!" 
#$%  $&'"( )

*#+,$& $
+&$$&% -.-,+   
"+ $& .$*0) 1 . 1, .. 34565* *.41, .5
1 *
(
 1*+), *+%4 Med,  002,  014, @ 074, *- 085, )* 095,
 4E4F 118, )G Lulu 126, 5* 155
 !4&@,  #4&$!) "&% #
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6&  *1   M- 


  ^__^
 4707xxx
Chiangmai Medical School

Internal medicine
1. 4)
6
1 "!" SLE +-& "+  % 
  @P4%4 +*

 SLE +-&# anti-dsDNA
 % 
ANA  sensitivity ) %$
* SLE
2. 3) M)@] Acute arthritis $ joint fluid @L septic profile (WBC > 50,000)  c/s "@L gram negative diplococci
intracellular $& Gonococcal arthritis +-& Drug of choice # Ceftriaxone
Joint fluid analysis
1. !@L Hemorrhagic effusion "!" trauma, coagulopathy, etc.
2. !$ Hemorrhagic effusion &)@L Inflammatory, noninflammatory  # septic profile
Noninflammatory
Inflammatory
Septic
WBC > 50,000 /L, PMN > 75%
WBC < 2,000 /L
WBC > 2,000 % < 50,000 /L
Osteoarthritis, trauma 
 crystal Gout, pseudogout
$
 crystal RA, seronegative

(Gram stain/Culture positive, glucose %+)

Septic arthritis

3. 1) Taenia solium 44

 Neurocysticercosis
Cysticercosis &   generalized, CT 
 multipled calcified cystic lesion
@L accidental host "+ 4$ Taenia solium $@ ($)%M&% ,)
Toxoplasma immunocompromised, CT 
 ring calcification,  transplacental transmission
4. 3) 6
1&)-
"!" TB +-& %#+
 sputum AFB M negative 3  
" $
 $
%&4@L TB + # bronchoscopy *#+ R/O CA * 
  CXR 6@L CA lung $&
Diagnosis of TB
1. :/:
< : $ #  (> 3 wk) , $@L#&, &, $,  #+ #
2. Chest X-ray: Not specific  Not prove active disease, Strongly suggest TB #+@L+ upper zone (apical  #
postr seg. of upper lobe, supr seg. of lower lobe),  cavitation  # calcified shadow
3. Acid-fast staining: detect $&#+ > 104 AFB/ml, Not specific to M. tuberculosis
4. Culture: Gold standard, sensitivity )  AFB (detect $&#+ > 103 AFB/ml)
5. Bronchoscopy:  # M)@]$ !$$&, R/O CA $$&, #@&% 

$*#  #M)@] massive hemoptysis *#+% +#&

6. Tuberculin skin test: $ Dx, & infection $$&& disease, @|

-+# &- TB 

-, - 44
 TB &, 44
 extrapulmonary TB,  -+ +% @}  %4&#
5. 2) Guillain-Barre syndrome
M)@] weakness  quadriplegia  # generalized weakness "+ 
4&$&
 CNS  # motor unit $& !

 CNS  conscious/cognitive change,  hypertonia, hyperreflexia )5 sensation &  !@L
neuromuscular cause 
 normal mental function, muscle tone @%4 #& , reflex @%4 #&  
" 

@L
 neuromuscular cause (nerve, muscle, NMJ) $@% 16. 
 ()

6. 1) Constrictive pericarditis
Neck vein engorgement, hepatomegaly = signs of right-sided heart failure
Diffuse ST-T change with low voltage = pericarditis
Pericarditis   pericardium "+ - myocardium ) 4& myocardial injury +, 4&@L
diffuse ST-T change, Low voltage
 pericardial effusion   heart  electrode
Pericarditis + Rt.-sided heart failure = Constrictive pericarditis
7. 1) Acute pancreatitis
Keyword: 4, @& 4@, $@ ,  %&"
8. 5) Varicella zoster infection
9. 1) S. aureus
Pyomyositis 4&#5, Quadriceps, Gluteus # most common # S. aureus
10. 1) TIA
@L%#&+@L Transient neurodeficit #+@L$@,
11. 3) Roxithromycin
Atypical pneumonia Clue : -,  URI , CXR: interstitial infiltration
Organism: Mycoplasma pneumonia most common
S/S:
Insidious onset *  - M)5%%
Progress
 URI  $@ LRI , viral infection
 *  $  #+  headache, myalgia, nausea, vomiting,
diarrhea, fatigue, sore throat
CXR:
Diffuse interstitial (reticular) infiltration
KL:
Macrolide (Erythromycin, Azithromycin, Clarithromycine), Doxycycline
12. 3) M)@]4 electrolyte % ,
 hypo & 4+ + %&# hyperK, hyperNa
hypoNa
 osmolality  #&%+ 
 shift  cell  1  brain edema  IICP %
hypoK $M% consciousness
" "!" 
hypoCa
& circumoral numbness, % 4
Acute gastric dilatation $ $ )??
SIADH !" 
 hypoNa %$
+
13. Lead
Lead poisoning: N<, P<: , motor neuropathy
Lead $@ $1 ferrochelatase  -ala dehydratase     heme M)@]&
MCHC  PBS 
 basophilic stippling
 Peripheral motor neuropathy (wrist drop, foot drop)
@&  #  @&
Renal tubule damage
Lead line + gingival-tooth border
14. 10% Calcium gluconate
3 K ) , # advanced EKG change 4+ +5+-&#%  protect heart 

KL HyperK
1. Protect heart : *#+ advanced EKG change  # K > 6.5 mmol/L
 10% Calcium gluconate (E4F antagonist)
2. Move K U cell :  Insulin + glucose, NB albuterol, (+ NaHCO3)
3. UKV K :  Kayexalate + sorbitol (+ Furosemide, Hemodialysis)
15. 3) Leptospirosis
DF, DHF

Enteric fever

Leptospirosis

Signs and
symptoms
Skin
Jaundice

$) @&#+
RUQ pain, N/V
Rash, Petechiae
$#

$ P<:

% 
%
#
%

eKVfe
6%+

%6%
$6%

$) P<
Z[\]: ([ : )
Rash (rare)
Z\: bPa[
icteric type
%6%
*

$%&

Meningitis

%& 

subconjunctival
hemorrhage
$

rare

Lung

Effusion

CBC

@%4

U/A

Hct, WBC,
Atyp.lymph,
plt
RBC

Others

i<j[

Peyers patch
ruptured
pneumoperitoneum

Rose spot (rare)



Murine typhus,
Scrub typhus
$

Malaria

Rash (rare)


$ (:`Pa[
pattern)
No rash
Zc[: d 

%6%
6%*+

%6%
$6%

e
<

%&

$%&

Aseptic
meningitis

* infiltration
(pulm hemorrhage)
WBC, neutrophil
&, plt

Aseptic
meningitis
Interstitial
pneumonia
varies

$

Eschar

nP
<[

 [e  <

RBC, WBC,
proteinuria, cast
CPK
Hx Zk[]l

Pulmonary edema
Anemia, WBC,
neutrophil &, plt

16. 2) Dermatomyositis
Proximal muscle weakness ("$& -)
1. Nerve:  sensory, reflex, autonomic involvement @L distal
Guillain-Barre syndrome
Acute autoimmune demyelination of peripheral nerve

$&@ %4 recent Campylobacter jejuni infection, viral infection  # influenza vaccination 
 weakness (
 CN involvement)  sensation loss  glove and stocking (!- #!- ),
hyporeflexia  # areflexia, LP 
6@ %)

 (: Plasmapheresis  IVIG ($ role    steroid )

Diabetic polyneuropathy
4&
  axon, *E1 chronic hyperglycemia
Affect motor (mild weakness), sensory (glove and stocking), autonomic % sensory &
2. Muscle: -$ sensation loss $ hyporeflexia/areflexia
Polymyositis/Dermatomyositis
Symmetric progressive proximal muscle weakness

 muscle pain, serum CK "
Dermatomyositis = polymyositis + skin involvement (Heliotrope: M#+ %, shawl sign: M#++$ 

, V-sign: M#+# V, Gottrons sign: M#++ # 4. bony prominent)

(: Steroid
Steroid-induced myopathy
Insidious onset,  Hx  steroid ,  @L asthma, COPD, rheumatoid
Hypokalemic periodic paralysis
M)@] -    %#+ @ %4#+ , #4 #5
(high carbohydrate meal)
% weak 
 serum K
%+
 
 TFT *#+4&
1) Familial !& AD,  Family Hx, TFT @%4
2) Thyrotoxic   thyrotoxicosis  # TFT @L hyperthyroidism
3. NMJ: -#- muscle %
 fluctuation ( ", ,)  fatigability (%  4+ 4+  )
Myasthenia gravis
Autoantibody % postsynaptic Ach receptor
*E1 thymoma
Ptosis,  Bulbar involvement $&
Fluctuation and fatigability
17. 5) PFT   Asthma
"   Pulmonary function test *#+&) FEV1/FVC &) response % bronchodilator
Abnormal PFT

FEV1/FVC > 70%

Restrictive lung disease

FEV1/FVC < 70%

Obstructive lung disease
Bronchodilator

FEV1 *4+ > 12%

Asthma

FEV1 *4+ < 12%

COPD

18. 2) Thiamine   signs  CHF #  #+ (Rt.-sided) + pulmonary edema, LV systolic failure (S3 gallop),
cardiomegaly (Lt.-sided)
%-+6
1
4&
 Cardiac beriberi (4 & Vitamin B1 (thiamine) Cardiac beriberi)
KL:  Vitamin B1 (thiamine)
19. 1) Chigger mite @L* Orientia tsutsugamushi
20. 3) Neurogenic shock
4&
%CO PCWP SVR
 (
Hypovolemic Trauma, blood loss, third
 isotonic solution  ##&

(volume & )
space loss, burn
Cardiogenic
Tension pneumothorax,
(%(#&

CHF, cardiac tamponade,
Dobutamine, dopamine or NE

$$&)
arrhythmia, MI, structural
heart disease
Distributive shock

(vasodilate)

Septic

Bacteremia 6&*
gram neg.

 fluid  ABO

*4
 . Swan-Ganz catheter
 dopamine  # NE
 Diphenhydramine
 1:1000 epinephrine ! -

Anaphylactic * , M" %

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

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

21. 1) Inhaled Salbutanol prn + inhaled corticosteroid

Management of asthma

Mild
intermittent
Mild
persistent
Moderate
persistent
Severe
persistent

Day attack

Night attack

< 1 /@&1

< 2 /&#

PEF  #
FEV1
> 80%

> 1 /@&1

> 2 /&#

> 80%

-


%&
limit activity

> 1 /@&1

60 - 80%

> 30%

+ LABA

 #

< 60%

> 30%

+ Theophylline  # oral
LABA  # Leukotriene
modifier  # oral
corticosteroid

Treatment

Variability
< 20%

SABA #+

20 - 30% + Inhaled corticosteroid

22. ASA + Propanolol

Subacute thyroiditis (de Quervains thyroiditis)  @L  # 1. Thyrotoxic phase 2. Hypothyroid
phase  3. Recovery phase M)@]
& %$ &16%
 (
$@ $ , )) 6&$& 
 thyrotoxicosis  hypothyroidism 
  URI @&1 56  %
  turn @L hypothyroidism !
KL  Aspirin high dose  # NSAIDs *#+& @& !@L
 steroid &  
thyrotoxicosis 
$&  # $&& -blocker ($ role    antithyroid drug  thyrotoxic phase)
23. 1) Simple goiter
24. 3) Thoracic area @L UMNL, cord lesion *  Hyperreflexia, loss of sphincter tone  level of sensation loss
&+
@L$@$&+-&# Thoracic area * !" &&# (T10)
25. 1) Atropine
Bradycardia
Airway, O2, monitor EKG,  IV

Adequate perfusion

Observe, monitor

Poor perfusion

Conscious change, 
%&,
BP drop, shock

%4& transcutaneous pacing

 Atropine 0.5 mg IV $& & 3  
 Epinephrine  # Dopamine IV drip
  pacer

26. 1) Anti-HIV   oral candidiasis

27. Pacemaker ($
)
AV black
PR prolong  & (> 0.02 sec  # 5  )
1st degree AV block
2nd degree AV block
Morbitz I
Morbitz II
3rd degree AV block
(complete heart block)

PR ,
 block $@ 1  
PR , %), block $@ 1  
Complete A-V dissociation # p wave  QRS
complex $*E1

1st degree  2nd degree Mobitz I @L+ 4&

 supranodal block  
@+$@ junctional
rhythm ( AV node @L%4&$}) $& HR @ . 45 ( 6)
 . 2nd degree Mobitz II 4&
 infranodal block (his, bundle branch) 6
 turn @L complete heart block
) "+ 

 idioventricular rhythm (ventricle @L%4&$}) HR @ . 20 ($ &) &  Mobitz II 
3rd degree AV block
" % %4& pacemaker

28. 4) Influenza vaccine M)) 29. 2) Pancarditis

4 ,
% pericarditis  Keyword # | $& rub (friction rub)
 | $& friction rub & !"   pleura  # pericardium ! *E1 % 


@L cardiac friction rub !*E1 

@L pleural friction rub
30. 1) Cardiac siderosis #3$@ deposit +

M)@] Thalassemia +% $&#&,

@ 4.4   4&3 hemochromatosis "+ 

$@+% , $& K
` heart failure, eKV cirrhosis/liver failure, eKV: :[ DM, Pituitary gland
hypogonadism, growth retardation
@. Choice 4) + 4&+  - -
31. 1) Ibuprofen
KL Rheumatoid arthritis
Physical, occupational therapy *4+   periarticular muscle
Drugs
Z< symptoms
ZsZ<:KV
Aspirin / NSAIDs E4F 
First line
Glucocorticoid (joint injection  # oral)
Second line
DMARDs d sZ:<l[[ft
First line
Hydroxychloroquine, sulfasalazine, methotrexate +6  active ,
Leflunomide, anti-TNF
Second line
#+, Azathioprine, gold, D-penicillamine, cyclosporine, cyclophosphamide
Surgery 
*4
 . + severe functional impairment
 deformity
32. 1) Ceftriaxone IV 
4 , % Aminoglycoside  Gentamycin 
Treatment of UTI
Acute cystitis: 3-day therapy
TMP-SMZ
+* Sulfa, & 4+&#"
fluoroquinolones
&
Acute pyelonephritis
OPD: GPC amoxicillin
GNB fluoroquinolones
IPD: GPC ampicillin
GNB aminoglycoside, cephalosporin (ceftriaxone, ceftazidime), fluoroquinolone
33. 2) Naloxone
$& Organophosphate poisoning
Organophosphate poisoning
Irreversible inhibit AChE enzyme
"   Ach overstimulation

Muscarinic effects: DUMBELS (Diaphoresis and Diarrhea; Urination; Miosis; Bradycardia, Bronchospasm,
Bronchorrhea; Emesis; Lacrimation; and Salivation)
Cardiovascular - Bradycardia, hypotension
Respiratory - Rhinorrhea, bronchorrhea, bronchospasm, cough, severe respiratory distress
Gastrointestinal - Hypersalivation, nausea and vomiting, abdominal pain, diarrhea, fecal incontinence
Genitourinary - Incontinence
Ocular - Blurred vision, miosis
Glands - Increased lacrimation, diaphoresis
Nicotinic effects $& muscle fasciculations, cramping, weakness,  diaphragmatic failure
CNS effects: anxiety, emotional lability, restlessness, confusion, ataxia, tremors, seizures,  coma
KL
GI decontamination, Activated charcoal
Antimuscarinic: Atropine 0.5 2 mg IV q 15 min
 complete atropinization (dry mouth)
Pralidoxime (2-PAM) 1 2 g IV $&- 8 +6
 nicotinic symptoms $@
! BDZ
34. 1) -
KL DM type II (Guideline  $ 2551)
1. FBG < 200 mg/dL  HbA1C < 8% Lifestyle modification 1 3 &# ! $$&%@}  start 
2. FBG 200 d 300 mg/dL Lifestyle modification + start  (%(.M)@])
Sulfonylurea
Metformin
(.& Insulin:
(. Insulin resistance:
2
2
BMI 23 kg/m
BMI < 23 kg/m
BP 130/85 mmHg  #$&&

%#&) &

&%#&) 
&
TG, HDL-C
Postprandial sugar )
 #: Glitazone, Repaglinide, -glucosidase inhibitor, DPP-4 inhibitor
( . FBS 250 350 mg/dL  # HbA1C > 9% 
*4
 . 2 4& )
3. FBG > 300 mg/dL  # HbA1C > 11% 
%#&)
 Insulin

Px

FBG 70 110 mg/dL

HbA1C < 6.5%
BP < 130/80 mmHg
LDL < 100 mg/dL (! CAD & keep + < 70 mg/dL)
 !"#$&'( )* $+,: keep FBG < 130 mg/dL, HbA1C 7%

35. 3) PTU
Treatment of Graveys disease (6  + &
KLft
1. Antithyroid drugs (PTU, Methimazole)

&  organification (PTU inhibit peripheral conversion T4 T3 $&)

!) &
 High recurrent rate, serious side effect: agranulocytosis
Indication: <c, t[: \:
[Vke (t
 PTU  ), Thyroid storm, 
6 $& +
 $ - , induce euthyroid stage  RAI  # Surgery, @L long term  + recurrent
hyperthyroidism  #+$$&M
Methimazole: Half-life  4  $&
%   2 @    %  L-thyroxine %
2. Radioactive iodine (I131)
High cure rate, safe & easy, &% , $M 
    infertility  # develop CA
 Hypothyroidism,  ophthalmopathy  , 
4& severe thyrotoxicosis / thyroid crisis M)@]
uncontrolled hyperthyroidism (  euthyroid)
Indication: @L First-line treatment  @ ', recurrent 
$& #M%&, :k (-!
4& hypothyroid
% 4%)
Contraindication / precaution:  /-% , -, Low radioiodine uptake, Severe hyperthyroidism,
Active ophthalmopathy,   CA thyroid, %5,, poor compliance
3. Surgery (Subtotal thyroidectomy)
@L euthyroid stage  
 Surgical complications (recurrent laryngeal n. injury, hypoparathyroidism), 6 relapse $&
Indication: e :
z , 
%$@&  , Severe Graves ophthalmopathy, :k[:,  
CA thyroid,   2nd trimester
Contraindication: previous neck surgery, severe systemic illness, lack of well-qualified surgeons
Z<: -blocker
%  # A. Radioactive iodine, B. Antithyroid drugs, C. Surgery
%6% 50 , moderate
B (6&+$@)
@L
 (& A, C
hyperthyroidism, new case
@L M%&$@
A
%5
A, C
-
A
$*
B, (A)
B, C
-
 hyperthyroidism - B then A, C

36. 1) Free T4 (*4+%4 #+ thyrotoxic hypoK periodic paralysis  16.)
37. 1) 2 wks
38. 5) NB salbutamol (
4 , iv steroid  )
KL Acute asthmatic attack
1.
 oxygen, keep O2 sat > 90%
2.
 bronchodilator
!:Vn k[


39. 4)

40. 1)

41. 3)
42. 5)

43. 3)
44. 4)
45. 5)
46. 1)

)& 2-agonist
 nebulizer  #
 MDI with spacer
!:Vk[
 (PEF < 50%  # #+
*)&$$&  # accessory muscle)
)& anticholinergic  2-agonist
3.
 Steroid :  IV  # oral steroid
4. #+,   antibiotic ! bacterial infection
Oral itraconazole
Treatment of Tinea unguium
Tinea unguium (Onychomycosis) @L6 +%  ( @L$& *$$&M % @L
4 6&+$@#
% %$&  +$& Oral griseofulvin, oral turbinafine, oral itraconazole
Psoriasis
@L-M#+- (papulosquamous) @L well-marginated, erythematous plaque with silvery scale * 4.
extensor surface,  ' (
Koebners sign positive +#+M#+", Auspitz sign positive #&4,
Associated findings: psoriatic arthritis, nail change (oil spot, onycholysis, pitting nail, subungual thickening)
Xanthelasma
* hyperlipidemia
Propanolol + Flunazine Propanolol = Beta blocker, Flunarizine = CCB
Migraine Drug
Prophylaxis: #+ > 3   %&#
TCA, -blocker, CCB, valproic acid, topiramate
Treatment (Abortive Rx):
1. ASA, acetaminophen, caffeine, high-dose NSAIDs
2. Dopamine agonist: Metoclopramide IV,
prochlorperazine IM or IV
3. 5-HT1 agonists (Triptan) M)@] CAD
4. Ergotamine  &  M)@] CAD
Subarachnoid hemorrhage
Keyword: @& + stiffness of neck
Myasthenia gravis
(&) 16.)
Intravenous immunoglobulin
@L Guillain-Barre syndrome (&) 16.)
Aspirin
Secondary prevention of STEMI
Smoking cessation
Aggressive lipid lowering
Control of hypertension and diabetes
Prophylactic use of aspirin, beta-blockers, and ACE inhibitors

10

47. 5) #$& Gout +-&#+

 *+4 Joint fluid @L4& inflammatory * Needleshaped crystal
 @+@  x-ray
$M4&@%4  , 6&
*% soft tissue  &)
@%4 #

(. #+ "+ @L @+@ %- % +M)@]@L tophi  % 
x-ray 
@L
soft tissue mass  4.  &) "+ @L punch out lesion, overhanging edge  +@L
!)
$@&
Gout
st
Acute monoarthritis @L 1 MTP joint, midfoot, , , #    &
Chronic:
 Tophi (urate crystal deposit)
Joint fluid: Needle-shaped, negatively birefringent crystal
X-ray:
Bone erosion with overhanging edge

* Soft tissue calcified mass !@L chronic tophaceous gout
 (:
o Acute attack: NSAIDs, colchicines, steroid
$ +& & uric acid * 
 %- attack
o & &@|

+*4+ uric acid (alcohol, diuretics, aspirin,  #+ , &M)

o Maintenance: Allopurinol (Xanthine oxidase &   uric acid)
Probenecid (*4+  uric acid  $%)
CPPD (pseudogout)
Acute monoarthritis @L+ #5,
X-ray:  Calcium deposit + articular cartilage   chondrocalcinosis
Synovial fluid: 
* CPPD crystal @L )  # rhomboid  # cuboid  weakly positive
birefringence
48. 3) M)@] & Acute monoarthritis
(. + - @L  $ &6 +4&!" $& Crystalinduced arthritis, Septic arthritis @L%  
&) Synovial fluid
 44
6  $&+-&
Differential diagnosis U: Acute arthritis
Monoarthritis
Polyarthritis
Pyogenic arthritis
Acute rheumatic arthritis
Crystal induced arthritis
Pyogenic arthritis
Acute rheumatic arthritis
Seronegative arthritis
Traumatic arthritis
Viral arthritis
Seronegative arthritis
SLE
Rheumatoid arthritis
Rheumatoid arthritis
49. 3) $
%
 !M) )
@L gout +-&
M)@] & Acute monoarthritis 6 +4&!" $& Crystal-induced arthritis, Septic arthritis, Rheumatoid
arthritis (RA) #+&) % % NSAIDs * RA % $&& @ 4&, 
" 4&!"

