ศรว 51 ANS By Cmu

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ศรว 51 ANS By Cmu

  1. 1. 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
  2. 2. Internal medicine 1. 4) ก F ก SLE ก ก F ก ก SLE ก ก anti-dsDNA ก ANA sensitivity F F F ก SLE 2. 3) F Acute arthritis F ก F joint fluid septic profile (WBC > 50,000) c/s gram negative diplococci intracellular F Fก Gonococcal arthritis ก Drug of choice Ceftriaxone Joint fluid analysis 1. F Hemorrhagic effusion ก trauma, coagulopathy, etc. 2. F F F Hemorrhagic effusion F Inflammatory, noninflammatory septic profile Noninflammatory Inflammatory Septic WBC < 2,000 /µL WBC > 2,000 F < 50,000 /µL WBC > 50,000 /µL, PMN > 75% (Gram stain/Culture positive, glucose ) Osteoarthritis, trauma crystal → Gout, pseudogout Septic arthritis F crystal → RA, seronegative 3. 1) Taenia solium Neurocysticercosis Cysticercosis ก F ก ก generalized, CT multipled calcified cystic lesion accidental host ก F Taenia solium F ( F F ก F ) Toxoplasma immunocompromised, CT ring calcification, transplacental transmission 4. 3) F F F F ก ก ก TB ก F ก sputum AFB F negative 3 ก F F F F F TB F bronchoscopy R/O CA ก ก CXR ก CA lung F Diagnosis of TB 1. ก / ก : (> 3 wk) , , ก , F, กก 2. Chest X-ray: Not specific Not prove active disease, Strongly suggest TB upper zone (apical r r post seg. of upper lobe, sup seg. of lower lobe), cavitation calcified shadow 4 3. Acid-fast staining: detect F > 10 AFB/ml, Not specific to M. tuberculosis 4. Culture: Gold standard, sensitivity ก F F AFB (detect F > 103 AFB/ml) 5. Bronchoscopy: F F F F ก F, R/O CA F F, F F F F massive hemoptysis ก F ก 6. Tuberculin skin test: F F F Dx, infection F F disease, F ก TB , ก TB ก, F extrapulmonary TB, กF F F ก ก 5. 2) Guillain-Barre syndrome F weakness quadriplegia generalized weakness ก F ก CNS motor unit ก F F ก CNS ก conscious/cognitive change, hypertonia, hyperreflexia sensation F F F neuromuscular cause ก normal mental function, muscle tone ก , reflex ก F ก neuromuscular cause (nerve, muscle, NMJ) F F F 16. F ( ก F) 1
  3. 3. 6. 1) Constrictive pericarditis Neck vein engorgement, hepatomegaly = signs of right-sided heart failure Diffuse ST-T change with low voltage = pericarditis Pericarditis ก ก pericardium F myocardium F F ก myocardial injury ก diffuse ST-T change, Low voltage ก pericardial effusion ก heart ก electrode Pericarditis Rt.-sided heart failure = Constrictive pericarditis 7. 1) Acute pancreatitis Keyword: ก F , F , F , 8. 5) Varicella zoster infection 9. 1) S. aureus Pyomyositis ก ก ก ก F F F Quadriceps, Gluteus most common S. aureus 10. 1) TIA ก Transient neurodeficit F F F ก 11. 3) Roxithromycin Atypical pneumonia Clue F : F , URI กF , CXR: interstitial infiltration Organism: Mycoplasma pneumonia most common S/S: Insidious onset F F F F F Progress ก URI LRI F viral infection ก ก F ก F ก ก F headache, myalgia, nausea, vomiting, diarrhea, fatigue, sore throat CXR: Diffuse interstitial (reticular) infiltration ก : Macrolide (Erythromycin, Azithromycin, Clarithromycine), Doxycycline 12. 3) F F ก ก electrolyte F hypo ก hyperK, hyperNa hypoNa F osmolality shift F cell F F brain edema IICP hypoK F F consciousness ก F hypoCa F circumoral numbness, Acute gastric dilatation F F?? SIADH F F hypoNa F F F ก 13. Lead Lead poisoning: , F , motor neuropathy • Lead F ferrochelatase ∆-ala dehydratase ก ก F heme F F MCHC PBS basophilic stippling • Peripheral motor neuropathy (wrist drop, foot drop) • F • Renal tubule damage • Lead line gingival-tooth border 14. 10% Calcium gluconate K ก advanced EKG change F protect heart กF 2
  4. 4. ก ก HyperK 1. Protect heart : advanced EKG change K > 6.5 mmol/L F 10% Calcium gluconate ( ก antagonist) 2. Move K F cell : F Insulin + glucose, NB albuterol, (+ NaHCO3) 3. K : F Kayexalate + sorbitol (+ Furosemide, Hemodialysis) 15. 3) Leptospirosis Murine typhus, DF, DHF Enteric fever Leptospirosis Malaria Scrub typhus Signs and F F F F F F( symptoms RUQ pain, N/V ก F ( F ) pattern) Skin Rash, Petechiae Rose spot (rare) Rash (rare) Rash (rare) No rash Jaundice ก F ก F ± F ก F ± ก F ก icteric type F F ± F ± F ± F ± F F F F F F subconjunctival hemorrhage Meningitis F rare Aseptic Aseptic F meningitis meningitis Lung Effusion infiltration Interstitial Pulmonary edema (pulm hemorrhage) pneumonia CBC Hct↑, WBC↓, ก ก WBC↑, neutrophil varies Anemia, WBC↑, Atyp.lymph↑, F , plt↓ neutrophil F , plt↓ plt↓ U/A RBC ± RBC, WBC, proteinuria, cast Others Peyer s patch CPK↑ Eschar ruptured → Hx F F pneumoperitoneum 16. 2) Dermatomyositis Proximal muscle weakness ( ก ก ก) 1. Nerve: sensory, reflex, autonomic involvement ก distal Guillain-Barre syndrome • Acute autoimmune demyelination of peripheral nerve • F recent Campylobacter jejuni infection, viral infection influenza vaccination กF • weakness ( CN involvement) F ก sensation loss glove and stocking ( F ), hyporeflexia areflexia, LP 3
  5. 5. • ก : Plasmapheresis IVIG ( F role ก F steroid ) Diabetic polyneuropathy • ก กก axon, Fก chronic hyperglycemia • Affect motor (mild weakness), sensory (glove and stocking), autonomic F sensory F 2. Muscle: ก F ก F sensation loss ก F hyporeflexia/areflexia Polymyositis/Dermatomyositis • Symmetric progressive proximal muscle weakness • muscle pain, serum CK • Dermatomyositis = polymyositis + skin involvement (Heliotrope: , shawl sign: F F ก F , V-sign: F V, Gottron s sign: bony prominent) • ก : Steroid Steroid-induced myopathy • Insidious onset, Hx F steroid F asthma, COPD, rheumatoid Hypokalemic periodic paralysis • F F ก F กก ก ก F (high carbohydrate meal) • weak serum K • TFT ก 1) Familial F AD, ก Family Hx, TFT ก 2) Thyrotoxic ก thyrotoxicosis TFT hyperthyroidism 3. NMJ: ก F ก F muscle F fluctuation ( ก ) fatigability ( ก F F ) Myasthenia gravis • Autoantibody F postsynaptic Ach receptor • Fก thymoma • Ptosis, Bulbar involvement F • Fluctuation and fatigability 17. 5) PFT Asthma F Pulmonary function test FEV1/FVC response F bronchodilator Abnormal PFT FEV1/FVC > 70% FEV1/FVC < 70% Restrictive lung disease Obstructive lung disease ← Bronchodilator FEV1 > 12% FEV1 < 12% Asthma COPD 4
