National Licence

2008

Thx Everyones
1. 32 urine protein 1+, red blood cell
cast specific
a. Rheumatoid factor
b. ANA
c. Anti- histone antibody
d. Anti ds-DNA antibody
SLE ARA criteria

1. (malar rash) (nasolabial fold)
2. discoid discoid lupus
3. (photosensitivity)
4. (oral ulcer)
5. (nonerosive arthritis)
6. (serositis)
7. 0.5 3+
8. ( psychosis)
9. 4,000/.. (
2 ) 1,500/.. ( 2 )
100,000/..
10. anti double stranded DNA anti-Sm antibodies
antiphospholipid antibodies
11. antinuclear antibodies (ANA)
4 96
lab Anti ds-DNA antibody titer 60-
70% SLE autoimmune titer
Antihistone antibodies (AHAs) drug-induced lupus erythematosus
autoimmune SLE unrelated to medications, rheumatoid arthritis, juvenile rheumatoid arthritis, primary biliary cirrhosis,
autoimmune hepatitis, dermatomyositis/polymyositis scleroderma
Rheumatoid factor immunoglobulin (antibody) rheumatoid arthritis juvenile
rheumatoid arthritis autoimmune rheumatoid factor positive
Sjogren's syndrome, Systemic lupus erythematosus, Scleroderma, Polymyositis, Dermatomyositis, Mixed Connective Tissue
Disease Bacterial endocarditis, Osteomyelitis
Anti-nuclear antibodies (ANAs) autoimmune
titer ANA 1:40 autoimmune lupus erythematosus ( 80-90%
SLE) Sjgren's syndrome (60%), rheumatoid arthritis, autoimmune hepatitis, scleroderma and
polymyositis & dermatomyositis (30%),
 (indication) :
1.) Systemic lupus erythematosus
2.) Connective tissue disease
3.) specific antibody

2. 35 4 WBC = 89000,
PMN = 90%, G/S: gram negative intracellular diplococci
a. Cloxacillin
b. Gentamicin
c. Ceftriazone
d. Doxycycline
e. Metronidazole
gonococcal arthritis
Gonococcal arthritis gonorrhea

Two forms of gonococcal arthritis exist:

One involves skin rashes and multiple joints, usually large joints such as the knee, wrist, and ankle
The second, less common form involves disseminated gonococcemia, which leads to infection of a single joint

Fever
Lower abdominal pain
Migrating joint pain for 1 to 4 days
Pain in the hands or wrists due to tendon inflammation
Pain or burning on urination
Single joint pain
Skin rash (lesions are flat, pink to red, may later contain pus or appear purple)
Exams and Tests
gonococcal arthritis hemoculture gonorrhea infection

Cervical gram stain

Culture of joint aspirate
Joint fluid gram stain
Throat culture
Treatment
Gonorrhea Penicillin
cephalosporins Ceftriaxone (Rocephin) Azithromycin (Zithromax)
uncomplicated infections.
follow-up 7
3. Generalized Tonic clonic
neurological deficit papilledema CT scan : multiple calcified
cystic lesion
a. Taenia solium
b. Taenia saginata
c. Toxocara
d. Toxoplasma
CT cysticercosis Taenia solium cysticercosis
,
, subcutaneous tissue , , ,

fibrous tissue cerebral cysticercosis
5 -8
20 , cyst
,
, ,

Taenia saginata
appendicitis intestinal obstruction
cysticercus bovis
Toxocara spp. Toxocariasis Toxocara (Toxocara
canis)(T. cati)
toxocariasis 2
1) Ocular larva migrans (OLM):
scar retina permanent partial loss of vision

2) Visceral larva migrans (VLM):

Toxocara infections VLM CNS
VLM fever, coughing, asthma,
pneumonia
Toxoplasma toxoplasmosis
Toxoplasmosis gondii
HIV

3
1.
- 2 - 3 2 - 3

-

2.
- ( 3 ) 45% 60%
10% 30% ( hydrocephalus) (
intracerebral calcification )
- 3
3.

TOXO MRI scan

lesion calcification cystic

4. 55 4 1 AFB negative 3
CXR reticulonodular infiltration with thickening cavity
a. culture for TB
b. Start anti-TB drug
c. Bronchoscopy
d. Aspiration
e. PCR for TB
c. Bronchoscopy
Case an old man with chronic non-productive cough,
approach non productive cough hemoptysis, weight loss
CXR reticulonodular infiltration with thickening cavity Pulmonary TB Sputum AFB Negative 3
Probable definite
definite diagnosis
Bronchoscopy R/O Lung cancer
chest X-ray thickening cavity necrotizing lung cancer
Bronchoscopy Smear Negative

c(O)nt 010 Med X
 5. 18 2
Upper motor power 4/5, lower 1/5, absent DTR
a. Transverse myelitis
b. GBS
c. MG
d. Neurosyphilis
b.GBS
muscle weakness Lower motor neuron

( 2
) Acute neuromuscular weakness
(LMN.) LMN
Guillain Barre
syndrome Myasthenia gravis

Diagnostic Criteria for Guillain-Barr Syndrome

REQUIRED
1. Progressive weakness of 2 or more limbs due to neuropathya
2. Areflexia
Ascending paralysis ( rubbery legs) 3. Disease course <4 weeks
Exclusion of other causes [e.g., vasculitis (polyarteritis
absent deep tendon reflex 4. nodosa, systemic lupus erythematosus, Churg-Strauss
GBS (over hours to a few days) syndrome), toxins (organophosphates, lead), botulism,
diphtheria, porphyria, localized spinal cord or cauda equina
Acute infectios process 1-3 syndrome]
respiratory & gastrointestinal SUPPORTIVE
1. Relatively symmetric weakness
2 2. Mild sensory involvement
Facial nerve or other cranial nerve involvement
3.
4. Absence of fever
Transverse myelitis inflammation of the 5. Typical CSF profile (acellular, increase in protein level)
6. Electrophysiologic evidence of demyelination
spinal cord lower back pain,
weakness in the legs and arms, sensory disturbance, spasms leading to gradual paralysis, and bowel or bladder dysfunction.
lesion spinal cord
Myasthenia gravis (MG) : relatively rare autoimmune disorder of peripheral nerves in which antibodies form against acetylcholine (ACh)
nicotinic postsynaptic receptors at the myoneural junction. A reduction in the number of ACh receptors results in a characteristic pattern of
progressively reduced muscle strength with repeated use of the muscle and recovery of muscle strength following a period of rest.
 Neurosyphilis : Symptoms : Personality change (including cognitive and/or behavioral impairment), Ataxia, Stroke, Ophthalmic
symptoms (eg, blurred vision, reduced color perception, impaired acuity, visual dimming, photophobia),Urinary symptoms (eg, bladder
incontinence),Lightning pains (larynx, abdomen, various organs), Headache, Dizziness, Hearing loss and Seizures

Signs of neurosyphilis : Hyporeflexia, Sensory impairment (eg, decreased proprioception, loss of vibratory sense), Pupillary changes
(anisocoria, Argyll Robertson pupils),Cranial neuropathy, Dementia, mania, or paranoia, Romberg sign, Charcot joint, Hypotonia and Optic atrophy
. c(O)nt 010 Med X

6. 30 1 neck vein
engorgement, Hepatomegaly EKG diffuse
ST-T change, low voltage
a. Restrictive pericarditis
b. Beri beri
c. Cardiac tamponade
d. Dilated cardiomyopathy
c. Cardiac tamponade
( a. Constrictive pericarditis Restrictive
cardiomyopathy )

CVS
Cardiac tamponade, Constrictive pericarditis
Restrictive cardiomyopathy

Features That Distinguish Cardiac Tamponade from Constrictive Pericarditis and Similar Clinical Disorders
Characteristic Tamponade Constrictive Restrictive RVMI
Pericarditis Cardiomyopathy
Clinical
Pulsus paradoxus Common Usually absent Rare Rare
Jugular veins
Prominent y descent Absent Usually present Rare Rare
Prominent x descent Present Usually present Present Rare
Kussmaul's sign Absent Present Absent Absent
Third heart sound Absent Absent Rare May be present
Pericardial knock Absent Often present Absent Absent

Electrocardiogram
Low ECG voltage May be present May be present May be present Absent
Electrical alternans May be present Absent Absent Absent

Echocardiography
Thickened pericardium Absent Present Absent Absent
Pericardial calcification Absent Often present Absent Absent
Pericardial effusion Present Absent Absent Absent
RV size Usually small Usually normal Usually normal Enlarged
Myocardial thickness Normal Normal Usually increased Normal
Right atrial collapse and RVDC Present Absent Absent Absent
Increased early filling, mitral flow velocity Absent Present Present May be present
Exaggerated respiratory variation in flow velocity Present Present Absent Absent

CT/MRI
 Thickened/calcific pericardium Absent Present Absent Absent

Cardiac catheterization
Equalization of diastolic pressures Usually present Usually present Usually absent Absent or present
Cardiac biopsy helpful? No No Sometimes No

Abbreviations: RV, right ventricle; RVMI, right ventricular myocardial infarction; RVDC, right ventricular diastolic collapse; ECG, electrocardiograph.
Source: From GM Brockington et al, Cardiol Clin 8:645, 1990, with permission. ( Reference : HARRISON )

typical cardiac tamponade EKG low voltage low voltage
cardiac tamponade pericardial effusion Constrictive pericarditis effusive-
constrictive pericarditis effusion ( http://emedicine.medscape.com/article/152083-overview)

Constrictive pericarditis pericardium

fibrin chronic fibrotic scarring calcification dyspnea
fatigue orthopnea Lower-extremity edema ,abdominal swelling ,Nausea, vomiting, and right upper
quadrant pain,( hepatic congestion bowel congestion) ( http://emedicine.medscape.com/article/157096-overview)

Restrictive cardiomyopathy : gradually worsening shortness of breath, progressive

exercise intolerance, fatigue,abdominal distension, chest pain, palpitation and syncope ( http://emedicine.medscape.com/article/153062-
overview)

Beri-Beri : Wet beri-beri CVS ( dry

beri-beri neuromuscular
system) acute wet beri-beri tachycardia, low diastolic pressure,
cardiomegaly, pulmonary edema, and cyanosis chronic wet beri-beri
high-output cardiac failure peripheral edema and pulmonary
effusions

Dilated cardiomyopathy :
Symptoms :Swelling of the feet,ankle and
abdomen ,Pronounced neck veins ,Loss of appetite,Shortness of breath, especially with
activity , Shortness of breath which occurs after lying down for a while , Fatigue,
weakness, faintness ,Sensation of feeling the heart beat (palpitations), Pulse may feel irregular or rapid , Decreased alertness or concentration ,
Cough ,Low urine production and Need to urinate at night c(O)nt 010 Med X
7. 9 BT= 39.0 oC, PR= 120 /min, RR
= 40 /min, crepitation both lungs, decreased breath sound left lung cellulitis

a. Salmonella spp.
b. S. aureus
c. H. influenzae
d. Mycoplasma pneumonia
e. Mycoplasma tuberculosis
s. aureus
acute onsetconfirm s.aureus
... source infection skin s.aureus (
) 2-3 film chest x-ray
2-3 x-ray x-ray
-samonella : clinical manifestation samonellosis
- acute asymptomatic infection
+acute gastroenteritis
-bacteremia with or without metastatic focal infection
-enteric fever
-asymptomatic chronic carrier state
Choice enteric fever
-1st wk : pea soup stool , fever increase
-2nd wk fever high and sustained , complication : PUP
Physical finding bradycardia high grade fever , hepatosplenomegaly, distended abd , rose spot ,
rhonchi and scattered rales
-H.influenza Nelson clinicalother microorganism

Nelson 12 parenteral ATB risk bacteremia >12 oral

ATB
- Mycoplasma pneumoniae atypical pneumonia 38.5C ,, school age(>8yrs) ,
subacute onset (5-6) , CXR more severe than clinical
macrolide ex erythromycin
- Mycoplasma tuberculosis expose, , ,,
,
NATTAPAT MED014

8. 50 5 tenderness
and guarding at epigastrium, liver dullness +ve
 a. acute pancreatitis
typical Hx , , (PUP) liver
dullness positive (confirm loss of liver dullness ) acute pancreatitis
-clinical feature : grey-turners sign cullens sign
-investigation acute pancreatitis :
-serum amylase >500 somogyi unit ( 80-180) 3
-urine amylase 7-10
-x-ray : colon cut off sign transverse colon
-treatment:
-NPO
-i.v. fluid
- morphine sphincter of oddi
- Antibiotic cholangitis
- calcium calcium

-Complication
-pseudocyst 2 serum amylase WBC investigation: U/S ,Upper GI
study
-Pancreatitis abscess (5) WBC serum amylase investigation: U/S , Upper
GI study ,CT
-DDx : PUP ,dissecting aneurysm, rupture aneurysm ,strangulation obstruction
DDx acute cholecystitis, cholangitis
-...
-PUP :
P.E.: loss of liver dullness , board-like rigidity
Investigation : film acute abdomen series free-air diaphragm 80%
Treatment: simple closure with omental patch or definitive: truncal vagotomy and pyroloplasty
-Acute cholecystitis :
P.E.: murphys sign positive
Investigation : U/S
-Cholangitis : charcots triad ,,
Investigation : Bilirubin SGOT SGPT , U/S
NATTAPAT MD014

9 rash vesicle
a. VZV
vesicle dermatome VZV
-VZV(herpes type 5) DNA virus
Herpes viruses known to cause human disease:

Herpes simplex virus Type 1 (HSV-1)

Herpes simplex virus Type 2 (HSV-2)
Varicella Zoster virus (VZV) herpes type3
Epstein Barr virus (EBV) herpes type4
Cytomegalovirus (CMV) herpes type5
Human herpes virus 6 (exanthum subitum or roseola infantum)
Human herpes virus 7
Human herpes virus 8 (Kaposis sarcoma)

- 1st trimester (1.2) fetal

or congenital varicella syndrome lesion cicatrical skin lesion

- 10-20 centripetal
multistage( )
-vesicle giant cell intranuclear inclusion body
-DDXDermatitis herpetiformis 2 papulovesicular
-- 5
- bacterial superimposed
-
5-30
- hemorrhagic chicken pox thrombocytopenia 2-3
- disseminated varicella
- reye syndrome VZV 2-3
-
Treatment
-immuncompromised host : acyclovir 1500mg/../day tid 7-10
- 12 , , , salicylate :
acyclovir 80mg/kg/day oral qid
NATTAPAT MD014
 10. 40 BT = 39 c, erythema and tender at
left upper thigh

a. S. aureus
b. S.pyogenes
c. H. influenzae
d. P. aeruginosa

ans. a. S. aureus Pyomyositis Suppurative stage

Pyomyositis acute bacterial infection deep abscess thigh
Quadriceps Staphylococcus aureus 66-90%
typical case 3
1. Invasive stage subcutaneous skin sign of local
inflammation , , , , aspiration pus
2. Suppurative stage 2-3 muscle abscess formation
90 needle aspiration pus
3. Late stage 2 sign toxicity septic shock
pyomyositis hematoma, cellulitis, deep vain thrombosis, septic arthritis, osteomyelitis, soft
tissue sarcoma gold standard pus aspiration muscle biopsy culture
leukocytosis, ESR 20-100 eosinophil parasite infection trichinosis
cysticercosis
S.pyogenes H. influenzae culture
Streptococcus pyogenes Scarlet fever, pharyngitis, erysipelas, severe invasive infections
pharyngitis (strep throat), scarlet fever (rash), impetigo (infection of the superficial layers of the skin) or cellulitis
(infection of the deep layers of the skin). Invasive, toxigenic infections can result in necrotizing fasciitis, myositis and
streptococcal toxic shock syndrome. Patients may also develop immune-mediated post-streptococcal sequelae, such as acute
rheumatic fever and acute glomerulonephritis, following acute infections caused by Streptococcus pyogenes.
H. influenzae Meningitis, Cellulitis, Epiglottitis, Pneumonia, Septic arthritis, Pericarditis, Occult bacteremia
-- ApplE_BlooM med 026

11. DM, HT 1 10

a. TIA
b. Temporal lobe ischemia
c. cerebella ischemia
d. Bells palsy
Ans.
Transient ischemic attack (TIA) mini stroke 1 brain damage

Sign & symptom :

- Visual loss in one or both eyes
- Double vision
- Vestibular dysfunction : True vertigo is likely to be described as a spinning sensation rather than nonspecific lightheadedness.
- Trouble swallowing may indicate brainstem involvement; if the swallowing problem is severe, there may be an increased risk
of aspiration.
- Unilateral or bilateral: either decreased sensation (numbness) or increased sensation (tingling, pain) in the face, arm, leg, or
trunk
- Slurring of words or reduced verbal output; language difficulty pronouncing, comprehending, or "finding" words
- Clumsy arms, legs, or trunk; loss of balance or falling (particularly to one side) with standing or walking
Bell's palsy is a unilateral, peripheral facial paresis or paralysis that has an abrupt onset and no detectable cause. Bell palsy is
one of the most common neurologic disorders affecting the cranial nerves, and it is certainly the most common cause of facial
paralysis Clinical The most common complaint is of weakness on one side of the face, Postauricular pain, Tear flow This is
due to the reduced function of the orbicularis oculi in transporting the tears. Fewer tears arrive at the lacrimal sac and overflow
occurs. The production of tears is not accelerated. Altered taste, Dry eyes, Hyperacusis
Temporal lobe ischemia cerebella ischemia
2 24 . cerebellum
temporal lobe
-- ApplE_BlooM med 026

12. 18 upper respiratory tract infection

CXR interstitial infiltration
a. Ampicillin
b. Ciprofloxacin
c. Roxithromycin
d. Gentamycin
e. Augmentin
Ans. c. Roxithromycin
pneumonia 1
S. pneumonia, C. pneumonia, M. pneumonia
oral macrorides roxithromycin, clarithromycin, azithromycin
7 10 doxycycline 100 mg. oral bid. 7-10 day 1
Ampicillin Aminopenicillins gram + ve (like penG) and gram ve : E. coli, P. mirabilis, H. influenzae
Ciprofloxacin fluoro-quinolone Lower Respiratory Tract Infections caused by Escherichia coli, Klebsiella
pneumoniae, Enterobacter cloacae, Proteus mirabilis, Pseudomonas aeruginosa, Haemophilus influenzae, Haemophilus
parainfluenzae, or penicillin-susceptible Streptococcus pneumoniae. Also, Moraxella catarrhalis for the treatment of acute
exacerbations of chronic bronchitis.
Roxithromycin macrolide
AUGMENTIN is an oral antibacterial combination consisting of the semisynthetic antibiotic amoxicillin and the -lactamase
inhibitor, clavulanate potassium (the potassium salt of clavulanic acid)
indication : Lower Respiratory Tract Infections caused by -lactamaseproducing strains of H. influenzae and M. catarrhalis.
Otitis Media caused by -lactamaseproducing strains of H. influenzae and M. catarrhalis.
Sinusitis caused by -lactamaseproducing strains of H. influenzae and M. catarrhalis.
Skin and Skin Structure Infections caused by -lactamaseproducing strains of S. aureus, E. coli, and Klebsiella spp.
Urinary Tract Infections caused by -lactamaseproducing strains of E. coli, Klebsiella spp., and Enterobacter spp.

-- ApplE_BlooM med 026

13.

Hyponatremia water intoxication (Pna < 135 mmol/L)

Approach to hyponatremia

: N/V alteration of consciousness

Treatment : hypotonic hyponatremia ( euvolemic ) DiureticSaline Na

Reference
http://medbhumibhol.com/Emed2008/13%20Hyponatremia.pdf
14. peripheral neuropathy (wrist drop)

lead ()
: /
Sign :
- Peripheral neuropathy : wrist drop, foot drop
- Brutons lines : purple line on gums
- Renal tubular acidosis
-
Lab investigate
PBS : basophilic stippling , hypochromic microcytic anemia
X-ray : lead line on bone ( 6 ) ,
Blood lead level > 25 microgram/dl.
Treatment
- EDTA
oral penicillamine 25-40 mg/kg/day x 5 day
( 1 g/day)
- Blood lead level > 70 microgram/dl.
o BAL 4mg/kg/dose IM q 4 hr x 5 day
o BAL 1 EDTA 5 mg/kg/dose IM q 4 hr x 5 day
-

Reference
- First aid for the wards 352-353
- 876-878

15. CKD K = 7 EKG change

Treatment acute hyperkalemia Pk > 6 mEq/L EKG change

EKG change hyperkalemia peaked T waves, QRS widening

Evaluate : ECG, electrolytes, BUN, Cr, and glucose.

Treatment
Emergency treatment (guideline CPR 2005)
: shift K cell, K ,stabilizing myocardial cell membrane
1. *** 10% calcium gluconate 10-20 ml. IV 2-3 min ( monitor EKG) 5-10 min (
)
digitalis 5% D/W 100 ml. in 30 min
2. Sodium bicarbonate 50 mEq IV over 5 minutes.
3. Glucose plus insulin (10 units of regular insulin and an amp of D50)
4. Nebulized albuterol (10 to 20 mg over 15 minutes)
5. Furosemide 40 to 80 mg IV

16. 40 3
BP = 120/80 , PR = 110/min , RR = 24/min , BT = 39 C , mild jaundice , lung clear , liver 2 cm BRCM

a. Enteric fever
b. Dengue fever
c. Leptospirosis
d. Scrub typhus
e. Murine typhus
c lepto enteric GI
murine
3 Dengue Lepto
Leptospirosis
leptospira interrogans mucous
Clinical manifestation
Musculoskeletal claves, back, neck increase CPK
GI N/V
U/A albumin WBC RBC BUN/Cr
Respiratory CXR patchy alveolar infiltration BLL
CBC Lymphocytosis 74% , PMN predominate, Plt < 100000
Dengue fever

Clinical manifestation
Musculoskeletal
GI
U/A
Respiratory plasma leakage Rt. Pleural effusion
CBC Lymphopenia WBC<5000 , Plt < 100000 , L Predominate atypical L
review LEPTOSPIROSIS !!!
17. 50 4 wkPTA PE : tenderness of quadriceps muscle,
purple-red discoloration over upper forehead eyelids and cheeks Dx
a. Polymyositis
b. Dermatomyositis
c. Psoriasis
d. Mixed connective tissue disease
e. SLE
a
Polymyositis autoimmune
PM 30-50 dermatomyositis

History

Symmetric proximal muscle weakness with insidious onset

Muscles usually painless (Myalgias occur in fewer than 30% of patients.)
Dysphagia (30%) and aspiration, if pharyngeal and esophageal muscles are involved
Arthralgias may be associated
Difficulty kneeling, climbing or descending stairs, raising arms, and arising from a seated position; weak neck
extensors cause difficulty holding the head up; involvement of pelvic girdle usually greater than upper body weakness
Family history and medication history are important in excluding other causes of myopathy.

Physical

Muscle tenderness on palpation

Normal sensory test results and reflexes (Reflexes may be abnormal with advanced disease.)
Muscle atrophy
In DM, a characteristic heliotrope rash preceding or accompanying muscle weakness
o The heliotrope rash is a symmetric, confluent, purple-red, macular eruption of the eyelids and periorbital
tissue. Edema may also be present.
o Other rashes seen with DM include erythematous nail beds and a scaly, purple erythematous papular
eruption over the dorsal metacarpophalangeal and interphalangeal joints (Gottron sign).
o Violaceous erythematous confluent macular eruption over the deltoids, posterior part of the shoulders, and the
neck is known as the shawl sign. A similar eruption of the V area of the anterior part of the neck and the upper
part of the chest is known as the V sign.
Extramuscular manifestations
o Cardiac - Congestive heart failure (CHF), arrhythmia
o Lung - Interstitial lung disease, pneumonia/aspiration
o Gastrointestinal - Dysphagia
o Joints - Arthralgias, symmetric arthritis
 Dermatomyositis musculoskeleton disease PM skin

Patients often present with skin disease (eruption on exposed surfaces. The rash is often pruritic, and intense pruritus
may disturb sleep patterns)
Muscle involvement PM
arthralgia, arthritis, dyspnea, dysphagia, arrhythmia, and dysphonia.

PM DM DM Psoriasis connective tissue disease

18. 40 1 . CXR

a. skin test
b. CT chest
c. sputum AFB
d. bronchoscopy
e. Pulmonary function test
e
Lung hypersensitivity TB
fuction lung

19. 50 25 1
BP = 120/70 mmHg, fine crepitation both lower lungs, PMI 6th ICS 1 cm lateral to MCL, S3 gallop

f. Digoxin
g. Thiamine
h. Atropine
Digoxin ( contractility)
both sides CHF CHF
congestive heart failure ,

1. ( , )
2. salt-water retention
3. Pharmacologic therapy congestive heart failure 2
3.1 congestive heart failure
preload, afterload cardiac output
hemodynamics hemodynamic effects
 Hemodynamic effects
1. preload
Diuretics
Venodilators ( organic nitrates)
ACEIs** ARBs**
Sodium nitroprusside**
5. afterload
Arterial vasodilators ( hydralazine)
ACEIs** ARBs**
Sodium nitroprusside**
6. contractility
Cardiac glycosides (digitalis)
Beta1 adrenergic agonists
Phosphodiesterase enzyme inhibitors
* ACEIs, ARBs, venodilators arterial vasodilators vasodilators
** preload afterload
3.2 cardiac remodeling
RAS angiotensin converting enzyme inhibitors (ACEIs) angiotensin receptor blockers
(ARBs) sympathetic nervous system ( beta-blockers)
ventricular wall stresses ( vasodilators) cardiac remodeling
By BuM

20.
a. Chigger mite
b. Louse
c. Aedes egypti
d. Tick
e. Flea
Chigger mite ( eschar )

Scrub Typhus (Rickettsia)

( Chigger) enzootic cycle
( Endemic foci) 4

1. ( Rodent) Rattus spp.

2. Leptortrombidium L.deliense

 3. ( Transitional vegetation) Fringe vegetation
4. Orientia tsutsugamushi

(Tropical zones) ( Temperate zones) (

rain forest)

: Rickettsia genus Orientia

tsutsugamushi ( R.tsutsugamushi ); accidental host
(Chigger)
0.5- 1.5
(Eschar) 6-18 30-40%
, , , , , ,
(Conjunctival injection), (Lymphadenopathy) eschar (Watt and
Olson,2000), , , 4-5 (Maculopapular rash)
2-3 Interstitial
infiltration Alveolar infiltration, (Stiff neck) (Jaundice)

O. tsutsugamushi
Tetracycline 500 mg 2 Doxycycline 100 mg 2 7
Chloramphenicol 50-75 mg/ 1 kg/
24-36
Tetracycline Chloramphenicol Azithromycin

By BuM

21. BP 60/30 mmHg sacral reflex

a. Cardiogenic shock
b. Spinal shock
c. Neurogenic shock
d. Hypovolemic shock
e. Obstructive shock
Neurogenic shock
sacral reflex
Neurogenic shock cardiovascular instability complete injury cervical / upper thoracic cord

pathophysiology
disruption descending sympathetic pathways parasympathetic innervation vagus nerve
sympathetic counteraction
sign and symptoms
Generalize vasodilatation with increase vessel capacitance
Decrease central venous return
Lower extremity venous stasis
Loss of body heat regulation below lesion denervation sweat gland
Bradycardia with hypotension hypovolemic shock ( hypobolemic shock tachycardia)

- Trenderlenburg position - intravenous fluid

- atropine -
pharmacologic treatment
second injury cascade spinal cord injury
- corticosteroid
- 21-aminosteroid
- antioxidants
- gangliosides
spinal shock transient loss of all motor,sensory,reflex function distal level of injury
bulbocarvernosus reflex,anal wink reflex spinal shock (
spinal cord injury cardiovascular collapse 24 . )
By BuM

22. 18 2-3

a. inhale salbutamol prn + inhale corticosteroid
b. alpha-agonist as need
c. steroid
d. beta-agonist as need + steroid
e. Oral bronchodilator
f. Salbutamol inhalation as needed
g. Long acting beta2 agonist + corticosteroid
h. Inhaled corticosteroid

Asthma
Characteristic Controlled Partly controlled Uncontrolled
(All of the following) (Any present in any week)
Daytime symptoms None (2 or less/wk) More than twice/wk 3 or more features
of partly controlled
Limitations of activities None Any asthma present in
Nocturnal symptoms / None Any any week
awakening
Need for rescue / reliever None (2 or less/wk) More than twice/wk
treatment
Lung function Normal < 80% predicted or personal
(PEF or FEV1) best (if known) on any day
Exacerbation None One or more/year 1 in any week

Reduce Increase
 2-3
partly controlled Step2 Rapid acting Beta2-agonist prn. + Low dose inhaled
corticosteroid or Leukotriene
## a. inhale salbutamol prn + inhaled corticosteroid ##
highlight B,C,D ?
--------------------------------------------------------
23. Motor Cycle Accident lesion T2 Foley Catheter BP 180/110 RR

a. Off F/C
b. Hydralazine
c.
d. BP
e. ADVICE

Autonomic dysreflexia
Definition : Acute onset T6 ( T2)
Autonomic

Pathophysiology :
sympathetic Spinal cord
VV. BP

AD : Full bladder, Impact feces

Clinical : ( Pt. BP>180 mmHg.) N/V , agitatiate, BP (Sys. = 190-250, Dias. = 130-
150 mmHg.) PR Baroreceptor
Complication : BP Hypertensive enphalopathy, subarachnoid hemorrhage, intracerebral hemorrhage
Treatment : ( D )
F/C ( A off F/C )
Medication :
Nifedipine 5-10 mg. oral, Nitroprusside 100 microgram/ml, Hydralazine 10 mg IV ( Choice ? ) ##
B. Hydralazine ? ^^
## choice C E
--------------------------------------------------------
24. 70 no Underlying Disease 5 EKG AF

a. ASA
b. Warfarin
 c. Clopidogrel

Anticoagulant to prevent thrombus formation and stroke Guideline

weaker risk Moderate risk High risk

Female gender Age 75 years Previous stroke, TIA or
Age 65-74 years Hypertension embolism
CAD Heart failure Mitral stenosis
Thyrotoxicosis LV ejection fraction 35% Prosthetic heart valve
Diabetes mellitus

Risk Category Recommended Therapy

No risk factors Aspirin : 81-325 mg daily
One moderate risk factor Aspirin : 81-325 mg daily or Warfarin (INR 2.0 - 3.0, target 2.5)
Any high risk factor Warfarin (INR 2.0 to 3.0, target 2.5)
or > 1 moderate risk

1 moderate risk (Age 75 years) + 1 high risk (stroke) Warfarin ##

B. warfarin ##
--------------------------------------------------------
By . 47460647
.

25. .. PE : HT + Cushing appearance Lab

Ans. Increase cortisal level

Cushing syndrome
glucocorticoids

20-50

1.

