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ศรว 51 ANS By Cmu
 

ศรว 51 ANS By Cmu

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step2 ครั้งที่ 1

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    ศรว 51 ANS By Cmu ศรว 51 ANS By Cmu Document Transcript

    • F กก F F F ก ก ก F F ก F ก Fก Fก F ก F กF F F F F F กก F F F F ก F F F ก F กF . F F , . F, .ก กก F ( F ), Med, 002, ก 014, 074, 085, 095, 118, F Lulu 126, 155 F F F ก F F ก F ก ก F F ก F F ก ก F F F F ก ก F F F ^__^ ก 4707xxx Chiangmai Medical School
    • 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
    • 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
    • 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
    • • 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
    • 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
    • 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
    • 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
    • • 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
    • • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • with insidious onset contaminated raw fruits not indicated unless there characterized by fever, and vegetables (alfalfa is extra-intestinal spread, headache, constipation, sprouts, melons). S. or the risk of extra- malaise, chills, and myalgia; typhi epidemics are intestinal spread, of the diarrhea is uncommon, and often related to fecal infection. Consider vomiting is not usually severe. contamination of water ampicillin, gentamicin, supplies or street- TMP-SMX, or quinolones vended foods. if indicated. A vaccine exists for S. typhi. Shigella spp. Abdominal cramps, fever, and 4 7 days Food or water Supportive care. TMP- diarrhea. Stools may contain contaminated with SMX recommended in blood and mucus. human fecal material. the U. S. if organism is Usually person-to- susceptible; nalidixic acid person spread, fecal- or other quinolones may oral transmission. be indicated if organism Ready-to-eat foods is resistant, especially in touched by infected developing countries. food workers, e.g., raw vegetables, salads, sandwiches. Staphylococcus Sudden onset of severe 24 48 hrs Unrefrigerated or Supportive care. aureus (preformed nausea and vomiting. improperly refrigerated enterotoxin) Abdominal cramps. Diarrhea meats, potato and egg and fever may be present. salads, cream pastries. Vibrio cholerae (toxin) Profuse watery diarrhea and 3 7 days. Contaminated water, Supportive care with vomiting, which can lead to Causes life- fish, shellfish, street- aggressive oral and severe dehydration and death threatening vended food typically intravenous rehydration. within hours dehydration. from Latin America or In cases of confirmed Asia cholera, tetracycline or doxycycline is recommended for adults, and TMP-SMX for children (<8 yr). Vibrio vulnificus Vomiting, diarrhea, abdominal 2 8 days Undercooked or raw Supportive care and pain, bactermia, and wound shellfish, especially antibiotics; tetracycline, infections. More common in the oysters, other doxycycline, and immunocompromised, or in contaminated seafood, ceftazidime are patients with chronic liver and open wounds recommended. disease (presenting with exposed to seawater bullous skin lesions). Can be fatal in patients with liver disease and the immunocompromised. Yersinia enterocolytica Appendicitis-like symptoms 1 3 wk, Undercooked pork, Supportive care. If and Y. (diarrhea and vomiting, fever, usually self- unpasteurized milk, septicemia or other pseudotuberculosis and abdominal pain) occur limiting tofu, contaminated invasive disease occurs, 30
    • primarily in older children and water. Infection has antibiotic therapy with young adults. May have a occurred in infants gentamicin or cefotaxime scarlitiniform rash or erythema whose caregivers (doxycycline and nodosum with Y. handled chitterlings. ciprofloxacin also pseudotuberculosis. effective). Rotavirus Vomiting, watery diarrhea, low- 4 8 days Fecally contaminated Supportive care. Severe grade fever. Temporary lactose foods. Ready-to-eat diarrhea may require fluid intolerance may occur. Infants foods touched by and electrolyte and children, elderly, and infected food workers replacement. immunocompromised are (salads, fruits). especially vulnerable. ก Nelson Textbook of Pediatric, 18th ed. 33. 4) croup - F 27 34. 1) F ก F 33. 35. 3) ก F Neonatal mastitis ก term F 2 3 ก ก F swelling, induration tenderness F F erythema warmth F F F purulent discharge ก nipple ก ก ก S. aureus, coliform bacteria (included anaerobes), group B streptococcus ก ก F ก subcutaneous tissue F ก systemic infection F ก ก ก ก F ก (mild cellulitis, no fluctuation) C/S F nipple discharge F F antibiotic F sensitivity F F ก F F cloxacillin + aminoglycoside F cefotaxime ก ก F admit ก F fluctuation drainage F 36. 1) ก F F F antibiotic-associated diarrhea ก ก overgrowth C. difficile ก F ก F ก ก F ampicillin, clindamycin cephalosporin ก ก F F ก F F F F F F metronidazole PO 7-10 F 37. 4) ก F FF ก ก primary hemostasis ก ก (epistaxis, menorrhagia, petechiae, ecchymoses, occasional hematomas, and less commonly, hematuria and gastrointestinal bleeding) ก F ก ก secondary hemostasis F hemophilia ก ก ก F กF F (ecchymosis, extensive hematoma) ก primary hemostasis F F ก 2 F ก vessel (Henoch-Schönlein purpura, vit. C def., collagen disease, etc.) ก platelet ก (quantitative) (qualitative) ก CBC F กF ก F PBS ก confirm CBC F plt. F F ก ก ก ก ก function ก F F bleeding time F กF ก primary hemostasis F ก F F F ก ก plt. vessel F F F F F F F กF F F F ก ITP ก F ITP ก viral infection กF 1-4 wk กF clinical bleeding ( F ก ก immune reaction) ก ก ก F ก F hepatosplenomegaly, lymphadenopathy ก ก F leukemia กก F ITP F CBC F series ก plt. ( ก F bleeding ก 31
    • anemia F) ก PBS F F blast cell platelet F F ก bone marrow F series ก megakaryocytes ก ก ITP F ก F IVIG, Prednisolone, IV anti-D ( F F Rh +ve) F 3 severe life-threatening acute ITP Chronic ITP plt. < 30,000/mm กF 1 F F ก ก 3 ก clinical bleeding plt. < 20,000 /mm F ก F plt. contraindication ITP ก F life- threatening bleeding DHF F petechiae, ecchymosis F F clinical course F DHF ก fever phase F 4-6 F F shock or hemorrhagic phase (1-2 d) F F ก shock F F F convalescent phase (1-3 d) convalescent rash APDE Acquired platelet dysfunction with eosinophilia F ก F ก F ก ก F ก ก ก ecchymosis CBC eosinophilia ก ก F F prolonged bleeding time F ก F ก parasite ก F ก F antiparasitic drug ก 38. 1)? ก seizure F ก F F seizure กกF F jitteriness ก ก F F non convulsive apnea F F sepsis F ก ก กก ก ก F F F seizure seizure F F hypoxic-ischemic cerebral injury, Intracranial hemorrhage, neonatal cerebral infarction, metabolic abnormalities (Hypoglycemia, hypocalcemia, hypoMg, HypoNa, hyperNa), infection, inborn errors of metabolism F rule out hypoxia ก clinical ก ก glucose level ก DTX ก hypoglycemia plasma glucose lv. confirm ( F F F C/S F indication F fetal distress? CPD? Fail V/E or F/E?; ก ก F macrosomia IUGR ก F 2 F F guide F ก ) 39. RDS newborn dyspnea F กF a. RDS Hyaline membrane disease F ก preterm ก surfactant ก ก chest wall compliance preterm F F ก GA ก ก ก F 2-4 กก ( กก 6 F F ก ก RDS) ก ก 48 ก ก F ก ก F ก F ก ก 48 F CXR diffuse reticulogranular pattern with superimposed air bronchograms, hypoaeration with loss of lung volume ก ก lung density heart density ก F white-out lung F lung haziness ก ก diffuse atelectasis pulmonary edema ก F prenatal corticosteroid กF F ก F b. Transient tachypnea of the newborn (TTNB) F ก ก delay lung fluid clearance กก F ก กF ก term, near term C/S precipitate labor, M>F ก ก F ก ก 2-3 CXR lung fluid ก pleural effusion sun burst appearance ก ก lymphatic vessel c. Meconium aspiration syndrome (MAS) F 15% ก meconium stained AF F ก ก ก ET intubation ก dyspnea ก ก 6 ก F meconium ก F 2-3 กF meconium stained , F ก post-term, IUGR CXR diffuse coarse density, area of hyperinflation, air trapping pneumothorax F F 32