  6. 6. 18. 2) Thiamine signs CHF (Rt.-sided) + pulmonary edema, LV systolic failure (S3 gallop), cardiomegaly (Lt.-sided) F F F F ก ก Cardiac beriberi (ก F → Vitamin B1 (thiamine) → Cardiac beriberi) ก : F Vitamin B1 (thiamine) 19. 1) Chigger mite Orientia tsutsugamushi 20. 3) Neurogenic shock CO PCWP SVR ก ก Hypovolemic Trauma, blood loss, third F isotonic solution (volume ) space loss, burn ↓ ↓ ↑ Cardiogenic Tension pneumothorax, ก ( ก ก CHF, cardiac tamponade, Dobutamine, dopamine or NE F F) arrhythmia, MI, structural ↓ ↑ ↑ heart disease Distributive shock ↑ ↓ ↓ (vasodilate) Septic Bacteremia F fluid ABO gram neg. F Swan-Ganz catheter F dopamine NE Anaphylactic F , F F Diphenhydramine F 1:1000 epinephrine F Neurogenic* Spinal cord injury * Loss of sympathetic activity CO Cardiac output = hypotension + bradycardia PCWP Pulmonary capillary wedge pressure F ก LV SVR Systemic vascular resistance 21. 1) Inhaled Salbutanol prn + inhaled corticosteroid Management of asthma PEF Treatment Day attack Night attack Variability FEV1 Mild <1/ F <2/ > 80% < 20% SABA ก intermittent Mild >1/ F >2/ > 80% 20 - 30% + Inhaled corticosteroid persistent Moderate ก >1/ F 60 - 80% > 30% + LABA persistent ก ก Severe < 60% > 30% + Theophylline oral persistent limit activity LABA Leukotriene modifier oral corticosteroid 5
  7. 7. 22. ASA + Propanolol Subacute thyroiditis (de Quervain s thyroiditis) F 1. Thyrotoxic phase 2. Hypothyroid phase 3. Recovery phase F F ก F F ( F ก ก, ) F ก thyrotoxicosis hypothyroidism ก URI กF F F F ก Fก F turn hypothyroidism ก ก F Aspirin high dose NSAIDs ก F ก F steroid F F F ก thyrotoxicosis F F F β-blocker ( F role ก F antithyroid drug thyrotoxic phase) 23. 1) Simple goiter 24. 3) Thoracic area F UMNL, cord lesion Hyperreflexia, loss of sphincter tone level of sensation loss F F ก Thoracic area (T10) 25. 1) Atropine Bradycardia Airway, O2, monitor EKG, IV Adequate perfusion Poor perfusion Conscious change, ก , BP drop, shock • Observe, monitor • transcutaneous pacing • F Atropine 0.5 mg IV F 3 • F Epinephrine Dopamine IV drip F pacer 26. 1) Anti-HIV oral candidiasis 27. Pacemaker ( F F ) AV black 1st degree AV block PR prolong F (> 0.02 sec 5 F ) 2nd degree AV block Morbitz I PR F ก block 1 Morbitz II PR F ก F F ก block 1 3rd degree AV block Complete A-V dissociation p wave ก QRS (complete heart block) complex F Fก • 1st degree 2nd degree Mobitz I ก ก ก supranodal block F ก F junctional rhythm ( F AV node ก ) F HR 45 (ก ) nd • ก 2 degree Mobitz II ก ก infranodal block (his, bundle branch) ก turn complete heart block F idioventricular rhythm (ventricle ก ) HR 20 ( F F ) Mobitz II rd 3 degree AV block F pacemaker 6
  8. 8. 28. 4) Influenza vaccine F F 29. 2) Pancarditis F pericarditis กก F Keyword F rub (friction rub) ก F friction rub ก ก pleura pericardium F Fก ก F ก F cardiac friction rub F Fก ก ก F pleural friction rub 30. 1) Cardiac siderosis ก deposit F Thalassemia F F F กก F ก ก hemochromatosis ก ก F F กF → heart failure, → cirrhosis/liver failure, F → DM, Pituitary gland → hypogonadism, growth retardation . Choice 4) -- 31. 1) Ibuprofen ก ก Rheumatoid arthritis • Physical, occupational therapy periarticular muscle • Drugs symptoms ก ก First line Aspirin / NSAIDs ก Second line Glucocorticoid (joint injection oral) DMARDs ก First line Hydroxychloroquine, sulfasalazine, methotrexate active ก Second line Leflunomide, anti-TNF Azathioprine, gold, D-penicillamine, cyclosporine, cyclophosphamide • Surgery severe functional impairment ก deformity 32. 1) Ceftriaxone IV F Aminoglycoside F Gentamycin กก F Treatment of UTI Acute cystitis: 3-day therapy TMP-SMZ F F F Sulfa, ก fluoroquinolones F F ก F Acute pyelonephritis OPD: GPC amoxicillin GNB fluoroquinolones IPD: GPC ampicillin GNB aminoglycoside, cephalosporin (ceftriaxone, ceftazidime), fluoroquinolone 33. 2) Naloxone F F Fก Organophosphate poisoning Organophosphate poisoning • Irreversible inhibit AChE enzyme ก Ach overstimulation 7
  9. 9. • Muscarinic effects: DUMBELS (Diaphoresis and Diarrhea; Urination; Miosis; Bradycardia, Bronchospasm, Bronchorrhea; Emesis; Lacrimation; and Salivation) Cardiovascular - Bradycardia, hypotension Respiratory - Rhinorrhea, bronchorrhea, bronchospasm, cough, severe respiratory distress Gastrointestinal - Hypersalivation, nausea and vomiting, abdominal pain, diarrhea, fecal incontinence Genitourinary - Incontinence Ocular - Blurred vision, miosis Glands - Increased lacrimation, diaphoresis • Nicotinic effects F กF muscle fasciculations, cramping, weakness, diaphragmatic failure • CNS effects: anxiety, emotional lability, restlessness, confusion, ataxia, tremors, seizures, coma • ก ก GI decontamination, Activated charcoal Antimuscarinic: Atropine 0.5 2 mg IV q 15 min complete atropinization (dry mouth) Pralidoxime (2-PAM) 1 2 g IV F F ก8 nicotinic symptoms F ก F BDZ 34. 1) ก ก DM type II (Guideline 2551) 1. FBG < 200 mg/dL HbA1C < 8% → Lifestyle modification 1 3 F F F F start 2. FBG 200 300 mg/dL → Lifestyle modification + start ( ก F ) Metformin Sulfonylurea ก Insulin resistance: ก Insulin: 2 2 • BMI ≥ 23 kg/m • BMI < 23 kg/m • BP ≥ 130/85 mmHg F • ก ก • ก • TG↑, HDL-C↓ • Postprandial sugar ก: Glitazone, Repaglinide, α-glucosidase inhibitor, DPP-4 inhibitor (ก FBS 250 350 mg/dL HbA1C > 9% F 2 F ก ) 3. FBG > 300 mg/dL HbA1C > 11% F ก ก ก → F Insulin FBG 70 110 mg/dL HbA1C < 6.5% BP < 130/80 mmHg LDL < 100 mg/dL ( F CAD F F F keep < 70 mg/dL) F F F ก F : keep FBG < 130 mg/dL, HbA1C ≈ 7% 35. 3) PTU Treatment of Grave s disease ก + ก ก 1. Antithyroid drugs (PTU, Methimazole) 8
