M)�@]����ก��*� ��ก� @ก%4 *������- 3-13 @� ����$&����������� -�� ����@ ���%4��*�+��� *���ก� ��ก��������.����� 6&�� 4+��ก-&�&-&��"+��+@�ก � #����� $@�)���� ������%�� ��������ก�*�� 1-2 � � �����4% ��*��ก .16 �&� %�����%����ก����ก&���ก .���+���#�กก4���ก����ก

Epileptic syndromes �#+����&�ก��+�� )��#� Childhood absence seizure �@L� generalized epilepsy syndrome *����- 4-10 @� *� ��ก� �%4@|55�@ก%4 ��ก�@L������ �, 4-20 �4���� 6&�$������ก� �����ก��� M)�@]�������ก(.��� absence seizure ��*� automatism ���&���$&� �������ก$&� 10-200 � � %����� �� ������ GTC ���&���$&� *��ก .16 �&� %�����%�� Valproic acid ��� ethosuximide

West syndrome - �� triad �#��@L� infantile spasms (sudden extensor/flexor trunk movements) *� psychomotor retardation ��� EEG hyparrythmia (disorganized high-voltage slow waves, spikes and sharp waves) ��ก*����� ก 3 �&#���" �$@ ����ก4&ก��� 1 @� *��ก .16 �$��&� �� ���ก�+�����ก�� tuberous sclerosis

62. 3) �ก6��1��&����M4&@ก%4�� secondary hemostasis ��#+��ก bleeding time @ก%4 ��� % � PTT *���� prolong "�"ก!"����%-�ก intrinsic factor �"+����+�� $&��ก� factor VIII ��M)�@]�� ���� "������3��� factor VIII deficiency (hemophilia A)

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Secondary hemostasis �� 2 pathway ���ก�#� intrinsic pathway ��� extrinsic pathway �"+�%��� pathway ���ก� ก �%-�� coagulation factors ��� cascade �� intrinsic pathway @ �ก��&��� HMWK, PK, FXII, FXI, FIX ��� FVIII ������ extrinsic pathway @ �ก��&��� FVII �� �� pathways ���ก� ก �%-�� FX ���ก���ก4&�@L� common pathway �"+�� FX, FV, prothrombin (FII) ��� fibrinogen (FI) �����-&�$&� fibrin �"+�!)กก �%-��&��� FXIIIa �"+����������+ stabilized fibrin clot

ก� ��&ก� ������� coagulation factors �� pathway %��, ���$&�6&� aPTT ��&ก� ������� intrinsic ��� common pathway ���� PT ��&ก� ������� extrinsic ��� common pathway

Lupus coagulopathy ��������ก4& prolonged PTT $&� �%�M)�@]�������� clinical �#+�, ��+��&����@L� SLE ��!"3����� ��ก�$���������ก4& bleeding tendency ���� Factor VII def. (hemophilia B or Christmas factor def.) ����*� isolated prolonged PT ������ก present &��� thrombosis ��กก���

von Willebrand factor def. M)�@]����� prolonged PTT ���ก�� prolonged bleeding time ± decrease plt. count ��ก���&�����ก� �� superficial bleeding, epistaxis, postop bleeding, menorrhagia, etc. ���� Hereditary platelet dysfunction M)�@]����� prolonged bleeding time

63. Iron def. anemia? �&�ก��+��&��� anemia 6&��� hypochromic microcytic RBC ������%-��+�� �"ก!"%��%� �

f�t ZKกL�s�< [ PBS Lab �KกL�

Iron def. �&�ก ½ -3 @�, &#+��%������, hookworm, menses, chronic blood 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. - marked anisopoikilosis Target cells Teardrop cells Schistocytes

Abnormal Hb typing

- Transfusion - Iron chelation - Splenectomy

Lead poisoning ������/��������, battery, ��ก, @�&���, lead band ��+ long bone X-ray

- Basophilic striping RBC

Screening urine coproporphyrin, whole blood lead

- Supportive - Chelation &��� dimercaprol ��� EDTA

64. 5) Caput succedaneum �#� diffuse edematous swelling �� soft tissues �����'� (� ������ suture line $&� ��ก����3����$��ก�+��� ��ก*��� prolonged vaginal delivery (��*������ hematoma $&� ��ก�� minimal bleeding) �4&!"��กก��� subgaleal hemorrhage �* ����ก��@L�%��&'� (� Subgaleal hemorrhage (hematoma) �ก4&�ก��#�&��+�%��� � aponeurosis �"+��-����'� (�%��& ������#�&������ก$&�$@�!" subcutaneous tissue ���� ��ก��&��� firm fluctuant mass, increases in size after birth ���� !���� suture line $&� ���$&����� 2-3 ��@&��1 ��ก�ก�+�����ก�� Vacuum-assisted delivery

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Cephalhematoma �@L� subperiosteal hemorrhage �$������ suture line (��)��� surface �� one cranial bone ������ �) ��ก*���ก(.��@L� firm tense mass with palpable rim localize over 1 area of skull �������� 2 ��@&��1 � 3 �&#�� �� calcification $&�

Epidural hematoma ��� subdural hematoma �����$��$&�������'� (���� ��� signs of IICP

65. 3) �ก6��1 �4&!"���M)�@]����3��� acute renal failure �ก����%-��+�����@L� intrinsic renal cause 6&��� signs �� volume

overload ����� pulmonary edema "��*4� .���� furosemide �*#+����� ����ก 66. 1) �ก6��1 M)�@]����3��� acute bronchiolitis �"+��ก*����&�ก���-%+��ก��� 2 @� �ก4&�ก��# � respiratory syncytial virus �@L�

������ก ��ก� � 4+�&���� ���)ก$�� �� ��$��%+��, ������ก� $������ก���@ ���. 2-4 ��� �ก�� ��� 4+�����ก� ���������ก ���$���ก ��� � $&��4��������& ��ก� �#+�, ��+*�$&��#� ก ����ก ����� ก4���� #�� ��$&������ ������ % � ��ก��*� signs of dyspnea, �ก6@]�* �����������@�& ����@�&*� hyperresonance, diminished vesicular breath sound ����������ก����" � $&��4����� wheezing ��+�, $@ ��$&��4� fine crackles ���&���$&� CXR *� hyperinflation ��@�&�����

ก� �ก(� Supportive treatment �#� ��� O2 ��������# � (keep O2 sat. > 95%), NPO ��กM)�@]�������ก, salbutamol/terbutaline NB (controversy), epinephrine, ribavarin (*4� .��@L� ��, $@)

��M)�@]�� ���� �4+� ก��+�� ����#� ��� O2 supplement 67. 2) ����%-�� pneumonia �����@L�����%-�&���ก�� cellulitis �#��ก4&�ก S. aureus 6&� pneumonia �ก��# ��� ������ก�ก4&�ก

hematogenous spreading ��ก*�$���) �������#+�� ���� �� CXR ��*� localized or diffused bronchopneumonia � #� ���@L� lobar pneumonia ��ก .���+�@L���ก��*���ก(.� necrotizing pneumonitis, pneumatocole � #� pneumothorax $&� �"+M)�@]�������ก� ����������#+����ก ��*�%������� ���&���

68. 3) �@L� APDE (������� 37.)

��ก Nelson Textbook of Pediatric, 17th ed.

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y 1. 4) Surgery

��ek�Z : M)�@]�� ���� ��@|5���#� ก�:[�kV � V�� � ��{U��[�V �Pa[ � ��� � ก� �4�4���� ก��+�"ก!" �#� Inguinal hernia �"+@ ��3��� Inguinal hernia �� �����)� 2 ��4& �#� 1. Indirect inguinal hernia �#� hernia sac ��ก�ก internal ring �"+��)� lateral %�� deep epigastric artery 2. Direct inguinal hernia �#� hernia sac ��ก�ก opening �"+��)� medial %�� deep epigastric artery

�� ���� �@L� inguinal hernia ����� 5 @� ���#+� 5 ��+�6�ก���*�����ก� ก�:[V�� fe ก<�`cV �Zs<K[ก�:[กZKV

n� n<� ��ก(.�&�ก����� ��ก�����3��� Incarcerated hernia �#� 3�����+ content $������ !�#�ก����)�������$&� �"+����� #�$���� complication $&��ก� obstruction � #� strangulation ก�$&� &��� � ��#+���M)�@]����+��&��� incarceration hernia %��% ������+��ก����������$���� strangulation � Obstructive hernia �@L� irreducible hernia ��+�� content �@L� intestine �ก4& obstruction 6&�$����ก� ��&��#�& �����ก�

colicky pain ��� tenderness � 4��. hernia site ��ก� ����� strangulated hernia Treatment : ��� Immediate surgery �* ����� closed loop intestinal obstruction

� Strangulated hernia �@L�3�����+ content �� sac �� impaired blood supply ��ก����ก� @�&� 4��. hernia sac ���� progress �@L� colicky pain � 4��. ����&#� ��#+�$�� ������ % � ��ก��*� hernia sac ���� %" ก&��� ��� � ���& ��� $����ก� ����%���� sac ��*���$�� � #� sepsis $&� Treatment : ��� Immediate surgery ����ก��

&��� ��� ���� �����@L� obstructive hernia �"+ก� �ก(� �#� immediate surgery ��� 1) $��!)ก �* �� $���� ���������ก�@�&� �����ก� ��� , �&�������ก4& complication -�� ��� 2) $��!)ก �* �� ��#+��ก ���� ������ sign �� incarcerated hernia $���� &��ก���ก������������� )ก+,-./.01)23456-

+7849.7:;15;<+ก=. 3-4 @A4,B;: ��� 3) $��!)ก �* �� ���#���@L�ก� ��ก��� , ������ observe ��$�����������$ ��� ��� 5) $��!)ก �* ����ก�#����ก�������$@ �&������ complication %���� &�ก�������%��$@����

Surgery

Inguinal hernia � History : ��ก�����+������ � #��� �����$@!"!-��.0� ก���������ก��-����6@]$&� � Diagnosis : Get above sign negative �#� $������ !�����������ก���$&� ����!���@L� mass ��+ testis �� �

����$&��������ก��� (positive) �����#+�����4 ��� ����������#�!)� 4��. sac ��#+� , �����M��$�� � ��ก silk sign � Ddx : !������ !&��ก���ก����������$&� �������4 ��-& )��+ internal ring �������M)�@]��$�� #���� ��ก�@L� indirect

ก����$����ก�ก����@�����4 ���+ก& internal ring �%�!���@L� direct ���ก���6M����ก medial %���4 ���+ก& ��ก�4E��#���&�4 ���+��������!-��.0� ���@����4 ���)��� external ring ��#+�M)�@]��$� ��ก�@L� indirect �

���ก ���@����4 � �%���ก�@L� direct �ก �����+&���������4 � � Tx : M)�@]����+���-�3�*&� �� $&� ��ก� M��%�&�-ก �� �* ��$����#+�����&���ก��6�ก���ก4& strangulation $&����

����ก� )�����@L� Direct � #� Indirect $�����������5�* ��%��ก� �ก(����#��ก��

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41

2. 1) Plain abdomen ��ek�Z : M)�@]����+��&��� acute abdomen �� �� plain film �@L�ก� % �� ก�-& �*#+�&)����M4&@ก%4��������

�����4�4���3���%�� , &�%��$@�� Perforated hollow viscus, Intestinal obstruction, paralytic ileus, &)ก� ��ก������������������ก gas forming organism, &) abnormal calcification, abnormal intraabdominal mass, ascites, abdominal abscess, foreign body �� GI tract, bowel infarction Plain abdomen @ �ก��$@&��� 3 ��� $&��ก� 1. Plain abdomen �������� ��@ �6���1��ก� &)��ก(.������$�� &)����+��)���ก���$�� &)� ���������� &)��ก(.�M4&@ก%4��

������%�� , ����� ��� , 2. Plain abdomen ������#� ��@ �6���1��ก� &)��ก(.��� �&��� �������$�� �"+��������ก3��� gut obstruction � #�

paralytic ileus 3. Chest ������#� ��@ �6���1��ก� &) free air @ 4��.���� , ���& 1-2 ��. 0F,A: !!! Plain abdomen )&DUก#Dก#U!�$+!� Acute abdominal series Ya[Y)#$ ��� 2) ��� 5) $��!)ก �* ��&)���ก$@ $�����ก� �#������# �%�� ��� 3) $��!)ก �* �� ultrasound $�������ก��ก� &)*�ก�� ��ก���M)�@]���@L� GI perforation �&)$��$&� ��� 4) $��!)ก �* �� ������ abdomen series �@ �ก��&��� plain abdomen ����� supine & upright ������ � $���� CXR !���

���!)ก %����������� Acute abdominal series � #� Plain abdomen 3. 2) Fibroadenoma

��ek�Z : fibroadenoma ��ก*����% ���� 20-30 @� ����@L� most common benign solid tumor �� breast ��ก(.�ก��� ��ก�@L� rubbery firm, discrete mass H=,+03)I non tender, extremely mobile ��#+��ก ������� calcification ����$&�

ก���KกL� : Excisional biopsy $���� %�&��4&ก��� �* ���������� capsule ���#� ���ก����@L�$&���ก ��� 1) $��!)ก �* �� Fat necrosis ��ก*���� chest wall � #� breast trauma 6&����&�����ก(.���� �& ��� !�����

needle biopsy �*� lipid material ก� ��� mammogram �������ก(������ก�� carcinoma $&� �ก(�&������ก�@�& ��������# ��� ���*�&�

��� 3) $��!)ก �* �� Fibrocystic disease ��ก*�$&��������% �%� �%����- 30 @�$@���&@ ����&#�� ��ก� �&����+M)�@]����ก��*��*��1�#� cyclic mastalgia ������5��@�&ก�����@ ����&#�� % �*� painful and tender breast with nodularity �� ���� nipple discharge $&� �"+������� , � #��-�� , ก�$&� ��#+�ก&$@%������� lactiferous duct ���� ����ก�� �� ����&���� #+� palpable cyst

��� 4) $��!)ก �* �� M)�@]�����-���� �����ก(.�ก���n� ����$&�ก����� �

7AกJKF234.<1LF+MN.;F+0O: P89 � ��ก(.�ก��� � irregular, hard, ill-defined margin, not tender � Skin dimpling � Nipple retraction � Skin involvement ���� ulceration, skin edema(peau d�orange), satellite nodule � Axillary lymph node 6%

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��� 5) $��!)ก �* ����ก(.��� intraductal papilloma ��ก����ก� �� bloody nipple discharge � #� serous �@L� most common cause in bloody nipple discharge �"+�ก4&�ก focal area of necrosis ��� hemorrhage �� papilloma

4. 1) Villous adenoma ��ek�Z : Polyp ����!" ก�����# ���+�#+���ก����M4� mucosa �����$�� �"+������ ����(pedunculated) � #� ��ª��

ก��� (sessile) ก�$&� ������ , �@L� 2 ก�-�� $&��ก� 1. กZk ���{n� � �[\]::ก ���� Benign lymphoid polyp , inflammatory polyp, metaplastic polyp, Juvenile polyp, Peutz-

Jeghers polyp ������� $��ก����@L���� � 2. กZk ���{�Pa[�[\]::ก *�$&�%��&���$����5� ���*�������+�-&��+ rectum ��� sigmoid colon *�$&�%� �%����- 20 @��" �$@ �%�

����% ��)�-&����� 60 @� ����@L� 3 @ ��3� $&��ก� 2.1) Tubular adenoma (adenomatous polyp) *�������+�-& �@L�ก������กก�� ��� ���� � M4�� ��� 2.2) Villous adenoma *�$������ ���������5���)��� rectum ก�����ª��ก��� ����$&��-����-�� 2.3) Tubulo-villous adenoma ก�������ก(.��� �� ���ก��

�[�< f:ก����{�Pa[�s��c Tubular

Tubulo-villous Villous

5% 20% 40%

5. 1) Reduction ��ek�Z : ����� M)�@]�������@L� inguinal hernia �� 1 ��+�6� ���$���� clinical �� strangulation ���� !��� reduction $&�&���

�����-����� !�� reduction ���� � ก��� ��� herniorrhaphy �� 2-3 ���%���� $�������ก�&)��+��� 1. ��� 2) $��!)ก �* �� $�� )�����$@���$� ��#+��ก���� !��'�� clinical ��ก� �4�4���$&� ��� 3) $��!)ก �* ���ก6��1$���E4���� #+� strangulation ��� 4) $��!)ก �* ��$�����ก� �ก(� inguinal hernia ��� 5) $��!)ก �* �� �ก6��1$��$&���ก������� !&��ก���$&�� #�$�� !����ก&��ก���$��$&� (irreducible) %��$��@�������M)�@]��

ก������� �� �ก(� $����� reassure 6. 1) Orchitis

��ek�Z: �กM� U/S ����� ��ก����� increase vascular blood flow �@���� ����#�&���*4+��" � ��&��� torsion �� %�&�4 $@$&���� �* ��!���� torsion ��#�&�$������ก�" �$&���$ ก� ����&���#+��ก!-��.0��" ��� ����%�&*�ก torsion ��ก$@$&���ก�" �����ก�� �* ��!���@L� torsion ������ก�" �!���ก!-��.0��" � (�%�$�����@L�����$@) %������&)��#�&��+$����ก�" �%�� ��&���������ก� ��ก����ก4&�" � ��#�&"$������ก�" � %���� ���#� Orchitis ก�� Epididymitis ��&)6��1��+��ก�����@�& ��� �& �"+ก������@L�� 4��.��M4����!-��.0������+��ก� ��ก��� �������4&!" Orchitis ��ก�" � �* ��!���@L� Epididymitis ��������� �& ��*����+ Epididymis ������ � $��$&��@L��� testis

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7. 4) Internal drainage ��ek�Z : ����� ��$���@L� pseudocyst �"+�@L� complication �กก� �@L� Acute pancreatitis ���&�%

Pseudocyst �@L� collection �� fluid ��+��@ 4��. enzyme ��%�������) ��ก�ก4&%�����%��������ก��� pancreatic trauma ������5���ก��)�����# �%������ � #�� 4��.�ก������ 6&���*���� lesser sac �ก4&�กก� �� fluid �+���ก�ก%������ ���!)ก�-��$��&���������������� fluid ��+&)&�"�$����&ก�������#���)��@L� pseudocyst ����!���4E�ก� �ก(� pseudocyst �"+���4E�ก� �ก(���)� 2 �4E� �" ���)�ก��%�������� pseudocyst &��� !�� pseudocyst ��)���+ Body, Head, ��< stomach ��\:�Pa[ posterior wall U: stomach �����4E� internal drainage �#�����@L� cystogastrostomy � #� cystojejunostomy

!�� pseudocyst ��)���+ distal pancreas �����4E� Distal partial pancreatectomy ��ก$@��� �"+����� pseudocyst �����)���+ front of pancreas &��� �"%����� 4) Internal drainage ��+���

8. 2) Explore wound at OR ��ek�Z : ����� �� Neck injury ��+ Zone II �#���)�% Sternal notch �" �$@!"�������� mandible (��)������%4� �.ก��

E�) �4E�ก� �ก(���+���������+�-&����� �#� 2) Explore wound at OR

9. 4) Ultrasound ����ก�� ���&% �%4&%���-ก , 6 �&#�� ��ek�Z : �����ก� &)��M)�@]����+��&�����ก� ����$&�ก�����+�%���� ����กก� ��ก@ ���%4���% � ��ก���#�������

��ก�����+�%���� 4���&)��ก(.���ก������� ������������ Breast imaging evaluation &��� ultrasound [����z�:��k[�:�ก� � 35 P� ���� ��M)��54���- 35 @��" �$@ ������������ mammogram ���&���

Penetrating neck injury �����ก�@L� 3 zone $&��ก� 1. Zone I ��)� �����ก �&)ก$�@�� �� (clavicle) �� �� ���ก �&)ก���� cricoid ��������+�����5 $&��ก� ���&��#�&�&

vertebral ��� carotid @�& ���&�� ���&���� $������������� ���� �����#� �������@ ����%�� , 2. Zone II ��)� �����ก �&)ก���� cricoid ก�� angle of mandible ��������+�����5 $&��ก� ���&��#�&&�� jugular ���&

��#�&�& vertebral ��� carotid �� ���� common, internal ��� external ���&�����ก������� ���&���� $�������

3. Zone III ��)� ����� angle of mandible ��� base of skull �����������5 $&��ก� pharynx ���&��#�&&�� jugular ���&��#�&�& vertebral ��� internal carotid

ก���KกL� • !����3������� ������#�&������ก expanding or pulsatile hematoma ������ก��@�ก�M� � #����������� ��

$&� ��ก� M��%�& neck exploration ����� 6&�$��%����% �%�� • ก� ��&��� zone I ��� zone III ��ก%��ก� ก� % �*4�'(ก���ก� M��%�& �*#+�������&�ก���@��&3����ก�

����!"�����������5��+$&� ����&��� • ก� ��&��� zone II ��+������&��6��4%@ก%4 ���$����ก� ��&���%�������������5 ��ก� �ก(� 2 ����� �#�

1. M��%�&��� neck exploration �-ก ����+��&�M��"ก�ก4��� � platysma 2. *4� .� �ก(�%������������� 6&���'��ก� % �*4�'(�ก panendoscopy

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!��% �*�����@L� solid mass ���ก��ก� &)�� �ก(� �#� ���@L�%��$&��4 ���# ���% �&���ก���-�� '�1�*#+��4�4��� (tissue histologic diagnosis) �*#+�*4�)�1� #���ก6 ���� ����%���� ก� % � ��ก�������&������� !���ก$&�����@L���� ��*�� 60-85% ������ � ก� ��+���#�ก��� fine needle aspiration, core needle biopsy � #� open surgical biopsy �� ��" �ก����������������!����+ �� #+��#� � #� '����*��1��+���#�ก�4E�&�ก�����*#+����$&�ก� �4�4�����+!)ก%�������� ����$&����ก� �ก(���+!)ก%��% %��6 ���+�@L�%��$@ ��kP��� 3������ก��� clinical examination → imaging → FNA (Triple assessment) *����M��@L� benign �� ��& ������������� ! �ก(�&���ก� %4&%��$&� !��ก��������&���กก��� 2 cm. ก� % �%4&%��3���� 1 @�� ก ������% ��-ก 3-4 �&#�� �ก�� ��-ก 6 �&#�� !������������ก��ก� ����4�4ก��������� core biopsy � #� excision ���!��ก��������&��5�ก��� 2 cm. ��������� excision ��� 1) $��!)ก �%�!�� choice �� �!)ก %���@L���ก .���+M)�@]������ก���$&�n� �K<�`[ �*��1%�����M)�@]�����% ��%������ ��� 2) $��!)ก ���#���@L��������*��1% ��#������� , ��$�*��1%�������)����� �*#+�*4�)�1����@L�ก��� 4� #�$�� ��� 3) $��!)ก �* �� �@L�ก� ������� �%��%���� $�������# �%�� ��� 5) $��!)ก �* �� ���- 16 @� ��$���������� mammogram �� ���%� �%����- 35 �" �$@�* �� breast tissue � 4+��� fat ����

����&)$&�&�ก��� 10. 3) Acute pancreatitis

��ek�Z : @ ���%4��+ suggest acute pancreatitis $&��ก�

• ����ก� @�&��� ���$@��� • ����ก� ���&#+��- �%4&%��ก�� 5 ��� 6&���+�$@��ก�� 4+�%�� ����� 12 !" 48 ��+�6� ����ก�"���� • Tender at epigastrium , decreased bowel sound

��ก�ก�� ����$�� pleural effusion �� ����+ -�� ���ก� ���� fluid ����$@�� retroperitoneal space M)�@]���� dehydration, tachycardia, hypotension �� ����+*��E4�3�*�@L� hemorrhagic necrotizing pancreatitis ��*���������� ��� 4��.��&#� (Cullen�s sign) � #������ (Grey turner�s sign) �"+�@L���#�&��+������ก���ก retroperitoneum

11. 3) Hemorrhoidectomy ��ek�Z : M)�@]�� ���� �@L� hemorrhoid ���ก������@L� internal hemorrhoid &����� ��กก��6&���'��%��������

dentate line ก�����#� ��ก��# ���#+� hemorrhoid ��)�!�&�ก dentate line ���� #���-�&��� squamous epithelium �� ��ก��� external hemorrhoids

@ ��3��� internal hemorrhoids ���$&��@L� 4 @ ��3� �#� 1. Grade I � Bleeding without prolapsed 2. Grade II � Prolapsed with spontaneous reduction 3. Grade III � Prolapsed with manual reduction 4. Grade IV � Incarcerated, irreducible prolapsed �� ���� �� role ��ก� M��%�& ก�����#� Indications for surgery $&��ก� • Prolapsed thrombosed hemorrhoids • Incarcerated hemorrhoids • ����ก� @�& -�� ��ก ���� ��M)���+����ก� � # � ������ ������ ���� ���������ก� *4� .�M��%�& &���

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1. Fail conservative treatment ���� sclerotherapy, rubber band ligation 2. M)�@]����+�� hemorrhoids ���ก��6 ������ ���ก�#+���+%��ก� M��%�& 3. M)�@]����+�@L� hemorrhoids grade III-IV ��+����ก� ��ก 4. M)�@]����+%�&�4�����#�กก� M��%�& ����ก�*��1$&��������#�ก��ก� �ก(�

���� �@L� grade III �"+�@L�� # � ������ "*4� .�M��%�&��� hemorrhoidectomy ��� 1) $��!)ก �* �������ก�� grade I-II ��� 2) $��!)ก �* �������ก�� grade I-II ��� 4) $��!)ก �* ���@L��4E���+�-���ก $���@L���+�4�� ���M�ก� �ก(�$��%���ก�4E�ก��������� ��� 5) $��!)ก �* ���@L��4E�ก� �ก(���+� , $@ ���� ก� ����-� dietary ��� life style modification ���� �� ���� %��ก� �ก(���+

��*�������กก����� 12. 1) Ceftriaxone + Metronidazole

��ek�Z : • 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

��#+��กM)�@]����3��� peritonitis �"+ก������@L� secondary peritonitis �กก� �� bowel perforation �"+��# �������5��@L� Streptococcus, enterococci, gram negative ��� anaerobe &��� �"��#�ก�� Ceftriaxone �*#+���-�ก�-�� GNR ��� Metronidazole (anaerobes below diaphragm)

��� 2) 4 , ����� ก��ก#���!)ก�������� �* ������ clindamycin ��� Gentamicin �"+ก�����������-���# �$&���&�� Gram positive ��� negative �%�*���������� 3) �"+�@L�����+ cover ��# �$&���กก����� Gram positive ��� negative (�* ��%���� � ���$�� )���# � ก�%������@L� broad spectrum $@ก���) ��� anaerobe �� clindamycin ��ก����� infection above diaphragm "��#�ก��� 1)

13. 1) Pleural tapping ��ek�Z : M)�@]���@L� tension pneumothorax (classic triad �#� deviation �� trachea $@&���% ����, cyanosis,

distended neck vein, ����6@ ���+@�&����� �, $���� breath sound ����� �) �"+�@L� life-threatening conditions "�� role ��ก� ��� thoracentesis � #� pleural tapping 6&����������� 1��5� ��� 4��. 2nd ICS ��+ MCL ����ก�� �"��� tube thoracostomy

14. 2) Pericardiocentesis ��ek�Z : M)�@]���@L� cardiac tamponade (Beck�s triad @ �ก��&��� BP drop, CVP %+��, distant heart sound) ��ก

�ก4&�ก stab wound �� anterior chest wall ก� �ก(��-ก��4� ��� needle aspiration &)&��#�&�ก pericardial sac �� subxiphoid approach ����-� 45 �'�ก��������� ���% $@��+ inferior angle left scapula �%�!��M)�@]����ก� $��&� %��*4� .���� emergency thoracotomy �����

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15. 2) Acute subdural hemorrhage ��ek�Z : ���� �ก CT scan �@L� crescent shape "�"ก!" subdural hemorrhage/hematoma ����@L�

hyperdensity area �"+�����@L� acute phase (0-7 ���) ��ก�����@L� isodensity area �&�@L� subacute phase (3-14 ���) �����ก�����@L� hypodensity area �&�@L� chronic phase (>21 ���)

������5��ก4&�กก� ��ก��&�� bridging vein ����� cerebral cortex ��� venous sinus ��� 1) $��%�� �* �� acute epidural hemorrhage ��ก*�� 4��. temporal ��� temporoparietal 6&���ก�ก4&�กก�

��ก��&�����&��#�&�& middle meningeal CT scan *��@L� high density mass ��ก(.� )@����1 � #� biconvex shape *� ���ก�� skull fracture ����

��� 3) , 4) , 5) $��%�� �* ���� ���� CT �@L� isodensity lesion ��#+��ก�@L� subacute phase 16. 2) ET intubations

��ek�Z : M)�@]���&�@L� 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 ��ek�Z : M)�@]������ก� ������� �� ����� (paraplegia) ���ก����!" �&����&#� �#� T10 (�� level ��&��) "�"ก

!"��������@L� cord lesion ��+ �&�� Thoracic cord ��+��� 18. 4) 340 mL/hr ??

��ek�Z : Thermal injury suggested fluid resuscitation (modified Parkland formula)

��+�����5�#�%���4&��*�� second degree burn �" �$@�� first degree $����� �"+�� ���� $������ &� �����ก��ก����� � ��&�������ก%������ ��กM)�@]�����ก��ก 50 kg ��ก�� �*���� Total volume for 24 hours = 4 x 50 x 27 = 5400 cc �� 24 hr

���� "+��"+ �#� 2700 cc �� 8 ��+�6�� ก � #��4&�@L� 337 cc/hr @ ���. 340 cc/hr

Day 1 (Hour 0 = Time burn occurred) (hour 0-24) Lactated ringer�s solution Total volume for 24 hours = 4 cc/kg/% burn Give ½ of total volume in 1st 8 hr Give 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 ��ek�Z : Esophageal rupture �* ��*��������� �@-�� esophagus ���ก� tear *� tear ���������@|5��� #+� lung

(decreased breath sound Lt. lung) ������� tear ก������������$&� ����� tender with guarding ��� 1) $��!)ก �* �� hiatal hernia �� ��" �, �, $&� ��ก� �$���@L������ ��� 3) ก�� 5) $��!)ก �* �� ��ก� $�����#�� ��� 4) $��!)ก �* �� !���@L� Mallory-Weiss tear ��ก����������@L���#�& ���&��� ����@L���#�&��� ����ก���ก�$����@|5��

� #+� lung 20. 2) Carotid cavernous fistula

��ek�Z : Carotid cavernous fistula (C-C fistula) �@L�6 ���+�����%4&%��6&�% ����� internal carotid artery ก�� cavernous sinus ����%-���ก4&�กก� ��&�����+'� (� ������ internal carotid artery �%ก�����)� cavernous sinus 6&�% � #��� aneurysm ��)�ก�������%����ก��%ก

M)�@]����ก�� clinical features $&��ก� 1. Pulsating exophthalmos 2. Chemosis 3. Veleorbital pain 4. Dyslogia

5. %���� 6. Ophthalmoplegia 7. Bruit M)�@]���$&��4�����&����#�����@]�

��'� (�%��&���� ��'��ก� % ��4�4���6&� cerebral angiography ����ก� �ก(� $&��ก� Embolization, Embolization with internal

carotid artery ligation, Occlusion of C-C fistula, Direct repair, Cavernous sinus occlusion 21. 5 Rabies vaccine and Rabies Ig

��ek�Z : �����ก� �������������4��)6�6ก��)�4� กZk � �[�<U:ก���K��K� ก��P��VKe�

WHO category I WHO category II WHO category III

���M����%�16&�M4����@ก%4 $����ก� ��ก��& 1. ��%�1ก�&� #������@L� ��� �� 2. �@L��M�!��ก$������#�&��ก 3. !)ก����� #�� �������%�1!)ก�M�!��ก� #� ����&���� 1. ��%�1ก�& � #����� �@L��M��&��� � #������M�����#�&��ก 2. !)ก������&�M� � #�� �������%�1!)ก��#+���#�ก %� @�ก

$��%����&������ ��&������

��&������ ��� RIG

���� !)ก���ก�& �M����& 2 x 1 cm (��������#�&��ก&�����) �4&����@L� grade III ก� @P4��%4 �#�ก� ��&������ ��� RIG 22. 5) BPH

��ก� �� BPH ������ก�ก4&�กก� �-&ก� �ก� $����@|�������ก�กก ��*��@|����� $&��ก� • %�� �ก���� 4+�!���@|����� • @|�����$��*-�� ����@ก%4 • %������ ��� • )��"ก@|�������ก$����& • @|����������" ��� ก��������ก���#� • @|���������&$����ก��#+�!����� �����

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• ������#���������%�� ��$@@|����� e��`� �ก�� ก� % ��������������ก ��*��@|�������+6@]*�$&��� ����+�� urinary retention ���������$%$&�

!���� hydronephrosis ก� % �%����)ก���ก�*���������&6%�" �ก���@ก%4 M4�� ��� rubbery 23. 4) Tracheostomy

��ek�Z : ���� �� ������� loss of laryngeal prominence , subcutaneous emphysema ��+ cervical �������"ก!" laryngeal injury �"+�&�@L� indication ���� �� ก� ��� tracheostomy Indication of tracheostomy n<��ก