2. Pituitary
adenoma 5
 3. Ectopic ACTH Syndrome

4.
5. Cushing's syndrome

6. Familial Cushing's Syndrome

CT scan MRI, 24
50100 Cushing's syndrome
Dexamethasone Suppression Test, CRH Stimulation Test,Dexamethasone-CRH Test

Diagram ...
26. Subacute thyroiditis
Ans. Propanolol

Subacute thyroiditis "De Quervain's Thyroiditis"

(painful) thyrotoxicosis (Classic presentation of a viral
illness. onset is sudden, with high fever, myalgia, and neck pain.)
: ( )
Beta blocker () Propanolol 40-120 mg./day atenolol 25-50 mg./day 3
() ,

27. T4 TSH
A. Simple Goiter
B. Iodine def.
C. Thyroid CA
D. Subacute thyroiditis
E. Hashimoto thyroiditis

Thyroid function test

FT3 FT4 TSH Diagnosis

 Hyperthyroid
T3 toxicosis
T4 toxicosis
Inappropriate TSH
Non thyroidal illness
Primary hypothyroid
Secondary hypothyroid
Subclinical hypothyroid
Subclinical hyperthyroid
B. Iodine def.

28. 28 2 PE: DTR 3+ , loss of sphincter tone

lesion
a.parasagital sinus
b.basal pons
c.thoracic area
d.lumbosarcal area
e.clonus medularis
lower urinary tract bladder
trauma bladder
autonomic system T1-L2 S2-S4
UMN or LMN
Clinical features UMN LMN
Pattern of weakness Pyramidal(arm extension,leg variable
flexion)
Tone Spastic(initial flaccid) Flaccid,hypotonic
DTRs hyperreflex Hyporeflex/areflex
Miscellaneous sign Babinskis ,other CNS Atriophy,fasciculation,Babinski
sign,clonus flexor response
UMN spinal cord tract
tract
- lateral corticospinal = movement of contralateral limb
 - dorsal column medial lemnicus = tactile ,vibration,sensation
- spinothamic = pain ,temperature
dermatome sensory T10 , paraplegia
The lower urinary tract innervated by 3 sets of peripheral nerves involving the parasympathetic,
sympathetic, and somatic nervous systems:

Pelvic parasympathetic nerves: arise at the sacral level of the spinal cord, excite the bladder, and relax the urethra
Lumbar sympathetic nerves: inhibit the bladder body and excite the bladder base and urethra
Pudendal nerves: excite the external urethral sphincter

lesion
thoracic area

29. bronchial asthma lung: epiratory wheezing

Cause:
bronchial hyperreactive,airway inflammation,mucous plugging,smooth muscke hypertrophy
History/PE:
cough,dyspnea,wheezing,chest tightness
PE tachypnea,tachycardia,decrease breath sound,prolong epiratory wheezing,decrease oxygen satuation,use accessory
muscle,possible pulsus paradoxus
Diagnosis:
ABGs : mild hypoxia and respiratory alkalosis
Spirometry/PETs: decrease FEV1/FVC, increase residual volume and TLC
CBC: eosinophil
CXR: hyperinflation
Methacholine challenge : test bronchial hyperreponsiveness
Treatment:
Acute: oxygen,bronchialdilating agent ( first line > bata2 >>>agonist,ipratropium,>>>>systemic steroid,>>>intubation in
severe case)
inhalation drug systemic steroid IV Dexamathasone
Ha

30.EKG : bradycardia V/S (80/50 mmHg, HP 30 )

a. atropine
 b. dobutamine

EKG arrhymia bradycardia 2

1.bradyarrhythmias
2.conduction abnormalities
Type etiology Sign and symptom EKG treatment
sinus bradycardia - Ventricular rate<60 -
- - bpm normal p
- lightheadadedness,syncope,c wave -
- cardiovascular hest pain,hypotention QRS complex
( MI ,sick system atropine HR
sinus sinus or pacemacker
syndrome) node replacement
- dysfunction or definite treatment in
- Myxedema beta severe case
- Mental blocker or
depression calcium channel
- Hyperventril blocker(CCB)
ation
syndrome

First-degree AV block - asymptomatic PR interval >200 None necessary

-
bata blocker or
CCB or
vagal tone

Secondary degree Drug -PR interval -
AV block(Mobitz I) effect(digoxin,ba reset PR
ta block,CCB) interval
vagal
tone
Secondary degree syncope or -unexpect beat pacemacker
AV block(Mobitz II) fibrotic disease progression third degree PR replacement
AV block inteeval
conductive
system or
previous MI
Third degree AV No electrical Syncope,dizziness,acute pacemacker
block(Complete) communication heart P wave and replacement
atrial failure,hypotension,cannon A QRS complex
and ventricle wave

Ha

.SomO-lucky>>>>>Odin-Mosa 12-1-52
Ha

31. 27 2 PE : white patch

white patch candida KOH budding yeast
and/or pseudohyphae
Candidal Thrush : soft white plaques that can be rubbed off, with an erythematous base and possible mucosal burning.
The differential includes oral hairy leukoplakia (lateral border of tongue, not easily rubbed off)
Risk factor : xerostomia, antibiotic use, denture use and immunosuppressed states (e.g. HIV, leukemia, lymphoma,
cancer, diabetes, corticosteroid inhaler use, immunosuppressive treatment)
... oral thrush
opportunistic infection HIV
1. ELISA test : [ high sensitivity, moderate specificity] screen test

2. Western blot : [low sensitivity, high specificity] comfirmator , after ELISA +ve

3. Rapid HIV tests

4. Baseline evaluation should include HIV RNA PCR(viral load) , CD4+ cell count , CXR, PPD skin test, Pap smear,
VDRL and serologies for CMV, hepatitis, toxoplasmosisand VZV.

32. ( EKG Mobitz II)

First degree AV block
- PR interval > 0.20 sec
Second degree AV block
- P wave QRS complex depolarize
ventricle

Mobitz I (Wenckebach)
PR interval P wave QRS complex (
AV node AV
node depolarize ventricle
)

: Atropine , Often paroxysmal/asymptomatic , no Rx required

Mobitz II
EKG Mobitz I Mobitz II PR interval Mobitz I

: Atropine , Pacemaker often require.

Third degree AV block (Complete block)

P wave QRS complex ventricle ventricle
depolarize pacemaker block

: permanent pacemaker
33. 68
a. Rabies vaccine
b. Tetanus vaccine
c. HBV vaccine
d. Influenza vaccine
e. HPV vaccine

Rabies vaccine :
Tetanus vaccine : 1 dose Td booster 10
HBV vaccine : high risk clinical, behavioral or travel exposure
,$ endemic country, hemodialysis
Influenza vaccine : routine annual administration to individual with chronic illness at any age, and to all adults > 50 yrs of age.
HPV vaccine : recommended for all woman aged <= 26 yrs ,
34. 18 PE lung:clear rub chest

a. Endocarditis c. Myocarditis
b. Pancarditis d. Pneumonia
B. pancarditis ref. medicinenet.com
( pericarditis )
Acute pericarditis is an inflammation of the sac surrounding the heart --- the pericardium --- usually lasting < 6
weeks

(35%) Neoplastic ( 6%) Bacterial (other than tuberculosis)

(23%) Autoimmune ( 6%) Uremia
(21%) Viral - adenovirus, enterovirus, ( 4%) Tuberculosis
cytomegalovirus, influenza virus, hepatitis B virus, ( 4%) Idiopathic
and herpes simplex virus, etc
(remaining) trauma, drugs, post-AMI, myocarditis, dissecting aortic aneurysm, radiation
pericarditis
Chest pain most common sharp and stabbing
arise slowly or suddenly and can radiate directly to the back, to the neck or to the arm.
lying flat , (pleuritic) leaning forward.
pericarditis
pericardial rub very specific sign of acute pericarditis rule out frictio
generated by the two inflamed layers of the pericardium

a. Infectious Endocarditis
Duke Criteria Major CriteriaMinor Criteria Clinical criteria for infective endocarditis
requires:
Two major criteria, or
One major and three minor criteria, or
Five minor criteria
c.myocarditis
1. stabbing
2.heart failure ,edema,breathlessness,hepatic congestion
3.Palpitations (due to arrhythmias)
4. Sudden death (in young adults, myocarditis causes up to 20% of all cases of sudden death
5.Fever (especially when infectious, e.g. in rheumatic
d.Pneumonia ref.
clinical
1.New pulmonary infiltration -Fever,cough , +/- productive sputum , Dyspnea ,
2.Acute onset(duration <= 2 weeks) pleuritic chest pain , consolidation or crackles on PE.
3.symptoms and signs of LRI(3 in 5)
35. 16 Homozygous Beta-thal 1
BP drop , irregular heart rate & rhythm , Hepatosplenomegaly heart
complication
A. cardiac siderosis
B. cardiac hypertrophy
C. immune cardiomyosotis
D. Extramedullary hematopoiesis at heart

A. cardiac siderosis

Homozygous Beta-thal = Chronic blood transfusion

iron overload
Hemochromatosis

1. Hepatomegaly 95% , LFT normal

2. Splenomegaly
3. Excessive skin pigmentation 90%
4. DM 65% Direct damage islets by iron deposit
5. Arthropathy 50
6. Cardiac involvement 15% : Congestive heart failure
Cardiac arrthymia : PVC , AF, A flutter

insidious onset Pericarditis dysarrthymia Pump failure

1 (+)
, irregular heart rate & rhythm , BP drop dysarrthymia Pump failure
Hepatosplenomegaly Hemochromatosis
36. 20 motorcycle accident CT crescent shape at frontl region

a. acute epidural hemorrhage

b. acute subdural hemorrhage
c. subacute epidural hemorrhage
.b. acute subdural hemorrhage
Subdural hematoma
subdural space = potential space bet .pia - arachnoid mb. + dura matter
freely extending across suture lines
limited by interhemispheric fissure + tentorium
CT : extra - axial peripheral crescentic fluid collection
: hyperdense (< 1 wk) / isodense(1-2 wks) /hypodense (3-4 wks)
Epidural hematoma
within potential space bet. inner table + calvarial periosteum
bound down at suture margins
Associated with skull fracture in 75 - 95 %
CT : lens - shaped, smoothly demarcated high density ( over the surface of the hemisphere )

Ref. ..
2. clinical rheumatoid arthritis
RA
a. Ibuprofen**

b. Paracetamol
c. MTX
d. Sulfazalazine
e. Chloroquine Film x-ray
jt spaces narrowing diffuse
jt line

marginal erosion OA
1. sign inflammation
central erosion
2. synovial thickening
3. rheumatoid nodule
4. Morning stiffness
5. chronic

Dx 1-2-3+specific
1 = morning stiffness>1 hr
2 symmetrical polyarthritis
3
Spec= rheumatoid nodule Tx
(,extensor area) 1. early intensive Tx permanent

= rheumatois factor+ 2. NSIAD

3. Drug of choice=DMARDS(combine)
= radio change
= > 6 mo DMARDS

1. Hydrochloroquine
S/E retinal toxicity & diarrhea
2. Sulfasalazine
+> MCP,PIP spare TL-spine,DIP S/E bone marrow suppression
3. Metrotrexate
+>C 1-2subluxation S/E BM, liver , lung
4. Gold salt & azathiopine
S/E BW , renal toxic

Note ( )
immune suppressive:
cyclophosphamine, TNF
,adalimumab,etanercept,infiximab

===== NSAIDs ========

39. 22 PR RR miosis

a. atropine
b. naloxone
c. diazepam
b. aof_pa!!
: PR RR miosis opioids euphoria,
N/V miosis ()
flaccidity benzodiazepine,barbiturate,ethnal

pinpoint pupils opiate

N/V miosis organophosphate/carbamate

Antidose
1. Acetaminophen N-acetylcysteine

2. Benzodiazepine flumazenil

3. Carbamate(not stable bond)/organophosphate( stable bond) atropine(muscarinic receptor bloker) and

2-PAM ( - organophosphate reactivation acetylcholinesterase)

4. Iron deferoxamine

5. Narcotics naloxone

40. 40 80 kg 160 cm Dx DM,

FBG 180

a.
b. Metformin
c. Acarbose
d. Glibenclamide

a.
pt. Dx DM a.
2
Evidence-based clinical practice guideline 2548
452
 41) c.
Graves disease
, AF, myopathy, thyrotoxic
periodic paralysis,cachexia
5 kg, pulse rate > 120 bpm,

1. long term medical treatment:
- 30
-
- 6
- ( 3 , 45 g)
2. :
- 20
- ( 5 , 75 g)
-
- thyroid
3. radioactive iodine:
- 30
-
-
- thyroid
- long term medical treatment


1. long term medical treatment
methimazole 1 FT3, FT4 2
2 FT3, FT4
B-blocker
PTU B-blocker
2. RAI
iodine 131 100 /
3. subtotal thyroidectmy
>>>> PTU methimazole
...........ref: evidence-base CPG by ReaL
42. 32 BP 150/100 mmHg PR 120 /min PE: neuro sensory normal, muscle weak
gr.1/5 both upper and lower , reflex 2+all
Na 136 mmol/l K 2.5 mmol/l
Cl 102 mmol/l CO2 22 mmol/l

a. Free T4
b. plasma glucose
c.CT brain
d.CSF profile

DDx.
Differential diagnosis
Electrolyte imbalance : K+ , Ca+(hypo ,hyper)
Muscle disorder : polymyositis , alcoholic myopathy parasitic polymyositis Neuromuscular : myasthenia gravis
Polyneuropathies : Guillain-Barre syndrome
- electrolyte Hypokalemia
Hypokalemia
Cause:
Inadequate intake at least 10-30 mEq/day
Excessive renal losses diuretic use, metabolic alkalosis, trauma and stress, aldosterone level
Excessive losses from GI tract and Skin
Redistribution: ECFICF
- Excess insulin
- Excess -adrenagic catecholamines
- Hypokalemic Paralysis Hypokalemic Paralysis
Thyrotoxic periodic paralysis Hyperaldosteronism
Insulin excess Infectious enteritis
Renal tubular acidosis Short bowel syndrome
DM , , thyrotoxic periodic
paralysis

thyrotoxocosis thyroid hormone sympathetic PR&BP

high carbohydrate insulin insulin
Na+K-ATPase K+ hypokalemia

investigation thyroid function test ( free T4)

bY : MeD X
43. muscle weakness DTR 1+, 1+, K 2.5

a. Free T4

proximal muscle weakness

- Myopathy
- NMJ disease
- Neuropathy
- Anterior horn cell disease
lab K weak Hypokalemia ( myopathy)
Hypokalemia thyrotoxic hypokalemic periodic paralysis
thyroid function test
hypokalemia thyrotoxicosis
hyperthyroidism

44. 15 webbed neck

a. Insulin
b. GH
c. Estrogen
d. Gonadrotropin
e. Parathyroid hormone
c. Estrogen
Turner syndrome 1:2,500
webbed neck, (shield chest ) , (increased carrying angle )
,
mosaic , pigmented nevi , lymphedema ,
, horseshoe kidneys ,
coarctation of the aorta , DM , thyroid , HT , autoimmune ,
turner syndrome ovaries non-function ovaries sex
hormones(estrogen and progesterone)
Estrogen

1. turner syndrome 45/X0 gene X long bone growth gene X

skeletal features short fingers and toes, and irregular rotations of the wrist and elbow joints
growth hormone (GH) treatment in childhood.
2. Estrogen-progesterone treatment to maintain their secondary sexual development and to protect their
bones from osteoporosis until ~ the usual age of menopause (50 years) estrogen

45. 30 1 3 . :
CXR : Reticulo-patchy infiltration with thick wall cavity, AFB sputum negative x 3
A. bronchoscope
B. FNA
C. Anti TB drug
D. culture for TB

D. culture for TB

1)
3


2)


3)
3.1
3

3.2

culture for TB

46. 30 bus AFB 3+ TB

a. 2 wk
b. 1 mo
c. 2 mo
d. 1 wk AFB neg
e.
. c. 2 mo
 47. 40 Asthma 2 PTA
T 37.4 oC BP 110/90 mmHg PR 100 bpm RR 28 /min Lung: wheezing at both lower lung with accessory muscle
used
b. Terbutaline Sc
c. IV steroid
d. IV dexamethasone
e. IV Theophyline
f. NB salbutamol

>> acute O2 mask B2 agonist

terbutaline , salbutamol 15-30 min dexa iv or
prednisolone oral anticholinergic , ipratropium
bromide

>> asthma
DX
> control / partial /uncontrol

(reference GINA 2006)

!!!!!!!!!!!!!!!!!
(o^o)
49.

a. Psoriasis
b. Lichen planus papulosquamous skin lesion
c. Discoid lupus erythematosus 4
a. aof_pa!! 1.
Psoriasis
2. non-coherent silvery scale

3. Erythematous skin

4.

- ,,
Tongue lesion : geographic tongue
Nail lesion : pits , onychodystrophy
Lab: increase uric acid , high ESR ,
hypocalcium
Tx. : tar / antralin /salicylic acid +steroid

Lichen planus
4P 1. Purple
2. Polygonal
3. Pruritic
4. Papule
Wickham striae
- ,,
Nail lesion :
brown discoloration , pterigium

autoimmume disease
Discoid lupus erythematosus
chronic cutaneous LE /
(
adherent scale) (follicular
plugging) (
carpettack sign)
- ,,,
50. Pt 50 yr 1wk , cholesterol 350, TG 250

a. Eczema
b. Lipoma
c. Xanthelasma
d. Seborrheic dermatitis
c. Xanthelasma
Dyslipidemia tendon xanthoma, xanthelasma, corneal arcus, palmar xanthoma,
eruptive xanthoma, hypothyroid, edema, reflex
Evidence-based clinical practice guideline 2548 181, 184

Cholesterol < 200 > 240
TG < 150 > 200
LDL < 100 > 130
HDL > 40 < 40

51) e.A,C (propranolol,flunarizine)

Indication for Migraine Prophylaxis
1. > 2
2.
3. 2
4. Hemiplegic migraine , aura ,migrainous infarction

: Propranolol, Timolol, Amitriptyline, Divalproex sodium , Sodium valproate

: Flunarizine, lissuride, pizotifen, time-released dihydroergotamine, methysergide

(abortive therapy):ASA, acetaminophen, caffeine, high-dose NAIDs, metoclopramide,

5-HT1 agonists(triptans), ergotamine

Ref:evidence-base CPG, pocket medicine.by ReaL

52. 30 drowsinsess, BP 150/110 , PR 80 , RR 22 , stiffness of
neck ,Babinski sign neg , retinal a. absent of pulse ,
no papilledema
a. migraine
b. viral encephalitis
c. subarachnoid hemorrhage
d. bacterial meningitis

. typical SAH
- sudden onset of severe headache >>
- localized generalized non-narcotic
analgesic
- : , alteration of consciousness , seizure, neck pain
- : BP , stiff neck +ve

SAH most common intracranial aneurysm 60-70% (spontaneous SAH)

Peri-mesencephalic hemorrhage 15-20% (non-(spontaneous SAH) Ateriovenous
malformations and associated aneurysms(AVM) 5%
Lab investigation
1. CT scan >> , (sense 24 .)
- NECT sulci , gyri ventricle
2. Lumbar puncture >>
- elevate opening pressure
- traumatic tap 4 tube SAH
4
- Xanthochromia >> 12 .
peak 7 14

- migraine typicalmigrain aura
- viral encephalitis focal neuro deficit
- bacterial meningitis LP&CSF profile
typical SAH

bY : MeD X
53. 35 yr 4 wk ptosis mild proximal muscle weakness,
normal DTR, normal sensory Dx
a. Polymyositis
b. Horners syndrome
c. Hyperthyroidism
d. Myasthenia gravis
e. CN III palsy
proximal muscle weakness
- Myopathy
- NMJ disease
- Neuropathy
- Anterior horn cell disease
pattern of weakness NMJ lesion MG
Lambert-Eaton myasthenic syndrome (LEMS)
- proximal muscle weakness involve extraocular and bulbar muscle LEMS
proximal muscle weakness with ocular sparing
- Fluctuating fatiquable (
) Ach LEMS

- MG : acetylcholine receptor antibodies LEMS : voltage gated calcium channel
antibodies
- LEMS hyporeflexia and autonomic dysfunction

54. 21 2 3 , Total ophthalmoplegia ,bilateral

facial palsy , paradoxical breathing , generalized decrease motor power gr II-III/V, areflexia,loss of vibration sense
all toe and fingers
a. Azatiopine
b. Interferon beta 1A
c. Cyclophosphamide
d. Methlprednisolone
e. Intravenous Immunoglobulin
E. Intravenous Immunoglobulin
Ref. .. 5.spinal cord diseaseapproach peripheral
nerve disease peripheral nerve disease nature of symptom
1. Motor
2. sensory
3. autonomic(sympathetic and parasympathetic)
Motor phenomena
Negative symptom : motor weakness LMN lesion flaccid , atrophy , hyporeflexia , areflexia , distal muscle
weakness
 Positive symptom
Fasciculation:sign of lower motor neuron lesion
Fibrillation:spontaneous discharge
Sensory phenomena
Negative symptom
Numbness,loss or absence of feeling , loss of propioception
Positive symptom
Paresthesia
Neuropathic pain
Autonomic phenomena
Orthostatic hypotension
Bowel and bladder dysfunction
Sexual dunction
demyelination
Acute : Guillain barre syndrome
Chronic: chronic inflammatory demyelinatig polyneuropathy CIDP slow progressive or relapsing
Guillain barre syndrome
Onset < 2 wk
Immune process
Demyelination process and axonal degeneration (GBS-varient)
Classic syndrome
1. Proximal muscle weakness
2. loss propioception sene
3. areflexia
4. may have autonomic involvement (autostatic hypotension , urinary incontinence)

No role of steroid
high-dose intravenous immunoglobulins (IVIg) at 400mg/kg for 5 days or plasmapheresis can be
administere (Wikipedia)
55. 70 EKG ST elevation
A. aspirin
B. Enoxaparin
C. Clopidogrel
D.warfarin
E.Dipyridamole

aspirin

STEMI
1. STEMI
- Aspirin 160 325 mg
- Nitrate IV
-
2.STEMI 3 Thrombolytic agent

3. stable
atherosclerosis

Antiplatelet agents
1. Antiplatelet drugs
1.1. Platelet cyclooxygenase inhibitor
1.2. Thienopyridine group
2. GP ( Glycoprotein) IIb/IIIa receptor antagonist
1. Antiplatelet drugs
1.1. Platelet cyclooxygenase inhibitor
Prostaglandin H-synthase
PGG2 PGH2 Arachidonic acid, PGH2
Thromboxane A2
Aspirin ()
Aspirin
1) (primary MI prevention) :
10 (10-year CAD risk) 10 (American Heart Association 2002)
40 (American Diabetes Association 2004)
- 50 1 , , ,
,
 2) (secondary prevention)
( Acute Coronary Syndrome, Coronary Artery
Disease), (Cerebral Vascular Disease), (Angioplasty),
(Coronary Artery Bypass Graft Surgery; CABG)

1.2 Thienopyridine groups

2 Ticlopidine Clopidogrel
Aspirin Aspirin Coronary stenting

1. Aspirin -, ASA,
2. 6

atherosclerosois
-
- LDL < 70 mg/dl
- HA1C < 7%
- BP < 140/90 mmHg
- Exercise > 30 min 3x4 per wk

Cardiovascular Cerebrovascular disease antiplatelet

ASA

56. male WBC 20,000 needle shaped crystal

x-ray finding
a. osteoporosis
b. osteophyte
c. chondrocalcinosis
d. bone ankylosis
e. lumpy soft tissue

e. lumpy soft tissue

Gouty arthritis gouty attacks ,k

- preservation of joint space joint space
- periarticular marginal erosion punch out lesion sclerosis
- eccentric periarticula soft tissue tophi calcium ,
tophi
- osteoporosis
- Asymmetrical Ref. ..
57. 50 2

PE: BT 38.5oC, Rt. knee swelling and

marked tender. Lab
a. Serum uric acid .
b. Rheumatoid factor
c. Joint fluid analysis
d. ESR
e. Knee plain film X-ray

Septic
1. Septic arthriris arthriris,Rheumatoid arthritis,Gout
2. Rheumatoid arthritis ()
3. Gout joint fluid analysis
4. OA Non inflame++++ OA
OA Inflame+++++++ RA
OA Septic++++++++ Septic
crepitation 37 RA OA
Joint fluid analysis OA
cartilage
DIP,PIP,1ST CMP ,Knee, hip,spine(C5-6,L3-4)
, crepitus , new bone
formation
Node= bouchard & Heberden s node
Film
o Jt spaces asymmetrical narrowing
o Subchondral bone sclerosis
o Marginal osteophyte
o Bone cyst
TX


Non inflamatory
Inflamatory Medication
Osteoarthritis RA
SpA o Paracetamol
Traumatic arthritis Crystal-induced arthritis
Avascular necrosis Septic arthritis o Weak opeiod ;tamadol,capsaicin
Rheumatic fever
Subsiding crystal-induced arthritis Reactive arthritis
o NSAIDs
Charcots/neuropathic joint CNT diseases o Intraarticular steroid()
SLE hyaluronate
Hypothyroidism

Amyloidosis
59. 49 3
PE: right lobeliver enlarged with mild tenderness , HBsAg positive
LAB: LFT: TB/DB = 1.0/0.2
AST = 60
ALT = 70
ALP = 112
Total protein = 5.0
Albumin = 2.3
U/S : Hyperechoic mass at right lobe liver diameter 6 cm. , no intrahepatic duct dilatation
a. metastatic CA
b. Amoebic liver abscess
c. Hepatocellular carcinoma
d. peripheral cholangiocarcinoma
e. postnecrotic cirrhosis with hepatic adenoma
b. aof_pa!!
metastatic CA
CA
Amoebic liver abscess Entameba histolytica
cyst trophozoites
= ()
epigastium ()
=
Lab = leukocytosis , AST, ALT , alkaline phosphatase , bilirubin
U/S = amebic liver abscess
amebic liver abscess
echo wall

hypoecho
low internal echo

posterior enhancement(distal sonic
enhancement)
treatment = metronidazole 400 mg. tid 7-10
60. 52 PE: profused sweating, decrease breath
sound Lt. lung, Abd: tender with guarding Dx?
a. Hiatal hernia
b. Ruptured esophagus
c. Mallotry-weiss syndrome
d. Tension pneumothorax
e. Acute MI
b. Ruptured esophagus
(Deja review USMILE Step2 126, 154)
Boerhaaves syndrome: characterized by esophageal perforation following severe vomiting
Tension pneumothorax: +/- trauma, pleuritic chest pain, dyspnea, tachypnea PE: BP drop, +ve jugular
venous distension, absent breath sound & hyperresonance, trachea debiation
Mallory-weiss syndrome: UGIB melena
Hiatal hernia: no symptom, heartburn, regurgitation
Acute MI: chest pain, decrease breath sound

61) c.

anorectal lesion
DDx. Common causes of anorectal lesion.
Hemorrhoid Proctits
Fissures Rectal trauma
Fistulas
cirrhosis hemorrhoid portal
hypertension ()

Internal hemorrhoid
Stage 1:
Stage 2:
Stage 3:
Stage 4:
hemorrhoid
1. : high
fiber diet branpsyllium
2. : 1 2
3. barrons ligation: 2 3
4. hemorrhoidectomy: 3
5. : anal dilatation, cryosurgery, infrared and bipolar diathermy
Ref: , ...............................................................by ReaL
62. 45 1 25 3-4 / 2
v/s scaling lesion 2 Dx
a. Pellagra
b. subdural hematoma
c. Wernickes encephalopathy
d. electrolyte imbalance
e. delirium tremens

Pellagra vitamin B3 (niacin) coenzymes

precursor tryptophan

Compromised intake of niacin or tryptophan

o Poverty , Poor nutrition
o Chronic alcoholism
o Anorexia nervosa
Compromised ability to absorb ingested niacin and tryptophan
o Malabsorptive states
o Prolonged diarrhea
Altered intermediary metabolism impacting niacin synthesis
o Hartnup disease
o Fad diets
o Isoniazid therapy: Treatment with the antituberculosis drug
o Carcinoid tumors
o Medications: 5-flurouracil, pyrazinamide, 6-mercaptopurine, hydantoins, ethionamide,
phenobarbital, azathioprine, and chloramphenicol.
Multifactorial, miscellaneous, or unknown mechanism
o Liver cirrhosis
o Diabetes mellitus
o Prolonged febrile illness, possibly leading to increased energy hence niacin requirements
o Human immunodeficiency virus (HIV) disease

"the 3 Ds" ( 4 Ds death)

D=diarrhea (GI findings)

o Patients with pellagra tend to suffer from poor appetite, nausea, epigastric discomfort, abdominal
pain, and increased salivation.
o Gastritis can be present and may result in achlorhydria.
o Glossitis typically causes soreness of the mouth and dysphagia.
o Diarrhea is the manifestation of intestinal inflammation. Diarrhea is typically watery (enteritis) but
is occasionally bloody and mucoid (colitis).
 D=dermatitis (Skin findings)

o Affected skin lesions are initially erythematous and are associated with a burning sensation.
o The distribution of the cutaneous eruption is typically symmetrical and bilateral in parts of the
body exposed to sun.
o As the dermatitis progresses, the affected skin becomes hyperpigmented and thickened.

D=dementia (Neuropsychiatric findings)

Early neuropsychiatric symptoms of pellagra include lethargy, apathy, depression, anxiety,

irritability, and poor concentration.
As the disease advances, patients become disoriented, confused, and delirious. Eventually, the
patient becomes stuporous and comatose.

D=Death

o Death is the result of the depletion of the coenzyme required to generate sufficient energy to
support vital body functions.
bY : MeD X

63. 33 dyspnea, engorged neck vein, no murmur, EKG: low voltage, generalized ST change with
inverted T
a. Constrictive pericarditis
b. Cardiac tamponade
c. RBBB
d. Lateral wall infarction
e. Pulmonary embolism
Cardiac temponade

Constrictive pericarditis

ventricle
preload
Clinical features
right side heart failure left side heart failure neck vein engorge , dyspnea ,
orthopnea , PND , hepatomegaly , peripheral edema pericarditis
pericardial friction rub Kussmaul s sign ( ) ,
pulsus paradoxus 25 % cardiac temponade
EKG
- low voltage 62 % - Inverted T 19%
- ST-T change 22% - AF 12%
 - *** generalized ST-T change pericarditis ST elevation
concave upward ( ST segment ) lead V1 aVR base
pericardium

Cardiac tamponade pressure pericardium

( ) pericardial
effusion temponade
Clinical features
Becks triad : Hypotension , neck vein engorge , distance heart sound
Dyspnea and tachypnea with lung clear
pulsus paradoxus 75% pericardial friction rub
EKG
- low voltage , electrical alternan +_ generalized ST-T change

Cardiac temponade .
. low voltage pericardial effusion , cardiac temponade , COPD ,
restrictive cardiomyopathy infiltrative amyloidosis

. constrictive pericarditis . 5 resident !!