  10. 10. • ก ก organification (PTU inhibit peripheral conversion T4 → T3 F) • ☺ ก ก • High recurrent rate, serious side effect: agranulocytosis • Indication: ก, F F ( F PTU กก F ), Thyroid storm, F ก F ก F , induce euthyroid stage กF RAI Surgery, F long term recurrent hyperthyroidism F F F • Methimazole: Half-life กF ก F • ก F F F F 2 F F L-thyroxine F ก 131 2. Radioactive iodine (I ) • ☺ High cure rate, safe & easy, F ก , F F ก F infertility develop CA • Hypothyroidism, F ophthalmopathy F , F ก severe thyrotoxicosis / thyroid crisis F uncontrolled hyperthyroidism ( F กF F euthyroid) • Indication: First-line treatment , recurrent ก F F , ก( F F F ก hypothyroid F ก F ก ) • Contraindication / precaution: F / F , F , Low radioiodine uptake, Severe hyperthyroidism, Active ophthalmopathy, CA thyroid, F F ก , poor compliance 3. Surgery (Subtotal thyroidectomy) • ☺ก euthyroid stage • Surgical complications (recurrent laryngeal n. injury, hypoparathyroidism), ก relapse F F • Indication: F F, ก ก F ก F , Severe Grave s ophthalmopathy, F , nd CA thyroid, F 2 trimester • Contraindication: previous neck surgery, severe systemic illness, lack of well-qualified surgeons ก → β-blocker F ก ก F A. Radioactive iodine, B. Antithyroid drugs, C. Surgery F 50 ก , moderate B ( F กF ) กก F A, C hyperthyroidism, new case F F A F F A, C ก A F ก B, (A) F B, C ก hyperthyroidism B then A, C 36. 1) Free T4 ( F thyrotoxic hypoK periodic paralysis F 16.) 37. 1) 2 wks 38. 5) NB salbutamol ( iv steroid ก F) ก ก Acute asthmatic attack 1. F oxygen, keep O2 sat > 90% 2. F bronchodilator F F 9
  11. 11. β2-agonist ก nebulizer ก MDI with spacer F (PEF < 50% F F F accessory muscle) anticholinergic F ก β2-agonist 3. F Steroid : F IV oral steroid 4. F F antibiotic F bacterial infection 39. 4) Oral itraconazole Treatment of Tinea unguium Tinea unguium (Onychomycosis) F Fก ก F F F F F F F F ก F F กF F F F กF Oral griseofulvin, oral turbinafine, oral itraconazole 40. 1) Psoriasis • กF (papulosquamous) well-marginated, erythematous plaque with silvery scale ก extensor surface, • Koebner s sign positive ก F , Auspitz sign positive ก F ก • Associated findings: psoriatic arthritis, nail change (oil spot, onycholysis, pitting nail, subungual thickening) 41. 3) Xanthelasma hyperlipidemia 42. 5) Propanolol + Flunazine Propanolol = Beta blocker, Flunarizine = CCB Migraine Drug Prophylaxis: ก >3 F TCA, β-blocker, CCB, valproic acid, topiramate Treatment (Abortive Rx): 1. ASA, acetaminophen, caffeine, high-dose NSAIDs 2. Dopamine agonist: Metoclopramide IV, prochlorperazine IM or IV 3. 5-HT1 agonists ( Triptan ) F F F CAD 4. Ergotamine F F F CAD 43. 3) Subarachnoid hemorrhage Keyword: ก + stiffness of neck 44. 4) Myasthenia gravis ( F 16.) 45. 5) Intravenous immunoglobulin Guillain-Barre syndrome ( F 16.) 46. 1) Aspirin Secondary prevention of STEMI • Smoking cessation • Aggressive lipid lowering • Control of hypertension and diabetes • Prophylactic use of aspirin, beta-blockers, and ACE inhibitors 10
  12. 12. 47. 5) F F Fก Gout ก ก ก F F Joint fluid inflammatory Needle- shaped crystal ก x-ray F ก ก F soft tissue ก ก ก ก F ก F F ก tophi ก x-ray ก soft tissue mass F ก ก ก F punch out lesion, overhanging edge กF ก Gout • Acute monoarthritis ก 1st MTP joint, midfoot, F , F F , F ก ก • Chronic: Tophi (urate crystal deposit) • Joint fluid: Needle-shaped, negatively birefringent crystal • X-ray: Bone erosion with overhanging edge Soft tissue calcified mass F chronic tophaceous gout • ก ก : o Acute attack: NSAIDs, colchicines, steroid F F uric acid ก F attack o ก uric acid (alcohol, diuretics, aspirin, , ก) o Maintenance: Allopurinol (Xanthine oxidase ก F uric acid) Probenecid ( ก uric acid ) CPPD (pseudogout) • Acute monoarthritis ก F F F F • X-ray: Calcium deposit articular cartilage ก chondrocalcinosis • Synovial fluid: CPPD crystal F F F rhomboid cuboid weakly positive birefringence 48. 3) F F Acute monoarthritis ก ก ก F F FF F Fก Crystal- induced arthritis, Septic arthritis F ก F Synovial fluid F ก ก F ก Differential diagnosis Acute arthritis Monoarthritis Polyarthritis Pyogenic arthritis Acute rheumatic arthritis Crystal induced arthritis Pyogenic arthritis Acute rheumatic arthritis Seronegative arthritis Traumatic arthritis Viral arthritis Seronegative arthritis SLE Rheumatoid arthritis Rheumatoid arthritis 49. 3) F F F F กก FF F F F gout ก F F Acute monoarthritis Fก Crystal-induced arthritis, Septic arthritis, Rheumatoid arthritis (RA) ก F NSAIDs F RA F ก ก ก ก ก ก F ก กก F 11
  13. 13. F ก septic arthritis WBC > 50,000 PMN > 75% ก joint fluid profile gout pseudogout ก gout F ก F ก ก F F CPPD ก F ก ( F F ก Dx) ก gout กก F ( F F -_-!) 50. 2) F F Acute fever F ก RUQ pain Infection Inflammation กก F Malignancy F ก ก , LFT F ALP , Ultrasound Hyperechoic mass กF F F Fก Amebic liver abscess กก F HCC F F ก F Bile duct dilatation ก CCA F 51. 2) ก ก ก F ก F F Esophagus ก (Rupture) กF Boerhaave s syndrome content ก ก ก breath sound F Mallory- Weiss F Upper GI bleed ก ก ก mucosa F F ก ก 52. 3) F F ก F Lower GI bleeding alcohol F ก Hemorrhoids ก F ก F F F กก Fก ก ก F ก ก F กF F fiber F F F 53. 