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

24. - ��ek�Z : M)�@]�� ���� �@L� acute cholangitis ก� �ก(���+$&� ���#� antibiotics 6&���+�$@������ก�@L� mild form ��������� 5-7 ��� ��ก hemoculture positive �%���������� 10-14 ��� �"+��6��1ก�$��$&���� ��������&��ก��ก �%���+�����5 �#� ������ก������$&� antibiotics ������ก� &��" � ��&���M)�@]�� respond %����@P4����� 6&�@ก%4���� 6 ��� ��กM)�@]��%�����%����3���� 24-48 ��+�6� �� �����ก� drain ���� ����+�-&�-ก �� �*#+���������� ! penetrate $@�� organ $&�&��" � &��� ��� ���� "�� ��� biliary drainage (decompression) +/- endoscopic spincterotomy 6&�������@L� semi-elective ($��%�� ��&��� �* ��%�����&�%����) ����� ����� ��$����6 *�����3���� 72 ��+�6� �4E�ก� ��������� ���� ERCP, PTBD � #� Surgical biliary drainage (�@�&�������)

����� #+� antibiotics �� � ��ก biliary drainage ����$���&� � ��������� 3 ���ก�*� $��%������� � 14 ���ก�$&� �"+�� ���� ก�����$&���@ ���. 3 ������� %������#+� drain + remove CBD stone ���� � "����*4� .� remove gallstone �*#+�@}�ก��ก� ก����@L�� �� 6&�����#�ก�@L�ก� M��%�&!-� ��&����ก��� (LC) %��$@ ��� 1) $��!)ก �* ��ก� �����$�����@L�%�����!" 14 ���ก�$&� M)�@]��%�����&���)����� ���� drain ก����� ��� 2) $��!)ก �* ��ก� ��� LC �@L��� �%���-&���� ����*#+� remove gallstone @}�ก��ก� �ก4&� �� ��� 3) $��!)ก �* �� 6��1��ก��&��M��%�&��$ ก�$�� )� 4 , ����� !���4&����@L�ก� M��%�&�*#+� ����� ��&� (surgical biliary

drainage) ก���!)ก%�� �%��� ���3���� 72 ��+�6� $�������&M)�@]���������ก 6 wk &��� ������ �� �%����� ��� Biliary drainage (decompression) ��\: ERCP +/- spincterotomy ��\: PTBD ��\:

Surgical biliary drainage :� �<:� ��[�{กcn<� |��[ 72 �K{�f�[f����V�Z 25. 2) Emergency surgery

��ek�Z : �&�ก���� ��&��� acute abdomen �� tender at RLQ ��� rebound tenderness �����@L� acute appendicitis �* ��ก� �4�4���$��%4+��ก�������@ ���%4���ก� % � ��ก������������&�@L����ก ก� % ������@P4��%4ก� �*������������-������� �

ก� �ก(��#�ก� M��%�&���$��%4+��ก �"+��ก����� ����+�-&��#+��4�4���$&� ���M)�@]��%��* ������� ��ก� M��%�& ก .�ก� �4�4���$����&�� �%���ก� �����ก� ��&���� ����@L�$��%4+��ก��� ��ก���ก� �ก(�6&�ก� M��%�&����ก��

��"+ M)�@]���&�ก��+�@L� acute appendicitis ��6�ก���ก4& generalized peritonitis $&���กก���M)���5� ����� morbidity ��กก�����M)���5� ��#+��ก �&�ก$������ !���@ ���%4��+!)ก%��$&� ��ก$�� ����#���ก� % � delay �ก�� �*��1���*��������&�ก ��ก�� pathology �ก�+��ก�� GI tract ���ก���� ������ diagnosis �����ก

26. 1) Diaphragmatic hernia ��ek�Z : Diaphragmatic hernia $����#+����ก����� �� 2 @ ��3� �#� 1. Congenital ก�����������*4ก� ��%� �%�ก����4&

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49

2. Acquired $����#+����ก��ก4&���ก� ��&�����ก����� �"+���ก4&�กก� !)ก��� #��������!)กก ���ก����� �ก�������ก

��ก(.���ก� $&��ก� progressive dyspnea, cyanosis ��� apparent dextrocardia �"+�ก4&�ก����!)กก ��*������ ������$��&��$@������ ����+�@L���ก���������������� ��ก6@]*�ก���@ก%4 ก� �|� ��ก�$&��4�����������&������ !���3�* ���� ��ก�*���:�ก��U:U<Zl�n��|��[���:ก �"+%4&%��ก������ก�'�����$��3���������� ������� mediastinum �Kก`sb�ก<K[nP<��[e�U��� 6&���+�$@$�����@L�%����� barium meal �"+�������� aspiration $&�

27. 2) Local flap ��ek�Z : ��ก ����������� Graft ก�� Flap ก��� • Graft �#� ก� ���M4������+�������� epidermis ��� dermis ������� #��� ��&%�&��&�กก� ������� ���������#�&

(donor) ���������@�)ก��+�M���ก�����"+ (Recipient site) • Flap �#� ��# ���#+���+���#+������$@@�&� 4��.�M� 6&�������#�&����� ���)�%��&���� �"+%���ก skin graft ��+%�&��&����

��#�&��+����� �6&��4 ���4 &��� � flap "���ก��� 6&����� skin ��� subcutaneous tissue ����������#�&��+�@L�����6&& , ก������# � ¨�¨ �����&���ก�$&�

P�sf��[�U:ก���� Graft �Zs flap Skin graft Skin flap

1. Facial wounds 2. Flexor surfaces ���� �� ���'�ก ����#� 3. �ก(���&�M�$�$���� �� �����ก 4. @�&�M���+�ก4&�กก� ��� skin flap � #� FTSG 5. �&��� mucosa ���� ���@�ก pharynx vagina 6. @�& dura, pericardium, pleura � #� peritoneum 7. ��� overgrafting � 4��. unstable scars, tattoos � #�

non-hairy pigmented nevi

1. poor vascular � #� avascular bed 2. structure �����5 ���� nerve artery joint 3. %��ก� ������� ���� ��&�M���+�@L���-� 4. bony prominence �*#+�����@L� padding 6&���*��

pressure sore 5. ��&�M���+�4&���%����ก� M��%�&��ก� � 6. �*#+�����ก4& sensation 7. ��&�M���+��& tissue �������� %�� reconstruction

�[�<U: Graft �Zs Flap Skin graft Skin flap

1. Split-thickness skin graft (STSG) ����!" skin graft ��+@ �ก��&��� epidermis

����������� dermis �"+��ก�-���� �����������ก$&��@L� • 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 �������ก������ก���� recipient �� ������ color texture hair ��� thickness , �� �%��ก� M��%�&����ก��� distant flap, ���� !ก�������$&�� ��ก��� distant flap 2. Distant skin flap ���������ก�@L�

�#� skin flap ��+��)�$ก���ก$@�ก defect

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50

&��� ��� ���� "��#�ก����@L� flap �* ���M��@L� bedsore �"ก!"� 4��. bony prominence �����#�ก�@L���4& local skin flap ��#+��ก�����&���กก��� distant skin flap

28. 2) U/S ��ek�Z : Approach to jaundice patient �� ���� �กM� liver function test *��@L���4& Direct hyperbilirubinemia

(�* ����� DB ��กก��� 30% �� TB) @ �ก��ก������� ALP �)�" ���&�� "�"ก!"�������� Post-hepatic cause $&��ก� 3��� cholestatic jaundice ����%-�������ก��ก� �-&%�������&4�� ��&� �"+����@L� 1. Benign causes ���� �4+������� ��&�, ���� ��&�%��%�� �@L�%�� 2. Malignant causes ���� ��� ����� ��&� �@L�%�� &��� � 6��1!�� investigation ��# �%����+�� �� �#���$ ก�%��%�� ultrasound $��� �* ������ !���&)ก� �-&%�������&4�� ��&�$&�

��� 1) $��!)ก �* ��$�����ก� investigation ��# �%�� ��� 3) $��!)ก �* ��$��������ก� �4�4����4+��+� ����� ��� 4) $��!)ก 4 , ก����$&� �%�@|-����4���������� �* �� invasive �����ก������ก� ����� ��&���กก��� ��� 5) $��!)ก �* ���@L��� �%����+%���������ก U/S ���� ����*#+��#����ก� �4�4������ �ก(�$@&���$&� 29. 3) C-spine protection

��ek�Z : $�� )����6��1����%�ก��$ � #��@��� �%�@ก%4���� &)��$�� Trauma ก�%�� A B C D ก������@]�� ���� A ��+ก�� C-spine protection $ �����$��$&���

30. 5) Surgery ��ek�Z : 4 , �4&���M)�@]�������@L� inguinal hernia �� ��&)��� 1. ก�$&� � ���� ��*��*��1&���� #+�P�<��: 1

�K{�f� ��:K��sfeU�][ �4&��������@L� strangulated hernia ������� �* ����#+����$��!)ก������&��!- �&��ก4&ก� %��%�� �����������ก� @�&� 4��. hernia sac ���� progress �@L� colicky pain � 4��. ����&#� ��#+�$�� ������ % � ��ก��*���� hernia sac ���� %" ก&��� ��� � ���& ��� $����ก� ����%���� sac �"+ก�% ก��M)�@]����+�����@�&��� �������.0�6%�" � (���ก���$�����)

&��� �ก� @P4��%4��+��������� ���� �#� Surgery ��+��� ��� 1) $��!)ก �* ��$���� reduction �� strangulated hernia ��� 2) $��!)ก �%� 4 , �������4&!"���������*��E4�3�*�����ก�$&� ��#+��กM)�@]����*��*��1&�����ก� acute abdomen

�%���ก����6��1&� , ���#��6��1���ก�#+�����������ก� @�&���� � �� �����@L�M����กก�����+��.0��&4���M)�@]�� @ �ก��ก��ก� ����.0�6%�" � "����������-�����%-�� acute abdomen � � �� ���ก hernia

��� 3) $��!)ก �* ��$��$&�����*��E4�3�*�� solid organ ����� ��� 4) $��!)ก �* �� $���� role �� antibiotic ��M)�@]�� ����

31. Tension pneumothorax ��ek�Z : ���#����� 13 32. 5) Ultrasound !��@ก%4�����&% ��-ก 1 @� ��ek�Z : �����ก������� 9. �#� ���� ���������@L� fibrocystic disease ��+��� 33. 1) Rabies vaccine

��ek�Z : �&�ก$&� ��������� �$@%�� 5 @� ��������+� ���� ก��#� tetanus toxoid �"+$&� �� ��ก�� DPT ��������- 2 �&#�� 4 �&#�� 6 �&#�� 18 �&#�� 4-6 @� �� 5 ����

���� !)ก����������& 2 cm �����@L� tetanus-prone wound $&� ��#+�*4� .�%��%� � Tetanus prophylaxis

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History of TT (dose) Non-tetanus prone wound Tetanus prone wound

Td TIG Td TIG Unknown or < 3 Yes No Yes Yes

3 or more No No No no ��#+��ก���$&� �� TT ����กก��� 3 ���� ���$&� ��$���ก4� 5 @� "$���� role ��ก� $&� Td � #� TIG ��ก ����ก� ��������� rabies �� � ��#+�&)%����� 21. ���� *���������&�@L��M�%�� WHO grade II �"+�� role ��ก�

$&� �� vaccine rabies &��� �* ��������%���M�ก� � ���� 4�3)�4�-��ก��6 ���ก �� ���E� .�-� $����ก� ��� rabies vaccine

34. 1) Off Foley�s catheter ��ek�Z : ����� �� !�������&��4&���M)�@]��������3��� autonomic dysreflexia

�� ���� �4&�������������%-���ก Bladder �"+ก��#� Blocked catheter ��ก��+�-& &��� �ก� �ก(� �#� % �&)!-

collecting bag, irrigate the catheter, remove any kinks or change the catheter �s�K !!! �%��ก@ ���ก� .1��M)������ $���� irrigate catheter �&����M)�@]���� shock $&� "����������@��+��

Foley�s catheter $@���&�ก���

Autonomic dysreflexia • �@L� complication ��"+��3��� spinal cord injury ��+ �&�����#� T6 �" �$@ �������)5����ก� ����-�����&��6��4%

���ก� �����������

• Sign & symptoms o Hypertension

(blood pressure greater than 200/100) o Pounding headache o Flushed (reddened) face o Red blotches on the skin above level of

spinal injury o Sweating above level of spinal injury

o Nasal stuffiness o Nausea (secondary to vagal parasympathetic

stimulation) o Bradycardia - slow pulse <60 beats per minute o Piloerection ("goose bumps") below level of

spinal injury o Cold, clammy skin below level of spinal injury

• ����%-��+�����5��6 � o Bladder (most common) - from overstretch or irritation of bladder wall ���� Urinary tract infection (UTI),

Urinary retention, Blocked catheter, Overfilled collection bag, Non-compliance with intermittent catheterization program

o Bowel � overdistention, constipation o Skin-related � Direct irritant below the injury o Sexual activity � Overstimulation during sexual activity o Other causes � Heterotopic ossification

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1. 2) ��%-M� : �ก6��1M)��54���� �� risk factor ��ก� % ���&ก � DM a. ���-��กก��� 30 @� *** b. ��@ ���%4�4&� (first degree relationship) @]���@L� DM *** c. @ ���%4 GDM ��� 31ก��� d. ����&��6��4%�) e. ��� ��%����@|����� f. @ ���%4ก� ���&� 31ก����� ก%��6% *4ก� 6&�ก����4& � #�%�����&6&�$��� ������%-

���ก�� GA 24 wk *�&� &��� �ก� % ���&ก ���+���������+�-&�����@L� 50g GCT ���� )��*4+��%4� :

• Screening DM �������� GA 24-28 wk • 100g OGTT �@L�ก� % ��#���� (Confirmatory test) �% �%����ก .���+ 50g GCT ���M���ก • Urine sugar �� � �@L� routine lab ��+������� �����$�����������+�%��% ���)����� ������ ANC (���#���@L� risk factor

��กก������!�� positive �������% � screening test %��) • FBS �� ������ก� % ���&ก �����@ก%4��+�$@ $��������������#+��ก��������3��� insulin resistance �ก HPL

(Human placental lactogen) ��+� ���ก placenta ��)����� • Random glucose $�������������5�&, (-*-)

2. 5) ��%-M� : �ก6��1% �*������ fluid ��+ posterior fornix ��� fern test : positive ��&�����3��� preterm premature rupture of membranes 4 �4+��+��������#� ก� PV �*#+�&) progression ����%����#+� ��#+��กก� PV ������ ���������+��� ���&4�����������+�%��ก� �ก4& Chorioamnionitis

���� )��*4+��%4� : • ����ก� observe sign of chorioamnionitis �@L��4+��+%�������)����� ���� ��$��, ��* � ��, � ��� +���-����ก�4+������, ก&���

�&�)ก, �# fetal tachycardia �%�$�����ก� PV &�ก���� • IV prophylactic ATB ���� !�&6�ก���ก4& chorioamnionitis, ก� �� sepsis ���� ก� ก���&� ��������#&���-� 31$&�

����" � 6&� prolong PROM (>18 hrs) ����������@L� ampicillin 2 g iv q 6 hr �ก�������& • Dexamethasone ����� �ก� *� ��ก� ��@�&�� ก �&ก� �ก4& RDS $&�M�&������ GA 30-32 wk • Tocolytic drug $�������������ก .� preterm PROM �ก�����*#+��# �������ก� ��� steroid � �@�&�� ก �%�%��$����ก� %4&

��# ���)� 3. 4) ��%-M� : ��#+��ก���������������&�ก�@L���ก(.�@����4 �ก������&�ก (Compound presentation) � ����� ! observe %��$@

ก���$&��"+��#+�����&�ก�� station %+�������ก�� ���6�ก����+���������������&�ก ���� �ก����@L������������&���$&� ���� )��*4+��%4� :

• �%�!���� arrest of labor � #� fetal distress ������ก� M�����& • �� compound presentation $��$&������������� Amniotomy ������ Syntocinon • U/S $������%������* ��$��$&��@��+��ก� management ��M)�@]�� ���� • C/S ����� ��������$�??? $�������ก�+��"%�&�4 ก���

Ob & Gyn

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4. 3) 6��1����� �*#+��, ����������, �����* ����� CVT ��� OB ��+%4�������������� ��%-M� : M)�@]��%� � 31��+�@L�6 ����� ��+��$��������-% ��� � #����-% ���&��� !���&��)������� -�� Class I ��� II %�� NYHA ���$��������������������ก�����-5�%���%� � 31%��$&� 6&���)�������&)�������ก���4&���*��1

���� )��*4+��%4� : • ���� �� Class II ��+�����@ ���%4�������������ก���, class III ��� IV $���� ���������%� � 31 • ก� �������*#+� �ก(� ��������� �#�

o ��@ ���%4�������������ก����"+��$��$&��ก�$�����%- 6&���*�������4+������������.�%� � 31 o *��E4�3�* -�� ���������+��)%��ก� %���)$&��ก� PHT, Aortic coarctation with valvular involvement, Marfan

syndrome with aortic ionvolvement o 6 ����� Class III, IV o ������ก��� � #�ก������ก������� -�� �ก$�� )�1��%4�

5. 3) ��%-M� : ��#+��ก��������-� 31 7-12 wk CRL (crown-rump length) ���������������ก��+�-& +/- 3-4 ��� ���� )��*4+��%4� :

Testing ���-� 31��+���������ก� % � ������%-

BPD 12 - 28 ± 1 wk • ����ก GA 28 wk ���6�ก��M4&*��&��ก�" � • ���������&�ก@ก%4

Head circumference 12 - 28 ± 1 wk • ����ก GA 28 wk ���6�ก��M4&*��&��ก�" � • ���������&�กM4&@ก%4 ���� ก����ก$@ � #� ���ก

$@ Femur length 12 - 26 ± 1 wk ����ก GA 26 wk ���6�ก��M4&*��&��ก�" � Abdominal

circumference $��$&������ก� @ ���.���-� 31

6. 2) ��%-M� : ����%-�� Post-partum hemorrhage ��M)�@]�� ���� �����ก4&�ก3��� uterine atony ��#+��ก PE *������ uterus : ½ FH> umbilicus �"+@|�����+���+�������ก4& uterine atony $&��ก� • ������&�#&��# ������� � #����&� ����ก • �&�)ก����-�#&%����ก�ก4�$@ ���� � 31��&, � 31��&� ��, �� ก%��6%****** • ������&�-% ������ ��@ ���%4�����ก� %ก��#�&������&��ก��� • ��ก� ���&��+ก �%-������ก4&ก� ���� 31

����� 31� ก ������& ก���$�����@|�����+���ก� �ก4& Post-partum hemorrhage ���� )��*4+��%4� :

����%-�� Post-partum hemorrhage �ก4&�ก 1. uterine atony 2. ��ก� ��ก��&����������& 3. ��#�&��ก�ก%������ ก�ก�� (placenta bed bleeding) 4. ก� #��'( ก�����6* �&�)ก 5. ����M4&@ก%4��ก� ���%������#�&

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7. 1) ��%-M� : �� �%����ก� �������&$�����ก%�����&�� $&��ก� 1. call for help 2. extend episiotomy 3. Suprapubic pressure 4. McRobert maneuver (flex hip �������%4&���) 5. ��-�$������� 6. Woods cockscrew maneuver 7. &"���&$������ 8. ��กก �&)ก$�@�� �� 9. +/- Zavanelli maneuver (�#� &������&�กก�������$@ �������$@M��%�&���&

���� )��*4+��%4� : Modified Crede �@L�ก� �������& ก�� 8. Cesarean section ��%-M� : �4&��������@L� Overt prolapse cord (�#� �����&#��������%+��ก������������ ก+!-� ��� +���%ก����) "����$@���

Cesarean section �@L��4E���+&���+�-& ���� )��*4+��%4� :

• ��� 31���, ��+@�ก�&�)ก�@�& 7-8 ��. �" �$@��+�@L� forelying cord ����� ก@ก%4 ������ก���������ก� ���&� �� �� ก$����3��� fetal distress *�����$�����!-� ���%ก ��� �������&����������&$&�

• ก .��&�ก�������4%-M4&@ก%4 ���@�������&����������& • �������������& !��@�ก�&�)ก�@�&��& ����&�ก���%+��*����� $���� CPD • ����� #+�&"�-55�ก�' �� ����+�@L�� 31��� $���� CPD

9. Cesarean section ��%-M� : ��ก� &)�� �ก(� HSV �� ���ก������&��� ������&

• �*����# ��*#+��#������#+��� ��6 ���+����� 4� !��$������ ��6 ��.�� 4+����� 31�� ������&��������& (no lesion, no cesarean)

• !���� ��6 �� #� prodome �� M��%�&���� ���&4�������ก4� 4 ��+�6� • ก� %4&��# ���ก�������#�*��E-1 $�������@L����% ��%���� ก ������&��������&$&� 6&���-�� #�@�&� 4��.��+%4&��# ����

�4&�4&���.�������& &��� ��ก6��1!���� ��6 ���)�����������&���M��%�&���& (Cesarean section)

10. 1) ��%-M� : ��#+��ก6��1 PE *���� �� FH ¾ > umbilicus �4&�����3����� �� ก������ก� lightening ���� "�4&��� myoma uteri ��M)��54%� � 31 ���� $��������M�%��ก� &����4�ก� ���& "�������� !������&��������&@ก%4$&�

���� )��*4+��%4� : • M�����# ��ก�&�)ก%��ก� %� � 31

o ��# ��ก�&�)ก���������ก4&3����� ก���� �����%� � 31$&��������� ���� ก� �����$% ���� ก, ก� %��&ก���ก����&, ��#�&��ก�ก������&ก��� ���������&, �� ก��)������M4&@ก%4, ��&��������&���������&��ก ���ก� �����)����&�)ก���

o @|����+�����5 �" ���)�ก�� %�������# ��ก, ���&����������ก�����# ��ก • ก� M��%�&�����# ��ก�&�)ก��ก

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o ������5���# ��ก�&�)ก��]����ก���������& 6&�*4� .�&)���&�&�)ก��ก� � @ ���. 6 ��@&��1������& ����ก� M��%�&��# ��ก�&�)ก���.�%� � 31$���� �����#+��ก��6�ก�����+�%��ก� ��� ก� ���&ก���ก����& ���������#�&��ก�%��%�&�&�)ก

• Large uterine myoma during pregnancy and delivery - choice of management o The authors suggest that myectomy during pregnancy and cesarean section must not be done routinely.

11. 1) ��%-M� : �4&�����ก� %ก�����M)�@]�� ���� �����ก4&�ก Bacterial vaginosis ��#+��ก����ก(.�%ก�����ก�4+������ (��������) ���� )��*4+��%4� :

• ��ก� %ก����ก Bacterial vaginosis ����ก(.� �#� ���ก�4+��������� ��%ก�����ก$&� ��ก�%ก�����ก�" ��.���@ ����&#�� � #������&@ ����&#�� �)��������������ก�4+���������ก� ����*' ��#+��ก� ����-4����E4F�@L�&�����@P4ก4 4��ก�� amine $&� ammonia

• �ก.01ก� �4�4���@ �ก��&��� 1. pH > 4.5 2. homogeneous leucorrhea (�����) $�������ก(.���ก��� 3. ��ก�4+�����������@������ ��#+���& 10% KOH (Whiff test) 4. *� clue cell �������� 20% ������1��#+��-������&�� ��&

����ก� �4�4��� Clue cell ���� !���$&��� wet smear ��� gram stain • ก� �ก(� ��� metronidazole 200 mg oral qid 7-10 ��� 6&� �ก(���*�� ����+����ก� $��%�� �ก(��)����

12. 3) ��%-M� : ��ก� ���&%4&$���$���� ���ก� ก& fundus �* �����������ก4& uterine rupture $&� ���� )��*4+��%4� : ก� ���&%4&$������&)��� 7 @ �ก�� 13. 3) ��%-M� : ���#����+ �. ������� �#�

• �����@L� Pelvic infection ��ก��+�-&��#+��ก PE : Cx : tender on motion ��� Adx : tenderness both sides ���� TOA ������� ����������ก����� ������$&� mass ��+ Adx �����ก��ก4&%����� PID

• ก� % ��%������M)�@]�� ���� �����@L� breast engorgement (��#+��ก����� engorge &tenderness $�����&��� ���) "$���4&!"3��� Mastitis � #� breast abscess

• �M�M��%�&&� $���� oozing $���"� $�� bleed $���4&!" C/S wound infection 14. 4) ��%-M� :

• ���% ���+$��$&� �� HRT �� $&� �� Ca ����� 1,500 ก �� • ���% ���+$&� �� HRT �� $&� �� Ca ����� 1,000 ก �� • �%��กก� ก4����� ���%������ �$&� Ca ����� 500 ก �� &��� ����% ���+$��$&� �� HRT �� $&� �� Ca ����� 1,000 ก ��

������% ���+$&� �� HRT �� $&� �� Ca ����� 500 ก �� 15. 3) ��%-M� : ��#+��กM���������กก� ������������$����ก� ��& �&) ���ก��M)�@]��$����@ ����&#�������� 6 ��@&��1 ����%��

rule out 3��� Pregnancy ก��� ���� )��*4+��%4� :

• ����������� �����% �ก� %� � 31����ก������-�ก����4& �#�*�@ ���. ����� 3 • ��ก� ��������กก� ������������

1. @�&����������@�& �&) *���������� 2-3 �&#��� ก ��������, �&� 2. ��#�&��กM4&@ก%4�ก6* �&�)ก 3. %ก���

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4. ก� %4&��# �������#�*��E-1 5. �����������-& 6. �&�)ก���- 7. ก� %� � 31��ก�&�)ก 8. ก� %� � 31�.�������

16. 1) ��%-M� : @|�����+���+�����5%��ก� �@L� DM �#�3��� Obesity ���� )��*4+��%4� :

17. 4) ��%-M� : �4%��4����� �E�%-��+���������*��E1ก��ก� �ก4& neural tube defect (spina bifida) �#� folic acid ���� )��*4+��%4� :

• !����&��ก������� -�� ��������ก4&��ก� ��#+����� � 45�%4�6%���ก�����+�� ��&�M������� ���!����& -�� ��ก, �������ก4& acrodermatitis enteropathica ��� dwarfism hypogonadism

• ��& Fe �������ก4& Iron def. anemia • Vit B6 ��@ �6���1��ก� �&��ก� �*����$&��� ���� ก��ก� %� � 31 �%���ก�$����& ���$�����@L�%���� 4�

18. 1) ��%-M� : Spontaneous abortion �����ก�@L� Type Cervical Os !-� ��� +�� Size &date Conceptus

Threatened abortion

Closed �Kn� �eก appropiate Not seen

Inevitable / Imminent abortion

Opened �%ก���� +/- Not seen

Incomplete abortion Opened +/- Size < date ��@ ���%4������������&�ก � #� ก��-&��ก������ �������4 ���# �����)���+@�ก�&�)ก

� #�������&

Complete abortion Closed +/- Size < date �� ����+�@L� Blighted ovum ����!-ก�

%� � 31��-&��ก���� ��� �%�$����%���&�ก��)� 19. 2) ��%-M� : ���+��กM)�@]�� ���� sure date(LMP) ���% �*������ FH : ¼> umbilicus (GA 24 wk ���.���+ GA by LMP =

20wk) &��� �M)�@]�� ���� "�� Size>Date �"+���@L�%�� Work-up ������%- $&��ก� ���@|�����ก���������% �����, U/S �"+����+�� �4+��+�� ���ก��� �#� ก� ���@|�����ก���������% ����� �������������+�-& !������ Size>Date ��)�����$@��� U/S %��

���� )��*4+��%4� :

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Differential Size > Date : 1. ����� LMP M4& � #�$�� sure date 2. Full bladder 3. Twin pregnancy 4. Macrosomia 5. Polyhydramnios 6. Pregnancy with myoma uteri

20. Mild PIH ��%-M� : ��#+��กM)�@]���� BP>= 140/90 mmHg ���ก���� Proteinuria �*�������&��� ���� )��*4+��%4� :

3��� Severe PIH $&��ก� ����&�����"+%��$@�� • SBP > 160 or DBP > 110 mmHg • Proteinuria > 5 g/day • Grand mal seizure (Eclampsia) • Pulmonary edema • Creatinine rising • Oliguria (< 500 cc/day) • IUGR, Oligohydramnios • Thrombocytopenia + Elevated liver enzyme + Hemolysis (HELLP syndrome) • End organ damage ���� ���%�M4&@ก%4, ����4 �@��� #��%����6� ���

21. 4) (����� $����� 1) 22. 2) (����� $����� 1) 23. 2) ��%-M� : ��#+��กM)�@]�� ���� �������������ก� %� � 31�ก4&�" � ���@L� intrauterine pregnancy � #� extrauterine

pregnancy ก�$&��"+�ก6��1$&���� Ultrasound ����$��*����กª��ก� %� � 31 ($����ก���-$����� ��) management %��$@�#� ก� @ ���4� �&�� hCG

���� )��*4+��%4� : ������ Ultrasound ����$��*����กª��ก� %� � 31 ก� ) management %��$@ ����@L�

• $����ก���$����� �� → @ ���4� �&�� hCG • ��ก���$����� �� → laparoscppy • $����ก������ �� → laparoscppy (��� cul-de-sac) • ��ก������ �� → laparoscppy (��� cul-de-sac)

24. 3) ��%-M� : ��M)�@]�� ���� �4&!"3��� Bartholin abscess �"+������5��@L�ก� %4&��# ������� ��ก�-�� Escherichia coli or staphylococcal or polymicrobial infection

���� )��*4+��%4� : • @ ���%4��+����$&�

Acute, painful unilateral labial swelling Dyspareunia Pain with walking and sitting Sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture)

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• % � ��ก�� Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema. In some cases, areas of cellulitis surrounding the abscess may be present. Fever, though not typical in healthy patients, may occur. If the abscess has spontaneously ruptured, purulent discharge may be noted. If completely drained, no obvious mass may be observed

• ก� �ก(������ก�@L� 1. Marsupialization �@L�ก� �ก(���+$&�M� 2. excision $����������+��� 3. Incision and drainage ��6�ก���ก4&ก� ก����@L�� ���)

25. 4) ���� )��*4+��%4� : $������%-M� 55555+ �%�$@���������� (�*-) • Efficacy of the Intradecidual Sign and Fallacy of the Double Decidual Sac Sign in the Diagnosis of Early

Intrauterine Pregnancy • Dr Laing and colleagues stressed the importance of the double decidual sac sign in diagnosing an intrauterine

pregnancy before the appearance of a yolk sac, and they considered the double decidual sac sign to be most useful at 4�6 weeks gestational age

26. 3) ��%-M� : M)�@]�� ���� ����ก� %ก����ก bacterial vaginosis ��#+��ก*� clue cell &��� �����+��� �ก(��#� metronidazole ���� )��*4+��%4� : &)�ก.01ก� �4�4�������� 11 @ �ก�� 27. 1) ��%-M� : ��#+��กก� % �3����*���� Rt.labia major �� ulcerative lesion �&, ������ก, ����� discharge �������ก

vagina �4&!"��� �����@L� vaginal candidiasis "���� !������&@ก%4��������&$&� ���� )��*4+��%4� :

• ��ก� �����ก� ��&�� vaginal candidiasis 1. ���������&���@�ก������& 2. %ก����@L��������� ������ ���� $����ก�4+� 3. % �3���� *���ก(.�����&� 4��. vulva, vestibule ��� labia ��*� ���ก�� #� ��!��ก$&� 3�������

���&��� erythema ���%ก����@L��M�����%4&����ก��M��������& • ก� �ก(� ����@L� clotrimazole 100 mg Vg 7 ��� �%��� ���ก���+�ก� �����$% ���� ก��ก� %� � 31 • ก� %4&��# � ��� ��ก�$��$&��ก4&�กก� %4&%�����*'���*��E1 ���*�$&� �� ����� 10-20 ���% �@ก%4��+���) .1 ก� *�

��# �6&���+$������ก� "$�����@L�%�� �ก(� 28. 1) ��%-M� :

• ���กก� �ก(��-��*#+��&M���ก & ��� pepsin �"+��������&ก & (antacid) � #������#�����@}�ก����#+��-ก ��*������ ��#+��ก������4&��$��� ��!"M�%���� ก��� 31 &��� ����&ก &"�@L�����+��#�ก������&��� ก !��$��$&�M��� �@��+���@L���ก�-�� H2-receptor blockers ���� sucralfate ���� !���$&����% �%� � 31

• �ก6��1%�&%����#�ก Misoprostal (Cytotec) ��#+��ก���� !ก �%-���&�)ก$&� ���������ก4&ก� ���$&� ���� omeprazole ��$��� ��!"M�%���� ก��� 31 ���#� ranitidne, cimetidine ��� sucralfate �%� ranitidne, cimetidine ��)���ก�-���&���ก�� ����ก���กก� �ก(����%�����#������@L� second line drug ก .� �ก(�����$��$&�M� ������� "�4&�����������@L� sucralfate (���,)

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29. 3) ��%-M� : �ก@ ���%4���ก� % � ��ก����M)�@]�� ���� ���� !"3��� uterine rupture ��#+��ก PE :���� !������������ ก$&���&��, �|���� fetal heart sound $��$&�, �� &���)���3��� shock (BP 80/50 mmHg) �@L���ก� �����ก� ��&���&�)ก��+�%ก���� ���ก����@ ���%4ก� drip syntocinon

���� )��*4+��%4� : ��ก� �����ก� ��&���&�)ก��+�%ก���� �#+�, $&��ก�

1. ��ก� @�&��������-���� ��������ก$&��������$ ��ก��ก 2. ������#�&��ก��������& 3. % �3����*���� �������!��ก��� � #�����)�" � � #�����$��$&� ������*� ���%ก$&� 4. !����ก� ��ก��&��ก ��*��@|����� ก� ���@|�������$&���#�&��ก��@|����� 5. ������$&�ก�����-��, ����&�)ก !������#�&����$@�� broad ligament