64. 18
Pink frothy sputum , Crepitation both lower lungs, BP 160/100 mmHg
Furosemide O2
a. Diogoxin
b. Propanolol
c. Dobutamine
d. Nitroprusside
e. Mophine
Ans c. Dobutamine
CHF with volume overload and Pulmonary
edema Treatment
Restrict salt/fluid
O2 therapy [ ]
ACE-I [ decrease mortality and sympyom ] low dose
Hypotension Renal insuf
EF<40 %
Diuretic [ ] volume overload
B-block HF NYHA class II III
Dobutamine [Drug of choice] (
NTG
obutamine)

Digitalis AF, severe CHF, EF<30%
readmission

Nitropusside BP Reflex
tachycardia

65. 32 Underlying Rheumatic heart disease eith mitral valve

stenosis Digoxin(0.25mg) 1 tab OD, Furosemide(40 mg) 1 tab OD
3 PE:
BP 100/70 mmHg, HR 50 bpm, Lung fine crepitation both lungs, Heart
loud S1, Diastolic murmur at apex
a. Hypokalemia
b. Hyponatremia
c. Drug interaction
 d. Volume depletion
e. Metabolic alkalosis

Ans a. Hypokalemia
Digitalis intoxication choice
condition worsen digitalis toxicity Digitalis
intox Elyte ( )
Elyte imbalance 3 K, Ca, Mg ( choice
Hypokalemia ..55) condition
Hypo/Hyperkalemia
HypoMg
HyperCa
on Furosemide toxic HypoK
worsen digitalis toxicity HyperK ,
digitalis

66. 32 Underlying Rheumatic heart disease eith mitral valve

stenosis Digoxin(0.25mg) 1 tab OD, Fuaosemide(40 mg) 1 tab OD
3 PE:
BP 100/70 mmHg, HR 50 bpm, Lung fine crepitation both lungs, Heart
loud S1, Diastolic murmur at apex
a. Atropine
b. Beta blocker
c. Digoxin
d. Steroid
e. Furosemide

Ans c. Digoxin
off digoxin
supportive care -> hydration with intravenous (IV) fluids,
oxygenation and support of ventilatory function
correction of electrolyte imbalances -> replace K
recomment replace K K < 4 mmol/L.
Diuretic
Digoxin-specific fragment antigen binding (Fab) antibody
fragments -> severe acute digitalis toxicity
 GI decontamination ->
o Activated charcoal [multiple-dose charcoal (1 g/kg/d) ]
o Gastric lavage early after ingestion
o Whole-bowel irrigation ( )
o Steroid-binding resins, such as cholestyramine and colestipol
renal insufficiency

67. 60 30 x-ray right upper lung mass Na ( urine

osmole 50)
a. SIADH
b. Polydipsia
a. SIADH Chronic smoking right upper lung
mass lung cancer SIADH CA
lung small cell urine osm. SIADH urine osm.
100

malignancy SIADH

Lung cancer, small cell type

Gastrointestinal cancers (pancreatic cancer, exocrine; duodenal or stomach cancer)

Genitourinary cancer (bladder cancer, prostate cancer, ovarian cancer)

Lymphoma, including Hodgkin's disease

Head and neck cancers (oral cancers, laryngeal cancer, nasopharyngeal cancer)

Thymoma

Brain and central nervous system tumors

Breast cancer

Melanoma

Certain cancers produce and secrete ADH themselves. This production occurs without regard
for the needs of the body. Thus, the kidneys receive repeated signals to save water, even when the
body already has a marked excess of fluid. Of all the types of cancer that produce ADH themselves,
small-cell lung cancer is by far the most common. Small-cell cancer of the lung is the cause in 75%
of cases of SIADH caused directly by a tumor. In some cases, the appearance of SIADH may be the
first indication that a cancer exists.

Syndrome of inappropriate ADH secretion (SIADH)
SIADH hypoosmolar euvolemic hyponatremia urine osmolality
( 100 mOsm/kg plasma osmolality) urine Na 20 mEq/L
Na ECF ( Na
urine Na ) hypothyroid,
adrenal insufficiency, renal failure reset osmostat ( 3)
SIADH hypovolemia urine Na 10 mEq/L
hypovolemia urine Na exclude SIADH
SIADH SIADH
800-1,000 ml hypotonic
isotonic fluid hyponatremia Na
ECF
Na hypertonic fluid Na
solute intake furosemide
urine osmolality

SIADH
Essential
1. Decreased effective osmolality of the extracellular fluid (Posm < 275 mOsm/kg H2O).
2. Inappropriate urinary concentration (Uosm > 100 mOsm/kg H2O with normal
kidney function) at some level of hypo-osmolality.
3. Clinical euvolemia, as defined by the absence of signs of hypovolemia
(orthostasis, tachycardia, decreased skin turgor, dry mucous membranes)
or hypervolemia (subcutaneous edema, ascites).
4. Elevated urinary sodium excretion while on a normal salt and water intake.
5. Normal thyroid, adrenal, and kidney function.
Supplemental
6. Abnormal water load test (inability to excrete at least 80% of a 20 mL/kg water
load in 4 hours and/or failure to dilute Uosm to < 100 mOsm/kg H2O).
7. Plasma AVP level inappropriately elevated relative to plasma osmolality.
8. No significant correction of serum Na with volume expansion but improvement after fluid
restriction. demeclocyclin chronic SIADH
nephrogenic insipidus ADH free water
 Excessive water intake primary polydipsia psychiatric
disorders ADH free
water
free water
(solute) 12
hyponatremia euvolemia low solute intake
By.Dew

68. pt. CHFBx: lymphocyte infiltration, most common virus?

a. Adenovirus
b. Coxsakie B
c. EBV
d. CMV
b. Coxsakie B
Coxsackie B viruses are responsible for numerous cases of central nervous system infections
in infants and children, as well as heart muscle infections in both children and adults. These viruses
are the most common agent for myocarditis (inflammation of the muscular walls of the heart) and
dilated cardiomyopathy (a group of disorders where the heart muscle is weakened and cannot pump
effectively resulting in the dilation of the cardiac chambers).
Infection of the heart by the Coxsackie B virus can lead to viral myocarditis an
inflammatory disease of the heart that can cause heart failure .The disease does not usually cause
death, but permanent heart damage can occur. There are usually no long-term complications from
the mild illnesses/symptoms caused by the Coxsackie B virus. However, some patients who have
paralysis may not fully recover. Those who develop dilated cardiomyopathy (heart failure) from
myocarditis will require long term care for their symptoms.
ByDew

69. 30 Dx.?
a. Leptospirosis
a. Leptospirosis
(
)
(Leptospirosis) ,
(zoonosis)



(spirochete)
(Leptospira interrogans) 200 (serovars)



.. 2540
31% 28.25% 27.35% 2.15%

90%
5-10%
(anicteric leptospirosis) 2
(leptospiremic phase)




1 1-3
(leptospiruric phase)

15% (aseptic
meningitis)


(severe leptospirosis)
(Weil's Syndrome)
5-15% /
(icterohaemorrhagiae/copenhageni)
4-9

20%



1-2 3
(leptospiremic phase) 1 1-3
(leptospiruric phase) 5-10%

-

4 7



(doxycycline) , 100 2

(ampicillin) , 500-750 4

(amoxicillin) , 500 4

(penicillin G) , 1.5 4

(ampicillin) , 1 4

(amoxicillin) , 1 4

(erythromycin) , 500 4

ByDew

70. 65 U/D AAA PE: multiple ecchymoses, , CBC: Hb 10, WBC 7,200
(N 75, L 25), Plt 30,000, PT, PTT, TT: prolong, fibrinogen decrease,
?
a. D-dimer
b. Euglobulin lysis time
c. Blood smear
U/D aortic aneurysm bleeding tendency bicytopenia,
coagulopathy hemostatic disorder aortic aneurysm turbulence flow vascular
injury primary and secondary hemostasis thrombosis RBC
anemia Plt coagulation factor clinical bleeding +
thrombocytopenia + coagulopathy : chronic DIC
Lab : blood smear MAHA blood picture (DDx: DIC, TTP, vasculitis, HUS,
prosthetic heart valve), D-dimer (DDx: thrombosis (PE, DVT), , DIC
etc.), Euglobulin lysis time global nonspecific screen of the fibrinolytic system
chronic DIC Lab

ByFon
 71. HbH disease typing
Hb MCV
13 76
13 87
Thalassemia Autosomal recessive a-
thal 1 gene (--) a-thal 2 gene (a-)
anemia a-thalassemia trait, heterozygous HbCS
a-thalassemia trait a-thal-1 trait (aa,--) a-thal 2 trait (aa,-a) MCV
a-thal-1 trait 2 . MCV a-thal-2 trait 1 .
MCV
a-thalassemia-1 trait (aa,--), a-thalassemia 2 trait (aa,-a)
HbH disease
ByFon
72. Na? K?
a. Methanol
b. Ethylene glycol
c. Salicylate
d. Paraquet
Methanol

-
(Salicylic acid)




oxidize 2
(Methyl alcohol) 1 3
6 -
60




(oxalic acid)
(Diethylene glycol)


24

methanol (wood alcohol) methanol

methanol methanol
ethanol methanol
mucosal irritaion

(snowfield vision) fundi retinal edema hyperemia optic disc CNS
confusion coma
hyperpnea acidosis acidosis
high gap metabolic acidosis serum osmolality osmolal gap

high gap metabolic acidosis toxic syndrome methanol
ByFon

73. 20 1*1 cm TT Rabies

a. Rabies vaccine
b. Rabies Ig
c. 1
d.
e. Rabies vaccine Rabies Ig
e. Rabies vaccine Rabies Ig
Rabies vaccine post exposure
6 1 stat
6 stat day 3
Ig
 Rabies Immunoglobulin(RIG)
1.
2.
3.
4.
5.
6.
7.



TT TIG TT TIG
,
3 < 5
3 5-10

3 >10

74. ER EKG
(VF)
a. Defibrillation
b. Atropine injection
c. Adenosine injection
d. Adrenaline injection
a. Defibrillation
EKG shockable 3 ventricular
fibrillation, pulseless ventricular tachycardia,
Torsade de Pointes

Advanced Cardiac Life Suppor

75. 35 ER 10 2
PE: BT 37oc , BP 140/90 mmHg, HR 120/min,
RR 14/min with shallow breathing, motor grade II/V, reflex 1+
a. Saxitoxin
b. Tetrodotoxin
c. Botulinum toxin
Botulinum Tetrodotoxin/Saxitoxin
1. 1-8 1/2-12
2. ,

3. -
4. , ,
5.

Saxitoxin
: 15
: sodium channel blocker, paralytic shellfish poisoning (PSP)
: 2-12 hr
Tetrodotoxin
: 20 3
:

:
4-6
Botulinum toxin Clostridium botulinum
: 12-36 (aerosol), 1-3 (food)
: acetylcholine
: - aerosol
- food food poisoning (botulism)
2-3
:-
- equine botulinum antitoxin (type A,B, E)
- 0.5% hypochlorite solution
: vaccine
^^
 79. TG = 210 LDL = 200 HDL =30

a. Gemfibrozil b. Simvastatin c.Fibric acid d. Niacin e. Cholestyramine
b. Fenofibrate
LDL = total cholesterol HDL TG/5
cholesterol = 272
hypercholesterolemia and hypertriglyceridemia Familial combined
Hyperlipidemia mixed dyslipidemia (plasma TG = 200-800 mg/dL ,cholesterol= 200-400 mg/dL
,HDL < 40 mg/dL)

HMG-CoA reductase inhibitor niacin
simvastatin
Hypolipidemic drugs lipoprotein class effected common side effects contraindications
HMG-CoA reductase inhibitors

Lovastatin 20-80 mg/d decrease(dec.) LDL 25-55 %

Pravastatin 40-80 mg qhs decrease TG 10-20 % acute or chronic liver

Simvastatin 20-80 mg qhs
Fluvastatin 20-80 mg qhs
Atorvastatin 10-80 mg qhs
increase(inc.) HDL 5-10% disease of myositis
Myalgias,arthralgias ,increase
increase by impaired
trasaminases, dyspepsia
renal function
fibrate

Rosuvastatin 10-40 mg qhs

Nicotinic acid dec.LDL 15-25%

flushing, hepatic dysfunction, nausea,
Peptic ulcer disease,
dec.TG 25-35% diarrhea, glucose intolerance,
hepatic disease gout
hyperuricemia
inc.15-30%

Bile acid sequestrants

Cholestyramine 4-32g qd dec.LDL 20-30%

cholestipal 5-40 g qd inc.TG 10% Constipation ,gastric discomfort biliary tract obstruction
,nausea ,gastric outlet obstruction
colesevelam 3750-4375 mg
inc.HDL 5%
qd
fibric acid derivatives

Gemfibrozil 600 mg bid inc. or dec. LDL hepatic or biliary disease,

Fenofibrate 160 mg qd
dec.absorption of other drug ,inc.gall
renal insufficiency
dec.TG 25-40% stone, dyspepsia ,hepatic
associated with inc. Risk
dysfunction, myalgia
inc.HDL 5-15% of myositis
By....
80. 56 2 DM ,HT 10 EKG
STEMI in V1-V4 ASA
a. Enoxaparin b. Warfarin c. Streptokinase d. Balloon e. PCI
STEMI
Initial therapy
Goal 1.quickly identify reperfusion therapy
2. relieve pain
3. , arrhythmia
ASA 162-325 mg 162-325 mg/d
EKG
Primary PCI effective fibrinolytic

IV fibrinolysis PCI PCI 1
fibrinolytic 1-3 12
EKG ST elevate Q wave bleeding
reperfusion arrhythmia
chest pain or ST elevate fibrinolysis 90 refer
PCI

By
81. 56 2 3-4 3 PTA BT=37.3 PR=98
RR=18 BP=104/80 stupor, mild jaundice ,mild ascites ,spider nevi positive ,palmar erythema
investigation
a. CBC b. Stool exam c. Coagulogram
d. LFT e. abdominal paracenthesis

..................
Hepatic encephalopathy hepatic
encep. Child-Pugh criteria

Factor 1 2 3
serum
<2 2 3 >3
bilirubin(mg/dL)
serum
>3.5 3 3.5 <3
albumin(g/dL)
Ascites None Easily control poorly control
Advanced
Neuroloic disorder None Minimal
coma
Prothrombin time 0 4 4 6 >6

class choice 2 c. d.
By
85. 50 4 purple-red
discoloration purple nodule
a. Psoriasis
b. Dermatomyositis
c. Discoid LE
d. SLE
e. Mixed connective tissue
: Dermatomyositis
Case proximal muscle weakness ( ) skin rash purple-red
discoloration
Criteria to define Polymyositis/Dermatomyositis
(PM 3 4 , DM 3 4 5)
 1. Proximal muscle weakness (insidious, symmetric, progressing over wks. to mos., ocular & facial
normal MG)
2. Elevated serum level of skeletal muscle enzyme (Creatine kinase)
3. Myopathic change (EMG)
4. Muscle biopsy evidence of inflammation
5. Skin rash
- Heliotrope rash : reddish purple discoloration on upper eyelid
- Grottons sign : violaceous papules, sometimes scaly over the knuckles
Psoriasis : skin lesion (erythematous, sharply demarcated papules and rounded plaqes cover by silvery scale),
Auspitzs sign ( scale ), lesion extensor area 50%
(pitting nail, onycholysis , subungual hyperkeratosis, yellowish discoleration)

Mixed connective tissue : overlapping features of SLE, Scleroderma, and Polymyositis

Reference
- Medicine 5

86. 30 3 Cachexia, muscular wasting (Capillaria philippinensis)

a.
b.
c.
d.
e.
f.

Capillaria philippinensis

5-10




mebendazole 200 mg 1x2 20 albendazole 400 mg 1x1 10

: Hookworm, Strongyloides stercoralis, Schistosoma ()

: Fasiolopsis buski ()
: Angiostrongylus cantonensis ( )
: Trichinella spiralis ( ), Taenia solium
: Taenia saginata
: Gnathostoma spinigerum ( )
: O. viverrini ( )
: Paragonimus ()

Reference :
- , . . :
, 2546. 2
- , , . . :
, 2544.
- . Atlas of Medical Parasitology

87. 42 FU .
PE: PR 128 /min RR 30 /min lung-clear, Rt leg-Swollen & tenderness

a. Pleuodynia
b. Pneumonia
c. Pulmonary embolism
d. Acute coronary syndrome
e. Dissected aortic aneurism
Pulmonary embolism
PE
- , , , , , , , , -
- tachycardia, respiratory crackles, S4 (Rt sided) gallop, accentuated P2, fever, circulatory collapse
clinic PE ( Wells)
- DVT 3
- Dx. DVT 3
- HR > 100 bpm 1.5
- Sx. 4 wk 1
- DVT PE 1
- 1
 - CA ( 6) 1
<2
2-6
>6
case DVT ( ), HR > 100 bpm , CA Dx.
DVT 8.5
Dissected aortic aneurism : sharp stabbing pain (
) dissection
hypertension hypotension cardiac temponade pulse deficit

Reference
-
- .

88. 18 3 PE: moderate pale ,mild jaundice, liver 2 cm below

costal margin, spleen 3 cm below costal margin, Hb 7.9, Hct 28, MCV 65, WBC 9500, N 80%, L 20%,
Plt.450,000
a.AIHA
b.HbH with crisis
c.PNH
d.G6PD
e.DIC
b. HbH with crisis HbH disease
hemolytic anemia
AIHA
PNH
G6PD
DIC Plt. PT &PTT prolonged
By Sa-ou X.054

89. 50 PE: Rt. Knee swelling, tender

a.x-ray
b.synovial analysis
b. Pt. infection (acute arthritis )
synovial analysis septic arthritis x-ray
By Sa-ou X.054
90. Pt. U/D Cirrhosis 3-4 / 3 PE: sign Chronic liver
disease &moderate ascites investigation Dx.
a. Abdominal paracentesis
b. stool exam
c. LFT
d.CBC
a. Abdominal paracentesis SBP (SBP
host)
Stool exam strongiloid.
By Sa-ou X.054

91. ... PE: tonsil enlargement grayish patch at pharynx and tonsil gland anterior
cervical lymphanode enlargement both side no hepatomegaly no splenomegaly

a. Diptheria

a. diphtheria tonsil gland enlargement grayish patch at

pharynx and tonsil diptheria patch
DPT
choice DDx infectious mononeucleosis generalized LN
enlargement +hepatosplenomegaly
scarlet fever sand paper (groose fresh) appearance
Vincent s angina poor oral hygiene
exudative tonsillitis patch tonsil gland differential
1. Diphtheria : pharynx tonsil
(grayish patch) (dirty patch)
cervical lymphadenopathy Bull neck
toxemia exotoxin myocarditis (10-25%) ,heart
block , neuritis upper airway obstruction membrane
Corynebacteriumdiptheria
2. Scarlet fever: beta-haemolytic streptococcus erythematous tonsil
gland enlargement , erythematous pharyngeal mucosa exudates tonsil gland
petechiae soft palate and uvula red strawberry tongue
erythematous punctiform eruption (sand paper like appearance)
circumoral pallor
3. Infectious Mononucleosis: EBV 38-39 C
clean white patch on tonsil gland 5-8 generalized
lymphadenopathy epitrochear node specific splenomegaly
 Hoagland sign posterior cervical lymphadenopathy, generalized
lymphadenopathy, , peripheral blood smear characteristic atypical
lymphocytosis. Heterophile antibody
4. Vincent's angina trench mouth disease:
pseudomembrane tissue ulcer , ,pharynx
smear Vincent organism mixed infection spirochete Fusobacterium
fusiforme Bacteroides sp. necrotic poor oral hygiene

5. Group A beta hemolytic streptoccus tonsillitis most common cause of acute

tonsillitis injected pharynx enlarge tonsil gland
exudative tonsillitis
6. Agranulocytosis exudate tonsil gland posterior pharyngeal wall
cervical
lymphadenopathy

: 1 , ,
pattarapon_bump@hotmail.com

92. 23 congestive heart failure

lymphocyte infiltrate
a. influenza virus
b. adenovirus
c. coxsackie B virus
d. EBV
C. Coxsackie B virus
coxsackie B virus dilated cardiomyopathy infection
50 % viral myocarditis Lymphocyte infiltration

Cardiomyopathy
myocardial infarction ,valvular heart disease or hypertension 3
2. dilated cardiomyopathy: most common cardiomyopathy left ventricular
dilatation systolic dysfunction (low EF)

Chronic excessive alcohol consumption

 Other drugs: Anthracyclines (daunorubicin and doxorubicin) Heavy metals
Emetine Cocaine Methamphetamine

Infections

Viral endocarditis/myocarditis coxsackievirus, adenovirus,

parvovirus, human immunodeficiency virus [HIV]) Parasites

Protozoa

Chagas disease (most common cause in parts of South America)

Thiamine deficiency (beriberi) and zinc deficiency

Family : genetic

ABCDs cause of dilated cardiomyopathy: Alcohol Beriberi Coxackie B Cocaine Chagass

disease Doxorubicin

3. hyperthophic cardiomyopathy: LVH diastolic

dysfunction (EF ) congenital idiopathic hypertrophic
subaortic stenosis;IHSS autosomal dominant sudden death

4. restrictive cardiomyopathy : elasticity diastolic filling
EF infiltrative disease sarcoidosis
hemochromatosis amloidosis scar doxurubicin

: First Aid for the USMILE STEP 2 Clinical Knowladge

pattarapon_bump@hotmail.com

93. 45 1 1-2 1-2

200/120 mmHg
210/130 mmHg Pulse rate 120 /min Respiratory rate 22/min Eyes: fundoscopic examination
show frame shape hemorrhage with early papilledema furosemide

a. Enarapril
b. Propanolol
c. Prazosin
d. Nitroprusside

d.nitroprusside hypertensive crisis hypertensive

emergency >=180 /120 (target
organ damage) frame shape hemorrhage with early papilledema nitroprusside
0.25-10 ug/kg/min IV drip mean arterial pressure 25% 2-3 h
hypertensive emergency
Hypertensive crises
SBP >=180 mmHg DBP >= 120-130 mmHg
( )
Hypertensive crises 2
1 hypertensive emergencies ( ) = HTN +
(HTN with TODs ;target organs damage)
1 hypertensive
encephalopathy stroke ,unstable angina ,myocardial infartion ,left side heart failure
,pulmonary edema ,aortic dissection ,pregnancy induced hypertension IV
antihypertensive drug ( )
2 hypertensive urgencies ( )= HTN+
(HTN without TODs) HTN stage II (BP >=160/100 mmHg )
, , , oral antihypertensive drug ER
24 h ( admit )

Management hypertensive emergency

Patient presentation
High risk patient hypertensive
encephalopathy IV anti HTN
stroke
unstable angina
myocardial infartion
left side heart failure
pulmonary edema
aortic dissection
pregnancy induced
hypertension
No high risk patient Eye ground :
-papilledema
-hemorrhage
-exudates
 IV antihypertensive drug hypertensive crises
:
Vasodilator Dose Side effect/

Nitroprusside 1-2 0.25-10 N/V
ug/kg/min IV
drip thiocyanate and
cyanide
:renal
failure ,liver failure

Nitroglycerine - myocardial 2-5 3-5 5-100 ug/min

ischemia/infartion IVdrip (tolerance)
methemoglobinuria
coronary a. tachycardia
-HTN

Nicardipine 5-10 30-60 5-15 mg/h IV Tachycardia ,head
heart failure /MI ( > 4 drip ache . ,
) vasculitis
Fenoldopam < 5 30 0.1-0.3 Tachycardia,
mcg/kg/min headache
( nausea, flushing.

)
glaucoma.
intracerebral
hemorrhage

Enalapilate left side heart 15-30 6 0.625 1.25 mg

failure IV q 6 h rennin
congestive heart
failure
Hydralazine Pregnacy induced 10-20 3-8 5-10 mg IV q 4-6 Tachycardia,
hypertension h headache, flushing,
(Alternative
drugs:MgSO4 20-30 10-50 mg IM
IV/IM ,methyl
dopa ,nicardipine
IV)
 Oral antihypertensive drug for hypertensive crises

Drug onset duration doses S/E

Captopril 15 4-6 6.25 -25 mg
PO /SL

Clonidine Alpha adrenergic 0.5-2 6-8 0.2 mg

antagonist 0.1
mg/h
0.8 mg
Labetalol Alpha and Beta 0.5-2 8-12 200-400 mg Bronchospasm,hypotension
adrenergic q 2-3 h
antagonist
Prasozin Alpha adrenergic 1-2 8-12 h 1-2 mg q 1h
antagonist

pheochromocytoma

:
Hypertensive emergency and urgency .
Hypertension 2006 .
pattarapon_bump@hotmail.com
 national license (medicine)

94. 45 . stomach
restlessness ,sweating , BP =150/100 ,
PR =120 ,tremor both hands treatment
a. chlorpromazine IM
b. Diazepam IV
c. Haloperidol IM
d. Thiamine IM

alcohol withdrawal diazepam IV

guideline( )
(guideline )
95. 60
a. cellulitis
b. contact dermatitis
c. dermatitis dermatiformis
d. Herpes simplex infection
e. vericella zoster infection

Herpes zoster lesion dermatome group of

blister on erythematous base postherpetic neuralgia
choice herpes zoster recurrent varicellar
zoster varicella zoster infection ( e )
- cellulitis : ( subcutaneous)
lesion
- contact dermatitis : reaction 2

irritant contact dermatitis :


Allergic contact dermatitis : reaction immune
hapten (
)
- Herpes simplex infection : 2
type 1 : lesion herpetic
gingivostomatitis with oral erosion
type 2 : bilateral erosive vesicular lesion
accompanied by edema and lymphadenopathy

96. anaphylaxis shock treatment

a. IM adrenaline subcutaneous adrenaline

anaphylaxis shock epinephrine IM 1:1000

0.01 / ( max dose 0.3 )
100. CXR : cavitary lesion with air fluid level

a. Lung abscess
Lung abscess
Cause : m/c = anaerobe; Peptostreptococcus,peptococcus, Bacteroides melaninogenicus ,
Fusovacterium nucleatum ( )
- Aerobic and facultative (S.aureus, K.pneumoniae, Norcadia spp. , Gram -ve) :
acute onset
- Fungus (Mucor,Aspergillus) , parasite
- Immunocompromise host : m/c aerobic,OIs
- DM : Mediodosis
sputum c/s lung abscess
Risk factor : Impaired upper airway and oral hygeien
Impaired swallow
Impair consciousness :
Symptoms: cough, purulent sputum production , pleuritic chest pain, fever , hemoptysis, Clue : fetid
breath ()
Sign : evidence of consolidation , +/- clubbing finger , crepitation
CXR : classical finding
- one or two thick wall cavities in dependent area of the lung (upper lobes and
posterior segment of the lower lobes)
- air fluid level
Treatment : penicillin 1 MU iv. Q 4 hr. 500 mg oral QID
penicillin clindamycin 150-300
mg q 6 hr (Harrison ed17 clindamycin
penicillin )
4-6 wks

Ref : Harrison ed.17 ; lung abscess ; 1631

; ;328
101. CRF urine BP Serum K = 7 EKG change

10% calcium gluconate

Hyperkalemia, defined as a plasma K+ concentration >5.0 mmol/L, occurs as a result of either K+

release from cells or decreased renal loss.
Causes of Hyperkalemia
I. Renal failure
II. Decreased distal flow (i.e., decreased effective circulating arterial volume)
III. Decreased K+ secretion
A. Impaired Na+ reabsorption

1. Primary hypoaldosteronism: adrenal insufficiency, adrenal enzyme deficiency (21-

hydroxylase, 3-hydroxysteroid dehydrogenase, corticosterone methyl oxidase)
2. Secondary hypoaldosteronism: hyporeninemia, drugs (ACE inhibitors, NSAIDs, heparin)
3. Resistance to aldosterone: pseudohypoaldosteronism, tubulointerstitial disease, drugs (K +-
sparing diuretics, trimethoprim, pentamidine)

B. Enhanced Cl- reabsorption (chloride shunt)

1. Gordon's syndrome
2. Cyclosporine

Clinical manefestation
hyperkalemia partially depolarizes the cell membrane. Prolonged depolarization impairs
membrane excitability and is manifest as weakness, which may progress to flaccid paralysis and
hypoventilation if the respiratory muscles are involved.
Hyperkalemia also inhibits renal ammoniagenesis and reabsorption of NH 4+ in the thick
ascending limb of the loop of Henle. Thus, net acid excretion is impaired and results in
metabolic acidosis, which may further exacerbate the hyperkalemia due to K+ movement out of cells.
The most serious effect of hyperkalemia is cardiac toxicity, which does not correlate well with the
plasma K+ concentration. The earliest electrocardiographic changes include increased T-wave
amplitude, or peaked T waves. More severe degrees of hyperkalemia result in a prolonged PR
interval and QRS duration, atrioventricular conduction delay, and loss of P waves. Progressive
widening of the QRS complex and merging with the T wave produces a sine wave pattern. The
terminal event is usually ventricular fibrillation or asystole.

Ref: Harrison ed. 17

102. . CXR: cavitary lesion + infiltration at RUL , AFB negative 3

impression pulmonary TB

: ( 2545)

By IM
103. Pt. HT Na 140(137-150) K 3(3.5-5)
HT
a. Pheochomocytoma
b.Primary hyperaldosteronism
c. Renal a. stenosis
b.Primary hyperaldosteronism

H T hypoK 2nd HT
1. Primary renal dis. : Renal a. stenosisrenal bruit
2. Pheochomocytoma: Norepi.
Lab: urine metanephrine
3. Primary hyperaldosteronism :aldoNaKhypoK,metabolic
alkalosis
proximalweakness,rhabdomyolysis,nephrogenic DI
4. Oral contraceptive
5. Hyper/hypothyroism
6. hyperparathyroism:hyperCa hypoPO4
7. cushing
8. sleep apnea syn.
9. coaratation of aorta

104. Pt tenia unguium

a. Topical ketoconazole
b. Oral ketoconazole
c. Oral itraconazole
d.Topical itraconazole

: c. Oral itraconazole ( 200 milligrams daily for a duration of 12 weeks)

:(Tinea ungium)

: Trichophyton

:
: - griseofulvin,itraconazole,fluconazole ,ketoconazole
-

Tinea unguium FDA AMOROLFINE, BIFONAZOLE, CICLOPIROX

OLAMINE, KETOCONAZOLE, NATAMYCIN, TIOCONAZOLE, TOLNAFTATE

105 . Pt. penicillin diarrhea proctoscope AAC

a. Metronidazole

: Antibiotic-associated colitis(AAC) intestinesantibiotic

treatment ( caused by toxins produced by the bacterium Clostridium difficile.)

antibiotics caused :clindamycin (Cleocin), ampicillin (Omnipen), amoxicillin (Amoxil, Augmentin, or

Wymox), cephalosporin class (such as cefazolin or cephalexin).

Symptoms :ATB 4-10 days lower abdominal cramps, an increased need to

pass stool, and watery diarrhea. Fever

:antibiotic to control the growth of the Clostridium difficile, usually vancomycin (Vancocin)
or metronidazole (Flagyl or Protostat). taken orally four times a day for 10-14 days.