11

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

4 , -_-!)
50. 2) M)@]& Acute fever  RUQ pain 4&!" Infection  # Inflammation  Malignancy % 
 *
%6% &
, M LFT * ALP ) ",  Ultrasound @L Hyperechoic mass & &5 $& Amebic
liver abscess  HCC +$
%6% &
 #+$ Bile duct dilatation 4&!" CCA 
51. 2)  
4&*% 
 % 4&&
" 4&!" Esophagus +& (Rupture) + 
Boerhaaves syndrome
  # content "+ E4 
 + breath sound & $& .+ MalloryWeiss
& Upper GI bleed #+
 &* mucosa $$&&-
52. 3) -

 #&@%$@L#& 4&@L Lower GI bleeding  @ %4&#+ alcohol & "!" Hemorrhoids
+-& %#+
 $
%-
 &#+- 
4  #$  (+*#+& !@L#&
" @L
 (# %$@# @  + fiber ) *#+!-

  
53. 1) Pellagra 4&
 & Niacin (Vit. B3) *M)+&#+ alcohol   , # 4Ds $& Diarrhea, Dermatitis,
Dementia, Death (.M#+
@L pigmented  scaling  
e
< :KV:
< U: U<e[{l tKz:|s{:`Pa[ek
Nutrient
Clinical Finding
Contributing Factors to Deficiency
Thiamine
Beriberi: neuropathy, muscle weakness and wasting,
Alcoholism
cardiomegaly, edema, ophthalmoplegia, confabulation
Riboflavin Magenta tongue, angular stomatitis, seborrhea, cheilosis

Niacin
Pellagra: pigmented rash of sun-exposed areas, bright red Alcoholism, vitamin B6 deficiency, riboflavin
tongue, diarrhea, apathy, memory loss, disorientation
deficiency
Vitamin B6 Seborrhea, glossitis convulsions, neuropathy, depression, Alcoholism, isoniazid
confusion, microcytic anemia
Folate
Megaloblastic anemia, atrophic glossitis, depression,
Alcoholism, sulfasalazine, pyrimethamine,
homocysteine,
triamterene
Vitamin B12 Megaloblastic anemia, loss of vibratory and position sense, Gastric atrophy (pernicious anemia), terminal
abnormal gait, dementia, impotence, loss of bladder and
ileal disease, strict vegetarianism
bowel control, homocysteine, methylmalonic acid
Vitamin C Scurvy: petechiae, ecchymosis, coiled hairs, inflamed and Smoking, alcoholism
bleeding gums, joint effusion, poor wound healing
Vitamin A Xerophthalmia, nightblindness, Bitt spots, follicular
Fat malabsorption, infection, measles,
hyperkeratosis, impaired embryonic development, immune alcoholism, protein-energy malnutrition
dysfunction
Vitamin D Rickets: skeletal deformation, rachitic rosary, bowed legs; Aging, lack of sunlight exposure, fat
osteomalacia
malabsorption
Vitamin E Peripheral neuropathy, spinocerebellar ataxia, skeletal
Occurs only with fat malabsorption, or genetic
muscle atrophy, retinopathy
abnormalities of vitamin E
metabolism/transport
Vitamin K Elevated prothrombin time, bleeding
Fat malabsorption, liver disease, antibiotic use
54. &) 6.

12

55. 5) M)@] clinical  Acute Pulmonary edema  Hypertension % $) 
"  $% &&
 (+ #  Morphine "+ @L Transient venodilator & Preload  & Afterload 
+ Hypertension & 
 & Dyspnea, Anxiety, Stress, Catecholamine level, Tachycardia
&
* 
 !M) ) $
 morphine  # nitroprusside
56. 1)  #+, N/V, #+ ,  M4&@%4 @L
* Digoxin intoxication +$ 4&*4(
3
Hypokalemia 4+ M)@] $&  Furosemide "+
M Hypokalemia  $@) 4& Digoxin
intoxication %+-&
57. 3) %-M% 56 #+4& Digoxin intoxication % -&& 
58. 2) 3 True Hyponatremia + Urine Osm < 100
4&!" Primary polydipsia, Beer protomania, Reset osmostat ! > 100

"
"!" SIADH (  ADH  function &))
59. 2) Coxsackie B virus @L virus +4& Dilated cardiomyopathy "+ Systolic function $& $@) 4& Congestive
heart failure +-&
60. 1) M)@] Platelet < 100,000  Coagulopathy (prolonged PT, aPTT) 4&!" 3 DIC  % 
D-dimer @ 61
 44
 (%-+) 44
6  

61. 1) HbH disease  genotype @L - - / - (Heterozygous -Thal-1 / -Thal-2) & )% $&  gene - -  -
*
 #+&)
M#&** MCV %+ (@%4 80 - 100) &  RBC %
" 
@L Thalassemia minor #
+ - - gene (- - / ) 
 - % MCV  $%+ 4&
@L Carrier (- / ) 
62. 1) 4!#+ 4&!" Methanol intoxication $ (6
1$
*$ )  



Metabolic acidosis "+ Methanol 4&$&
Causes of High-Anion-Gap Metabolic Acidosis
Lactic acidosis
Ketoacidosis: diabetic, alcoholic, starvation
Toxins: ethylene glycol, methanol, salicylates, propylene glycol, pyroglutamic acid
Renal failure (acute and chronic)
63. 1) Ventricular fibrillation  (+& #  Defibrillation
64. 2) Key point #  @ "+ @L +"!" Tetrodotoxin (&@@|@}
#&M)@ #+
@L+3)
65. 4) ($
) M)@]  Candiduria (Candida  urine)   Bladder thrush  + Foleys catheter  Bladder
irrigation & Amphotericin B !$$& Foleys  oral Fluconazole 
66. 1) M)@]@ %4   
 ( ) #&@L -.3)4)  signs  dehydration 4&!"
Exertional heat stroke +-& (3 dehydration  ! %-4& Heat stroke $&)

13

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

68. 2) - HMG CoA reductase inhibitor (- Statin) @ 4E43*+-& & LDL  & Triglyceride $&
&"+
Drug
HMG-CoA reductase
inhibitors (statins)

Major Indications
Elevated LDL-C

Cholesterol absorption
inhibitors (Ezetimibe)
Bile acid sequestrants
(Cholestyramine)
Nicotinic acid

Elevated LDL-C
Elevated LDL-C

Elevated LDL-C
low HDL-C
elevated TG
Elevated TG, elevated
Fibric acid derivatives
(Gemfibrozil, Fenofibrate) remnants
Elevated TG
Omega 3 fatty acids

Mechanism
Cholesterol synthesis, hepatic
LDL receptors, VLDL production

Common Side Effects

Myalgias, arthralgias, elevated
transaminases, dyspepsia

Intestinal

Elevated transaminases

cholesterol absorption

Bile acid excretion and LDL

receptors
VLDL hepatic synthesis

LPL, VLDL synthesis

TG catabolism

Bloating, constipation, elevated

triglycerides
Cutaneous flushing, GI upset,
elevated glucose, uric acid, and
liver function tests
Dyspepsia, myalgia, gallstones,
elevated transaminases
Dyspepsia, diarrhea, fishy odor
to breath

69. 5) M)@]4& Myocardial infarction  $4 3 +6   Thrombolytic agent  Streptokinase, Tissue
plasminogen activator (tPA)
 @ 61) %!!  (++-&#$ % % PCI )&

14

70. 2) M)@]+& Diarrhea    Stool examination @ 61 44
   underlying @L
Cirrhosis 4&!" Spontaneous (Primary) bacterial peritonitis $ DDx. &% "+
%  Abdominal paracentesis
*#+ 44
 %M)@]
&$ @& 
" 4&!"   
71. 4) M)@]-$ @ %4)- +  Cyanosis @4 % 
* Radial pulse & % Brachial pulse @%4  !"
distal vessels M4&@%4 proximal vessels 4&!" 6  Thromboangiitis obliterans (Buergers disease) "+ @L Small
to Medium-sized vascular disease
72. 2) M)@]& Acute monoarthritis $ & (. Synovial fluid @L Septic group (Group III)
" 4&!" Septic
arthritis  +* WBC  Synovial fluid 50,000 /mm3 "$@$(. ! Empirical

15

73. 4)
74. 3)
75. 2)

76. 4)
77. 1)
78. 1)

79. 4)
80. 4)
81. 1)
82. -

83. 1)

84. 4)
85. 2)

86. 1)

Antibiotics $&   

@L Gonococcal arthritis $&* *+  WBC 50,000 "$@ PMN & 

 #*#$$&
*E4 Capillaria philippinensis 
#&@L*
M)@] &
 @ %4 + !, $$&4&!" DVT #+ #+ 
 %| Breath sound
@%4
" 4&!" Pulmonary embolism
% 
 
 Hepatosplenomegaly  M)@] 6  #  )6&* Hematologic disease #+&) CBC
*(. Microcytic anemia "+ 6 +(.& %6%#- Thalassemia & Hemoglobinopathies
"+ # HbH disease  & # "!" 3 Acute hemolysis 4&% $ "+ @L Stress 4&3
& "6 
M)@] clinical $& Hypertensive crisis  # BP > 180/120 
&@L Hypertensive emergency & * 
 4+  % &&6& +-&
 ( Anaphylactic shock # Adrenaline 1:1,000 & 0.3-0.5 ml Intramuscular (IM) % +&+-&# Vastus
lateralis muscle % %
M)@] 4&"&      
-&5# pupil    Pin-point pupil @L
(. Pontine hemorrhage  @& &4
*$& Cerebellar hemorrhage %
 
(@L+6 ) $ pin-point pupil
(.5#   4.M#+ M#+ ,
" "!" Leprosy (6  #)  
($
) Diastolic rumbling murmur  Opening snap 4&!" Mitral valve stenosis (MS) #+&)
%#@ 
-M)@] "!" Calcification %##+
4& Regurgitation 
(. clinical  CXR 
 Cavity + Air-fluid level $& Lung abscess +-&
M)@]  Hypokalemia (&)
%# @L Renal loss)  Hypertension %-+@L$@$& # Diuretics,
Hyperaldosteronism, Renal a. stenosis, Cushings syndrome "+  &) plasma aldosterone/plasma renin activity
(PA/PRA) ratio
$& 6&! > 20
4&!" Primary hyperaldosteronism % )$* *+
 Primary
hyperaldosteronism  Renal a. stenosis $&
M)@]@ %4 Penicillin  Diarrhea *(. Antibiotic associated colitis (AAC) 4&!" Pseudomembranous
enterocolitis
 Clostridium difficile  (# Metronidazole @L Drug of choice (* PO !$$&
"  IV)

 Vancomycin $& % *
M)@](.& # 4&!" Hemolytic anemia "+ M)@]
6%#+
@L  RBC %
%$6% 6 -+$6%
"!" G-6-PD deficiency   % 
+
" @L G-6-PD screening
%* @L (+
@L 2 %# $ 3 M)@]   DKA   %  IV fluid
& Intra & Extravascular volume @L+5+-&

"  Insulin  &%& 50-70 mg/dL/hr

# 200 mg/dL
M)@] DIC + prolonged Pt, aPTT &  & coagulation factor
"   FFP    FFP  # Platelet

@ 61#+M)@]#& #+ ) +
#& % ( DIC +5+-&# KLek $% $
 #+&)%#+ Antibiotics (ATB) & &6
1
 4& DIC
 Sepsis  (+
" @L
Antibiotics

16


4 , %  Sustained VT
PVC %4& 3 %   Triplet PVC !%4& 4 %"$@
  Nonsustained VT %! PVC %4&%4 30
4
"
  Ventricular tachycardia (VT)
88. 1)  ( Complete heart block &# Atropine  Isoproterenol IV *#+*4+ HR + 
$&M#+@L block +
AV node %  Pacemaker implantation @L ( AV conducting system disease +&+-& 6&
#+
Indication
89. 1)  $ , @L Side effect  Enalapril "+ @L ACEI
Drug Class
Other Indications
Contraindications/Cautions
Diuretics
Thiazides (HCTZ)
Diabetes, dyslipidemia, hyperuricemia,
gout, hypokalemia
Loop diuretics
CHF,
Diabetes, dyslipidemia, hyperuricemia,
(Furosemide)
renal failure
gout, hypokalemia
Aldosterone antagonists CHF, primary aldosteronism
Renal failure, hyperkalemia
(Spironolactone)
K+ retaining (Amiloride,
Renal failure, hyperkalemia
Triamterene)
Beta blockers
Cardioselective (Atenolol, Angina, CHF, post-MI, sinus
Asthma, COPD, 2nd or 3rd degree heart
Metoprolol)
tachycardia, ventricular
block, sick-sinus syndrome
tachyarrhythmias
Nonselective
(Propranolol)
Combined alpha/beta
? Post-MI, CHF
(Labetalol, Carvedilol)
Alpha antagonists
Selective (Prazosin,
Prostatism
Doxazosin, Terazosin)
Nonselective
Pheochromocytoma
(Phenoxybenzamine)
Sympatholytics
Central (Clonidine,
Methyldopa, Reserpine)
ACE
Post-MI, CHF, nephropathy
Renal failure, bilateral renal artery
inhibitors (Captopril,
stenosis, pregnancy, hyperkalemia
Lisinopril, Ramipril)
Angiotensin II
CHF, diabetic nephropathy, ACE Renal failure, bilateral renal artery
antagonists (Losartan,
inhibitor cough
stenosis, pregnancy, hyperkalemia
Valsartan, Candesartan)
Calcium antagonists
Dihydropyridines
Angina
Heart failure, 2nd or 3rd degree heart
(Nifedipine)
block
87. -

17

Nondihydropyridines
(Verapamil, Diltiazem)
Direct vasodilators
Direct vasodilators
(Hydralazine, Minoxidil)

Post-MI, supraventricular
tachycardia, angina
Severe coronary artery disease

90. 2) M)@]@L Chronic oligoarthritis @L"   Crepitus $& Osteoarthritis
91. 1) M)@] 4&!" Uncomplicated UTI (! underlying structural/neurological disease, pregnancy  #@L upper UTI
 UTI *'
&@L Complicated UTI)  (  Co-trimoxazole (Bactrim)  #- Fluoroquinolone
3 *
92. 4) 4&!" 3 Hypercalcemia (Dx. #+ Ionized Ca > 4.5  # Corrected Ca > 10.5 mg/dL) #+ & Ca )  12
mg/dL
 4+  Neuro, KUB ( ), Heart  GI  ( $& Fluid &#    Ca 
6&- Loop diuretics
93. 2) 4&!" Migraine headache

!@}  ( *  @L ( 4 choices @L@}  1 choice (&) 42. *4+%4)
94. 1)  # 5) $ )

18

Pediatrics
1. 1) EBV $ tonsilar patch, splenomegaly with cervical node enlargement
ft
Diphtheria
(Pharyngeal
diphtheria)

:
-$ #$$&
-

-#
- 
-
dyspnea

EBV infection
(Infectious
mononucleosis)

-$) (>39C)
-Nausea, not
vomiting

GAS (Group A
Streptococcal
pharyngitis)

-Fever (>38C)
-Odynophagia
-$&
) #
$
-$ GI
-3C
(conjunctivitis,
cough, coryza)
-$) 

Measles

:
<
-Mild pharyngeal injection
-Uni/bilateral tonsillar grayish
- pseudomembrane (Bleeding
if scrape) and may extended
wildly to uvula, pharynx,
larynx, trachea, bronchus etc.
-Cervical lymphadenopathy
(Bullneck!@L)
-Tonsilar exudates or patch
-Splenomegaly
-Generalized
lymphadenopathy (esp. post.
Cervical)
-Atypical lymphocytosis
-Tonsilar yellow blood-tinged
exudates
-Enlarged/tender anterior
cervical lymph nodes
-Inflamed buccal mucosa
-Erythematous, nonpruritic,
maculopapular rash
-Koplik spot (white/bluish
lesions with an erythematous
halo)
-Cervical adenitis

KL/Px: K[
Specific tx.
-Antitoxin in 48 hr
-Penicillin G iv 14d
Prevention
-DTaP or DT

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

Supportive tx.
(hydration,
acetaminophen)
-! ampicillin  #
amoxicillin
4&
rash
Specific tx.
-Amoxicillin 10d
-Erythromycin (*
penicillin) 10d

-
* Hepatomegaly

Supportive tx.
Prevention
-MMR

-Gold standard 
Dx # throat swab C/S

-$ M#+ 4++

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

2. 2) Pityriasis alba
Pityriasis alba @L hypopigmented lesion (. round or oval, macular of slightly elevated patched 
fine adherent scale *+ , %, % proximal portions   
$ $ %- 6 
 %
@L"M4 

&@L mild form  eczema $& 6 !)

M4&@L vitiligo, tinea
vesicolor  # tinea corporis (6& lubricant 
&"%&#
Vitiligo  $ %-+& %#+4&
 immunologic abnormalities "+   antibody % melanocytes
 $&@L 2 4&# generalized  localized *-18 @ @L generalized form "+
* symmetric
pattern of white macules and patches with hyperpigmented margin * vitiligo *E1 autoimmune disease

19

6  !" DM & (& topical steroid, topical tacrolimus  +@L

 narrow-band UVB
(UVB311)
Pityriasis vesicolor  # tinea vesicolor 4&
 chronic fungal infection  stratum corneum

Malassezia furfur "+
&@L normal flora @|

+ #   #,  #+, plasma cortisol ) ,

immunosuppression, malnourishment * - $*@L hypopigmented macules, covered with a fine
scale #+% 
KOH
*(.+  Spaghetti and meatball (6& Selenium sulfide susp., imidazole or
terbinafine cream  # ketoconazole/itraconazole PO
Tinea facialis 4&
 %4&# M4
 
* dermatophyte (Trichophyton, Microsporum, 
Epidermophyton) *@L dry, mildly erythematous, elevated scaly papule or plaque "+
* 
%  $@ 6&
clear central      @L annular lesion #+  % 
&   KOH
* filamentous fungus (6&
Ketoconazole/clotimazole topical  # Terbanafine, griseofulvin PO  . Tinea +M
Contact leukoderm $
# chemical leukoderma (.# vitiligo *+# 
satellite lesion $@  4.+$6&  4&
 melanocyte &
  4., %-
 M +
 melanocyte (# vitiligo +  ,
3. 3)
4&!" 3 foreign body aspiration +-& 6& FB )+ rt. Main bronchus "+ @L common site for bronchial
foreign body aspiration %-+"!" 3#+
 @L acute onset   $"+ & !" aspiration 
 &  partial LRT obstruction (rhochus  2 4& # sibilant rhonchus = wheezing  sonorous rhonchus
= rhonchus ++$@) @ M)@]@L&- 3 @ "+ *3&- 1-3 @ 
&-3*&%&
{ {t V\]: e[
[[] (Stable patient) # Plain chest film *#+&) Resp. tract obstruction $
(segmental atelectasis)  #&) opaque foreign body   inspiratory and expiratory film 
*4
 .% 
plain CXR @%4 #+
 partial obs.
4&3 ball-valve " (insp.=air @&$&, exsp.=air $$&4& air
trapping) *#+&) hyperinflation  @&!)-&%, mediastinal shift  ipsilateral diaphragm #+ &+
  #$ # 
 fluoroscope  # bilateral decubitus chest film $& 
*4
 . bronchoscopy 
lateral film $4 .
4. 2) + 5)
3 Hypoglycemia  newborn # plasma glucose lv. < 40 mg/dl (   45 mg/dl @L whole
blood glucose <50 mg/dl *  WBG. < PG. 10-15 mg/dl 
 DTX  plasma glucose confirm &) 4&

sudden withdrawal of transplacental glucose supply 6&
%+-& 1-3 hr. of life  12-24 hr. of life 
*
hypoglycemia $&*  gluconeogenesis  ketogenesis  
45$& @|

  4# preterm,  DM mother, 

erythroblastosis fetalis,  asphyxia  SGA
KLf< ! ! D#& feeding
! D#& (apnea, hypotonia, irritability, irreg. respiration, tremors, eye rolling, seizures, etc.)  IV 10%
glucose 2 ml/kg (rate1 ml/min)  seizure 
 4 ml/kg $& maintain & IV fluid with GPR 6-8 mg/kg/min
(3.6-4.8 ml/kg/h of D10W) recheck - 15-30  6&@ *4+ rate/concentration $&

20

5. $!)