��ก� �����ก� ��&�%#������&�)กก������%ก $&��ก� 1. �&�)ก�& �&%��%��&���� 2. @�&�������� 4��.���#������������� -�� �ก ����ก ����� 3. ก&���� 4��.���#��������� 4. *� Bandl�s (pathological retraction) ring �#� ก� % ������������������&�)ก�@L� 2 ��� �"+�@L� ����&%��

����� upper ��� lower uterine segment 30. 2) ��%-M� : Incidence of Down Syndrome with Increasing Maternal Age

Maternal Age Risk

32 1/725

33 1/592

34 1/465

35 1/365

36 1/287

37 1/255

38 1/177

39 1/139

40 1/109**

41 1/85

42 1/67

43 1/53

44 1/41

45 1/32

46 1/25

47 1/20

48 1/16

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31. 6��1� �����#����� 8 32. 6��1� �����#����� 4 33. 3) ��%-M� : ��#+��ก�&�ก��)������ transverse lie ก� M��%�&������&�@L��4E����&��+@��&3����+�-& 34. 4) ��%-M� : M)�@]�� ���� ��&���3��� post-menopausal bleeding �ก6* �&�)ก �"+��6�ก���ก4&�ก��� ���#+��-6* �&�)ก$&�

���ก��M)�@]�������-���������ก����%����ก� �#�����*4+��%4��*#+�������%- $&��ก� U/S, Endometrial biopsy, ก� �)&�&�)ก �"+�4&����ก%����#�ก����%�� endometrial sampling ��ก��+�-& �*#+����$&��4 ���# ���% ��*#+� rule out CA

���� )��*4+��%4� : Differential diagnosis of post-menopausal bleeding • ����M4&@ก%4����#+��-6* �&�)ก

1. ��#+��-6* �&�)ก�]� (*�$&�������+�-&) 2. ��#+��-6* �&�)ก��� proliferative 3. ��#+��-6* �&�)ก���%�� �� ��4&�� atypia � #�$���� 4. ��� ���#+��-6* �&�)ก (10-20% ����#�&��ก��������& �&))

• %4+��# �@�ก�&�)ก • ��# ��กก������# ��&�)ก • ก� ��ก���%4&��# � • ��� ��#+�, ���� @�ก�&�)ก, ������&, sarcoma • ¡� 16�������&

35. 4) ��%-M� : ���#��ก����� 2 �#� ก� % �3�����@L� ��� �*#+�&) cervical progression �@L� Contraindication 36. Polyhydramnios ��%-M� : Risk �� uterine atony $&��ก� Polyhydramnios ���� )��*4+��%4� : ���&)����� 6 @ �ก�� 37. 4) ��%-M� : ก� % �*������ AFP ��+�)�" ����������*��E1ก��ก� �ก4& NTD (anencephalus and spina bifida) 38. 3) Imperforated hymen

��%-M� : �@L�M)�@]���&�ก�54���- 14 @� $������� �&), ����ก� @�&�����ก�" �, @�&�@L����(���#��@�&%�� ���&#�����), �� secondary sex characteristics, )��"ก�������6%�" � PE : tense cystic mass 1/3 >suprapubic, gaping labia minor with purple tissue �ก@ ���%4���ก� % � ��ก����M)�@]�� ���� ����$&�ก��3��� imperforated hymen ��ก��+�-&

39. 3) ��%-M� : M)�@]�� ���� ����ก� �����ก� ��&�%#������&�)กก������%ก (threaten uterine rupture) $&��ก� a. *� Bandl�s (pathological retraction) ring �#� ก� % ������������������&�)ก�@L� 2 ��� �"+�@L� ����&%��

����� upper ��� lower uterine segment b. �&�)ก�& �&%��%��&���� c. @�&�������� 4��.���#������������� -�� �ก ����ก �����

���� )��*4+��%4� : &)����� 29 @ �ก��� �� 40. 4) ��%-M� : ����#�&��กก�@ 4&ก�@ ����ก� ก4����-�ก����4&

• ��#�&��กก�@ 4&ก�@ �� ����� ��@ ������ *�����6&���*���� 3 �&#��� ก��ก� ����� ��� ��@ ����%��$@%��@ก%4 ��#�&���-&$@��

• ��#�&��กก�@ 4&ก�@ �������� OCP $@��������&#����ก�ก4&�ก��#+��-6* �&�)ก��

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• !����#�&��ก����ก�����&�-&������ OCP �� �����-&�� ����� 4+��M������ 7 ���%���� • !����#�&��ก��ก � #���ก��� $���������&�� ���&#�� �������������-�&���ก� ��� estrogen ����� �, ���� premarin

1.25 mg/day, estradiol 2 mg/day * 7 ��� ���ก��ก4��� OCP %��@ก%4 ���� )��*4+��%4� :

��ก� ��������#+�, �กก� ก4������&�-�ก����4& • ��#+�$��/������ �ก4&����� 2-3 �&#��� ก ���������, �&� ������$@ • ก� ��& �&) �������� OCP • � �����ก�*4+� • �����@L��}� • @�&' �(� • �� �.1�@��+���@� • �&@ 4��.����-.3�*��� ����

41. 6��1� ��ก����� 46 42. Imperforate hymen �����ก����� 38 43. 4) ��%-M� : ����+�� ��������!"����@ก%4 �"+ก� �*4+�� �����ก��+��������� �@L� 11.5 � 16 kg. &��� �� �����ก��+�*4+��" �$���� �ก4�

16 kg. ���� )��*4+��%4� :

• ���� ����� �����ก���� (BMI <19.8) � �����ก�� ��*4+� 12.5-18 kg • ���� ����� �����ก��ก (BMI >26) � �����ก�� ��*4+� 7-11.5 kg

44. - 45. 4) ($�������&��,) ��%-M� :

• ��#+��กM)��54 ���� ��)������ ���ก� ������-% "�� ���ก���+����-�ก����4&��� combined pill �"+�� estrogen ��+�$@ �ก��ก� � ��� ���� (�&@ 4��.����-.3�*� ����)

• M)��54 ���� ��@ ���%4 dysmenorrhea "$��������� IUD �* ��M���������� IUD ������"+�#� ��ก� @�&������� ���@�& �&)

• ������+ $����#�ก condom �* �����M)��54 ���� %��ก� �-�ก����4& 2-3 @� ������#�กก� �-�ก����4&&���ก� ก4��� progesterone ��ก��+�-&��#+��ก $����M�%��ก� � ��� ���� ������������&��ก� �� dysmenorrhea �$&�

46. 4) ��%-M� : M)�@]�� ���� ��)���3��� severe PIH (��#+��ก SBP >160 or DBP > 110 mmHg ����� End organ damage ���� ����4 �@��� #��%����6� ��� �"+�4E���% ª����ก� �ก(� �#� ����-%4ก� %� � 31 6&�$��������-� 31 6&������ก��ก� �ก(���+�����5 �#� @}�ก����ก, ����-�����&��6��4% ����-%4ก� %� � 31 ��6��1����� $&������ ������� ก���� ���#��%�ก� �-%4ก� %� � 31�"+����4E� induction of labour+painless labour �������������+�-&

���� )��*4+��%4� : ���ก��ก� �ก(���+�����5 �#� • @}�ก����ก ��� MgSO4 %����}� ���M����������+���ก4&�" �$&� $&��ก� EKG change, absence DTR, apnea, cardiac

arrest • ����-�����&��6��4% ����+�4�����ก������ �#� Hydralazine *4� .������#+� DBP> 110 mmHg

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• �-%4ก� %� � 31 ก� M��%�&������&����������� �@L�$@%��������� ���)%4'��% 1 ���� fetal distress, 6 � -�� ��ก, �%�@�ก�&�)ก��$��* ��� (HELLP syndrome), thrombocytopenia �����&���$��!#�����@L�������� ��ก� M��%�&������&

47. 3) ��%-M� : M)�@]�� ���� ��@ ���%4 ���ก� % � ��ก����+����$&� $&��ก� ��ก� ���ก ���@ ���%4��+������-� �#�

1. 3������-% ��ก (30%) 2. progressive dysmenorrheal 3. ��ก������-���4ก �� 4. dyspareunia (���������&�"ก, �.����*'���*��E1) 5. �� �&)��ก��ก������ 6. �%� ����� 60 ��$������ก� �&, ���

1 + 2 + 3 = classic triad ���� �� endometriosis ��ก� ��&��+*����� $&��ก�

1. �� ���� ก, % �3������ก@ก%4 2. ����+�@L���ก, % �3������ก*������ก���%-��, (nodularity) ������� 4��. uterosacral ligament � #��� Cul-de-

sac (1/3 ��M)�@]��) 3. ก��� �$��6% ���ก&��� ���&��� 4. *�ก���� 4��.@�ก�&�)ก �"+�#� endometrioma (endometriotic cyst) 6�ก���#+��$��$&����� ������

48. 4) ��%-M� : �กM�ก� % � U/S ��+*� 3cm. homogenous hypoechogenic cyst, no contents inside at Rt.adnexa �4&!"��� �����@L�3��� benign condition ���ก���ก@ ���%4���ก� % �3������M)�@]�� ���� *��*���%�!-� ��&�ก����"�����@L� functional cyst ��ก��+�-&

��ก(.��กก� % � U/S • Endometriotic cyst � #� Hemorrhagic cyst ������@L�!-� ����+�� echogenic fluid ��)�3����, irregular border • Polycystic ovarian syndrome ������@L�!-� �����ก, ����, ��� ก �����)� ����ก� ��ก�������� ����� (necklace

like pattern) • CA ovary �������ก(.�ก����@L���� solid mixed cyst • Functional ovarian cyst ������@L���ก(.� homogenous hypoechogenic cyst

49. 4) ���� )��*4+��%4� : Asherman�s syndrome �#� *�M#&��6* �&�)ก

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3�����& �&)

prolactin

TSG for hypothyroid

Progestin challenge test

prolactinemia

Positive Negative

Estrogen-Progestin challenge test

Normal/low High

FS

Sella imaging /GnRH test

t�����<Pกe�[e :�e���:

t�����<Pกe�[ Hypothalamus

�KnU Z����Z�

|��sn� eก

Positive Negative

t�����<Pกe� U:�<Z�ก

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1. $�� )� ><� *����������%�������%�$�����������ก$�� 2. 6��1����M4& ��+�����@L�$@$&���+�-&�#� posterior hip dislocation �%�%���@L� adduction Fx of the pelvis �����$&�%��ก�$กก� �ก4& 3 @ ��3� �#� AP compression (pubic symphysis + ante. SI joint

���, open book type), lateral compression ��� vertical shearing ( -�� �-&) % � ��ก��*� ��� ����� ก&���� 4��. pelvis ��� AP ��� lat. Compression ��� ก& pubic symphysis ��ก� �#���� manage ��# �%��%�� ATLS��ก�� vital sign unstable ��� resuscitation, pelvic binder ��������#�&) assoc. injury �#+�, ���� intra-abdominal bleeding

Fx. of the acetabulum ����ก� �����6*ก ก �&)ก%���� ��6*กM4& )@��ก�� dislocation ���&��� ������ก�ก4&�ก dashboard injury

Fx. neck of femur (intracapsular fx.) �� 2 ก�-���#� non displaced ��� groin pain �����&�����%���� �� antalgic gait ��� limitation of motion ��กก�-���#� displaced �@�&��ก� 4��.��6*ก ����$��$&���� �#� �&4�$��$&� ���� ����ก���� ก&� 4��.%+��ก��� midinguinal point ��&��� distal 1� ��� lateral 1�

Intertrochanteric fracture (extracapsular fx.) ก&�����+ greater trochanter ��ก*� ecchymosis ����� � ����� external rotation

Posterior hip dislocation M)�@]��������� flexion, adduction ��� internal rotation ��*���� head of femur $@ก& sciatic n. $&� %��% � sensation �� common peroneal n. ��+�������, tibial n. ��+�]����� ���% � motor �� nerves �� ��6&� dorsiflexion ��� plantarflexion %�����&�� %�� �� �ก(��� 6 ��+�6��* ����ก �ก(������*4+�6�ก���ก4& avascular necrosis (anterior hip dislocation ���&��� ������ flexion, abduction, external rotation)

3. 3) Displaced supracondylar fracture common ���&�ก ��ก*������- 5-10 ��� ������ก�ก4&�ก����#����*# � *� cubitus varus $&���������@L� 2 ��4& �#� extension ��� flexion type *� extension type ��กก��� ��ก$�� displaced % � ��ก��*����'�ก���$����ก �%���ก�@L���ก ��*� S-shape deformity %��% � radial, median ��� ulnar n. ��� radial a. ���� X-ray *� fat pad sign ����@L�fracture �&���������� ��+$�������� Hueter�s line ��� triangle M4&@ก%4

Fx. lat. condyle of humerus *�$������ �@L� epiphyseal plate injury % �

��ก�����'�ก��� ก&��� ����� supracondylar fracture ��#+� X-ray ����� �� ������&���ก� 4��.����@����� metaphysic ��ก�@L� nondisplaced fx. �%���ก�@L� displaced ����� metaphysic ���ก, ���#+����ก�ก lat. of humerus ��&�� ������ Heuter�s line ��� triangle M4&@ก%4

Medial ��� Lateral epicondylar fx. � rare ��ก ��������� Heuter�s line ��� triangle M4&@ก%4 Elbow dislocation � *�$������ �ก4&�ก��������'�ก�����& 90% ��ก�@L� post. � #� post.lat. M)�@]������@�&��ก

����#���ก�����"+@ ���$�� '�ก����ก���� ����$&� olecranon process �)���)���&������ Heuter�s line M4&@ก%4 ��*� fx. radial head, coronoid process, medial epicondyle ���&���$&� %�� ��� ulnar n. injury

Ortho & Rehab

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4. 1) %��%� � Nerve root Motor Sensation Reflex C5 Biceps brachii, brachialis Lateral arm Biceps C6 Wrist extensors Lateral forearm Brachioradialis C7 Ticeps brachii Middle finger Triceps C8 Finger flexor (FDP, 3rd finger) Medial forearm - T1 Hand intrinsic (Abductor digiti minimi) Medial arm - L2 Hip flexors (iliopsoas) Upper ante.med. thigh - L3 Knee extensors (Quadriceps femoris) Lower ante.med. thigh - L4 Ankle dorsiflexors (Tibialis anterior) Ante.med. leg Patella L5 Extensor hallucis longus Ante.lat. leg, med. dorsal foot

Web space of great and 1st toe -

S1 Gastrocnemius, soleus Lateral foot, plantar foot Achilles 5. 1) � 4��. Surgical neck of humerus ��� axillary n. ��&M��� &��� �"�������� axillary n. �������$&� (���������ก�� midshaft

of humerus fracture �"+���� radial n. injury) Nerve Motor Musculocutaneous Coracobrachialis, biceps, brachialis Median Flexor group in arms (except: FCU, FDP of 4th and 5th digits), Pronator group,

thenar muscles, lumbrical (1st+2nd) Ulnar FCP of 4th+5th digit, FCU, Intrinsic hand. (except thenar m, lumbrical 1st+2nd) Axillary Teres minor, deltoid Radial Triceps, brachioradialis, Extensor group in arm, supinator

Posterior elbow

dislocation associated

with fracture of the

coronoid process

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6. 2)? �ก6��1M)�@]���@L� Carpal tunnel syndrome �"+���&���@�&�� �#�&����4 �6@} !"�4 ����|� radial ����ก� ��ก��%��ก���#� � #���#+���������ก� ��$@�� % � ��ก��&��� Phalen�s test, Durkan pressure test ��ก����M���ก % �ก������# � APB, FPB ��� OP ��M4&@ก%4 % ������ ����ก� ���ก ���$��}�������@ ���������

ก� �ก(��������4E� �#� ����-@ก .1&��, NSAIDs, carpal tunnel steroid injection ��� operative treatment Long arm cast ���ก�� supracondylar fx. � #� fx. forearm ���� A1 pulley release �����ก� �ก(� Stenosis

tendovaginitis ���4 � (Trigger digit - 6 ��4 ����ก) 7. 2)? M)�@]�� OA knee ��������������

a. ��กก����ก������# � ������������ �� ���@�&������ isometric quadriceps exercise ก��� ����%��&��� isotonic exercise ��� progressive resistance exercise ��#+�$��@�&���� (�� ��กก����ก��ก������# � hamstring &���)

b. ���ก���-@ก .1�� 4� ���� �� 4�*# � �����&�����ก ก .���+������#+�� �*#+�������� ��� �����ก��+ lat. Compartment ��ก�" � c. ������� #+������&4� ����$�����������&4�6&���ก����������!#�$�����������% ����ก�������+@�&

8. 4) M)�@]�������@L� Cervical spondylosis (radiculopathy) $����� myelopathy ��กก��� �* ����ก� �@L���� radicular pain ���$���� long tract sign �"+��&3��� myelopathy (myelopathy !#�����@L� contraindication ��ก� ��� cervical traction)