1) Pellagra ก กก Niacin (Vit. B3) F alcohol ก ก ก ก 4Ds F กF Diarrhea, Dermatitis, Dementia, Death ก pigmented scaling ก ก ก ก F Nutrient Clinical Finding Contributing Factors to Deficiency Thiamine Beriberi: neuropathy, muscle weakness and wasting, Alcoholism cardiomegaly, edema, ophthalmoplegia, confabulation Riboflavin Magenta tongue, angular stomatitis, seborrhea, cheilosis Niacin Pellagra: pigmented rash of sun-exposed areas, bright red Alcoholism, vitamin B6 deficiency, riboflavin tongue, diarrhea, apathy, memory loss, disorientation deficiency Vitamin B6 Seborrhea, glossitis convulsions, neuropathy, depression, Alcoholism, isoniazid confusion, microcytic anemia Folate Megaloblastic anemia, atrophic glossitis, depression, ↑ Alcoholism, sulfasalazine, pyrimethamine, homocysteine, triamterene Vitamin B12 Megaloblastic anemia, loss of vibratory and position sense, Gastric atrophy (pernicious anemia), terminal abnormal gait, dementia, impotence, loss of bladder and ileal disease, strict vegetarianism bowel control, ↑ homocysteine, ↑ methylmalonic acid Vitamin C Scurvy: petechiae, ecchymosis, coiled hairs, inflamed and Smoking, alcoholism bleeding gums, joint effusion, poor wound healing Vitamin A Xerophthalmia, nightblindness, Bitôt spots, follicular Fat malabsorption, infection, measles, hyperkeratosis, impaired embryonic development, immune alcoholism, protein-energy malnutrition dysfunction Vitamin D Rickets: skeletal deformation, rachitic rosary, bowed legs; Aging, lack of sunlight exposure, fat osteomalacia malabsorption Vitamin E Peripheral neuropathy, spinocerebellar ataxia, skeletal Occurs only with fat malabsorption, or genetic muscle atrophy, retinopathy abnormalities of vitamin E metabolism/transport Vitamin K Elevated prothrombin time, bleeding Fat malabsorption, liver disease, antibiotic use 54. F 6. 12
  14. 14. 55. 5) F clinical Acute Pulmonary edema F ก Hypertension F F ก ก F F ก ก ก F Morphine Transient venodilator F Preload F Afterload Hypertension F F ก ก F ก Dyspnea, Anxiety, Stress, Catecholamine level, Tachycardia F * F กก FF กF F F F morphine nitroprusside 56. 1) ก , N/V, , ก ก Digoxin intoxication ก กก ก ก Hypokalemia F F Furosemide F Hypokalemia F ก Fก ก Digoxin intoxication 57. 3) F 56 ก Digoxin intoxication ก F กF 58. 2) True Hyponatremia Urine Osm < 100 Primary polydipsia, Beer protomania, Reset osmostat F > 100 ก SIADH ( F ก F ADH function F) 59. 2) Coxsackie B virus virus F ก Dilated cardiomyopathy Systolic function F Fก ก Congestive heart failure 60. 1) F Platelet < 100,000 F ก Coagulopathy (prolonged PT, aPTT) DIC ก D-dimer F ก ( ก ) ก 61. 1) HbH disease genotype - - / - α (Heterozygous α-Thal-1 / α-Thal-2) ก F F gene - - ก - α ก F F ก F F F MCV ( ก 80 - 100) F RBC ก F Thalassemia minor - - gene (- - / αα) F Fก - α F MCV F F F F Carrier (- α / αα) กก F 62. 1) ก F Methanol intoxication F ( F F F ก F F) ก ก F ก Metabolic acidosis Methanol Fก F Causes of High-Anion-Gap Metabolic Acidosis • Lactic acidosis • Ketoacidosis: diabetic, alcoholic, starvation • Toxins: ethylene glycol, methanol, salicylates, propylene glycol, pyroglutamic acid • Renal failure (acute and chronic) 63. 1) Ventricular fibrillation ก ก ก ก Defibrillation 64. 2) Key point ก ก F ก Tetrodotoxin ( F ก F F F ) 65. 4) ( F F ) F Candiduria (Candida urine) Bladder thrush Foley s catheter F Bladder irrigation F Amphotericin B F F F F Foley s F oral Fluconazole 66. 1) F กก ก F กก F ( ก ก ) F signs dehydration Exertional heat stroke ก ( dehydration ก F F ก Heat stroke F) 13
  15. 15. 67. 4) MAHA blood picture DIC, HUS, TTP F Platelet < 100,000 F ก prolonged PT, aPTT DIC Fก Sepsis ก Bed sore DIC ก 68. 2) ก F HMG CoA reductase inhibitor (ก F Statin) ก ก LDL F Triglyceride F Drug Major Indications Mechanism Common Side Effects HMG-CoA reductase Elevated LDL-C ↓ Cholesterol synthesis, ↓ hepatic Myalgias, arthralgias, elevated inhibitors (statins) LDL receptors, ↓ VLDL production transaminases, dyspepsia Cholesterol absorption Elevated LDL-C ↓ Intestinal cholesterol absorption Elevated transaminases inhibitors (Ezetimibe) Bile acid sequestrants Elevated LDL-C ↑ Bile acid excretion and ↑ LDL Bloating, constipation, elevated (Cholestyramine) receptors triglycerides Nicotinic acid Elevated LDL-C ↓ VLDL hepatic synthesis Cutaneous flushing, GI upset, low HDL-C elevated glucose, uric acid, and elevated TG liver function tests Fibric acid derivatives Elevated TG, elevated ↑ LPL, ↓ VLDL synthesis Dyspepsia, myalgia, gallstones, (Gemfibrozil, Fenofibrate) remnants elevated transaminases Omega 3 fatty acids Elevated TG ↑ TG catabolism Dyspepsia, diarrhea, fishy odor to breath 69. 5) F F ก Myocardial infarction Fก 3 ก F Thrombolytic agent F Streptokinase, Tissue plasminogen activator (tPA) F F F F F ก ก ก F PCI F 14
  16. 16. 70. 2) F F Diarrhea ก F Stool examination F ก FF underlying Cirrhosis Spontaneous (Primary) bacterial peritonitis F DDx. F ก F Abdominal paracentesis ก F F ก F F F กก F F 71. 4) F F ก Cyanosis Radial pulse F Brachial pulse ก F ก distal vessels ก กก F proximal vessels Thromboangiitis obliterans (Buerger s disease) Small to Medium-sized vascular disease 72. 2) F F Acute monoarthritis F F F ก Synovial fluid Septic group (Group III) Septic 3 arthritis WBC Synovial fluid 50,000 /mm F ก ก ก F Empirical 15
  17. 17. Antibiotics F Gonococcal arthritis ก F F F WBC 50,000 PMN F ก F F F F 73. 4) Capillaria philippinensis 74. 3) F ก F F F DVT ก ก F Breath sound ก Pulmonary embolism 75. 2) F ก Hepatosplenomegaly F ก F F FกF F Hematologic disease CBC ก Microcytic anemia F ก กF F ก ก F Thalassemia & Hemoglobinopathies HbH disease ก ก Acute hemolysis ก F Stress F ก กF 76. 4) F clinical F Fก Hypertensive crisis F BP > 180/120 Hypertensive emergency F F 77. 1) ก ก Anaphylactic shock F Adrenaline 1:1,000 0.3-0.5 ml Intramuscular (IM) F Vastus lateralis muscle F 78. 1) F ก ก ก F F pupil ก ก Pin-point pupil ก Pontine hemorrhage F F ก F F Cerebellar hemorrhage F ก F F กF( ) F pin-point pupil 79. 4) ก ก F ก Leprosy ( ) 80. 4) ( F F ) Diastolic rumbling murmur Opening snap Mitral valve stenosis (MS) ก ก ก ก F F ก Calcification ก ก Regurgitation กก F 81. 1) ก clinical CXR Cavity Air-fluid level F Fก Lung abscess ก 82. - F Hypokalemia ( ก ก Renal loss) F ก Hypertension F Diuretics, Hyperaldosteronism, Renal a. stenosis, Cushing s syndrome ก plasma aldosterone/plasma renin activity (PA/PRA) ratio F F F > 20 Primary hyperaldosteronism F F F ก Primary hyperaldosteronism ก Renal a. stenosis F 83. 1) F F Penicillin F Diarrhea ก Antibiotic associated colitis (AAC) Pseudomembranous enterocolitis ก Clostridium difficile ก ก F Metronidazole Drug of choice ( F PO F F F F IV) F Vancomycin ก F F 84. 4) F ก F ก Hemolytic anemia F F ก F ก F RBC F F F กF F F ก G-6-PD deficiency ก F G-6-PD screening 85. 2) F ก ก ก 2 ก F F DKA F ก F F IV fluid Intra & Extravascular volume F ก F Insulin F 50-70 mg/dL/hr 200 mg/dL 86. 1) F DIC prolonged Pt, aPTT F ก coagulation factor F FFP ก F FFP Platelet F F ก ก Fก ก DIC ก ก F กF ก F ก Antibiotics (ATB) F F F F F ก DIC ก Sepsis ก ก Antibiotics 16