    • d. Persistent pulmonary hypertension (PPHN) ก severe and prolonged hypoxia F ก met. acidosis F pulmonary vessel constriction ก pulmonary hypertension F F ก กF hypoxia F F F FiO2 40. 5) F F drowning management F ABCDE F F respiratory insufficiency F ก drowsiness intubation F positive end-expiratory pressure ก pulmonary edema ( F F F F steroid diuretics ก ) 41. ITP? F 37. 42. 2) Guillain-Barré syndrome (GBS) postinfectious demyelinating polyneuropathy ก ก nonspecific viral infection 10 ก ก GI (esp. C. jejuni) respiratory tract (esp. M. pneumoniae) ก typical ก F ก lower extremities F ก F trunk, upper limbs bulbar m. ก pattern F Landry ascending paralysis ก involve proximal & distal m. F ก onset F ก F F ก lab F CSF study protein ก F ก กก F 2 F , glucose lv. ก F cell กก F ก motor nerve conduction velocity F F ก F sensory nerve velocity F EMG ก acute denervation of muscle ก muscle biopsy F ก ก ก F IVIG, plasmapheresis immunosuppressive drug (steroid F F F ) Supportive care respiratory support etc. ก ก F 2-3 wk ก กก ก DTR ก F Beriberi ก 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 ก ก ก cardiomegaly F ก EKG ↑QT interval, inverted T waves, low voltage ก Fก ก high-output cardiac failure F ก ก peripheral neuropathy DTR↓ 43. 2) F F organophosphate ก ( F F diaphoresis F F dysphoresis) Toxidrome Representative Most Common Findings Additional Signs and Potential Interventions Agent(s) Symptoms Opioid Heroin CNS depression, miosis, Hypothermia, Ventilation or naloxone respiratory depression bradycardia. Death may Morphine result from respiratory arrest, acute lung injury Sympathomimetic Cocaine Psychomotor agitation, Seizures, Cooling, sedation with mydriasis, diaphoresis, rhabdomyolysis, benzodiazepines, hydration Amphetamine tachycardia, hypertension, myocardial infarction hyperthermia Ephedrine Death may result from seizures, cardiac arrest, hyperthermia Cholinergic Organophosphate Salivation, lacrimation, Bradycardia, Airway protection and 33
    • insecticides diaphoresis, nausea, miosis/mydriasis, ventilation, atropine, vomiting, urination, seizures, respiratory pralidoxime (only in Carbamate defecation, muscle failure, paralysis Organophosphate insecticides fasciculations, weakness, poisoing) bronchorrhea Death may result from respiratory arrest from paralysis, bronchorrhea, or seizures Anticholinergic Scopolamine Altered mental status, Seizures, dysrhythmias, Physostigmine (if mydriasis, dry/flushed skin, rhabdomyolysis appropriate), sedation with Atropine urinary retention, decreased benzodiazepines, cooling, bowel sounds, Death may result from supportive management hyperthermia, dry mucous hyperthermia and membranes dysrhythmias Salicylates Aspirin Altered mental status, Low-grade fever, MDAC, alkalinization of the respiratory alkalosis, ketonuria urine with potassium Oil of wintergreen metabolic acidosis, tinnitus, repletion, hemodialysis, hyperpnea, tachycardia, Death may result from hydration diaphoresis, nausea, acute lung injury vomiting ก Tintinalli's Emergency Medicine, 6th ed. 44. 3) Congenital diaphragmatic hernia ก respiratory distress (tachypnea, grunting, accessory muscles usage, cyanosis) ก F F ก (honeymoon period) F 48 scaphoid abdomen, increased chest wall diameter F bowel sound decreased breath sounds bilaterally (or ipsilaterally) F PMI CXR with nasal gastric tube F confirm dx. ก ก F F F respiratory support (ET intubation, sedation, probably paralysis) F hyperventilation F PaCO2 45-60 mmHg (permissive hypercapnia), pH >7.3 Situs inversus abdominal organs, lung lobation atrium F F ก F dextrocardia F F ก TE fistula F ก F ก VACTERL syndrome F ก ก frothing bubbling ก ก , respiratory distress ก feeding ก F ก F ก ก regurgitation ก aspiration gastric content F distal fistula F ก pneumonitis early-onset respiratory distress ก F NG OG tube F pass F F ก Esophageal atresia ก polyhydramnios ก CXR with NG/OG tube coiled feeding tube in esophageal pouch air stomach Fก F ก TEF ก ก F F F prone position ก gastric secretion F distal fistula intermittent esophageal suction ก aspiration ก blind pouch F ET intubation with mechanical ventilation F 45. 4) Eisenmenger complex (syndrome) ก F VSD partially totally right to left shunt ก pulmonary vascular disease ก ( ก ก ADS, AVSD, PDA left-to-right-shunt anomaly ) ก F ก ก F F right heart failure edema, hepatomegaly F ก F 34
    • RV impulse PSM RV LV ก P2 ก F Diastolic rumbling murmur left upper sterna border ก PR F ก F Graham Steel s murmur Pulmonary embolism F F U/D F lung F F adventitious sound (localized crackles) sign of dyspnea, diaphoresis, chest pain AR F diastolic rumbling murmur upper and mid left sternal border radiation to the apex and the aortic area F F ก Hypoxic spell: F 26. 46. 2) F nonbilious vomiting Hypertrophic pyloric stenosis ก F 2-8 F F ก ก progressive nonbilious emesis ก ก F RUQ mass peristalsis epigastrium F ก กก F F ก chronic malnutrition dehydration with hypochloremic alkalosis F ก F Duodenal atresia complete obstruction of duodenal lumen ก maternal polyhydramnios, bilious projectile emesis abdominal distension ก 24-48 ก plain abdomen double bubble sign 47. 4) ก F ก hyperthyroid F ก F Fก Grave s disease lab ก F F TSH↓, FT4↑ antithyroglobulin ก ก ก ก F (methimazole, PTU) 48. 2) Chickenpox or varicella incubation period 2-3 wk F F F F 48 กF vesicular rash vesicles F ก ก 49. 1) F 22 50. 4) F 12 51. 2) ก F meningitis ก ก ก ก bacteria ก ก ก F ก F ก ก ก F F ก ก F F ก tense and bulging fontanel F ก F F ก F ก signs of meningeal irritation stiff neck (>1 yr), Kernig s sign Brudzinski s sign sign of IICP F ก LP CSF ก ก F F F F signs of IICP etc. F F 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 Ampi + 3rd gen ceph 1 3 yr: H. influenzae, S. pneumoniae, N. meningitidis Ampi + 3rd gen ceph 3 15 yr: S. pneumoniae, H. influenzae, N. meningitidis PGS or 3rd gen ceph. + Vanco typical appearance F purpuric rash ก meningococcal septicemia (embolic phenomenon) F ก ก CFS ก ก F ก Fก ก F post-exposure antibiotic F F rifampicin ก ก contact N. meningitidis Fก ก ก F 4 contact ก H. influenzae 52. 4) F 5 35
    • 53. 2) F 4 54. ? F F F F F subdural hematoma ก ก ก ก subdural hematoma leukocytosis with neutrophilia F infection induced DIC? 55. 4) ก F F acute bacterial rhinosinusitis ( F F F foreign body obstruction ก F F 2 F F F ) F กFก ก ก ก F ก ก ก F ก F F 5-7 F ก 10 ก F F F ก ก /ก F ก ก Fก F ก F ก ก F 10 ก ก F F 14 F F st ก ก 1 line F Amoxicillin 45- 50 MKD PO bid ก F F drug resistance S. pneumoniae ( F antibiotic 1-3 , F daycare < 2 ) F 80-90 MKD PO bid ก F amoxicillin F F F nd cephalosporin F 2 gen. cephalosporin (cefuroxime, ceprozil) ก F cephalosporin F F F erythromycin, clarithromycin, azithromycin cotrimoxazole 2 line F กF Amoxicillin/clavulanate, 2nd gen. cephalosporin, 3rd gen cephalosporin (cefpodoxime, cefdinir) nd ก F amoxicillin cephalosporin F clarithromycin, azithromycin F ก F ก F F F ก F ก ก F 1st line antibiotic กF F ก 3-7 F F F F F ก7 ก F nd F 2 line F F F F 2 ก 1-5 F response F compliance F ( ก clinical ก ) F ก F PNS film F ก F Fก ก Fก ก F F ก FF ก F ก F bacterial rhinosinusitis F ก 3 F F speculum examination ก F foreign body F( ก F foreign body ก ) 56. 3) Motor Adaptive Language Social 2m ก Social smiles 4m F F ก, F F 6m , F F ก ก F ก 12 m ก ก F ก F F ก (10 m.) 18 m F F F3 10 ก F 2 yr F ก F F ก 3 yr F, ก ก F F F F F ก F ก 4 yr F, ก กก ก F1 กก F FกF ก F F F 5 yr F ก ก F4 F F F 6 yr F F ก F F F กก ก F 57. 3) F 36. 36