6.

7.

8.

9.
10.
11.

M)@] Turner syndrome (45, XO) (.# webbed neck, short stature, cubitus valgus, short neck, 1
amenorrhea  multiple congenital anomalies in phenotypic females 6&
M4&@%4 ovarian development
* % ' X chromosome   % *#+ * ovary &  Turner syndrome
" *(. ovary 
streak ovary "+ % stromal cell & 
"  1 amenorrhea
 low estrogen and low progesterone 
gonadotrophin  GnRH ) " % ) "  16 4&$%- amenorrhea
4)? $
%
Henoch-Schnlein Purpura 4&
 small vessel vasculitis   & # palpable purpuric rash
*+ waist  buttocks; arthritis @L+ knees ankles; abdominal pain 4&
 vasculitis  #& GI
tract  glomerulonephritis "+ & hematuria  # proteinuria $&   % 
+@ 4 prognosis +5+-&#
U/A #+
* renal involvement 
*4& chronic hypertension  # CRF %$&
Polyarteritis nodosa? ($
, #+
6
1))
@L necrotizing vasculitis  small  medium sized arteries -++*# 9 @ $ %- 6  %
*4&% URI, Group A Strep. Infection  chronic hepatitis B M)@]
& $6&$ % #+, % 
* mesenteric a. inflammation @&  renovascular arteritis &64%)
* purpura, edema and linear erythema wih palpable, painful nodule % arteries + 
*  
neuro, cardio &  44
$&6& biopsy skin lesion (6& oral/IV corticosteroid
5)   4&+%#
  pathological jx. #+ jx. 4& 24 hr.  ; jx + unconj.bili. > 12.9 mg/dl  term
 # > 15 mg/dl  preterm; conj.billi. > 2 mg/dl; bili. lv *4+ > 5 mg/dl/d  jx.  1 wk  term  2 wk 
preterm & M)@]  3 pathological jx.
%-+"!" +-&# ABO incompatibility #+
  &)64% O,  jx.  1st 24 hr @ 3
anemia "+ "!" hemolytic anemia +-& %-#+, +
"!" $&# sepsis "+ 
* jx.  1st 24 hr $&
3 anemia $& %#+
 sepsis + sign *  jx.  &*$&
" 4&!"  (@ %4
&4 4 hr   &
&@L PROM +$ prolong
" $*4+ risk % infection)
Jx. of prematurity 
*+ 3-4 6&% %&6 #+, !"
44
3 (!#@L physiologic jx.)
  G6PD def.  mutation  promoter region  UDP-glucuronyl transferase-1 @L%-+
  4&+3 G6PD def.  jx. 6&$4& hemolysis & 
" 4&!"     Thalassemia $*@L
%- neonatal jaundice
$

2) %-M% 1 (!@L Diphtheria 6

1
 patch $@+#+
 tonsil)  candidiasis
*(. white
plaque 
* immunocompromised host
5) M)@]&+& asthma exacerbation  @ 4 -  6  6&@L severe exacerbation
*(.#
dyspnea, retraction, accessory muscle use, tachypnea, mental status change, poor air entry.  (#  O2
supplement  inhaled bronchodilator # SABAs (Short-acting inhaled 2 agonist- albuterol, salbutamol, levalbuterol)
-, 20  @L 1 +6   $&"  1st inhaled -agonist 
*4
 . inhaled ipratropium
"+ M)@] 
 SABA  &" %  expiratory wheezing )
"  (*4+& inhaled
ipratropium  systemic corticosteroids 
*4
 .$&!
@L

21

 @L 
*4
 . intramuscular injection of epinephrine  # -agonist %#+,
Mucolytics, chest physical therapy  spirometry $  asthma exacerbation * 4& severe
bronchoconstriction $&
12. 3)   splenectomy
*4++  %4&#- parasite encapsulated bacteria " * #+%&

$ !
& +!) opsonized (  + complement 6&* C3b $@
#6 ) 

 #& 
*     Ab % T cell-independent antigen  polysaccharide +) capsule 
 $&
 4& Pneumococcal vaccine (S. pneumoniae), meningococcal vaccine (N. meningitides)
 H. influenzae type B vaccine  M%& 2 4%1 *#+& 4& postsplenectomy sepsis %@ '$
meningococcal vaccine serotype B (serotype +*$) $@ '$ & $
" &
Pneumococcal vaccine  H. influenzae vaccine
 Oral penicillin V *#+ prophylaxis % 2 @
 splenectomy % ++ ) 

*4
 .%
!" M)5
13. 1) &)%   #+ abdominal tumors & ( 14)
14. 1) Wilms tumor  !& abdominal mass, abdominal pain, hematuria  vomiting $&  15-25 
Hydronephrosis "+ 4&
 obstructive uropathy 
 recurrent UTI & "+ 
 pyuria &
TUMOR
Wilms

AGE
Preschool

Neuroblastoma

(1 - 5 yr)

Preschool

(median age 2 yr,

almost < 5yr

Non-Hodgkin lymphoma > 1 yr

Rhabdomyosarcoma All
Germ cell/teratoma

Preschool, teens

Hepatoblastoma
Hepatoma

Birth 3 yr
School age, teens

CLINICAL SIGNS
Unilateral flank mass, aniridia,
hemihypertrophy
GI/GU obstruction, raccoon eyes,
myoclonus-opsoclonus, diarrhea, skin
nodules (infants), mass may cross
midline
Intussusception in >2-yr-old
GI/GU obstruction, sarcoma botryoides,
vaginal bleeding, paratesticular mass
Girls:abdominal pain, vaginal bleeding
Boys:testicular mass, new-onset
hydrocele
Sacrococcygeal mass/dimple
Large, firm liver
Large, firm liver; hepatitis B, cirrhosis

LABORATORY FINDINGS
Hematuria; bone scintigraphy (clear
cell sarcoma)
Increased VMA;increased
HVA;increased ferritin; stippled
calcification in mass.
Bone marrow positive
urate; bone marrow positive
Increased hCG;Increased AFP

Increased AFP
Increased AFP

 Nelson Textbook of Pedriatric, 18th ed.

15. 1)

M)@]&& anemia  jaundice % 

lab * NCNC RBC  reticulocyte count ) 3+"!" 
+-&# hemolytic anemia "+  ! %-$&@L 2 -, # Corpuscular hemolytic anemia (Membrane
defects, enzyme defects, Thalassemia and hemoglobinopathies)  extracorpuscular hemolytic anemia (Immune
hemolytic anemia, mechanical hemolytic anemia, direct toxic effect on RBC) "+   %-6& Coombs
test "+
M negative  positive %&

22

Inclusion test 
!" supravital stain * inclusion bodies "+ @L HbH +%%&#&& *
 HbH disease (--/-) "+  % 
Coombs test M negative 
" *4
 . &  hemoglobin
typing, G6PD def. screening
 bone marrow aspiration  $   #+
 bone marrow response +& (RC ) )
"  $4&!"
bone marrow defect % investigation  -,   $ !E4 anemia $& 
*4
 . bone
marrow aspiration ( &) algorithm  #& @ 5  #+ anemia in children)
16. Adrenaline (Epinephrine)
3 anaphylaxis 4&
 + potent active mediator
 mast cells  basophils  & 
 % % , # M4 (urticaria, angioedema, flushing), 
(bronchospasm, laryngeal edema), CVS
(hypotension, arrhythmias, MI)  GI (nausea, colicky abdominal pain, vomiting, diarrhea) @L IgE mediated immune
response "+ % @L exposed % antigen   + @L%$@ 3
&@L3-4 % $&  (
  & +% @L& # IM epinephrine #+, +$& IM or IV H1 and H2 antihistamine antagonists,
oxygen, IV fluids, inhaled -agonists  corticosteroid 
*M)@] biphasic anaphylaxis $&3 4 hr
" 
observe   4 hr  D/C
 ER
17. 2)

6
1*M)@]3 sepsis ( SIRS + suspected/proven infection)  DIC (low platelet with
prolong PT and PTT with clinical bleeding) 6&$ shock  management +5+-& DIC #  
%-
"   antibiotic *#+$%- #+
  $ septic shock   fluid resuscitation
" 
$ management +5+-&.   FFP, platelet conc.  PRC  *4
 .#+ clinical bleeding
6& plt. conc. FFP PRC (% control bleeding $&!" #&) "+   clinical bleeding
4 %
management +5+-&.# control DIC +4&
 sepsis  control bleeding
SIRS systemic inflammatory response syndrome #3+ 2
 4 %$@
Core temp. >38.5 C  # < 36 C (&  , *@|,  @  # central catheter)
Tachycardia (mean heart rate > 2SD above normal for age)  #&- 1 @  persistent
bradycardia  hr (mean heart rate<10th percentile for age)
RR > 2SD above normal for age or acute need for mechanical ventilation (not related to Neuromuscular
disease or GA)
Leukocyte count elevated  # depressed for age  # >10% immature neutrophils
18. Idiopathic Vit K def. of infant
&& ecchymosis 4&!" 3 coagulopathy 6&
@ %4*&+  & vit K #4&
+ 
$$&  vit K 1 mg IM  & $&4"+ vit K %+
" 
4& vit K def. $& & 4& 3 )@
#
Classic hemorrhagic disease of the newborn 4&#+ 1 -14  & 4&
 vit K +#+
 vit K M
 $&$&   &&4$&$& 
 $   vit K2 #+
$ sterile
%-5#  4 #+
 vit K  & & 4&-
" % $& Vit K 1 mg IM
Late VKDB (Vit K-def. bleeding) 4&#+ 2-12 @&1 & 
4&$&!" 6 &# & %-#4
6&@|

+ #  &)&" vit K $&  cholestatic liver disease

23

4&.&  #
&$ #+
 &  warfarin, phenobarbital, phenytoin "+ M $&
    vit K
 #+,  vit K def. # GI bleeding, mucosal and cutaneous bleeding, bleeding + umbilical stump  #
post-circumcision site  Intracranial bleeding *$&%$
19. 1)
6
1 M)@]
3 nephrotic syndrome ( 44
 nephritic syndrome #  heavy proteinuria: >3.5 g/d 
M)5  # > 40 mg/m2/hr,  hypoalbuminemia: <2.5g/dl, edema  hypercholesterolemia) #+
 proteinuria,
edema  hypercholesterolemia (&)$&
 + oval fat body
 UA) %- edema  nephrotic syndrome 
$ -@+& %+@L$@$&+-&#  massive urine protein loss 4& hypoalbuminemia  plasma
oncotic pressure &  fluid
 IV compartment $@ interstitial space
20. 5)

6
1
$&M)@]
3 Reflex syncope  # Neurocardiogenic syncope "+ 4&
 *4+
peripheral sympathetic activity  venous pooling "+
4& myocardial contraction of a relatively empty lt.
ventricle "+
 %- myocardial mechanoreceptor  vagal afferent nerve fiber  sympathetic activity %-
parasympathetic activity 
Syncope 4&*$&4 "+   & 
4&"$& %- %-# 3*4+ &+&  # ,
1, extreme fatigue, severe pain, hunger, prolonged standing, emotional or stressful situations
%-+"!" 3+-& *  M)@]@ %4+$& &%4$ #+&%4 !$& $
  %- % 
 @%4
" 
$
@L%  % 
*4+%4  % 
EKG
#+% 
   #@ %4
  arrhythmia & %4& Holter monitor  blood sugar 
*4
 .  hypoglycemia 
M)@]$$&%4# @ %4@L DM -& 4&  # insulin @L%

 Harrisons Principle of Medicine, 17th edition.

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

24

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

 ( LTBI &+$@ %4M6 %#+

1. &@%4  & - 5 @ , TT reaction > 15 mm. 6&& BCG
2. Immunocompromised host
a. Severe malnutrition TT 10 mm.
b. Steroid therapy TT 10 mm.
c. HIV infection - TT 5 mm.
3. Old fibrotic scar +$ ( (TT 10 mm.)
4. Recent converter (TT @+
@L *4+" 6 mm.)

25

22.

23.

24.
25.

 44
 TB  criteria #   &  .6   $ #  & $ %$@
  2 
1. @ %4M.6 
M)5
2. M& M4 @L
3. M4&@%4
 % 
3*  @&
4.  % 
#+, -  % 
 AFB M
2)
6
1 4&!" M)@]3 ketoacidosis +-& #+
#+% 
electrolyte * HCO3 %+ @ % 
*
ketone @| %- 4& ketoacidosis $ !$&
)+ (4&$&
 starvation, alcohol
 DM) %%-+
@L$@$&+-&# DKA  (# %+ #@L& #  IV fluid #+

% 
 * poor perfusion 6&+6   10-20 ml/kg IV bolus 0.9% NaCl or LRS *#+4& volume
expansion  &  
*4
 .$&   Insulin drip at 0.1U/kg/hr  # 1 g/kg IV push for cerebral edema

 4++6 + 2 *#+& 4& hypokalemia   Potassium    #&
"

*4
 . % @|&  HCO3
*4
 .#+ pH < 7.0
2)  delivery room * term infant with meconium staining   hypopharyngeal suction - &$ 4+ +
 *4
 .%# & 4&3 distress  #$ ( hypoxia, bradycardia, fetal acidosis or apnea) 
*4
 . endotracheal intubation  suction M endotracheal tube *#+ meconium 
 &4
%
@L preterm infant < 34 wk  4&!"  &3 IUGR  #$,  +@L meconium
4  #@L purulent fluid

 infection  #  + bile stained "+ 4&

 proximal intestinal obstruction
3)? %%-M 18 %6
1+M)@]3 anemia 6&$ jaundice  bulging of AF 
4&!" 3 intracranial
bleeding +-&  sepsis  $ SIRS
" 4&!"   SDH M)@]
  seizure @L%
Rubella
  Congenital infection +*& 
MANIFESTATION
PATHOGEN
IUGR
CMV, Plasmodium, rubella, toxoplasmosis, Treponema pallidum, Trypanosoma cruzi, VZV
Congenital Anatomic Defects
Cataracts
Rubella
Heart defects
Rubella (esp. PDA)
Hydrocephalus
HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis
Intracranial calcification CMV, HIV, toxoplasmosis, T. cruzi
Microcephaly
CMV, HSV, rubella, toxoplasmosis
Neonatal Organ Involvement
Encephalitis
CMV, enteroviruses, HSV, rubella, toxoplasmosis, T. cruzi, T. pallidum
Hepatitis
CMV, enteroviruses, HSV
Hepatosplenomegaly CMV, enteroviruses, HIV, HSV, Plasmodium, rubella, T. cruzi, T. pallidum
Hydrops
Parvovirus, T. pallidum, toxoplasmosis
Retinitis
CMV, HSV, lymphocytic choriomeningitis virus, rubella, toxoplasmosis, T. pallidum
Late Sequelae
Deafness
CMV, rubella, toxoplasmosis
Mental retardation
CMV, HIV, HSV, rubella, toxoplasmosis, T. cruzi, VZV
&&@
 Nelson Textbook of Pedriatric, 18th ed.

26

26. 1)

  M)@] 4&!" 3 hypoxic spells (Paroxysmal hypercyanotic attacks)

 TOF +-& * 
 @L% %- 4 &# "+ $& TOF "+  
$ cyanosis  & 6&
 cyanosis 3
@  & #+
 progressive pulmonary stenosis % 
 $& pansystolic murmur at lt. parasternal border*
"+ 
| $& TOF + lt. lower parasternal border (%@%4 TOF murmur 
@L SEM at lt. upper parasternal
border)
Hypoxic spells *4& - 1-2 @ M)@]
 
  " 
&%4$& 

4&  #*"+ %#+  #
  $  %-4&
 &  already compromised pulmonary
blood flow (
 infundibular spasm) "+ 4& systemic hypoxia  metabolic acidosis %
 (#  Knee-chest position *#+*4+ peripheral vascular resistance #&$@@&$&" 
O2  MO $4 0.2 mg/kg sc. *#+M)@]  
& infundibular spasm *4
 . NaHCO3 *#+&
metabolic acidosis 
*4
 .*#+*4+ systemic vascular resistance  phenylephrine, levophed  # ketamine
@L%  (   -blocker *#+- E%-*#+ (3& 
*4
 . palliative Sx.
# modified Blalock-Taussig shunt *4
 . definitive Sx.
Breath-holding spells * - 6 &# 2 @ 4&#+&  $
6 E  #
 6&&
  $
-  
  %&  -&

    $@$  3 30 4 


%@%43$+ "+ &
-3*  & $6 @ 
%
" $
 cyanosis
+
  $ 
Asthmatic attack 
*M)@]$& %
&  severity  % asthma 
| $& wheezing $

 cyanosis &# !" $
| $& murmur  pulmonary embolism M)@]
 U/D
 # condition + !" 
| $& adventitious sound +@&| $& murmur
*#RR,SRTUVWX, )YZ[#$R\)]"(*#$ PSM @ Lt. parasternal border TD[ D cyanotic heart &!+ ,+UTD['X,_$,'Z#
Tricuspid atresia `_[$ aRb)*DU+cUdY 1 ),Z#Y, truncus arteriosus `_[$ aRb)*DU+ !  efb aRb]a+dR+UcUdY#U( 1 ),Z#Y
\!+Y VSD Rbhi PSM TD["je]Y!$YDk,e"!Rb !)*DU+ l Wm)nfU
27. 5)
Retropharyngeal abscess * - 1-6 @ 4&%  %4&# &4
 (M)5
4&
 foreign body) 4&
 mixed organism 
 irritable, fever,  food intake #+@L"
 
  
 %
  (muffled voice) # drooling  airway obstruction $&
 
 posterior pharyngeal wall    lat. neck film *#+&) retropharyngeal space (+ &C2 >
7mm, or C6 > 14 mm)  ($&6& IV antibiotic (3rd gen. Cephalosporin + ampicillin-sulbactam or clindamycin)
surgical drainage
Acute tracheitis (Bacterial tracheitis) 4&% Viral URI 6&* laryngotracheitis (croup) 4&

# S. aureus !#@L life-threatening condition 4& airway obstruction $& -++*# 5-7 @ (. typical
# brassy cough, high fever  toxicity with respiratory distress  purulent secretion 6&M)@] ! $& $
drooling $ dysphagia  (& epinephrine $$&M 44

 clinical  $*(. epiglottitis
 ($&6& IV antibiotic  *4
 . O2 supplement  intubation
Acute epiglottitis *- 2-7 @ 4&
# H. influenzae type B (Hib)  +$$&  
+$& *4&
 S. pyogenes, S. pneumoniae, S. aureus  *4&
 Hib $&  + typical &

27

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

 secure airway $& 
" (& IV antibiotic
Viral Croup (Laryngotracheobronchitis  # Laryngotracheitis  mild form croup) *&- 1-3 @
4&
 %4&# parainfluenza virus type 1-3 M)@] $& # ) 
 $ $
%+, 1-3 
  upper airway obstruction "+
&  # barking cough, hoarseness  inspiratory
stridor % 
 * coryza, normal-mod. Inflamed pharynx  slightly RR @L
* dyspnea, marked
RR, cont. stridor, cyanosis, hypoxia, pallor  #" "+   *4
 . airway management
 ()+ 
&$ )&$  @L$ % @L **1
#+!" 6 *  &$ $*M)@] 
*4
 . NPO    O2  humidification
  Nubulized epinephrine @L ( moderate-severe croup (stridor at rest, possible need for intubation,
respiratory distress and hypoxia) E4F6& constriction precapillary arterioles M -adrenergic receptors 
resorption    interstitial space &  laryngeal mucosa   oral corticosteroids  !
& )6 *   )6 *& $  antibiotics  croup
Acute laryngitis # &4&
#$  ( diphtheria)   4+ # UTI # sore throat, cough
    6&+  $@$      
  +  
@L  , % 
  
* pharyngeal
inflammation $& inflammation  vocal cord  subglottic tissue 
*$&#+&)M laryngoscope
28. 3) +%  1   $&   $   %$@%&&  !  %$@
$& 6&$%  4+% &  & $&  !" - 1 @ + %$@# DTP4, OPV4, JE %% 
%$@

<
2m
4m
6m
9m
12 m
18 m 2-2yr 4-6 yr 12-16 yr
BCG,
MMR1
JE3
DTP1, DTP2, DTP3,
DTP4,
DTP5, dT -,
HBV1 OBV1, OPV2 OBV3,
OPV4
OPV5, 10 @
MMR2
HBV2
HBV3
JE1JE2   1-4 wk
29. 2) M)@] preterm GA 32 wk & #+ dyspnea 3+4&!" +-&# RDS "+ %-+4& %-"+ 4&