  18. 18. 87. - F F F Sustained VT PVC ก 3 ก Triplet PVC F ก 4 ก Nonsustained VT F F PVC F ก ก ก F 30 ก Ventricular tachycardia (VT) 88. 1) ก ก Complete heart block F Atropine Isoproterenol IV HR F block AV node Fก Pacemaker implantation ก ก AV conducting system disease Indication 89. 1) ก F Side effect Enalapril ACEI Drug Class Other Indications Contraindications/Cautions Diuretics Thiazides (HCTZ) Diabetes, dyslipidemia, hyperuricemia, gout, hypokalemia Loop diuretics CHF, Diabetes, dyslipidemia, hyperuricemia, (Furosemide) renal failure gout, hypokalemia Aldosterone antagonists CHF, primary aldosteronism Renal failure, hyperkalemia (Spironolactone) K+ retaining (Amiloride, Renal failure, hyperkalemia Triamterene) Beta blockers Cardioselective (Atenolol, Angina, CHF, post-MI, sinus Asthma, COPD, 2nd or 3rd degree heart Metoprolol) tachycardia, ventricular block, sick-sinus syndrome Nonselective tachyarrhythmias (Propranolol) Combined alpha/beta ? Post-MI, CHF (Labetalol, Carvedilol) Alpha antagonists Selective (Prazosin, Prostatism Doxazosin, Terazosin) Nonselective Pheochromocytoma (Phenoxybenzamine) Sympatholytics Central (Clonidine, Methyldopa, Reserpine) ACE Post-MI, CHF, nephropathy Renal failure, bilateral renal artery inhibitors (Captopril, stenosis, pregnancy, hyperkalemia Lisinopril, Ramipril) Angiotensin II CHF, diabetic nephropathy, ACE Renal failure, bilateral renal artery antagonists (Losartan, inhibitor cough stenosis, pregnancy, hyperkalemia Valsartan, Candesartan) Calcium antagonists Dihydropyridines Angina Heart failure, 2nd or 3rd degree heart (Nifedipine) block 17
  19. 19. Nondihydropyridines Post-MI, supraventricular (Verapamil, Diltiazem) tachycardia, angina Direct vasodilators Direct vasodilators Severe coronary artery disease (Hydralazine, Minoxidil) 90. 2) F Chronic oligoarthritis ก F Crepitus F Fก Osteoarthritis 91. 1) F Uncomplicated UTI ( F underlying structural/neurological disease, pregnancy upper UTI UTI Complicated UTI) ก ก F Co-trimoxazole (Bactrim) ก F Fluoroquinolone 3 ก 92. 4) Hypercalcemia (Dx. Ionized Ca > 4.5 Corrected Ca > 10.5 mg/dL) Ca ก F 12 mg/dL ก Neuro, KUB ( ), Heart GI ก ก F Fluid F ก ก F Ca ก F ก F Loop diuretics 93. 2) Migraine headache F F ก กก F ก ก 4 choices ก 1 choice ( F 42. ) 94. 1) 5) F F 18
  20. 20. Pediatrics 1. 1) EBV F tonsilar patch, splenomegaly with cervical node enlargement ก ก ก ก / ก Diphtheria - F Fก F -Mild pharyngeal injection Specific tx. -Complication: (Pharyngeal -F ก -Uni/bilateral tonsillar grayish -Antitoxin in 48 hr Myocarditis, polyneuritis, diphtheria) -ก ก - pseudomembrane (Bleeding -Penicillin G iv × 14d bronchopneumonia - if scrape) and may extended Prevention -Droplet transmission - dyspnea wildly to uvula, pharynx, -DTaP or DT -Bull neck = prog. F larynx, trachea, bronchus etc. -Cervical lymphadenopathy (Bullneck F ก) EBV infection - F (>39°C) -Tonsilar exudates or patch Supportive tx. - Hepatomegaly (Infectious -Nausea, not -Splenomegaly (hydration, mononucleosis) vomiting -Generalized acetaminophen) lymphadenopathy (esp. post. - F F ampicillin Cervical) amoxicillin ก -Atypical lymphocytosis rash GAS (Group A -Fever (>38°C) -Tonsilar yellow blood-tinged Specific tx. -Gold standard ก Streptococcal -Odynophagia exudates -Amoxicillin × 10d Dx throat swab C/S pharyngitis) - F ก -Enlarged/tender anterior -Erythromycin ( F cervical lymph nodes penicillin) × 10d - F ก GI Measles -3C -Inflamed buccal mucosa Supportive tx. - FกF F (conjunctivitis, -Erythematous, nonpruritic, Prevention / cough, coryza) maculopapular rash -MMR F confluent - F ก -Koplik spot (white/bluish - F ~ 4d lesions with an erythematous -AOM, croup, halo) pneumonia: -Cervical adenitis complications 2. 2) Pityriasis alba Pityriasis alba hypopigmented lesion ก round or oval, macular of slightly elevated patched fine adherent scale ก F, , F proximal portions ก F F F ก ก F F mild form eczema F ก ก F F vitiligo, tinea vesicolor tinea corporis ก F lubricant ก F F Vitiligo F F F F ก ก immunologic abnormalities F antibody F melanocytes F F 2 generalized localized ก กF 18 F ก generalized form symmetric pattern of white macules and patches with hyperpigmented margin F vitiligo Fก autoimmune disease 19
  21. 21. DM F ก F topical steroid, topical tacrolimus ก F narrow-band UVB (UVB311) Pityriasis vesicolor tinea vesicolor ก ก chronic fungal infection stratum corneum ก Malassezia furfur F normal flora ก F , ก ก, plasma cortisol , immunosuppression, malnourishment F F ก hypopigmented macules, covered with a fine scale KOH ก ก F Spaghetti and meatball ก Selenium sulfide susp., imidazole or terbinafine cream ketoconazole/itraconazole PO Tinea facialis ก กก ก ก dermatophyte (Trichophyton, Microsporum, Epidermophyton) ก dry, mildly erythematous, elevated scaly papule or plaque F ก ก clear central F annular lesion F KOH filamentous fungus ก Ketoconazole/clotimazole topical Terbanafine, griseofulvin PO ก Tinea Contact leukoderm F F F chemical leukoderma ก vitiligo ก กF satellite lesion F ก ก melanocyte กก melanocyte ก vitiligo ก 3. 