By:kaew^^

106. pt .post arrest EKG VT

A . defibrillation
cardioinversion=== VT pulse post arrest pulse

1 amiodarone 150 mg iv 10 2.2 gm 24 .

2. electrical synchonized cardioconversion unstable { chest pain, decrease level of
conscious, low blood flow , shock }
107. pt pale +jx
a. Hb typing
b. inclusion body
c. BMA
d. G-6 PD screening
e. Croombs test

d. G-6 PD screening
anemia + jx hemolysis anemia G-6 PD def
< AIHA >
Location Mechanism Example
Intrinsic Enz def G-6 PD def
Hemoglobinopathy Sikle cell anemia, thallussemia
Membrane defect Heretary sperocytosis
Immune AIHA

extrinsic Traumatic MAHA

infection Malaria
Entrapment hypersplenism

108. pt clinical DKA

a. iv insulin
b. iv fluid

iv fluid
expand intravascular volume Elyte imbalance
metabolism insulin
- iv fluid 0.9 NSS maintenance + def 8 . . .16
iv
- insulin continouse low dose iv or low dose IM 80-100 mg/dl
,
109. Clinical DIC
A. Antibiotic
B. platelet
C. FFP

severe DIC
purpura , injury , hemorrhagic bullae , focal
necrosis
shock , acidosis , , thromboembolism
oligouria , azotemia , hematuria , acute tubular necrosis ,
renal cortical necrosis
jaundice , parenchymal damage
ARDS , hypoxemia , pulmonary edema
GI UGIH mucosal necrosis
CNS stupor , coma , seizure , focal lesion
Adrenal gland adrenal insufficiency

1. DIC Antibiotic
2. supportive treatment
3. specific treatment
- Plt plasma
- Plt Plt
- PT,PTT prolong FFP
- fibrinogen (acute head injury, abruptio placenta)
hyperfibrinolysis (CA prostate) Cryoprecipitate

DIC sepsis
condition
110. EKG PVC 3
A. Ventricular tachycardia

Premature ventricular complex

QRS complex 0.12 sec (3 ) Pwave PVC
PVC QRS complex upright Twave inverted QRS complex inverted T
wave upright
- PVC 2 QRS complex couplet
- PVC 3 QRS complex short run of
Ventricular tachycardia
- PVC 1 QRS complex 1 Bigeminy of PVC
- PVC 1 QRS complex 2 Trigeminy of PVC
- PVC 1 QRS complex 3 Quadrigeminy of
PVC
111. EKG complete heart block
A. Atropine

Congenital : corrected transposition of great artery ,

Ebstein s anomaly , ASD premum , VSD
- prognosis
Atropine , Isoproterenol
- prognosis PR < 40/min prolong QT
PVC pause dependent Pacemaker

Acquired : most common Acute inferior wall MI
dominant Rt. LCA AV node
1 3 7
Atropine, Isoproterenol

complete heart block pacemaker

condition

By Mai ^o^
 national license (Ped)

1. 5 cervical lymphadenopathy, splenomegaly and gray

patch at tonsil
a. EBV
b. Diptheria
c. GAS
d. Measles
EBV
EBV infectious mononucleosis 'glandular fever', 'Mono' 'Pfeiffer's
disease'. "The Kissing Disease,"
airborne 3

pharynx petechiae common signs

lymphadenopathy splenomegaly hepatitis hemolysis
Diphtheria pseudomembrane tonsil pharynx nasal cavity
10 toxin
cardiomyopathy, peripheral
neuropathy (sensory type)
GAS group A strep
Bacteremia
Impetigo, cellulites, erysipelas
Focal infection
- pneumonia
- tonsillitis - peritonitis
- septic arthritis - meningitis
- osteomyelitis - vaginitis
necrotizing fasciitis
scarlet fever
sinusitis
strep throat *** Cervical lymphadenopathy , not general lymphadenopathy
toxic shock syndrome

Measles
C =cough, coryza (runny nose), conjunctivitis (red eyes) 40
Kopliks spots second upper molar pathognomonic sign
1

generalized maculopapular erythematous rash

2. 6 3
multiple ill-defined, fine scaly patch, hypopigmented macule and patch KOH:
negative
a. Vitiligo
b. Pityriasis alba
c. Pityriasis vesicolor
d. Tinea Facialis
e. Contact leukoderm
pityriasis alba

Vitiligo
Vitiligo leukoderma loss of pigment irregular pale patches
melanocyte
autoimmune genetic environmental factors.
macular depigmentation, extensor ,

Pityriasis alba
Pityriasis alba

moisturizer
Pityriasis alba
corticosteroid
eczema melanocytes
melanosomes
3-16
 dry scaling
patch 3
1. Raised and red
2. Raised and pale
3. Smooth flat pale patches
0.5-2 cm 4-5 20
redness, scale emollients hydrocortisone 1

Pityriasis vesicolor
Pityriasis versicolor Malassezia
patches
pityriasis
versicolor alba
woods light

Pityriasis versicolor

Tinea facialis describe lesion : sharply marginated

erythematous scaling and crusted plaque
Contact leukoderm delayed type hypersensitivity
3. 3 lung: rhonchi right lung investigation

a. AP, lateral
b. PA, lateral
c. Inspiration and expiration
d. Right lateral decubitus
e. Left lateral decubitus

upper airway obstruction trachea and right main bronchus () Right

main bronchus dependent part aspiration
posterior segment of upper lobe apical segment of lower lobe
inspiration and expiration film indication unilateral obstruction of major
bronchus CXR indication
Standard Views iii. Unilateral diaphragmatic paralysis
1. Standing (Upright Chest XRay) iv. Unilateral obstruction of major
4. Posteroanterior (PA) Film bronchus
5. Left Lateral XRay 2. Lordotic View Indications
a. Request right lateral film if v. Posterior Apical Disease
right-sided finding vi. Middle Lobe disease
b. More sensitive than PA for 3. Reverse Lordotic View Indications
abdominal free air vii. Anterior apical disease
2. Supine (Portable Chest XRay) 4. Oblique Film
i. Anteroposterior (AP) Film viii. Peripheral small lesions
1. Magnifies heart and 1. Separated from overlying
anterior mediastinum chest shadows
2. Emphasizes rib and 2. Lesions poorly seen on
calcium contrast lateral chest XRay
3. Lung parenchyma may ix. Rib Fractures (at axillary lines)
appear washed out 5. Lateral decubitus Film
Special Views x. Detect small areas of air at
1. Inspiration and Expiration Film Indications uppermost pleural space
***** xi. Detect small areas of dependent
ii. Pneumothorax accentuated on Pleural Fluid
expiration
 1. Measure size and mobility
of fluid collection
2. Accessible with sampling
needle (>1 cm size)
xii. Uncover Lung tissue obscured by
Pleural Fluid
1. Place side of interest up
xiii. Mobility of mediastinal or pleural
masses
xiv. Assess mobility of solids and fluids
within cavities
xv. Assist with maximizing inspiration
of uppermost lung
6. High Penetration Film with moving grid
(Bucky Film)
xvi. Obesity
xvii. Dense pleural or pulmonary
opacities
xviii. Calcified lesions
xix. Lesions obscured by heart or
diaphragms
xx. Air Bronchograms in densely
infiltrated areas
7. Intrathoracic Pressure Maneuvers
xxi. Valsalva Maneuver: shrinks
pulmonary vessels
xxii. Muller Maneuver: distends
pulmonary vessels
xxiii. Indications
1. Distinguish blood vessel
from lymph node
2. Distinguish A-V
malformation from solid
lesion
8. Barium Swallow
xxiv. Enlarged retro-mediastinal nodes
xxv. Define Posterior intrathoracic mass
xxvi. Confirm ruptured diaphragm or
Diaphragmatic Hernia
xxvii. Impaired swallowing with
aspiration
9. Diagnostic Pneumothorax (instill air in
pleural space)
xxviii. Distinguish peripheral lung mass
from pleural lesion
xxix. Define Mesothelioma
xxx. Parenchymal disease extending
towards chest wall
6. Circumstances that decrease Chest XRay
quality
a. Semi-upright position (neither standing nor
supine)
i. May enlarge normal structures
ii. Changes air-fluid levels
b. Lordosis or vertical axis rotation
i. Widens heart and mediastinum
c. Inadequate sustained inspiration
i. Breathing film
1. Lung structures and
diaphragm blurred
ii. Expiration film
1. Basilar infiltrates
accentuated
2. Interstitial structures
accentuated
a. Vessels
b. Pleural Fluid
 3. Increased heart size 3. Air-Fluid levels (e.g. Lung
d. Supine Film Abscess) disappear
i. Decreases Lung Volume v. Pneumothorax signs on supine film
1. Highlights infiltrates and 1. Deep Sulcus sign
interstitium a. Costophrenic angle
ii. Increases venous return to heart sharply outlined by
1. Distends azygous vein and air
pulmonary vein b. Diaphragm-
iii. Diaphragm rises and intracardiac mediastinal junction
pressure increases sharply outlined
1. Heart and mediastinal 2. Hyperlucency
structures enlarge superimposed over liver
iv. Fluid and air migrate shadow
1. Pleural Effusions disappear
2. Small Pneumothorax References
disappears A Marini (1987) Respiratory Medicine,
Williams & Wilkins Katz (1999) Clin Chest Med
20(3):549
4. Term new born BW = 4000 g DM Blood sugar =26 mg%

A) oral 10% D/W 10ml/kg

B) IV 10% D/W 2 ml/kg
C) IV 10% D/W 2 ml/kg
D) IV fluid with GPR 4-6 mg/kg/min
E) IV fluid with GPR 6-8 mg/kg/min
F) IV hydrocortisone 10 mg/kg/day

IDM
> 40 early feeding
<40 fluid GPR (glucose production rate) 6-8 mg/kg/min

40
<40 IV fluid with GPR 6-8 mg/kg/min
5. 4 BP 90/60 mmHg, PR= 120/min stiff neck
positive Meningococcal Meningitis
Neisseria meningitides group B

(
)

()
2 10





24

6. webbed neck, wide nipple distance and low hair line

A) Decrease Insulin
B) Decrease GH
C) Increase estrogen
D) Increase GnRH
E) Decrease PTH
Decrease GH
Turners syndrom
eye problems (drooping eyelids, lazy eye) curvature of the spine (scoliosis)
high palate (roof of mouth) arms that turn out more than usual at the
small jaw elbows
low hairline at the back of the head missing 4th or 5th knuckle
wide and short neck, sometimes with an puffiness of the hands , feet (lymphedema)
excess of skin that joins the neck with the narrow fingernails
collar bone (called neck webbing) knock knees
broad chest increased numbers of moles on the skin
Skeletal
: GH
estrogen osteoporosis, increased risk of bone fractures ,spine
scoliosis
Kidney
horseshoe-shaped kidney, abnormal urine-collecting system, Poor blood flow to the kidneys
Thyroid :hypothyroid

7. 14 8

progesterone challenge test : negative estrogen-progesterone challenge : negative

a. Ovarian failure
b. PCOS (Polycystic Ovarian Syndrome)
c. Exercise amenorrhea
d. Ashermans syndrome
amenorrhea 2
1. primary amenorrhea
- 14 secondary sexual characteristics

- 16 secondary sexual
characteristics
2. secondary amenorrhea 3
6
8
secondary amenorrhea
secondary amenorrhea
1. 3.3 Sheehans syndrome
1.1 Ashermans syndrome 3.4 Cushing s syndrome
2. 2.1 4. Hypothalamus and brain
2.2 4.1
3. 4.2 / anorexia
3.1 hyperprolactinemia 4.3 Hypothalamic suppression
3.2 empty sella syndrome 4.4 Hypothyroidism
 secondary amenorrhea
1
- human chorionic gonadotropin

- TSH
- serum prolactin
- Progesterone challenge test estrogen
estrogen estrogen
proloferative phase progestin secretory phase
progestin withdrawal bleeding
2-7 withdrawal bleeding

2
Progesterone challenge test (negative) estrogen (estrogen-
progesterone challenge test)

3
Serum FSH ovary , pituitary hypothalamus
20 IU/L
5 IU/L pituitary hypothalamus

2 estrogen-progesterone challenge test : negative

Ashermans syndrome (
)
8. 5
prognosis
a. CBC
b. ESR
c. skin biopsy
d. UA
2 Henoch Schonlein
purpura
Henoch Schonlein purpura
7 IgA immune complex post-capillary venules
alternative pathway complement C3 immune complex
palpable purpura skin submucosal bleeding

1. palpable purpura skin

2. submucosal edema hematoma
3.
4. hematuria proteinuria
5. CNS vasculitis
prognosis

elevated BUN , persistent high grade proteinuria
prognosis UA

9.
Differential diagnosis
1. SLE : Butterfly, discoid
2. Juvenile rheumatoid arthritis : Salmon-pink macules
3. Rheumatic fever : Erythema marginatum
4. Kawasaki disease : diffuse maculopapular , desquamation
5. Henoch Schonlein purpura : palpable purpura
6. Gonococcemia : palms/soles papulopustules
10. NB 35 wk, 2700 g Blood group O, Rh positive 4 Hct 40% TB =
10
A) Sepsis
B) Prematurity
C) Thalassemia
D) G6PD deficiency
E) ABO incompatibility
preterm, , normal birth weight, blood gr.
24 hr. pathologic jaundice
Ans : ABO incompatibility 24 hr.
; gr.O
Sepsis clinical: BTstable
Risk factor: preterm, 4 . risk sepsis ( prolong
ROM > 18-24 hr. ) sepsis
Prematurity: physiologic jaundice preterm 5-6

Thalassemia:
G6PD deficiency: precipitating blood gr.
bias onsetjaundice G6PD deficiency day
2-3

Pathologic jaundice
1. MB>15
2. 24 hr.
3. direct B >20% TB >2 mg/dl
4. 2 wk
5. MB >3
6. rate rising >5 mg/dl/day >0.2/hr.
7.
11. 2 1 1-2
3-5
A) Pneumococcal vaccine
B)
C) antihistamine
D) skin test
E) normal


Ans : A
B
.............
E
CD allergic rhinitis 2 atopy

AB
- vaccine bacteria
(ref.)
-
------ ------
12. 2 1 wk retraction, greenish patch at posterior
pharynx and tonsils
A) Croup D) Streptococcus tonsillitis
B) Diptheria E) Infectious mononucleosis
C) Candidiasis
Ans : Diptheria
greenish patch
DDX. Tonsil with patch
- Streptococcus tonsillitis : patch
- Infectious mononucleosis: patch +lymphadenopathy+spleenomegaly
Croup: patch stridor
suprasternal retraction
Candidiasis : clinical onset
reaction
 Pediatric
13. 6 U/D Asthma 2 d PE: suprasternal, intercostal, subcostal
retraction, inspiratory and expiratory wheezing, RR 40/min salbutamol 3 dose 20 min
exp.wheezing
A. Oral mucolytic
B. Oral antibiotic
C. IV Aminophylline
D. IV Dexamathasone
E. NB Ipratropium bromide
D. IV Dexamethasone
asthma salbutamol 3 dose wheezing
(RR>30/min, exp.wheezing)
- NB salbutamol 2.5 mg q 1-2 hr. 2 hr. 3-4 hr. 4-6 hr.
- Corticosteroids Oral prednisolone IV hydrocortisone 5 mg/kg/dose q 6 hr

14. 10 U/D Bthal/HbH splenectomy vaccine

prophylaxis
A. Typhoid vaccine
B. Influenza vaccine
C. Pneumococcal vaccine
D. Meningococcal vaccine
C. Pneumococcal vaccine + D. Meningococcal vaccine
Splenectomy Encapsulated organism Sterptococcus pneumoniae, Haemophilus
influenzae type b, Neisseris meningitidis vaccine splenectomy 2 wk
Streptococcal pneumoniae : Polyvalent pneumococcal vaccine (pneumovax23)
Haemophylus influenzae : Haemophylus influenzae b vaccine (HibTITER)
Neisseris meningitidis
- age 16 55 yr : Meningococcal (group A, C, Y, W135) polysaccharide diphtheria toxiod
conjugated vaccine (Menactra)
15. 13 generalize 3 mo FT4 1.25, TSH 3.5 Dx?
A. Simple goiter
B. Hashimoto thyroiditis
C. Subacute thyroiditis
D. Iodine deficiency
E. CA thyroid
 A. Simple goiter
FT4 (0.8 2.4 ng/dl), TSH (2 -10 mu/l) euthyroid
Simple goiter : -
- (Diffuse or generalize)
-
- TFT euthyroid hyperthyroid
Hashimoto thyroiditis : autoimmune disease B-lymphocyte thyroid

- (diffuse) simple goiter

- (pebbly surface)
- TFT hypothyroid subacute TFT
Subacute thyroiditis :
Iodine deficiency : (endermic goiter)
-
-
- hypothyroid ,
- TFT FT4 , TSH
CA thyroid : - nodule ,
- ,
- ,
- TFT euthyroid, FNA, Thyroid scan

16. 2 PE : mild pale no Jx nodule 6x8 cm cross

midline hard consistency Dx
A Neuroblastoma
B Wilm s tumor
C ANLL
D Non-Hodgkin lymphoma
E Retroperitoneal teratoma
A Neuroblastoma

17. 4 RUQ pain with mass urine : RBC 10 -20 , WBC 1-2
A Wilm s tumor
B Neuroblastoma
C Lymphoma
D Hydronephrosis
E .
A Wilm s tumor
2
 NEUROBLASTOMA

- Neuroblastoma highly malignant tumor neural crest sympathetic

chain pelvis 70 neuroblastoma 40 medulla
25 paraspinal sympathetic ganglia 5 pelvis
20 3-5 neuroblastoma malignant
tumor 50 2 85 4 (cachexia)
fixed retroperitoneum, , , Wilms
tumor metastases , ( skull, long, bone) bone marrow, ,
subcutaneous nodules, , plain film calcification 50-60 IVP
displacement calyceal system

Clinical Presentation 70% ( disseminated disease)

Wilms' tumor 15-20%

1. Localized Symptoms primary tumor large abdominal mass,

paraspinal tumor paralysis
neural foramen spinal canal ("dumbbell tumor")

2. Systemic Symptoms
, , , , failure to thrive catecholamine
production flushing, headache, tachycardia

3. Metastatic Symptoms
, , ,
 WILMS' TUMOR ( NEPHROBLASTOMA )

Definition : Highly malignant embryonal tumor of the kidney

Wilms' tumor Genitourinary tract 7.7 : 1,000,000

1-15 5 ,

Clinical Presentation ( palpable mass)

, , ( 80)
6
, hematuria, , 5
5-10 (gross hematuria),
( associated congenital
anomalies) genitourinary tract, hemihypertrophy aniridia

Teratoma abdominal teratoma rectroperitoneum, mixed cystic-solid

calcification 8 retroperitoneal teratoma endodermal sinus tumor tumor marker
AFP, HCG, CEA
Lymphoma abdominal lymphoma GI tract lymphoid tissue , mesertery
retroperitoneum lymphoma 2 Hodgkin non-Hodgkin lymphoma Hodgkin lymphoma
3:1 10 Reed-Sternburg cells 4 lymphocyte predominance ( 23),
nodular sclerosis ( 38.8) mixed cellularity ( 33.5), lymphocyte depletion ( 4.7)
lymphocyte fibrosis lymphoma exploratory staging
stage I II nodal biopsy, wedge liver biopsy splenectomy Non-
Hodgkins lymphoma 3:1 7-11 3 lymphoblastic lymphoma (derived T cells)
mediastinum small cell lymphoma Burkitt non Burkitt lymphoma
abdominal lymphoma (intussusception) large-cell
lymphoma ,

hydronephrosis dilatation renal pelvis collecting system mechanical obstruction functional

obstruction hydronephrosis hydronephrosis
mechanical obstruction hydronephrosis
ureteropelvic junction (UPJ) obstruction UPJ obstruction idiopathic stenosis extrinsic pressure
UPJ, aperistatic , ureteral polyp hydronephrosis ureterocele
ureterocele ureterocele complete duplex system
hydronephrosis 30 hydronephrosis
posterior urethral value
bilateral hydronephrosis posterior urethral value hydronephrosis
cystic consistency dilatation
calyceal system dilatation
 DTPA scan IVP voiding
cystourethrography vesicoureteral junction
hydronephrosis

ANLL Leukemia: Signs and Symptoms

Bone marrow infiltration

Anemia: Pallor, lethargy , Dyspnea, murmur

Platelets : Bleeding, petechiae, purpura
Neutropenia :Fevers and infections
Bone pain :Limp, walking, irritability

Extramedullary spread

Lymphadenopathy
Hepatosplenomegaly
Orthopnea, cough
mediastinal mass
tracheal compression
Facial nerve palsy
Testicular enlargement
Skin lesions
Gingival hypertrophy

Fever of malignancy

18. 3 reticulocyte 7 %
A G6PD screening
choice
Reticulocyte count
1-2%
hemolysis hypoxuia
bone morrow
iltrative condition
G6PD

G-6-PD 3 (acute hemolytic anemia

hemolytic crises) chronic
nonspherocytic hemolytic anemia (CNSHA)

1. ( Acute hemolytic anemia)

G-6-PD
oxidatie stress
( acute intravascular hemolysis)
acute hemolytic anemia G-6-PD

1.1 Drug-induced hemolytic anemia
( 16.18)
hemolysis G-6-PD



1.2 Spontaneous hemolysis without drug exposure hemolytic anemia

acute hemolysis


1.3 Favism G-6-PD
(fava bean) divicine isouramil hemolysis Favism
hemolysis 7 5 2 hemolysis
favic crisis G-6-PD
hemoglobinuria haptoglobin
Acute hemolytic anemia G-6-PD acute intravascular hemolysis
48-72


shock
extravascular hemolysis Favism

acute hemolytic anemia G-6-PD

 Favism Favism
glycosides aglycone
peroxide granulocyte (phagocytosis)
G-6-PD acute intravascular hemolysis
hemolysis ( self limited)
3-6

2. ABO -

1.6:1 G-6-PD 1.7:1
G-6-PD
( 64 6.5)
G-6-PD variant kernicterus
( naphthalene)

reticulocytosis G-6-PD
20 G-6-PD
-
kernicterus
3. (CNSHA)
1 100 G-6-PD Sunderland, G-6-PD Beverly Hill
1 G-6-PD Bangkok 2
G-6-PD hereditary
spherocytosis

16.18 Drugs and chemicals that should be avoided by persons with G-6-PD deficiency(2)
Acetanilid Sulfacetamide
Furazolidone (Furoxone) Sulfamethoxazole (Gantanol)
Methylene blue Sulfanilamide
Nalidixic acid (NegGram) Sulfapyridine
Naphthalene Thiazolesulfone
Niridazole (Ambilhar) Toluidine blue
Isobutyl nitrite Trinitrotoluene (TNT)
Nitrofurantoin (Furadantin) Urate oxidase
Phenazopyridine (Pyridium) Phenylhydrazine
Primaquine


exposure
bile
G-6-PD

hemoglobin H disease anemia crises, autoimmune

hemolytic anemia hereditary spherocytosis anemic crises

CNSHA hematocrit ,
reticulocytosis, indirect bilirubin G-6-PD
complete blood count acute hemolysis hematocrit
plasma intravascular hemolysis hemoglobinemia plasma
hemoglobinuria Heinz body brilliant cresyl blue crystal violet
hemoglobin inclusion body hemoglobin H
disease Hb hemoglobinemia
hemoglobinuria reticulocytosis polychromasia
anisocytosis, poikilocytosis fragmented cell, eccentrocyte, contracted cell, bite cell,
spherocyte hemoglobin haptoglobin
unconjugated bilirubin

G-6-PD activity G-6-PD G-6-P

NADP NADPH

19 9 .3 IQ test 109 79 80
97
A) dyslexia
B) dyscalculia
C) mental retardation
D) Attention deficit disorder
E) Autism
A) dyslexia Dyslexia (phonological awareness)
IQ
Dyscalculia ()
ADD ADHD
MR IQ 70
Autism
 20 3 3 PE: Moderately pale , mild icteric sclera, No hepatosplenomegaly +
Lab: Hb 7.7, WBC 4,800, Lym , plt 380,000 , RC 7.5 , MCV 87
A) Coombs test
B) Inclusion test
C) Hemoglobin typing
D) G6PD screening
E) Bone marrow aspiration

G6PD screening
normocytic anemia RC hemorrhage
hemolysis hemolysis
G6PD 2-3
anemia normochromic normocytic anemia
choice thalassemia lab red cell
hemoglobin typing Bone marrow aspiration invasive
disease Bone marrow RC normochromic normocytic series
red cell
AIHA ab RBC
RC Hb AIHA Coombs test
Hb H disease RC Hb
RBC Inclusion test

21 wheeze anaphylaxis first med

Adrenaline(Epinephrine)

anaphylaxis
1. Epinephrine (1:1,000) 0.01-0.03 cc/kg sc IM drug of choice 20
IV arrhythmia MI Epinephrine
angioedema/urticaria mediators mast cells laryngeal edema
upper airway obstruction epinephrine
2. Antihistamine : H1 & H2 antagonist diphenhydramine (H1 antagonist) 1
mg/kg IM IV cimetidine 10 mg/kg
3. corticosteroid late phase methylprednisolone 1-2 ./. 4-6 hr
4. salbutamol nebulization 0.1-0.3 mg/kg 5% salbutamol solution
5. vasopressor dopamine 0.01 mg/kg
22. 1 1 T 39.8 PR 140 RR 40 BP 90/60 CBC: Hb 11, WBC 20,000 N 93% Plt 50,000 coagulogram
prolong , petechiae and necrotic purpura at legs management
A. fluid therapy
B. antimicrobial
C. platelet concentration
D. FFP
E. vasopressin
Discussion
1
Wt. 10 kg PR 120/min RR 20-30/ min SBP 96+/-30 DBP 66+/-25
CBC
RBC : borderline anemia
WBC : leukocytosis , Neutrophil predominate = impression , severe bacterial infection
Decreased platelet & coagulogram prolong =bleed primary & secondary hemostasis

- PR &RR BP shock = fluid resuscitate shock

-DDx: DIC from severe infection R/O bacteria
Management of DIC
- Tx the underling cause severe infection R/O bacteria
-factor replacement : FFP (source of coagulation factor and protein C&S, AT III ) , cryoprecipitate(Provide
higher concentration of fibrinogen) and platelet transfusion . Aim to keep fibrinogen> 1.0 g/l, platelet>50,000 , & PT
normal
-anticoagulation therapy : Heparin (controversial)
management
Ans B. antimicrobial

23. 2 ascites UA: proteinuria 3+, RBC 0-1/HPF, Fine

granular cast 0-1, Fat oval cast 0-1
A. Decrease plasma oncotic pressure
B. Increase plasma hydrostatic pressure
C. Oncotic pressure cavity
D. Hydrostatic pressure cavity
E. Increase vascular permeability
Discussion
urinalysis
Proteinuria:
Dipstick Protein concentration (mg/dl)
Trace 10-20
1+ 30
2+ 100
3+ 300
4+ 1000-2000
Protein excretion normal 4 mg/m2/hr
Abnormal 4-40mg/m2/hr
Nephritic range>40 mg/m2/hr
RBC 0-1/HPF= no significant
Granular cast= non specific renal parenchymal disease
Fatty cast= heavy protein
Nephrotic syndrome
S&S periorbital edema
Anasarca
Weight gain
Pleural effusion
Ascites
Pitting edema
Hypertension (15%)
Lab 3-4+ proteinuria
Serum cholesterol
Serum triglyceride
Serum albumin < 2g/dl
Normal C3 level
>2 g urine protein in 24 hr

Serum Ca secondary to low albumin

Urine protein: Cr ratio > 2.0
Microscopic hematuria (15%)
Pathophysiology
Proteinuria glomerular wall permeability capillary oncotic pressure
fluid intravascular shift interstitial space edema

Ans A. Decrease plasma oncotic pressure

24. 12 1 management
A. EKG
B. Blood glucose
C. 24 hr holter monitoring
D. EEG
E. no further inestigation
Discussion
Holter monitor (also called an ambulatory electrocardiography device), named after its inventor, Dr.
Norman J. Holter, is a portable device for continuously monitoring the electrical activity of the heart for 24 hours or
more. Its extended recording period is sometimes useful for observing occasional cardiac arrhythmias that would
be difficult to identify in a shorter period of time. For patients having more transient symptoms, a cardiac event
monitor which can be worn for a month or more can be used.
cardiac cause (Ix:EKG, 24 hr holter
monitoring=arrhythmia) Cardiac syncope may be due to vascular disease, cardiomyopathy, arrhythmia, or valvular
dysfunction
= postictal period seizure (Ix:EEG)
Serum glucose level :In one study, 2 of 170 patients with syncope tested for serum glucose were found to
be hypoglycemic.hypoglycermia syncope headache, mental
dullness, fatigue

Vasovagal syncope is the most common type in young adults but can occur at any age. It usually occurs in
a standing position and is precipitated by fear, emotional stress, or pain (eg, after a needlestick). Autonomic
symptoms are predominant. Classically, nausea, diaphoresis, fading or "graying out" of vision, epigastric discomfort,
and light-headedness precede syncope by a few minutes. Syncope is thought to occur secondary to efferent
vasodepressor reflexes by a number of mechanisms, resulting in decreased peripheral vascular resistance. It is not
life threatening and occurs sporadically.
Ans E. no further inestigation
28.) newborn 41 wk with meconium stain amniotic fluid + fetal distress
A) +
B) ET tube + suction
B
MAS (Meconium Aspiration Syndrome)

1. suction meconium
( vigorous 2)
2. direct tracheal suction meconium trachea non-
vigorous (heart rate >100 bpm. ,tone , ) tone
tracheal suction

MAS
1.) 2.) gasping respiration Fetal asphyxia
MAS
1.
2.
3. Chest X-ray
4. direct tracheal suction
Reference .
. #47460431

29.) term 2 BW 4,600 gm PE: BT = 37, PR = 150, AF (Anterior fontanelle ) bulging, mod
pale, no jaundice, CBC: WBC 8,500 platelet 190,000
A) sepsis
B) SDH
C) Idiopathic vitamin K deficiency of infancy
Idiopathic vitamin K deficiency of infancy
BBA (Birth before admit) vitamin K bleeding tendency 2

1.) The hemorrhagic disease of the newborn (HDN) 2-7

() LAB : CBC
platelet , coagulogram : APTT, PT prolong , TT ( factor
II,VII,IX,X)
2.) Acquired prothrombin complex deficiency syndrome (APCD) Idiopatic vitamin K deficiency of
infancy (IVKDI) - 2 K

anterior fontanelle bulging ,
hypoventilation Subdural subarachnoid space LAB : Hb: < 5-10 g/dl
platelet WBC coagulogram : APTT, PT prolong , TT

sepsis prolong PROM poor feeding , active

CBC with platelet sepsis WBC Platelet
SDH (subdural hemorrhage) ) Idiopathic vitamin K deficiency of infancy
Reference .
. #47460431
30.) newborn heart murmur, cataract, congenital infection
Rubella
Congenital Rubella syndrome 2 categories
1.) (cataract) / (congenital glaucoma) , congenital heart disease (PDA, pulmonary stenosis) ,
hearing impairment , (pigmentation retinopathy)
2.) purpura Radiolucent
bone disease ( )