    • 58. 4) ก F F Fก Cushing syndrome ก ก moon facies, generalized/truncal obesity, purplish striae, , delay pubertal development, F , , F , , hyperglycemia, ก ก F hirsutism, F , enlarged clitoris delayed or amenorrhea cushing syndrome F bilateral adrenal hyperplasia, hypersecretion of corticotrophin (Cushing disease), ectopic secretion of ACTH, exogenous ACTH or steroid, tumor, etc. Lab cortisol lv. ( ก cortisol F F ก F cushing syndrome F circadian rhythm) urine cortisol 24-hr single-dose dexamethasone suppression F plasma cortisol lv. bone age F delayed bone age electrolyte ก F serum calcium lv. ก (glucocorticoid action ก serum calcium F ก ก hypercalcemia F ก PTH response F serum calcium ก ) hypokalemia, hypochloremia metabolic alkalosis F ก ก ectopic production of ACTH 59. 5) ก F F F pancytopenia investigation F bone marrow aspiration ก F ก serum ferritin iron-def. anemia, bleeding time ก primary hemostasis, screening coagulogram ก secondary hemostasis, reticulocyte count erythropoietic activity Pancytopenia ก aplastic anemia, bone marrow infiltration with leukemic cells, paroxysmal nocturnal hemoglobinuria, SLE, B12 or folate deficiency, etc. 60. 4)? F ก postprandial regurgitation F ก GERD F ก aspiration pneumonia F F GERD ก respiratory symptoms F กก refluxed gastric content ก respiratory tract ( ก aspiration, laryngeal penetration microaspiration) กก reflux ก F vagal /neural reflex Fก airway resistance airway reactivity F ก wheezing F wheezing infant F ก F bronchodilator ก wheezing F bronchodilator F F ก F ก ก 61. Benign rolandic epilepsy (Benign focal epilepsy of childhood or benign epilepsy with centro-temporal spikes) ก F F ก ก F idiopathic partial epilepsy F ก ก ก 3-13 F F F F ก ก F F ก ก F F ก 1-2 ก F F ก ก ก กก ก ก Epileptic syndromes ก F Childhood absence seizure generalized epilepsy syndrome 4-10 ก ก ก F 4-20 F ก กF F ก absence seizure automatism F F F F ก F 10-200 F GTC F F F ก F F Valproic acid ethosuximide West syndrome - triad infantile spasms (sudden extensor/flexor trunk movements) psychomotor retardation EEG hyparrythmia (disorganized high-voltage slow waves, spikes and sharp waves) ก ก3 ก กF 1 ก F F ก F ก tuberous sclerosis 62. 3) ก F ก secondary hemostasis ก bleeding time ก PTT F prolong ก ก intrinsic factor F กF factor VIII F F factor VIII deficiency (hemophilia A) 37
    • Secondary hemostasis 2 pathway ก intrinsic pathway extrinsic pathway F pathway ก ก F coagulation factors cascade intrinsic pathway ก F HMWK, PK, FXII, FXI, FIX FVIII F extrinsic pathway ก F FVII pathways ก ก F FX F ก ก common pathway FX, FV, prothrombin (FII) fibrinogen (FI) F F fibrin กก F F FXIIIa F stabilized fibrin clot ก ก coagulation factors pathway F F aPTT ก intrinsic common pathway F PT ก extrinsic common pathway Lupus coagulopathy F ก prolonged PTT F F F F clinical F SLE ก F F ก bleeding tendency F Factor VII def. (hemophilia B or Christmas factor def.) F isolated prolonged PT ก present F thrombosis กก F von Willebrand factor def. F prolonged PTT F ก prolonged bleeding time ± decrease plt. count ก F ก superficial bleeding, epistaxis, postop bleeding, menorrhagia, etc. F Hereditary platelet dysfunction F prolonged bleeding time 63. Iron def. anemia? ก F anemia hypochromic microcytic RBC ก ก F PBS Lab ก Iron def. ก ½ -3 , F , Mild -mod. ↓SI, ↑TIBC, Fe supplement hookworm, menses, chronic Anisopoikilosis, SI/TIBC < 16% blood loss, pica, koilonychias ↓ or ↔ RC, Pencil-shaped RBC Thalassemia Hepatomegaly, splenomegaly, Mod. - marked Abnormal Hb - Transfusion jaundice, failure to thrive, anisopoikilosis typing - Iron chelation thalassemic facies, Fam. Hx, Target cells - Splenectomy gallstone, hemosiderosis Teardrop cells Schistocytes Lead poisoning F / F , battery, ก, - Basophilic striping Screening urine - Supportive F , lead band long RBC coproporphyrin, - Chelation F bone X-ray whole blood lead dimercaprol EDTA 64. 5) Caput succedaneum diffuse edematous swelling soft tissues F suture line F ก Fก ก prolonged vaginal delivery ( F hematoma F ก minimal bleeding) กก F subgaleal hemorrhage ก Subgaleal hemorrhage (hematoma) ก ก F aponeurosis ก F subcutaneous tissue ก F firm fluctuant mass, increases in size after birth F suture line F F 2-3 F ก ก F ก Vacuum-assisted delivery 38
    • Cephalhematoma subperiosteal hemorrhage F F suture line ( F surface one cranial bone F ) ก ก firm tense mass with palpable rim localize over 1 area of skull 2 F 3 calcification F Epidural hematoma subdural hematoma F FF signs of IICP ก Nelson Textbook of Pediatric, 17th ed. 65. 3) ก F F F acute renal failure ก F intrinsic renal cause signs volume overload pulmonary edema F furosemide ก 66. 1) ก F F acute bronchiolitis ก ก กF 2 ก ก respiratory syncytial virus F ก ก F ก F ก กF 2-4 ก ก ก ก F ก F ก ก F ก F F F ก signs of dyspnea, ก F hyperresonance, diminished vesicular breath sound ก F wheezing F fine crackles F F F CXR hyperinflation F ก ก Supportive treatment F O2 (keep O2 sat. > 95%), NPO ก F ก, salbutamol/terbutaline NB (controversy), epinephrine, ribavarin ( ) F ก F O2 supplement 67. 2) pneumonia F ก cellulitis ก ก S. aureus pneumonia ก F กก ก hematogenous spreading ก F CXR localized or diffused bronchopneumonia lobar pneumonia ก ก ก necrotizing pneumonitis, pneumatocole pneumothorax F F ก ก F F 68. 3) APDE ( F F 37.) 39
    • Surgery y 1. 4) Surgery : F กF ก ก ก Inguinal hernia Inguinal hernia F2 1. Indirect inguinal hernia hernia sac ก ก internal ring F lateral F deep epigastric artery 2. Direct inguinal hernia hernia sac ก ก opening F medial F deep epigastric artery Inguinal hernia History : กF กF F ก F Diagnosis : Get above sign negative F กF F F F mass testis F กF (positive) F F sac F F ก silk sign Ddx : F กF ก F F F F F internal ring F F F F ก indirect กF F ก กF F ก internal ring F F direct กF F ก medial F ก ก F F F external ring F ก indirect ก F ก direct ก F F Tx : F F ก F ก F ก ก ก strangulation F F F ก FF Direct Indirect F F F กก ก inguinal hernia 5 5 กF ก กF ก กF ก F F ก กF กF Incarcerated hernia content F ก F F F F F complication F กF obstruction strangulation ก F F F incarceration hernia F F กF F F strangulation Obstructive hernia irreducible hernia content intestine ก obstruction F ก ก colicky pain tenderness hernia site ก F strangulated hernia Treatment : Immediate surgery closed loop intestinal obstruction Strangulated hernia content sac impaired blood supply ก ก hernia sac F progress colicky pain F F ก hernia sac ก F F ก sac F sepsis F Treatment : Immediate surgery F ก F obstructive hernia ก ก immediate surgery F 1) F ก F F F กF ก ก complication F 2) F ก ก F sign incarcerated hernia F กF ก F F F ก F F F ก 3-4 F 3) F ก ก ก F F observe F F 5) F ก ก Fก F complication กF F F F 40
    • 2. 1) Plain abdomen : F F acute abdomen F plain film ก ก ก F F F F F Perforated hollow viscus, Intestinal obstruction, paralytic ileus, ก ก F ก gas forming organism, abnormal calcification, abnormal intraabdominal mass, ascites, abdominal abscess, foreign body GI tract, bowel infarction Plain abdomen ก F 3 F F กF 1. Plain abdomen F F ก ก F F ก F F F ก ก F F F 2. Plain abdomen F F ก ก F F ก gut obstruction paralytic ileus 3. Chest F F ก free air F 1-2 . !!! Plain abdomen ก ก F F Acute abdominal series F 2) 5) F ก ก F Fก F F F 3) F ก ultrasound F ก ก ก กF F GI perforation F F F 4) F ก F abdomen series ก F plain abdomen F supine & upright F F CXR F F ก F F F Acute abdominal series Plain abdomen 3. 2) Fibroadenoma : fibroadenoma ก 20-30 most common benign solid tumor breast ก กF ก rubbery firm, discrete mass non tender, extremely mobile ก calcification F ก ก : Excisional biopsy F กF F capsule ก Fก F 1) F ก Fat necrosis ก chest wall breast trauma F ก F F needle biopsy lipid material ก mammogram ก F ก carcinoma F ก F กF F 3) F ก Fibrocystic disease ก F F F 30 ก F F ก F cyclic mastalgia F F กF painful and tender breast with nodularity nipple discharge F F ก F ก lactiferous duct ก F palpable cyst F 4) F ก F F ก กF F F Fก ก F ก กF irregular, hard, ill-defined margin, not tender Skin dimpling Nipple retraction Skin involvement F ulceration, skin edema(peau d orange), satellite nodule Axillary lymph node 41
    • F 5) F ก ก intraductal papilloma ก ก bloody nipple discharge serous most common cause in bloody nipple discharge ก ก focal area of necrosis hemorrhage papilloma 4. 1) Villous adenoma : Polyp กF ก mucosa F (pedunculated) ก F (sessile) ก F F F 2 ก F F กF 1. ก F F F ก F Benign lymphoid polyp , inflammatory polyp, metaplastic polyp, Juvenile polyp, Peutz- Jeghers polyp F Fก 2. ก F ก F F F F rectum sigmoid colon F F 20 F 60 F 3 F กF 2.1) Tubular adenoma (adenomatous polyp) F กF กก 2.2) Villous adenoma F F F F F rectum กF กF F F F 2.3) Tubulo-villous adenoma กF ก F ก ก Tubular 5% Tubulo-villous 20% Villous 40% 5. 1) Reduction : F F F inguinal hernia 1 F clinical strangulation reduction F F F F reduction ก herniorrhaphy 2-3 F F F ก F 1. F 2) F ก FF ก clinical ก F F 3) F ก ก F F strangulation F 4) F ก F Fก ก inguinal hernia F 5) F ก ก F F F กF ก F F F ก ก F F (irreducible) F F F F F ก F ก F F reassure 6. 1) Orchitis : ก U/S F ก F increase vascular blood flow F F torsion F F torsion ก F ก ก F ก torsion ก F ก F ก F torsion ก F ก ( F F ) F ก F F F ก ก ก ก Orchitis ก Epididymitis F ก F ก F F ก ก F Orchitis ก F Epididymitis Epididymis F F F testis 42