3) foreign body aspiration ก FB F rt. Main bronchus common site for bronchial foreign body aspiration ก ก ก acute onset ก aspiration ก partial LRT obstruction (rhochus 2 sibilant rhonchus = wheezing sonorous rhonchus = rhonchus Fก ) ก ก F ก 3 F ก 1-3 กF F ก F F (Stable patient) Plain chest film F Resp. tract obstruction (segmental atelectasis) opaque foreign body F ก inspiratory and expiratory film F ก plain CXR ก ก partial obs. ก ball-valve (insp.=air F F, exsp.=air ก F F ก air trapping) hyperinflation ก , mediastinal shift ipsilateral diaphragm F F ก ก ก FF fluoroscope bilateral decubitus chest film F ก bronchoscopy F lateral film F F ก 4. 2) + 5) Hypoglycemia newborn plasma glucose lv. < 40 mg/dl ( F F 45 mg/dl ก whole blood glucose <50 mg/dl WBG. < PG. 10-15 mg/dl ก F ก DTX F F plasma glucose confirm F ) ก ก sudden withdrawal of transplacental glucose supply ก 1-3 hr. of life F 12-24 hr. of life hypoglycemia F ก gluconeogenesis ketogenesis F F preterm, DM mother, erythroblastosis fetalis, asphyxia SGA ก F F ก F feeding F ก (apnea, hypotonia, irritability, irreg. respiration, tremors, eye rolling, seizures, etc.) F IV 10% glucose 2 ml/kg (rate1 ml/min) ก F ก seizure F 4 ml/kg F F maintain F IV fluid with GPR 6-8 mg/kg/min (3.6-4.8 ml/kg/h of D10W) recheck ก 15-30 rate/concentration F 20
  22. 22. 5. F F ก F Turner syndrome (45, XO) ก webbed neck, short stature, cubitus valgus, short neck, 1° amenorrhea multiple congenital anomalies in phenotypic females ก ovarian development F X chromosome ก ovary Turner syndrome ก ovary streak ovary F stromal cell 1° amenorrhea ก low estrogen and low progesterone F gonadotrophin GnRH Fก F F F amenorrhea 6. 4)? F F Henoch-Schönlein Purpura ก ก small vessel vasculitis ก ก palpable purpuric rash ก waist buttocks; arthritis ก knees ankles; abdominal pain ก ก vasculitis F GI tract glomerulonephritis F hematuria proteinuria F ก F F prognosis U/A ก ก F renal involvement F F ก chronic hypertension CRF F 7. Polyarteritis nodosa? ( F F ก ก F F F F ก) necrotizing vasculitis small medium sized arteries 9 F F ก F ก URI, Group A Strep. Infection chronic hepatitis B F F ก F F กF ก mesenteric a. inflammation F F renovascular arteritis F purpura, edema and linear erythema wih palpable, painful nodule arteries ก ก neuro, cardio F F ก F biopsy skin lesion ก oral/IV corticosteroid 8. 5) ก กก F pathological jx. jx. ก 24 hr. ก; jx unconj.bili. > 12.9 mg/dl term > 15 mg/dl preterm; conj.billi. > 2 mg/dl; bili. lv > 5 mg/dl/d jx. ก F 1 wk term ก F 2 wk preterm F pathological jx. ก ก ABO incompatibility ก F O, jx. 1st 24 hr ก ก anemia F ก hemolytic anemia ก ก F sepsis jx. 1st 24 hr F F ก anemia F F ก F ก sepsis sign F jx. F F F ก F ( 4 hr F PROM F prolong F risk F infection) Jx. of prematurity ก 3-4 F ( F physiologic jx.) ก G6PD def. F ก mutation promoter region UDP-glucuronyl transferase-1 ก F ก กก G6PD def. jx. F ก hemolysis F F Thalassemia F F neonatal jaundice 9. F F 10. 2) F 1( F Diphtheria F F F patch ก ก tonsil) F candidiasis ก white plaque immunocompromised host 11. 5) F ก F asthma exacerbation ก severe exacerbation ก dyspnea, retraction, accessory muscle use, tachypnea, mental status change, poor air entry. ก ก F O2 supplement F inhaled bronchodilator SABAs (Short-acting inhaled β2 agonist- albuterol, salbutamol, levalbuterol) ก 20 1 ก ก F ก F 1st inhaled β-agonist F inhaled ipratropium F ก F SABA F ก F F expiratory wheezing F ก F inhaled ipratropium F systemic corticosteroids F F F 21
  23. 23. ก ก ก F intramuscular injection of epinephrine β-agonist Mucolytics, chest physical therapy spirometry F asthma exacerbation F ก severe bronchoconstriction F 12. 3) ก splenectomy F ก ก F parasite encapsulated bacteria ก F F F ก ก opsonized (ก ก complement C3b ก ) ก กก ก F ก F Ab F T cell-independent antigen F polysaccharide F capsule F ก F Pneumococcal vaccine (S. pneumoniae), meningococcal vaccine (N. meningitides) H. influenzae type B vaccine กF ก F 2 F ก ก postsplenectomy sepsis F meningococcal vaccine serotype B (serotype F ) F F Pneumococcal vaccine H. influenzae vaccine F F Oral penicillin V prophylaxis F ก 2 ก splenectomy F F F F F 13. 1) abdominal tumors ก ( F 14) 14. 1) Wilms tumor F ก abdominal mass, abdominal pain, hematuria vomiting F F 15-25 F Hydronephrosis ก ก obstructive uropathy ก recurrent UTI F F F pyuria F F TUMOR AGE CLINICAL SIGNS LABORATORY FINDINGS Wilms Preschool Unilateral flank mass, aniridia, Hematuria; bone scintigraphy (clear (1 - 5 yr) hemihypertrophy cell sarcoma) Neuroblastoma Preschool GI/GU obstruction, raccoon eyes, Increased VMA;increased (median age 2 yr, myoclonus-opsoclonus, diarrhea, skin HVA;increased ferritin; stippled almost < 5yr nodules (infants), mass may cross calcification in mass. midline Bone marrow positive Non-Hodgkin lymphoma > 1 yr Intussusception in >2-yr-old ↑ urate; bone marrow positive Rhabdomyosarcoma All GI/GU obstruction, sarcoma botryoides, vaginal bleeding, paratesticular mass Germ cell/teratoma Preschool, teens Girls:abdominal pain, vaginal bleeding Increased hCG;Increased AFP Boys:testicular mass, new-onset hydrocele Sacrococcygeal mass/dimple Hepatoblastoma Birth 3 yr Large, firm liver Increased AFP Hepatoma School age, teens Large, firm liver; hepatitis B, cirrhosis Increased AFP ก Nelson Textbook of Pedriatric, 18th ed. 15. 1) F ก F anemia jaundice lab NCNC RBC reticulocyte count ก ก hemolytic anemia F F 2ก F ก Corpuscular hemolytic anemia (Membrane defects, enzyme defects, Thalassemia and hemoglobinopathies) extracorpuscular hemolytic anemia (Immune hemolytic anemia, mechanical hemolytic anemia, direct toxic effect on RBC) กก F Coomb s test F negative positive 22