��M)�@]�� ���� ����������ก� ���� ������ก �����&4������ก�" � "�� ��-& traction ������ MRI �*#+�&)�����ก� ก&���$�������� #�$��

9. C5 - C6 Disorder Lesion Common cause Clinical features Erb-Duchene palsy Upper brachial

plexus (C5, C6) Hyperadduction of arm Waiter tip position (arm extended and

adducted ,forearm pronated) Klumpke�s palsy Lower brachial

plexus (C7-T1) Hyperabduction of arm Claw hand from ulnar n. involvement,

wraist and hand dysfunction, assoc. with Horner�s syndrome

Claw hand Ulnar n. Epiphyseal separation of the medial epicondyle of humerus in children

Weak finger adduction, medial hand numbness, dysfunction of 4th and 5th digits flexion

Radial n. palsy Radial n. Fx. of mid-humersus Wristdrop, loss of sensation from dosum of hand

Carpal tunnel syndrome

Median n. Compression of n. Wrist flexion elicits pain, wrist extension relieves pain, worse at night

Med. Winging of scapula

Long thoracic n. Surgery (e.g., mastectomy) Limited arm abduction and flexion, serratus ante. Paralysis

Fx. of surgical neck of humerus

Axillary n. A fall landing on the elbow Loss of deltoid innervations, compromised shoulder flexion and extension

10. 5) $������ ������#���ก��� 4 � 6 ��@&��1 (28 � 42 ���)

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1. 5) Retropharyngeal abcess ��#+��ก 6��1��� film lateral neck �� %��ก� ���&)prevertebral soft tissue Lateral neck film: &)ก� ���%����prevertebral soft tissue > 7 mm at c2 level ��� >14mm (C6 level) ���&�ก, >22 mm

��M)���5� , ��*� loss of lordosis �กก� �� spasm �� prevertebral muscle ����%- ��ก�ก4&�ก ก� %4&��# ���+ adenoid nasopharynx paranasal sinus ��ก�ก�� ���ก4&�ก trauma, FB �|�"ก ��ก� ���&�ก��ก�ก4&%����� URI, ��ก����ก� ก ���ก ����$����������� ��$�� ����ก� air way obstruction, neck rigidity

% � ��ก��*�ก� ����� posterior pharyngeal wall ��M)���5� ����ก� ���@�&������� ���������ก������&� ������ก� ��&�)ก��#+����� %���� �����#�6% ���� mediastitis

ก� �ก(� �� ��� cellulitis adenitis -���high dose IV penicillin �� ��� abscess %�����ก� M�%�&��������ก&��� Epiglottitis (supraglottitis) �$��%������� �* ����ก*����&�ก 3-6 @� M)���5�*����� �ก4&�กก� %4&��# � H.influenza ��ก� ��ก�@L�� ���@L���+�6�������� ก�#������ก �� muffled voice �����������ก$&� % � ��ก�� ����ก� ���������ก

inspriatory stridor ,hot potato voice,� 4��. supraglottis area �����& ,air way ���� Film lateral neck *��� epiglottis ���6% ก� �ก(� ��� ET tube ����� ��ก����ก(.� upper air way obstruction, ����� ampicillin, steroid Ludwig angina �#�ก� %4&��# ���+ submandibular space @ �ก��&��� submaxillary space (�%� mylohyoid line) ���

sublingual space(���#� mylohyoid line), bilat 80% �ก4& �ก periodontal disease 6&���*�� mandibular teeth !���@L�����%�� 2nd molar ����$@ sublingual space �%�!���@L���+ 2nd 3rd molar ����$@��+ submandibular space��#+��ก �ก�|���)�%+��ก��� mylohyoid line

��ก� ��@�&� 4��.@�ก����� ��trismus, odynophagia drooling of saliva ,airway obstruction,� 4��.�%������6@]�)� &���4 �$@&���������&������4&ก���*&���������ก4& airway compromise

FOL supraglottis endolarynx @ก%4 �%� base of tongue��5��" �&��epiglottis $@������ Dx ���clinical �@L����ก X-ray,lab �*������ confirm Dx Treatment Early stage: IV Antibiotic !���|���+�@L�����%- Advanced disease: ��� ET tube ���$&���ก ��ก �%-�� airway obstruction $&� *4� .���� tracheostomy

�������ก���, *4� .� Sx drainage 2. pseudoephridine ��� decongestant M)�@]���@L� barotrauma �ก4&�กก� �@��+���@�����&������ �&� �� ����ก� &��� �� ก� �@��+�� �&������ #+��4�

���� ��ก ��� euatachiantube �����M4&@ก%4 ����������&���� middle ear %+��ก���atmosphic pressure$&��������ก���)!)ก&" � ����$@����� ���ก4&��#�&��ก ��+TM ,fluid exudates ��middle ear ��� � �� TM rupture

��ก� @�&�) $�������) ���ก� $&��4��&� % �*��ก���)�&����-�%��(retract),hemotympanum ,conductive HL ก� �ก(� @}�ก��6&�ก� @ ������&�����)�� �ก���������ก���4+��&���� ����ก�#�� ����� ��� �����ก� �+ valsava maneuver

�ก(�%����ก� �&��ก� @�&���ก� ��ก��� ����������ก�@�& decongestant���� pseudoephridine ���� myringotomy $�����@L���#+��กHemotympanum ��ก�����$@��3����1-2 �&#��

ENT

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3. 1) acoustic trauma �ก4&�" ���#+����M������&� -�� 130-140 dB �������*���(����@¤�� ���4&)"�������ก4&ก� ������������1@ ����

��ก(.��@L������ ���!�� ������ก� ����&����) (Tinnitus) ���&��� ��#+�% �ก� $&��4� �������ก����!�+�) "�������ก4&ก� ������������1@ ����������%� acoustic trauma ��ก�@L� SNHL M�ก� ����� % � weber rinne �@L� conductive HL ??

4. 2) amoxycillin M)�@]���@L� acute otitis media �� �ก(���+�@L� 1st line drug �#� amoxycillin ��ก�#+����ก� �ก(�$@���� 48-72 ��.

��ก� $��&��" ����@L���# ���+&# �����+� �� enzyme beta lactamase $&�����@��+���@L� amoxicillin-clavulanate 5. 3) �ก@ ���%4�"ก!" obstructive sleep apnea ����%-��+ common ���&�ก�#� tonsillar or adenoid hypertrothy ����

��ก(.���palate ��+���+�%�� OSA �#� elongation of soft palate and uvula $����� high arch palate ���� Choanal atresia �#� ก� �-&%��������)ก6&�*������ก �&)ก� #��M����# ���#+�@�&������@�&&���������)ก

�ก4&�ก bucconasal membrane $������%��$@�� ��� 7-8 ��@&��1��%������ M)�@]�������ก� %�+�%��ก4& !���@L�����&��������ก� ��&�)ก � ���)ก$������� �%��&��������ก� %� �%�������&���� , ���������ก %������� !���@L�����������ก� %�+�%�������&���� ,���������ก %������� ��$�������������� �*��1%�� ���ก�$�&���6&�������������@�ก (oral tube)

6. 4) Rhinitis medicamentosa ��@ ���%4ก� ��� Topical decongestant ����� Rhinitis medicamentosa �@L�3�����+��ก� �������#+��-�)ก 6&�������%-�กก� ��� Topical decongestant ��� ,

�������ก4& rebound vasodilatation %�����ก� �&%�������&��#�& (vasoconstriction) �@L�������� �ก4&�กก�$กก� �&%�������&��#�&������� �ก3��� hypoxia ����ก4& reactive hyperemia ��#+������*��%4&%��$@��� , ��&ก� �&%�������&��#�&����*4+�ก� ����%�������&��#�& "$���������������ก4� 3-5��� ��ก�ก�� �� ��@ ������������+����E4F�@L� alpha-adrenergic blocking ����M��� 4�ก� ����%�������&��#�& (beta-receptor) �������ก4&��ก� ��&�)ก$&� ���� ���&����&��(reserpine, hydralazine, methyldopa) �� antidepressant (chlordiazepoxide ��� amitriptyline) ������-�ก����4&

ก� �ก(� ��-&�����*���)ก � #��� ��@ ������4&�� � , ������� )��ก�M)�@]������@��+���������%������%������� decongestant ��4& ��@ ���� *���� topical corticosteroid � #� �����prednisone ��4& ��@ ����@ ���. 7 � 10 ��� �������� , �&���&� �%�!����ก�@L���������&�)ก -�� %������4E�M��%�& turbinate ��ก������

Atrophic rhinitis ����ก(.���*��6 ��#� �� atrophy ����#+��-�)ก ��������� ���)ก����@L����ก�& (crust) �����ก�4+������ (����� ��ก Ozaena) *�������M)��54 �����@ ���'��+��$��*� ��

����%- ��$��� �������& ����4(ª����� ���ก4&�กก� �@��+���@�¡� 16��, ก� %4&��# � �"+��+*������#� ��# � Klebsiella ozaena 3����-63���ก� ������&6@ %��, �4%��4���, &� ���E�%-����ก

��ก(.�������4� ��ก� ��&�)ก��#+��ก crust, ��ก�4+���������)ก� #�@�ก (halitosis) ��#�&ก���&�$�����@�&' �(� % ��)ก*� crust �@L��M�������������ก����)���+�$@ ��#+���&"��ก*���#+��-�)ก���+���]���+�$@ 6* �)ก�������ก���

ก� �ก(� ��#+��ก$��� ������%-��+��� 4" �ก(�%����ก� �#������������&���)ก6&�&" crust ��ก ���M)�@]������)ก��6&�����)ก������ ���ก�#�����)ก �����%���-���*�@L�� � � ��������������������� ��+��6@ %����ก�" � ����4%��4� �ก�#�� � ���E�%-����ก�� 4� ��ก�@L���ก��ก� M��%�&����������)ก����6&���� implant � #�M��%�&@�&����)ก����� ����+�@L� -��

Vasomoter rhinitis 3����� ���ก4&�กก� ก �%-��@ ����*� ��4�*��%%4ก ��+��ก�ก4�$@����#+��-�)ก�������ก4&ก� ����%�������&��#�& ก� ��������� ���)ก��ก M)�@]����ก����ก� ��&�����)ก � ���)ก$�� ���%�$������ @�&� 4��.���������'� (��กก� �-&%�� )�@�&6* $���� ��ก� ��!)กก �%-��6&�@|����+$���ก�+��ก��ก� �*� ���� �� ������#� ($&��ก� �����-� �+ ��3��� ก�4+��-�) ก� �@��+���@��-.�3)�4��������# �, �� 1@ ����ก�', ���3�����4%� ���� �� ��& ก�����������*���

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ก� �4�4��� 6&�ก� ��ก6 ��#+���+�������ก4&��#+��-�)ก��ก��� ���� 6 �%4&��# ����)ก,rhinitis �กก� %� � 31 , hypothyroidism , �ก������4& � #�������M4&@ก%4��ก���43�����)ก

ก� �ก(� ������������ก���+��� ������#�%�� , ������&���&��#�&�� ����+����ก� ���� ��%���¡4�%���� �������&� ���)ก�ก��E4F anticholinergic �� corticosteroid ��4&*���)ก �����& inflammation ���M��%�&�� ����+�����$��$&�M� ���� M��%�& turbinate � #�%�&����@ ���� vidian

7. �"ก!" FB �������&�ก 8. 1) CA nasopharynx ��#+��ก���-, ��ก� ����$&�&��� Nasopharyngeal cancer (NPC) �-��%4ก� .1 *��)�-&����������������%������ก�����%� *�$&����-ก��� ���-����+��.��4�4���6 ��#� 51 @� ����%- ������@|�� ���� ��# � EBV (Epstein-Barr virus), �� $�6% ����� (�"+*���@������), polycyclic hydrocardons �ก

����$����ก� �M�$���, ก� %4&��# ����)ก���$����� # � �, �-�������$��&� ��ก� �����ก� ��& ��+*�������+�-&$&��ก� ก�����+�� ���ก� $&��4��&�

1. ก�����+�� �กก� ก ���6 �����+%���� �����#�� 4��.�� *�$&�������#+��ก��#+��-M4�����6��� 4�1�� ���������� �����#���)���ก ������� !%4&%���������ก"+ก��%��$&� &��� � ก� *�%���� �����#���+��6%�� �����6&�ก ����ก retropharyngeal lymph node "*�$&�����

2. ก� $&��4��&� �ก4&�กก������ ���+M��&����������6��� 4�1��� Rosenmuller fossa ����������)��%������-&%���ก4& serous otitis media %����

3. ��&�����)ก �กก������ ���5���-&��+6* �)ก&������ 4. ��#�&ก���&�$��� #� �����@���#�&$����� 5. ��ก� ����� ��#+��ก��� ���ก� �-ก����" ���&���������6��� 4�1 ��ก�4�4����ก����M4&@ก%4��

����@ ������� &��� • ����@ ��������)���+ 6 �@L�������+��ก!)ก�-ก���ก��� �������ก4&��ก� ����3�*���� • ����@ ��������)���+ 3, 4 ��� 6 �������ก4& opthalmoplegia ����ก������ ��-ก����)� superior orbital fissure

� #� cavernous sinus • ����@ ��������)���+ 5 �������ก4&��ก� @�&%�������� �������� � #�@�&��ก��+�� �&���) , • ����@ ��������)���+ 9, 10, 11 ����ก������ ��-ก����)� jugular foramen • ����@ ��������)���+ 12 ��#+���� ��-ก���!"ª��ก �6��ก' �(���ก�" � • ����@ �����4�*��%%4ก ����#+��-�� carotid �������ก4&��ก� ก�-�� Horner's

6. ก� �ก4& distant metastasis $@��@�& ก �&)ก ���%�� ก� �4�4���6 � $&��กก� % � ��ก��� 4��.' �(��������� ก� % ���6��� 4�1&���ก �ก� #�ก�������)ก��4&6��� #�

% %�&�4 ���# �$@*4�)�1 ก� % ���#�&EBV serology ��������ก� �4�4��� ก� �ก(� RT+/- chemotherapy 9. Macrolide ��#+��ก Bullous myringitis ���*��E1ก����# � Mycoplasma pneumoniae "�������ก�-�� Macrolide ���� erythromycin Bullous myringitis �@L�ก� %4&��# ����ก���) (tympanic membrane) ����%-����# ��� �$�����������ก4&�ก��# �$� ��,��# �

influenzae ,�� �����*��E1ก����# � Mycoplasma pneumoniae ��ก� M)�@]�������ก� @�&�)��ก6&���*����#+��ก���)���#+��$��, �����) % ��)�*���%-��� �� bleb ��+M4�&�����ก���ก���)

ก� �ก(� Supportive tx ������ก�@�& @�&��ก�������� bleb �%ก �����������&�)��+�����ก�@�&M����)� ��ก .���#+����6 ��ก4&�ก M.pneumoniae ����� ABO ����erythromycin , tetracyclin

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1. 4) Refractive error ���� �� VA drop �"+ correct $&�&��� pinhole "�ก4&�ก refractive error 2. 4) Retinitis pigmentosa

�@L�6 ���+�ก4&�กก� ��#+���� retina �� � RPE ������ photoreceptor ��#+���$@&��� (rod > cone) 6&���ก��&��� Progressive night blindness %������� ring scotoma (���� VF &��� periphery) �"+ VF �����,����� #+��, �%�6&���ก��ก$��������%���& Cataract �����ก� ��$����&��%��ก������ #�������ก

3. 2) Phacomorphic glaucoma ����� %��������ก� ��+����$&�ก�� Acute angle-closure glaucoma �#� %��&��� ciliary injection (DDx glaucoma,

uveitis, corneal ulcer), ���, %����, cloudy cornea, pupil fix dilate ��� anterior chamber ��� ��#+�% �%�����*������ Lens sclerosis "������ cataract ���&��� �"+�����������ก4& glaucoma �� ���� Lens-induced glaucoma ���ก, �� 2 ��� �#� 1) Phacomorphic glaucoma �ก4&�ก����1��� ������ anterior chamber ���� �"+�������ก4& angle-closure

glaucoma 2) Phacolytic glaucoma �ก4&�ก lens protein �+���ก�� �� Mφ ����ก4����$@�-& aqueous drainage �ก4&�@L� open-

angle glaucoma ����#+� ���� lens particle glaucoma, phacoanaphylaxis ��� lens subluxation !�����$@�����*4+���ก����� ��

4. 4) Biopsy and microbial investigation ��M)�@]����+�� recurrent chalazion %���"ก!" sebaceous gland CA $��&��� &��� ��� Biopsy $@% ���*��E4�4���

5. &)��� 10. 6. 2) Ceftriaxone IM

����� �����@L� Gonococcal conjunctivitis ��#+��ก �@L� neonate (���- < 1 �&#��) ���� %��@L���� Gonococcal conjunctivitis • Hyperacute onset of severe purulent conjunctivitis, marked conjunctival hyperemia ��� chemosis • ��*� preoricular lymphadenopathy (*��� viral &���) • Drug of choice �#� Ceftriaxone 1 g IM + topical antibiotic