    • 7. 4) Internal drainage : F F pseudocyst complication กก Acute pancreatitis Pseudocyst collection fluid enzyme F กก F ก pancreatic trauma F F ก F F กF lesser sac ก กก fluid ก ก F ก F F F F fluid F ก F pseudocyst F ก ก pseudocyst ก ก F2 Fก F pseudocyst F pseudocyst F Body, Head, stomach posterior wall stomach F internal drainage cystogastrostomy cystojejunostomy F pseudocyst F distal pancreas F Distal partial pancreatectomy ก F pseudocyst F front of pancreas F 4) Internal drainage 8. 2) Explore wound at OR : F Neck injury Zone II F Sternal notch F mandible ( F .ก ) ก ก F 2) Explore wound at OR Penetrating neck injury F ก 3 zone F กF 1. Zone I F F ก ก F (clavicle) ก ก F cricoid F กF vertebral carotid F F F F 2. Zone II F F ก ก F cricoid ก angle of mandible F กF jugular vertebral carotid F common, internal external กF 3. Zone III F F angle of mandible base of skull F กF pharynx jugular vertebral internal carotid ก ก • F F F ก expanding or pulsatile hematoma ก ก F ก F neck exploration F F F F • ก zone I zone III ก F ก ก กF ก F ก ก F F • ก zone II ก F ก F ก ก 2 1. F neck exploration ก กก platysma 2. ก ก ก panendoscopy 9. 4) Ultrasound ก ก 6 : ก F F ก FกF F กก ก F ก F กF F ก กF F F Breast imaging evaluation F ultrasound F F ก F 35 F 35 F mammogram F F 43
    • F F solid mass ก ก ก F F F กF F (tissue histologic diagnosis) F ก F ก F ก F ก FF 60-85% F ก ก fine needle aspiration, core needle biopsy open surgical biopsy ก F ก กF F Fก ก F F F Fก ก ก F F F ก clinical examination → imaging → FNA (Triple assessment) F benign F ก F ก F F กF กก F 2 cm. ก 1 ก ก 3-4 ก ก6 F F ก ก ก core biopsy excision F กF Fก F 2 cm. excision F 1) F ก F F choice ก F ก F กF F F F F F F F F 2) F ก F F F F F F F F F กF F F 3) F ก ก F F F F F 5) F ก 16 F mammogram F 35 breast tissue fat F F กF 10. 3) Acute pancreatitis : suggest acute pancreatitis F กF • ก F F • ก Fก 5 ก F F 12 48 ก • Tender at epigastrium , decreased bowel sound ก ก F pleural effusion ก fluid F retroperitoneal space F dehydration, tachycardia, hypotension hemorrhagic necrotizing pancreatitis F (Cullen s sign) F (Grey turner s sign) ก ก retroperitoneum 11. 3) Hemorrhoidectomy : F hemorrhoid ก F internal hemorrhoid F กก F dentate line ก F ก hemorrhoid F ก dentate line F squamous epithelium กF external hemorrhoids internal hemorrhoids F F 4 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 F ก F Indications for surgery F กF • Prolapsed thrombosed hemorrhoids • Incarcerated hemorrhoids • ก ก F ก F ก F 44
    • 1. Fail conservative treatment F sclerotherapy, rubber band ligation 2. F hemorrhoids F ก ก F ก F 3. F hemorrhoids grade III-IV ก ก 4. F กก F ก F F F ก ก ก grade III F hemorrhoidectomy F 1) F ก ก grade I-II F 2) F ก ก grade I-II F 4) F ก F ก F ก ก F F ก กF F F 5) F ก ก ก F ก dietary life style modification F ก ก กก F 12. 1) Ceftriaxone + Metronidazole : • Ceftriaxone : Streptococcus, enterococci, GNR • Metronidazole : Anaerobes (including B. fragilis) above the diaphragm • Clindamycin : Gram positive (except enterococci) & anaerobes (including B. fragilis) below the diaphragm • Gentamicin : Some enterococci, GNR, no activity against anaerobes • Ampicillin : Exteded-spctrum penicillin GPB and GNR (E.coli, H.influenzae, enterococci) • Cetazidime : Same as Ceftriaxone and Pseudomonas ก F peritonitis ก F secondary peritonitis กก bowel perforation F F Streptococcus, enterococci, gram negative anaerobe ก Ceftriaxone ก F GNR Metronidazole (anaerobes below diaphragm) F 2) F กก ก F clindamycin Gentamicin ก F F Gram positive negative F F 3) cover F กก F Gram positive negative ( F F ก F F broad spectrum กF ) anaerobe clindamycin ก F infection above diaphragm ก F 1) 13. 1) Pleural tapping : F tension pneumothorax (classic triad deviation trachea F F , cyanosis, distended neck vein, F F , F breath sound F ) life-threatening conditions role nd ก thoracentesis pleural tapping F F F 2 ICS MCL ก F tube thoracostomy 14. 2) Pericardiocentesis : F cardiac tamponade (Beck s triad ก F BP drop, CVP , distant heart sound) ก ก ก stab wound anterior chest wall ก ก ก needle aspiration ก pericardial sac subxiphoid approach 45 ก F F inferior angle left scapula F F F ก F F emergency thoracotomy 45
    • 15. 2) Acute subdural hemorrhage : ก CT scan crescent shape ก subdural hemorrhage/hematoma hyperdensity area F acute phase (0-7 ) ก isodensity area subacute phase (3-14 ) ก hypodensity area chronic phase (>21 ) F F ก กก ก bridging vein F cerebral cortex venous sinus F 1) F acute epidural hemorrhage ก temporal temporoparietal ก ก กก ก middle meningeal CT scan high density mass ก F biconvex shape F ก skull fracture F 3) , 4) , 5) F CT isodensity lesion ก subacute phase 16. 2) ET intubations : F severe head injury (GCS 3-8) ก management F กF • Oxygenation F กF Oxygen administration, Endotracheal intubation in ALL • Blood pressure F กF maintain SBP > 90 mmHg • Intravenous fluid F กF Isotonic crystalloid, keep euvolemia • Ventilation F กF Keep PaCO2 35-40 mmHg , Hyperventilation in severe IICP • Hyperosmolar therapy F กF mannitol, glycerol • Antiepileptic drug 17. 3) Thoracic cord : F ก F F (paraplegia) F ก T10 ( level ) ก F F cord lesion Thoracic cord 18. 4) 340 mL/hr ?? : Thermal injury suggested fluid resuscitation (modified Parkland formula) 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 F second degree burn first degree F F ก ก ก F ก F ก ก 50 kg ก F Total volume for 24 hours = 4 x 50 x 27 = 5400 cc 24 hr F 2700 cc 8 ก 337 cc/hr 340 cc/hr 46
    • 19. 2) Esophageal rupture : Esophageal rupture esophagus ก tear tear F lung (decreased breath sound Lt. lung) F tear ก F F F tender with guarding F 1) F ก hiatal hernia F ก F F 3) ก 5) F ก ก F F 4) F ก F Mallory-Weiss tear ก F F Fก ก F lung 20. 2) Carotid cavernous fistula : Carotid cavernous fistula (C-C fistula) F F F internal carotid artery ก cavernous sinus ก กก F internal carotid artery ก F F cavernous sinus aneurysm FกF F F ก ก F ก clinical features F กF 1. Pulsating exophthalmos 5. 2. Chemosis 6. Ophthalmoplegia 3. Veleorbital pain 7. Bruit F F 4. Dyslogia ก cerebral angiography F ก ก F กF Embolization, Embolization with internal carotid artery ligation, Occlusion of C-C fistula, Direct repair, Cavernous sinus occlusion 21. 5 Rabies vaccine and Rabies Ig : ก F ก ก F ก ก WHO category I F ก F ก ก F F WHO category II 1. Fก F 2. ก F ก 3. ก F ก ก F WHO category III 1. Fก F ก RIG 2. ก F ก ก ก ก ก 2 x 1 cm ( F ก F ) F grade III ก ก RIG 22. 5) BPH ก BPH F ก ก กก ก ก ก กก F กF • F กF F • F F F ก • F F F • Fก ก F • F ก ก • ก F F 47
    • • F F F ก ก F F ก F urinary retention F F hydronephrosis ก F ก ก F กF ก rubbery 23. 4) Tracheostomy : loss of laryngeal prominence , subcutaneous emphysema cervical F ก laryngeal injury indication ก tracheostomy Indication of tracheostomy F กF • Acute laryngeal trauma • Age under 12 (cricothyroidotomy is not recommended) 24. - : F acute cholangitis ก ก F antibiotics F ก mild form F 5-7 ก hemoculture positive F F 10-14 Fก F F F ก ก F F กF F antibiotics F ก F F respond F ก F ก F F 24-48 ก drain F ก F penetrate organ F biliary drainage (decompression) +/- endoscopic spincterotomy semi-elective ( F F F F ) F F F 72 ก F ERCP, PTBD Surgical biliary drainage ( F F ) F antibiotics ก biliary drainage F F F F3 ก F F F 14 ก F ก F F 3 F F drain + remove CBD stone F remove gallstone ก ก ก ก ก F F ก F (LC) F F 1) F ก ก F F F F 14 ก F F F F F drain กF F 2) F ก ก LC F remove gallstone ก ก ก F 3) F ก F ก F ก FF F F F ก F (surgical biliary drainage) ก ก F F 72 F F F ก 6 wk F F Biliary drainage (decompression) ERCP +/- spincterotomy PTBD Surgical biliary drainage F F ก F 72 25. 2) Emergency surgery : ก F acute abdomen tender at RLQ rebound tenderness F acute appendicitis ก F ก F ก F ก F กก F ก F F ก ก ก F F ก ก F F F F ก F ก ก F F ก ก F F F ก ก ก ก ก F F ก F ก acute appendicitis ก ก generalized peritonitis F กก F F F morbidity กก F F F ก ก F F ก F F ก FF ก delay ก F F F ก ก pathology ก ก GI tract ก F diagnosis ก 26. 1) Diaphragmatic hernia : Diaphragmatic hernia F ก 2 1. Congenital ก ก Fก 48