  24. 24. Inclusion test F supravital stain F inclusion bodies HbH ก ก HbH disease (--/-α) Coomb s test F F negative กF F ก ก hemoglobin typing, G6PD def. screening F bone marrow aspiration F ก bone marrow response (RC ) F bone marrow defect F ก investigation ก F F F anemia F bone marrow aspiration ( algorithm ก 5 anemia in children) 16. Adrenaline (Epinephrine) anaphylaxis ก กก potent active mediator ก mast cells basophils F F ก F (urticaria, angioedema, flushing), (bronchospasm, laryngeal edema), CVS (hypotension, arrhythmias, MI) GI (nausea, colicky abdominal pain, vomiting, diarrhea) IgE mediated immune response F ก exposed F antigen F ก F F ก ก F F F F F ก IM epinephrine F F กF IM or IV H1 and H2 antihistamine antagonists, oxygen, IV fluids, inhaled β-agonists corticosteroid F F biphasic anaphylaxis F 4 hr observe F F 4 hr กF D/C ก ER 17. 2) ก F F F sepsis ( SIRS + suspected/proven infection) F ก DIC (low platelet with prolong PT and PTT with clinical bleeding) F ก shock ก management DIC ก กF F antibiotic กF กF ก F ก septic shock ก F fluid resuscitation F F management ก F FFP, platelet conc. PRC F clinical bleeding F plt. conc. → FFP → PRC ( F control bleeding F FกF F ) clinical bleeding Fก management ก control DIC ก ก sepsis กก F ก control bleeding SIRS systemic inflammatory response syndrome 2 ก4 F F • Core temp. >38.5 °C < 36 °C ( ก, ก , F ก central catheter) • Tachycardia (mean heart rate > 2SD above normal for age) ก F กF 1 persistent th bradycardia ก F ½ hr (mean heart rate<10 percentile for age) • RR > 2SD above normal for age or acute need for mechanical ventilation (not related to Neuromuscular disease or GA) • Leukocyte count elevated depressed for age >10% immature neutrophils 18. Idiopathic Vit K def. of infant ก F ecchymosis F coagulopathy ก F ก ก vit K ก F F F vit K 1 mg IM Fก F vit K ก vit K def. F ก กก 3 • Classic hemorrhagic disease of the newborn ก 1 -14 ก ก vit K F ก vit K F ก F F F ก กก F F ก ก F ก F vit K2 ก F sterile ก ก F ก vit K F F ก กก ก F F Vit K 1 mg IM • Late VKDB (Vit K-def. bleeding) ก 2-12 F ก F 6 ก F ก vit K F F cholestatic liver disease 23
  25. 25. • ก ก F ก F F warfarin, phenobarbital, phenytoin F ก F ก ก vit K ก vit K def. GI bleeding, mucosal and cutaneous bleeding, bleeding umbilical stump post-circumcision site F Intracranial bleeding F F F ก 19. 1) ก F F F nephrotic syndrome (ก nephritic syndrome heavy proteinuria: >3.5 g/d 2 F F > 40 mg/m /hr, hypoalbuminemia: <2.5g/dl, edema hypercholesterolemia) ก proteinuria, edema hypercholesterolemia ( F กก oval fat body ก UA) edema nephrotic syndrome F F F F F ก massive urine protein loss F ก hypoalbuminemia F plasma oncotic pressure F fluid ก IV compartment interstitial space 20. 5) ก F FF F F Reflex syncope Neurocardiogenic syncope ก กก peripheral sympathetic activity venous pooling F ก myocardial contraction of a relatively empty lt. ventricle ก F myocardial mechanoreceptor vagal afferent nerve fiber F sympathetic activity ก F parasympathetic activity Syncope Fก ก F ก F F F , ก F, extreme fatigue, severe pain, hunger, prolonged standing, emotional or stressful situations ก ก F F F F F F F ก กก ก F ก ก F F F ก EKG F ก F arrhythmia F ก ก Holter monitor F blood sugar ก hypoglycemia F F F F ก DM F insulin F ก Harrison s Principle of Medicine, 17th edition. 21. F ( ก ก F ก ก ; 6 ก. . 2551 ) 24
  26. 26. LTBI = Latent tuberculosis infection ก F ก , TT F ก, CXR ก ( ก F TB กF ) ( ก F F HIV ) LTBI ก ก TB F 1-2 host F กF 5 ( F < 2 ), F ก , กก ก F F Isoniazid 6-9 ก LTBI ก F F 1. ก ก F ก F F ก 5 , TT reaction > 15 mm. BCG 2. Immunocompromised host a. Severe malnutrition TT ≥ 10 mm. b. Steroid therapy TT ≥ 10 mm. c. HIV infection - TT ≥ 5 mm. 3. Old fibrotic scar F ก (TT ≥ 10 mm.) 4. Recent converter (TT ก ก 6 mm.) 25
  27. 27. ก TB F criteria ก ก F ก F F ก F F F F 2 F 1. ก F F 2. ก 3. ก กก 4. ก F ก AFB F ก 22. 2) ก F F F ketoacidosis ก ก electrolyte F HCO3 ก ก ketone F ก ก ketoacidosis F ก F ก F F (ก F ก starvation, alcohol DM) F F F DKA ก ก F ก ก F IV fluid ก F ก F poor perfusion ก F 10-20 ml/kg IV bolus 0.9% NaCl or LRS F ก volume expansion F F F ก F Insulin drip at 0.1U/kg/hr 1 g/kg IV push for cerebral edema F 2 ก ก hypokalemia F ก F Potassium กF F F ก กF F F ก F HCO3 F pH < 7.0 23. 2) delivery room ก term infant with meconium staining hypopharyngeal suction ก กF F F ก กก distress F ( F hypoxia, bradycardia, fetal acidosis or apnea) ก endotracheal intubation suction F endotracheal tube meconium ก ก F ก preterm infant < 34 wk F ก IUGR F, meconium F purulent fluid ก infection bile stained ก ก proximal intestinal obstruction 24. 3)? F 18 F F F anemia F jaundice bulging of AF intracranial bleeding ก F sepsis F SIRS F F SDH F F ก F seizure F 25. Rubella ก Congenital infection F MANIFESTATION PATHOGEN IUGR CMV, Plasmodium, rubella, toxoplasmosis, Treponema pallidum, Trypanosoma cruzi, VZV Congenital Anatomic Defects Cataracts Rubella Heart defects Rubella (esp. PDA) Hydrocephalus HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis Intracranial calcification CMV, HIV, toxoplasmosis, T. cruzi Microcephaly CMV, HSV, rubella, toxoplasmosis Neonatal Organ Involvement Encephalitis CMV, enteroviruses, HSV, rubella, toxoplasmosis, T. cruzi, T. pallidum Hepatitis CMV, enteroviruses, HSV Hepatosplenomegaly CMV, enteroviruses, HIV, HSV, Plasmodium, rubella, T. cruzi, T. pallidum Hydrops Parvovirus, T. pallidum, toxoplasmosis Retinitis CMV, HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis, T. pallidum Late Sequelae Deafness CMV, rubella, toxoplasmosis Mental retardation CMV, HIV, HSV, rubella, toxoplasmosis, T. cruzi, VZV ก Nelson Textbook of Pedriatric, 18th ed. 26