References : TORCHS Infection

. #47460431

31. 6 4 PE: tachycardia, tachypnea,

pansystolic murmur 2/6 at left parasternal border, cyanosis
A. Hypoxic spell
B. Asthma
C. Pulmonary

A. Hypoxic spell
Congenital heart disease 2
1. (Acyanotic congenital heart disease)

physiology work load 2

. Left to right shunt lesion volume load VSD, PDA, ASD, AV septal
defect
. Obstructive lesions pressure load Pulmonary stenosis(PS),
Coarctation of aorta(COA), Aortic stenosis(AS)

2 Asymptomatic Symptomatic
anatomical defect Symptomatic CHF


2. (Cyanotic congenital heart disease)
3
. Decreased pulmonary blood flow Tetralogy of fallot(TOF), Double outlet right ventricle with
PS, Single ventricle with PS, Pulmonary atresia with intact ventricular septum, Pulmonary atresia
with VSD, Tricuspid atresia with PS
. Increased pulmonary blood flow Double outlet right ventricle, Single ventricle, Single atrium,
Total anomalous pulmonary venous connection, Truncus arteriosus
. d-Transposition of the great arteries(d-TGA)
 2
1) Hypoxic spells
Decreased pulmonary blood flow
precipitating factor
spell
Hypoxic spell squatting()

2) Congestive heart failure

Acyanotic congenital heart disease d-TGA

32. 2 4 PTA 38C PE: drooling, , posterior pharynx Dx

A. Acute tracheitis
B. Acute epiglottitis
C. Viral croup
D. Laryngitis
E. Retropharyngeal abscess
E. Retropharyngeal abscess
Acute respiratory tract infection in children(ARIC) 1 5
() Lower tract Upper tract larynx larynx = upper larynx
lower
( pharynx) upper URI
Diseases : Acute rhinitis : Acute sinusitis
: Acute pharyngitis : Otitis media
: Acute tonsillitis Infectious upper airway obstruction
: : Viral croup
nasopharyngitis(common cold) , pharyngotonsillitis : Acute epiglottitis
Complications : Peritonsillar abscess : Spasmodic croup
: Retropharyngeal abscess : Bacterial tracheitis
Clinical presentation
Diseases
Complications
Peritonsillar abscess : pharyngitis
lesion muscle spasm inflame tonsil
abscess +ATB tonsillectomy
Retropharyngeal abscess : pharyngitis
stridor ( drooling) fluctuation
X-ray soft tissue C3 vertebral body c3 loss of cervical lordosis

Acute sinusitis : 10

AOM : conductive hearing loss weber = tunning fork 256Hz lesion
, Rinne = tunning fork 256Hz mastoid bone fork
lesion
Infectious upper airway obstruction
Croup = RI larynx &trachea subglottic obstruct
Viral croup : stridor croup score 5 1.
2. stridor 3. 4. 5. diag lateral
neck pencil sign steeple sign() score 4 score 4-7 admit score > 7 severe
intubation admit epinephrine budesonide improve treat bacteria
Acute epiglottitis : stridor
cherry-red epiglottis diag Film lateral neck Thumb sign
Spasmodic croup : viral croup viral croup
Bacterial tracheitis : viral croup treat viral croup intubation
bacteria antibiotic

33. 3 vaccine vaccine 1 vaccine vaccine

visite
A. OPV, DPT
B. HiB
C. MMR, OPV, DPT
D. HBV
E. OPV, DPT, JE
 E. OPV, DPT, JE
vaccine
vaccine memory cell vaccine
vaccine

Immunization
BCG , HBV 1
2 mo. DPT 1 , OPV 1 , HBV 2
4 mo. DPT 2 , OPV 2
6 mo. DPT 3 , OPV 3 , HBV 3
9 mo. MMR 1
18 mo. DPT 4 , OPV 4 , JE 1 , JE 2 ( 1-4 wk.)
2 yr. JE 3
4 yr. DPT 5 , OPV 5 , MMR 2

34. newborn preterm GA 32 wk 1,500 gm 12

A. Spyringomyelin
B. Lacitin
C. Phosphatidyl inositol
D. Phosphatidyl glycerol

20 Pneumocyte type II
35
Phosphatidylcholine phospholipids
Phosphatidylglycerol

35. 4 39 C PE: milky patch at tonsil, cervical LN 1-2 node 2 cm 2 ,

liver 2 cm BRCM, spleen 2 cm BLCM
1) Infectious mononucleosis
2) TB lymphadenitis
3) Streptococcal pharyngitis
4) Dipthelia
5) Lymphoma

Infectious mononucleosis
Infectious mononucleosis
triad
exudates

Streptococcal pharyngitis
2

13

Dipthelia
2-3 (patch)
(pharynx)
bull neck

Lymphoma
B
symptoms
Fever
Night sweats
Weight loss > 10% of body weight in 6 mo.

TB lymphadenitis
2 .

36. 4 TB BCG scar CXR tuberculin test 13 mm

A) INH prophylaxis
B) start TB
C) repeat tuberculin test 3
D) BCG
E) AFB from gastric lavage

A) INH prophylaxis
5 TB TT INH 6-9

TT, CXR

< 5 > 5 HIV

TT +ve, -ve TT +ve TT -ve INH 9

INH 6-9 INH 6-9 observe

and F/U

Modified from
2546;24(2):87-93l

1. < 15 CXR Tuberculin skin test antiHIV

2. LTBI TB disease
3. TB chemoprophylaxis isoniazid (INH) 5-10 mk/kg/day
- < 5
INH 6 BCG tuberculin test
> 5 BCG Tuberculin test 15 mm. LTBI
chemoprophylaxis
HIV INH 9 BCG Tuberculin test

Tuberculin test positive

>10mm
>5 mm
>15 mm BCG
37. 9 para, amoxy 3 PE: sunken eye ball,
dry lips, perianal redness

1) Salmonella
2) Shigella
3) Rotavirus
4) Lactose deficiency
5) Antibiotic related diarrhea
rotavirus

Perianal erythema
o Frequent stools can cause perianal skin breakdown, particularly in young children.
o Secondary carbohydrate malabsorption often results in acidic stools.
o Secondary bile acid malabsorption can result in a severe diaper dermatitis that is often
characterized as a "burn."

(rotavirus) 10-
50 % , Shigella 9-12%, E.coli 12%, Campylobacter jejuni 8-12%

Rotavirus 2 rotavirus
villi crypt
1. transport
2. immature
lactose malabsorption
3. immature

4.
rotavirus absorptive diarrhea
Na pH 6 reducing substance > 1+ lactose
Osmotic diarrhea
(osmotic + secretory diarrhea)

Watery diarrhea non-invasive diarrhea

- activate adenyl cyclase guanyl cyclase
mucosa hypersecretion
Vivrio cholerae 01, O139, Enterotoxigenic E.coli (ETEC), enteropathogenic E.coli (EPEC),
Staphylococcus, Clostridium perfringens, Vibrio parahemolyticus, Bacillus cereus
hypersecretion pH>6, reducing substance < 1+
- Rotavirus, Norwalk virus tip villi
crypt ... ( rotavirus)
 Mucous bloody invasive diarrhea

Salmonella local damage secretion

shigella cytotoxin
rectosigmoid colon
dysentery diarrhea
shigella spp. , Salmonella spp., Enteroinvasive E.coli (EIEC), campylobacter jejunia, Yersenia
enterolitica, Entamoeba histolytica hemolytic uremic syndrome
shigella dysenteriae 1 EHEC O157:H7

38. 1 Barking cough, inspiratory stridor, expiratory rhonchi IV

1) ampicillin IV
2) Cloxacillin IV
3) beta-agonist
4) adrenaline
5) ETT
adrenaline
Croup Score
Score
0 1 2
Cough None Hoarse cry Barking
Stridor None Inspiratory Biphasic
Retraction and nasal None Flaring and suprasternal As 1 + Subcostal and
flaring retraction Intercostal retraction
Cyanosis None In room air In 40% oxygen
Inspiratory breath Normal Harsh with rhonchi delayed
sounds
Score < 4 = mild, 4-7 = moderate, >7 = severe airway obstruction

croup score= 4 moderate

Viral Croup
Mild ( croup score <4)
- Treat as OPD case
- Corticosteroid

Moderate :Admit : , Stridor at rest,

Severe airway obstruction: (score > 7) -> intubations

Supportive Treatment
Rest:
Hydration : IV fluid
Mist therapy: no evidence suggestion
Humidified oxygen: if SpO2 <90%
Adrenaline Nebulization
Racemic epinephrine or L- epinephrine (1:1000)
Dose : 0.05-0.5 mg/kg (<4yr max 2.5cc , >4yr max 5cc )
Action in 10-30 min duration 2hr
At ER observe at least 2-3 hr (to 8-12 hr) at ER
Corticosteroid
Dexametasone 0.6 mg/kg IM single dose action in 6hr
Mild case: Budesonide nebulization 2mg/dose
Prednisolone 1mg/kg
39. 3 Barking cough management
1) adrenaline NB stat
2) Salbutamol NB stat
3) Dexamethasone IV
4) Prednisolone PO

38
score
score management
40. 7 2 , PE: lethargy,
moderate jaundice, erythematous indurated mass at Rt. Breast, ATB ?
1. Ceftriaxone 4. Fortum + Amikacin
2. Ampicillin +Gentamicin 5. Fortum + Vancomycin
3. Cloxacillin + Gentamicin
2. Ampicillin +Gentamicin
common antibiotic regimen in infants with suspected sepsis is a beta-lactam antibiotic
(usually ampicillin) in combination with an aminoglycoside (usually gentamicin) or a third-
generation cephalosporin (usually cefotaximeceftriaxone is generally avoided in neonates due
to the theoretical risk of causing biliary stasis.) The organisms which are targeted are species
that predominate in the female genitourinary tract and to which neonates are especially
vulnerable to, specifically Group B Streptococcus, Escherichia coli, and Listeria monocytogenes

41. ampicillin 14 endoscope

hyperemia Tx?
1. Metronidazole
2. Ceftriaxone

Ampicillin-Associated Diarrhea. antibiotic-
associated diarrhea clindamycin, ampicillin ,cephalosporins ,
cephalexin




Clostridium difficile
C. difficile
C. difficile metronidazole (Flagyl)
vancomycin (Vancocin)
42. 8 1 PTA,
2 wk PTA, vital sign , PE : Oozing per gum, petichiae & ecchymosis
trunk & extremities, no lymphadenopathy, no hepatosplenomegaly, Dx?
1. Hemophilia 4. ITP
2. Acute leukemia 5. APDE
3. DHF

4. ITP = Idiopathic thrombocytopenic purpura

I. Idiopathic thrombocytopenic purpura
- Primary autoimmune immune thrombocytopenia (ITP)
Acute childhood ITP
chronic or adult ITP
- Secondary Autoimmune thrombocytopenia
Acute post viral ITP(acute childhood ITP)
- - 2
- - 6

Chronic ITP
-
-
-
-
-
 chronic ITP
- Skin bleeding petechiae,ecchymoses
- Mucosal bleeding-bleeding per gum,epistaxis,hematuria
- Intra cerebral hemorrhage
- Anemia related to degree of bleeding
- No hepatosplenomegaly if splenomegaly was detected should be considered
hypersplenism or lymphoproliforative disorders
Criteria for diagnosis ITP
- Isolated thrombocytopenia
- Normal or increase megakaryocyte in bone marrow
- No splenomegaly
- Autoantibody to platelets
- No other cause of thrombocytopenia
Treatment
1. General treatment
- Bleeding precaution avoid trauma,Intramuscular injection,antiplatelets medication
- Local treatment;nasal packing,oral contraceptive drug
- Blood transfusion in active bleeding,iron replacement therapy,platelets transfusion
in life thretening situations
2. Specific treatment
Corticosteroid actions:
- Inhibit autoantibody bind to platelets
- decrease phargocytosis by RE cell,
- decrease autoantibody production,
- increase vascular suppor
Indication for splenectomy
- Steroid relaspe =steroid dependent
- Stroid partial and non response
Diagnosis and treatment over 6 weeks with platelets less than 10,000
Treatment for 3 months and platelets less than 30,000 with or without bleeding
- Complication of streroid
- Ememegency condition
- Difficulties in follow up
 Pediatric

43. Female Infant 5 hr APGAR 8,9 1,5 min BW 4,200 gm. 52 cm. Hc 35
cm. The most appropriate investigation for Dx this Patients Disease is?
1. Plasma Glucose
2. Urine Ketone
3. Serum Ammonia

1. Plasma Glucose
Clinical manifestation of hypoglycemia : tremor, jitteriness,
apnea, cyanosis, pallor, hypotonia, irritability, seizures, coma
Management :
***10% D/W or 25% D/W IV push 0.25-0.5 g/kg and continuous infusion rate 4-6 mg/kg/min
***Reference : pocket ped
Hypoglycemia (Blood glucose < 40 mg/dL)
Infant of diabetics mother (IDM)
1-6 Insulin

Preterm 15
Small for gestational age (SGA) glycogen 1-2
2-3
perinatal stress anaerobic metabolism

hypothermia, sepsis, polycytemia, adrenal insufficiency
*** Reference : ascessment and care of newborn .. 15

---------------------------------------------------------------------------------------------------------------------By
44.( A) Case preterm 32 wk. BW 1,500 g
1. Respiratory distress syndrome

Respiratory distress syndrome or Hyaline membrane disease Risk factor

1. GA < 35 wks
2. cesarean section labor pain
3. DM class A,B, C
4. acute perinatal asphyxia
5. antepartum hemorrhage : abruption of placenta or placenta previa
6.
7.
RDS surfactant GA < 28 wks
Clinical manifestation :
(, , , grunting, cyanosis)
3-4 6
2-3
24 24-72

Preterm RDS CNS hemorrhage, PDA, air leak,
infection
Film x-ray : hypoaeration, airbronchograms, atelectasis, diffuse reticulogranular infiltration
ground glass appearance , bilateral opacity (white-out lung)
*** Reference : Respiratory distress of the newborn ..
----------------------------------------------------------------------------------------------------------------------By

4 resuscitation ER
P.E. : T = 36.5 , PR = 140 , RR = 55 ,BP = 90/60 , drowsy , mild cyanosis , diffuse fine crepitation and
expiratory wheezing , capillary refill 4 sec , O2 sat 85% On O2 mask with bag 5 LPM frothy pink

A. IV dopamine D. On O2 mask with bag 10 LPM

B. Nebulized adrenaline E. Positive pressure ventilation
C. Nebulized bronchodilator

Positive pressure ventilation Nebulized bronchodilator
Near drowning
non - cardiogenic pulmonary edema persistant pulmonary
hypoxemia O2 sat 85% hypoxic pulmonary vasoconstriction pulmonary edema
Category B
tube () Positive pressure ventilation
Catergory B
Catergory B

3 hypoxia, aspiration , hypothermia

laryngospasm laryngospasm
dry drowning 10%
FB aspiration and contaminated water
airway resistance bacterial pneumonitis hypoxia
wet drowning
90%
Surfactant dysfunction atelectasis , decreased FRC , lung compliance
ventilation - perfusion mismatch
hypoxic pulmonary vasoconstriction
non - cardiogenic pulmonary edema ( ARDS ) persistant pulmonary
hypoxemia

1. Category A ( awake )
Glasgow coma score = 15
CXR blood gas mild metabolic
acidosis mild hypoxemia
2. Category B ( blunted )
( impaired cortical function ) (
normal brainstem function ) cyanosis, tachypnea , dyspnea , blood
gas hypoxemia , hypercabia , metabolic acidosis CXR
hypothermia
 3. Category C ( comatose )
( cortical function )
( brainstem dysfunction )

1. Ventilation 100% O2
2. IV fluid 5% D/NSS/3 ( CBC, electrolyte, urine, CXR, blood gas )
3. Mornitor vital signs
4. category ABC
Category A hypothermia , sodium bicarbonate
metabolic acidosis, pulmonary infiltration 24

Category B lasix 0.5 1 mg/kg pulmonary edema sodium
bicarbonate 1 2 ml/kg metabolic acidosis ,
,
CXR
Category C endotrachial tube PEEP 5 10 cmH2O PaO2 >
100 mmHg , PH 7.35 7.5, PaCo2 20 30 mmHg sodium bicarbonate
hypotension isotonic solution NSS
RLS bolus dose dopamine 2 20 .//
diazepam , ARDS ,
cerebral edema
----------------------------------------------------------------------------------------------------------------------By

45. 11 , 1 , CBC : Plt ,Dx?

1. ITP

1. ITP

1. ITP
ITP 80 3-5
Postinfection thrombocytopenia
2 petechiae, ecchymosis,

20,000 cell/cu.mm. 3
 2. Acquired platelet dysfunction with eosinophilia (APDE)
APDE
ecchymosis 1-2
6 1
Eosinophil 8-69% platelet
3. von Willebrands disease (vWD)

hemophilia A

4. Hemophilia


*** Reference : bleeding disorder ..
----------------------------------------------------------------------------------------------------------------------By

46. 15 2 Upper/Lower motor weak grade IV/II

DTR no impaired pain and touch, glottic stroking pattern
1. Beri Beri
2. GBS

Beri-Beri
Guillain-Barre syndrome
ascending symmetrical muscle weakness lower extremities
gait disturbance,
deep tendon reflex ,
sensory changes : pain , proprioception , touch
cranial nerve involvement + bulbar paralysis trancient urinary incontinence or retention
CSF profile : normal glucose, elevated protein, lymphocyte
Guillain-Barre syndrome 3-4

Campylobator, mycoplasma, CMV EBV, chicken pox, influenza, coxsackie
virus, echovirus,
***Reference : pocket ped 2
 Beri-Beri
(glove
and stocking pattern) (hyperesthesia)
DTR
2 Beri-Beri
sensory
sensory
----------------------------------------------------------------------------------------------------------------------By
47. 7 1 Giant papillae Cobble stone

1. Trachoma
2. Inclusion Conjunctivitis
3. Hay fever Conjunctivitis
4. Vernal karatoconjunctivitis
5. Epidemic Conjunctivitis
4. Vernal karatoconjunctivitis
eye
Key word 1 Giant papillae cobble stone 3
Vernal karatoconjunctivitis Allergic conjunctivitis immediate hypersensitivity
3 Palpebral
type, Limbal type Mixed type Palpebral type (
2 117)

1. Trachoma ( 2 114)
2. Inclusion Conjunctivitis ( 2 113)
3. Hay fever Conjunctivitis ( 2 116-117)
5. Epidemic Conjunctivitis ( 2 115)
.
------------------------------------------------------------------------------------------------------------------By bever

48. Drooling, miosis, dysphoresis, profuse sweating

1. Ethanol 4. Ephedrine
2. Organophosphate 5. Cocaine
3. Opioid
 2. Organophosphate
Organophosphate
- Term
Drooling =>
Miosis =>
Dysphoresis diaphoresis => ,
Profuse sweating =>
-
Ethanol : CNS depression ( CNS depression ethanol )
Organophosphate : Miosis, cramps, salivation, urination, diaphoresis, myofibrillation, sialorrhea,
bronchorrhea, defecation, garlic odor
Opioid : nausea and vomiting, drowsiness, itching, dry mouth, miosis, constipation dose-related
respiratory depression, confusion, hallucinations, delirium, urticaria, hypothermia, bradycardia/tachycardia,
orthostatic hypotension, dizziness, headache, urinary retention, ureteric or biliary spasm, muscle rigidity,
myoclonus, and flushing
Ephedrine (Amphetamine) : Track marks, heat stroke, toxic psychosis, flushing, diaphoresis,
hyperthermia, hypertension, dilated pupils (reactive), active bowel sound, anxiety, hyperactivity, dysrhythmias
Cocaine : perforated nasal septum, dilated pupils (reactive), psychosis, hyperthermia, diaphoresis, skin
tracks, seizures, agitation, tremor, tactile hallucination, anxiety
------------------------------------------------------------------------------------------------------------------By bever

49. 6 breath sound

X-ray heart right chest Dx.
1. Situs inversus
2. TE fistula
3. Diaphragmatic hernia
3. Diaphragmatic hernia

1. Situs inversus
case
2. TE fistula (Tracheoesophageal fistula) trachea
esophagus esophageal atresia polyhydramnios

 3. Diaphragmatic hernia diaphragm bowel
dyspnea, cyanosis, decrease
breath sound , bowel sound ,
decrease breath sound,
------------------------------------------------------------------------------------------------------------------By bever

50. 10
3 2 PE: central
cyanosis, clubbing finger, Loud P2, diastolic rumbing murmur 3/6 at Lt upper parasternal border lung:
clear
1. Pulmonary embolism 4. Eisenmenger complex
2. Aortic regurgitation 5. Congestive heart failure
3. Hypoxic spell
VSD ASD
Left-right shunt lesion heart failure
10 Right-left shunt lesion , loud P2 (
pulmonary hypertension)
Eisenmenger complex
Eisenmenger complex : A defect of the interventricular septum with pulmonary hypertension and a consequent
right-to-left shunt through the defect.
: Right-left shunt pulmonary hypertension
loud P2
Hypoxic spell : tetralogy of Fallot
:

: squatting
Congestive heart failure :
increase pulmonary blood flow
Pulmonary embolism(PE) :
thromboemboli
Symptoms : sudden-onset dyspnea , tachypnea, chest pain , cough, hemoptysis. More severe cases can
include signs such as pleural rub, cyanosis, collapse, and circulatory instability. About 15% of all cases of
sudden death
------------------------------------------------------------------------------------------------------By Gift^zee
^
51. 12 1
, neurologic exam normal
1. EKG
2. Blood sugar
3. 24hr Holter monitor
4. EEG
5.
Causes of Syncope and Dizziness

1. Cardiovascular syncope
1. Neurocardiogenic syncope (most commontype of syncope in childhood and adolescence)
2. Cardiac syncope
1. Congenitaland acquired heart disease
2. Hypercyanotic episodes
3. Arrhythmias in structurally normalheart
4. Arrhythmias in structurally abnormalheart
3. Vascular syncope : 1.Orthostaticsyncope 2. Cerebrovascular syncope 3.Carotid sinus syncope
2. Noncardiovascular syncope : 1.Breath-holding 2. Hyperventilation 3.Migraine 4.Metabolic( Hypoxia including
anemia , Hypoglycemia) 5. Psychologic

Neurocardiogenic Syncope (Common Faint)

Most common type of syncope in childhood and adolescence.
Often a response to anxiety, fear, pain , or other emotional stress.
Dizziness, nausea, sweating, and abdominal discomfort may precede syncope. Interruption of cerebral
perfusionfor 23 secs produces dizziness, but lying down during presyncopal phase may prevent
syncopal episode.
Most episodes are associated with upright position, and child becomes limp and falls to ground. Loss of
consciousness usually lasts <1 min.
1. EKG invasive
R/O cardiac syncope
---------------------------------------------------------------------------------------------------By Gift^zee
^
52. 7 2,800 gm
2,400 gm Dx.
1. Duodenal atresia 4. Sepsis
2. Pyloric stenosis 5. Hirchsprung disease
3. Inborn error metabolism
Pyloric stenosis
present in the first weeks to months of life with progressively worsening vomiting
bile
poor feeding and weight loss
Duodenal atresia
duodenum (the first part of the small bowel)
bile ()
loss of appetite, failure to gain weight
Hirchsprung disease








(sphincter of Oddi) gastric outlet
obstruction
bile 2. Pyloric stenosis

2 Inborn error of metabolism :

Sepsis : look sick

-------------------------------------------------------------------------------------------------------- Gift^zee
53. 9 PE: Thyroid diffuse^enlarged,
exophthalmos, smooth skin. PR120 FT4 TSH Antityroglobulin 1:1600
1. Iodized oil 3. Lugol solution
2. Iodized salt 4. Methimazole
Ans. 4
Graves Disease (hyperthyriod) hyperthyroid
methimazole lugol solution lugol solution thyroid strom
conscious change clinical hyperthyroid Methimazole
----------------------------------------------------------------------------------------------------------------------By
54. 6 yr vaccine 5 yr 2 cm vaccine
1. Rabies vaccine
2. TT
3. Rabies vaccine + Tetanus toxoid
4. Rabies vaccine Rabies Ig
5. TT + Rabies vaccine Rabies Ig
Ans. 1
TT vaccine 5
Rabies vaccine Rabies Ig
----------------------------------------------------------------------------------------------------------------------By
55. 7 Dx Chickenpox
1.
2.
3.
4. Acyclovir 48 hr
5.
Ans. 2
Chicken pox 1
6-7 ()
.
----------------------------------------------------------------------------------------------------------------------By
56. 9
3 wk Dx
1) Generalized anxiety
2) Separation anxiety
3) Simple phobia
Separation anxiety
Separation anxiety ,
4%
-
-
-
-
-
 Simple phobia specific phobia
A.
( )
B. Panic Attack
C.
D.
E.
F. 18 6
GAD criteria GAD 6 3 6
, , , , ,
---------------------------------------------------------------------------------------------------------------------By
57. hyperpnea, +ve urine ketone 4+ Dx
1) DKA 3) meningitis
2) Sepsis
DKA pediatric emergency 5 .
Diagnostic criteria* DKA
Blood glucose : >250 mg per dL (13.9 mmol per L)
pH : <7.3
Serum bicarbonate : <15 mEq per L
Urinary ketone : >=3+
Serum ketone : positive at 1:2 dilutions
Serum osmolality : variable
DM type I
: Often insidious , Fatigue and malaise, Nausea/vomiting, Abdominal pain, Polydipsia, Polyuria,
Polyphagia, Weight loss, Fever
PE : Tachypnea or hyperventilation (Kussmaul respirations), Acetone odor of the breath
insulin def hyperglycemia + gluconeogenesis + glycogenolysis + lypolysis
ketosis
hyperglycemia osmotic diuresis hypovolumia tissue hypoperfusion + lactic acidosis
Hypernatremic dehydration (corrected serum sodium > 150 mmol/L)
hyperglycemia serum sodium (Na)

---------------------------------------------------------------------------------------------------------------------By
58. 9 mo otitis media 3 mo
pneumonia, S.pneumo, Hib, defect
1) B cell
2) T cell
3) Phagocytic defect
4) Complement
B cell
immune 3
Primary immunodeficiency
B cell deficiency (Humoral ID)
B cells
pyogenic bacteria pneumococcus, Haemophilus influenza streptococcus
polio Giardia B cells T cells

opsonin phagocytes
11-3
B cell B cell antibody = IgA, IgM, IgG
6 6
immunoglobulin infection ... B
cell ^^
T cell def. fungal viral infection B cell
T cell B cell plasma cell
Complement defect phagocytes

components (C1,C4 C2) immune complex
immune complex SLE like disease ,
C3 , C5-C9
Neisseria spp
---------------------------------------------------------------------------------------------------------------------By
59. 4 yr 1 d . PE: BP 90/60, RR 40, PR 120, stiff neck +ve,
Purpura??? Dx
1) Salmonella 4) S. pneumonia
2) N. meningitidis 5) H. influenza
3) Listeria monocytogenes
 N. meningitides meningitis
- Salmonella : < 1
- N. meningitides : intracellular gram negative diplococci, respiratory secretion ,
respiratory tract infection 2-3 , purpura
ecchymosis
- Listeria monocytogenes : food borne transmition, , ,
immunocompromised host, diarrhea or gastroenteritis, CNS encephalitis
brain stem
S. pneumonia respiratory tract infection
H. influenza
---------------------------------------------------------------------------------------------------------------------By
60. 10 mo 3 mo inspiratory stridor, chest drawning
epinephrine epinephrine
1.
2.
3.
4.

1.
Epinephrine
selective adrenergic receptor agonist mixed alpha and beta agonist
alpha 1= alpha 2 , beta 1= beta 2
alpha 1 vasoconstriction
alpha 2 insulin
beta 1 HR , SBP DBP
beta 2 vasodilation , insulin
bronchial smooth muscle relaxation bronchodilation
alpha 2 beta 2 TPR DBP

insulin glucose triglyceride

Side effects
palpitations, tachycardia, arrhythmia, anxiety, headache, tremor, hypertension, and acute pulmonary
edema
Ref sheet pharmaco sympathetic 3
------------------------------------------------------------------------------------------------------------------- By
61. DM sign hypoglycemia DTX 30 Hct 63 Management
1. Early feeding
2. Bolus 10%D/W 2ml/kg
3. Plasma exchange

2. Bolus 10%D/W 2ml/kg

Hypoglycemia sign hypoglycemia DTX 30 (hypoglycemia
new born 40)
Hct 63 polycythemia > 65
Hypoglycemia
1. Transient hypoglycemia : preterm, SGA, IDM =infant DM of mother
2. Persistent hypoglycemia : hyperinsulinism, hormone, glycogen storage disease,
fatty acid oxidation,

Guide line 2
Patient at risk
(IDM =infant DM of mother, LBW, SGA, LGA, preterm, asphyxia(APGAR 5 min 7))

Check DTX at 1-2 hr

DTX >45 mg/dl DTX <45 mg/dl

Early feeding asymptomatic symptomatic

(apnea, jitteriness, tremors)

Check DTX DTX 30-45 mg/dl DTX <30 mg/dl 10%DW 2-4 ml/kg
before neck feeding IV then GIR 4-8 mg/kg/min

>45 mg/dl <45 mg/dl Early feeding check DTX 1 hr later

Routine care check DTX 1 hr later >45 mg/dl <45 mg/dl

>45 mg/dl <45 mg/dl adjust GIR + continue same IV

10%DW2ml/kg and check DTX
Feed+IV check DTX 2 hr later
 GIR 4-8 mg/kg/min before neck feeding

<45 mg/dl >45 mg/dl

Check DTX q 1 hr Routine care

Until euglycemia

1. (jitteriness tremors irritable)

2.
3.
4. , hypothermia

LBW 2500
VLBW 1500
Preterm infant 37
Post term infant 42
Small for gestational age (SGA): (SGA) 10
percentile
Appropriate for gestational age (AGA)
10-90 percentile
Large for gestational age (LGA) 90 percentile

------------------------------------------------------------------------------------------------------------------- By

62. 4 mo WBC 18000 (N 80%), Hct 6.9%, Dx

1. Subdural hematoma

choice
Subdural hematoma

1.Head trauma
2.Coagulopathy or medical anticoagulation (eg, warfarin [Coumadin], heparin, hemophilia, liver
disease, thrombocytopenia)
 3.Nontraumatic : cerebral aneurysm, arteriovenous malformation, or tumor (meningioma or dural
metastases)
4.Intracranial hypotension (eg, after lumbar puncture, lumbar CSF leak,
lumboperitoneal shunt)
5.Child abuse or shaken baby syndrome (in the pediatric age group)
6.Spontaneous

1.Altered level of consciousness

2.A dilated or nonreactive pupil ipsilateral to the hematoma
3.Hemiparesis contralateral to the hematoma.
:
CT scan: crescent-shaped hyperdense , midline
Treatment
1. Subdural tapping
2. Surgery
------------------------------------------------------------------------------------------------------------------- By
63. 4-5 Amoxy 2

a. X-ray PNS
b. nasal speculum
c. Amoxicillin/Clavulinic acid
d. Amoxycillin
e. Consult

b. nasal speculum
foreign body

1.