7. �ก(����#�� Acute angle-closure glaucoma (&)��� 10.) 8. &)��� 14. 9. 4) Acute glaucoma 10. 3) Oral glycerine

������ek !�� ��� 4) �@L� topical beta-blocker �� %������� ��กก��� �* ��!#��@L� agent of choice ��ก� � 4+�%��ก� �ก(� Treatment of acute angle-closure glaucoma 1. Z<ก������ aqueous

1.1 α2-adrenergic agonist (apraclonidine) 1.2 β-blocker (timolol) � agent of choice ��ก� � 4+�%��ก� �ก(� ���: bronchospasm, bradycardia 1.3 carbonic anhydrase inhibitor (acetazolamide) � ������������*� sulfa, S/E: ��@����#�@�������, HypoK

Eye

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2. ���{�ก���sV�� aqueous 2.1 Parasympathomimetic (pilocarpine) �*4+� outflow �� trabecular meshwork ������� pupil constrict ��� $�� react

to light (miotic agent) 2.2 Prostaglandin (latanoprost) �*4+� uveoscleral outflow 6&������� ciliary ��� loose, S/E: hypertrichosis 2.3 Hyperosmotic agent (mannitol: iv drip, glycerin ก4�M��� �����) ����&���� �&� ��, short term 2.4 Laser iridotomy Definite treatment**, �������� aqueous $���ก posterior chamber ���� anterior chamber

ก� �ก(����&��� ก������+ก� �&����&���)ก%� 6&�ก� ��� acetazolamide ���ก�� topical agent ���� β-blocker ��� apraclonidine 6&������ hyperosmotic agents (glycerin) ���&��� ����ก�� ���#+� IOP �&���� iris ischemia �&� �� 4+���� pilocarpine 2% ��#+��-�����&��%�$&����� ������� definitive treatment �#� laser iridotomy %���ก����� ��� prophylactic laser iridotomy &���

11. 1) Topical antibiotic M)�@]�� ���� �@L� corneal abrasion �ก contact lens Corneal abrasion

M)�@]����ก����ก� @�&%� ��#�%� �� �%�$�� ��� )��"ก$������%�����ก �* 4�%� Corneal abrasion ���ก4&$&��กก� ���M��ก���4 ��#� ���� ก��@|¥� � #�����%����ก �&�( � #����ก4&�ก�4+

�@�ก@�����+���#+����+��%� � #��กก� ��� contact lens (�������ก4�$@ � #� fitting $���������) �� ��M)�@]��ก�@P4��E@ ���%4 trauma �& , �%���&�����ก� �����ก� ��&�� corneal abrasion M)�@]��&�ก������ ���� herpes simplex keratitis $��&���

���@L������4+��+%��% � slit lamp �*#+���ก����� corneal abrasion ก������&$������"ก��ก�����*��$ �%����ก����@L� �clean� corneal abrasion �"+��ก������ ��� ������$����ก� ��ก��� (!��M)�@]����� ��) � #��@L� true corneal ulcer

Corneal abrasion ��+�����&���ก �ก(�$&�6&�ก� ��� antibiotics drop ��� ointment ������ �ก��*��*� �%� ����+�@L�� 4��.ก��� �%����� topical antibiotic, cycloplegics ��� ก� @�&%�����

12. 4) UV keratitis Corneal epithelium �� ����%��ก� !)ก��� ����ก�� UV (������5��ก sunlamps � #�ก� ��#+��6���, �����4%�1��+

�������ก*# �M4� �����!���+���4�� �*�M)�@]����+��3��� snow blindness �@L�%��) M)�@]����ก4&��ก� ���$&� ���� UV @ ���. 2-3 ��+�6� ��#+���ก� ���& epithelial cells ��ก$@ ��ก� @�&���ก �%������$&� 6&���+�$@���3�������� 24 ��+�6�

ก� �ก(� ���@}�ก��6&��������� #+�@}�ก���� UV ��#+��ก4&�" �����ก����@�&%����� ������&�� cycloplegia ��ก@�&��ก��%�� ��@ �������ก�@�& ���&���

13. 4) Meibomian gland dysfunction �� ���� ����ก� @�&%� ����$&�ก�����+ upper eyelid �"ก!" hordeolum ��ก��+�-&

Hordeolum Hordeolum �@L� staphylococcal abscess ��+*�$&����� ����ก(.���� �& ก&�����*����+� 4��. eyelid Internal hordeolum �@L� meibomian gland abscess ��+��)�&��� conjunctival surface �� eyelid ���� external

hordeolum � #� sty ��ก������&���กก��������)���+����@�#�ก%� ก���KกL� Warm compression, topical antibiotic + systemic antibiotic

Incision and curettage �����#+�$����� / ��ก� $��&��" ��� 48 ��+�6�

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14. 4) Vernal keratoconjunctivitis Vernal keratoconjunctivitis

*��������&) ���� #��&)��$��M�4 M)�@]��������5���@L��&�ก6% �ก4&���&�กM)������กก���M)��54 ����ก� ���%���ก�� 2 ����@L�, ���, @�&���@�& ��� �� �%�$���������ก� ก����� discharge ��$����ก�������ก(.��@L����� �@�#�ก%���������ก������#+��กก� ��� %� �����ก�@L� 2 ��4&

1. Palpebral form *� giant ("cobblestone") papillae �@L���ก(.� )@ 6 ����+�� M4��@L����, �������+ Tarsal conjunctiva % �@�#�ก%���

2. Limbal form ��#+��-%�� 4��. limbus �����ก(.��)�M4��@L������ก����� ก� % ���&��� Histology *������ Hyperplasia ��� Hyalinization �� connective tissue �� ���#+��-M4�����#+��-%����ก� ���%�����������ก �� cellular infiltration 6&���+����1������5���@L� Eosinophil Choices :\{[� Trachoma ( 4&��&�%�)

�ก4&�กก� %4&��# � Chlamydia trachomatis 6&�ก� ���M�� ����4+�� ���ก������+�@L�6 � 6&���+�, $@���%��& ���%� ��#�%� ก����� � ��%�$�� ก �* 4�%����� $��*� discharge ��+�@L����

��ก� ���� ก������ก�� conjunctivitis E �&� %����� �V follicles ��������&���)���&���ก��+ tarsal plate �-�� ก&������$&� ���%����%��&��&� follicles ���� ���ก����@L��M��@L��"+��&���� 4+�������� *� pannus ��+ cornea �� )�-G���+� ��ก��� Herbertys pit ����-&����%������& �%��*��M��@L���+� 4��.&��������@�#�ก%��� �"+���� !&" � ���������%�$�� ��� ��� ��%�����������&�������+� ��ก��� Trichiasis �������4+���ก �ก%�$&� �ก4&ก �ก%���ก��� �� ���@�#�ก%���������&������ ��ก��� Entropion

ก� �ก(� 1. Tetracycline ���&� #�@}����� + sulfonamide ก4� � #� Tetracycline ก4� 2. ก� �ก(� trichiasis, entropion %�� ��M��%�&� #�����4E����+�!����%� � #����$��}�� ������ �ก��%�

Inclusion conjunctivitis 6 �%��&%4&�ก� ������ �� ����%-�กก� %4&��# �$� �� ������� 1 � 2 ���4%�1 ����� topical antibiotics

Hay fever conjunctivitis �@L�%��&��+���*��E1ก�� Hay fever (allergic rhinitis) ��ก$�� -�� �ก(�6&���� topical antihistamine/vasoconstrictor

+ Cold compression Epidemic conjunctivitis

�@L� presentation ��"+�� adenoviral keratoconjunctivitis �� corneal involvement ��ก��$�����&�����ก��� ��*� petechial hemorrhage, pseudomembrane, preauricular lymphadenopathy ก� �ก(���� Supportive 6&� cool compression + � ��%������ ± topical antibiotic !���@L��&�ก�����-&� ���

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1. 3) Haloperidol ��ก(.���ก� �-&�4&�����M)�@]�� ���� ����$&�ก�� akathisia 6&�����ก� motor ��� mental restlessness 6&��@L�

M����������ก�-���� neurological side effect �� antipsychotic �"+M����������ก�-���� ��ก�ก4&ก��M)��������ก�-�� High potency &��� �"��&���M)�@]�� ���� ����$&� ���� Haloperidol

ก� �ก(�$&��ก�ก� �&�� Haloperidol ������ anticholinergic, benzodiazepine � #� beta-blocker 2. 5) Separation Anxiety Disorder ��ก� �� Separation anxiety disorder $&��ก� ��ก� �4%กก��� $��$@6 � ��� $����� �ก��%4&M)���� �&) �|� ��� ��

��ก� ��ก�� ���� @�&'� (� ��#+�$�� ������ *�$&���ก��������- 7-8 @� �"+����$&�ก��M)�@]�� ���� 3. 5) )��"ก���%������M4& ����� )��"กM4&� #���� Guilt feeling �@L� criteria ��"+��ก� �4�4��� MDD �� 4. 5) MDD with psychotic feature ��M)�@]�� ���� $����� normal grief reaction �* ������@L�����6'ก�' ����+����ก� ��4%��&������� ก��#�ก� ��+M)�@]��

������������+����%�� (����ก� Hallucination) ����ก� ����$&�ก�� MDD �#� �� depressed mood, psychomotor retardation, decreased appetite, insomnia "%������@L� MDD with psychotic feature

5. 1) Delirium ��M)�@]�� ���� ��@ ���%4 trauma �����ก��� �����ก� behavioral change ��+�ก4&�" ��ก4&���� acute ������%���"ก!"

organic cause "�"ก!" delirium 6&����� !�E4�����ก� ��M)�@]��$&��กก� �� altered cognition �ก4& anxious, paranoid, sleep-wake cycle disturbance

6. 5) Amphetamine �ก%����#�ก M��ก intoxication ���%���������&���

1. ก�5�� (marijuana) �� euphoria ,slow sense of time, impair judgement, social withdrawal, increase appetite, dry mouth, conjunctival injection, hallucination, anxiety, paranoid, amotivational syndrome

2. ��ก ����� ??? 3. �¡6 ��� (ก�-�� opioid) CNS depression, N/V, constipation, papillary constriction, respiratory depression, seizures 4. 6���� (cocaine) psychomotor agitation, euphoria, impair judgement, HTN, pupillary dilatation, paranoid, angina,

hallucination, sudden death 5. �����%���� (amphetamine) psychomotor agitation, impair judgement, HTN, pupillary dilatation, tachycardia, fever,

euphoria, prolong wakefulness/attention, arrhythmias, delusion, hallucination �ก@ ���%4M)�@]����� !� �-ก ����%��ก� ������������ก��ก� ����$&�"�"ก!"��ก��+�-&

7. 3) decrease respiratory rate �4+��+�ก4&�" ��� REM sleep ����"ก!"�4+��+�ก4&�" �%��%#+� �ก����ก� �� paralysis ��ก������# � &��� ������ ������

Decrease respiratory rate ��������#+��ก4&�� REM sleep �� ��& 8. 1) Fluoxetine M)�@]�� ���� ��ก� ����$&�ก�� bulimia nervosa �#��4%กก���� #+�� �����ก�ก4� ��� compensatory method �*#+��&ก�

�*4+���� �����ก ���M)�@]��ก�-���� � maintain normal weight (%��ก�� anorexia ��+�� �����ก����ก���@ก%4) &��� �ก� �ก(�&�����$&��ก�ก� ��� antidepressant "%�� fluoxetine

Psychiatry

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9. 2) IV Diazepam M)�@]�� ���� ����ก� alcohol withdrawal delirium &��� �ก� �ก(��#�ก� �������ก�-�� benzodiazepine �"+�ก%����#�ก

ก�����)�%���&��� �#�����@L� IV diazepam 10. 1) Denial @P4ก4 4��%��ก� %�����ก� �)5����6&� Elisabeth-kubler-Ross $&��ก� Denial (shock), Anger, Bargaining,

Depression, Acceptance �"+$�����@L�%���ก4&�" �%�����&�� ���$��%���ก4&�-ก�������-ก�� ������+%����กก���#���� denial �"+�@P4��E���%�$��$&�@]�� ���*�����$@ �ก(�ก��6 *���������*��1��+�#+�,

ก�� ��� bargaining �"+��@L�ก� %�� �ก������%�� 6&��@L���ก(.���+���ก���#+��������ก$@�*#+�@ ��@ -�4!����4%���� � #��*#+������������%��������#+���%� &��� �������� M)�@]��"��)������ Denial

11. 1) Haloperidol M����������+���������+���ก4&��กก�� high potency antipsychotics ���%�� Haloperidol ���� Fluphenazine ���

Perphenazine �@L� medium potency antipsychotics, Thioridazine ��M�%������ �������ก4& arrhythmia ����!����$����&��� syncope ����"ก!"ก�-�� low potency antipsychotics ���� Thioridazine � #� chlorpromazine ��

�* �����M� anti alpha adrenergic &��� 12. 1) �&�� Haloperidol ���#�����%����� 1 �� 13. 4) Depressive disorder ��ก� ���� ����$&�ก�� MDD ก�% $@% ���� 14. 4) Clomipramine M)�@]�� ���� ���ก� �4�4��� Obsessive compulsive disorder �* ����� ����ก(.� obsession fear to harm to oneself

of loved ones ก���ก� $@���+����ก�����* ��ก���� ��� ���@L����% �� ����ก� compulsion 6&�ก������������ก��ก@ �%)�-ก� � �* ��ก�����%- ��� �"+����$&�ก����ก(.���+���ก� ก ����*�%4ก ���+�& anxiety �ก�����4& obsession �� � &��� �ก� �ก(�$&��ก�ก� ����� clomipramine � #� SSRI &��� ������ %�� clomipramine ��

15. 3) Clonazepam ��ก� ��M)�@]������ ����$&�ก�� panic disorder ��6&���*��% ��+��ก���ก�������%�� ก� �ก(�ก����� !���$&���

antidepressant � #� benzodiazepine �"+�ก%����#�กก��@L� benzodiazepine �� ��&��� %����+�4������� 2 %���#� clonazepam ��� alprazolam &��� ������ ก�%�� clonazepam ��

16. 4) Delusional disorder: somatic type M)�@]�� ���� ��ก(.���ก� ��M4&��#+��|����%����@L� HIV ����$&�ก�� delusional disorder ��+��@L���ก(.� non

bizarre delusion (��M4&�ก�+��ก��� #+���+�ก4&�" �$&������4% 4) 6&�M)�@]�� delusion ก����� !����ก� �)����$&��%�$���&����&���� #+���+$&��4�����*��E1ก��� #+���+��M4&�� �,

17. %����� ??? ��+�$@���ก�ก����ก6 � 3D ก��#�

1. Delirium- confusion and alteration of conscious and cognitive impairment 2. Depression- �"��' �� ��ก� %�� criteria 3. Dementia- ��ก� �@L� chronic �ก�+��ก�������� 6&� recent ����ก��� remote memory

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�����4 ����@L� depression $&��%�$���� choice ��� �"+!�������#�ก%��%����#�ก�%�� withdraw ก�$&� 6&�@P4ก4 4��%��ก� %������� terminal phase �� E. Mansell Pattison ก��������@L� �����+M)�@]��� 4+��&������&�����+�����ก6 � % ����ก���6 ����ก� ก��� 4���ก�" � ��ก%���กM)��#+�����4&!"%�����ก�" �

18. 1) &����%-ก� .1$��$&���� ��ก� �� PTSD ���@ �����%-��+����4��� 6&���+�$@$&��ก� - ��ก� �@L������กก��� 1 �&#�� - ����ก� reexperiencing of the event �����|� ��� - ���ก���+��4+��+�ก�+�����ก��ก� �ก4&��%-�� � - numbed responsiveness - increase arousal ��ก� �ก%����#�ก������� ��+$�������ก� �� PTSD ก��#�ก� ��+����%-ก� .1$��$&���� �"+��@L���ก� dissociative

symptom ���� M)�@]�� dissociative amnesia 19. 2) Acute stress disorder 6&���+�$@ ASD ���� !��ก�ก panic � #� phobia $&�6&�

1. ASD ��� traumatic event �����ก��� 2. M)�@]�� ASD ���ก� ���ก��� stimuli ��+�������"ก!" event �� �, � #���3��� emotional numbness �ก��%��$���-�4ก��M)��#+�

��#+��กก���ก� *)&� #������$ ����"ก!"��%-ก� .1�� � 3. M)�@]�� ASD ����ก� increase arousal ��&�������%� %#+��%��%ก���� ก4�$��$&����$������

�ก����� ������+$&�����)������ก%����� Traumatic event �����ก��� "�"ก!" ASD �%�!��6��1��� ���������&������%��&)����ก4� 1 �&#��� #�$�� �"+��ก�ก4� 1 �&#����@��+��ก� �4�4����@L� PTSD

20. 5) Methylphenidate �&�ก�@L� ADHD ก� �ก(�&�����$&��ก�ก� ��� CNS stimulant $&��ก� methylphenidate (�@L� Drug of choice) �%� 4,

���� imipramine ก����$&��� 21. Depression (pseudodementia) Tx &��� Fluoxetine �* �������$�������#������$�� ���� �@L����ก�������������"ก!" dementia �%���� ���� ����ก� �� depression

&����#� ก� ��+�"� ก4�$��$&� ���$������ �������"ก!"����@L� depression ��กก��� 6&���ก� ���#���ก4&�กก� ��+�� poor concentration �"+� ��ก��� pseudodementia ก� �ก(�ก�����@L� fluoxetine ��

22. 1) Dyslexia M)�@]�� ���� ��@|5��&���ก� � ��� 6&���)���ก�-���� Learning disorder �"+��������M4&@ก%4��ก� ���� ��������

������ �����&������"+� #���������ก�$&� 6&���#+�% ���& IQ �����@ก%4&� ����� %�� Dyslexia �"+�@L�����M4&@ก%4������ก� ����-�����

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1. 3) M)�@]���� Postmortem hypostasis (Livor mortis) ���� �"+�� 4+�����$&� ½ - 2 ��. ���%�� �%����ก&���������)� ��&�����$�� fix ��ก���%������$��!" 8 ��. (fix ��+ 8-12 ��.)