 & surfactant +@&

   +&  + +& "+ surfactant  @  dipalmitoyl
phosphatidylcholine (lecithin), phosphatidylglycerol, apoproteins  cholesterol   %&
$@ 6&
!)
 
 type II alveolar cell 6&+ surfactant #& surface tension  alveoli @}  collapse 
small air spaces .4 -&   
 &  M) @]     +  
&+ -& # dipalmitoyl
phosphatidylcholine  # lecithin
  4& RDS #  &@L DM, C/S delivery, precipitous delivery, asphyxia ),
@L @|

+&+ $&  31+ &@L PAH  # PIH,  & heroin, PROM   steroid
prophylaxis
30. 1) %-M% 1
31. 1) %-M% 21

28

32. $
>< ) #+ diarrhea 
Congenital Lactase deficiency @L3+*$& 
@L primary adult type hypolactasia  #
secondary lactose intolerance "+ . 4&% small bowel mucosal damage 
 celiac disease
 # rotavirus infection 
!-

 @L,  %"  @L*, #+-

  -

 4+
 * , )   M4 $&
Antibiotic-related diarrhea 4&
M   antibiotic "+ $& amoxicillin, ampicillin, amoxicillinclavulanate, cefepime, clindamycin, doxycycline, erythromycin "+ 
 $& 
   antibiotic ,
6&*-+@L broad spectrums 
 4&$&-  $  C. difficile 4&
overgrowth  diarrhea $&  +$ pseudomembrane +  psuedomembranous colitis
ETIOLOGY
SIGNS AND SYMPTOMS
DURATION ASSOCIATED FOODS TREATMENT
OF ILLNESS
Bacillus cereus
Sudden onset of severe
24 hr
Improperly refrigerated Supportive care
(preformed
nausea and vomiting. Diarrhea
cooked or fried rice,
enterotoxin)
may be present.
meats
Campylobacter jejuni Diarrhea, cramps, fever, and
210 days
Raw and undercooked Supportive care. For
vomiting; diarrhea may be
poultry, unpasturized
severe cases, antibiotics
bloody.
milk, contaminated
such as erythromycin and
water
quinolones may be
indicated early in the
diarrheal disease.
Guillain-Barr syndrome
can be a sequela.
Enterohemorrhagic E. Severe diarrhea that is often
510 days
Undercooked beef
Supportive care, monitor
coli (EHEC) including bloody, abdominal pain and
especially hamburger, renal function,
E. coli O157 : H7 and vomiting. Usually, little or no
unpasteurized milk and hemoglobin, and platelets
other Shiga toxin
fever is present. More common
juice, raw fruits and
closely. E. coli O157 : H7
producing E. coli
in children <4 yr old.
vegetables (e.g.,
infection is also
(STEC)
sprouts), salami
associated with hemolytic
(rarely), and
uremic syndrome (HUS),
contaminated water
which can cause lifelong
complications. Studies
indicate that antibiotics
may promote the
development of HUS.
Enterotoxigenic E. coli Watery diarrhea, abdominal
3 to >7 days Water or food
Supportive care.
(ETEC)
cramps, some vomiting
contaminated with
Antibiotics are rarely
human feces
needed except in severe
cases. Recommended
antibiotics include TMPSMX and quinolones.
Salmonella spp.
Diarrhea, fever, abdominal
47 days
Contaminated eggs,
Supportive care. Other
cramps, vomiting. S. typhi and
poultry, unpasteurized than for S. typhi and S.
S. paratyphi produce typhoid
milk or juice, cheese, paratyphi, antibiotics are

29

with insidious onset

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

contaminated raw fruits

and vegetables (alfalfa
sprouts, melons). S.
typhi epidemics are
often related to fecal
contamination of water
supplies or streetvended foods.

Shigella spp.

Abdominal cramps, fever, and

diarrhea. Stools may contain
blood and mucus.

47 days

Staphylococcus
aureus (preformed
enterotoxin)

Sudden onset of severe

nausea and vomiting.
Abdominal cramps. Diarrhea
and fever may be present.
Profuse watery diarrhea and
vomiting, which can lead to
severe dehydration and death
within hours

2448 hrs

Vibrio cholerae (toxin)

Vomiting, diarrhea, abdominal

pain, bactermia, and wound
infections. More common in the
immunocompromised, or in
patients with chronic liver
disease (presenting with
bullous skin lesions). Can be
fatal in patients with liver
disease and the
immunocompromised.
Yersinia enterocolytica Appendicitis-like symptoms
and Y.
(diarrhea and vomiting, fever,
pseudotuberculosis
and abdominal pain) occur
Vibrio vulnificus

37 days.
Causes lifethreatening
dehydration.

Food or water
contaminated with
human fecal material.
Usually person-toperson spread, fecaloral transmission.
Ready-to-eat foods
touched by infected
food workers, e.g., raw
vegetables, salads,
sandwiches.
Unrefrigerated or
improperly refrigerated
meats, potato and egg
salads, cream pastries.
Contaminated water,
fish, shellfish, streetvended food typically
from Latin America or
Asia

28 days

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

13 wk,
usually selflimiting

Undercooked pork,
unpasteurized milk,
tofu, contaminated

30

not indicated unless there

is extra-intestinal spread,
or the risk of extraintestinal spread, of the
infection. Consider
ampicillin, gentamicin,
TMP-SMX, or quinolones
if indicated. A vaccine
exists for S. typhi.
Supportive care. TMPSMX recommended in
the U. S. if organism is
susceptible; nalidixic acid
or other quinolones may
be indicated if organism
is resistant, especially in
developing countries.

Supportive care.

Supportive care with

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

Supportive care. If
septicemia or other
invasive disease occurs,

Rotavirus

primarily in older children and

young adults. May have a
scarlitiniform rash or erythema
nodosum with Y.
pseudotuberculosis.
Vomiting, watery diarrhea, low- 48 days
grade fever. Temporary lactose
intolerance may occur. Infants
and children, elderly, and
immunocompromised are
especially vulnerable.

water. Infection has

occurred in infants
whose caregivers
handled chitterlings.
Fecally contaminated
foods. Ready-to-eat
foods touched by
infected food workers
(salads, fruits).

antibiotic therapy with

gentamicin or cefotaxime
(doxycycline and
ciprofloxacin also
effective).
Supportive care. Severe
diarrhea may require fluid
and electrolyte
replacement.

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

33. 4) @L croup - %-M% 27

34. 1) & 33.
35. 3)
6
14&!" 3 Neonatal mastitis * term 6&*4%1+ 2 3  &  
& swelling,
induration  tenderness  % +@L 6&
* erythema  # warmth &$&  
* purulent
discharge
 nipple 4&
# S. aureus, coliform bacteria (included anaerobes),  # group B streptococcus 
(
-$@+ subcutaneous tissue 
4& systemic infection $&
&&ap  .+ $ (mild cellulitis, no fluctuation) 
C/S  nipple discharge 
antibiotic %#+*@+% sensitivity +$& %$*#  @L cloxacillin + aminoglycoside  #
cefotaxime  .+ -   admit $& fluctuation  drainage & & 
36. 1)
6
1 M)@]3 antibiotic-associated diarrhea "+ 4&
 overgrowth  C. difficile "+ *+ 
  ampicillin, clindamycin  cephalosporin  (#  -&%&4 @L$@$& %!@L$@
$$&*4+ metronidazole PO 7-10   &
37. 4)

6
1
$&&M4&@%4 primary hemostasis *  #&%#  4.M4 
#+- (epistaxis, menorrhagia, petechiae, ecchymoses, occasional hematomas, and less commonly, hematuria and
gastrointestinal bleeding) "+
%% M4&@%4 secondary hemostasis  hemophilia +
#&
##+" # # (ecchymosis, extensive hematoma)
M4&@%4 primary hemostasis  $&, 2 #
 vessel (Henoch-Schnlein purpura, vit. C
def., collagen disease, etc.) 
 platelet "+ 
M4&@%4+@ 4. (quantitative)  # -.3* (qualitative) "+  % 

CBC
M4&@%4 @ 4. #$ PBS @L % 
*#+ confirm CBC  plt. %+
4  #$ 

 @ 4&  %4&  &#& "+ M4&@%4
& !" function +M4&@%4$&  bleeding time 
M4&@%4 primary hemostasis  $$&4&
 plt.  # vessel
M)@]  6
1$) .1* $ @L&$ 6 * %6 +
@L$@$&
+-&# ITP #+
M)@] ITP @ %4 viral infection  1-4 wk +
 clinical bleeding " (#+4&

 immune reaction) @  % 

 "+ $* hepatosplenomegaly, lymphadenopathy "+ *(.
 4&!" leukemia  ITP #+ CBC  * series #+, @%4 * plt. +%+ ( bleeding 

31

 anemia +E4$&) #+&)

 PBS % $* blast cell  
* platelet &5"$&
 bone marrow

* series #+, @%4  megakaryocytes 
*4+
"
&&ap ITP $&6&  IVIG, Prednisolone, IV anti-D ($&* Rh +ve)  #%&"+
#+@L
severe life-threatening acute ITP  # Chronic ITP + plt. < 30,000/mm3  1 @+$% % ( 6&

(#+ clinical bleeding  # plt. < 20,000 /mm3   plt. !#@L contraindication  ITP 
 lifethreatening bleeding
DHF 
& petechiae, ecchymosis $&% clinical course  $# DHF "+  +#&+
M4
@L fever phase "+ $
)   4-6  
%& shock or hemorrhagic phase (1-2 d) "+ $

 &  shock 
) convalescent phase (1-3 d) "+
* convalescent rash
APDE  # Acquired platelet dysfunction with eosinophilia *&$ &
#&%% #&&
$ % 
 $*M4&@%4#+, 
 ecchymosis % 
CBC * eosinophilia  &#&
@%4 %
%4&
  prolonged bleeding time #++  parasite (&  antiparasitic drug **E4
38. 1)?  +@|5 #+ seizure % 3+$ seizure  jitteriness "+
 %- %#+#

-&
 #3 non convulsive apnea "+ % %- sepsis %@L   %-
4  4&!" @L
seizure
4 %- seizure $&%- hypoxic-ischemic cerebral injury, Intracranial hemorrhage, neonatal
cerebral infarction, metabolic abnormalities (Hypoglycemia, hypocalcemia, hypoMg, HypoNa, hyperNa), infection,
inborn errors of metabolism  4+ + %$@# rule out hypoxia 6&&)
 clinical @%4 % 
&) glucose
level
 DTX 3 hypoglycemia   plasma glucose lv. *#+ confirm
( $
 C/S & indication $  fetal distress? CPD? Fail V/E or F/E?;  &$
@L macrosomia $  #@L IUGR $ "+ $&@ %4 2 
 guide %-$&")
39. RDS
 newborn %- dyspnea +5$&
a. RDS  # Hyaline membrane disease @L%-+*+-& * preterm #+
& surfactant @ 
 chest wall compliance  preterm  $&*
*$&"#+ GA &  
 

 &  # 2-4 +6  4& (4& 6 +6 $4&
 RDS) 
@L" 48 +6 
$&     (+  $  6      
& "  48 +  6  CXR
* diffuse
reticulogranular pattern with superimposed air bronchograms, hypoaeration with loss of lung volume @L

 lung density # heart density   white-out lung #+ lung haziness 4&
 diffuse atelectasis
 pulmonary edema   prenatal corticosteroid  && &-%4 .1 -  6 
b. Transient tachypnea of the newborn (TTNB) #+%-4&
 delay lung fluid clearance
 $  &
%& * term, near term + C/S  # precipitate labor, M>F  6&$ &" 2-3
 CXR * lung fluid   
* pleural effusion  #
* sun burst appearance
+$
lymphatic vessel
c. Meconium aspiration syndrome (MAS) *$& 15%   + meconium stained AF @L3+%   &)
.& 6&  ET intubation  dyspnea 4&3 6 +6  & ! meconium 
 2-3 +6 &
 meconium stained %M4 ,  &# 3*$&" post-term,
IUGR #+ CXR
* diffuse coarse density, area of hyperinflation, air trapping 
* pneumothorax $&

32

40.

41.
42.

43.

d. Persistent pulmonary hypertension (PPHN)  +@|5 severe and prolonged hypoxia
4& met.
acidosis 
 pulmonary vessel constriction 4& pulmonary hypertension #&@&$@@+
& 6&
 hypoxia $% % FiO2 +*4+
5) M)@]+& drowning management # %# ABCDE M)@]  *  respiratory insufficiency 
drowsiness
"  *4
 . intubation  positive end-expiratory pressure #+
 pulmonary edema ($
 steroid  # diuretics  .)
ITP? % 37.
2) Guillain-Barr syndrome (GBS) @L postinfectious demyelinating polyneuropathy   6 
%
nonspecific viral infection @ . 10   #
4&%  %4&# GI (esp. C. jejuni)  # respiratory tract
(esp. M. pneumoniae)  typical  6 #    4+
 lower extremities @L" #+,

  trunk, upper limbs  bulbar m. "+   pattern  Landry ascending paralysis 
 involve proximal &
distal m. ,  onset  6 
@L  #@&1  
*  &
 % 
lab +# CSF study
* protein ) @%4 2 , glucose lv. @%4 $ cell
@%4 % 
motor nerve conduction velocity *
&    sensory nerve velocity 
& $& EMG

*(. acute denervation of muscle   muscle biopsy $

@L  44

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

-&
Beriberi #6 +4&
 & vitamin B1  2 forms # wet beriberi (undernourished, pale, edematous,
dyspnea, vomiting, tachycardia, waxy skin)  dry beriberi (fat, pale, flabby, unenergetic, dyspnea, tachycardia,
hepatomegaly)  %
6 %-
 cardiomegaly  EKG +* QT interval, inverted T waves, low
voltage "+ $ (
4&@L high-output cardiac failure $& 
 * peripheral neuropathy 
*
  DTR
2) %%    4&!" organophosphate +-& (6
1
@L diaphoresis $ dysphoresis)

Toxidrome
Opioid

Representative
Agent(s)
Heroin
Morphine

Sympathomimetic Cocaine
Amphetamine
Ephedrine
Cholinergic

Organophosphate

Most Common Findings

CNS depression, miosis,
respiratory depression
Psychomotor agitation,
mydriasis, diaphoresis,
tachycardia, hypertension,
hyperthermia

Salivation, lacrimation,

33

Additional Signs and

Symptoms
Hypothermia,
bradycardia. Death may
result from respiratory
arrest, acute lung injury
Seizures,
rhabdomyolysis,
myocardial infarction
Death may result from
seizures, cardiac arrest,
hyperthermia
Bradycardia,

Potential Interventions
Ventilation or naloxone

Cooling, sedation with

benzodiazepines, hydration

Airway protection and

insecticides
Carbamate
insecticides

Anticholinergic

Scopolamine
Atropine

Salicylates

Aspirin
Oil of wintergreen

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

Altered mental status,

mydriasis, dry/flushed skin,
urinary retention, decreased
bowel sounds,
hyperthermia, dry mucous
membranes
Altered mental status,
respiratory alkalosis,
metabolic acidosis, tinnitus,
hyperpnea, tachycardia,
diaphoresis, nausea,
vomiting

44. 3)

miosis/mydriasis,
seizures, respiratory
failure, paralysis
Death may result from
respiratory arrest from
paralysis, bronchorrhea,
or seizures
Seizures, dysrhythmias,
rhabdomyolysis
Death may result from
hyperthermia and
dysrhythmias
Low-grade fever,
ketonuria
Death may result from
acute lung injury

ventilation, atropine,
pralidoxime (only in
Organophosphate
poisoing)

Physostigmine (if
appropriate), sedation with
benzodiazepines, cooling,
supportive management
MDAC, alkalinization of the
urine with potassium
repletion, hemodialysis,
hydration

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

Congenital diaphragmatic hernia

  respiratory distress (tachypnea, grunting, accessory muscles
usage, cyanosis) "+ 
4& &  # $ (honeymoon period) $&!" 48 +6 * scaphoid
abdomen, increased chest wall diameter 
| $& bowel sound  decreased breath sounds bilaterally (or
ipsilaterally) % PMI 
#+$@+#+, CXR with nasal gastric tube *#+ confirm dx.  (%$&6&
 respiratory support (ET intubation, sedation, probably paralysis) $ hyperventilation   PaCO2 45-60 mmHg
(permissive hypercapnia), pH >7.3
Situs inversus @L3+ abdominal organs, lung lobation  atrium )   dextrocardia !"

)    
TE fistula "+ ++  VACTERL syndrome M)@] frothing  bubbling +@
)
 & 
 $, %  respiratory distress  feeding
 %-  #+
4& regurgitation 

4& aspiration gastric content M$@ distal fistula 4& pneumonitis
 early-onset respiratory distress   NG  # OG tube  pass $$&& !" Esophageal atresia
!"  + &3 polyhydramnios  CXR with NG/OG tube
* coiled feeding tube in esophageal pouch
6&
 air  stomach  #$$& 
& !" TEF  (# %$&6&
& prone position *#+@} 
gastric secretion $@ distal fistula   intermittent esophageal suction *#+& aspiration
 blind pouch
 ET intubation with mechanical ventilation $ 
45. 4)
Eisenmenger complex (syndrome) # +M)@] VSD  partially  # totally right to left shunt
 pulmonary
vascular disease +4&" (
4& ADS, AVSD, PDA  # left-to-right-shunt anomaly #+,)  +*# M)@]

   
+
&" %%
 right heart failure # edema, hepatomegaly % 
 $&

34

46. 2)

47. 4)
48. 2)
49. 1)
50. 4)
51. 2)

52. 4)

RV impulse  " PSM

 * & RV  LV *,   P2
&  
$&4 Diastolic rumbling
murmur + left upper sterna border
 PR $&  3 Graham Steels murmur
Pulmonary embolism M)@]
 U/D #+, +4&!" #+| lung 
$& adventitious sound (localized
crackles)  sign of dyspnea, diaphoresis, chest pain
AR
| $& diastolic rumbling murmur + upper and mid left sternal border 6& radiation to the apex and the
aortic area %
$ 
Hypoxic spell: &) 26.
 4&!" @L nonbilious vomiting "+ 4&!" Hypertrophic pyloric stenosis +-& * - 2-8 @&1 

*@&1  progressive nonbilious emesis "+ 
@L 4 
$& RUQ mass
* peristalsis + epigastrium * *'54 M)@]
 chronic malnutrition 
dehydration with hypochloremic alkalosis  " $&
Duodenal atresia @L complete obstruction of duodenal lumen 
* maternal polyhydramnios, bilious
projectile emesis  abdominal distension 6 
* 24-48 +6  &  plain abdomen
*
double bubble sign
&&  hyperthyroid % 
 $& Graves disease % 
lab *(.+$&# TSH, FT4
% 
* & antithyroglobulin )  (+&#  (methimazole, PTU)
Chickenpox or varicella  incubation period 2-3 wk M)@] !* #$&% % 48 +6  vesicular rash
!"
vesicles  & %&
&) 22
&) 12

6
14&!" 3 meningitis +-& %-6&4&
 bacteria   & $*


"-M)@]  & 
&$ "  
 # $&)& 
 % 
 
*
tense and bulging fontanel &6%
& $ @&' ( 
 "  # -& 4&  
% 
 
* signs of meningeal irritation # stiff neck (>1 yr), Kernigs sign  # Brudzinskis sign 

% 
* sign of IICP $&  .+   LP *#+% 
CSF - $  signs of IICP etc.
#+*5
"- #
Neonatal: gram negative bacilli  GBS
1 2 m: gram negative bacilli (Salmonella, E. coli) Ampi + genta, ampi + 3rd gen cephalosporin
2 12 m: H. influenzae, S. pneumoniae, Salmonella l Ampi + 3rd gen ceph
1 3 yr: H. influenzae, S. pneumoniae, N. meningitidis l Ampi + 3rd gen ceph
3 15 yr: S. pneumoniae, H. influenzae, N. meningitidis l PGS or 3rd gen ceph. + Vanco

* typical appearance  # 4 & * purpuric rash "+ 
@L (.& 
meningococcal septicemia (embolic phenomenon)  $ %  % 
CFS 5 4& # *#+
 %&4
 (  post-exposure antibiotic  rifampicin -+ contact  N. meningitidis
&%+ 4 @+ contact  H. influenzae
&) 5

35

53. 2) &) 4
54. ? 6
1$  $ subdural hematoma * &&)&4$@+
4&
 subdural hematoma   leukocytosis
with neutrophilia &
" 
@L infection induced DIC?
55. 4)
6
1  @L acute bacterial rhinosinusitis (6
1+$&
 @L foreign body obstruction @L
& % @L 2 
" 4&!" $& ) "+ $& * $ "+ 4&
# 
 M)@]
+ 
)   
@L$&3 5-7   #@L$&4 10    &
 "+ %$@ # ) &
) @&/&
 4. )$   $&4+& $ $ @&#@&| )
# &%   10 @L" #+,  #    14 $
&"
 ( 1st line  Amoxicillin 45- 50 MKD PO bid + % drug resistance S. pneumoniae ($&
antibiotic  1-3 &#, ) daycare  #- < 2 @)
 80-90 MKD PO bid * amoxicillin %$*
cephalosporin
 2nd gen. cephalosporin (cefuroxime, ceprozil) * cephalosporin & erythromycin,
clarithromycin, azithromycin  # cotrimoxazole
2nd line $& Amoxicillin/clavulanate, 2nd gen. cephalosporin, 3rd gen cephalosporin (cefpodoxime, cefdinir)
%& * amoxicillin  # cephalosporin *4
 . clarithromycin, azithromycin %$@   $&
"@ "(*1*
 (
 1st line antibiotic  &)  3-7 &" #$ !&"%$@ 7  $&"
*4
 . 2nd line  # %$@ M) +5
  $&* 2  &)  1-5  response  #$ @ 4 compliance & ( clinical
#+, @%4&)   PNS film
#+M)@] $&6 $ % % 
36*
)$*
M4&@%4*+
44
$&@L6 $
%6
1@+@L  bacterial rhinosinusitis  & ( 3 $   speculum
examination &)  *#+&) foreign body  #$ (&# #+ foreign body -  )
56. 3)
:k Motor
Adaptive
Language
Social
2 m 
#,
 
Social smiles
4 m  @, +
&)%4+ 
  &
&

6 m + , + $&
@+ #$&
@
  
12 m  # &4
4 &4#  * #*)&6&&
6# (10 m.) %#
18 m &4 4+ "$&
  $& 3  *)&@L 10 
4  $&
2 yr &4"$& %$& %
*)&@ 6, $&
@|
3 yr "$&,
 
)*' #+
  %#$& $
+
 
@| &+% #
4 yr &4 $&,

$& 1  #
 4+-
6&&&
 * $&
5 yr  )
&+
$& 4 
 #$&
6 yr %#&$&
&#M *)&$&& )   #$&
57. 3) %-M# 36.