2. antibiotic
------------------------------------------------------------------------------------------------------------------- By
64.
A. 10 (12 )
B. 12 .. (15)
C. 2 . (3)
D. 3 10-20 .. (18)
E. 5 .. (5 )
D
() Gross motor Fine motor Languages Social
1
2 45
4 , 90

6

9


12

15 2

18 3


2 2 6 2-3

3 50%

4


5 20
Reference: 39
-------------------------------------------------------------------------------------------------------------- By natty
65. UTI Ampicillin 14 WBC 1-5,
RBC >100 patch
A.Cotrimoxazole
B.Norfloxacin
C.Metronidazole

C
Antibiotic-associated diarrhea (ADD) antibiotic normal flora
intestine bacteria Clostridium difficile growth toxin
cell wall inflammation diarrhea
:

carriers bacteria

watery diarrhea mild abdominal cramping.

severe cases (colitis) patches bleed pus

(pseudomembranous colitis). watery diarrhea (up to 10 to 15 times per day), blood or
pus in the stool, dehydration, abdominal tenderness and cramping, a low-grade fever, nausea,
loss of appetite, and weight loss.
Life-threatening complications abdominal distension, severe lower abdominal
pain, fever and profuse diarrhea. In rare cases, the bowels can rupture, potentially leading to a
bodywide infection (sepsis), organ failure, or even death.

TREATMENT The most important step in treatment of C. difficile is to stop the antibiotic that allowed
the infection to develop. If an antibiotic is necessary to treat an underlying infection, the healthcare provider
may choose an antibiotic that is less likely to allow further growth of C. difficile, when possible.
Antibiotic treatment An oral antibiotic such as metronidazole (Flagyl) or vancomycin (Vancocin) is
usually recommended to treat people who are infected with C. difficile. It is important to take each dose of the
antibiotic on time and to finish the entire course of treatment (usually up to 10 to 14 days).

-------------------------------------------------------------------------------------------------------------- By natty
66. cushing syndrome
A. Hypocalcemia
B. Hyperkalemia
C.Increased cortisol level
D.Advance bone age
E.Increased rennin plasma activity
C
Cushings syndrome (CS) cortisol rare 10-15
1

- pre-pubertal children : adrenal tumors (e.g. adenoma, carcinoma, or bilateral

hyperplasia) are a more common
- older children : pituitary adenomas are a more common

-increase in rate of weight gain accompanied by a decrease in growth rate

-rounded face, reddened cheeks, acne, headache, excess hair growth, purplish-
pink stretch marks, darkened skin around neck and armpit areas, easy
bruising, development of pubic hair at a younger age than usual, irregular or
absent menstrual periods, and high blood pressure
Diagnosis
- elevated cortisol levels in children is a 24 hour urine collection for urinary free cortisol (UFC)
determination
- Salivary cortisol levels ( cortisol midnight
cushing syndrome cortisol midnight )
- low-dose dexamethasone
reference
http://www.csrf.net/page/cushings_syndrome_in_children.php
http://www.md.chula.ac.th/rcat/htdocs/previous/200448745.pdf
-------------------------------------------------------------------------------------------------------------- By natty
67. 4 yr 2 wk PE: Pallor, petichiae CBC Hb 7, Hct 22, WBC
3200(N 35, E 3, L 62), Platelet 26000, MCV 90 Investigation
A. Serum ferritin
B. Bleeding time
C. Reticulocyte count
D. Screening coagulogram
E. Bone marrow aspiration
Ans E. bone marrow aspiration
Series Pancytopenia
ALL Bone marrow aspiration
-------------------------------------------------------------------------------------------------------------- By
68. 9 3 BW 7 kg PR 120 lung: wheezing both lung,
CXR: perihilar infiltration, PPD 4 mm brochodilator Dx
A. Retian FB D. GERD
B. Diaphragmatic hernia E. Asthma
C. TB
Ans D. GERD
Retain foreign body 9

Diaphragmatic hernia PPV

CXR bowel 90% posterior left
Presentation respiratory distress (from pulmonary hypoplasia and pulmonary hypertension)
TB ( Tuberculin test negative 5 mm) H x expose

Asthma wheezing response bronchodilator Dx Asthma

5 Criteria Dx
Major Minor
3 Eosinophil >= 4%
Asthma Wheezing apart from cold
Atrophic dermatitis
GERD

18
-------------------------------------------------------------------------------------------------------------- By
69. (Purpura fulminan) Stiff neck : positive
- N.meningitidis
N.meningitidis

pustule, bullae hemorrhagic lesion with central necrosis stellate-shape
purpura purpura fulminan Gram stain Gram
negative diplococci bean shape
-------------------------------------------------------------------------------------------------------------- By
70. asthma 2-3
A. Oral salbutamol C. Inhale steroid
B. Inhale sulbutamol D. Inhale ipratropium + Salbutamol
2-3 Step
3: Moderate persistent , noc.>1/wk , Exacerbatation.activity medium
dose inhaled glucocorticosteroid
C. Inhale steroid

Step asthma <5 Gina 2004

Level of severity
Step 1:mild intermittent
<1/wk,nocturnal<2/mo
FEV1>80%
Step 2: mild persistent
<1/wk, <1/d, noc.>2/mo
FEV1>80%
Step 3: Moderate persistent
- , noc.>1/wk
- Exacerbat.activity
- Beta-2
- FEV1 60-80%
Daily controller medication Other Tx
none
- Low dose inhaled - Sustain-release theophyline
glucocorticosteroid (ICS) - Leukotriene modifier
-medium dose ICS - medium dose ICS+ Sustain-
release theophyline
- medium dose ICS+long acting
beta-2
- medium dose ICS+ Leukotriene
modifier
 Level of asthma control Gina 2007
characteristic Controller Partly controlled uncontrolled
()
Daytime symptoms None >2/wk =>3 Partly controlled
(=<2/wk) wk
Limitation of activity none Any
Nocturnal symptoms/ awakening none Any
Need for reliever/rescue Tx None >2/wk
(<2/wk)
Lung Fx Normal <80%
(PEF or FEV1) >80%
<5
Exacerbation none =>1/yr. One in any wk.
------------------------------------------------------------------------------------------------------------ By
71. 6 2

Infantile spasm
west syndrome
1. Infantile spasm 3 (flexion), (extension),mixed flexion and extension
2.
3. hypsarrthmia
------------------------------------------------------------------------------------------------------------ By
72. 10 MCA ER
PE: swelling at Rt elbow, normal triangle landmark of Rt elbow, notmal neurovascular Dx
A. Elbow dislocation D. Displaced lateral condylar fracture
B. Displaced olecranon fracture E. Displaced medial supracondylar fracture
C. Displaced supracondylar fracture
Displaced lateral condylar fracture Fx distal radius 10
Epiphyseal cartilage
CIRTOE=2,4,5,8,10,12 T = trochlea 8
C = capitulum 2 O= olecranon 10
I = internal (medial )epicondyle 4 E = external (lateral) epicondyle 12
R = radial head 5
Displaced lateral condylar fracture 10 Displaced lateral condylar fracture
------------------------------------------------------------------------------------------------------------ By
 Surgery

2. epigastrium 2
Abdomen : generalized guarding, absent bowel sound

a. Plain abdomen
b. CT abdomen
c. Ultrasound
d. Abdomen series
e. MRI
c.Ultrasound
acute pancreatitis acute epigastric pain

tachycardia, Abdominal tenderness, muscular guarding, distension, hypoactive bowel sound gastric
transverse colonic ileus, jaundice . dyspnea irritation of the diaphragm, pleural effusionIn
hemodynamic instability, hematemesis, melena, pale Cullen
sign, Grey-Turner, Erythematous skin, Purtscher retinopathy

Abdominal ultrasonography
most useful initial test
edematous, swollen pancreas, peripancreatic fluid collection, pseudocyst technique of choice
gallstones ileus

Abdominal radiography
specific dilate pancreas duodenum, jejunum
transverse colon ( Sentinel loop) colon cutoff sign gas ascending
transverse colon colon spasm
CXR pleural effusion

Abdominal CT scanning
2-3

3. 22 3 2 cm oval shape,
firm, smooth and movable
a. Fat necrosis
b. Fibroadenoma
c. Fibrocystic disease
d. Intraductal carcinoma
e. Intraductal papilloma

b.Fibroadenoma
Fibroadenoma
20-30

Fat necrosis
chronic inflammation fibrosis foreign body
giant cell fascia
Fibrocystic disease
hyperplasia
regression
glandular hyperplasia (adenosis), connective tissue hyperplasia (fibrosis), micro and macrocyst,
ductal papillomatosis lymphocytic infiltration
30

1.
1.1 upper outer quadrant

2
1.2 cyst

fascia
2. lactiferous
duct
3. (mastalgia)

Intraductal carcinoma (Ductal carcinoma in situ)
 non-invasive carcinoma (
)

pectoral fascia
Intraductal papilloma
epithelium 40
areola

4. 56
colonoscopy polyps at descending colon polypectomy

a. Villous adenoma
b. Tubulovillous adenoma
c. Tubulous adenoma

a. Villous adenoma
polyp

Tubular 5%
Tubulo-villous 20%
Villous 40%
2-4 X

5. Hernia testis 1 ..
a. Reduction
b. Ultrasound
c. Surgery
d. Radiation
e. Reassure
. Surgery

1.
( )


2. .

3.

1. -

2. -
3. -

4. -


definite treatment )

6. 30 5 .
Ultrasound
increase vascular blood flow
a. orchitis
b. epididymitis
c. incarcerated hernia
d. acute torsion testis
e. torsion of appendix testis
 DDx: Scrotal pain
Acute pain ( acute scrotal pain DDx )

Infection - Acute epididymitis; epididymoorchitis

Ischemia - Torsion of Spermatic cord or testicular appendage
Trauma - Hematocoele; Rupture testis
Complicated inguinal hernia
Refer pain from ureter

Chronic pain

: Dull heavy sensation from mass Hydrocoele; Chronic epididymitis; Tumor

: Venous strangulation --Varicocoele
: Reversible ischemia --Torsion

Epididymitis
Clinical Manifestration
acute pain in the scrotum
fever and pyuria.
Physical examination
enlarged and tender epididymis
Pain scrotum symphysis pubis (Prehn sign).
cremasteric reflex
present testicular torsion
Torsion of the appendix of the testis pain systemic symptoms
blue dot sign, torsion of the appendix of the testis
Prehn sign positive acute epididymitis negative testicular torsion.
cremasteric reflex acute epididymitis testicular torsion.
Preferred Examination
acute epididymitis
 Ultrasound detect epididymitis and/or epididymo-orchitis.
exclude testicular torsion
Differential Diagnoses
Testicle, Malignant Tumors
Testicle, Trauma
Testicular Torsion
Testicular Torsion
Clinical Manifestration
acute onset of scrotal pain, ; ( 40% of patients);
scrotal swelling and erythema; testis
appendicitis abdominal , nausea and vomiting.
flank pain radiating to the groin.
Physical Examination,
hemiscrotum is swollen and erythematous.
normal separation of the testis from the epididymis
High lying testis or horizontal position (Brunzel sign) and skin pitting at the scrotal base (Ger sign)
transillumination, ischemic testicle (blue-dot sign).
scrotum pain (Prehn sign)
spermatic cord - thickened and tender.
Tenderness alone acute epididymitis.
Bilaterality 10%
Preferred Examination
ultrasonography

Epididymo-orchitis Torsion
Pain 2-3 days 1-2 hours
Fever Yes Absence
Urination Abnormal Normal
Skin swollen Yes No
Spermatic Cord Normal Palpable tender
Prehns Sign pain relieve pain constant

orchitis
Clinical Manifestration Fever
Discharge from penis
Testicular swelling on one or both sides Blood in semen
Pain ranging from mild to severe
Tenderness in one or both testicles
Nausea
Physical Examination
Testicular examination Rectal examination
o Testicular enlargement o Soft boggy prostate (prostatitis)

o Induration of the testis often associated with epididymo-

o Tenderness orchitis
o Erythematous scrotal skin o Stool for occult blood

o Edematous scrotal skin Other

o Enlarged epididymis associated o Parotitis

with epididymo-orchitis o Fever

hernia
Prehns Sign epididymitis orchitis ( testicular inflammation )
orchitis epididymitis b. epididymitis
ultrasound increase vascular blood flow
epididymis epididymitis testis orchitis
7.
pseudocyst at the front of pancreas 4

a. partial pancreatectomy
b. total pancreatectomy
c. excision of pseudocyst
d. internal drainage
e. percutaneous drainage

management
powerpoint Kashaf Sherafgan, MD Surgery IV Conference May 5th 2006

Pancreatic Pseudocyst Similar electrolyte concentrations

A fluid collection contained within a well-
defined capsule of fibrous or granulation tissue
or a combination of both
Does not possess an epithelial lining
Persists > 4 weeks
May develop in the setting of acute or chronic
pancreatitis
Most common cystic lesions of the pancreas,
accounting for 75-80% of such masses
Location
Lesser peritoneal sac in proximity
to the pancreas
Large pseudocysts can extend into
the paracolic gutters, pelvis, mediastinum,
neck or scrotum
May be loculated
Composition
Thick fibrous capsule not a true
epithelial lining
Pseudocyst fluid
to plasma
High concentration of amylase,
lipase, and enterokinases such as
trypsin
Pathophysiology
Pancreatic ductal disruption 2 to
Acute pancreatitis Necrosis
Chronic pancreatitis Elevated
pancreatic duct pressures from
strictures or ductal calculi
Trauma
Ductal obstruction and pancreatic
neoplasms
Presentation
Symptoms
 Abdominal pain > 3 weeks (80 Pseudoaneurysm formation Splenic
90%) artery (most common), GDA, PDA

Nausea / vomiting Management of Pancreatic Pseudocysts

Initial
Early satiety
NPO
Bloating, indigestion TPN
Octreotide
Signs Antibiotics if infected
1/3 1/2 resolve spontaneously
Tenderness
Intervention
Abdominal fullness Indications for drainage
Presence of symptoms (>
Diagnosis 6 wks)
CT scan Enlargement of
MRI / MRCP pseudocyst ( > 6 cm)
Complications
Ultrasonography Suspicion of malignancy

Endoscopic Ultrasonography (EUS)

ERCP Intervention
Percutaneous drainage
Complications Endoscopic drainage
Infection Surgical drainage
S/S Fever, worsening abd pain, Percutaneous Drainage
Continuous drainage until output < 50
systemic signs of sepsis
ml/day + amylase activity
CT Thickening of fibrous wall Failure rate 16%
or air within the cavity Recurrence rates 7%
Complications
GI obstruction Conversion into an infected
pseudocyst (10%)
Perforation
Catheter-site cellulitis
Hemorrhage Damage to adjacent organs
Pancreatico-cutaneous fistula
Thrombosis SV (most common)
 GI hemorrhage Head of gland with strictures of
Endoscopic Management pancreatic or bile ducts
Indications pancreaticoduodenectomy
Mature cyst wall < 1 cm thick External drainage
Adherent to the duodenum or Internal drainage
posterior gastric wall Cystogastrostomy
Previous abd surgery or Cystojejunostomy
significant comorbidities Permanent resolution
Contraindications confirmed in b/w 91%
Bleeding dyscrasias 97% of patients*
Gastric varices Cystoduodenostomy
Acute inflammatory changes that Can be complicated by duodenal fistula and
may prevent cyst from adhering to bleeding at anastomotic site
the enteric wall Laparoscopic Management
CT findings The interface b/w the cyst and the enteric
Thick debris lumen must be 5 cm for adequate
Multiloculated drainage
pseudocysts Approaches
Endoscopic Drainage Pancreatitis 2 to biliary etiology
Transenteric drainage extraluminal approach w/
Cystogastrostomy concurrent laparoscopic
Cystoduodenostomy cholecystectomy
Transpapillary drainage Non-biliary origin intraluminal (combined
40-70% of pseudocysts laparoscopic/endoscopic) approach
communicate with pancreatic Surgical management of complications a/w
duct percutaneous and/or endoscopic management of
ERCP with sphincterotomy, balloon dilatation of pseudocyst of the pancreas
pancreatic duct strictures, and stent placement
beyond strictures Indications for Operation in Patients with
Surgical Options Complications of Percutaneous or Endoscopic
Excision management
Tail of gland & a/w proximal
strictures distal pancreatectomy Discussion
& splenectomy Morbidity rates of operative management
of pseudocyst range from 4% 30%
 Success rates
Endoscopic/percutaneous 60%
90%
Surgical 94%99%
Patients who failed non-operative
measures should have a period of
stabilization prior to operation
Important to reverse sepsis and to
improve nutritional status prior to
intervention
Technically challenging to operate on
patients who failed nonoperative measures
Necessary to completely abolish
the prior cystic structure once it
has been decompressed and the
walls have fused
Dissection is more challenging
than the dissection involved in
simply defining a pseudocyst and
draining it

Management Recommendations
Without evidence of complications, simple observation x min 6 wks

Infected pseudocysts should be managed with percutaneous drainage until the patient is stabilized

Severe nutritional deficits, at times an indication for percutaneous drainage, should be addressed

Once the pseudocyst is established as persistent, observe truly asymptomatic patients with small cysts
Intervention in all pseudocysts > 6 cm, symptomatic patients

Use ductal anatomy to guide choice of modality

Types V, VI, and VII ductal injuries are all managed operatively

Types I and II are always managed nonoperatively

Types III and IV are still under debate

Significant complications are likely to occur should nonoperative measures be used in patients most likely to
sustain complications

Indications for drainage
Presence of symptoms (> 6 wks)
Enlargement of pseudocyst ( > 6 cm)
Complications
Suspicion of malignancy
4
Complication
Malignancy
6 . intervention
Intervention 3
Percutaneous drainage
Endoscopic drainage
Surgical drainage excision, external drainage, internal drainage
e. percutaneous drainage

Mature cyst wall < 1 cm thick

Adherent to the duodenum or posterior gastric wall
Previous abd surgery or significant comorbidities
Endoscopic management ( )
fail non- operative surgical option

8. 30
, 86/70 mmHg
laceration 3 cm anterior to sternocleidomastoid

a. Explore wound at ER
b. Explore wound at OR
c. CT
d. MRI
e. Angiography
 Schwartz
zone 1 clavicle zone 2
zone 3 zone 3 zone 2

Mx

zone 2 stable Explore wound at OR

zone 3 Angiography carotid
and vertebral artery 3 Angiography
1 . exposure of distal internal carotid and vertebral artery is difficult
2. the internal carotid artery may have to be ligated, a maneuver associated with high risk of stroke
3. active hemorrhage from external carotid artery and vertebral artery can be controlled by selective
embolization
E Angiography by off NUH

9. 30 distal below knee amputation stump

a. 7
b. 10
c. 15
d. 30
e. 45

. . sheet estimate time of mature stump
E. 45 by off NUH

10 16 2 cm.
well define 2.5 centimeter mass, firm consistency at the right breast

f.
g.
h. Fine needle aspiration
i. Ultrasound 6
j. Mammogram 12
 C Fibrocystic change
cyst mass cyst mass
- Mammogram 12

- Ultrasound 6 cyst
mass
- FNA benign
malignancy line
Ref. schwartzs ..

11. pt 45 gangrene
Buerger disease, a nonatherosclerotic vascular disease also known as
thromboangiitis obliterans (TAO)
TAO is characterized by the absence or minimal presence of atheromas, segmental vascular inflammation,
vasoocclusive phenomenon, and involvement of small- and medium-sized arteries and veins of the upper and
lower extremities. The condition is strongly associated with Age younger than 45 years , heavy tobacco use,
and progression of the disease is closely linked to continued use. The typical presentations are rest pain,
unremitting ischemic ulcerations, and gangrene of the digits of hands and feet, and as the disease evolves, the
patients may require several surgical amputations.

Ob & Gyn
1. 32 G2P1 GA 24 wk

A) Fasting blood sugar D) Random glucose

B) 50 g GCT E) Urine sugar
C) 100 g OGTT

>=1
35
( ideal weight 20)


 (
4,000 )

(glycosuria)
24-28
GDM

24-28
()
25



(BMI <26 kg/m2)

High risk

50 g GCT
140 mg/dL < 140 mg/dL

100 g OGTT No further test

 100-gram OGTT (3-hour)
- 3
- 150
- NPO 10-12
- 100
- FPG 1 3
- >= = GDM
- 1 => 1

(mg/dl)
105
1 190
2 165
3 145

2. internal rotation of right arm, extended arm with flex wrist

A) C1-2 D) C8-T1
B) C3-4 E) T2-3
C) C5-6

upper limb (ventral primary rami) brachial plexus C5 C6
Brachial plexus Injury Erb s palsy Erb-Duchenne palsy
abduct elbow flexion
posterior
Sensation dermatome C5, C6
- Deltoid >>> Axillary nerve ( C5,C6)
- Biceps brachii
Musculocutaneous nerve(C5,C6,C7)
- Brachialis
- Brachioradialis >>> Radial Nerve ( C5,C6,C7)
- Supraspinatus
Suprascapular nerve (C5,C6)
- Infraspinatus
- Teres minor >>> Axillary nerve ( C5,C6)
- Supinator >>> Deep branch of radial nerve( C5,C6,C7)
3. G1P0 GA 34 wk sterile speculum fluid
posterior fornix fern test: positive
A) Tocolytic drug
B) Dexamethasone
C) IV prophylactic ATB
D) Observe sign of chorioamnionitis
E) PV progression

PPROM

Speculum

Posterior fornix
Posterior fornix
Fern test Slide
(Crystallization ) NaCl
Test 12

Meconium

1. Admit
2.
3.

(chorioamnionitis intraamniotic
infection)
0.5-1
3-15 (preterm)
> 38.C


Ampicilin 2 4-6
Penicellin G sodium 5 4-6 Gentamicin 1.5 /
 8 2 group B streptococci (GBS)
E.coli
4.
37 Preterm 34
Corticosteroid Tocolytic drug
Corticosteroid 24-48

17.
A) wet smear
B) G/S
C) C/S
A) wet preparation, gram stain
BV()-,pH>4.5,clue cell, whiff test
positive(KOH) mucopurulent cervicitis gonorrhea
C.tracomatis herpes simplex virus TV
,, strawberry cervixpathognominic sign candida
KOHpsuedohyphe with budding yeast cell
18. 18 U/S mass Rt. Adnexal hypoecoic without internal content
A) functional ovarion cyst
B) PCOS
A AB Follicle cysts most common

adnexal mass content hypoecoic masss olid part

U/S

Follicle cysts

Follicle cysts of the ovary are the most common cystic structures found in healthy ovaries. These cysts arise
from temporary pathologic variations of a normal physiologic process and are not neoplastic. The tumors result
from either nonrupture of the dominant mature follicle or failure of an immature follicle Solitary follicle cysts
are common and occur during all stages of life, from the fetal stage to the postmenopausal period. The cysts are
thin walled and unilocular, usually ranging from several millimeters to 8 cm in diameter (average, 2 cm)
Corpus luteum cysts

Corpus luteum cysts are less prevalent than follicular cysts. The cysts mainly result from intracystic
hemorrhage. They are hormonally inactive but may tend to rupture with intraperitoneal bleeding, especially in
patients on anticoagulant therapy. Radiographically, these cysts may have a clear region of homogenous debris
(blood) at the gravity-dependent portion of the cyst.

observe

PCOS-Ultrasonographic findings suggestive of PCOS commonly include ovary enlargement,

increased follicle count, and stromal echogenicity. The ovaries are usually bilaterally enlarged and spherical
in shape, rather than ovoid 2 of 3 criteria are required to diagnosis PCOS. The 3 criteria are (1) polycystic
ovaries (multiple small cysts, often around the periphery of the ovary, the classic "string of pearls" appearance),
(2) signs of androgen excess (acne, hirsutism, temporal balding, male pattern hair loss, clitoromegaly, etc), and
(3) menstrual irregularities (oligomenorrhea or polymenorrhea)

Functional cyst

Functional ovarian cyst (FOC)

Follicular
Corpus luteum -
cyst
cyst ,
cyst cyst

19.

A) perineum
B) suprapubic
C) fundus
D) flex hip
E)
C)
shoulder dystocia
1.
2.
 3.
4. mediolateral (deep mediolateral episiotomy)
episioproctotomy
5. aspirate

6.
branchial plexus injury
7. (suprapubic pressure) McRoberts
maneuver (-
)
: 209-210

20. Pt 28 y. G_P_ C/S day 2 breast engorge , lochia rubra

, c/s no oozing PV- tender on cervix motion, tender adnexa, Cx.: lochia rubra Dx (
10)
A. breast abscess
B. mastitis
C. pelvic infection
D. TOA
E. C/S wound infection

B. mastitis
mastitis day 2 breast
engorgement c/s
( obstruction)

finding PV tender on cervical motion , adnexal tenderness
() day 2 PV
(- PV ) cervix lochia rubra
day 3
 : pelvic infection/TOA

(metritis) C/S metritis
( day 2 ) (>38.5) anaerobes
PV (
) (V/E, F/E)

A breast abscess
fluctuation

E : C/S wound infection

3 oozing discharge per gauze

21. 52 menopause
A) 300 D) 1000
B) 500 E) 2000
C) 800

D) 1000

.
HRT 1.5 HRT
1 500
HRT 1
HRT 500

HRT

D
22. IUD 6
A) Ultrasound
B) X-ray
C) urine pregnancy test
D) hook IUD
E) IUD
C) urine pregnancy test
R/O pregnancy
6 UPT
UPT investigation non-invasive
ultrasound
6 wk TVS (Transvaginal sonography) invasive
UPT positive TVS

X-ray :
film
uterine sound
film
X-ray

:
- PID
- actinomycoses
pap smear
pap smear
-
-
( GA U/S )
septic abortion
IUD :

( 572
)
26. GA 20 wk LMP fundal height umbilicus
A) ultrasound
B) void
void

- ~ 12 week
- 1/3 ~ 14 week
- 2/3 ~ 16 week
- ~ 20 week
- 1/4 ~ 24 week
- 2/4 ~ 28 week
- 3/4 ~ 32 week
fundal height umbilicus 1/4 24 week
LMP 20 week 2 week

( size>date )
- - twin
- full bladder - polyhydramnios
- -
-
size>date 2 week full bladder size>date
size>date ultrasound

( size<date )
- - ( IUGR )
- - oligohydramnios

27. severe preeclampsia

A) urgent C/S
B) obsererve
urgent C/S
severe preeclampsia magnesium sulfate
magnesium sulfate 4-6 hr.



34 week corticosteroid
48 hr.

28. Pt. pregnancy BP 140/90 mmHg, urine alb 1+

A) mild preclamsia
mild preclamsia
mild severe preeclampsia
Mild preeclampsia Severe preeclampsia
160/110 mmHg 160/110 mmHg
2 gm/d 2 gm/d
(dipstick 1+ +) (dipstick 3+ 4+)



Oliguria (<500ml/24hr)
(eclampsia)
Serum creatinine
100,000 .3
Liver enzyme

Pulmonary edema

1. Chronic hypertension 20
12
2. Gestational hypertension (Transient hypertension) 140/90 mmHg
20 (proteinuria)
12
3. Preeclampsia 140/90 mmHg
(300 mg 24 . urine protein random specimen 30
distick 1+)
4. Eclampsia preeclampsia
5. Superimposed preeclampsia preeclampsia chronic hypertension
superimposed preeclampsia
300 mg 24
systolic 30 mmHg
diastolic 15 mmHg 100,000 .
29. 7 3 2 Asthma
Asthma
1.
2. soy formular milk
3. Hydrolysated extend casein formular
4.
5. Serum IgE

30. TB Tuberculin test 4 mm ?

1. TB
2. INH prophylaxis 1 month
3. Observe chest X ray 6
4. ...
INH prophylaxis 1 month
: 3
active INH Prophylaxis
10 mg./kg/day Tuberculin test 4 mm
TB INH Prophylaxis
active 50%

31. 21 LMP 6 wk. vagina PV: uterine normal size, soft, no

adnexal mass, not tender, TVS : no intrauterine sac, no mass, Mx?
A) D&C
B) Serun -hCG
C) Exploratory laparotomy
D) Diagnostic laparotomy
E) MTX injection
 B) Serun -hCG

ectropic pregnancy

Clinical triad
-
-
-
ectropic pregnancy
Serun -hCG R/O
-hCG 48 66 %

36. 30 3 EGD DU
1. Omeprazole 4. Ranitidine
2. Misoprostol 5. Cimetidine
3. Sucralfate
Pregnancy category A

Pregnancy category B

Pregnancy category C

Pregnancy category D

Pregnancy category X
meprazole = C Ranitidine = B (
Misoprostal = X ranitidine cimetidine )
Sucralfate = B Cimetidine = B
DU PPI H2 blocker Ranitidine
(sucralfate )

By. Kwangsha 47490479

37. 30 GP1021 GA 38 wk in labor Drip Syntocinon BP 80/50 mmHg Fetal
part Fetal heart sound Dx.
1. Abruptio placentae
2. Placenta previa
3. Uterine rupture
4. Vasa previa
5. Prolapse cord

Placenta previa

7

Abruptio placentae


- GA 38 week
Uterine rupture /
/ / (
) /
fetal part
key word uterine rupture
engage

Vasa previa

uterine rupture By. Kwangsha

38. 40 G2P1 GA 8 wk Down syndrome
1. 1/50 4. 1/300
2. 1/100 5. 1/400
3. 1/200

Incidence of Down Syndrome with Increasing Maternal Age

Maternal Age at Delivery Risk at Term
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
49 1/12

1/100 by.kwnagsha
38. 40 G2P1 GA 8 wk Down syndrome
a.1/50 d.1/300
b.1/100 e.1/400
c.1/200

b.1/100

39. 38 G4P3 GA 39 wk, no ANC, 2hr PTA .,

contraction 5 30, PV: 7cm,station -2 Management
a.Observe d.Total breech extraction
b. syntocinon e.Emergency C/S
c.Partial breech extraction
e.Emergency C/S

:

1.
- trendelenberg
, knee-chest
-
- oxygen 100%
 -

- 500-700 .

2.
- c/s
- Breech extraction

-
Breech extraction
Ref . ,

40. 8 wk Mitral stenosis

a.
b.
c. Tertiary care
d.
e.

a.
NYHA
Class I
Class II
Class III
Class IV

Class I
Class I Class II
1.
i.
ii.
iii.

iv.
 v.
vi.
vii. 10
viii.
28 wk 2 wk
1 wk

2.
class 0.4%
3.
4. :

Class III

1 3

:
Class IV


Class III IV 4-7 %

Ref .