    • 2. Acquired F ก ก ก ก ก กก ก F F กก ก F ก ก ก ก F กF progressive dyspnea, cyanosis apparent dextrocardia ก ก กก F F ก F ก กF ก ก ก F F F ก ก F ก F ก ก F F F mediastinum ก ก F F F F barium meal F aspiration F 27. 2) Local flap : ก F F Graft ก Flap กF • Graft ก F epidermis dermis F กก F F (donor) F ก ก F (Recipient site) • Flap F F F ก skin graft F flap กF skin subcutaneous tissue F F กF F F ก F F ก F Graft flap Skin graft Skin flap 1. Facial wounds 1. poor vascular avascular bed 2. Flexor surfaces F F ก F 2. structure F nerve artery joint 3. ก F F ก 3. F ก F 4. ก กก skin flap FTSG 4. bony prominence F padding 5. mucosa F F ก pharynx vagina pressure sore 6. dura, pericardium, pleura peritoneum 5. F F ก F ก 7. F overgrafting unstable scars, tattoos 6. F ก sensation non-hairy pigmented nevi 7. tissue F F reconstruction Graft Flap Skin graft Skin flap 1. Split-thickness skin graft (STSG) F F F F skin graft ก F epidermis operative technique F กF F dermis กF F F ก 1. Local skin flap F skin flap Fก F ก defect • Thin STSG F skin กF ก • Intermediate STSG recipient F color texture hair • Thick STSG thickness , ก F F ก F distant 2. Full-thickness skin graft (FTSG) flap, ก F F ก F distant flap skin graft ก F epidermis 2. Distant skin flap F F ก dermis skin flap F ก ก ก defect 49
    • ก flap bedsore ก bony prominence ก local skin flap ก F กก F distant skin flap 28. 2) U/S : Approach to jaundice patient ก liver function test Direct hyperbilirubinemia ( F DB กก F 30% TB) ก ก F ALP ก F Post-hepatic cause F กF cholestatic jaundice F ก ก F 1. Benign causes F F , F F 2. Malignant causes F F F F investigation F F ก F ultrasound F F ก F F 1) F ก F Fก investigation F F 3) F ก F F ก F 4) F ก ก F F F F F invasive ก F ก กก F F 5) F ก F ก U/S F F ก ก F F 29. 3) C-spine protection : FFF F F ก F F ก F Trauma ก F A B C D กF F F A ก C-spine protection F F F 30. 5) Surgery : F F F inguinal hernia F 1. ก F F F F 1 F F strangulated hernia F F F กF ก ก F ก hernia sac F progress colicky pain F F ก F hernia sac ก F F ก sac ก ก F F F ( ก F ) ก Surgery F 1) F ก F reduction strangulated hernia F 2) F ก F F F F F ก F ก F F F ก acute abdomen F กF F F ก F Fก F F กกF F ก ก ก F acute abdomen ก hernia F 3) F ก F F solid organ F F 4) F ก F role antibiotic F 31. Tension pneumothorax : F 13 32. 5) Ultrasound F ก F ก1 : F ก F 9. F fibrocystic disease 33. 1) Rabies vaccine : ก F 5 ก tetanus toxoid F ก DPT F 2 4 6 18 4-6 5 ก F 2 cm F tetanus-prone wound F Tetanus prophylaxis 50
    • Non-tetanus prone wound Tetanus prone wound History of TT (dose) Td TIG Td TIG Unknown or < 3 Yes No Yes Yes 3 or more No No No no ก F TT กก F 3 F Fก 5 F role ก F Td TIG ก F ก F rabies F 21. F F F WHO grade II role ก F vaccine rabies F ก F F ก ก F ก F rabies vaccine 34. 1) Off Foley s catheter : F F F F F F autonomic dysreflexia Autonomic dysreflexia • complication spinal cord injury T6 F ก ก • Sign & symptoms o Hypertension o Nasal stuffiness (blood pressure greater than 200/100) o Nausea (secondary to vagal parasympathetic o Pounding headache stimulation) o Flushed (reddened) face o Bradycardia - slow pulse <60 beats per minute o Red blotches on the skin above level of o Piloerection ("goose bumps") below level of spinal injury spinal injury o Sweating above level of spinal injury o Cold, clammy skin below level of spinal injury • o Bladder (most common) - from overstretch or irritation of bladder wall F 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 F F ก Bladder ก Blocked catheter ก ก ก collecting bag, irrigate the catheter, remove any kinks or change the catheter !!! F ก ก F F F irrigate catheter F shock F F Foley s catheter กF 51
    • Ob & Gyn 1. 2) : ก F F risk factor ก ก DM a. กก F 30 *** b. (first degree relationship) DM *** c. GDM FกF d. e. f. ก FกF ก ก ก F F ก GA 24 wk ก ก F 50g GCT F : • Screening DM F GA 24-28 wk • 100g OGTT ก (Confirmatory test) F ก 50g GCT F ก • Urine sugar routine lab F F F F F ANC ( risk factor กก F F F positive F F screening test F ) • FBS F ก ก ก F F F ก F insulin resistance ก HPL (Human placental lactogen) F ก placenta F F • Random glucose F (-*-) 2. 5) : ก F F fluid posterior fornix fern test : positive F preterm premature rupture of membranes F ก PV progression F F กก PV F F F F ก ก Chorioamnionitis F : • F ก observe sign of chorioamnionitis F F F F F, , F ก ,ก ก, fetal tachycardia F F Fก PV ก F • IV prophylactic ATB ก ก chorioamnionitis, ก sepsis ก ก F F F prolong PROM (>18 hrs) F ampicillin 2 g iv q 6 hr ก F • Dexamethasone F Fก ก ก ก ก RDS F F GA 30-32 wk • Tocolytic drug F F ก preterm PROM ก F ก F steroid F ก F F F ก F 3. 4) : ก F F ก ก ก ก (Compound presentation) observe F กF F ก station ก ก F F ก ก F F F F : • F F arrest of labor fetal distress F ก F • compound presentation F F F Amniotomy F Syntocinon • U/S F F F F F ก management F • C/S F ??? F F ก กF 52
    • 4. 3) F F F F F CVT OB F : F F F F F Class I II NYHA F F กF F F F F F F กF F F : • Class II F กF , class III IV F F F • ก F ก F F o F กF F F กF F F F o F ก F กF PHT, Aortic coarctation with valvular involvement, Marfan syndrome with aortic ionvolvement o Class III, IV o ก ก ก F ก F F 5. 3) : ก F F 7-12 wk CRL (crown-rump length) F ก +/- 3-4 F : Testing F ก • ก GA 28 wk ก ก BPD 12 - 28 ± 1 wk • F ก ก • ก GA 28 wk ก ก Head circumference 12 - 28 ± 1 wk • F ก ก F ก ก ก Femur length 12 - 26 ± 1 wk ก GA 26 wk ก ก Abdominal F F F ก F circumference 6. 2) : Post-partum hemorrhage F F ก ก uterine atony ก PE F uterus : ½ FH> umbilicus F ก uterine atony F กF • ก • ก - กก F F , F , ก ****** • ก ก กF • ก ก F Fก ก F F F ก ก F F ก ก Post-partum hemorrhage F : Post-partum hemorrhage ก ก 1. uterine atony 2. ก ก F 3. ก ก F ก ก (placenta bed bleeding) 4. ก ก F ก 5. ก ก 53
    • 7. 1) : ก F F ก F กF 1. call for help 2. extend episiotomy 3. Suprapubic pressure 4. McRobert maneuver (flex hip F F F ) 5. F F 6. Woods cockscrew maneuver 7. F 8. กก ก F 9. +/- Zavanelli maneuver ( กก F F F F : Modified Crede ก F ก 8. Cesarean section : F F Overt prolapse cord ( F กF F ก+ ก F) F Cesarean section F : • F ก ก 7-8 . forelying cord F ก ก กF F ก ก F fetal distress F F ก F F F • ก ก - ก F F F • F F F ก ก ก F CPD • F ก F F CPD 9. Cesarean section : ก ก HSV กF • F F F F F (no lesion, no cesarean) • F prodome F F ก 4 • ก ก F F F F ก F F F F ก F F F F F F (Cesarean section) 10. 1) : ก F PE F FH ¾ > umbilicus F ก F ก lightening F F myoma uteri F F F F Fก ก F F F ก F F : • ก ก Fก F o ก ก Fก ก F F F F F F ก F ก, ก กF ก , ก ก F กF , ก F F ก , F ก ก F F ก F o Fก F ก, กF ก • ก F ก ก ก 54
    • o F F ก ก ก กก 6 F F ก F ก ก F F ก ก F ก F ก กF ก ก F 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) : F ก ก F F ก ก Bacterial vaginosis ก ก ก ก ( ) F : • ก ก ก Bacterial vaginosis ก ก ก ก F ก ก ก F F F ก ก F ก F ก ก amine F ammonia • ก Fก ก F 1. pH > 4.5 2. homogeneous leucorrhea ( ) F Fก ก 3. ก F F 10% KOH (Whiff test) 4. clue cell F F 20% F F F ก Clue cell F wet smear gram stain • ก ก F metronidazole 200 mg oral qid 7-10 ก ก F F ก F 12. 3) : ก F F ก ก fundus F ก uterine rupture F F :ก F F F 7 ก 13. 3) : . • F Pelvic infection ก ก PE : Cx : tender on motion Adx : tenderness both sides F TOA F F กF F mass Adx ก ก PID • ก F F F breast engorgement ( ก F engorge &tenderness F F ) F Mastitis breast abscess • F F oozing F F bleed F C/S wound infection 14. 4) : • F F HRT F Ca 1,500 ก • F HRT F Ca 1,000 ก • F กก ก F F Ca 500 ก F F HRT F Ca 1,000 ก F HRT F Ca 500 ก 15. 3) : ก F กก F F F ก F ก F F F 6 F F F rule out Pregnancy กF F : • F ก F F กF ก F 3 • ก F กก F F 1. F F F F 2-3 ก F 2. ก ก ก ก 3. ก 55
    • 4. ก F F 5. F 6. ก 7. ก F ก ก 8. ก F F F 16. 1) : Fก DM Obesity F : 17. 4) : F Fก ก ก neural tube defect (spina bifida) folic acid F : • F ก F Fก ก FกF F F ก F ก acrodermatitis enteropathica dwarfism hypogonadism • Fe F ก Iron def. anemia • Vit B6 F ก ก F F F ก ก F F ก F F F 18. 1) : Spontaneous abortion F ก Type Cervical Os Size &date Conceptus Threatened Closed F ก appropiate Not seen abortion Inevitable / Opened ก F +/- Not seen Imminent abortion F F ก ก ก Incomplete abortion Opened +/- Size < date F F ก ก F Blighted ovum ก Complete abortion Closed +/- Size < date F ก F F ก F 19. 2) : ก F sure date(LMP) F FH : ¼> umbilicus (GA 24 wk GA by LMP = 20wk) F Size>Date F Work-up F กF F กF F F, U/S กF ก F กF F F F F Size>Date F F U/S F F : 56