  28. 28. 26. 1) ก ก F hypoxic spells (Paroxysmal hypercyanotic attacks) ก TOF ก ก F 4 F Fก TOF F F cyanosis ก cyanosis ก ก progressive pulmonary stenosis F ก F pansystolic murmur at lt. parasternal border* F TOF lt. lower parasternal border ( ก TOF murmur ก SEM at lt. upper parasternal border) Hypoxic spells ก F ก F 1-2 F ก ก ก F ก ก F F กF F F ก ก กก already compromised pulmonary blood flow ( ก infundibular spasm) F ก systemic hypoxia metabolic acidosis ก ก F F Knee-chest position peripheral vascular resistance F F ก F O2 F MO F ก 0.2 mg/kg sc. F F F infundibular spasm F NaHCO3 metabolic acidosis F systemic vascular resistance F phenylephrine, levophed ketamine F ก ก F β-blocker ก ก ก palliative Sx. modified Blalock-Taussig shunt กF definitive Sx. Breath-holding spells ก F 6 2 ก กF F ก ก ก ก F F F ก F ก F F 30 F ก F ก Fก F ก ก ก F F F cyanosis กF F F F F Asthmatic attack F F F F F severity ก F asthma F F wheezing F F cyanosis กF F F F murmur F pulmonary embolism F F U/D condition F F F adventitious sound กก F F murmur * F ก PSM @ Lt. parasternal border cyanotic heart F F F Tricuspid atresia ก 1 , truncus arteriosus ก F ก ก 1 F VSD PSM F F F F F 27. 5) Retropharyngeal abscess F F 1-6 ก ก ก F ( F F ก ก ก foreign body) ก ก ก mixed organism ก irritable, fever, ↓food intake ก ก ก F (muffled voice) ก ก drooling airway obstruction F กก posterior pharyngeal wall ก F lat. neck film retropharyngeal space ( C2 > rd 7mm, or C6 > 14 mm) ก ก F F IV antibiotic (3 gen. Cephalosporin + ampicillin-sulbactam or clindamycin) ± surgical drainage Acute tracheitis (Bacterial tracheitis) ก ก Viral URI laryngotracheitis (croup) ก ก ก S. aureus F life-threatening condition F ก airway obstruction F 5-7 ก typical brassy cough, high fever toxicity with respiratory distress purulent secretion F F F drooling F dysphagia ก ก F epinephrine F F ก clinical ก F ก epiglottitis ก ก F F IV antibiotic F O2 supplement intubation Acute epiglottitis ก 2-7 ก ก ก H. influenzae type B (Hib) F F F F F ก ก S. pyogenes, S. pneumoniae, S. aureus F ก ก Hib F ก typical ก 27
  29. 29. fever, irritability, sore throat, drooling, muffled voice, rapidly progressive stridor, respiratory distress F F F F F ก erythematous and swollen epiglottis thumb sign ก ก ก secure airway F ก F ก ก F IV line placement F ก F F ก F secure airway F F ก F IV antibiotic Viral Croup (Laryngotracheobronchitis Laryngotracheitis mild form croup) ก ก 1-3 F ก ก กก parainfluenza virus type 1-3 F ก ก F F กF ก F 1-3 กF ก upper airway obstruction ก barking cough, hoarseness inspiratory stridor F ก coryza, normal-mod. Inflamed pharynx slightly ↑RR ก ก dyspnea, marked ↑RR, cont. stridor, cyanosis, hypoxia, pallor ก ก ก airway management ก ก ก F F F F ก ก F ก F ก ก ก F F F F ก F NPO ก ก ก F O2 humidification F ก F Nubulized epinephrine ก ก moderate-severe croup (stridor at rest, possible need for intubation, respiratory distress and hypoxia) ก constriction precapillary arterioles F β-adrenergic receptors F ก resorption interstitial space ก laryngeal mucosa F ก F oral corticosteroids F ก F ก F F F ก F antibiotics croup Acute laryngitis ก ก ก ( ก F diphtheria) ก ก UTI sore throat, cough ก F ก ก F ก F ก F ก pharyngeal inflammation F F inflammation vocal cord subglottic tissue F F laryngoscope 28. 3) F F กก F 1 ก F F F F ก F F F F F F F ก F 1 F F DTP4, OPV4, JE F กก 2m 4m 6m 9m 12 m 18 m 2-2½yr 4-6 yr 12-16 yr BCG, DTP1, DTP2, DTP3, MMR1 DTP4, JE3 DTP5, dT ก HBV1 OBV1, OPV2 OBV3, OPV4 OPV5, 10 HBV2 HBV3 JE1 JE2 F ก 1-4 wk MMR2 29. 2) F preterm GA 32 wk F dyspnea ก RDS Fก ก กก surfactant กก F ก surfactant F ก dipalmitoyl phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins cholesterol ก ก F ก F ก type II alveolar cell F surfactant surface tension alveoli F ก ก collapse small air spaces ก ก F F ก dipalmitoyl phosphatidylcholine lecithin ก ก RDS DM, C/S delivery, precipitous delivery, asphyxia ก กF F F กF F PAH PIH, F heroin, PROM ก F steroid prophylaxis 30. 1) F 1 31. 1) F 21 28
  30. 30. 32. F F >< FF diarrhea Congenital Lactase deficiency F ก ก F ก ก primary adult type hypolactasia secondary lactose intolerance กก F ก กก small bowel mucosal damage F ก celiac disease rotavirus infection ก F ก F F ก ก ก ก ก ก F Antibiotic-related diarrhea ก ก F antibiotic F กF amoxicillin, ampicillin, amoxicillin- clavulanate, cefepime, clindamycin, doxycycline, erythromycin F F F ก ก ก F antibiotic ก F broad spectrums Fก F F F C. difficile ก overgrowth F ก diarrhea F F pseudomembrane ก F psuedomembranous colitis ETIOLOGY SIGNS AND SYMPTOMS DURATION ASSOCIATED FOODS TREATMENT OF ILLNESS Bacillus cereus Sudden onset of severe 24 hr Improperly refrigerated Supportive care (preformed nausea and vomiting. Diarrhea cooked or fried rice, enterotoxin) may be present. meats Campylobacter jejuni Diarrhea, cramps, fever, and 2 10 days Raw and undercooked Supportive care. For vomiting; diarrhea may be poultry, unpasturized severe cases, antibiotics bloody. milk, contaminated such as erythromycin and water quinolones may be indicated early in the diarrheal disease. Guillain-Barré syndrome can be a sequela. Enterohemorrhagic E. Severe diarrhea that is often 5 10 days Undercooked beef Supportive care, monitor coli (EHEC) including bloody, abdominal pain and especially hamburger, renal function, E. coli O157 : H7 and vomiting. Usually, little or no unpasteurized milk and hemoglobin, and platelets other Shiga toxin fever is present. More common juice, raw fruits and closely. E. coli O157 : H7 producing E. coli in children <4 yr old. vegetables (e.g., infection is also (STEC) sprouts), salami associated with hemolytic (rarely), and uremic syndrome (HUS), contaminated water which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS. Enterotoxigenic E. coli Watery diarrhea, abdominal 3 to >7 days Water or food Supportive care. (ETEC) cramps, some vomiting contaminated with Antibiotics are rarely human feces needed except in severe cases. Recommended antibiotics include TMP- SMX and quinolones. Salmonella spp. Diarrhea, fever, abdominal 4 7 days Contaminated eggs, Supportive care. Other cramps, vomiting. S. typhi and poultry, unpasteurized than for S. typhi and S. S. paratyphi produce typhoid milk or juice, cheese, paratyphi, antibiotics are 29

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