��#+���*4� .� Postmortem rigidity (Rigor mortis) �"+�� 4+���+ 2-4 ��. ���%�� �������%����+ 6-12 ��. ���%�� �� ���� �#����������&��� Rigor mortis �ก4&�� ���������"+ �* ��ก� ���%���� 4+��กก������# ���&���กก��� ���� ������ �4 � ����"�@L��#� '�ก $��� ��6*ก %�����&�� �%����ก4&$���%����+ (����$�����) &��� � �ก�� 2 @P4ก4 4��"� -@$&����M)�%���������4%���ก��� 4 ��. �%���$��!" 6 ��.

2. 4) � #� 5) �� �& (Ligature mark) ����ก(.��ก� ������� ��!��ก ��ก(.� ��� )&�� �, ���, ����ก4&�กM)�%��*��������

�#��ก���%!-��+ �&��ก� #����ก4&�& ������ก�$&� ���� fracture of Hyoid bone �� �*��� Hanging � #� Manual strangulation ก�$&� ก� *� ��� ����+���&��#�&�&�������#�&��ก���� �ก������# � ��&����� moderate to severe bruise %���ก Hanging ��+ �� �&�$����&����ก ��� �� ��!��ก � #���#�&��ก��$����ก ��#+��ก6��1���$�����) .1"����ก Ligature strangulation ก�� Manual strangulation $��$&���&����ก !��������)��*4+��%4��" ��� ���� *� Subconjunctival hemorrhage ���ก$&�����@L� Manual strangulation �* ����ก(.�����������*�� �%�!�������#�กก���@L� Manual strangulation

3. 4) %�����กก� ����ก� ��-����%-��ก� �������4%�$�� ��-�@L�ก�-����ก� � #���ก� ก���, � ����-��ก4�$@ ��!"3�����+$�����*�� &��� ������+�@L� Acute heart failure, Cardiopulmonary failure ��!" Acute poisoning "%�&��ก$@$&�ก��� ����%-��ก� �������4%����ก ���������+*���ก��+�-&ก��#� 6 � �������������&��#�& M)�@]����+�������4%��������� �&� ������ ���� ��"ก!"����M4&@ก%4��+ก������# ������ #�������#�&���&��5���ก�" � �%��� �� ��ก$�����ก� M������)% ���� $������ !��ก$&�����������4%�ก Rupture aneurysm $&��* ��$��$&����� 4 "%�����%�� incidence ��ก� �ก4& �"+ก��#� Coronary heart ��+��� �������� ���� EKG �$���@��+���@�ก�%���"+ก�*�$&��� Early MI

4. 2) ��#+��ก Choice $�����) .1"$����+����ก �%�!��*4� .��%���������� ก� ����� ��������)% ��ก� +Q3).+MN.R1J152) �@L����ก�*#+����������% ก��������$@����4���� �'��$&� � #����������@L�3�(���ก�(ก�$&� �%�%�� ��-)-9.L1กก10I1S+LOI5MT161+TUV ���� �Brain laceration due to fracture base of skull from gunshot wound� &��� ���� 1 "�ก#��!)ก!��������+������� �ก%������ ��������)% ����� �1����, ����������������� WXก)=: + ก10I1S+LOI2340V.Z0:2346VSZ7F2[1/T-U1) $��$&������ก� ��&�����+*��� ��& ���� ���&�M�ก ��-�@¤���������# �����@L���%-%��� �@L�%�� � -@�������%�� 2 �* �� ���ก� ��&�����+ -�� ��+�-&���������%��ก�*� $��%���������&

5. 3) (�� �)�) ก� *���&�M�� #�ก� ��&���%�� ��ก�� %�� vagina ����������������ก� ���ก���� ���&��� $�������ก4&�กก�

�4���� ����*' ����ก� *� sperm �� � ����ก�����ก� ����*' 4 �%�����ก$��$&���&������4����� #����ก��������� �����&���ก�� foreign body �����@L�ก� ก �������� �ก�%����#+��������$@���������*'� #���� ���ก @�ก�$�����

6. 3) !���@L��K�ก�s�k[ S-1.Q-1:����$��&) ���ก����ก ���ก@¤��*#+����$@�@ ����������@¤���+�4 "�����������$ ���&���������ก ��-�@¤� �%�&���ก��(ª��) ��*������$&��* ��$��$&������ก �%�!���@L�PZ:กก�s�k[���� S-1.ก-.����$��&) ������������ "���������&���ก��

7. � (��%-M�&)��� 10) 8. 1) ก� % � blood for amphetamine ��@ �6���1��ก� ���� �� ��� acute ����ก� % � urine �� � ������$&���������@ 4��.

�� ��กก��� �%����ก$&���� +P)0AI610.A\.+Q-10<1:ก1) ��ก$��$&����$&� ����������$������

Forensic

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9. 2) ก �&)ก����%�������%4 Mongoloid �ก�� $����&���� (Round, non-sloping) ������%4 Caucasian �@L�����+���-���ก'�ก ��&���� (Angular, sloping) ������%4 Negroid �@L���+����+��� #���+����+���%- �� (Rectangular)

ZKกL�sกsf�Zก���Ls�e Zs�[��e� Caucasians generally have no prognathism; a notable size prominence of the cranium and forehead region; a

narrow, tear-shaped nasal cavity; a "silled" nasal aperture; tower-shaped nasal bones; a triangular-shaped palate; and an angular and sloping eye orbit shape.

Negroids typically have a broad and round nasal cavity; no dam or nasal sill; Quonset hut-shaped nasal bones; notable facial projection in the jaw and mouth area (prognathism); a rectangular-shaped palate; and a square or rectangular eye orbit shape.

Mongoloids are often characterized by relatively no prognathism; no nasal sill or dam; an oval-shaped nasal cavity; tent-shaped nasal bones; a horseshoe-shaped palate; and a rounded and non-sloping eye orbit shape

10. 4) %��@ ����ก¯������5� ��% � 297 ������ ����% �������� $&��ก� (°) %���& �)���ก �4 ���& � #� ���� ±��@ ���� ( ��ก�4+�)

(²) ���� �������#�*��E-1 � #� �������� !�#�*��E-1 (³) ���� ��� �� �#� ���� �4 � � #� �������#+��& (´) ��������6�� ����%4&%�� (�) ���Z�ก*** (µ) 4%*4ก� ����%4&%�� (¶) �-**�3�* � #� @]������ # � � �"+ ��!" %��&���4% (·) �-**�3�* � #� @]����� &�����ก� �-ก������ �ก4�ก��� ��+�4���� � #��@ �ก��ก .��ก4%��@ก%4$��$&� �ก4�ก��� ��+�4����

&��� � �� ���� "�������� �$&� �����% �������� �����)ก �%��� �� ก� ��-��� ����% �������� � #�$���� � +MN.T.-1234Q9:].Aก:1.69I6,. 5;</@<Z]2)̂ &��� ��� ���� "���$&��*�� ��-���%��*�ก �ก(�%����������& ������*�ก�¤¥�&��� (���กก� �&���ก��ก� % �@ ���4���&�M�M)����������+ ��-�*�� �������ก� �ก(�%��������� ������������*��1� ������ �)

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1. 3) Fasting blood sugar

ก� % ���&ก �6 ���+��)�3���%�6� ก� ���ก@ �ก���-�3�*!������� $&��ก� 1) CA cervix � Pap smear (��+���- 35, 40, 45, 50, 55) 2) CA breats � Breast examination (7 ��������&@ ����&#��) 3) DM � Hx, if suggest → DTX, if ≥ 126 mg/dL → FBG 4) Hypertension � BP (���- ≥ 35) 5) Thalassemia � OFT ���54%� � 31������� 6) Congenital hypothyroidism & phenylketonuria � TSH, PKU 7) Vaccination ��% ª��

2. 4) ����#��-ก� � ก������������M��M)�@]�� 3. 60%

Disease No disease Test positive 120 30 150 Test negative 80 1770 1850

200 1800 2000

6��1!��!" Positive predictive value = ×120 100150

= 60%

����� %� �$��% ก����� 8. ��� ����@L���� )����กก� *��� 6��1���M4&&����* ��!��!�������� �������� 150 ก�� 30 ก�*� ����� ���: CXR M4&@ก%4 �@���� Test positive !�� ��,������$@�%4���� negative $&�

4. 4) %��M)�@]���� M)�@]����+���-%� �%� 18 @�� 4�) .1�" �$@���� !����4�E4$&�&���%���� %����� 10 �����@ �ก�'�4�E4M)�@]�� ����� !��M)�@]�����- < 18 @� M)���+����4�E4�#� �4&�, �� &� ������ �

5. $������ 4) ก�� 5) !���"&%�� Ottawa charter ก��� ����� 4) ��� 5) �%�����%���4&���%�� 4) �&)&�ก��� �* ��%��ก¯��������*%4&���ก������ ����-���)����� (�%�� #+���ก� ��ก-�����$��� ����-�) �*���%���ก�����*����*%4&�* ��$��% ����ก!"6�(3��/M���+%���� ��� 1) $��$&� �* ������4&�4�E4M)�@]�� M)�@]���� $&� ��� 4ก� �-�3�*6&�$����ก� ��#�ก@P4��%4 (�4�E4��� 2.) ��� 2) �ก4�������+���$@@]�� - -� ��� 3) �ก�@|5��@�����%- !��$���ก���+����*%4&ก�$����������-�$&� ���� )��*4+��%4� ก� ���� 4��-�3�*%��ก�VKe�::ee������4E�ก� @P4��%4��+�����5 5 @ �ก� �#� 1) � ���6������E� .���+��# �%���-�3�* &���ก� ��กก¯���� ��% ก� ��ก� �4� ก� �&�ก��3�(� ���ก� �@��+���@�

��1ก �*#+�ก������ก4&ก� ���-�3�*&� �� ��$&� ������6����������+�������ก4&��������3����ก�" � 2) � ��� �1�4+��&������+� ���-�3�*&� 6&�ก� ��- �ก(1�3�*��&������E ���%4 �"+�� 6�ก%��!#��@L����� ��M4&���

���ก�� 6&���*�����@L�%��ก����&$����ก��-�E1��ก� ���� 4��-�3�* 3) ก� �� 4�� ���-�����+������� �*#+��������4ก���-��������� )��"ก�@L������ &���ก� &"����-����������������ก4&ก�

*"+*�%���

Ethics, Preventive & Commed

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4) ก� *� ����ก(������-����*#+��-�3�*&� �@L�ก� ������-�ก� *� ���-���������� 6&�ก� �������)������� ก� '"ก(��*#+��-�3�* ���ก� �� 4���ก(����4%�*#+��*4+�����#�ก���@ ����� ��+����$@�)�ก� ���-�3�*&�

5) @ ���@��+��� 4ก� �-�3�* �@L�ก� ����3� ก4ก� � 4ก� �-�3�*��+* ���&�������������������� *%������%��ก� ���� �E ����-������ �-���

6. 4) Randomization �@L�ก� ก �����*#+�ก ��� confounding factor ����� ก�-���&�����ก�-������-����������#��ก����ก��+�-& 7. 2) Autonomy �@L��4�E4��M)�@]����+�$&� ��� ������)������*��*��*#+�������� !%�&�4����ก� �4���� �ก(�

Biomedical ethics 1) Autonomy � ��� *���4�E4��M)�@]��

�#����ก����� �3�*�����-�����%��M)�@]���� �"+��������*��1�� ��� * ���������� !��M)�@]�� ������%� �ก ������������M)�@]�� 3���%�ก� �� )���������������M)�@]�� �*��1%�����ก���+�$������$@���4�E4*����#�M)�@]�� �*#+����M)�@]������ !%�&�4��$&������4� �@ �'�กก� � ���� ���ก����� �@L�*# �ª����� #+� informed consent

2) Beneficence � !#�@ �6���1��M)�@]���@L����ก �#����ก��ก� ก��@ �6���1�ก�M)�@]�� �"+�@L�� #+�@ก%4��+�$@��+�*��1�&)��M)�@]���*#+������ก�@ �6���1��M)�@]�� ��

$@!"ก� @}�ก�� � #���&���% ����ก�ก���4%M)�@]��&��� ���ก�� ��&����ก����( �̄ @ �6���1�4�� � teleology �"+��&������������@L� )@E �����ก(.�@P4���*��E1 ������*��1ก��M)�@]����4& paternalism �"+�*��1�&)���������-ก����%��M)�@]��@ �&-&��4&��� &�&)���-%

3) Nonmaleficence (Do no harm) � $��ก ����ก� ��+��@L�M�����%��M)�@]�� �#����ก��ก� $���@L�3��%��M)�@]�� %�����ก�� �*��1�$���������ก4&���% ��� #���&���%��M)�@]�� $������6&�%� ��

�#�ก ����ก� � #������$��ก ����ก� �&, �"+�� ก ���� �*#+�����@L�$@%�����ก����� �*��1"�� �@L�%�������� )��������� !�����@P4��%4�����*��*� �*#+���+�$��ก������ก4&���% �� � #��������+���+��ก4&���% ��%��M)�@]��

4) Justice � @P4��%4%��M)�@]��&����������������ก�� ���ก�������-%4E � 6&���+�$@ ����!" ก� ก ���� �*��ก ��$@!"� 4ก� �����-%4E ������� �%�&�����%-

��+� �*��ก ���� 4ก� %��, ��ก����)�������ก�& $���*��*����� ���-ก�� ���กก� �� "��ก�@L�@|5����ก%��ก� @P4��%4�������) .1

8. &)��� 3. 9. &)��� 11. 10. 1) Bias

�4+��+�������� �� -@�������*��E1M4& (Error) $&��ก� 1. Random error ����M4&*��&�กก� �-��%������ ���� ก�-��%����������$@��$���������%ก%�� ����� ��ก

��������45 (Chance) 2. Systemic error �����+M4&*��&��+�ก4&�ก����%-�#+� ��ก���#��ก random error � #�� ��ก��ก������� ��%4 (Bias) �� 3

��4&���ก, (�%�����4&������,��ก) �#� • Selection bias � ����M4&*��&��+�ก4&�ก�� �%��ก� ��&��#�ก@ ���ก ��+��'"ก(���+$��������� • Information bias � ก� ��&����� exposure � #� outcome ��+$���-%4E � • 3rd variable or confounder � @|����+ 3 � #�%��ก�� (��%�� �$���&�@L� bias) �@L�@|����+��M�%���������*��E1

�����@|����+'"ก(�ก�� outcome/disease 6&�%�����-.����%4�#� o �@L�����%-��"+ (Causal relationship) �� outcome

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o $�����������*��E1����@L�����%- (Non-causal relationship) ก�� exposure o $���@L� intermediate step �� causal pathway ����� exposure ��� outcome

����� �����@L� Information bias Contamination = ก� ��+ก�-���&��� #�ก�-������-�ก�-���&ก�-����"+ $&� �� intervention ����กก�-���"+$���� �$&� ���� ก�-������-�����$&������� � #�ก�-���&������$&� placebo �@L�%�� Co-intervention = ก� ��+ก�-���&��� #�ก�-������-� $&� intervention �#+���ก���#��ก��+'"ก(��*��ก�-���&��� 6&���กก�-��$��$&� ���� *������&)�����%4&%��M���M)�@]��ก�-���&����กก����* ����#+��������������$&�M�&� �"+!��M���ก��&� 4 ก���$��$&��ก4&�ก�����������&����%����@L�M��กก� &)����+��กก�����กก�-�� ���&��� ��+������� �ก�$&�6&� double blind technique

11. 3) � #� 4) ����� �" �ก��&-��*4�4��� �@L�3���� �&���� #�$�� �%�����&)ก����#���� �&����� 12. 1) Social empowerment