    • Differential Size > Date : 1. LMP F sure date 2. Full bladder 3. Twin pregnancy 4. Macrosomia 5. Polyhydramnios 6. Pregnancy with myoma uteri 20. Mild PIH : ก F BP>= 140/90 mmHg F ก Proteinuria F F : Severe PIH F กF F F F • 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 F ก , F 21. 4) ( F F) 22. 2) ( F F) 23. 2) : ก F F F ก Fก intrauterine pregnancy extrauterine pregnancy ก F ก F F Ultrasound F F ก ก F ( F กF - F ) management F ก hCG F : Ultrasound F F ก ก F ก ) management F F • F กF F → hCG • กF F → laparoscppy • F กF → laparoscppy ( cul-de-sac) • กF → laparoscppy ( cul-de-sac) 24. 3) : F Bartholin abscess F F ก ก F Escherichia coli or staphylococcal or polymicrobial infection F : • F F Acute, painful unilateral labial swelling Dyspareunia Pain with walking and sitting Sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture) 57
    • • F 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 F ก 1. Marsupialization ก ก F 2. excision F F F 3. Incision and drainage ก ก ก ก 25. 4) F : F 55555+ F F ( *-) • 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) : F ก ก ก bacterial vaginosis ก clue cell Fก metronidazole F : ก Fก F 11 ก 27. 1) : กก F Rt.labia major ulcerative lesion ก discharge F ก vagina F F vaginal candidiasis F ก F F F : • ก ก vaginal candidiasis 1. F ก F 2. ก F F F ก 3. ก vulva, vestibule labia ก ก F F erythema ก F F ก F • ก ก F clotrimazole 100 mg Vg 7 F ก ก F ก ก F • ก ก F F ก กก F F F F 10-20 ก Fก F ก F F ก 28. 1) : • กก ก F ก pepsin F ก (antacid) ก ก ก F F ก F ก ก F ก F F F ก F H2-receptor blockers F sucralfate F F F • ก F ก Misoprostal (Cytotec) ก ก F ก F Fก ก F F F omeprazole F F ก F ranitidne, cimetidine sucralfate F ranitidne, cimetidine F ก F ก ก กก ก F F F second line drug ก ก F F F F F F F sucralfate ( ) 58
    • 29. 3) : ก ก F ก F F uterine rupture ก PE : F ก F , fetal heart sound F F, F shock (BP 80/50 mmHg) ก ก ก ก F F ก ก drip syntocinon F : ก ก ก ก F F กF 1. ก F F ก FF ก ก 2. ก F 3. F F ก F F ก F 4. F ก ก ก ก F ก 5. FกF F F ก F F broad ligament ก ก F กก ก F กF 1. ก 2. F F F F ก ก F 3. ก F 4. Bandl s (pathological retraction) ring ก F F ก 2 F F upper lower uterine segment 30. 2) : 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 59
    • 31. F F 8 32. F F 4 33. 3) : ก ก F F transverse lie ก F 34. 4) : F F post-menopausal bleeding ก ก ก ก ก ก F F ก F F F ก F F ก F F กF U/S, Endometrial biopsy, ก ก F ก ก F endometrial sampling ก F F rule out CA F : Differential diagnosis of post-menopausal bleeding • ก ก 1. ก ( F F ) 2. ก proliferative 3. ก atypia F 4. ก (10-20% ก ) • ก ก • กก F ก • ก ก • F ก ก, F , sarcoma • F 35. 4) : ก F 2 ก cervical progression Contraindication 36. Polyhydramnios : Risk uterine atony F กF Polyhydramnios F : F F 6 ก 37. 4) :ก F AFP Fก ก ก NTD (anencephalus and spina bifida) 38. 3) Imperforated hymen : F ก 14 F , ก F ก , F ( ), secondary sex characteristics, F ก F F PE : tense cystic mass 1/3 >suprapubic, gaping labia minor with purple tissue ก ก F ก F F Fก imperforated hymen ก 39. 3) : F ก ก F กก ก (threaten uterine rupture) F กF a. Bandl s (pathological retraction) ring ก F F ก 2 F F upper lower uterine segment b. ก c. F F F F ก ก F F : F 29 ก 40. 4) : กก ก ก ก ก • กก ก F F 3 ก ก F F F ก • กก ก F OCP กก ก ก 60
    • • F ก F กF F OCP F F F 7 F • F ก ก ก FF F F F ก F estrogen F F premarin 1.25 mg/day, estradiol 2 mg/day * 7 F ก ก OCP ก F : ก F กก ก ก • F/ ก F 2-3 ก F F • ก F F OCP • ก • F • • F • 41. F ก F 46 42. Imperforate hymen F ก F 38 43. 4) : F ก ก ก 11.5 16 kg. ก F ก 16 kg. F : • ก F (BMI <19.8) ก 12.5-18 kg • ก ก (BMI >26) ก 7-11.5 kg 44. - 45. 4) ( F F F ) : • ก F F F ก F ก ก combined pill estrogen ก ก F ( ) • F dysmenorrhea F F F IUD F IUD F ก F F • F F ก condom F F F ก ก 2-3 F กก ก F ก ก progesterone ก ก F Fก F F ก dysmenorrhea F 46. 4) : F F severe PIH ( ก SBP >160 or DBP > 110 mmHg End organ damage F F ก ก F ก F F F ก ก ก ก ก, ก F F F F F ก F Fก ก F F induction of labour+painless labour F F : ก ก ก • ก ก F MgSO4 F F ก F F กF EKG change, absence DTR, apnea, cardiac arrest • Fก F Hydralazine F DBP> 110 mmHg 61
    • • ก Fก F F F F F F F fetal distress, ก F ก ก F F (HELLP syndrome), thrombocytopenia F F F F F ก F 47. 3) : F ก F ก F F F กF ก ก 1. ก (30%) 2. progressive dysmenorrheal 3. กF F ก 4. dyspareunia ( F ก F) 5. ก ก 6. FF 60 F ก 1 + 2 + 3 = classic triad endometriosis ก F F กF 1. ก ก ก 2. ก ก F กF F (nodularity) uterosacral ligament Cul-de- sac (1/3 F ) 3. กF F ก F F 4. กF ก ก endometrioma (endometriotic cyst) ก F F 48. 4) : ก ก U/S 3cm. homogenous hypoechogenic cyst, no contents inside at Rt.adnexa F F benign condition F ก ก ก F F กF F functional cyst ก ก กก U/S • Endometriotic cyst Hemorrhagic cyst echogenic fluid F , irregular border • Polycystic ovarian syndrome ก ก F ก ก F F (necklace like pattern) • CA ovary ก กF solid mixed cyst • Functional ovarian cyst ก homogenous hypoechogenic cyst 49. 4) F : Asherman s syndrome ก 62
    • TSG for hypothyroid prolactin prolactinemia Progestin challenge test Positive Negative F ก Estrogen-Progestin challenge test Positive Negative FS ก ก Normal/low High Sella imaging /GnRH test F F ก ก F F Hypothalamus 63
    • Ortho & Rehab 1. F F >< F F F ก F 2. F F F F posterior hip dislocation F F adduction Fx of the pelvis F F ก กก ก 3 AP compression (pubic symphysis + ante. SI joint F , open book type), lateral compression vertical shearing ( ) F ก ก pelvis AP lat. Compression ก pubic symphysis ก manage F ATLS ก vital sign unstable F resuscitation, pelvic binder F assoc. injury F intra-abdominal bleeding Fx. of the acetabulum ก กก ก F ก ก dislocation F F F กก ก dashboard injury Fx. neck of femur (intracapsular fx.) 2 ก F non displaced groin pain F F F antalgic gait limitation of motion กก F displaced ก ก F F F F ก F ก ก F midinguinal point F distal 1 lateral 1 Intertrochanteric fracture (extracapsular fx.) ก greater trochanter ก ecchymosis external rotation Posterior hip dislocation F flexion, adduction internal rotation F head of femur ก sciatic n. F F sensation common peroneal n. F , tibial n. F motor nerves dorsiflexion plantarflexion F ก 6 กก F ก ก avascular necrosis (anterior hip dislocation F flexion, abduction, external rotation) 3. 3) Displaced supracondylar fracture common ก ก 5-10 F กก ก F cubitus varus F F F 2 extension flexion type extension type กก F ก F displaced F ก F ก F ก F ก ก S- shape deformity F radial, median ulnar n. radial a. X-ray fat pad sign fracture F F F Hueter s line triangle ก Fx. lat. condyle of humerus F F epiphyseal plate injury F ก F ก ก F supracondylar fracture X-ray F ก F metaphysic ก nondisplaced fx. F ก displaced metaphysic ก ก ก lat. of humerus F Heuter s line triangle ก Medial Lateral epicondylar fx. rare ก F Heuter s line triangle ก Elbow dislocation F F ก กF F ก 90% ก post. post.lat. F ก F ก F F ก ก F F olecranon process F F Heuter s line ก fx. radial head, coronoid process, medial epicondyle F F F F ulnar n. injury 64
    • Posterior elbow dislocation associated with fracture of the coronoid process 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) Surgical neck of humerus axillary n. F F axillary n. F( F 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 65
    • 6. 2)? ก F F Carpal tunnel syndrome F F radial ก ก ก ก F ก F Phalen s test, Durkan pressure test ก F ก กF APB, FPB OP ก ก ก F F ก ก F ก F , NSAIDs, carpal tunnel steroid injection operative treatment Long arm cast Fก supracondylar fx. fx. forearm F A1 pulley release F ก ก Stenosis tendovaginitis (Trigger digit - ก) 7. 2)? F OA knee F F a. กก ก F F F F isometric quadriceps exercise กF F F isotonic exercise progressive resistance exercise F F ( กก ก ก F hamstring F ) b. Fก ก F F F F กก F F F ก lat. Compartment ก c. F F F F F F ก F F F F F ก F 8. 4) F F Cervical spondylosis (radiculopathy) F F myelopathy กก F ก radicular pain F long tract sign myelopathy (myelopathy F contraindication ก cervical traction) F ก F ก ก traction MRI F ก ก F 9. C5 - C6 Disorder Lesion Common cause Clinical features Erb-Duchene palsy Upper brachial Hyperadduction of arm Waiter tip position (arm extended and plexus (C5, C6) adducted ,forearm pronated) Klumpke s palsy Lower brachial Hyperabduction of arm Claw hand from ulnar n. involvement, plexus (C7-T1) wraist and hand dysfunction, assoc. with Horner s syndrome Claw hand Ulnar n. Epiphyseal separation of Weak finger adduction, medial hand the medial epicondyle of numbness, dysfunction of 4th and 5th humerus in children digits flexion Radial n. palsy Radial n. Fx. of mid-humersus Wristdrop, loss of sensation from dosum of hand Carpal tunnel Median n. Compression of n. Wrist flexion elicits pain, wrist extension syndrome relieves pain, worse at night Med. Winging of Long thoracic n. Surgery (e.g., mastectomy) Limited arm abduction and flexion, scapula serratus ante. Paralysis Fx. of surgical Axillary n. A fall landing on the elbow Loss of deltoid innervations, neck of humerus compromised shoulder flexion and extension 10. 5) F F กF 4 6 F (28 42 ) 66