36

58. 4)   M)@]$& Cushing syndrome "+  # moon facies, generalized/truncal obesity, purplish striae,
%%, delay pubertal development,  , @&' (,  .1@ @ , &64%) , hyperglycemia, &)* -
M)54 
* hirsutism,  -, enlarged clitoris  delayed or amenorrhea
%- cushing syndrome %-  bilateral adrenal hyperplasia, hypersecretion of corticotrophin
(Cushing disease), ectopic secretion of ACTH, exogenous ACTH or steroid, tumor, etc.
Lab
* cortisol lv. *4+) " (@%4 cortisol
)   &%+% # % cushing syndrome

$ circadian rhythm) % 

urine cortisol 24-hr
) " #+% 
single-dose dexamethasone suppression
*
plasma cortisol lv.   ) % 
bone age
* delayed bone age
% 
electrolyte * serum calcium lv. @%4 (glucocorticoid  action  & serum calcium 
( hypercalcemia %#+
  PTH response  & serum calcium @%4)    
* hypokalemia,
hypochloremia  metabolic alkalosis $&6&*+4&
 ectopic production of ACTH
59. 5)

6
1M)@]& pancytopenia "+
"  investigation & bone marrow aspiration
" +-&*#+
 44
  % 
serum ferritin #+  iron-def. anemia, bleeding time #+ M4&@%4 primary
hemostasis, screening coagulogram #+ M4&@%4 secondary hemostasis, reticulocyte count *#+&)
erythropoietic activity
Pancytopenia & 4&!" 6  aplastic anemia, bone marrow infiltration with leukemic cells, paroxysmal
nocturnal hemoglobinuria, SLE, B12 or folate deficiency, etc.
60. 4)? M)@] postprandial regurgitation "+ @L  GERD "+ 
4& aspiration pneumonia $& M)@]
GERD 
  respiratory symptoms $&
 + refluxed gastric content M respiratory tract 6&%
(
 aspiration, laryngeal penetration  # microaspiration)  #
 + reflux %- vagal /neural reflex 4&
airway resistance  airway reactivity 4& wheezing $& "+ wheezing  infant  6&
% %
bronchodilator &  + wheezing $@ $& bronchodilator $$&4&
%-$
61. Benign rolandic epilepsy (Benign focal epilepsy of childhood or benign epilepsy with centro-temporal spikes)
@L6 +*$&+-&& - idiopathic partial epilepsy M)@]* @%4 *- 3-13
@
$&   - 
@ %4*+ *  . 6& 4+

-&&
-&"+ +@  # $@)
 %  
* 1-2   4% * .16 & % %& .+
#4
Epileptic syndromes #+&+ )# Childhood absence seizure @L generalized epilepsy syndrome *4-10 @ * %4@|55@%4 @L , 4-20 4 6&$  M)@] 
(. absence
seizure 
* automatism &$& 
$& 10-200   %  
 GTC &$& * .16 &
% % Valproic acid  ethosuximide
West syndrome -  triad #@L infantile spasms (sudden extensor/flexor trunk movements) * psychomotor
retardation  EEG hyparrythmia (disorganized high-voltage slow waves, spikes and sharp waves) * 3
&#"$@ 4& 1 @ * .16 $&  +  tuberous sclerosis
62. 3)
6
1& M4&@%4 secondary hemostasis #+
 bleeding time @%4  % 
PTT * prolong
" "
!" %-
 intrinsic factor "+ +$& factor VIII M)@] 
" 
3 factor VIII deficiency (hemophilia A)

37

Secondary hemostasis  2 pathway # intrinsic pathway  extrinsic pathway "+ % pathway

%- coagulation factors  cascade  intrinsic pathway @ & HMWK, PK, FXII, FXI, FIX  FVIII 
extrinsic pathway @ & FVII   pathways
 %- FX 4&@L common pathway "+  FX, FV,
prothrombin (FII)  fibrinogen (FI) -&
$& fibrin "+
!) %-& FXIIIa "+
+ stabilized fibrin clot
 &   coagulation factors  pathway % , $&6& aPTT &   intrinsic 
common pathway  PT &   extrinsic  common pathway
Lupus coagulopathy
4& prolonged PTT $& %M)@]
 clinical #+, +& @L SLE !" 3

$4& bleeding tendency  Factor VII def. (hemophilia B or Christmas factor def.) 
* isolated
prolonged PT 
 present & thrombosis 
von Willebrand factor def. M)@]
 prolonged PTT  prolonged bleeding time decrease plt. count

&  superficial bleeding, epistaxis, postop bleeding, menorrhagia, etc.  Hereditary platelet
dysfunction M)@]
 prolonged bleeding time
63. Iron def. anemia?
&+& anemia 6& hypochromic microcytic RBC %-+ "!" %% 
ft
ZKLs< [
PBS
Lab
KL
Iron def.
& -3 @, &#+%,
SI, TIBC,
Fe supplement
Mild -mod.
hookworm, menses, chronic
SI/TIBC < 16%
Anisopoikilosis,
blood loss, pica, koilonychias or RC,
Pencil-shaped RBC
Thalassemia
Hepatomegaly, splenomegaly, Mod. - marked
Abnormal Hb
- Transfusion
jaundice, failure to thrive,
anisopoikilosis
typing
- Iron chelation
thalassemic facies, Fam. Hx, Target cells
- Splenectomy
gallstone, hemosiderosis
Teardrop cells
Schistocytes
Lead poisoning  /, battery, , - Basophilic striping Screening urine - Supportive
@& , lead band + long
RBC
coproporphyrin,
- Chelation &
bone X-ray
whole blood lead dimercaprol 
EDTA
64. 5) Caput succedaneum # diffuse edematous swelling  soft tissues   ' ( 
 suture line $& 

3$+ * prolonged vaginal delivery (
* hematoma $&  minimal bleeding) 4&!" 
subgaleal hemorrhage * 
@L%&' (
Subgaleal hemorrhage (hematoma) 4&
#&+ % aponeurosis "+ - ' (%& 
#&
$&$@
!" subcutaneous tissue   & firm fluctuant mass, increases in size after birth  !
suture line $& $&  2-3 @&1 +  Vacuum-assisted delivery

38

Cephalhematoma @L subperiosteal hemorrhage

$ suture line () surface  one cranial bone
) *(.@L firm tense mass with palpable rim localize over 1 area of skull
  2 @&1 3
&# 
calcification $&
Epidural hematoma  subdural hematoma
$$& ' (
 signs of IICP

 Nelson Textbook of Pediatric, 17th ed.

65. 3)
6
1 4&!" M)@]3 acute renal failure
%-+
@L intrinsic renal cause 6& signs  volume
overload  pulmonary edema
" 
*4
 . furosemide *#+
66. 1)
6
1 M)@]3 acute bronchiolitis "+ *&-%+ 2 @ 4&
# respiratory syncytial virus @L
   4+&)$
 $%+, 
 $@ . 2-4 

 4+ 

$    $&4 &  #+, +*$&#   4 #$& 
 % 
 *
signs of dyspnea, 6@] *  @& @&* hyperresonance, diminished vesicular breath sound 

" $&4 wheezing +, $@ 
$&4 fine crackles &$& CXR * hyperinflation  @&

 ( Supportive treatment #  O2 # (keep O2 sat. > 95%), NPO M)@],
salbutamol/terbutaline NB (controversy), epinephrine, ribavarin (*4
 .@L , $@)
M)@] 4+  + #  O2 supplement
67. 2) %- pneumonia 
@L%-& cellulitis #4&
 S. aureus 6& pneumonia
#4&

hematogenous spreading *$) 
#+   CXR 
* localized or diffused bronchopneumonia  #

@L lobar pneumonia  .+@L
*(. necrotizing pneumonitis, pneumatocole  # pneumothorax $&
"+ M)@]
 
#+ 
*% &
68. 3) @L APDE ( 37.)

39

Surgery y
1. 4) Surgery
ekZ : M)@] @|5# :[kV  V  {U[V Pa[     44
 +"!" # Inguinal
hernia "+ @ 3 Inguinal hernia ) 2 4& #
1. Indirect inguinal hernia # hernia sac 
 internal ring "+ ) lateral % deep epigastric artery
2. Direct inguinal hernia # hernia sac 
 opening "+ ) medial % deep epigastric artery
Inguinal hernia
 History : +  # 
 $@!" !- .0 
-6@] $&
 Diagnosis : Get above sign negative # $ ! $& !@L mass + testis 

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

$

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

  @4 %@L direct
 +&  4
 Tx : M)@]+-3*&  $&  M%&-  * $#+&64& strangulation $& 
 )@L Direct  # Indirect $5* %  (#
 @L inguinal hernia  5 @
#+ 5 +6 * :[V fe <`cV
Zs<K[:[ZKV
n n< (.&  3 Incarcerated hernia # 3+ content $ !#)  $& "+ 
 #$
 complication $& obstruction  # strangulation $& &  #+
M)@]+& incarceration hernia % % 

+
$ strangulation
 Obstructive hernia @L irreducible hernia + content @L intestine 4& obstruction 6&$ &#&

colicky pain  tenderness  4. hernia site   strangulated hernia
Treatment :  Immediate surgery * 
 closed loop intestinal obstruction
 Strangulated hernia @L3+ content  sac  impaired blood supply  @& 4. hernia sac 
progress @L colicky pain  4. &# #+$ 
 % 
 * hernia sac
 %" &
    
&  $ % sac 
*$  # sepsis $&
Treatment :  Immediate surgery 
&   
@L obstructive hernia "+  ( # immediate surgery
 1) $!) *  $ @&   , &
4& complication -
 2) $!) *  #+
 
 sign  incarcerated hernia $ &  )+,-./.01)23456+7849.7:;15;<+=. 3-4 @A4,B;:
 3) $!) *  #@L  ,  observe  $$ 
 5) $!) * #$@ & complication % &  %$@

40

2. 1) Plain abdomen
ekZ : M)@]+& acute abdomen   plain film @L % 
 -& *#+&)M4&@%4  
44
3% , & %$@ Perforated hollow viscus, Intestinal obstruction, paralytic ileus, &)  
 
 gas forming organism, &) abnormal calcification, abnormal intraabdominal mass, ascites, abdominal
abscess, foreign body  GI tract, bowel infarction
Plain abdomen @ $@& 3  $&
1. Plain abdomen  @ 61 &)(. $ &)+)$ &)  &)(.M4&@%4
% ,    ,
2. Plain abdomen # @ 61 &)(. &$ "+ 
3 gut obstruction  #
paralytic ileus
3. Chest # @ 61 &) free air @ 4. , & 1-2 .
0F,A: !!! Plain abdomen )&DU#D#U!$+! Acute abdominal series Ya[Y)#$
 2)  5) $!) * &)
$@ $ ## %
 3) $!) *  ultrasound $ &)* M)@]@L GI perforation
&)$$&
 4) $!) *   abdomen series
@ & plain abdomen  supine & upright  $ CXR !

!) %  Acute abdominal series  # Plain abdomen
3. 2) Fibroadenoma
ekZ : fibroadenoma *%  20-30 @ @L most common benign solid tumor  breast (.
 @L rubbery firm, discrete mass H=,+03)I non tender, extremely mobile #+
 
 calcification

 $&
KL : Excisional biopsy $ %&
4& *  capsule # @L$&
 1) $!) *  Fat necrosis * chest wall  # breast trauma 6&
&(. &  !
needle biopsy
* lipid material   mammogram 

( carcinoma $& (&@&

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

 & #+ palpable cyst
 4) $!) *  M)@]- (.n $& 
7AJKF234.<1LF+MN.;F+0O: P89
 (.
 irregular, hard, ill-defined margin, not tender
 Skin dimpling
 Nipple retraction
 Skin involvement  ulceration, skin edema(peau dorange), satellite nodule
 Axillary lymph node 6%

41

 5) $!) * (. intraductal papilloma   bloody nipple discharge  # serous @L most
common cause in bloody nipple discharge "+ 4&
 focal area of necrosis  hemorrhage  papilloma
4. 1) Villous adenoma
ekZ : Polyp !" #+#+M4 mucosa  $ "+ 
(pedunculated)  # 
 (sessile) $&   , @L 2 - $&
1. Zk {n
 [\]: :  Benign lymphoid polyp , inflammatory polyp, metaplastic polyp, Juvenile polyp, PeutzJeghers polyp $@L 
2. Zk {Pa[[\]: : *$&%&$5 *+-&+ rectum  sigmoid colon *$&% %- 20 @"$@ %
% ) -& 60 @  @L 3 @ 3 $&
2.1) Tubular adenoma (adenomatous polyp) *+-& @L   M4 
2.2) Villous adenoma *$ 5) rectum  $&--
2.3) Tubulo-villous adenoma (.  
[<
f:{Pa[sc
Tubular
5%
Tubulo-villous
20%
Villous
40%
5. 1) Reduction
ekZ : M)@]
@L inguinal hernia  1 +6 $ clinical  strangulation  ! reduction $&&
- ! reduction  
  herniorrhaphy  2-3 % $
&)+ 1.
 2) $!) *  $ )
$@$ #+
 !' clinical  44
$&
 3) $!) * 
6
1$E4 #+ strangulation
 4) $!) * $ ( inguinal hernia
 5) $!) * 
6
1$$& !&$& #$ !&$$& (irreducible) % $@M)@]
  ( $ reassure
6. 1) Orchitis
ekZ:
M U/S  increase vascular blood
flow @ #&*4+" &  torsion %&4 $@$& * 
! torsion #&
$"$& $  
& #+!-
.0"%&* torsion $@$&" * !@L
torsion

"!!- .0" (%$
@L$@) %
&) #&+$"% & 
 4&" #&
"
$" %# Orchitis  Epididymitis &)6
1+
@&  & "+ 
@L 4 . M4 !- .0 +
  4&!" Orchitis " * !@L Epididymitis 

 & *+ Epididymis  $$&@L testis

42

7. 4) Internal drainage
ekZ : $@L pseudocyst "+ @L complication
 @L Acute pancreatitis &%
Pseudocyst @L collection  fluid +@ 4. enzyme  %) 4&% % pancreatic
trauma 5)#%  # 4. 6&* lesser sac 4&
  fluid +
%
!)-$&  fluid +&)&"$&
 #)@L pseudocyst
!4E ( pseudocyst "+ 4E () 2 4E ")%  pseudocyst & 
! pseudocyst )+ Body, Head, < stomach \:Pa[ posterior wall U: stomach
4E internal
drainage #@L cystogastrostomy  # cystojejunostomy
! pseudocyst )+ distal pancreas
4E Distal partial pancreatectomy $@
"+  pseudocyst )+ front of pancreas & 
" % 4) Internal drainage +
8. 2) Explore wound at OR
ekZ :  Neck injury + Zone II #)% Sternal notch "$@!"   mandible ()%4 .
E) 4E (++-&# 2) Explore wound at OR
Penetrating neck injury
 @L 3 zone $&
1. Zone I )  &)$@  (clavicle)    &) cricoid +5 $& &#&&
vertebral  carotid @& & & $  # @ % ,
2. Zone II )  &) cricoid  angle of mandible +5 $& &#&& jugular &
#&& vertebral  carotid   common, internal  external &  & $

3. Zone III )  angle of mandible  base of skull 5 $& pharynx &#&& jugular
&#&& vertebral  internal carotid
KL
!3 #&  expanding or pulsatile hematoma  @M  #
 
$&  M%& neck exploration  6&$%  % 
%
 &
 zone I  zone III %   % 
*4'( M%& *#+&@&3
!" 5+$& &

 &
 zone II +&64%@%4 $ &
%5  ( 2  #
1. M%& neck exploration - +&M"4 platysma
2. *4
 . (% 6&' % 
*4'(
 panendoscopy
9. 4) Ultrasound 
&% 
%4&%- , 6 &#
ekZ :   &)M)@]+& $&+% 
 @ %4% 
 #
+%
4 &)(.   Breast imaging evaluation & ultrasound
[z :k[:
  35 P  M)54 - 35 @"$@  mammogram &

43

!% 
*@L solid mass  &) ( #
@L% $&4#% 
&
- '1*#+44

(tissue histologic diagnosis) *#+*4)
1 #6    %  % 
  & !
$&@L
  * 60-85%   +
# fine needle aspiration, core needle biopsy  # open surgical biopsy 
" !+  #+ #  # '*1+
#4E& *#+$& 44
+!)%  
$&
 (+!)% % %6 +@L%$@
kP 3
 clinical examination imaging FNA (Triple assessment) *M@L benign
 &  ! (& %4&%$& !& 2 cm.  % 
%4&%3 1 @ % 

- 3-4 &#
- 6 &# ! 
  44 core biopsy  # excision !&
5 2 cm.  excision
 1) $!) %! choice 
!) % @L .+M)@]$&n K<`[ *1% M)@]% 
%
 2) $!) #@L*1% 
# ,  $ *1% ) *#+*4)
1@L
4  #$
 3) $!) *  @L %% $# %
 5) $!) *  - 16 @  $ mammogram  % %- 35 "$@*  breast tissue  4+ fat 

&)$&&
10. 3) Acute pancreatitis
ekZ : @ %4+ suggest acute pancreatitis $&
 @& $@
  &#+- %4&% 5  6&+$@
 4+%  12 !" 48 +6 
"
Tender at epigastrium , decreased bowel sound

 
$ pleural effusion  + -
  fluid $@ retroperitoneal space M)@]
dehydration, tachycardia, hypotension  +*E43*@L hemorrhagic necrotizing pancreatitis 
* 
 4.&# (Cullens sign)  # (Grey turners sign) "+ @L#&+
 retroperitoneum
11. 3) Hemorrhoidectomy
ekZ : M)@] @L hemorrhoid 
@L internal hemorrhoid & 6&'% 
dentate line # ##+ hemorrhoid )!&
 dentate line   #-& squamous epithelium
 
external hemorrhoids
@ 3 internal hemorrhoids  $&@L 4 @ 3 #
1. Grade I Bleeding without prolapsed
2. Grade II Prolapsed with spontaneous reduction
3. Grade III Prolapsed with manual reduction
4. Grade IV Incarcerated, irreducible prolapsed
  role   M%& # Indications for surgery $&
Prolapsed thrombosed hemorrhoids
Incarcerated hemorrhoids
 @& - 
 M)+  #       *4
 .M%& & 

44

1. Fail conservative treatment  sclerotherapy, rubber band ligation

2. M)@]+ hemorrhoids 6   #++%  M%&
3. M)@]+@L hemorrhoids grade III-IV + 
4. M)@]+%&4

# M%& 

*1$& # (
@L grade III "+ @L #  
" *4
 .M%& hemorrhoidectomy
 1) $!) *  grade I-II
 2) $!) *  grade I-II
 4) $!) * @L4E+-  $@L+4 M ($%
4E
 5) $!) * @L4E (+ , $@   - dietary  life style modification   %  (+
*


12. 1) Ceftriaxone + Metronidazole
ekZ :
Ceftriaxone : Streptococcus, enterococci, GNR
Metronidazole : Anaerobes (including B. fragilis) above the diaphragm
Clindamycin : Gram positive (except enterococci) & anaerobes (including B. fragilis) below the diaphragm
Gentamicin : Some enterococci, GNR, no activity against anaerobes
Ampicillin : Exteded-spctrum penicillin GPB and GNR (E.coli, H.influenzae, enterococci)
Cetazidime : Same as Ceftriaxone and Pseudomonas
#+
M)@]3 peritonitis "+ 
@L secondary peritonitis
  bowel perforation "+ #5
@L Streptococcus, enterococci, gram negative  anaerobe & 
" # Ceftriaxone *#+-- GNR 
Metronidazole (anaerobes below diaphragm)
 2)
4 , #
!) *  clindamycin  Gentamicin "+ 
-#$&&
Gram positive  negative %* 3) "+ @L+ cover #$& Gram positive  negative (* 
%  $ )# % @L broad spectrum $@)  anaerobe  clindamycin  infection above
diaphragm
" # 1)
13. 1) Pleural tapping
ekZ : M)@]@L tension pneumothorax (classic triad # deviation  trachea $@&% , cyanosis,
distended neck vein, 6@  +@& , $ breath sound  ) "+ @L life-threatening conditions
"  role 
  thoracentesis  # pleural tapping 6& 15   4. 2nd ICS + MCL 

