step2 ครั้งที่ 1

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Chiangmai Medical School

2. Internal medicine
1. 4) ก F ก SLE ก ก F ก ก SLE ก ก anti-dsDNA
ก ANA sensitivity F F F ก SLE
2. 3) F Acute arthritis F ก F joint fluid septic profile (WBC > 50,000) c/s gram negative diplococci
intracellular F Fก Gonococcal arthritis ก Drug of choice Ceftriaxone
Joint fluid analysis
1. F Hemorrhagic effusion ก trauma, coagulopathy, etc.
2. F F F Hemorrhagic effusion F Inflammatory, noninflammatory septic profile
Noninflammatory Inflammatory Septic
WBC < 2,000 /µL WBC > 2,000 F < 50,000 /µL WBC > 50,000 /µL, PMN > 75%
(Gram stain/Culture positive, glucose )
Osteoarthritis, trauma crystal → Gout, pseudogout Septic arthritis
F crystal → RA, seronegative
3. 1) Taenia solium Neurocysticercosis
Cysticercosis ก F ก ก generalized, CT multipled calcified cystic lesion
accidental host ก F Taenia solium F ( F F ก F )
Toxoplasma immunocompromised, CT ring calcification, transplacental transmission
4. 3) F F F F ก ก ก TB ก F ก sputum AFB F negative 3 ก F F F
F F TB F bronchoscopy R/O CA ก ก CXR ก CA lung F
Diagnosis of TB
1. ก / ก : (> 3 wk) , , ก , F, กก
2. Chest X-ray: Not specific Not prove active disease, Strongly suggest TB upper zone (apical
r r
post seg. of upper lobe, sup seg. of lower lobe), cavitation calcified shadow
4
3. Acid-fast staining: detect F > 10 AFB/ml, Not specific to M. tuberculosis
4. Culture: Gold standard, sensitivity ก F F AFB (detect F > 103 AFB/ml)
5. Bronchoscopy: F F F F ก F, R/O CA F F, F F
F F massive hemoptysis ก F ก
6. Tuberculin skin test: F F F Dx, infection F F disease, F ก TB
, ก TB ก, F extrapulmonary TB, กF F F ก ก
5. 2) Guillain-Barre syndrome
F weakness quadriplegia generalized weakness ก F ก CNS motor unit ก F F
ก CNS ก conscious/cognitive change, hypertonia, hyperreflexia sensation F F F
neuromuscular cause ก normal mental function, muscle tone ก , reflex ก F
ก neuromuscular cause (nerve, muscle, NMJ) F F F 16. F ( ก F)
1

3. 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 F myocardium F F ก myocardial injury ก
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: ก F , F , F ,
8. 5) Varicella zoster infection
9. 1) S. aureus Pyomyositis ก ก ก ก F F F Quadriceps, Gluteus most common S. aureus
10. 1) TIA ก Transient neurodeficit F F F ก
11. 3) Roxithromycin
Atypical pneumonia Clue F : F , URI กF , CXR: interstitial infiltration
Organism: Mycoplasma pneumonia most common
S/S: Insidious onset F F F F F
Progress ก URI LRI F viral infection
ก ก F ก F ก ก F headache, myalgia, nausea, vomiting,
diarrhea, fatigue, sore throat
CXR: Diffuse interstitial (reticular) infiltration
ก : Macrolide (Erythromycin, Azithromycin, Clarithromycine), Doxycycline
12. 3) F F ก ก electrolyte F hypo ก hyperK, hyperNa
hypoNa F osmolality shift F cell F F brain edema IICP
hypoK F F consciousness ก F
hypoCa F circumoral numbness,
Acute gastric dilatation F F??
SIADH F F hypoNa F F F ก
13. Lead
Lead poisoning: , F , motor neuropathy
• Lead F ferrochelatase ∆-ala dehydratase ก ก F heme F F
MCHC PBS basophilic stippling
• Peripheral motor neuropathy (wrist drop, foot drop)
• F
• Renal tubule damage
• Lead line gingival-tooth border
14. 10% Calcium gluconate
K ก advanced EKG change F protect heart กF
2

4. ก ก HyperK
1. Protect heart : advanced EKG change K > 6.5 mmol/L
F 10% Calcium gluconate ( ก antagonist)
2. Move K F cell : F Insulin + glucose, NB albuterol, (+ NaHCO3)
3. K : F Kayexalate + sorbitol (+ Furosemide, Hemodialysis)
15. 3) Leptospirosis
Murine typhus,
DF, DHF Enteric fever Leptospirosis Malaria
Scrub typhus
Signs and F F F F F F(
symptoms RUQ pain, N/V ก F ( F ) pattern)
Skin Rash, Petechiae Rose spot (rare) Rash (rare) Rash (rare) No rash
Jaundice ก F ก F ± F ก F ± ก F ก
icteric type
F F ± F ± F ± F ±
F F F F
F F
subconjunctival
hemorrhage
Meningitis F rare Aseptic Aseptic F
meningitis meningitis
Lung Effusion infiltration Interstitial Pulmonary edema
(pulm hemorrhage) pneumonia
CBC Hct↑, WBC↓, ก ก WBC↑, neutrophil varies Anemia, WBC↑,
Atyp.lymph↑, F , plt↓ neutrophil F , plt↓
plt↓
U/A RBC ± RBC, WBC,
proteinuria, cast
Others Peyer s patch CPK↑ Eschar
ruptured → Hx F F
pneumoperitoneum
16. 2) Dermatomyositis
Proximal muscle weakness ( ก ก ก)
1. Nerve: sensory, reflex, autonomic involvement ก distal
Guillain-Barre syndrome
• Acute autoimmune demyelination of peripheral nerve
• F recent Campylobacter jejuni infection, viral infection influenza vaccination กF
• weakness ( CN involvement) F ก sensation loss glove and stocking ( F ),
hyporeflexia areflexia, LP
3

5. • ก : Plasmapheresis IVIG ( F role ก F steroid )
Diabetic polyneuropathy
• ก กก axon, Fก chronic hyperglycemia
• Affect motor (mild weakness), sensory (glove and stocking), autonomic F sensory F
2. Muscle: ก F ก F sensation loss ก F hyporeflexia/areflexia
Polymyositis/Dermatomyositis
• Symmetric progressive proximal muscle weakness
• muscle pain, serum CK
• Dermatomyositis = polymyositis + skin involvement (Heliotrope: , shawl sign: F F ก
F , V-sign: F V, Gottron s sign: bony prominent)
• ก : Steroid
Steroid-induced myopathy
• Insidious onset, Hx F steroid F asthma, COPD, rheumatoid
Hypokalemic periodic paralysis
• F F ก F กก ก ก F
(high carbohydrate meal)
• weak serum K
• TFT ก
1) Familial F AD, ก Family Hx, TFT ก
2) Thyrotoxic ก thyrotoxicosis TFT hyperthyroidism
3. NMJ: ก F ก F muscle F fluctuation ( ก ) fatigability ( ก F F )
Myasthenia gravis
• Autoantibody F postsynaptic Ach receptor
• Fก thymoma
• Ptosis, Bulbar involvement F
• Fluctuation and fatigability
17. 5) PFT Asthma F Pulmonary function test FEV1/FVC response F bronchodilator
Abnormal PFT
FEV1/FVC > 70% FEV1/FVC < 70%
Restrictive lung disease Obstructive lung disease
← Bronchodilator
FEV1 > 12% FEV1 < 12%
Asthma COPD
4