40. 7 2 , PE:
lethargy, moderate jaundice, erythematous indurated mass at Rt. Breast, ATB ?
1. Ceftriaxone
2. Ampicillin +Gentamicin
3. Cloxacillin + Gentamicin
4. Fortum + Amikacin
5. Fortum + Vancomycin
 2. Ampicillin +Gentamicin
common antibiotic regimen in infants with suspected sepsis is a beta-lactam antibiotic
(usually ampicillin) in combination with an aminoglycoside (usually gentamicin) or a third-
generation cephalosporin (usually cefotaximeceftriaxone is generally avoided in neonates
due to the theoretical risk of causing biliary stasis.) The organisms which are targeted are
species that predominate in the female genitourinary tract and to which neonates are
especially vulnerable to, specifically Group B Streptococcus, Escherichia coli, and Listeria
monocytogenes

41. ampicillin 14 endoscope

hyperemia Tx?
1. Metronidazole
2. Ceftriaxone

Ampicillin-Associated Diarrhea.
antibiotic-associated diarrhea
clindamycin, ampicillin ,cephalosporins , cephalexin





Clostridium difficile C. difficile

C. difficile metronidazole
(Flagyl) vancomycin (Vancocin)
42. 8 1 PTA,
2 wk PTA, vital sign , PE : Oozing per gum, petichiae & ecchymosis trunk &
extremities, no lymphadenopathy, no hepatosplenomegaly, Dx?
1. Hemophilia
2. Acute leukemia
3. DHF
4. ITP
5. APDE
4. ITP = Idiopathic thrombocytopenic purpura
I. Idiopathic thrombocytopenic purpura
- Primary autoimmune immune thrombocytopenia (ITP)
Acute childhood ITP
chronic or adult ITP
- Secondary Autoimmune thrombocytopenia
Acute post viral ITP(acute childhood ITP)
-
-
- 2
- 6
Chronic ITP
-
-
-
-
-
chronic ITP
- Skin bleeding petechiae,ecchymoses
- Mucosal bleeding-bleeding per gum,epistaxis,hematuria
- Intra cerebral hemorrhage
- Anemia related to degree of bleeding
- No hepatosplenomegaly if splenomegaly was detected should be considered hypersplenism
or lymphoproliforative disorders
Criteria for diagnosis ITP
- Isolated thrombocytopenia
- Normal or increase megakaryocyte in bone marrow
- No splenomegaly
- Autoantibody to platelets
- No other cause of thrombocytopenia
Treatment
1. General treatment
- Bleeding precaution avoid trauma,Intramuscular injection,antiplatelets medication
- Local treatment;nasal packing,oral contraceptive drug
- Blood transfusion in active bleeding,iron replacement therapy,platelets transfusion in life
thretening situations
2. Specific treatment
Corticosteroid actions:- Inhibit autoantibody bind to platelets
- decrease phargocytosis by RE cell,
- decrease autoantibody production,
- increase vascular support
Indication for splenectomy
- Steroid relaspe =steroid dependent
- Stroid partial and non response
Diagnosis and treatment over 6 weeks with platelets less than 10,000
Treatment for 3 months and platelets less than 30,000 with or without bleeding
- Complication of streroid
- Ememegency condition
- Difficulties in follow up
73. 6 truncal obesity , Buffalo hump , moon face , acne ,

A. Hypocalcemia D. Increase serum cortisol
B. Hyperkalemia E. Increase activity of rennin
C. Advance bone age

D. Increase serum cortisol

Cushings syndrome serum
cortisol
A. Hypocalcemia
- Cortisol Osteoclastic activity Hypercalcemia (mechanism
)
B. Hyperkalemia
- Cortisol weak aldosterone Na K
Hypokalemia
C. Advance bone age
- Serum cortisol Hypothalamus, Pituitary GH, GnRH, TRH
Bone growth Delay bone age
E. Increase activity of rennin
- Cortisol Decrease activity of rennin
74. 6 2 petechiae & ecchymosis
at extremities CBC : Hb 12 Hct 36 WBC 6500 Plt.150,000 Lab
A. Bleeding time D. Thrombin time
B. PT E. Venous clotting time
C. PTT
A. Bleeding time
petechiae & ecchymosis sign Primary hemostasis
Platelet Vessel
 platelet function
A. Bleeding time primary hemostasis , platelet function
B. PT extrinsic and common pathway
C. PTT intrinsic and common pathway
D. Thrombin time fibrinogen fibrin conversion
E. Venous clotting time clotting factor (Prolong if clotting factor < 5%)

by Med NU X .. 1
75. 2 VSD pulse BP AMbu tube
Amiodalone EKG ventricular tachycardia management
A. Defibilation
B. Ca gluconate
C. NaHCO3
D. Adenosine
E. Direct current synchronized cardioversion
 E. Direct current synchronized cardioversion
Protocol for management of haemodynamically unstable ventricular tachycardia

The steps used in the resuscitation procedure are outlined:

provide high flow oxygen

establish i.v. access
consider sedation or ideally, intubation with general anaesthesia
perform cardioversion i.e. synchronised DC shocks
o for a monophasic defibrillator, start at 100 J

o if VT persists, increase to 200 J

o if VT persists, increase to 360J

o (if using a biphasic defibrillator, use the equivalent biphasic energy levels)

check serum potassium and correct if less than 4 mmol/l:

o give up to 60 mmol potassium chloride at maximum rate of 30 mmol per hour

if hypokalaemic, assume patient also to be hypomagnesaemic:

o give 10 mmol magnesium sulphate over 30 minutes (5 mls of 50% solution)

if VT persists, obtain expert help; but consider:

o amiodarone 150 mg in 20 mls 5% dextrose over 10 minutes

o further cardioversion

o other anti-arrhythmics

o overdrive pacing

Ref : http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1523253221&linkID=35230&cook=no
by Med NU X .. 1
76. 19
PTT 50 sec (control 30 sec), PT 13 sec (control 14 sec), no
prolonged bleeding time
A. Lupus coagulopathy D. von Willebrand factor
B. Factor VII deficiency deficiency
C. Factor VIII deficiency E. Hereditary platelet dysfunction
 C. Factor VIII deficiency
prolonged PTT lupus coagulopathy, factor VIII or IX deficiency
or inhibitor, Von Willebrand disease (if factor VIII is decrease), factor XI or Xii deficiency,
prekallikrein or HMW kinigen def. or inhibitor, heparin contamination of sample
Lupus coagulopathy, Factor VIII deficiency von
Willebrand factor deficiency
prolong PTT bleeding
thrombosis prolong PTT bleeding heparin, factor VIII/ IX/
XI def./ihb. vWD prolong PTT thrombosis factor XII
def./ihb., lupus coagulopathy contact factor def./inh.
Factor VIII deficiency von Willebrand factor deficiency
vWF 2 Plt. Adhesion membrane
receptor carrier factor VIII vWD lab prolong bleeding time (
function plt. ), reduced factor VIII activity ( prolong PTT), reduction plasma vWF
concentration reduction biologic activity

Factor VIII deficiency hemophilia A

bleeding lab PTT prolong factor
VIII conc.

77. 3 mild pale other WNL 13.5 kg , blood smear : hypochromic

microcytic anemia
A. Iron deficiency

blood smear RBC

morphology anemia
 Classification of anemia based on morphology
1. normocytic normochromic anemia
acute blood loss
hemolytic anemia
hemoglobin- erythrocyte mass def. :
chronic disease, toxic agent
2. microcytic normochromic anemia
hemoglobin- erythrocyte mass def. :
chronic disease, toxic agent,
malignancy, splenomegaly, endocrine
disorders
3. microcytic hypochromic anemia
iron deficiency anemia
chronic lead poisoning
thalassemia
miscellaneous rare disorder : Vit B6
def., sideroblastic anemia
4. macrocytic normochromic anemia
pernicious anemia
GI abnormalities : malabsorption
syndromes, inflammatory disease,
acute and chronic liver disease
Def. of Vit B12, folic, Vit C
Bone marrow failure or hypoplasia :
aplastic anemia, uremia
Anticonvulsant drugs and
folic acid antimetabolites

2. 47 3
5

a. Analgesic d. Surgery
b. Try reducing e. Reassure and plan discharge
c. Observe and plan admit
b. Try reducing= irreducible (incarcerated) hernia

try reducing obstructed strangulated hernia

strangulation
mesentery

infact gangrene toxic
surgery
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

DON_1 ) 45

a. CXA
b. CBC
c. Fasting Blood Glucose
d. Mammogram
e. Total cholesterol

 llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

(Periodic Health Examination )

+

risk risk

. 1. . / . q. 1

2. BP age 18 -35 q. 2 y
..age >35 q. 1ys

3. age >40 q. 1 y

4. TT q. 10 y

1.Vaccine MMR 1

2. Papsmear q.1 y (SI ) if

3 q.3 y

3.

( age > 20 )

. 1. PR (> 40y) q.3-5y

2. Stool exam q.3-5y

3. Stool occult blod (>40y) q.5y Add

4. U/A q.3-5y
(20-40y ) q. 3y
TC FBS 5. Total cholsterol(>35y) q.3-5y
( >40y) q.1y
TC FBS 6. TG,HDL(>45) q.3-5y

(TC 35 ) (FBS 45) 7. FBS(>45) q.3y

8.HBV vaccine 1
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

. 1.

2.Hct,Hb
3.HBsAg
1. T4,TSH (menopause)
4.VDRL
2. Bone density
(menopuase)
5.

6.CXR

7.Chol age<35y

8.FBS age< 45y

9.EKG,EST

10.Conoscope age >40y

11.Hb typing

12.

13.

. / 1.TB ( CXR, tuberculin test) 1.TB ( CXR, tuberculin test)

2. T4,TSH 2. Hb typing

3.Tumor marker 3.Tumor marker

-AFP(CA liver) -AFP(CA liver)

-CA 19-9 (CA Pancrease) -CA 19-9 (CA Pancrease)

-CEA ( CA colon) -CEA ( CA colon)

-PSA ( CA Prostate) -CA 125 ( CA Ovary)

4. UGI study 4. UGI study

5.Gastro scope 5.Gastro scope

6.U/S Liver, Pancrese 6.U/S Liver, Pancrese,pelvic

7.Transrectal U/S ( CA Prostate)

8.Bone density 7.Bone density

9.EKG,EST (< 40y) 9.EKG,EST (< 40y)

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

10. BCG 9. BCG

11. 10.

12. 11.

13. TB,Malaria, 12.. TB,Malaria,

choice TC FBC TC early screening

FBS 45 TC FBS( >45)

assume TC
FBS
45 TC ( >35y)
TC

DON_2) 2000 TB 200 CXR 150 TB CXR 30

CXR TB

A.3

B.7

C.15

D.27

E.

TB CXR
30
TB Non-TB total
CXR 150
+ ve CXR 120 30 150
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

- ve CXR 80 1770 1850

total 200 1800 2000

2000
TB 200

CXR TB positive predictive value (PPV)

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

= (120 / 150) x 100 = 80% choice => / choice ?=>

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

()
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

DON_3) Nosocomial infection 20%

A.
B.
C. 6
D.
E.

D.
Through its program, the hospitals infection-control committee must determine the
general and specific measures used to control infections and must review and recommend specific
antiseptics and disinfectants for hospital use. Given the prominence of cross-infection, hand hygiene is the
single most important preventive
measure in hospitals (Table 116-2).
Health care workers rates of adherence to
hand-hygiene recommendations are
abysmally low (_50%). Reasons cited
include inconvenience, time pressures, and
skin damage from frequent washing.
Sinkless alcohol rubs are quick and highly
effective and actually improve hand
condition since they contain emollients and
allow the retention of natural protective oils
that are removed with repeated rinsing. Use
of alcohol hand rubs between patient
contacts is now recommended for all health
care workers except when the hands are
visibly soiled, in which case washing with
soap and water is still required

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

4. 19 20
30

A.
B.
C.
D.
E.
10

1.
2.


3.

4.

5.

6.

" ."

7.
()
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

8.

9.

10.

10.1 ( 2 )
"_" ","
28

10.2 10

10.3 18
20 ( 20 )

18
20

22 27

15

". 23, 24
"

10 ""

10.2.1 21

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

10.2.2

. "" ""

. "" ""
"" "" 34 32

21

10

10.4 2

10.4.1
3

10.4.2 9

5. RCT chemo 2 ?

A. ........
B. ........
C.
D.
confounding factor

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

Cross-sectional
(Prevalence)

(Experimental Research)
Longitudinal
Exposure (Incidence)

(Descriptive Study)

(Cross-sectional)
(Observational Research)

Exposure

(Analytic Study) (Cohort or Prospective)

(Case control or
Retrospective)

(experimental research)


1. (full experimental study) (true experimental
study)



( confounding
facter)

()
( randomized double blind control
trial = RCT )
1.1 classical experimental study
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

2 (pre-test)
(post-test) 2
(beforeafter
experimental with control group pretestposttest control group study)
1.2after-only experimental with one control group posttest-only control group study)
(random allocation)

2. (quasi-experimental study)
4
4
(1) (control group)
(experimental group) ( intervention)


(2)

(3) (random allocation)

(4)

(ref .Research Design.().. . biases of research . )

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

6. BP cuff adult

A. Bias
B. Confounder
C. Contamination
D. Co-intervention
information bias

= (truth) + (errors)

- (systematic errors) (bias)

- (random errors or variations) sample size

1. Selection bias =
-
-
case control

- study design
- loss follow up
- non-response
- selective survival =
2. Information bias = exposure outcome
- invalid measurement= cuff BP
- incorrect diagnostic criteria
-omission/ imprecision of record data=
-unequal diagnostic surveillance= follow up
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3.Confounding bias = (confounding factor)

(ref. biases of research . (Control Bias).

)
By Toie

7.

A. Beneficence
B. Autonomy
C. Confidentiality
Autonomy

1. (beneficence) ,

2. (non-maleficence) ,,,
,

3.(personal autonomy)

- consent 3
(appropriateness) , (capacity),
( voluntariness)

- confidentiality

4. (justice)

5. (Euthanasia)

Reference:
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

8.

A.
B.
C. .
B.

9. 2.000 xray 80 CA 50
1,920 xray CA 150 x-ray CA % (
choice )

CA CA

X-ray 50 30 80

X-ray 150 1770 1920

200 1800 2000

false negative (test - disease +)

sensitivity = TP/all disease = 50/200 = 0.25

False negative = 1- sensitivity = 0.75 75%

By PAR

10. 16 LP

- 16
llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

1.
2.
3.
communicating hydrocephalus
4. lumbar myelography

1.
2. space occupying lesion

11. autonomy

autonomy

1. (personal autonomy)
/
- (appropriate information)

- ( capacity)
- ( voluntariness)
(confidentiality)
(truth telling)

llllllllllllllllllllllllllllllllllll 83.333%Loading Medicine.5603

2. (non-maleficence)
3. (Beneficence)
4. (confidentiality)
5. (justice)

12. people empowerment

choice empowerment

Empowerment is the process of increasing the capacity of individuals or groups to make choices
and to transform those choices into desired actions and outcomes. Central to this process are actions which
both build individual and collective assets, and improve the efficiency and fairness of the organizational and
institutional context which govern the use of these asset.

ByPraew
 ENT
1. 40 muffled voice
film lateral neck soft tissue technique
A. Epiglotitis
B. Ludwigs angina
C. Laryngotracheitis
D. Retropharyngeal abscess
E. Parapharyngeal abscess

specific symptom
Deep neck infection space
choice
Deep neck infection Deep neck infection
A. Epiglottitis C.Laryngotracheitis( Croup ) Infectious Upper
Airway Obstruction
Epiglottitis
stridor
Laryngotracheitis Viral croup 3 5 2 3
Croup score (barking cough) stridor
Deep neck infection
Ludwigs angina
Submandibular space
complication Airway obstruction
Criteria diag Ludwigs angina
- cellulitis
- Involve submaxillary sublingual space ( submaxillary )
- Infection direct extension fascial planes
- Involvement muscle fascia submandibular gland Lymph node
investigate film lateral
Retropharyngeal abscess
Retropharyngeal space
muffled voice hot potato voice (
Peritonsillar abscess) airway obstruction most
common complication Pneumonia with lung abscess abscess space aspirate
investigate film lateral neck soft tissue C2 7 mm
C6 22 mm.

Parapharyngeal abscess
2 compartment
Anterior compartment Classical triad
1. Trismus ()
2. Perimandibular swelling
3. Protusion Prolapse tonsil fossa
Posterior compartment Neurological deficit Horners syndrome(,,,)
investigation film lateral neck Epiglottis swelling

1. ,

2. 30 1
2
left ear drum: normal , right ear drum: dark blue, retracted ear drum, Weber
test: localized to right, Rinne test: left AC>BC, right BC>AC
A. Loratadine
B. Pseudoephredine
C. Serrtic peptidase
D. Chloramphenical eardrop
E. Myringotomy
 Barotrauma
Barotrauma

tympanic
membrane ( retracted ear drum)

hemotympanium dark blue ear drum

1.
2. Eustatian tube
3. decongestant
4. (Myringotomy)
Myringotomy

Rinne test : AC > BC (Rinne positive) = normal , sensory neural hearing loss
Bc > AC (Rinne negative) = conductive hearing loss
Weber teat lateralize conductive hearing loss
2 ! .

3. ear drum : intact , Weber : no lateralization ,

Rinne : Rt BC > AC , Lt AC>BC
A. Acoustic trauma D. Steatosis
B. Otosclerosis E. Otitis media
C. Meniere
Acoustic trauma

exposed Noise induce
hearing loss Sensory neural hearing loss

expose (
)
BC > AC
Acoustic trauma SNHL AC > BC choice
A.
Choice
 Otosclerosis
labyrinth capsule conductive
hearing loss stapes oval window
conducive hearing loss
progress

Menieres disease
idiopathic endolymphatic hydrops endolymph
membranous labyrinth sensory neural hearing loss
( vertigo)
Steatosis
steatosis abnormal retention of lipids within a cell
fatty liver

Cholesteatoma
keratinizing stratified squamous epithelium keratin debris
mastoid antrum
complication facial nerve palsy

3
. Compre&License 100%

4. 29 5
PE: 0.5 cm.
A. ? D. allergic rhinitis
B. entropion E. Meibomian gland dysfunction
C. ectropion
hordeolum

chalazion

- Entropion
- Ectropion
- Allergic Rhinitis 2
- Meibomian gland dysfunction meibomitis chalazion punctate
keratitis
5. erythematous with bulging at posterior TM
A. Tetracycline
B. Amoxycillin
C. Erythromycin
D. Doxycycline
E. Amoxy-clavulonic
B Acute Otitis media
Eustachian tube TM
6 H.influenzae M.Caharrhalis S.Pneumoniae
H.Influenzae Amoxycillin Bactrim 2 - 3
H.influenzae M.Caharrhalis beta lactamase Augmentin Cephalosporin

6. 5
A. Choanal atresia
B. High arch palate
C. Hypertrophy of adenoid
D. Foreign body of nasal cavity
E. Congenital tumor of nasal cavity
C hypertrophy of adenoid hypertrophy of tonsil
chronic
sinusitis source infection
- Choanal atresia
2 5
- High arch palate AllergicRhinitis
- Foreign body of nasal cavity 5
- Congenital tumor of nasal cavity

7. 25
6 3
Dx
A. Atrophic rhinitis
B. Vasomotor rhinitis
C. Chronic irritative rhinitis
D. Rhinitis medicamentosa
E. Severe allergic rhinitis with polypoid change
D Topical decongestants Alpha 1 & 2 receptor vasoconstriction
2-3 7 rebound effect
Rhinitis medicamentosa
8. ?
Foreign body of the nose
Unilateral rhinorrhia

9. 45
A. CA nasopharynx
B. Otitis media ?
A (?)
Nasopharyngeal CA
90%
50% 2
posterior nasal cavity
^ ^

10. Bullous myringitis ?

* ==> Pneumonia Bullous myringitis
* Bullous myringitis Otitis externa
blister on the tympanic membrane ( intact )
* Pneumonia Bullous myringitis Mycoplasma
pneumonia
* ( ) ==> Macrolides ( Erythromycin,Clarithromycin,Azithromycin )
==> Doxycycline, Levofloxacin
==> continue ABO 14-21 days
 Eye : .

1. 5 VA 20/200 20/40 with pinhole, VA 20/100 20/30 with pinhole

A. Cataract
B. Amblyopia
C. Strabismus
D. Refractive error
E. Color blindness
D. Refractive error
Visual acuity 20/200 = 20 200
VA pinhole VA Refractive error
VA retina optic n.
Amblyopia (Lazy eyes)
2 () 2
2 Snellen chart 6/12

2. 40

A. Dry eye
B. Cataract
C. Glaucoma
D. Retinitis pigmentosa
E. Loss of accommodation
......

(Night blindness)
- Refractive error uncorrected myopia
- Advance glaucoma :
- small pupil miotic drops
- Retinitis pigmentosa : cone dystrophy
=> Pt. =>
Choices
- Dry eye =>
- Cataract pupil dilate nuclear cataract
refractive index hyperopia myopia
 () nuclear
cataract
- Glaucoma
glaucoma
- Loss of accommodation ( Presbyopia)
40 ( 40 )
ciliary muscle

focus
defect pupil

E. Loss of accommodation

3. 58 3
PE : Rt eye - ciliary injection, cloudy cornea, shallow anterior chamber, pupil 5 mm no reactive to light
Lt eye - deep anterior chamber, lens sclerosis
Dx.
A. Acute iridocyclitis
B. Phacomorphic glaucoma
C. Phacolytic glaucoma
D. Acute dry eye
E. intermittent dry eye
B. Phacomorphic glaucoma
painful visual loss
- Acute angle closure glaucoma :
- Optic neuritis :
- Uveitis :
Acute angle closure glaucoma (ciliary injection) shallow
anterior chamber, fixed mid-dilated pupil
choices 2 ( secondary closed angle glaucoma )
- Phacomorphic glaucoma intumescent cataract iris
aqueous humor anterior
chamber
- Phacolytic glaucoma (hypermature cataract)
meshwork aqueous humor anterior chamber
 4. 55 1 3
chalazion I&C 3 recurrent

a. Local steroid injection.
b. I&C with culture.
c. Warm compression with systemic antibiotics.
d. Biopsy and microbial investigation.
e. Aspiration and gram staine, KOH exam and culture.
Chalazion (chronic lipogranulomatous inflammation) meibomian


internal hordeolum

-
- internal hordeolum
steroid hypopigmentation

- meibomian
reference.
- Small, inconspicuous, asymptomatic chalazia may be ignored.
- Conservative treatment with lid massage, moist heat, and topical mild steroid drops usually suffices.
- Acute therapy with oral tetracycline (eg, doxycycline 100 mg or minocycline 50 mg qd for 10 d) minimizes
the infectious component and decreases the inflammation, reputedly by inhibiting polymorph
degranulation.
- Chronic therapy with low-dose tetracycline (eg, doxycycline 100 mg PO qwk for 6 mo) frequently prevents
recurrence. If tetracycline cannot be used, then metronidazole has been used in a similar fashion.
- In most cases, surgery should be performed only after a few weeks of medical therapy.
Biopsy and microbial investigation. Recurrent chalazion

Ans. D. Biopsy and microbial investigation.

 5. glaucoma (acute closed angle glaucoma)
a. beta blocker.
b. atropine eyes drop.
c. pilocapine eyes drop.
d. oral glycerol.
Primary glaucoma 2
1. Primary angle closure glaucoma 2
- Intermittent angle closure glaucoma.
- acute angle closure glaucoma.
2. Primary open- angle glaucoma.
acute angle closure glaucoma. ocular emergency iris root
trabecular meshwork 360 aqueous humor

1.
2.
3. corneal edema
4. Ciliary or mixed injection.
5. semidilated and fixed pupil.
6. anterior subcapsular cataract. glaukomflecken.
7. increase intraocular pressure. ~ 60 - 80 mmHg.
acute closed angle glaucoma hyperosmotic agent IOP
IOP extravascular intravascular component aqueous
vitreous volume 2
- 50 % Glycerol and isosorbide. glycerol
isosorbide
- 20 % Manital parenteral hyperosmotic agent systemic side effect
rapid intravascular volume expansion.
cholinergic agent pilocapine aqueous outflow
trabecular meshwork sphincter pupillae iris (miosis)
4 8
glycerol definite treatment acute closed
angle glaucoma emergency peripheral iridectomy LASER iridotomy.
Ans. D. oral glycerol.
6. 30 PE: mild cornea and lens ? , Ciliary injection, pupil 5
cm fixed Dx.
A. Migraine
B. Uveitis
C. Acute glaucoma

-
angle closure glaucoma
-
o angle closure glaucoma pupil dilate
o optic neuritis
o uveitis ( photophobia)
- glaucoma
- Mild increase corneal and lens opacity.
o Keratitis
o Corneal ulcer
o Corneal edema Uveitis Acute glaucoma
- Ciliary injection corneal abrasion, keratitis, iriditis, iridocyclitis
acute closed angle glaucoma
- Pupil 5mm fixed acute closed angle glaucoma
acute
closed angle glaucoma Uveitis
acute closed angle glaucoma Uveitis meiosis Pupil 5mm fixed
acute closed angle glaucoma
Ans. C. Acute glaucoma

7. 20 contact lens mild conjunctival

injection, corneal ulcer 2 cm
A. Topical ATB
B. Pressure patch
C. Contact lens culture
Ans
infection
corneal ulcer 2 cm ( cornea )
corneal ulcer Pressure patch abrasion B.
contact lens infection Pseudomonas aeruginosa admit
cornea 1-2 ulcer Ciprofloxacin
IV Ref : .
8. miosis, diaphoriasis, BP drooling
A. Opioid
B. Cocaine
C. Carbamate
Ans C Carbamate
(Organophosphate) (Parathion), (Malathion),
(Carbamate) 2 - 3

Opioids morphine, heroin
pethidine -opiate receptors
(Euphoria)
(Opioid intoxication):

(opioid overdose) clinical triad
coma, pinpoint pupil, respiratory depression
Cocain

9. 3 normal cornea
A.
B. ceftriazone IM
Ans B. ceftriazone IM
Neisseria gonorrhea


Silver nitrate 24 hr PMN
Neisseria gonorrhea 2-4 Gram neg diplococci

Chlamydia trachomatis 4-10 Giemsa
basophilic cytoplasmic
(pseudomembrane) inclusion bodies
4-7

Herpes simplex 7-14 Gram stain :
multinucleated giant
cells
 1-12 Neisseria
gonorrhea
Neisseria gonorrhea Lab
: sterile NSS erythromycin third-
generation cephalosporin ceftriaxone 30-50 mg/kg 125 mg cefotaxime 100 mg/kg IV
IM

10. mature cataract glaucoma on top (Phagomorphic)

phagomorphic glaucoma
- Hyperosmotic agent 20%manitol 50%glycerol

- Carbonic anhydrase inhibitor aqueous humor acetazolamide 1
/ 2-4
- 2%pilocarpine trabecular meshwork 15 4
6
- Beta-adrenergic blocking agent timolol aqueous humor

11. 9 1 cobble bone stone (papillaly) 2

Vernal keratoconjunctivitis
Vernal keratoconjunctivitis
Vernal keratoconjunctivitis(VKC)
2 10
atopic, asthma mucoid discharge
2
1. Palpable vernal keratoconjunctivitis papillae tarsal cobble stone
2. Limble vernal keratoconjunctivitis limbus eosinophil
Horner-Trantus dots

-
- hyposensitization
- steroid steroid

- mast cell stabilizer, NSAID cyclosporine
- papillae steroid papillae

By Natt ji
1-3 ( 8,10,11
4-6 ) !!
() 7,9
 FORENSIC

1.
A. 2 hr
B. 2-4 hr
C. 4-6 hr
D. 6-8 hr
E. 8-10 hr

ANSWER: B. 2-4 hr
:
Postmortem Rigidity (rigor mortis) 2-4 .
6-12 . 2-4 .



Postmortem hypostasis fix early stage 12 .
12 . Fix ( over 8-12 hours: Unblanched by compression and
not displace)

..................................................................................................................................................................................................

2.
Hyoid bone
A. Mothering ( Smothering )
B. Complete hanging
C. Incomplete hanging
D. Ligature strangulation
E. Manual strangulation

ANSWER: E. Manual strangulation

:
Smothering



Hanging

2
Complete hanging
 petechial hemorrhage direct trauma
Incomplete hanging

(occlude only vein)
Ligature strangulation
hyoid bone and/or thyroid cartilage cricoid
hanging hanging hyoid thyroid intact
B. C.
Manual strangulation
hyoid (usually fractures at superior horn), thyroid, cricoid underlying
soft tissues bruises, abrasion of the chin E.
..................................................................................................................................................................................................

3. 57
. ER EKG 20


A. Acute poisoning
B. Rupture aneurysm
C. Acute heart failure
D. Cardiopulmonary failure
E. Coronary heart disease

ANSWER : E. Coronary heart disease

:


24 .


20-65
coronary artherosclerosis

coronary artherosclerosis
- 1 .
................................................................................................................................................................................................
4.

a)
b) .
c)
d)
ANS D. ()



Preventive Psychiatry

( Ref. . )
...................................................................(5 ) .....................................................................................
6. 3 1 severe brain laceration, fracture base of skull
rupture trachea
A. severe brain laceration with gun short wound ,fracture base of skull
B. ..()
C. ..( )
D. severe brain laceration with fracture base of skull with tracheal rupture
ANS key

()
A. severe brain laceration with gun short wound ,fracture base of skull
primary cause gun short wound
secondary cause fracture base of skull severe brain laceration
secondary cause



( 2.5) ( 2.3 , 2.4)

- the disease , injury ,or combication of disease and injury responsible for the fatality. (
)
- cause of death should be etiologically specific disease or injury
- the underlying or proximate cause of death,natural and continuous sequence
- Immediate cause of death are complication of the underlying cause.
.

....................................................................................................................................................................................................
7.
A. sperm
B. sperm & acid phosphatase
C. vagina sperm
D. sperm
:

.. 2499 2 9 276


Keyword

Ref. forensic Sex crime
..............................................................................................................................................................................