"  tube
thoracostomy
14. 2) Pericardiocentesis
ekZ : M)@]@L cardiac tamponade (Becks triad @ & BP drop, CVP %+, distant heart sound) 
4&
 stab wound  anterior chest wall  (-4  needle aspiration &)&#&
 pericardial sac 
subxiphoid approach - 45  '  % $@+ inferior angle left scapula %!M)@] $& %
*4
 . emergency thoracotomy 

45

15. 2) Acute subdural hemorrhage

ekZ : 
 CT scan @L crescent shape
" "!" subdural hemorrhage/hematoma @L
hyperdensity area "+ 
@L acute phase (0-7 ) @L isodensity area
&@L subacute phase (3-14 ) 
@L hypodensity area
&@L chronic phase (>21 )
54&
 & bridging vein  cerebral cortex  venous sinus
 1) $% *  acute epidural hemorrhage * 4. temporal  temporoparietal 6&4&

& &#&& middle meningeal CT scan *@L high density mass (. )@1  # biconvex shape
*  skull fracture 
 3) , 4) , 5) $% *   CT @L isodensity lesion #+
@L subacute phase
16. 2) ET intubations
ekZ : M)@]
&@L severe head injury (GCS 3-8)  management $&
Oxygenation $& Oxygen administration, Endotracheal intubation in ALL
Blood pressure $& maintain SBP > 90 mmHg
Intravenous fluid $& Isotonic crystalloid, keep euvolemia
Ventilation $& Keep PaCO2 35-40 mmHg , Hyperventilation in severe IICP
Hyperosmolar therapy $& mannitol, glycerol
Antiepileptic drug
17. 3) Thoracic cord
ekZ : M)@]     (paraplegia) !" &&# # T10 ( level &
)
" "
!" 
@L cord lesion + & Thoracic cord +
18. 4) 340 mL/hr ??
ekZ : Thermal injury suggested fluid resuscitation (modified Parkland formula)
Day 1 (Hour 0 = Time burn occurred) (hour 0-24)
Lactated ringers solution
Total volume for 24 hours = 4 cc/kg/% burn
Give of total volume in 1st 8 hr
Give of total volume in 2nd 15 hr
Adjust infusion rate as necessary to keep urine output :
Adult : 30-50 cc/hr
Children : 1.0 cc/kg/hr
+5#% 4&* second degree burn "$@ first degree $
"+   $
& & % M)@] 50 kg 

* Total volume for 24 hours = 4 x 50 x 27 = 5400 cc  24 hr

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

46

19. 2) Esophageal rupture

ekZ : Esophageal rupture * *
 
@- esophagus  tear * tear @|5 #+ lung
(decreased breath sound Lt. lung)  tear  $&  tender with guarding
 1) $!) *  hiatal hernia 
",  , $& 
$@L
 3)  5) $!) *   $#
 4) $!) *  !@L Mallory-Weiss tear 

@L#& & @L#& 
$@|5
 #+ lung
20. 2) Carotid cavernous fistula
ekZ : Carotid cavernous fistula (C-C fistula) @L6 + %4&%6&%  internal carotid artery 
cavernous sinus %-
4&
 &
+' (  internal carotid artery %) cavernous sinus 6&%
 # aneurysm )%%
M)@] clinical features $&
1. Pulsating exophthalmos
5. %
2. Chemosis
6. Ophthalmoplegia
3. Veleorbital pain
7. Bruit M)@]
$&4 & #@]
4. Dyslogia
' (%&
' % 
44
6& cerebral angiography  ( $& Embolization, Embolization with internal
carotid artery ligation, Occlusion of C-C fistula, Direct repair, Cavernous sinus occlusion
21. 5 Rabies vaccine and Rabies Ig
ekZ :   4)66)4
Zk 
[<U: KK
PVeK 
WHO category I
M%16&M4 @%4 $ &
$% &
WHO category II 1. %1& #@L 
&
2. @LM!$#&
3. !) #%1!)M! # &
WHO category III 1. %1&  # @LM&  #M#&
&  RIG
2. !)&M  #%1!)#+# % @
!)& M& 2 x 1 cm (
#&&) 4&@L grade III  @P4%4 # &  RIG
22. 5) BPH
  BPH 4&
 -& $ @|
 *@| $&
%  4+!@|
@|$*-  @%4
%  
)"@|$&
@|"   #
@| &$#+! 


47

 # 
% $@@|
e`    % 
 
 *@|+6@] * $& + urinary retention 
$%$&
! hydronephrosis  % 
%)
*&6%"@%4 M4  rubbery
23. 4) Tracheostomy
ekZ :    loss of laryngeal prominence , subcutaneous emphysema + cervical "!"
laryngeal injury "+
&@L indication     tracheostomy
Indication of tracheostomy n<

Acute laryngeal trauma
Age under 12 (cricothyroidotomy is not recommended)
24. ekZ : M)@] @L acute cholangitis  (+$& # antibiotics 6&+$@@L mild form

 5-7   hemoculture positive
%  10-14  "+ 6
1$$& & %+5 #
 $& antibiotics  &" & M)@] respond %@P4 6&@%4 6 M)@]%
%3 24-48 +6   drain  +-&-  *#+ ! penetrate $@ organ $&&" & 

"   biliary drainage (decompression) +/- endoscopic spincterotomy 6&
@L semi-elective ($%
& * % &%)   $6 *3 72 +6 4E   ERCP, PTBD
 # Surgical biliary drainage (@& )
 #+ antibiotics   biliary drainage $ &   3 * $% 
  14 $& "+ 

$&@ . 3  %#+ drain + remove CBD stone  

" *4
 . remove gallstone *#+
@}  @L 6&
#@L M%&!- &  (LC) %$@
 1) $!) *  $
@L% !" 14 $& M)@]% &) 
 drain 
 2) $!) *   LC @L%-& *#+ remove gallstone @}  4&
 3) $!) *  6
1&M%&$ $ )
4 ,  !4&@L M%&*#+ & (surgical biliary
drainage) 
!)% % 3 72 +6 $&M)@] 6 wk
& 
%  Biliary drainage (decompression) \: ERCP +/- spincterotomy \: PTBD \:
Surgical biliary drainage : 
<:  [{ cn< |
[ 72 K{f
[f VZ
25. 2) Emergency surgery
ekZ : && acute abdomen  tender at RLQ  rebound tenderness 
@L acute
appendicitis *  44
$%4+ 
@ %4 % 
  &@L  % 
  @P4%4
* -
 (# M%&$%4+  "+ 
 +-&#+44
$& M)@]% *   M%& .
44
$&
 %  &  @L$%4+   (6& M%&
"+ M)@]&+@L acute appendicitis 64& generalized peritonitis $&M)5  morbidity
M)5 #+
 &$ !@ %4+!)% $& $ # % 
delay
 *1*
&  pathology + GI tract   diagnosis 
26. 1) Diaphragmatic hernia
ekZ : Diaphragmatic hernia $#+    2 @ 3 #
1. Congenital  *4 % %4&

48

2. Acquired $#+
4&  &
   "+ 
4&
 !)  # !)  

 
(. $& progressive dyspnea, cyanosis  apparent dextrocardia "+ 4&

!) *
 $&$@  +@L
   6@] * @%4  |   
$&4 

 & !3*    

* :U: U<Zln|
[ : "+ %4&% ' $3
 
 mediastinum K`sb<K[nP<[e U 6&+$@$
@L%  barium meal "+ 
 aspiration
$&
27. 2) Local flap
ekZ :    Graft  Flap 
Graft #  M4 + epidermis  dermis   # &%&&
   #&
(donor) @)+M "+ (Recipient site)
Flap # ##++#+$@@& 4.M 6& #& )%& "+ %
 skin graft +%&&
#&+ 6&44 &  flap
"  6& skin  subcutaneous tissue 
#&+@L6&& ,
#  &$&
Psf[U: 
 Graft
Zs flap
Skin graft
Skin flap
1. Facial wounds
1. poor vascular  # avascular bed
2. Flexor surfaces   ' #
2. structure 5  nerve artery joint
3. (&M$$ 
3. %    &M+@L-
4. @&M+4&
  skin flap  # FTSG
4. bony prominence *#+@L padding 6&*
5. & mucosa   @ pharynx vagina
pressure sore
6. @& dura, pericardium, pleura  # peritoneum
5. &M+4&%  M%& 
7.  overgrafting  4. unstable scars, tattoos  # 6. *#+4& sensation
non-hairy pigmented nevi
7. &M+& tissue  % reconstruction
[<U: Graft
Zs Flap
Skin graft
1. Split-thickness skin graft (STSG)
!" skin graft +@ & epidermis
  dermis "+ -  
$&@L
Thin STSG
Intermediate STSG
Thick STSG
2. Full-thickness skin graft (FTSG)
!" skin graft +@ & epidermis
 dermis  &

Skin flap
 $&
%+
 %
operative technique $&
1. Local skin flap
# skin flap +)  defect & 

" & # skin  

recipient    color texture hair 
thickness , % M%& distant
flap,  !$&  distant flap
2. Distant skin flap  @L
# skin flap +)$$@
 defect

49

28.

29.

30.

31.
32.
33.

&  

" #@L flap * M@L bedsore "!"  4. bony prominence #@L4& local
skin flap #+
& distant skin flap
2) U/S
ekZ : Approach to jaundice patient  
M liver function test *@L4& Direct hyperbilirubinemia
(*  DB  30%  TB) @  ALP ) "&

" "!"  Post-hepatic cause $&
3 cholestatic jaundice %-

 -&%  &4& "+  @L
1. Benign causes  4+&, &%% @L%
2. Malignant causes    & @L%
&  6
1! investigation # %+  #$ % % ultrasound $  *  !&) -&%
  &4&$&
 1) $!) * $ investigation # %
 3) $!) * $ 44
4+ +  
 4) $!)
4 , $& %@|

-4 *  invasive  &

 5) $!) * @L%+% 
 U/S  *#+# 44
 ($@&$&
3) C-spine protection
ekZ : $ )6
1%$  #@ %@%4 &)$ Trauma % A B C D @]  A +
C-spine protection $
$$&
5) Surgery
ekZ :
4 , 4&M)@]
@L inguinal hernia   &) 1. $&  **1& #+ P<: 1
K{f :KsfeU][ 4&
@L strangulated hernia  * #+$!)& !- &
4& %%

 @& 4. hernia sac  progress @L colicky pain  4. &# #+$ 
 % 
 *
hernia sac
 %" &
    &  $ % sac "+ % M)@]+@& .06%"
(

$)
&  @P4%4+  # Surgery +
 1) $!) * $ reduction  strangulated hernia
 2) $!) %
4 , 
4&!" 
*E43* $& #+
M)@]**1& acute abdomen
%6
1& , #6
1#+ @&   
@LM
+.0&4 M)@]
@  .06%"
" 
-%- acute abdomen   
 hernia
 3) $!) * $$& *E43* solid organ 
 4) $!) *  $ role  antibiotic M)@] 
Tension pneumothorax
ekZ : # 13
5) Ultrasound !@%4&% 
- 1 @ ekZ :  9. #  
@L fibrocystic disease +
1) Rabies vaccine
ekZ : &$&  $@% 5 @ + 
# tetanus toxoid "+ $&   DPT  - 2
&# 4 &# 6 &# 18 &# 4-6 @  5 
!)& 2 cm 
@L tetanus-prone wound $& #+*4
 .%%  Tetanus prophylaxis

50

Non-tetanus prone wound

Tetanus prone wound
Td
TIG
Td
TIG
Unknown or < 3
Yes
No
Yes
Yes
3 or more
No
No
No
no
#+
$&  TT  3  $& $4 5 @
" $ role  $& Td  # TIG 
  rabies  #+&)% 21.  *

&@LM% WHO grade II "+  role  
$&  vaccine rabies & * %M    43)4-6    E .- $  rabies
vaccine
34. 1) Off Foleys catheter
ekZ :  !
&4&M)@]
3 autonomic dysreflexia
History of TT (dose)

Autonomic dysreflexia
@L complication "+ 3 spinal cord injury + &# T6 "$@ )5 -&64%
   

Sign & symptoms

o Hypertension
o Nasal stuffiness
(blood pressure greater than 200/100)
o Nausea (secondary to vagal parasympathetic
o Pounding headache
stimulation)
o Flushed (reddened) face
o Bradycardia - slow pulse <60 beats per minute
o Red blotches on the skin above level of
o Piloerection ("goose bumps") below level of
spinal injury
spinal injury
o Sweating above level of spinal injury
o Cold, clammy skin below level of spinal injury
%-+5 6 
o Bladder (most common) - from overstretch or irritation of bladder wall  Urinary tract infection (UTI),
Urinary retention, Blocked catheter, Overfilled collection bag, Non-compliance with intermittent
catheterization program
o Bowel overdistention, constipation
o Skin-related Direct irritant below the injury
o Sexual activity Overstimulation during sexual activity
o Other causes Heterotopic ossification
 4&
%-
 Bladder "+ # Blocked catheter +-& &  ( # % 
&)!-
collecting bag, irrigate the catheter, remove any kinks or change the catheter
sK !!! %
@  .1 M) $ irrigate catheter &M)@]
shock $&
" @+
Foleys catheter $@&

51

Ob & Gyn
1. 2) %-M :
6
1M)54  risk factor  % 
&  DM
a. - 30 @ ***
b. @ %44& (first degree relationship) @]@L DM ***
c. @ %4 GDM  31
d. &64%)
e. %@|
f. @ %4 & 31 %6% *4 6&4&  #%&6&$ %  GA 24 wk *& &  % 
&  ++-&
@L 50g GCT
 )*4+%4 :
Screening DM  GA 24-28 wk
100g OGTT @L % 
# (Confirmatory test)
% 
% .+ 50g GCT M
Urine sugar  @L routine lab +  $+ % % 
)  ANC (#@L risk factor
! positive % 
screening test %)
FBS  % 
&  @%4+$@ $ #+

3 insulin resistance
 HPL
(Human placental lactogen) + 
 placenta )
Random glucose $5&, (-*-)
2. 5) %-M :
6
1% 
* fluid + posterior fornix  fern test : positive & 3 preterm premature rupture
of membranes
4 4+ +#  PV *#+&) progression  %#+ #+
 PV  +&4

+ % 4& Chorioamnionitis
 )*4+%4 :
 observe sign of chorioamnionitis @L4+ +% )  $, *
 ,  +-4+, &

&), # fetal tachycardia %$ PV & 
IV prophylactic ATB  !&64& chorioamnionitis,   sepsis   & #&- 31$&
" 6& prolong PROM (>18 hrs) @L ampicillin 2 g iv q 6 hr

&
Dexamethasone    *  @& & 4& RDS $&M& GA 30-32 wk
Tocolytic drug $ . preterm PROM *#+#  steroid   @& %% $ %4&
#)
3. 4) %-M : #+
  &@L(.@4& (Compound presentation)   ! observe %$@
$&"+ #+& station %+ 6+  & 
@L &$&
 )*4+%4 :
%! arrest of labor  # fetal distress  M&
 compound presentation $$& Amniotomy  Syntocinon
U/S $
% * $$&@+ management M)@] 
C/S $??? $+
" %&4 

52

4. 3) 6
1*#+, 
, *  CVT  OB +%4
%-M : M)@]%  31+@L6 
+ $-%   #-% & !
&) - Class I  II %
NYHA $
-5%%  31%$& 6&)&) 4& *1
 )*4+%4 :
  Class II +@ %4
, class III  IV $ %  31
  *#+ (  #
o @ %4
"+  $$&$%- 6&* 4+ 
.%  31
o *E43* - + ) % %) $& PHT, Aortic coarctation with valvular involvement, Marfan
syndrome with aortic ionvolvement
o 6 
Class III, IV
o 
  #  -
$ )1%4
5. 3) %-M : #+
 - 31 7-12 wk CRL (crown-rump length) +-& +/- 3-4 
 )*4+%4 :
- 31+
%Testing
 % 


 GA 28 wk
6M4&*&"
BPD
12 - 28 1 wk
&@%4

 GA 28 wk
6M4&*&"
Head circumference
12 - 28 1 wk
&M4&@%4  $@  # 
$@
Femur length
12 - 26 1 wk

 GA 26 wk
6M4&*&"
Abdominal
$$& @ .- 31
circumference
6. 2) %-M : %- Post-partum hemorrhage M)@] 
4&
3 uterine atony #+
 PE * uterus
: FH> umbilicus "+ @|

+ +4& uterine atony $&

&#&#  #& 
&)-#&%4$@   31&,  31&,  %6%******
&-%  @ %4 %#& &
 &+ %-4& 
 31
 31 & $@|

+  4& Post-partum hemorrhage

 )*4+%4 :
%- Post-partum hemorrhage 4&

1. uterine atony
2.  &   &
3. #&
%  (placenta bed bleeding)
4.  #'(  6* &)
5. M4&@%4   % #&

53

7. 1) %-M : % &$%& $&

1. call for help
2. extend episiotomy
3. Suprapubic pressure
4. McRobert maneuver (flex hip %4& )
5. -$
6. Woods cockscrew maneuver
7. &" &$
8.  &)$@ 
9. +/- Zavanelli maneuver (# &&$@ $@M%&&
 )*4+%4 : Modified Crede @L & 
8. Cesarean section
%-M : 4&
@L Overt prolapse cord (# &# %+ +!-  +%)
" 
$@
Cesarean section @L4E+&+-&
 )*4+%4 :
 31 , +@&)@& 7-8 . "$@+@L forelying cord  @%4   &  
$3 fetal distress *$!- % 

 &   &$&

.&4%-M4&@%4 @&   &
& !@&)@&& & %+* $ CPD
 #+ &" -55'  +@L 31 $ CPD
9. Cesarean section
%-M :  &) ( HSV  & &
*#*#+##+ 6 +  4 !$ 6 . 4+
 31 &  & (no lesion, no
cesarean)
! 6  # prodome  M%&&44 4 +6
 %4&##*E-1 $@L% % &  &$& 6&- #@& 4.+%4&#
4&4&.&
& 
6
1! 6 )  &M%&& (Cesarean section)
10. 1) %-M : #+
6
1 PE *  FH > umbilicus 4&3 
 lightening 
" 4& myoma
uteri M)54 %  31 $
M% &4 &
" 
 !&  &@%4$&
 )*4+%4 :
M # &)% %  31
o # &)
4&3   %  31$&    $%  ,  %&
&, #&
 &  &,  )M4&@%4, &  && 
 ) &)
o @|

+5 ") % # , &

 # 
 M%&# &)

54

5# &)
]   & 6&*4
 .&)&&)  @ . 6 @&1 & 
 M%&# &).%  31$ #+
6+ %   && 
#&
% %&&)
Large uterine myoma during pregnancy and delivery - choice of management
o The authors suggest that myectomy during pregnancy and cesarean section must not be done routinely.
%-M : 4& %M)@] 
4&
 Bacterial vaginosis #+
(.%4+ ()
 )*4+%4 :
 %
 Bacterial vaginosis (. #
4+ 
%$& 
%".
@ 
&#  # &@ 
&# )
4+  *' #+
-
4E4F @L& 
@P44 4 amine $& ammonia
.01 44
@ &
1. pH > 4.5
2. homogeneous leucorrhea () $(.
3. 4+@ #+& 10% KOH (Whiff test)
4. * clue cell   20%  1#+- & &
 44
 Clue cell  !$& wet smear  gram stain
 (  metronidazole 200 mg oral qid 7-10  6& (* + $% ()
%-M :  &%4&$$  & fundus * 
4& uterine rupture $&
 )*4+%4 :  &%4&$&) 7 @ 
%-M : #+ .  #

@L Pelvic infection +-&#+
 PE : Cx : tender on motion  Adx : tenderness both sides  TOA

  
$& mass + Adx 
4&% PID
 % 
% M)@] 
@L breast engorgement (#+
 engorge &tenderness $&  )

" $4&!" 3 Mastitis  # breast abscess

MM%&& $ oozing $" $ bleed $4&!" C/S wound infection
%-M :
% +$$&  HRT  $&  Ca  1,500 
% +$&  HRT  $&  Ca  1,000 
%
 4 %
$& Ca  500  & % +$$&  HRT  $&  Ca  1,000 
% +$&  HRT  $&  Ca  500 
%-M : #+
M 
  $ & &) M)@]$@ 
&# 6 @&1 
%
rule out 3 Pregnancy 
 )*4+%4 :
 %  %  31-4& #*@ .  3
  
  
1. @& @& &) * 2-3 &# 
, &
2. #&M4&@%4
6* &)
3. %
o

11. 1)

12. 3)
13. 3)

14. 4)

15. 3)

55

4.  %4&# #*E-1
5.  -&
6. &)7.  %  31&)
8.  %  31.
16. 1) %-M : @|

+ +5% @L DM #3 Obesity

 )*4+%4 :

17. 4) %-M : 4%4 E%-+*E1 4& neural tube defect (spina bifida) # folic acid
 )*4+%4 :
!&  -
4& #+ 
45%46%+ &M !& - ,
4& acrodermatitis enteropathica  dwarfism hypogonadism
& Fe 4& Iron def. anemia
Vit B6 @ 61 & * $&    %  31 %
$& $
@L%  4
18. 1) %-M : Spontaneous abortion  @L
Type
Cervical Os !-  + Size &date
Conceptus
Threatened
Closed
K n
e appropiate
Not seen
abortion
Inevitable /
Opened
%
+/Not seen
Imminent abortion
@ %4 &  # -&
Incomplete abortion
Opened
+/Size < date
 
4#)+@&)
 # &
 +@L Blighted ovum !- 
Complete abortion
Closed
+/Size < date
%  31-&  %$%&)
19. 2) %-M : +
M)@]  sure date(LMP) % 
* FH : > umbilicus (GA 24 wk .+ GA by LMP =
20wk) & M)@] 
"  Size>Date "+
@L% Work-up %- $& @|% 
, U/S "+ 
+4+ +  #  @|% 
 
+-& !  Size>Date )$@ U/S %
 )*4+%4 :

56

20.