6. 18. 2) Thiamine signs CHF (Rt.-sided) + pulmonary edema, LV systolic failure (S3 gallop),
cardiomegaly (Lt.-sided)
F F F F ก ก Cardiac beriberi (ก F → Vitamin B1 (thiamine) → Cardiac beriberi)
ก : F Vitamin B1 (thiamine)
19. 1) Chigger mite Orientia tsutsugamushi
20. 3) Neurogenic shock
CO PCWP SVR ก ก
Hypovolemic Trauma, blood loss, third F isotonic solution
(volume ) space loss, burn ↓ ↓ ↑
Cardiogenic Tension pneumothorax, ก
( ก ก CHF, cardiac tamponade, Dobutamine, dopamine or NE
F F) arrhythmia, MI, structural ↓ ↑ ↑
heart disease
Distributive shock
↑ ↓ ↓
(vasodilate)
Septic Bacteremia F fluid ABO
gram neg. F Swan-Ganz catheter
F dopamine NE
Anaphylactic F , F F Diphenhydramine
F 1:1000 epinephrine F
Neurogenic* Spinal cord injury
* Loss of sympathetic activity CO Cardiac output
= hypotension + bradycardia PCWP Pulmonary capillary wedge pressure F ก LV
SVR Systemic vascular resistance
21. 1) Inhaled Salbutanol prn + inhaled corticosteroid
Management of asthma
PEF Treatment
Day attack Night attack Variability
FEV1
Mild <1/ F <2/ > 80% < 20% SABA ก
intermittent
Mild >1/ F >2/ > 80% 20 - 30% + Inhaled corticosteroid
persistent
Moderate ก >1/ F 60 - 80% > 30% + LABA
persistent ก ก
Severe < 60% > 30% + Theophylline oral
persistent limit activity LABA Leukotriene
modifier oral
corticosteroid
5

7. 22. ASA + Propanolol
Subacute thyroiditis (de Quervain s thyroiditis) F 1. Thyrotoxic phase 2. Hypothyroid
phase 3. Recovery phase F F ก F F ( F ก ก, ) F ก
thyrotoxicosis hypothyroidism ก URI กF F F F ก Fก
F turn hypothyroidism
ก ก F Aspirin high dose NSAIDs ก F ก F steroid F F F ก
thyrotoxicosis F F F β-blocker ( F role ก F antithyroid drug thyrotoxic phase)
23. 1) Simple goiter
24. 3) Thoracic area F UMNL, cord lesion Hyperreflexia, loss of sphincter tone level of sensation loss
F F ก Thoracic area (T10)
25. 1) Atropine
Bradycardia
Airway, O2, monitor EKG, IV
Adequate perfusion Poor perfusion Conscious change, ก ,
BP drop, shock
• Observe, monitor • transcutaneous pacing
• F Atropine 0.5 mg IV F 3
• F Epinephrine Dopamine IV drip
F pacer
26. 1) Anti-HIV oral candidiasis
27. Pacemaker ( F F )
AV black
1st degree AV block PR prolong F (> 0.02 sec 5 F )
2nd degree AV block
Morbitz I PR F ก block 1
Morbitz II PR F ก F F ก block 1
3rd degree AV block Complete A-V dissociation p wave ก QRS
(complete heart block) complex F Fก
• 1st degree 2nd degree Mobitz I ก ก ก supranodal block F ก F junctional
rhythm ( F AV node ก ) F HR 45 (ก )
nd
• ก 2 degree Mobitz II ก ก infranodal block (his, bundle branch) ก turn complete heart block
F idioventricular rhythm (ventricle ก ) HR 20 ( F F ) Mobitz II
rd
3 degree AV block F pacemaker
6

8. 28. 4) Influenza vaccine F F
29. 2) Pancarditis F pericarditis กก F Keyword F rub (friction rub)
ก F friction rub ก ก pleura pericardium F Fก ก F ก
F cardiac friction rub F Fก ก ก F pleural friction rub
30. 1) Cardiac siderosis ก deposit
F Thalassemia F F F กก F ก ก hemochromatosis ก
ก F F กF → heart failure, → cirrhosis/liver failure, F → DM, Pituitary gland
→ hypogonadism, growth retardation
. Choice 4) --
31. 1) Ibuprofen
ก ก Rheumatoid arthritis
• Physical, occupational therapy periarticular muscle
• Drugs
symptoms ก ก
First line Aspirin / NSAIDs ก
Second line Glucocorticoid (joint injection oral)
DMARDs ก
First line Hydroxychloroquine, sulfasalazine, methotrexate active ก
Second line Leflunomide, anti-TNF
Azathioprine, gold, D-penicillamine, cyclosporine, cyclophosphamide
• Surgery severe functional impairment ก deformity
32. 1) Ceftriaxone IV F Aminoglycoside F Gentamycin กก F
Treatment of UTI
Acute cystitis: 3-day therapy
TMP-SMZ F F F Sulfa, ก
fluoroquinolones F F ก F
Acute pyelonephritis
OPD: GPC amoxicillin
GNB fluoroquinolones
IPD: GPC ampicillin
GNB aminoglycoside, cephalosporin (ceftriaxone, ceftazidime), fluoroquinolone
33. 2) Naloxone
F F Fก Organophosphate poisoning
Organophosphate poisoning
• Irreversible inhibit AChE enzyme ก Ach overstimulation
7

9. • 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 F กF muscle fasciculations, cramping, weakness, diaphragmatic failure
• CNS effects: anxiety, emotional lability, restlessness, confusion, ataxia, tremors, seizures, coma
• ก ก
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 F F ก8 nicotinic symptoms
F ก F BDZ
34. 1)
ก ก DM type II (Guideline 2551)
1. FBG < 200 mg/dL HbA1C < 8% → Lifestyle modification 1 3 F F F F start
2. FBG 200 300 mg/dL → Lifestyle modification + start ( ก F )
Metformin Sulfonylurea
ก Insulin resistance: ก Insulin:
2 2
• BMI ≥ 23 kg/m • BMI < 23 kg/m
• BP ≥ 130/85 mmHg F • ก ก
• ก
• TG↑, HDL-C↓ • Postprandial sugar
ก: Glitazone, Repaglinide, α-glucosidase inhibitor, DPP-4 inhibitor
(ก FBS 250 350 mg/dL HbA1C > 9% F 2 F ก )
3. FBG > 300 mg/dL HbA1C > 11% F ก ก ก → F Insulin
FBG 70 110 mg/dL HbA1C < 6.5%
BP < 130/80 mmHg LDL < 100 mg/dL ( F CAD F F F keep < 70 mg/dL)
F F F ก F : keep FBG < 130 mg/dL, HbA1C ≈ 7%
35. 3) PTU
Treatment of Grave s disease ก + ก
ก
1. Antithyroid drugs (PTU, Methimazole)
8