    • ENT 1. 5) Retropharyngeal abcess ก F F film lateral neck F ก F prevertebral soft tissue Lateral neck film: ก prevertebral soft tissue > 7 mm at c2 level >14mm (C6 level) ก, >22 mm F F, loss of lordosis กก spasm prevertebral muscle กก กก adenoid nasopharynx paranasal sinus ก ก ก ก trauma, FB ก ก ก กก URI, ก ก ก ก F F F ก air way obstruction, neck rigidity F ก ก posterior pharyngeal wall F F ก F ก ก ก F mediastitis ก ก cellulitis adenitis - Fhigh dose IV penicillin abscess F ก F ก F Epiglottitis (supraglottitis) F F ก ก 3-6 F F F ก กก H.influenza ก ก ก ก muffled voice ก F F ก ก ก inspriatory stridor ,hot potato voice, supraglottis area ,air way Film lateral neck epiglottis ก ก F ET tube ก ก upper air way obstruction, F ampicillin, steroid Ludwig angina ก submandibular space ก F submaxillary space ( F mylohyoid line) sublingual space( mylohyoid line), bilat 80% ก ก periodontal disease mandibular teeth F F nd nd rd F 2 molar sublingual space F F 2 3 molar submandibular space ก ก F ก F mylohyoid line ก ก trismus, odynophagia drooling of saliva ,airway obstruction, F F F ก F ก airway compromise FOL supraglottis endolarynx ก F base of tongue F epiglottis F Dx Fclinical ก X-ray,lab F confirm Dx Treatment Early stage: IV Antibiotic Advanced disease: F ET tube F ก ก F airway obstruction F tracheostomy กF, Sx drainage 2. pseudoephridine F decongestant F barotrauma ก กก F F ก ก F ก F euatachiantube ก F middle ear ก F atmosphic pressure F F กF ก F F ก ก TM ,fluid exudates middle ear TM rupture ก F ก F กF (retract),hemotympanum ,conductive HL ก ก ก ก ก F Fก F F ก ก valsava maneuver ก ก ก ก ก F F กF decongestant F pseudoephridine F myringotomy F กHemotympanum ก 1-2 67
    • 3. 1) acoustic trauma ก 130-140 dB F ( ) Fก ก F ก ก (Tinnitus) F F ก F ก Fก ก F F acoustic trauma ก SNHL ก F weber rinne conductive HL ?? 4. 2) amoxycillin F acute otitis media ก 1st line drug amoxycillin ก Fก ก F 48-72 . ก F F F enzyme beta lactamase F F amoxicillin-clavulanate 5. 3) ก ก obstructive sleep apnea common ก tonsillar or adenoid hypertrothy F ก palate F OSA elongation of soft palate and uvula F F high arch palate F Choanal atresia ก F ก F ก ก F F F ก ก ก bucconasal membrane F 7-8 F F F ก Fก F F ก ก ก F ก F F ก F F ก F F ก F F F F F กF F F F ก (oral tube) 6. 4) Rhinitis medicamentosa ก F Topical decongestant Rhinitis medicamentosa ก ก กก F Topical decongestant F ก rebound vasodilatation ก (vasoconstriction) ก กก กก F F ก hypoxia ก reactive hyperemia F F F ก ก F F F ก 3-5 ก ก F alpha-adrenergic blocking ก (beta-receptor) Fก ก ก F F (reserpine, hydralazine, methyldopa) antidepressant (chlordiazepoxide amitriptyline) ก ก ก F F ก F F กF F F F decongestant F topical corticosteroid Fprednisone 7 10 F F F F ก ก F F F turbinate ก F Atrophic rhinitis ก atrophy ก F ก F ก (crust) ก ( ก Ozaena) F F F F F F ก กก F ,ก F Klebsiella ozaena ก F , , ก ก ก ก ก crust, ก ก ก (halitosis) ก ก crust F F ก F ก ก ก F F กF ก ก ก F F ก ก ก crust ก F F F ก Fก ก F ก F F F ก F ก F ก ก ก ก F F F ก F implant F F ก Vasomoter rhinitis ก กก ก F ก กก ก Fก ก ก ก ก F ก ก F ก ก F F F F กก ก กก F Fก ก ก F F ( F กF ก )ก , F ก , F ก F 68
    • ก ก ก Fก กก F ก,rhinitis กก F , hypothyroidism , ก ก ก ก ก ก F ก F F ก F F F ก ก anticholinergic corticosteroid F ก F inflammation F F F F F F turbinate F vidian 7. ก FB ก 8. 1) CA nasopharynx ก , ก F F Nasopharyngeal cancer (NPC) ก F ก F F ก 51 F EBV (Epstein-Barr virus), ( ), polycyclic hydrocardons ก ก F, ก ก , F ก ก F F กF กF ก F 1. กF กก ก F F F ก F F F F ก F F กก F ก F F ก ก retropharyngeal lymph node F F 2. ก F ก กกF F F F Rosenmuller fossa F F ก serous otitis media 3. F ก กกF F ก F 4. ก 5. ก ก ก ก F F ก ก ก F • F F 6 F ก ก ก กF Fก ก F • F F 3, 4 6 F ก opthalmoplegia F ก F ก F superior orbital fissure cavernous sinus • F F 5 Fก ก F F ก • F F 9, 10, 11 F ก F ก F jugular foramen • F F 12 ก ก ก ก • F ก F carotid F ก ก ก F Horner's 6. ก ก distant metastasis ก ก ก F กก F ก ก F F ก ก กF F ก F Fก EBV serology F ก ก ก RT+/- chemotherapy 9. Macrolide ก Bullous myringitis Fก Mycoplasma pneumoniae F ก F Macrolide F erythromycin Bullous myringitis ก กF (tympanic membrane) F F ก ก , influenzae , Fก Mycoplasma pneumoniae ก F ก ก กF , F F bleb F ก กF ก ก Supportive tx F กF ก F bleb ก F กF F ก F ก ก M.pneumoniae F ABO F erythromycin , tetracyclin 69
    • Eye 1. 4) Refractive error VA drop correct F F pinhole ก ก refractive error 2. 4) Retinitis pigmentosa ก กก retina RPE F photoreceptor F (rod > cone) ก F Progressive night blindness F ring scotoma ( VF F periphery) VF F F ก ก F F Cataract ก F ก ก 3. 2) Phacomorphic glaucoma F ก F Fก Acute angle-closure glaucoma ciliary injection (DDx glaucoma, uveitis, corneal ulcer), , , cloudy cornea, pupil fix dilate anterior chamber F F Lens sclerosis F cataract F F F F ก glaucoma Lens-induced glaucoma ก 2 1) Phacomorphic glaucoma ก ก F F anterior chamber F ก angle-closure glaucoma 2) Phacolytic glaucoma ก ก lens protein ก Mφ ก aqueous drainage ก open- angle glaucoma F lens particle glaucoma, phacoanaphylaxis lens subluxation F F ก 4. 4) Biopsy and microbial investigation F recurrent chalazion F ก sebaceous gland CA F F Biopsy 5. F 10. 6. 2) Ceftriaxone IM F F Gonococcal conjunctivitis ก neonate ( < 1 ) Gonococcal conjunctivitis • Hyperacute onset of severe purulent conjunctivitis, marked conjunctival hyperemia chemosis • preoricular lymphadenopathy ( viral F ) • Drug of choice Ceftriaxone 1 g IM + topical antibiotic 7. ก Acute angle-closure glaucoma ( F 10.) 8. F 14. 9. 4) Acute glaucoma 10. 3) Oral glycerine F F 4) topical beta-blocker กก F agent of choice ก F ก ก Treatment of acute angle-closure glaucoma 1. ก F aqueous 1.1 α2-adrenergic agonist (apraclonidine) 1.2 β-blocker (timolol) agent of choice ก F ก ก : bronchospasm, bradycardia 1.3 carbonic anhydrase inhibitor (acetazolamide) F F F sulfa, S/E: F , HypoK 70
    • 2. ก aqueous 2.1 Parasympathomimetic (pilocarpine) outflow trabecular meshwork F F pupil constrict F react to light (miotic agent) 2.2 Prostaglandin (latanoprost) uveoscleral outflow F ciliary loose, S/E: hypertrichosis 2.3 Hyperosmotic agent (mannitol: iv drip, glycerin ก F ) F F , short term 2.4 Laser iridotomy Definite treatment**, F aqueous ก posterior chamber anterior chamber ก ก ก F ก ก ก F acetazolamide F ก topical agent F β-blocker apraclonidine F hyperosmotic agents (glycerin) F F ก IOP iris ischemia F pilocarpine 2% F F F definitive treatment laser iridotomy ก F prophylactic laser iridotomy F 11. 1) Topical antibiotic F corneal abrasion ก contact lens Corneal abrasion F ก ก Fก F ก Corneal abrasion ก F กก ก ก F F ก ก ก ก กก F contact lens ( F ก fitting F ) F ก trauma F F ก ก corneal abrasion F กF herpes simplex keratitis F F F F slit lamp ก F corneal abrasion ก F ก ก F F กF clean corneal abrasion ก F ก ก ( F F ) true corneal ulcer Corneal abrasion กก F ก F antibiotics drop ointment F ก F กF F F topical antibiotic, cycloplegics ก F 12. 4) UV keratitis Corneal epithelium F F ก ก ก UV ( F F ก sunlamps ก , F F ก F F snow blindness F ) F ก ก F UV 2-3 ก epithelial cells ก ก ก F F 24 ก ก F ก F ก UV ก Fก F F cycloplegia ก ก F กF F F 13. 4) Meibomian gland dysfunction ก FกF upper eyelid ก hordeolum ก Hordeolum Hordeolum staphylococcal abscess F F ก ก eyelid Internal hordeolum meibomian gland abscess F F conjunctival surface eyelid F external hordeolum sty ก กก F F ก ก ก Warm compression, topical antibiotic + systemic antibiotic Incision and curettage F / ก F 48 71