21.
22.
23.

24.

Differential Size > Date :

1.
 LMP M4&  #$ sure date
2. Full bladder
3. Twin pregnancy
4. Macrosomia
5. Polyhydramnios
6. Pregnancy with myoma uteri
Mild PIH %-M : #+
M)@] BP>= 140/90 mmHg  Proteinuria *  &
 )*4+%4 :
3 Severe PIH $& &"+ %$@
SBP > 160 or DBP > 110 mmHg
Proteinuria > 5 g/day
Grand mal seizure (Eclampsia)
Pulmonary edema
Creatinine rising
Oliguria (< 500 cc/day)
IUGR, Oligohydramnios
Thrombocytopenia + Elevated liver enzyme + Hemolysis (HELLP syndrome)
End organ damage  %M4&@%4, 
4@ #%6 
4) ($ 1)
2) ($ 1)
2) %-M  : #+
M) @]      
  %  31 4&" 
@L intrauterine pregnancy  # extrauterine
pregnancy $&"+
6
1$& Ultrasound $* %  31 ($-$) management %$@# 
@ 4 & hCG
 )*4+%4 :
  Ultrasound $* %  31  ) management %$@  @L
$$ @ 4 & hCG
$ laparoscppy
$ laparoscppy (
 cul-de-sac)
 laparoscppy (
 cul-de-sac)
3) %-M : M)@] 4&!" 3 Bartholin abscess "+  5@L %4&# - Escherichia coli or
staphylococcal or polymicrobial infection
 )*4+%4 :
@ %4+$&
Acute, painful unilateral labial swelling
Dyspareunia
Pain with walking and sitting
Sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture)

57

% 
 
Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema.
In some cases, areas of cellulitis surrounding the abscess may be present.
Fever, though not typical in healthy patients, may occur.
If the abscess has spontaneously ruptured, purulent discharge may be noted. If completely drained, no obvious
mass may be observed
 ( @L
1. Marsupialization @L (+$&M
2. excision $+
3. Incision and drainage 64& @L)
 )*4+%4 : $%-M 55555+ %$@
 (*-)
Efficacy of the Intradecidual Sign and Fallacy of the Double Decidual Sac Sign in the Diagnosis of Early
Intrauterine Pregnancy
Dr Laing and colleagues stressed the importance of the double decidual sac sign in diagnosing an intrauterine
pregnancy before the appearance of a yolk sac, and they considered the double decidual sac sign to be most
useful at 46 weeks gestational age
%-M : M)@]  %
 bacterial vaginosis #+
* clue cell & + (# metronidazole
 )*4+%4 : &).01 44
 11 @ 
%-M : #+
 % 
3* Rt.labia major  ulcerative lesion & , ,  discharge 

vagina 4&!"  
@L vaginal candidiasis
"  !&@%4  &$&
 )*4+%4 :
  &  vaginal candidiasis
1.  &@ &
2. %@L   $4+
3. % 
3 *(.&  4. vulva, vestibule  labia 
*  # !$& 3
&
 erythema %@LM%4&M  &
 ( @L clotrimazole 100 mg Vg 7  % +  $%    %  31
 %4&# 
$$&4&
 %4&% *'*E1 *$&   10-20  % @%4+) .1  *
#6&+$
" $
@L% (
%-M :
 (- *#+&M &  pepsin "+ 
 & & (antacid)  ##@} #+- *
 #+
 4& $ !" M%  31 & & &
" @L+#& !$$&M
 @+@L- H2-receptor blockers  sucralfate  !$&% %  31

6
1%&%# Misoprostal (Cytotec) #+
 ! %-&)$& 
 4&  $&  omeprazole
 $ !" M%  31 # ranitidne, cimetidine  sucralfate % ranitidne, cimetidine )-
& 
 ( %#@L second line drug . ($$&M 
" 4&

@L sucralfate (,)

25. 4)

26. 3)
27. 1)

28. 1)

58

29. 3) %-M :
@ %4 % 
  M)@]   !" 3 uterine rupture #+
 PE : !
 $&&
, |  fetal heart sound $$&,  &)3 shock (BP 80/50 mmHg) @L  &
 &)+% @ %4 drip syntocinon
 )*4+%4 :
  &  &)+% #+, $&
1.  @& -  
$&$ 
2. 
#&  &
3. % 
3* !  #) "  #$$& 
* %$&
4. ! & *@|  @|
$&#&@|
5. 
$&-,  &) !#&$@ broad ligament
  & %#&)
% $&
1. &)& &%%&
2. @&  4.# -
  
3. &
 4.#
4. * Bandls (pathological retraction) ring #  % 
  &)@L 2  "+ @L &%
 upper  lower uterine segment
30. 2) %-M : Incidence of Down Syndrome with Increasing Maternal Age
Maternal Age
Risk
32
1/725
33
1/592
34
1/465
35
1/365
36
1/287
37
1/255
38
1/177
39
1/139
40
1/109**
41
1/85
42
1/67
43
1/53
44
45
46
47
48

1/41
1/32
1/25
1/20
1/16

59

31.
32.
33.
34.

35.
36.

37.
38.

39.

40.

6
1# 8
6
1# 4
3) %-M : #+
&) transverse lie  M%&&@L4E&+@&3+-&
4) %-M : M)@] &3 post-menopausal bleeding
6* &) "+ 64&
  #+-6* &)$&
M)@]- 
%  #*4+%4*#+%- $& U/S, Endometrial biopsy,  )&&) "+
4&
%#
% endometrial sampling +-& *#+$&4#% 
*#+ rule out CA
 )*4+%4 :
Differential diagnosis of post-menopausal bleeding
M4&@%4 #+-6* &)
1. #+-6* &)] (*$&+-&)
2. #+-6* &) proliferative
3. #+-6* &)%  4& atypia  #$
4.   #+-6* &) (10-20%  #& & &))
%4+ #@&)
# #&)
 %4&#
  #+,  @&),  &, sarcoma
 16&
4) %-M : # 2 #  % 
3@L  *#+&) cervical progression @L Contraindication
Polyhydramnios
%-M : Risk  uterine atony $& Polyhydramnios
 )*4+%4 : &) 6 @ 
4) %-M :  % 
* AFP +) "*E1 4& NTD (anencephalus and spina bifida)
3) Imperforated hymen
%-M : @LM)@]&54 - 14 @ $ &),  @& ", @&@L (#@&% &#), 
secondary sex characteristics, )" 6%" PE : tense cystic mass 1/3 >suprapubic, gaping labia minor with
purple tissue
@ %4 %    M)@] $&3 imperforated hymen +-&
3) %-M : M)@]   & %#&)
% (threaten uterine rupture) $&
a. * Bandls (pathological retraction) ring #  % 
  &)@L 2  "+ @L &%
 upper  lower uterine segment
b. &)& &%%&
c. @&  4.# -
  
 )*4+%4 : &) 29 @  
4) %-M : #&@ 4&@  4-4&
# &@ 4& @     @  * 6&* 3 &#          @ % $@
%@%4 #&
-&$@
#&@ 4&@   OCP $@&#4&
#+-6* &)

60

!#& &-& OCP  -&  4+M  7 %

!#&  # $ & &# -&  estrogen  ,  premarin
1.25 mg/day, estradiol 2 mg/day * 7  4 OCP %@%4
 )*4+%4 :
   #+,
 4&-4&
#+$/
 4& 2-3 &# 
, & $@
 & &)   OCP
*4+
@L}
@&' (
 .1@+@
&@ 4.-.3* 
6
1 46
Imperforate hymen  38
4) %-M : +
!" @%4 "+  *4++ @L 11.5 16 kg. & +*4+"$ 4
16 kg.
 )*4+%4 :
  (BMI <19.8) 
*4+ 12.5-18 kg
  (BMI >26) 
*4+ 7-11.5 kg
4) ($
&,)
%-M :
#+
M)54 )  -%
"  + -4& combined pill "+  estrogen +
$@
    (&@ 4.-.3*)
M)54 @ %4 dysmenorrhea
" $
 IUD * M   IUD  "+ #  @&  
@& &)
  + $   #  condom *   M)  54  %   -    4 & 2-3 @  
#   -    4 & &   4  
progesterone +-&#+
 $M%     
&  dysmenorrhea  $&
4) %-M : M)@] )3 severe PIH (#+
 SBP >160 or DBP > 110 mmHg  End organ damage  

4@ #%6  "+ 4E%  ( # -%4 %  31 6&$
- 31 6& (+
5 # @} , -&64% -%4 %  31 6
1$&     #% -%4
%  31"+ 4E induction of labour+painless labour 
+-&
 )*4+%4 :
 (+5 #
@}   MgSO4 % }  M  +
4&"$& $& EKG change, absence DTR, apnea, cardiac
arrest
-&64% +4 # Hydralazine *4
 .#+ DBP> 110 mmHg

41.
42.
43.

44.
45.

46.

61

-%4 %  31  M%&&   @L$@%  )%4'% 1  fetal distress, 6  - ,
%@&) $*  (HELLP syndrome), thrombocytopenia  &$!#@L  M%&&
47. 3) %-M : M)@] @ %4  % 
 +$& $&
  @ %4+- #
1. 3-%  (30%)
2. progressive dysmenorrheal
3. - 4 
4. dyspareunia (
 &", .*'*E1)
5.  &)
6. %  60 
$ &, 
1 + 2 + 3 = classic triad   endometriosis
 & +* $&
1.   , % 
3@%4
2. +@L, % 
3*%-, (nodularity) 
 4. uterosacral ligament  # Cul-desac (1/3  M)@])
3.   $6% &
 &
4. * 4.@&) "+ # endometrioma (endometriotic cyst) 6#+$$& 

48. 4) %-M :
M % 
U/S +* 3cm. homogenous hypoechogenic cyst, no contents inside at Rt.adnexa 4&!" 

@L3 benign condition 
@ %4 % 
3 M)@]  ** %!- & 
" 
@L
functional cyst +-&
(.
 % 
U/S
Endometriotic cyst  # Hemorrhagic cyst
@L!- + echogenic fluid )3, irregular border
Polycystic ovarian syndrome
@L!- , ,  
)     (necklace
like pattern)
CA ovary
(.@L solid mixed cyst
Functional ovarian cyst
@L(. homogenous hypoechogenic cyst
49. 4)  )*4+%4 : Ashermans syndrome # * M#&6* &)

62

TSG for
hypothyroid

3& &)

prolactinemia

prolactin
Progestin
challenge test
Positive

Negative

|sn e

Estrogen-Progestin
challenge test
Positive

Negative

FS

t<Pe
U: <Z

Normal/low

High

Sella imaging
/GnRH test

K nU ZZ

t<Pe
[
e :
e:

t<Pe
[
Hypothalamus

63

Ortho & Rehab

1. $ ) >< *%%$$
2. 6
1
M4& +
@L$@$&+-&# posterior hip dislocation %% @L adduction
Fx of the pelvis 
 $&%$ 4& 3 @ 3 # AP compression (pubic symphysis + ante. SI joint
, open book type), lateral compression  vertical shearing ( - -&) % 
 *  &
 4.
pelvis  AP  lat. Compression  & pubic symphysis  # manage # %% ATLS vital sign
unstable  resuscitation, pelvic binder #&) assoc. injury #+,  intra-abdominal bleeding
Fx. of the acetabulum  
6* &)% 6*M4& )@ dislocation & 4&

dashboard injury
Fx. neck of femur (intracapsular fx.)  2 -# non displaced
 groin pain &%  antalgic
gait  limitation of motion -# displaced
@& 4.6* $$& # &4$$&  &
 4.%+ midinguinal point & distal 1  lateral 1
Intertrochanteric fracture (extracapsular fx.) &
+ greater trochanter * ecchymosis 
 
external rotation
Posterior hip dislocation M)@]
  flexion, adduction  internal rotation 
* head of femur $@
& sciatic n. $& % % 
sensation  common peroneal n. + , tibial n. +] % 
motor  nerves
  6& dorsiflexion  plantarflexion %& %  ( 6 +6 *  (
*4+64& avascular
necrosis (anterior hip dislocation
&   flexion, abduction, external rotation)
3. 3) Displaced supracondylar fracture
common &  *- 5-10   4 &
 #*# *
cubitus varus $& @L 2 4& # extension  flexion type * extension type
 $ displaced % 
 *'$ %@L 
* Sshape deformity % % 
radial, median  ulnar n.  radial a.  X-ray * fat
pad sign @Lfracture &+$ Hueters line  triangle M4&@%4
Fx. lat. condyle of humerus *$ @L epiphyseal plate injury % 

 ' &
  supracondylar fracture #+ X-ray
  &
 4.@ metaphysic @L nondisplaced fx. %@L displaced

 metaphysic , #+
 lat. of humerus &
  Heuters line 
triangle M4&@%4
Medial  Lateral epicondylar fx. rare   Heuters line  triangle M4&@%4
Elbow dislocation *$ 4&
'& 90% @L post.  # post.lat. M)@]

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

64

Posterior elbow
dislocation associated
with fracture of the
coronoid process

4. 1) %% 
Nerve root
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1

Motor
Biceps brachii, brachialis
Wrist extensors
Ticeps brachii
Finger flexor (FDP, 3rd finger)
Hand intrinsic (Abductor digiti minimi)
Hip flexors (iliopsoas)
Knee extensors (Quadriceps femoris)
Ankle dorsiflexors (Tibialis anterior)
Extensor hallucis longus

Sensation
Lateral arm
Lateral forearm
Middle finger
Medial forearm
Medial arm
Upper ante.med. thigh
Lower ante.med. thigh
Ante.med. leg
Ante.lat. leg, med. dorsal foot
Web space of great and 1st toe
Lateral foot, plantar foot

Gastrocnemius, soleus

Reflex
Biceps
Brachioradialis
Triceps
Patella
Achilles

5. 1)  4. Surgical neck of humerus

 axillary n. &M & 
" 
 axillary n. $& ( midshaft
of humerus fracture "+ 
 radial n. injury)
Nerve
Motor
Musculocutaneous
Coracobrachialis, biceps, brachialis
Median
Flexor group in arms (except: FCU, FDP of 4th and 5th digits), Pronator group,
thenar muscles, lumbrical (1st+2nd)
Ulnar
FCP of 4th+5th digit, FCU, Intrinsic hand. (except thenar m, lumbrical 1st+2nd)
Axillary
Teres minor, deltoid
Radial
Triceps, brachioradialis, Extensor group in arm, supinator

65

6. 2)?
6
1M)@]@L Carpal tunnel syndrome "+
&@& #&46@} !" 4 | radial  %
 #  ##+ $@ % 
 & Phalens test, Durkan pressure test 
M % 
#
APB, FPB  OP 
M4&@%4 % 
   $} @ 

 (4E # -@ .1&, NSAIDs, carpal tunnel steroid injection  operative treatment
Long arm cast  supracondylar fx.  # fx. forearm  A1 pulley release  ( Stenosis
tendovaginitis  4 (Trigger digit - 6 4)
7. 2)? M)@] OA knee 
a.  #    @& isometric quadriceps exercise  %& isotonic
exercise  progressive resistance exercise #+$@& (  # hamstring &)
b. -@ .1 4   4*#  & .+#+ *#+ + lat. Compartment "
c. 
 #+ &4 $&46&
!#$ %  +@&
8. 4)
M)@]
@L Cervical spondylosis (radiculopathy) $ myelopathy  *  @L radicular
pain $ long tract sign "+ & 3 myelopathy (myelopathy !#@L contraindication   cervical traction)
M)@]         &4"
"  -& traction  MRI *#+&)
&$  #$
9. C5 - C6
Disorder
Lesion
Common cause
Clinical features
Erb-Duchene palsy Upper brachial
Hyperadduction of arm
Waiter tip position (arm extended and
plexus (C5, C6)
adducted ,forearm pronated)
Klumpkes palsy
Lower brachial
Hyperabduction of arm
Claw hand from ulnar n. involvement,
plexus (C7-T1)
wraist and hand dysfunction, assoc.
with Horners syndrome
Claw hand
Ulnar n.
Epiphyseal separation of
Weak finger adduction, medial hand
the medial epicondyle of
numbness, dysfunction of 4th and 5th
humerus in children
digits flexion
Radial n. palsy
Radial n.
Fx. of mid-humersus
Wristdrop, loss of sensation from
dosum of hand
Carpal tunnel
Median n.
Compression of n.
Wrist flexion elicits pain, wrist extension
syndrome
relieves pain, worse at night
Med. Winging of
Long thoracic n. Surgery (e.g., mastectomy) Limited arm abduction and flexion,
scapula
serratus ante. Paralysis
Fx. of surgical
Axillary n.
A fall landing on the elbow Loss of deltoid innervations,
neck of humerus
compromised shoulder flexion and
extension
10. 5) $
 # 4 6 @&1 (28 42 )

66

ENT
1. 5) Retropharyngeal abcess #+
 6
1 film lateral neck  %  &)prevertebral soft tissue
Lateral neck film: &) % prevertebral soft tissue > 7 mm at c2 level  >14mm (C6 level) &, >22 mm
M)5 , 
* loss of lordosis
  spasm  prevertebral muscle
%- 4&
  %4&#+ adenoid nasopharynx paranasal sinus 

4&
 trauma, FB | "
 &4&% URI,   $ $  air way obstruction, neck rigidity
% 
 *  posterior pharyngeal wall M)5  
@& 
 & 

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

inspriatory stridor ,hot potato voice, 4. supraglottis area
& ,air way 
Film lateral neck *  epiglottis 6%
 (  ET tube 
 (. upper air way obstruction,  ampicillin, steroid
Ludwig angina # %4&#+ submandibular space @ & submaxillary space (% mylohyoid line) 
sublingual space(# mylohyoid line), bilat 80% 4&
 periodontal disease 6&* mandibular teeth !@L
% 2nd molar
$@ sublingual space %!@L+ 2nd 3rd molar
$@+ submandibular space#+
 |)%+
 mylohyoid line
 @& 4.@ trismus, odynophagia drooling of saliva ,airway obstruction, 4.% 6@] ) &
4$@& &4&*&4& airway compromise
FOL supraglottis endolarynx @%4 % base of tongue5"&epiglottis $@ 
Dx clinical @L X-ray,lab *  confirm Dx
Treatment Early stage: IV Antibiotic !|+@L%Advanced disease:  ET tube $& 
%- airway obstruction $& *4
 . tracheostomy
, *4
 . Sx drainage
2. pseudoephridine  decongestant
M)@]@L barotrauma 4&
 @+@ & &   &  @+ &  #+ 4
   euatachiantube  M4&@%4 & middle ear %+atmosphic pressure$&)!)
&"  $@  
4&#& +TM ,fluid exudates middle ear     TM rupture
 @&) $)  $&4& % 
*)& -%(retract),hemotympanum ,conductive HL
 ( @} 6& @ &) 4+ & #  + valsava maneuver
(% & @&  @& decongestant pseudoephridine  myringotomy $

@L#+
Hemotympanum $@ 31-2 &#

67

3. 1) acoustic trauma
4&"#+M & - 130-140 dB  *( @ 4&)
" 4&  1@ 
(.@L ! 
  & ) (Tinnitus) & #+% 
 $&4
!+)
" 4&
  1@ % acoustic trauma @L SNHL M % 
weber rinne @L conductive HL ??
4. 2) amoxycillin
M)@]@L acute otitis media  (+@L 1st line drug # amoxycillin #+ ($@ 48-72 .
 $&"@L#+&#+  enzyme beta lactamase $&@+@L amoxicillin-clavulanate
5. 3)
@ %4"!" obstructive sleep apnea %-+ common &# tonsillar or adenoid hypertrothy

(. palate ++ % OSA # elongation of soft palate and uvula $ high arch palate
 Choanal atresia #  -&% 
)6&* &) #M##+@&  @&& 
)
4&
 bucconasal membrane $%$@  7-8 @&1 % M)@]
 %+ %4& !@L &