10. • ก ก organification (PTU inhibit peripheral conversion T4 → T3 F)
• ☺ ก ก
• High recurrent rate, serious side effect: agranulocytosis
• Indication: ก, F F ( F PTU กก F ), Thyroid storm, F ก F
ก F , induce euthyroid stage กF RAI Surgery, F long term recurrent
hyperthyroidism F F F
• Methimazole: Half-life กF ก F
• ก F F F F 2 F F L-thyroxine F ก
131
2. Radioactive iodine (I )
• ☺ High cure rate, safe & easy, F ก , F F ก F infertility develop CA
• Hypothyroidism, F ophthalmopathy F , F ก severe thyrotoxicosis / thyroid crisis F
uncontrolled hyperthyroidism ( F กF F euthyroid)
• Indication: First-line treatment , recurrent ก F F , ก( F F F
ก hypothyroid F ก F ก )
• Contraindication / precaution: F / F , F , Low radioiodine uptake, Severe hyperthyroidism,
Active ophthalmopathy, CA thyroid, F F ก , poor compliance
3. Surgery (Subtotal thyroidectomy)
• ☺ก euthyroid stage
• Surgical complications (recurrent laryngeal n. injury, hypoparathyroidism), ก relapse F F
• Indication: F F, ก ก F ก F , Severe Grave s ophthalmopathy, F ,
nd
CA thyroid, F 2 trimester
• Contraindication: previous neck surgery, severe systemic illness, lack of well-qualified surgeons
ก → β-blocker
F ก ก F A. Radioactive iodine, B. Antithyroid drugs, C. Surgery
F 50 ก , moderate B ( F กF ) กก F A, C
hyperthyroidism, new case
F F A
F F A, C ก A
F ก B, (A) F B, C
ก hyperthyroidism B then A, C
36. 1) Free T4 ( F thyrotoxic hypoK periodic paralysis F 16.)
37. 1) 2 wks
38. 5) NB salbutamol ( iv steroid ก F)
ก ก Acute asthmatic attack
1. F oxygen, keep O2 sat > 90%
2. F bronchodilator
F F
9

11. β2-agonist ก nebulizer ก MDI with spacer
F (PEF < 50% F F F accessory muscle)
anticholinergic F ก β2-agonist
3. F Steroid : F IV oral steroid
4. F F antibiotic F bacterial infection
39. 4) Oral itraconazole
Treatment of Tinea unguium
Tinea unguium (Onychomycosis) F Fก ก F F F F F F F F
ก F F กF F F F กF Oral griseofulvin, oral turbinafine, oral itraconazole
40. 1) Psoriasis
• กF (papulosquamous) well-marginated, erythematous plaque with silvery scale ก
extensor surface,
• Koebner s sign positive ก F , Auspitz sign positive ก F ก
• 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 F
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 ) F F F CAD
4. Ergotamine F F F CAD
43. 3) Subarachnoid hemorrhage
Keyword: ก + stiffness of neck
44. 4) Myasthenia gravis ( F 16.)
45. 5) Intravenous immunoglobulin Guillain-Barre syndrome ( F 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
10

12. 47. 5) F F Fก Gout ก ก ก F F Joint fluid inflammatory Needle-
shaped crystal
ก x-ray F ก ก F soft tissue ก ก ก
ก F ก F F ก tophi ก x-ray ก
soft tissue mass F ก ก ก F punch out lesion, overhanging edge กF ก
Gout
• Acute monoarthritis ก 1st MTP joint, midfoot, F , F F , F 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 F chronic tophaceous gout
• ก ก :
o Acute attack: NSAIDs, colchicines, steroid
F F uric acid ก F attack
o ก uric acid (alcohol, diuretics, aspirin, , ก)
o Maintenance: Allopurinol (Xanthine oxidase ก F uric acid)
Probenecid ( ก uric acid )
CPPD (pseudogout)
• Acute monoarthritis ก F F F F
• X-ray: Calcium deposit articular cartilage ก chondrocalcinosis
• Synovial fluid: CPPD crystal F F F rhomboid cuboid weakly positive
birefringence
48. 3) F F Acute monoarthritis ก ก ก F F FF F Fก Crystal-
induced arthritis, Septic arthritis F ก F Synovial fluid F ก ก F ก
Differential diagnosis 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) F F F F กก FF F F F gout ก
F F Acute monoarthritis Fก Crystal-induced arthritis, Septic arthritis, Rheumatoid
arthritis (RA) ก F NSAIDs F RA F ก ก ก ก ก ก F ก กก F
11

13. F ก septic arthritis WBC > 50,000 PMN > 75% ก joint fluid profile gout
pseudogout ก gout F ก F ก ก F F CPPD ก F ก ( F
F ก Dx) ก gout กก F ( F F -_-!)
50. 2) F F Acute fever F ก RUQ pain Infection Inflammation กก F Malignancy F ก
ก , LFT F ALP , Ultrasound Hyperechoic mass กF F F Fก Amebic
liver abscess กก F HCC F F ก F Bile duct dilatation ก CCA F
51. 2) ก ก ก F ก F F Esophagus ก (Rupture) กF
Boerhaave s syndrome content ก ก ก breath sound F Mallory-
Weiss F Upper GI bleed ก ก ก mucosa F F ก ก
52. 3) F F ก F Lower GI bleeding alcohol F ก Hemorrhoids
ก F ก F F F กก Fก ก ก F
ก ก F กF F fiber F F F
53. 1) Pellagra ก กก Niacin (Vit. B3) F alcohol ก ก ก ก 4Ds F กF Diarrhea, Dermatitis,
Dementia, Death ก pigmented scaling
ก ก ก ก F
Nutrient Clinical Finding Contributing Factors to Deficiency
Thiamine Beriberi: neuropathy, muscle weakness and wasting, Alcoholism
cardiomegaly, edema, ophthalmoplegia, confabulation
Riboflavin Magenta tongue, angular stomatitis, seborrhea, cheilosis
Niacin Pellagra: pigmented rash of sun-exposed areas, bright red Alcoholism, vitamin B6 deficiency, riboflavin
tongue, diarrhea, apathy, memory loss, disorientation deficiency
Vitamin B6 Seborrhea, glossitis convulsions, neuropathy, depression, Alcoholism, isoniazid
confusion, microcytic anemia
Folate Megaloblastic anemia, atrophic glossitis, depression, ↑ Alcoholism, sulfasalazine, pyrimethamine,
homocysteine, triamterene
Vitamin B12 Megaloblastic anemia, loss of vibratory and position sense, Gastric atrophy (pernicious anemia), terminal
abnormal gait, dementia, impotence, loss of bladder and ileal disease, strict vegetarianism
bowel control, ↑ homocysteine, ↑ methylmalonic acid
Vitamin C Scurvy: petechiae, ecchymosis, coiled hairs, inflamed and Smoking, alcoholism
bleeding gums, joint effusion, poor wound healing
Vitamin A Xerophthalmia, nightblindness, Bitôt spots, follicular Fat malabsorption, infection, measles,
hyperkeratosis, impaired embryonic development, immune alcoholism, protein-energy malnutrition
dysfunction
Vitamin D Rickets: skeletal deformation, rachitic rosary, bowed legs; Aging, lack of sunlight exposure, fat
osteomalacia malabsorption
Vitamin E Peripheral neuropathy, spinocerebellar ataxia, skeletal Occurs only with fat malabsorption, or genetic
muscle atrophy, retinopathy abnormalities of vitamin E
metabolism/transport
Vitamin K Elevated prothrombin time, bleeding Fat malabsorption, liver disease, antibiotic use
54. F 6.
12