    • 14. 4) Vernal keratoconjunctivitis Vernal keratoconjunctivitis F F F F F F ก ก ก F กก F F ก ก 2 F F ก ก discharge F ก ก F ก ก F กก F ก 2 1. Palpebral form giant ("cobblestone") papillae ก 6 Tarsal conjunctiva ก 2. Limbal form limbus ก ก ก F Histology F Hyperplasia Hyalinization connective tissue ก F F F ก cellular infiltration FF F Eosinophil Choices Trachoma ( ) ก กก Chlamydia trachomatis ก F F ก ก ก F F discharge ก ก F ก conjunctivitis F follicles F ก tarsal plate F ก F F F follicles ก F F pannus cornea F ก F Herbert s pit F F F ก F F F F F ก F Trichiasis F ก ก F ก ก ก ก ก F F F ก F Entropion ก ก 1. Tetracycline + sulfonamide ก Tetracycline ก 2. ก ก trichiasis, entropion F F F F ก Inclusion conjunctivitis ก F กก 1 2 F F topical antibiotics Hay fever conjunctivitis Fก Hay fever (allergic rhinitis) ก F ก F topical antihistamine/vasoconstrictor + Cold compression Epidemic conjunctivitis presentation adenoviral keratoconjunctivitis corneal involvement ก F กF petechial hemorrhage, pseudomembrane, preauricular lymphadenopathy ก ก Supportive cool compression + ± topical antibiotic F ก F 72
    • Psychiatry 1. 3) Haloperidol ก ก F F F Fก akathisia ก motor mental restlessness F ก F neurological side effect antipsychotic F ก F กก ก F F ก F High potency F F F F Haloperidol ก ก F กFก Haloperidol F anticholinergic, benzodiazepine beta-blocker 2. 5) Separation Anxiety Disorder ก Separation anxiety disorder F กF ก กก F F ก F F ก ก F F F ก F 7-8 F Fก F 3. 5) F ก F F Fก F Guilt feeling criteria ก MDD 4. 5) MDD with psychotic feature F F F normal grief reaction F ก F ก F ก ก F F ( ก Hallucination) ก F Fก MDD depressed mood, psychomotor retardation, decreased appetite, insomnia F MDD with psychotic feature 5. 1) Delirium F trauma กF ก behavioral change ก ก F acute F F ก organic cause ก delirium ก F F กก altered cognition ก anxious, paranoid, sleep-wake cycle disturbance 6. 5) Amphetamine ก ก ก intoxication F F 1. ก (marijuana) euphoria ,slow sense of time, impair judgement, social withdrawal, increase appetite, dry mouth, conjunctival injection, hallucination, anxiety, paranoid, amotivational syndrome 2. ก F ??? 3. (ก F opioid) CNS depression, N/V, constipation, papillary constriction, respiratory depression, seizures 4. (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 F ก Fก F F ก ก F F ก ก 7. 3) decrease respiratory rate ก REM sleep F ก ก ก F ก paralysis กF F F Decrease respiratory rate F F ก REM sleep 8. 1) Fluoxetine F ก F Fก bulimia nervosa กก ก ก F compensatory method ก ก F กF maintain normal weight ( F ก anorexia ก F กF ก ) ก ก F F กFก F antidepressant fluoxetine 73
    • 9. 2) IV Diazepam F ก alcohol withdrawal delirium ก ก ก F ก F benzodiazepine ก ก ก F F IV diazepam 10. 1) Denial ก F ก ก Elisabeth-kubler-Ross F กF Denial (shock), Anger, Bargaining, Depression, Acceptance F F ก F F ก ก F ก F F กก F denial F F F ก ก F ก F bargaining ก F ก ก ก ก F F F F F F Denial 11. 1) Haloperidol F F ก กก high potency antipsychotics Haloperidol F Fluphenazine Perphenazine medium potency antipsychotics, Thioridazine F F ก arrhythmia F F F F syncope F ก ก F low potency antipsychotics F Thioridazine chlorpromazine anti alpha adrenergic F 12. 1) Haloperidol F 1 13. 4) Depressive disorder ก F Fก MDD ก 14. 4) Clomipramine F Fก Obsessive compulsive disorder F ก obsession fear to harm to oneself of loved ones ก ก ก F ก ก compulsion กF F ก ก ก ก F F Fก ก ก ก ก anxiety ก obsession ก ก F กFก F clomipramine SSRI F clomipramine 15. 3) Clonazepam ก F F Fก panic disorder กFก F ก ก ก F F antidepressant benzodiazepine ก กก benzodiazepine F 2 clonazepam alprazolam F ก clonazepam 16. 4) Delusional disorder: somatic type F ก ก F HIV F Fก delusional disorder ก non bizarre delusion ( ก ก ก F ) F delusion ก ก F F F F F F Fก 17. F ??? กFก ก 3D ก 1. Delirium- confusion and alteration of conscious and cognitive impairment 2. Depression- F ก criteria 3. Dementia- ก chronic ก ก recent กF remote memory 74
    • depression F F F choice F F F ก ก withdraw ก F ก F ก F terminal phase E. Mansell Pattison ก F F F ก กF ก ก ก ก ก F ก 18. 1) ก F F F ก PTSD F กF - ก กก F 1 - ก reexperiencing of the event F F - ก ก F ก ก ก - numbed responsiveness - increase arousal ก ก ก F F F ก PTSD ก ก ก F F F ก dissociative symptom F F dissociative amnesia 19. 2) Acute stress disorder ASD ก ก panic phobia F 1. ASD traumatic event กF 2. F ASD ก ก stimuli F ก event emotional numbness ก F ก F กก ก F ก ก F 3. F ASD ก increase arousal F F ก F ก F F F กF F FF ก F Traumatic event กF ก ASD F F F F F F F ก 1 F กก 1 ก PTSD 20. 5) Methylphenidate ก ADHD ก ก F F กFก F CNS stimulant F กF methylphenidate ( Drug of choice) F F imipramine ก F F 21. Depression (pseudodementia) Tx F Fluoxetine F F F กF F ก dementia F F ก depression F ก ก F F F F ก F depression กก F ก ก กก poor concentration ก F pseudodementia ก ก ก F fluoxetine 22. 1) Dyslexia F F ก F กF Learning disorder ก ก F F F F ก F IQ F ก F Dyslexia ก F ก F - 75
    • Forensic 1. 3) F Postmortem hypostasis (Livor mortis) F F½-2 . FFก F F F F fix กF F 8 . (fix 8-12 .) Postmortem rigidity (Rigor mortis) 2-4 . 6-12 . F F Rigor mortis ก ก กก F กกF F F F ก F ก F ก F ( F ) ก 2 ก FF F กF 4 . F F 6 . 2. 4) 5) (Ligature mark) ก ก ก ก ก ก F F ก ก ก ก F F fracture of Hyoid bone Hanging Manual strangulation ก Fก ก กF F moderate to severe bruise F ก Hanging F ก ก ก F ก ก F F F ก Ligature strangulation ก Manual strangulation F F ก F F F Subconjunctival hemorrhage ก FF Manual strangulation ก F F F F F กก Manual strangulation 3. 4) กก F ก ก F กF ก ก กF ก F F Acute heart failure, Cardiopulmonary failure Acute poisoning ก F กF ก F ก ก ก F F ก ก กF F F ก F ก F ก F F F ก F F ก Rupture aneurysm F F F F F incidence ก ก ก Coronary heart FF EKG F ก ก F Early MI 4. 2) ก Choice F F F ก F F F F F ก ก ก F ก F F ก ก F F F F กก F Brain laceration due to fracture base of skull from gunshot wound F 1 ก ก F F ก F F F ก +ก F F F ก F ก F F F 2 ก F ก F F 5. 3) ( F) ก ก F ก vagina F F ก Fก F F F F ก กก F F ก sperm F กF ก F F ก F F F Fก F ก foreign body ก ก ก F F F ก ก F 6. 3) F ก F F F ก ก ก F F F ก F F กF ( ) F F F F ก F F กก F F กF F F F กF 7. ( F 10) 8. 1) ก blood for amphetamine F ก acute F ก urine F FF กก F F ก FF F F ก ก F FF F F F 76
    • 9. 2) ก ก F Mongoloid ก F (Round, non-sloping) Caucasian ก ก (Angular, sloping) Negroid (Rectangular) ก ก ก F 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 297 F F กF ( ) ก ( ก ) ( ) F F ( ) F ( ) F F ( ) F ก*** ( ) ก F ( ) ( ) F ก ก ก กF ก ก ก ก F F ก กF F F F F ก F ก F F F ก F F F F F F กก F ก F ( กก ก ก F ก ก F F F ) 77
    • Ethics, Preventive & Commed 1. 3) Fasting blood sugar ก ก F F ก ก ก F F F กF 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 F 6) Congenital hypothyroidism & phenylketonuria TSH, PKU 7) Vaccination 2. 4) F ก กF F 3. 60% Disease No disease Test positive 120 30 150 Test negative 80 1770 1850 200 1800 2000 F Positive predictive value = 120 × 100 = 60% 150 F F ก F 8. F F F กก F F F F F F 150 ก 30 ก F : CXR ก F Test positive F F negative F 4. 4) F F F 18 F F F F F 10 ก F F F F < 18 F , F 5. F F 4) ก 5) F Ottawa charter ก 4) 5) F F F 4) กF ก ก F F F ( F ก ก F ) F ก F ก / F 1) F F F F F ก F ก ก ( F 2.) F 2) ก F -- F 3) กF F F กF ก F F F ก F ก ก 5 ก 1) F F F ก กก ก ก ก ก ก Fก กF Fก ก F Fก ก 2) F F F F ก ก F F ก F F ก F ก F ก F ก F 3) ก F F F ก F ก F F ก F Fก ก 78
    • 4) ก ก F ก ก ก F F F ก ก ก ก ก F Fก 5) ก ก กก ก F F F F F ก 6. 4) Randomization ก ก ก confounding factor F ก F กF ก ก 7. 2) Autonomy F F F F F ก ก Biomedical ethics 1) Autonomy F ก F F F F F F ก F F Fก F F F F F ก F F F F F F F กก ก F informed consent 2) Beneficence F F ก ก ก กF F กF F ก F F กF F F ก ก ก ก F F ก F ก F teleology F F ก F F Fก F paternalism F ก F F F 3) Nonmaleficence (Do no harm) Fก ก F F ก ก F F F ก F F Fก F F FF ก ก Fก ก ก F ก F F F F F FกF F ก ก F F 4) Justice F F F F ก ก ก ก ก ก F F F ก ก F ก F F ก F ก กก ก ก F ก F F 8. F 3. 9. F 11. 10. 1) Bias F F (Error) F กF 1. Random error กก F F F กF F F F ก F ก (Chance) 2. Systemic error F ก ก ก ก random error กก F F (Bias) 3 ก ( F F ก) • Selection bias ก ก ก ก ก ก F • Information bias ก F exposure outcome F rd • 3 variable or confounder 3 ก ( F bias) F F F ก ก outcome/disease F o (Causal relationship) outcome 79
    • o F F (Non-causal relationship) ก exposure o F intermediate step causal pathway F exposure outcome F F Information bias Contamination = ก ก F กF กF กF F intervention กก F F F F กF F F กF F placebo F Co-intervention = ก ก F กF F intervention ก ก ก กF กก F F F F F กF กก F F F F F F ก ก F Fก ก F F F กก กก F กก F F F กF F double blind technique 11. 3) 4) F ก F F F F FF ก F F 12. 1) Social empowerment 80