8.
A.
B.
C.
: C.
DNA


.................................................................................................................................................................................
9. inevitable abortion

A.
: A.
2 parts
1) : wounds and injuries
2)
a. /
b. ?
c. /
d. /
e.
f.

.......................................................................................END...............................................................................................
 Ortho&Rehab
2. orbit
A) Caucasian
B) Mongolian
C) Nigroid

ANS. B) Mongolian

Item caucasoid negroid mongoloid

1. skull height high low medium

2. skull length long long long
3. skull width narrow narrow broad
4. face width narrow narrow wide
5. face height high low high
6. sagittal contour rounded flat arches
7. nasal opening narrow wide arrow
8. orbital opening angular rectang rounded
9. lower nasal margin sharp troughed sharp
10. nasal profile straight slant straight
11. palatal plate narrow wide medium

6. C myelopathy 1 5-8
A) traction + MRI
B) traction
C)

ANS. A) traction + MRI

cervical myeopathy traction
sign of radiculopathy contraindication traction
management traction MRI

cervical myelopathy
1. Neck immobilization with a soft collar, Philadelphia collar, rigid orthoses,
Minerva jacket, or a molded cervical pillow for support
2. Pharmacologic treatment :NSAIDs, Tricyclic antidepressants (TCAs),Steroid
3. Lifestyle modifications :ergonomics and/or workplace modifications,relaxation techniques
postural awareness
 4. Physical modalities :used for spine-related disorders
-Cervical mechanical traction 10 lb
-Manipulation : low-velocity, high-amplitude manipulation; high-velocity,
low-amplitude manipulation
5. Exercises designed for cervical pain : isometric neck strengthening ,neck and shoulder
stretching and flexibility exercises,back strengthening exercises,aerobic exercises
6. Other modalities for pain include heat, cold, acupuncture, massage, trigger-point
injection, transcutaneous electrical nerve stimulation, and low-power cold laser
7.Surgical Tx : indication For Surgical decompression
-intractable pain
-progressive neurologic deficits
-documented compression of nerve roots or of the spinal cord that
leads to progressive symptoms

7. RA swan neck modality

A) block exercise
B) tension-gliding exercise
C) low-load, high repetitive resistant exercise
D) high load, high repetitive resistant exercise

ANS. A) block exercise

RA swan neck (hyperextension of PIP joint, flexion of DIP joint) deformities
stiffness RA
1. stabilization of the joint
2. increase in range of movement
3. relaxation of antagonists
4. reduction of atrophy
stabilize function of finger block exercise(
rehab RA Bunnell exercise choice
) fixed active motion range of motion
ROM choice Tension gliding exercise hand injury
involve nerve,tendon
Tension gliding exercise low-load, high repetitive resistant exercise high load, high repetitive resistant
exercise load ( traction ) hand (
rehab )
 8. 22 hip flexion, adduction, internal rotation
diagnosis
A) Fx pelvic D) Intertrochanteric Fx
B) Fx acetabulum E) Posterior hip dislocation
C) Fx neck of femur

ANS. E) Posterior hip dislocation

80 % hip dislocation
( simple dislocation)
( fracture dislocation)

1. limit range of motion
2.
3. gluteus maximus
4. flextion, adduction internal rotation hip injury
Sciatic nerve
sensation common peroneal nerve Tibial nerve motor
common peroneal nerve dorsiflexion Tibial nerve
plantar flexion

head of femur acetabulum head of femur

close reduction
1. Gavity Method Stimson
pelvis sacrum 90 femur Internal external rotate

2. The Allis Manever Anterior superior illiac spine

flex hip 90 internal external rotate

3. The Bigelow Manever anterior superior

iliac spine defformity

flex hip 90 acetabulum

 5. 10 PE:
swelling at Rt elbow, triangle landmark at Rt elbow
A) Dislocation elbow
B) Displaced olecranon fracture
C) Displaced supracondylar fracture
D) Displaced lateral condylar fracture
E) Displaced medial condylar fracture
C) Displaced supracondylar fracture
: case swelling and triangle landmark at Rt elbow
triangle landmark Heuters triangle olecranon process , medial lateral
epicondyle

triangle landmark
normal triangle
landmark
olecranon process , medial lateral epicondyle
Displaced supracondylar fracture

supracondylar fracture of humerus

case
C Displaced supracondylar fracture

supracondylar fracture
- extension (95%) flexion (5%)

- Dislocation elbow Dislocation elbow triangle

- Inveatigate : film AP , Lat
- Treatment :
flex elbow 90o , pronation 3-4 wk
reduction under GA fluoroscope
K-wire fixation indication K-wire fixation
1. open fx
2. reduction
3. vascular injury
Ref: 2550
 6. 65 crepitation Dx
a) OA
b) RA
c) gout
d) pseudogout

a) OA
: ( 65 ^,^) crep choice

OA ( > )
DIP
joint crepitation

RA 30-50 symmetrical poly arthritis

PIP , MCP

Gout 35
acute monoarthritis abruptness of onset
crepitation

Pseudogout calcium pyrophosphate dihydrate deposition disease

OA Pseudogout , MCP

OA knee
1.
2. (crepitation)
3. 30
4. 38
5.
OA knee 1-4 1,2,5 Sensitivity 89% , Specificity 88 %

Ref : 2550 + short note in medicine

 7. 10 MCA PE:swelling at elbow, triangle landmark
at Rt. Elbow, Dx?
1. Dislocation elbow
2. Displaced olecranon Fx
3. Displaced supracondylar Fx
4. Displaced lateral condylar Fx
5. Displaced medial epicondyla Fx
3) Displaced supracondylar fracture
: 5 case swelling and triangle landmark at Rt elbow
triangle landmark Heuters triangle olecranon process ,
medial lateral epicondyle

triangle landmark
normal triangle
landmark
olecranon process , medial lateral epicondyle
Displaced supracondylar fracture

supracondylar fracture of humerus

case
C Displaced supracondylar fracture

supracondylar fracture
- extension (95%) flexion (5%)

- Dislocation elbow Dislocation elbow triangle

- Inveatigate : film AP , Lat
- Treatment :
flex elbow 90o , pronation 3-4 wk
reduction under GA fluoroscope
K-wire fixation indication K-wire fixation
4. open fx
5. reduction
6. vascular injury
Ref: 2550
 8. 25 Motorcycle accident
PE: Leg - internal rotation, adduction, hip flexion Dx.
a. Posterior hip dislocation

a. posterior hip dislocation

: Posterior hip dislocation flexion-
adduction-internal rotation

flexion-adduction-
posterior hip
internal rotation
dislocation

simple dislocation femur head acetabulur rim

hip dislocation

posterior hip dislocation flexion-adduction-internal rotation

anterior hip dislocation
Central dislocation
1. Obturator tupe : flexion abduction-external rotation
2. iliac type : extension-abduction-external rotation
anterior and/or posterior column
head of femur
greater trochanter

Ref: 2550
9. 59 Biceps reflex
1. C5 4. C8
2. C6 5. T1
3. C7
1. C5 deep tendon reflex
Biceps C5-C6 Knee L3-L4
Triceps C7-C8 Ankle S1-S2
Wrist C6-C7
11. 20 X-ray fracture neck of humerus

1. Deltoid 4. Triceps
2. Brachialis 5. Coracobrachialis
3. Biceps
1. deltoid injury neck of humerus injury axillary nerve deltoid

12. 52 yr PE: sensory intact, no thenar atrophy, Phalen test +ve

Tx
1. Observation 4. Long arm cast
2. NSAIDS 5. A1 pulley release
3. Epidural steroid injection
Carpal tunnel syndrome median nerve
compression neuropathy upper extremity
Clinical picture - palmar radial median nerve

Thenar muscle
NSAID synovitis, steroid injection
choice 3
steroid epidural carpal tunnel ( Palmaris longus ) 4
long arm cast 5 A1 pulley release trigger finger carpal tunnel
2 NSAID ...

13. 22 10 .
T2
BP 180/110, PR 56 bpm Mx
1. Foley catheter
2.
3. Hydralazine
4. BP
5.
Autonomic dysreflexia over-activity of the Autonomic Nervous
System T6 irritating stimulus spinal
cord injury

Bladder (most common) - from overstretch or irritation of bladder wall

A. Urinary tract infection D. Overfilled collection bag
B. Urinary retention E. Non-compliance with intermittent
catheterization program
C. Blocked catheter


Signs & Symptoms

Pounding headache Flushed (reddened) face

(caused by the elevation in blood pressure)
Red blotches on the skin above level of
Goose Pimples spinal injury

Sweating above the level of injury Sweating above level of spinal injury

Nasal Congestion Nausea

Slow Pulse Slow pulse (< 60 beats per minute)

Blotching of the Skin Cold, clammy skin below level of spinal

injury
Restlessness

Hypertension (blood pressure greater than

200/100)

Immediate sitting position, but do a pressure release immediately. You may transfer yourself to bed, but always
keep your head elevated
check most common
medication Immediate/emergent

o Procardia - 10 mg. p.o./sublingual

o Nitroglycerine - 1/150 sublingual or 1/2 inch Nitropaste topically

o Clonidine - 0.1 to 0.2 mg. p.o.

o Hydralazine - 10 to 20 mg. IM/IV

Chronic (recurrent episode prevention)

o Prazosin ("Minipress") - 0.5 to 1.0 mg. daily

o Clonidine ("Catapres") - 0.2 mg. p.o. b.i.d.

2
14. Pt 69 yr , OA genu varus
1. isotonic
2.
3. isometric Hamstring strength
4. medial

Ans. 2.
American College of Rheumatology(15)
-
- osteophyte
- 1
1. 50
2. 30
3.
OA
1.
- (range of motion/ flexibility exercise)
- ( isometric
isotonic) strengthening quadriceps , stretching hamstring
-
3.
-
- (heel wedging) external varus moment
medial compartment load
4.
5. Transcutaneus electrical nerve stimulation (TENS)

6.

14. Cervical traction

1. MRI
2. Cervical traction . 8 kg
3. Cervical traction
4. Heat
Ans. cervical traction 8 kg.
spondylosis management film c-spine
cervical traction contraindication 5 10 kg.
investigate CT

1. whiplash injury
radicular pain x-ray
lordotic curve
2. cervical disc syndrome

dermatome
3. cervical spondylosis
4. myofascial pain syndrome
Traction

Contraindication to traction
- osteomyelitis or discitis , infection
- primary bone tumor or spinal cord tumor
- unstable fracture , myelopathy
- severe osteoporosis
- hypertension
- cardiovascular disease

15. 25 Fracture head of humerus

a. Brachioradialis m.
b. Deltoid m.
c. Brachialis m.
d. Coracobrachialis m.
e. Biceps m.

Ans. b. Deltoid m.
fracture of head of humerus
axillary nerve injury axillary nerve
ORIF
nerve innervation
a. Brachioradialis m. innervated by radial nerve
b. Deltoid m. innervated by axillary nerve
c. Brachialis m. innervated by musculocutaneous nerve
d. Coracobrachialis m. innervated by musculocutaneous nerve
e. Biceps m. innervated by musculocutaneous nerve

deltoid muscle
 : fracture shaft of humerus radial nerve
(Holdstein Lewis fracture)
innervation muscles in the posterior compartment of the arm and forearm

16. 90 1 cervical traction 30 5-8 kg

1 wk
a. traction
b. traction
c. physical modality
d. traction then MRI
e. +

Ans d. traction then MRI

cervical spondylotic myelopathy MRI
cervical traction
cervical spondylotic myelopathy contraindication cervical traction
cervical spondylotic myelopathy


long tract
sign ( )
17. Rt. Below knee amputation stump

A. 7 D. 30
B. 10 E. 45 s
C. 15
Ans 7 -
Post operative rehab. -
Stump - neuroma phantom pain
- Above knee amputation
- 2
- Below knee amputation
- 1
-
18. Erbs palsy Lesion
Ans. C5-7
Erbs palsy (brachial plexus palsy, Erb-Duchenne paralysis )
- paralysis of the arm caused by injury to the upper group of the arm's main nerves
(specifically, C5-C6), almost always occurring during birth.
-

- Clinical :

: adduction internal rotation
extension pronation phrenic nerve
paralysis of diaphragm
- Investigation : chest x-ray
Fluoroscope movement diaphragm
- Diagnosis :
- Treatment : 80-90% recovery
Passive movement exercise 1 wk. 1-2
wk.

19. Rheumatoid arthritis

Ans. finger extensor , wrist extensor , foot intrinsic,
quadriceps muscle toe extensor, peroneus, Gastrocnemius,
Hamstring, Hip flexor Hand intrinsic m.
-
,

- ( )
1-10 ( 10 ) - ( 10-
20 )
 20. 59 Biceps,Bicep reflex
A. C5 D. C8

B. C6 E. T1

C. C7

Ans. C5
Key muscle : C5 - Biceps brachii L2 - Hip flexor
C6 - ECR L3 - Knee extensor
C7 - Tricep brachii L4 - Tibialis anterior
C8 - FDP L5 - EHL
T1 - ADM S1 - Gastrocnemius

17. carpal tunnel syndrome tx :

1. observe
2. tendon release
3. NSAIDs
carpal tunnel syndrome ( )
Non operative therapy : splint neutral position o
NSAID synovitis
Diuretic edema
underling disease
Steroid injection : Operative therapy :
o 1
o o Classic open carpal tunnel release
o thenar atrophy o Limited incision technique
o o Endoscopic carpal tunnel release
o Two-point discrimination
22. C-spine traction -
Mx : MRI
Cervical spine disease ( trauma, stenosis disc
herniation) conservative treatment
progressive neurological deficit investigate conservative
treatment
predominantly brachial pain failure to respond to four weeks of conservative therapy
MRI for evaluation
Worsening of brachial pain during adequate conservative therapy
neurologic deficit in the upper or lower extremities
23. triangular landmark
a) supracondylar fracture
b) lateral condylar fracture
c) olecranon fracture
d)...
triangular landmark isosceles triangle
olecranon process medial and
Lateral epocondye
fracture triangle
bony landmark

a) Supracondylar fracture
isosceles triangle Baumann angle 70 780
long axis of humerus physis of lateral condyle

b) Lateral condylar fracture

2nd most common fracture of elbow isosceles triangle
c) Olecranon fracture
triceps isosceles triangle
 Psychiatry
1. 35
A. Midazolam
B. Lorazepam
C. Clonazepam
D. Temazepam
E. CDZ

C. Clonazepam
panic disorder panic attack
SSRI fluoxetine 10 mg/day 20-40 mg/day
antidepressant Tricyclic imipramine 25 mg 25 mg/wk
BZD
Alprazolam 2-4 mg/day 4-6 wk Clonazepam 0.25 mg 2
Clonazepam interdose rebound

2.
A. Thioridazine
B. Risperidone
C. Haloperidol
D. Chlorpromazine
E. Clozapine

C. Haloperidol
side effect
EPS Akathisia

EPS Haloperidol

3. 9 3

A. sibling rivalry
B. Schizophrenia
C. simple phobia
D. simple reaction
E. separation anxiety disorder

E. separation anxiety disorder


A.
3
1.
2.
3.
4.
5.

6.
7.
8. ( )

4. 45
A.
B.
C.
D.
E.
E

Major Depressive Disorder

Major Depressive Disorder

A. 5 1. 2.
1.
2.
3. 5 1
4.
5. Psychomotor agitation OR retardation
6.
7. ------- E
8.
9.
B.

 5. 25 3

2
A. Normal grief reaction
B. Delirium
C. Brief psychosis
D. Adjustment disorder with depress mood
E. MDD with psychotic feature

Normal grief reaction The normal process of reacting to a loss. The loss may be physical
(such as a death), social (such as divorce), or occupational (such as a job).
Loss of appetite, Changes in weight, Sleep disturbance, Fatigue
Headache, Palpitations , Gastrointestinal distress, hallucination, Depression
Delirium Disturbance of consciousness, Disorientation, Attention deficit,
Sleep-wake disturbance, Illusion, Disorganized thinking


Brief psychotic disorder

1 1

Adjustment disorder with depress mood

6. 24 underlying Schizophrenia
20

A. Delirium
B. Akathisia
C. Acute stress disorder
D. Relapsed schizophrenia
E. Brief psychotic disorder
A. Delirium
Delirium Disturbance of consciousness, Disorientation, Attention deficit,
Sleep-wake disturbance, Illusion, Disorganized thinking


 Akathisia Dopamine antagonist Antipsychotic drug

Acute stress disorder (Anxiety disorder)

(Re-experienced)
(Hyperarousal)
(Avoidance)

Relapsed schizophrenia
, Disorganized speech, Grossly disorganized behavior, Sleep disturbance

Brief psychotic disorder

1 1

7. 22 ER

3 5
A. D.
B. E.
C.
Ans. E (paranoid type )
A.

B. (mitragynine)
-

-
-
-
C.

D.

1.
2.

3.

E.







8. REM sleep
A. Dream
B. Penile erection in male
C. Decrease respiratory rate
D. Change in body temperature
E. Near-total paralysis in skeleton muscle
Ans. E
REM atonia, a state in which the motor neurons are not stimulated and thus the body's muscles don't move.
Heart rate and breathing rate are irregular during REM sleep.
Body temperature is not well regulated during REM.
Erections of the penis (Nocturnal Penile Tumescence or NPT)
Clitoral enlargement, with accompanying vaginal blood flow and transudation (i.e. lubrication)
Dreams are strongly associated REM sleep (Always dream)

9. 18

A. Fluoxitine
B. Paroxetine
C. Lithium
D. Imipramine
E. Amitrytyline

Ans. A.
eating-disorder (Anorexia & Bulimia nervosa) antidepressants
SSRIs depression ,
fluoxetine fluoxetine ( 60 mg/day)
appetite anorexia nervosa
antidepressants anorexia nerrosa
hypotension arrhythmia depression
(Paroxetine 18 )
10. 40 admit
BP 150/110 HR 80
A. IM Haloperidol
B. IV Diazepam
C. IM Clopixel adepine
D. IM Clopomazine
E. IM Thiamine
--------------------------------------------------------------------------------------------------------------------------------------

Impression: Alcohol withdrawal

Clinical presentation
Classic signs
Tremor: 6-8 hr
Delusion & hallucination: 8-12 hr
Seizure: generalized tonic clonic
Delirium tremens: 72 hr
Sympathetic autonomic hyperactivity: , tachycardia, , , ,
mydriasis, alert

Treatment
Benzodiazepines signs & symptoms long acting Diazepam,
Chlordiazepoxide seizure liver disease short acting Lorozepam
Antipsychotic drugs: Haloperidol agitation
Thiamine: Wernikes encephalopathy Korsakoffs syndrome
Folic acid
Electrolytes

B. IV Diazepam
11. 50

A. Denial
B. Depair
C. Depression
D. Bargaining
E. Anger
----------------------------------------------------------------------------------------------------------------------------- ---------
Denial
Defense mechanism
Level 1 Defense Mechanisms
The mechanisms on this level, when predominating, almost always are severely pathological. These three defences,
in conjunction, permit one to effectively rearrange external reality and eliminate the need to cope with reality. The
pathological users of these mechanisms frequently appear crazy or insane to others. These are the "psychotic"
defences, common in overt psychosis. However, they are found in dreams and throughout childhood as healthy
mechanisms.
They include:
Denial: Refusal to accept external reality because it is too threatening; arguing against an anxiety-provoking stimulus
by stating it doesn't exist; resolution of emotional conflict and reduction of anxiety by refusing to perceive or
consciously acknowledge the more unpleasant aspects of external reality.
Distortion: A gross reshaping of external reality to meet internal needs.
Delusional Projection: Grossly frank delusions about external reality, usually of a persecutory nature.
Level 2 Defence Mechanisms
These mechanisms are often present in adults and more commonly present in adolescence. These mechanisms
lessen distress and anxiety provoked by threatening people or by uncomfortable reality. People who excessively use
such defences are seen as socially undesirable in that they are immature, difficult to deal with and seriously out of
touch with reality. These are the so-called "immature" defences and overuse almost always lead to serious problems
in a person's ability to cope effectively. These defences are often seen in severe depression and personality
disorders. In adolescence, the occurrence of all of these defences is normal.
These include:
Fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts.
Projection: Projection is a primitive form of paranoia. Projection also reduces anxiety by allowing the expression of the
undesirable impulses or desires without becoming consciously aware of them; attributing one's own unacknowledged
unacceptable/unwanted thoughts and emotions to another; includes severe prejudice, severe jealousy,
hypervigilance to external danger, and "injustice collecting". It is shifting one's unacceptable thoughts, feelings and
impulses within oneself onto someone else, such that those same thoughts, feelings, beliefs and motivations are
perceived as being possessed by the other.
Hypochondriasis: The transformation of negative feelings towards others into negative feelings toward self, pain,
illness, and anxiety.
Passive aggression: Aggression towards others expressed indirectly or passively.
Acting out: Direct expression of an unconscious wish or impulse without conscious awareness of the emotion that
drives that expressive behavior.
Idealization: Subconsciously choosing to perceive another individual as having more positive qualities than he or she
may actually have.[2]
Level 3 Defence Mechanisms
These mechanisms are considered neurotic, but fairly common in adults. Such defences have short-term advantages
in coping, but can often cause long-term problems in relationships, work and in enjoying life when used as one's
primary style of coping with the world.
These include:
Displacement: Defense mechanism that shifts sexual or aggressive impulses to a more acceptable or less
threatening target; redirecting emotion to a safer outlet; separation of emotion from its real object and redirection of
the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing
directly with what is frightening or threatening. For example, a mother may yell at her child because she is angry with
her husband.
Dissociation: Temporary drastic modification of one's personal identity or character to avoid emotional distress;
separation or postponement of a feeling that normally would accompany a situation or thought.
Isolation: Separation of feelings from ideas and events, for example, describing a murder with graphic details with no
emotional response.
Intellectualization: A form of isolation; concentrating on the intellectual components of a situation so as to distance
oneself from the associated anxiety-provoking emotions; separation of emotion from ideas; thinking about wishes in
formal, affectively bland terms and not acting on them; avoiding unacceptable emotions by focusing on the
intellectual aspects (e.g. Isolation, Rationalization, Ritual, Undoing, Compensation, Magical thinking).
Reaction Formation: Converting unconscious wishes or impulses that are perceived to be dangerous into their
opposites; behavior that is completely the opposite of what one really wants or feels; taking the opposite belief
because the true belief causes anxiety. This defence can work effectively for coping in the short term, but will
eventually break down.
Repression: Process of pulling thoughts into the unconscious and preventing painful or dangerous thoughts from
entering consciousness; seemingly unexplainable naivety, memory lapse or lack of awareness of one's own situation
and condition; the emotion is conscious, but the idea behind it is absent.
Regression: Temporary reversion of the ego to an earlier stage of development rather than handling unacceptable
impulses in a more adult way.
Level 4 Defence Mechanisms
These are commonly found among emotionally healthy adults and are considered the most mature, even though
many have their origins in the immature level. However, these have been adapted through the years so as to optimize
success in life and relationships. The use of these defences enhances user pleasure and feelings of mastery. These
defences help the users to integrate conflicting emotions and thoughts while still remaining effective. Persons who
use these mechanisms are viewed as having virtues.
These include:
Altruism: Constructive service to others that brings pleasure and personal satisfaction
Anticipation: Realistic planning for future discomfort
Humor: Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk
about) that gives pleasure to others. Humor, which explores the absurdity inherent in any event, enables someone to
call a spade a spade, while "wit" is a form of displacement (see above under Category 3). Wit refers to the serious or
distressing in a humorous way, rather than disarming it; the thoughts remain distressing, but they are 'skirted round'
by the witticism.
Identification: The unconscious modeling of one's self upon another person's character and behavior
Introjection: Identifying with some idea or object so deeply that it becomes a part of that person
Sublimation: Transformation of negative emotions or instincts into positive actions, behavior, or emotion
Suppression: The conscious process of pushing thoughts into the preconscious; the conscious decision to delay
paying attention to an emotion or need in order to cope with the present reality; able to later access uncomfortable or
distressing emotions and accept them

Oh !!!!!!
NO
12. 40 Schizophrenia 1 PR 120 /min,
other: WNL, EKG: sinus tachycardia
A. Haloperidol
B. Thioridazine
C. Fluphennazine
D. Perphenazine
E. ?
----------------------------------------------------------------------------------------------------------------------------- ---------

Haloperidol
CNS: seizure, extrapyramidal reaction, confusion, drowsiness, restlessness, tardive dyskinesia
EENT: blurred vision, dry eyes
Respiratory: respiratory depression
CVS: hypotension, tachycardia
GI: constipation, drymouth, anorexia, drug-induced hepatitis, ileus, weight gain
GU: urinary retention
Derm: diaphoresis, photosensitivity, reshes
Endo: galactorrhea, amenorrhea
Hemat: anemia, leukopenia
Metab: hyperpyrexia
Misc: neuroleptic malignant syndrome, hypersensitivity reaction
Thioridazine
CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reaction, tardive dyskinesia
EENT: blurred vision, dry eyes, lens opacities, pigmentary retinopathy (high dose)
CVS: arrhythmia, qtC prolongation, hypotension, tachycardia
GI: constipation, drymouth, anorexia, drug-induced hepatitis, ileus, weight gain
GU: urinary retention, priaprism
Derm: , photosensitivity, pigment change, rashes
Endo: galactorrhea, amenorrhea
Hemat: agranulocytosis, leucopenia
Metab: hyperthermia
Misc: allergic reactions
Fluphennazine
CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reaction, tardive dyskinesia
EENT: blurred vision, dry eyes
CVS: hypertension, hypotension, tachycardia
GI: anorexia, constipation, drymouth, drug-induced hepatitis, ileus, nausea, weight gain
 GU: urinary retention
Derm: , photosensitivity, pigment change, rashes
Endo: galactorrhea
Hemat: agranulocytosis, leukopenia, thrombocytopenia
Misc:allergic reactions
Perphenazine
CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reaction, tardive dyskinesia
EENT: blurred vision, dry eyes, lens opacities
CVS: hypotension, tachycardia
GI: constipation, drymouth, anorexia, ileus, weight gain
GU: discoloration of urine, urinary retention
Derm: photosensitivity, pigment change, rashes
Endo: galactorrhea, amenorrhea
Hemat: agranulocytosis, leukopenia
Metab: hyperthermia
Misc:allergic reactions

13. Schizophrenia Haloperidal 20 mg/d , Trihexyphenidyl 6 mg/d

A. Haloperidal
B. Haloperidal .................
C. Psychotherapy
D. long acting
E. ?
A ( A B)
extrapyramidal system(EPS) side effect Haloperidal
Trihexyphenidyl(Artane) EPS
EPS Akathisia ( ) Akatisia
propranolol diazepam ( choice)
Schizophrenia Haloperidal 6-10 mg/d 2 wk
20 mg/d ()
serotonin dopamine antagonist EPS
( )

14. 3
A. Schizophrenia
B. Bipolar disorder
C. Anxiety disorder
D. Depressive disorder
E.?
D
Depressive ( )

15. 18
()
A. Buspirone
B. Imipramine
C. Chlorpromazine
D. Clomipramine
E.?
B.
Agoraphobia without history of panic disorder
SSRI Fluoxetine (chioce)
TCA Imipramine
Buspirone Antianxiety
Chlorpromazine DA (Antipsychotic drug)
Clomipramine TCA (Antidepressant

16. 35 2

A. Lorazepam B. Midazolam C. Tenazepam D. Chlordiazepoxide E. ???
Clinical panic attack
Criteria : 4 10
1. 2.
3. 4.
5. 6.
7. 8.
9. Derealization depersonalization 10.
11.
Treatment : durg + cognitive behavioral therapy
- First line drug : SSRI Fluoxetine : start 10 mg/d 20-40 mg/d oral pc
 - TCA Imipramine : start 25 mgx1 wk dose 25 mg/wk ~ 50-75 mg
- Benzodiazepine Alprazolam 2-4 mg/d
*** antidepressant + benzodiazepine X 4-6 wk antidepressant
dose benzodiazepine antidepressant
choice 3 (Fluoxetine, Imipramine, Alprazolam) E.

17. 25 2 SI 6 HIV
negative 3 3 DSM IV
A. Conversion disorder B. Chronic schizophrenia C. Schizotypal personality disorder
D. Delusional disorder : somatic type E.?
non-bizarre delusion 6 auditory hallucination 3
Delusional disorder Schizophrenia criteria

Schizophrenia Delusional disorder

A. 2 1 A. non-bizarre delusion 1
- delusion B. A. schizophrenia
- hallucination C.
- disorganized speech
- grossly disorganized behavior D. mood episode
- negative symptom : flat affect, alogia, avolition
B. social/occupation function E.
C. 6 active
phase 1
prodromal residual phase
D.

Delusional disorder schizophrenia

(systematized delusion) schizophrenia

Schizophrenia (paranoid type) delusional disorder schizophrenia

hallucination bizarre delusion schizophrenia

18. emphysema BP , conscious

A. withdraw B. develop dementia C. develop personality disorder
develop personality disorder cluster A ( paranoid, schizoid, schizotypal)
schizoid personality disorder criteria
A.
4

1.
2.
3.
4.
5.
6.
7.
B. schizophrenia, mood disorder with psychotic feature psychotic disorder

19. PTSD PTSD

A. B. C. D. ? E. ?
Criteria PTSD
1.
2.
3. (re-experienced) ()
4. ( avoidance)
5. (hyperarousal)
6.
7. 1 ( 1 Dx. Acute stress disorder)
A.
20. ( )
A. Methanal
B. Ethalene glycol
:
..
(Alcohol)
2
1 (Gramoxone)
(Kingzone)
4-5 3-4
2

(Folidol) (Lannate)

2


(fusel oil), (nitrosamine), (iso amyl alcohol), (iso
butyl alcohol) (n-propyl alcohol)
(co-carcinogen) (carcinogen)

( ) (,
)
paraquat poisoning choice 2
http://webdb.dmsc.moph.go.th/Hazardous/content1.asp?info_id=17
21. NS intact .
A. B1 IV B. 50% glucose IV
:
Alcohol intoxication
Neuro sign intact

1. 4. glucose iv thiamine
2. 100 mg iv
3. agitate diazepam 5-10 mg
iv alcohol
Valium alcohol choice
103
22. panic,
A. Panic attack
B. Acute stress disorder
:
Review panic attack Panic attack
DDX
Phobia specific
Acute stress disorder/Posttraumatic stress disorder panic
(Acute stress disorder/Posttraumatic stress disorder 4 wk )
..... B

165,177
23. diaphoresis, miosis, drooling
A. opioid
B. organophosphate

:
Diaphoresis, miosis, drooling orgnophosphate Opioid drooling
organophosphate/carbamate poisioning
muscarinic: SLUDGE
Nicotinic: Miosis and Fasciculation
Opiate
nausea and vomiting, drowsiness, itching, dry mouth, miosis, and constipation
By Fiat
24. learning diaorder
Reading disorder Dyslexia
:

Learning disorder 3
1. Reading disorder Dyslexia
2. Mathemathic disorder
3. Disorder of written expression (
reading disorder)
25. ADHD
Methylphenidate
: Attention deficit hyperactivity DisorderADHD 3
1. Inattentiveness
2. Hyperactivity
3. Impulsivity

Psychostimulant ADHD

methylphenidate

26. amphetamine overdose comfirm

Whole Blood 100 ml () , urine 100 ml
reference
Unknown case

Blood ( WB 100 ml, Clotted blood 10 ml )

- ChE , paraquat , drugs , ()

Blood (WB)
- Alcohol , toluene

Gastric content 100 ml

- Insecticides , herbicide , rodenticides , drugs

Urine 100 ml
- ChE , paraquat , drugs ,

Bile : opiates
Liver : opiates , drugs
Vitreous humor : alcohol
27. 65
choice
mood disorder neuro disorder ( Dementia
onset )
mood disorder MDD 2 wk
fluoxitine oral od,pc amitryptyline diazepam