14. 55. 5) F clinical Acute Pulmonary edema F ก Hypertension F F ก ก F F
ก ก ก F Morphine Transient venodilator F Preload F Afterload
Hypertension F F ก ก F ก Dyspnea, Anxiety, Stress, Catecholamine level, Tachycardia
F
* F กก FF กF F F F morphine nitroprusside
56. 1) ก , N/V, , ก ก Digoxin intoxication ก กก ก ก
Hypokalemia F F Furosemide F Hypokalemia F ก Fก ก Digoxin
intoxication
57. 3) F 56 ก Digoxin intoxication ก F กF
58. 2) True Hyponatremia Urine Osm < 100 Primary polydipsia, Beer protomania, Reset osmostat F > 100
ก SIADH ( F ก F ADH function F)
59. 2) Coxsackie B virus virus F ก Dilated cardiomyopathy Systolic function F Fก ก Congestive
heart failure
60. 1) F Platelet < 100,000 F ก Coagulopathy (prolonged PT, aPTT) DIC ก D-dimer F
ก ( ก ) ก
61. 1) HbH disease genotype - - / - α (Heterozygous α-Thal-1 / α-Thal-2) ก F F gene - - ก - α ก F
F ก F F F MCV ( ก 80 - 100) F RBC ก F Thalassemia minor
- - gene (- - / αα) F Fก - α F MCV F F F F Carrier (- α / αα) กก F
62. 1) ก F Methanol intoxication F ( F F F ก F F) ก ก F ก
Metabolic acidosis Methanol Fก F
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 ก F ก Tetrodotoxin ( F ก F F
F )
65. 4) ( F F ) F Candiduria (Candida urine) Bladder thrush Foley s catheter F Bladder
irrigation F Amphotericin B F F F F Foley s F oral Fluconazole
66. 1) F กก ก F กก F ( ก ก ) F signs dehydration
Exertional heat stroke ก ( dehydration ก F F ก Heat stroke F)
13

15. 67. 4) MAHA blood picture DIC, HUS, TTP F Platelet < 100,000 F ก prolonged PT, aPTT
DIC Fก Sepsis ก Bed sore DIC ก
68. 2) ก F HMG CoA reductase inhibitor (ก F Statin) ก ก LDL F Triglyceride F
Drug Major Indications Mechanism Common Side Effects
HMG-CoA reductase Elevated LDL-C ↓ Cholesterol synthesis, ↓ hepatic Myalgias, arthralgias, elevated
inhibitors (statins) LDL receptors, ↓ VLDL production transaminases, dyspepsia
Cholesterol absorption Elevated LDL-C ↓ Intestinal cholesterol absorption Elevated transaminases
inhibitors (Ezetimibe)
Bile acid sequestrants Elevated LDL-C ↑ Bile acid excretion and ↑ LDL Bloating, constipation, elevated
(Cholestyramine) receptors triglycerides
Nicotinic acid Elevated LDL-C ↓ VLDL hepatic synthesis Cutaneous flushing, GI upset,
low HDL-C elevated glucose, uric acid, and
elevated TG liver function tests
Fibric acid derivatives Elevated TG, elevated ↑ LPL, ↓ VLDL synthesis Dyspepsia, myalgia, gallstones,
(Gemfibrozil, Fenofibrate) remnants elevated transaminases
Omega 3 fatty acids Elevated TG ↑ TG catabolism Dyspepsia, diarrhea, fishy odor
to breath
69. 5) F F ก Myocardial infarction Fก 3 ก F Thrombolytic agent F Streptokinase, Tissue
plasminogen activator (tPA) F F F F F ก ก ก F PCI F
14

16. 70. 2) F F Diarrhea ก F Stool examination F ก FF underlying
Cirrhosis Spontaneous (Primary) bacterial peritonitis F DDx. F ก F Abdominal paracentesis
ก F F ก F F F กก F F
71. 4) F F ก Cyanosis Radial pulse F Brachial pulse ก F ก
distal vessels ก กก F proximal vessels Thromboangiitis obliterans (Buerger s disease) Small
to Medium-sized vascular disease
72. 2) F F Acute monoarthritis F F F ก Synovial fluid Septic group (Group III) Septic
3
arthritis WBC Synovial fluid 50,000 /mm F ก ก ก F Empirical
15

17. Antibiotics F Gonococcal arthritis ก F F F WBC 50,000 PMN F
ก F F F F
73. 4) Capillaria philippinensis
74. 3) F ก F F F DVT ก ก F Breath sound
ก Pulmonary embolism
75. 2) F ก Hepatosplenomegaly F ก F F FกF F Hematologic disease CBC
ก Microcytic anemia F ก กF F ก ก F Thalassemia & Hemoglobinopathies
HbH disease ก ก Acute hemolysis ก F Stress F ก
กF
76. 4) F clinical F Fก Hypertensive crisis F BP > 180/120 Hypertensive emergency F
F
77. 1) ก ก Anaphylactic shock F Adrenaline 1:1,000 0.3-0.5 ml Intramuscular (IM) F Vastus
lateralis muscle F
78. 1) F ก ก ก F F pupil ก ก Pin-point pupil
ก Pontine hemorrhage F F ก F F Cerebellar hemorrhage F ก F F
กF( ) F pin-point pupil
79. 4) ก ก F ก Leprosy ( )
80. 4) ( F F ) Diastolic rumbling murmur Opening snap Mitral valve stenosis (MS) ก ก ก ก
F F ก Calcification ก ก Regurgitation กก F
81. 1) ก clinical CXR Cavity Air-fluid level F Fก Lung abscess ก
82. - F Hypokalemia ( ก ก Renal loss) F ก Hypertension F Diuretics,
Hyperaldosteronism, Renal a. stenosis, Cushing s syndrome ก plasma aldosterone/plasma renin activity
(PA/PRA) ratio F F F > 20 Primary hyperaldosteronism F F F ก Primary
hyperaldosteronism ก Renal a. stenosis F
83. 1) F F Penicillin F Diarrhea ก Antibiotic associated colitis (AAC) Pseudomembranous
enterocolitis ก Clostridium difficile ก ก F Metronidazole Drug of choice ( F PO F F F F IV)
F Vancomycin ก F F
84. 4) F ก F ก Hemolytic anemia F F ก F ก F RBC F
F F กF F F ก G-6-PD deficiency ก F G-6-PD screening
85. 2) F ก ก ก 2 ก F F DKA F ก F F IV fluid
Intra & Extravascular volume F ก F Insulin F 50-70 mg/dL/hr
200 mg/dL
86. 1) F DIC prolonged Pt, aPTT F ก coagulation factor F FFP ก F FFP Platelet
F F ก ก Fก ก DIC ก ก F กF ก F
ก Antibiotics (ATB) F F F F F ก DIC ก Sepsis ก ก
Antibiotics
16

18. 87. - F F F Sustained VT
PVC ก 3 ก Triplet PVC F ก 4 ก Nonsustained VT F F PVC F ก ก ก F 30
ก Ventricular tachycardia (VT)
88. 1) ก ก Complete heart block F Atropine Isoproterenol IV HR F block
AV node Fก Pacemaker implantation ก ก AV conducting system disease
Indication
89. 1) ก F Side effect Enalapril ACEI
Drug Class Other Indications Contraindications/Cautions
Diuretics
Thiazides (HCTZ) Diabetes, dyslipidemia, hyperuricemia,
gout, hypokalemia
Loop diuretics CHF, Diabetes, dyslipidemia, hyperuricemia,
(Furosemide) renal failure gout, hypokalemia
Aldosterone antagonists CHF, primary aldosteronism Renal failure, hyperkalemia
(Spironolactone)
K+ retaining (Amiloride, Renal failure, hyperkalemia
Triamterene)
Beta blockers
Cardioselective (Atenolol, Angina, CHF, post-MI, sinus Asthma, COPD, 2nd or 3rd degree heart
Metoprolol) tachycardia, ventricular block, sick-sinus syndrome
Nonselective tachyarrhythmias
(Propranolol)
Combined alpha/beta ? Post-MI, CHF
(Labetalol, Carvedilol)
Alpha antagonists
Selective (Prazosin, Prostatism
Doxazosin, Terazosin)
Nonselective Pheochromocytoma
(Phenoxybenzamine)
Sympatholytics
Central (Clonidine,
Methyldopa, Reserpine)
ACE Post-MI, CHF, nephropathy Renal failure, bilateral renal artery
inhibitors (Captopril, stenosis, pregnancy, hyperkalemia
Lisinopril, Ramipril)
Angiotensin II CHF, diabetic nephropathy, ACE Renal failure, bilateral renal artery
antagonists (Losartan, inhibitor cough stenosis, pregnancy, hyperkalemia
Valsartan, Candesartan)
Calcium antagonists
Dihydropyridines Angina Heart failure, 2nd or 3rd degree heart
(Nifedipine) block
17

19. Nondihydropyridines Post-MI, supraventricular
(Verapamil, Diltiazem) tachycardia, angina
Direct vasodilators
Direct vasodilators Severe coronary artery disease
(Hydralazine, Minoxidil)
90. 2) F Chronic oligoarthritis ก F Crepitus F Fก Osteoarthritis
91. 1) F Uncomplicated UTI ( F underlying structural/neurological disease, pregnancy upper UTI
UTI Complicated UTI) ก ก F Co-trimoxazole (Bactrim) ก F Fluoroquinolone
3 ก
92. 4) Hypercalcemia (Dx. Ionized Ca > 4.5 Corrected Ca > 10.5 mg/dL) Ca ก F 12
mg/dL ก Neuro, KUB ( ), Heart GI ก ก F Fluid F ก ก F Ca ก
F ก F Loop diuretics
93. 2) Migraine headache
F F ก กก F ก ก 4 choices ก 1 choice ( F 42. )
94. 1) 5) F F
18

20. Pediatrics
1. 1) EBV F tonsilar patch, splenomegaly with cervical node enlargement
ก ก ก ก / ก
Diphtheria - F Fก F -Mild pharyngeal injection Specific tx. -Complication:
(Pharyngeal -F ก -Uni/bilateral tonsillar grayish -Antitoxin in 48 hr Myocarditis, polyneuritis,
diphtheria) -ก ก - pseudomembrane (Bleeding -Penicillin G iv × 14d bronchopneumonia
- if scrape) and may extended Prevention -Droplet transmission
- dyspnea wildly to uvula, pharynx, -DTaP or DT -Bull neck = prog. F
larynx, trachea, bronchus etc.
-Cervical lymphadenopathy
(Bullneck F ก)
EBV infection - F (>39°C) -Tonsilar exudates or patch Supportive tx. - Hepatomegaly
(Infectious -Nausea, not -Splenomegaly (hydration,
mononucleosis) vomiting -Generalized acetaminophen)
lymphadenopathy (esp. post. - F F ampicillin
Cervical) amoxicillin ก
-Atypical lymphocytosis rash
GAS (Group A -Fever (>38°C) -Tonsilar yellow blood-tinged Specific tx. -Gold standard ก
Streptococcal -Odynophagia exudates -Amoxicillin × 10d Dx throat swab C/S
pharyngitis) - F ก -Enlarged/tender anterior -Erythromycin ( F
cervical lymph nodes penicillin) × 10d
- F ก GI
Measles -3C -Inflamed buccal mucosa Supportive tx. - FกF F
(conjunctivitis, -Erythematous, nonpruritic, Prevention /
cough, coryza) maculopapular rash -MMR F confluent
- F ก -Koplik spot (white/bluish - F ~ 4d
lesions with an erythematous -AOM, croup,
halo) pneumonia:
-Cervical adenitis complications
2. 2) Pityriasis alba
Pityriasis alba hypopigmented lesion ก round or oval, macular of slightly elevated patched
fine adherent scale ก F, , F proximal portions ก F F
F ก ก F F mild form eczema F ก ก F F vitiligo, tinea
vesicolor tinea corporis ก F lubricant ก F F
Vitiligo F F F F ก ก immunologic abnormalities F antibody F melanocytes
F F 2 generalized localized ก กF 18 F ก generalized form symmetric
pattern of white macules and patches with hyperpigmented margin F vitiligo Fก autoimmune disease
19

21. DM F ก F topical steroid, topical tacrolimus ก F narrow-band UVB
(UVB311)
Pityriasis vesicolor tinea vesicolor ก ก chronic fungal infection stratum corneum ก
Malassezia furfur F normal flora ก F , ก ก, plasma cortisol ,
immunosuppression, malnourishment F F ก hypopigmented macules, covered with a fine
scale KOH ก ก F Spaghetti and meatball ก Selenium sulfide susp., imidazole or
terbinafine cream ketoconazole/itraconazole PO
Tinea facialis ก กก ก ก dermatophyte (Trichophyton, Microsporum,
Epidermophyton) ก dry, mildly erythematous, elevated scaly papule or plaque F ก ก
clear central F annular lesion F KOH filamentous fungus ก
Ketoconazole/clotimazole topical Terbanafine, griseofulvin PO ก Tinea
Contact leukoderm F F F chemical leukoderma ก vitiligo ก กF
satellite lesion F ก ก melanocyte กก
melanocyte ก vitiligo ก
3. 3) foreign body aspiration ก FB F rt. Main bronchus common site for bronchial
foreign body aspiration ก ก ก acute onset ก aspiration
ก partial LRT obstruction (rhochus 2 sibilant rhonchus = wheezing sonorous rhonchus
= rhonchus Fก ) ก ก F ก 3 F ก 1-3 กF F
ก
F F (Stable patient) Plain chest film F Resp. tract obstruction
(segmental atelectasis) opaque foreign body F ก inspiratory and expiratory film F ก
plain CXR ก ก partial obs. ก ball-valve (insp.=air F F, exsp.=air ก F F ก air
trapping) hyperinflation ก , mediastinal shift ipsilateral diaphragm F F ก
ก ก FF fluoroscope bilateral decubitus chest film F ก bronchoscopy F
lateral film F F ก
4. 2) + 5) Hypoglycemia newborn plasma glucose lv. < 40 mg/dl ( F F 45 mg/dl ก whole
blood glucose <50 mg/dl WBG. < PG. 10-15 mg/dl ก F ก DTX F F plasma glucose confirm F ) ก ก
sudden withdrawal of transplacental glucose supply ก 1-3 hr. of life F 12-24 hr. of life
hypoglycemia F ก gluconeogenesis ketogenesis F F preterm, DM mother,
erythroblastosis fetalis, asphyxia SGA
ก F F ก F feeding
F ก (apnea, hypotonia, irritability, irreg. respiration, tremors, eye rolling, seizures, etc.) F IV 10%
glucose 2 ml/kg (rate1 ml/min) ก F ก seizure F 4 ml/kg F F maintain F IV fluid with GPR 6-8 mg/kg/min
(3.6-4.8 ml/kg/h of D10W) recheck ก 15-30 rate/concentration F
20

22. 5. F F ก
F Turner syndrome (45, XO) ก webbed neck, short stature, cubitus valgus, short neck, 1°
amenorrhea multiple congenital anomalies in phenotypic females ก ovarian development
F X chromosome ก ovary Turner syndrome ก ovary
streak ovary F stromal cell 1° amenorrhea ก low estrogen and low progesterone F
gonadotrophin GnRH Fก F F F amenorrhea
6. 4)? F F
Henoch-Schönlein Purpura ก ก small vessel vasculitis ก ก palpable purpuric rash
ก waist buttocks; arthritis ก knees ankles; abdominal pain ก ก vasculitis F GI
tract glomerulonephritis F hematuria proteinuria F ก F F prognosis
U/A ก ก F renal involvement F F ก chronic hypertension CRF F
7. Polyarteritis nodosa? ( F F ก ก F F F F ก)
necrotizing vasculitis small medium sized arteries 9 F F
ก F ก URI, Group A Strep. Infection chronic hepatitis B F F ก F F
กF ก mesenteric a. inflammation F F renovascular arteritis F
purpura, edema and linear erythema wih palpable, painful nodule arteries ก ก
neuro, cardio F F ก F biopsy skin lesion ก oral/IV corticosteroid
8. 5) ก กก F pathological jx. jx. ก 24 hr. ก; jx unconj.bili. > 12.9 mg/dl term
> 15 mg/dl preterm; conj.billi. > 2 mg/dl; bili. lv > 5 mg/dl/d jx. ก F 1 wk term ก F 2 wk
preterm F pathological jx.
ก ก ABO incompatibility ก F O, jx. 1st 24 hr ก ก
anemia F ก hemolytic anemia ก ก F sepsis jx. 1st 24 hr F F ก
anemia F F ก F ก sepsis sign F jx. F F F ก F (
4 hr F PROM F prolong F risk F infection)
Jx. of prematurity ก 3-4 F ( F physiologic jx.)
ก G6PD def. F ก mutation promoter region UDP-glucuronyl transferase-1 ก F
ก กก G6PD def. jx. F ก hemolysis F F Thalassemia F F
neonatal jaundice
9. F F
10. 2) F 1( F Diphtheria F F F patch ก ก tonsil) F candidiasis ก white
plaque immunocompromised host
11. 5) F ก F asthma exacerbation ก severe exacerbation ก
dyspnea, retraction, accessory muscle use, tachypnea, mental status change, poor air entry. ก ก F O2
supplement F inhaled bronchodilator SABAs (Short-acting inhaled β2 agonist- albuterol, salbutamol, levalbuterol)
ก 20 1 ก ก F ก F 1st inhaled β-agonist F inhaled ipratropium
F ก F SABA F ก F F expiratory wheezing F ก F inhaled
ipratropium F systemic corticosteroids F F F
21

23. ก ก ก F intramuscular injection of epinephrine β-agonist
Mucolytics, chest physical therapy spirometry F asthma exacerbation F ก severe
bronchoconstriction F
12. 3) ก splenectomy F ก ก F parasite encapsulated bacteria ก
F F F ก ก opsonized (ก ก complement C3b ก ) ก
กก ก F ก F Ab F T cell-independent antigen F polysaccharide F capsule
F
ก F Pneumococcal vaccine (S. pneumoniae), meningococcal vaccine (N. meningitides)
H. influenzae type B vaccine กF ก F 2 F ก ก postsplenectomy sepsis F
meningococcal vaccine serotype B (serotype F ) F F
Pneumococcal vaccine H. influenzae vaccine
F F Oral penicillin V prophylaxis F ก 2 ก splenectomy F
F F F F
13. 1) abdominal tumors ก ( F 14)
14. 1) Wilms tumor F ก abdominal mass, abdominal pain, hematuria vomiting F F 15-25 F
Hydronephrosis ก ก obstructive uropathy ก recurrent UTI F F F pyuria F F
TUMOR AGE CLINICAL SIGNS LABORATORY FINDINGS
Wilms Preschool Unilateral flank mass, aniridia, Hematuria; bone scintigraphy (clear
(1 - 5 yr) hemihypertrophy cell sarcoma)
Neuroblastoma Preschool GI/GU obstruction, raccoon eyes, Increased VMA;increased
(median age 2 yr, myoclonus-opsoclonus, diarrhea, skin HVA;increased ferritin; stippled
almost < 5yr nodules (infants), mass may cross calcification in mass.
midline 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 Increased hCG;Increased AFP
Boys:testicular mass, new-onset
hydrocele
Sacrococcygeal mass/dimple
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) F ก F anemia jaundice lab NCNC RBC reticulocyte count ก ก
hemolytic anemia F F 2ก F 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 F Coomb s
test F negative positive
22

24. Inclusion test F supravital stain F inclusion bodies HbH ก ก
HbH disease (--/-α) Coomb s test F F negative กF F ก ก hemoglobin
typing, G6PD def. screening
F bone marrow aspiration F ก bone marrow response (RC ) F
bone marrow defect F ก investigation ก F F F anemia F bone
marrow aspiration ( algorithm ก 5 anemia in children)
16. Adrenaline (Epinephrine)
anaphylaxis ก กก potent active mediator ก mast cells basophils F F
ก F (urticaria, angioedema, flushing), (bronchospasm, laryngeal edema), CVS
(hypotension, arrhythmias, MI) GI (nausea, colicky abdominal pain, vomiting, diarrhea) IgE mediated immune
response F ก exposed F antigen F ก F F ก ก F
F F F F ก IM epinephrine F F กF IM or IV H1 and H2 antihistamine antagonists,
oxygen, IV fluids, inhaled β-agonists corticosteroid F F biphasic anaphylaxis F 4 hr
observe F F 4 hr กF D/C ก ER
17. 2) ก F F F sepsis ( SIRS + suspected/proven infection) F ก DIC (low platelet with
prolong PT and PTT with clinical bleeding) F ก shock ก management DIC ก กF
F antibiotic กF กF ก F ก septic shock ก F fluid resuscitation
F F management ก F FFP, platelet conc. PRC F clinical bleeding
F plt. conc. → FFP → PRC ( F control bleeding F FกF F ) clinical bleeding Fก
management ก control DIC ก ก sepsis กก F ก control bleeding
SIRS systemic inflammatory response syndrome 2 ก4 F F
• Core temp. >38.5 °C < 36 °C ( ก, ก , F ก central catheter)
• Tachycardia (mean heart rate > 2SD above normal for age) ก F กF 1 persistent
th
bradycardia ก F ½ hr (mean heart rate<10 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 F ecchymosis F coagulopathy ก F ก ก vit K ก
F F F vit K 1 mg IM Fก F vit K ก vit K def. F ก กก 3
• Classic hemorrhagic disease of the newborn ก 1 -14 ก ก vit K F ก vit K F
ก F F F ก กก F F ก ก F ก F vit K2 ก F sterile
ก ก F ก vit K F F ก กก ก F F Vit K 1 mg IM
• Late VKDB (Vit K-def. bleeding) ก 2-12 F ก F 6 ก F
ก vit K F F cholestatic liver disease
23

25. • ก ก F ก F F warfarin, phenobarbital, phenytoin F ก F
ก ก vit K
ก vit K def. GI bleeding, mucosal and cutaneous bleeding, bleeding umbilical stump
post-circumcision site F Intracranial bleeding F F F ก
19. 1) ก F F F nephrotic syndrome (ก nephritic syndrome heavy proteinuria: >3.5 g/d
2
F F > 40 mg/m /hr, hypoalbuminemia: <2.5g/dl, edema hypercholesterolemia) ก proteinuria,
edema hypercholesterolemia ( F กก oval fat body ก UA) edema nephrotic syndrome
F F F F F ก massive urine protein loss F ก hypoalbuminemia F plasma
oncotic pressure F fluid ก IV compartment interstitial space
20. 5) ก F FF F F Reflex syncope Neurocardiogenic syncope ก กก
peripheral sympathetic activity venous pooling F ก myocardial contraction of a relatively empty lt.
ventricle ก F myocardial mechanoreceptor vagal afferent nerve fiber F sympathetic activity ก F
parasympathetic activity
Syncope Fก ก F ก F F F ,
ก F, extreme fatigue, severe pain, hunger, prolonged standing, emotional or stressful situations
ก ก F F F F F F F
ก กก ก F ก ก F F F ก EKG F ก
F arrhythmia F ก ก Holter monitor F blood sugar ก hypoglycemia F
F F F ก DM F insulin F
ก Harrison s Principle of Medicine, 17th edition.
21. F ( ก ก F ก ก ; 6 ก. . 2551 )
24

26. LTBI = Latent tuberculosis infection ก F ก , TT F ก, CXR ก ( ก F
TB กF ) ( ก F F HIV ) LTBI ก ก TB F 1-2
host F กF 5 ( F < 2 ), F ก , กก ก F
F Isoniazid 6-9
ก LTBI ก F F
1. ก ก F ก F F ก 5 , TT reaction > 15 mm. 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 F ก (TT ≥ 10 mm.)
4. Recent converter (TT ก ก 6 mm.)
25

27. ก TB F criteria ก ก F ก F F ก F F
F F 2 F
1. ก F F
2. ก
3. ก กก
4. ก F ก AFB F ก
22. 2) ก F F F ketoacidosis ก ก electrolyte F HCO3 ก ก
ketone F ก ก ketoacidosis F ก F ก F F (ก F ก starvation, alcohol
DM) F F F DKA ก ก F ก ก F IV fluid ก
F ก F poor perfusion ก F 10-20 ml/kg IV bolus 0.9% NaCl or LRS F ก volume
expansion F F F ก F Insulin drip at 0.1U/kg/hr 1 g/kg IV push for cerebral edema
F 2 ก ก hypokalemia F ก F Potassium กF F F ก กF
F F ก F HCO3 F pH < 7.0
23. 2) delivery room ก term infant with meconium staining hypopharyngeal suction ก กF F
F ก กก distress F ( F hypoxia, bradycardia, fetal acidosis or apnea) ก
endotracheal intubation suction F endotracheal tube meconium ก ก F
ก preterm infant < 34 wk F ก IUGR F, meconium F purulent fluid
ก infection bile stained ก ก proximal intestinal obstruction
24. 3)? F 18 F F F anemia F jaundice bulging of AF intracranial
bleeding ก F sepsis F SIRS F F SDH F F ก F seizure F
25. Rubella
ก Congenital infection F
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.
26

28. 26. 1) ก ก F hypoxic spells (Paroxysmal hypercyanotic attacks) ก TOF ก
ก F 4 F Fก TOF F F cyanosis ก cyanosis
ก ก progressive pulmonary stenosis F ก F pansystolic murmur at lt. parasternal border*
F TOF lt. lower parasternal border ( ก TOF murmur ก SEM at lt. upper parasternal
border)
Hypoxic spells ก F ก F 1-2 F ก ก ก F ก
ก F F กF F F ก ก กก already compromised pulmonary
blood flow ( ก infundibular spasm) F ก systemic hypoxia metabolic acidosis
ก ก F F Knee-chest position peripheral vascular resistance F F ก F
O2 F MO F ก 0.2 mg/kg sc. F F F infundibular spasm F NaHCO3
metabolic acidosis F systemic vascular resistance F phenylephrine, levophed ketamine
F ก ก F β-blocker ก ก ก palliative Sx.
modified Blalock-Taussig shunt กF definitive Sx.
Breath-holding spells ก F 6 2 ก กF F ก ก ก ก F F
F ก F ก F F 30 F
ก F ก Fก F ก ก ก F F F cyanosis
กF F F F F
Asthmatic attack F F F F F severity ก F asthma F F wheezing F
F cyanosis กF F F F murmur F pulmonary embolism F F U/D
condition F F F adventitious sound กก F F murmur
* F ก PSM @ Lt. parasternal border cyanotic heart F F F
Tricuspid atresia ก 1 , truncus arteriosus ก F ก ก 1
F VSD PSM F F F F F
27. 5) Retropharyngeal abscess F F 1-6 ก ก ก F ( F F ก
ก ก foreign body) ก ก ก mixed organism ก irritable, fever, ↓food intake ก ก
ก F (muffled voice) ก ก drooling airway obstruction F กก
posterior pharyngeal wall ก F lat. neck film retropharyngeal space ( C2 >
rd
7mm, or C6 > 14 mm) ก ก F F IV antibiotic (3 gen. Cephalosporin + ampicillin-sulbactam or clindamycin)
± surgical drainage
Acute tracheitis (Bacterial tracheitis) ก ก Viral URI laryngotracheitis (croup) ก ก ก
S. aureus F life-threatening condition F ก airway obstruction F 5-7 ก typical
brassy cough, high fever toxicity with respiratory distress purulent secretion F F F
drooling F dysphagia ก ก F epinephrine F F ก clinical ก F ก epiglottitis
ก ก F F IV antibiotic F O2 supplement intubation
Acute epiglottitis ก 2-7 ก ก ก H. influenzae type B (Hib) F F F
F F ก ก S. pyogenes, S. pneumoniae, S. aureus F ก ก Hib F ก typical ก
27

29. fever, irritability, sore throat, drooling, muffled voice, rapidly progressive stridor, respiratory distress F
F F F F ก erythematous and swollen epiglottis thumb sign ก
ก ก secure airway F ก F ก ก F IV line placement
F ก F F ก F secure airway F F ก F IV antibiotic
Viral Croup (Laryngotracheobronchitis Laryngotracheitis mild form croup) ก ก 1-3
F ก ก กก parainfluenza virus type 1-3 F ก ก F F กF ก F
1-3 กF ก upper airway obstruction ก barking cough, hoarseness inspiratory
stridor F ก coryza, normal-mod. Inflamed pharynx slightly ↑RR ก ก dyspnea, marked
↑RR, cont. stridor, cyanosis, hypoxia, pallor ก ก ก airway management
ก ก ก F F F F ก ก F ก F ก ก ก F
F F F ก F NPO ก ก ก F O2 humidification
F ก F Nubulized epinephrine ก ก moderate-severe croup (stridor at rest, possible need for intubation,
respiratory distress and hypoxia) ก constriction precapillary arterioles F β-adrenergic receptors F ก
resorption interstitial space ก laryngeal mucosa F ก F oral corticosteroids
F ก F ก F F F ก F antibiotics croup
Acute laryngitis ก ก ก ( ก F diphtheria) ก ก UTI sore throat, cough
ก F ก ก F ก F ก F ก pharyngeal
inflammation F F inflammation vocal cord subglottic tissue F F laryngoscope
28. 3) F F กก F 1 ก F F F F ก F F
F F F F F ก F 1 F F DTP4, OPV4, JE
F
กก 2m 4m 6m 9m 12 m 18 m 2-2½yr 4-6 yr 12-16 yr
BCG, DTP1, DTP2, DTP3, MMR1 DTP4, JE3 DTP5, dT ก
HBV1 OBV1, OPV2 OBV3, OPV4 OPV5, 10
HBV2 HBV3 JE1 JE2 F ก 1-4 wk MMR2
29. 2) F preterm GA 32 wk F dyspnea ก RDS Fก ก
กก surfactant กก F ก surfactant F ก dipalmitoyl
phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins cholesterol ก ก F ก
F ก type II alveolar cell F surfactant surface tension alveoli F ก ก collapse
small air spaces ก ก F F ก dipalmitoyl
phosphatidylcholine lecithin
ก ก RDS DM, C/S delivery, precipitous delivery, asphyxia ก กF
F F กF F PAH PIH, F heroin, PROM ก F steroid
prophylaxis
30. 1) F 1
31. 1) F 21
28

30. 32. F F >< FF diarrhea
Congenital Lactase deficiency F ก ก F ก ก primary adult type hypolactasia
secondary lactose intolerance กก F ก กก small bowel mucosal damage F ก celiac disease
rotavirus infection ก F ก F F ก ก ก ก
ก ก F
Antibiotic-related diarrhea ก ก F antibiotic F กF amoxicillin, ampicillin, amoxicillin-
clavulanate, cefepime, clindamycin, doxycycline, erythromycin F F F ก ก ก F antibiotic
ก F broad spectrums Fก F F F C. difficile ก
overgrowth F ก diarrhea F F pseudomembrane ก F psuedomembranous colitis
ETIOLOGY SIGNS AND SYMPTOMS DURATION ASSOCIATED FOODS TREATMENT
OF ILLNESS
Bacillus cereus Sudden onset of severe 24 hr Improperly refrigerated Supportive care
(preformed nausea and vomiting. Diarrhea cooked or fried rice,
enterotoxin) may be present. meats
Campylobacter jejuni Diarrhea, cramps, fever, and 2 10 days Raw and undercooked Supportive care. For
vomiting; diarrhea may be poultry, unpasturized severe cases, antibiotics
bloody. milk, contaminated such as erythromycin and
water quinolones may be
indicated early in the
diarrheal disease.
Guillain-Barré syndrome
can be a sequela.
Enterohemorrhagic E. Severe diarrhea that is often 5 10 days Undercooked beef Supportive care, monitor
coli (EHEC) including bloody, abdominal pain and especially hamburger, renal function,
E. coli O157 : H7 and vomiting. Usually, little or no unpasteurized milk and hemoglobin, and platelets
other Shiga toxin fever is present. More common juice, raw fruits and closely. E. coli O157 : H7
producing E. coli in children <4 yr old. vegetables (e.g., infection is also
(STEC) sprouts), salami associated with hemolytic
(rarely), and uremic syndrome (HUS),
contaminated water which can cause lifelong
complications. Studies
indicate that antibiotics
may promote the
development of HUS.
Enterotoxigenic E. coli Watery diarrhea, abdominal 3 to >7 days Water or food Supportive care.
(ETEC) cramps, some vomiting contaminated with Antibiotics are rarely
human feces needed except in severe
cases. Recommended
antibiotics include TMP-
SMX and quinolones.
Salmonella spp. Diarrhea, fever, abdominal 4 7 days Contaminated eggs, Supportive care. Other
cramps, vomiting. S. typhi and poultry, unpasteurized than for S. typhi and S.
S. paratyphi produce typhoid milk or juice, cheese, paratyphi, antibiotics are
29