 &
) )$ %& % % & , 
 % !@L 
 %+
% & ,
 %  $ *1% $&6&
 @ (oral tube)
6. 4) Rhinitis medicamentosa @ %4  Topical decongestant 
Rhinitis medicamentosa @L3+  #+-
) 6&%-
  Topical decongestant  ,
4& rebound vasodilatation %  &% &#& (vasoconstriction) @L 4&
$ &%
 &#&
3 hypoxia 4& reactive hyperemia #+*%4&%$@ ,
& &%
&#&*4+ % &#&
" $4 3-5 
 @   +E4F@L
alpha-adrenergic blocking 
M 4 % &#& (beta-receptor) 4& &
)$&  &
&(reserpine, hydralazine, methyldopa)  antidepressant (chlordiazepoxide  amitriptyline) -4&
 ( -&*
)  # @ 4& ,  )M)@]@+ %%
decongestant 4& @  * topical corticosteroid  # 
prednisone 4& @ @ . 7 10  
 , && %!@L&
) - % 4EM%& turbinate  
Atrophic rhinitis (.*6 #  atrophy  #+-
) ) @L& (crust) 4+
 (   Ozaena) *M)54 @ '+ $*
%-  $ & 4( 
4&
 @+@  16,  %4&# "+ +*# # Klebsiella
ozaena 3-63 &6@ %, 4%4, & E%-
(. 4  &
)#+
 crust, 4+
) #@ (halitosis) #&&$@&' ( % 

)* crust @LM )+$@ #+

&" *#+-
)+]+$@ 6*
) 
 ( #+
$ %-+
4
" (% #&
)6&&" crust  M)@]
)
6&) #
) %
-*@L    +6@ %" 4%4 # 
E%- 4 @L M%&
) 6& implant  #M%&@&
) +@L -
Vasomoter rhinitis 3
4&
 %-@ * 4*%%4 +4$@ #+-
)4&
% &#&  ) M)@] &
) )$
%$ @& 4.
' (
 -&% )@&6* $  
!) %-6&@|

+$+ *   # ($& 

- + 3 4+-)  @+@ -.3)4#,  1@ ', 3
4%
  &  
*

68

 44
 6& 6 #++4&#+-
)  6 %4&#
),rhinitis
 %  31 , hypothyroidism
,
 4&  #M4&@%4 43
)
 ( +  # % , &&#& +  %4% 
&
)
E4F anticholinergic  corticosteroid 4&*
) & inflammation M%& +$$&M 
M%& turbinate  #%&@  vidian
7. "!" FB &
8. 1) CA nasopharynx #+
-,  $&& 
Nasopharyngeal cancer (NPC)
-%4 .1 *) -&
% % *$&- -+.44
6 # 51 @
%- @|

  # EBV (Epstein-Barr virus),  $6%  ("+ *@), polycyclic hydrocardons

$ M$,  %4&#
)$ #  , -$&
  & +*+-&$& +  $&4&
1. +
 
6 +%#  4. *$&#+
#+-M4 6 4 1  
# )  !%4&%"+  %$& &   *%# +6%   6&


 retropharyngeal lymph node
" *$&
2.  $&4& 4&
  +M &  6 4 1 Rosenmuller fossa )%-&%
4& serous otitis media %
3. &
)
  5
-&+6*
)&
4. #&&$ # @#&$ 
5.    #+
   -" & 6 4 1 44

M4&@%4
@  & 
@  )+ 6 @L+!)- 4& 3*
@  )+ 3, 4  6 4& opthalmoplegia    -) superior orbital fissure
 # cavernous sinus
@  )+ 5 4& @&%   #@&+ &) ,
@  )+ 9, 10, 11    -) jugular foramen
@  )+ 12 #+  -!"  6' ("
@ 4*%%4 #+- carotid 4& - Horner's
6.  4& distant metastasis $@ @& &) %
 44
6  $&
 % 
  4.' (  % 
6 4 1& 
 # 
)4&6  #
% %&4#$@*4)
1  % 
#&EBV serology 
 44

 ( RT+/- chemotherapy
9. Macrolide #+
 Bullous myringitis *E1# Mycoplasma pneumoniae
" 
- Macrolide  erythromycin
Bullous myringitis @L %4&# ) (tympanic membrane) %- #$
4&
#$ ,#
influenzae , *E1# Mycoplasma pneumoniae
 M)@]
 @&)6&*#+)#+$, ) % 
)
*%- bleb +M4& )
 ( Supportive tx @& @&

 bleb % &)+@&M)  .#+
6 4&
 M.pneumoniae 
 ABO erythromycin , tetracyclin

69

Eye
1. 4) Refractive error  VA drop "+ correct $&& pinhole
" 4&
 refractive error
2. 4) Retinitis pigmentosa
@L6 +4&
 #+ retina  RPE  photoreceptor #+ $@& (rod > cone) 6&&
Progressive night blindness %
 ring scotoma ( VF & periphery) "+ VF
,  #+, %6&
$%&
Cataract
  $&%  # 
3. 2) Phacomorphic glaucoma
% +$& Acute angle-closure glaucoma # %&  ciliary injection (DDx glaucoma,
uveitis, corneal ulcer), 
, %, cloudy cornea, pupil fix dilate  anterior chamber 
#+% 
%* Lens sclerosis
" 
 cataract & "+ 
4& glaucoma  
Lens-induced glaucoma ,  2  #
1) Phacomorphic glaucoma 4&
1  anterior chamber  "+ 4& angle-closure
glaucoma
2) Phacolytic glaucoma 4&
 lens protein +  M 
4$@-& aqueous drainage 4&@L openangle glaucoma
#+  lens particle glaucoma, phacoanaphylaxis  lens subluxation !
$@*4+ 
4. 4) Biopsy and microbial investigation
M)@]+ recurrent chalazion % "!" sebaceous gland CA $& &  Biopsy $@% 
 *E44
5. &) 10.
6. 2) Ceftriaxone IM

@L Gonococcal conjunctivitis #+
 @L neonate (- < 1 &#) %@L
Gonococcal conjunctivitis
Hyperacute onset of severe purulent conjunctivitis, marked conjunctival hyperemia  chemosis

* preoricular lymphadenopathy (* viral &)
Drug of choice # Ceftriaxone 1 g IM + topical antibiotic
7. (# Acute angle-closure glaucoma (&) 10.)
8. &) 14.
9. 4) Acute glaucoma
10. 3) Oral glycerine
ek !  4) @L topical beta-blocker  % * !#@L agent of choice   4+% (
Treatment of acute angle-closure glaucoma
1. Z< aqueous
1.1 2-adrenergic agonist (apraclonidine)
1.2 -blocker (timolol) agent of choice   4+% (  : bronchospasm, bradycardia
1.3 carbonic anhydrase inhibitor (acetazolamide) * sulfa, S/E: @#@, HypoK

70

2. { sV aqueous

2.1 Parasympathomimetic (pilocarpine) *4+ outflow  trabecular meshwork  pupil constrict  $ react
to light (miotic agent)
2.2 Prostaglandin (latanoprost) *4+ uveoscleral outflow 6& ciliary  loose, S/E: hypertrichosis
2.3 Hyperosmotic agent (mannitol: iv drip, glycerin 4M) & & , short term
2.4 Laser iridotomy Definite treatment**,   aqueous $
 posterior chamber  anterior chamber
 (& + &&)% 6&  acetazolamide  topical agent  -blocker 
apraclonidine 6&
 hyperosmotic agents (glycerin) & 
#+ IOP &  iris ischemia &
 4+
 pilocarpine 2% #+-&%$&  definitive treatment # laser iridotomy %   prophylactic
laser iridotomy &
11. 1) Topical antibiotic M)@] @L corneal abrasion
 contact lens
Corneal abrasion
M)@] @&% # % %$  )"$% * 4%
Corneal abrasion 
4&$&
 M4#  @|  #% &(  #
4&
4+
@@+#++%  #
  contact lens (4$@  # fitting $)  M)@]@P4E@ %4
trauma & , %&  &  corneal abrasion M)@]&    herpes simplex keratitis $&

@L 4+ +% % 

slit lamp *#+ corneal abrasion  &$"* $
%
@L clean corneal abrasion "+   $  (!M)@] )  #@L true corneal ulcer
Corneal abrasion +& ($&6&  antibiotics drop  ointment * * % +@L
 4.
%  topical antibiotic, cycloplegics   @&%
12. 4) UV keratitis
Corneal epithelium  % !) 
 UV (5
 sunlamps  # #+6,  4%1+

*#M4 !+4
*M)@]+3 snow blindness @L%) M)@ ]
4&  $&  UV
@ . 2-3 +6 #+ & epithelial cells $@  @&
 % $& 6&+$@3 24
+6
 ( @} 6& #+ @}  UV #+4&"@&% & cycloplegia 
@&
% @ @& &
13. 4) Meibomian gland dysfunction
  @&% $&+ upper eyelid "!" hordeolum +-&
Hordeolum
Hordeolum @L staphylococcal abscess +*$& (. & &
*+ 4. eyelid
Internal hordeolum @L meibomian gland abscess +)& conjunctival surface  eyelid  external
hordeolum  # sty 
&)+@#%
KL Warm compression, topical antibiotic + systemic antibiotic
Incision and curettage #+$ /  $&" 48 +6

71

14. 4) Vernal keratoconjunctivitis

Vernal keratoconjunctivitis
*&)  #&)$M4 M)@]5
@L&6% 4&&M)M)54  %
2  @L, , @&@&  %$  discharge $(.@L @#%

#+
 %  @L 2 4&
1. Palpebral form * giant ("cobblestone") papillae @L(. )@ 6 + M4@L, + Tarsal
conjunctiva % @#%
2. Limbal form #+-% 4. limbus
(.)M4@L
 % 
 & Histology * Hyperplasia  Hyalinization  connective tissue #+-M4#+-%

  %   cellular infiltration 6&+15

@L Eosinophil
Choices :\{[
Trachoma ( 4&& %)
4&
 %4&# Chlamydia trachomatis 6& M 4+  +@L6  6&+, $@
%& 
% # %  %$ * 4% $* discharge +@L
 
 conjunctivitis E & %
 V follicles &)&+ tarsal plate -
&$& %%&
& follicles
  @LM@L"+ &  4+ * pannus +
cornea  )-G+  Herbertys pit -&%
& %
*M@L+ 4.& @#% "+
 !&"  %$   %
&+  Trichiasis 4+ 
%$& 4& 
%
  @#%&  Entropion
 (
1. Tetracycline & #@} + sulfonamide 4  # Tetracycline 4
2.  ( trichiasis, entropion % M%& #4E+!%  #$}
 %
Inclusion conjunctivitis
6 %& %4&
  %-
 %4&#$    1 2 4%1 
 topical antibiotics
Hay fever conjunctivitis
@L%& +*E1 Hay fever (allergic rhinitis) $ - (6& topical antihistamine/vasoconstrictor
+ Cold compression
Epidemic conjunctivitis
@L presentation "+  adenoviral keratoconjunctivitis  corneal involvement $& 
*
petechial hemorrhage, pseudomembrane, preauricular lymphadenopathy  ( Supportive 6& cool
compression + % topical antibiotic !@L&-& 

72

Psychiatry
1. 3) Haloperidol
(.  -& 4&  M)@] $& akathisia 6& motor  mental restlessness 6&@L
M  - neurological side effect  antipsychotic "+ M  -4&M)- High
potency & 
" &M)@] 
$&  Haloperidol
 ($& & Haloperidol  anticholinergic, benzodiazepine  # beta-blocker
2. 5) Separation Anxiety Disorder
  Separation anxiety disorder $&  4%  $$@6   $ %4&M) &) |  
    @&' ( #+$ 
 *$& - 7-8 @ "+ $&M)@] 
3. 5) )"% M4&
 )"M4& # Guilt feeling @L criteria "+  44
 MDD 
4. 5) MDD with psychotic feature
M)@]  $ normal grief reaction * @L6'' + 
4%&  # +M)@]
+  % ( Hallucination)  $& MDD #  depressed mood, psychomotor retardation,
decreased appetite, insomnia
" %@L MDD with psychotic feature
5. 1) Delirium
M)@] @ %4 trauma   behavioral change +4&"4& acute % "!"
organic cause
" "!" delirium 6& !E4  M)@]$&
  altered cognition 4& anxious, paranoid,
sleep-wake cycle disturbance
6. 5) Amphetamine

%# M
 intoxication  % & 
1. 5 (marijuana)  euphoria ,slow sense of time, impair judgement, social withdrawal, increase appetite, dry
mouth, conjunctival injection, hallucination, anxiety, paranoid, amotivational syndrome
2.   ???
3. 6  (- opioid) CNS depression, N/V, constipation, papillary constriction, respiratory depression, seizures
4. 6 (cocaine) psychomotor agitation, euphoria, impair judgement, HTN, pupillary dilatation, paranoid, angina,
hallucination, sudden death
5. % (amphetamine) psychomotor agitation, impair judgement, HTN, pupillary dilatation, tachycardia, fever,
euphoria, prolong wakefulness/attention, arrhythmias, delusion, hallucination

@ %4M)@] ! -  % 

 $&
" "!" +-&
7. 3) decrease respiratory rate
4+ +4&" REM sleep "!" 4+ + 4&"%%#+   paralysis  # & 
Decrease respiratory rate #+4& REM sleep  &
8. 1) Fluoxetine
M)@]  $& bulimia nervosa #4%  #+ 4  compensatory method *#+&
*4+  M)@]-
 maintain normal weight (%  anorexia +
@%4) &  (&
$&  antidepressant
" % fluoxetine

73

9. 2) IV Diazepam
M)@]  alcohol withdrawal delirium &  (# - benzodiazepine "+
%#
)%& #@L IV diazepam
10. 1) Denial
@P44 4 % % )5  6& Elisabeth-kubler-Ross $& Denial (shock), Anger, Bargaining,
Depression, Acceptance "+ $
@L% 4&"%& $% 4&- -
+% # denial "+
@P4E%$$&@] *$@ (6 **1+#+,
  bargaining "+
@L %  % 6&@L(.+
#+$@*#+@ @ - 4!4%  #
*#+   %#+ % & M)@]
" ) Denial
11. 1) Haloperidol
M  +
+
4& high potency antipsychotics % Haloperidol  Fluphenazine 
Perphenazine @L medium potency antipsychotics, Thioridazine M%
4& arrhythmia
!$& syncope "!" - low potency antipsychotics  Thioridazine  # chlorpromazine 
* 
M anti alpha adrenergic &
12. 1) & Haloperidol
#% 1 
13. 4) Depressive disorder
 $& MDD % $@% 
14. 4) Clomipramine
M)@]  44
 Obsessive compulsive disorder *  (. obsession fear to harm to oneself
of loved ones  $@+*   @L%   compulsion 6&@ %)
-  * %-  "+ $&(.+
 *%4 +& anxiety
4& obsession  & 
($&  clomipramine  # SSRI & % clomipramine 
15. 3) Clonazepam
  M)@]$& panic disorder 6&*% +
%  ( !$&
antidepressant  # benzodiazepine "+
%#@L benzodiazepine  & %+4 2 %# clonazepam
 alprazolam & % clonazepam 
16. 4) Delusional disorder: somatic type
M)@]  (.  M4&#+| 
% @L HIV $& delusional disorder +
@L(. non
bizarre delusion ( M4&+ #+ +4&"$&4%
4 ) 6&M)@] delusion  ! )$&%$&&
 #+ +$&4
*E1 #+ + M4&,
17. % ???
+$@
6  3D #
1. Delirium- confusion and alteration of conscious and cognitive impairment
2. Depression- "'   % criteria
3. Dementia-  @L chronic +
 6& recent  remote memory

74

18.

19.

20.

21.

22.

4

@L depression $&%$ choice  "+ !#%%#

% withdraw $& 6&@P44 4%
 % terminal phase  E. Mansell Pattison @L +M)@] 4+&& +

6 
% 6 
  4" %
M)#+4&!" % "
1)
&
%- .1$$&
  PTSD  @ %-+4
6&+$@$&
-  @L 1 &#
-  reexperiencing of the event | 
- + 4+ ++  4&%-
- numbed responsiveness
- increase arousal

%#+$  PTSD # +
%- .1$$& "+
@L dissociative
symptom  M)@] dissociative amnesia
2) Acute stress disorder
6&+$@ ASD  !
 panic  # phobia $&6&
1. ASD
 traumatic event 
2. M)@] ASD
  stimuli +"!" event ,  #3 emotional numbness %$- 4 M)#+
#+
 *)& #$ "!" %- .1
3. M)@] ASD  increase arousal &% %#+%%
 4$$&$

+$&) % Traumatic event 

" "!" ASD %!6
1 &


% &)4 1 &# #$ "+ 4 1 &#
@+ 44
@L PTSD
5) Methylphenidate
&@L ADHD  (&$&  CNS stimulant $& methylphenidate (@L Drug of choice) %
4 ,
 imipramine $&
Depression (pseudodementia) Tx & Fluoxetine
* $ #$ @L
"!" dementia %   depression
&#  +" 4$$& $ "!" @L depression  6&  #
4&
 + poor
concentration "+   pseudodementia  (@L fluoxetine 
1) Dyslexia
M)@] @|5&   6&)- Learning disorder "+ 
M4&@%4  
  & "+  # $& 6&#+% 
& IQ 
@%4& % Dyslexia "+ @LM4&@%4 
  -

75

Forensic
1. 3) M)@] Postmortem hypostasis (Livor mortis)  "+
 4+$& - 2 .  % %&
 ) &  $
fix % $!" 8 . (fix + 8-12 .)
#+*4
 . Postmortem rigidity (Rigor mortis) "+
 4++ 2-4 .  %  %+ 6-12 .  %
 # &  Rigor mortis 4& "+ *   %
 4+
#&  
4 
" @L# ' $ 6* %& % 4&$%+ ( $ ) & 
 2 @P44 4
"  -@$&M)%
4% 4 . % $!" 6 .
2. 4)  # 5)
 & (Ligature mark) (. ! (.  )&, , 

4&
M)%*
#%!-+ & #
4&
& $&  fracture of Hyoid bone * Hanging  # Manual strangulation
$&  * +&#&& #&# &  moderate to severe bruise %
 Hanging +
  &
$ & 
   !  #  # & $   #+ 
6
1  

$  ) .1
"   Ligature
strangulation  Manual strangulation $$&&
 !)*4+%4"  * Subconjunctival hemorrhage

$&@L Manual strangulation * (.
* %!# @L Manual strangulation
3. 4) %  -%-  4%
$ -@L-  #  ,  -4$@ !" 3+$

* & +@L Acute heart failure, Cardiopulmonary failure !" Acute poisoning
" %&$@$& %  4% +*+-&# 6  
&#& M)@]+4% &  

"!" M4&@%4+#

 ##&&5" % $ M)%  $ !$&
4%
 Rupture aneurysm $& * $$&
4
" % % incidence   4& "+ # Coronary heart
+   EKG
$@+@ %"+ *$& Early MI
4. 2) #+
 Choice $) .1
" $+
 %!*4
 .%    )% 
 +Q3).+MN.R1J152)
@L*#+
% $@ 4 '$&  #

@L3( ($& %% -)-9.L110

I1S+LOI5MT161+TUV  Brain laceration due to fracture base of skull from gunshot wound &  1
" #!)!
+
%  )%  
 1, 
 WX)=: + 10I1S+LOI2340.V Z0:2346VSZ7F
2[1/T-U1) $$& &
+* &  &M -@# @L%-% @L%  -@

% 2 *   &
+ - +-&%* $% &
5. 3) ( ))
 *&M # &
%   % vagina
   & $
4&

4 *'  * sperm     *'
4 % $$&&
4 #  
& foreign body
@L  %#+$@*' #  @
$
6. 3) !@LKsk[ S-1.Q-1:
$&)  @*#+ $@@ @+4
" $  &
 -@ %&()  *$&* $$& %!@LPZ:sk[ S-1.-.
$&) 

" &
7. (%-M&) 10)
8. 1)  % 
blood for amphetamine @ 61    acute  % 
urine  $& @ 4.
  %
$& +P)0AI610.A\.+Q-10<1:1) $$&$& $

76

9. 2) &)% %4 Mongoloid

 $& (Round, non-sloping)
 %4 Caucasian @L+-' & (Angular, sloping)
 %4 Negroid @L++ #++
%-  (Rectangular)
ZKLssfZLs
e Zs[e
Caucasians generally have no prognathism; a notable size prominence of the cranium and forehead region; a
narrow, tear-shaped nasal cavity; a "silled" nasal aperture; tower-shaped nasal bones; a triangular-shaped palate; and
an angular and sloping eye orbit shape.
Negroids typically have a broad and round nasal cavity; no dam or nasal sill; Quonset hut-shaped nasal bones;
notable facial projection in the jaw and mouth area (prognathism); a rectangular-shaped palate; and a square or
rectangular eye orbit shape.
Mongoloids are often characterized by relatively no prognathism; no nasal sill or dam; an oval-shaped nasal
cavity; tent-shaped nasal bones; a horseshoe-shaped palate; and a rounded and non-sloping eye orbit shape
10. 4) %@ 5 %  297  %  $&
() %& ) 4&  #  @  ( 4+)
()  #*E-1  #  !#*E-1
()    #  4  # #+&
() 6  %4&%
()
 Z***
()
4%*4  %4&%
() -**3*  # @]
 #  "+ 
!" %&4%
() -**3*  # @]
 & - 4 +4  #
@  .4
%@%4$$& 4
+4
&   
"  $& % 
 ) %   - %   #$ +MN.T.-1234
Q9:].A:1.69I6,. 5;</@<Z]2)^ &  
" $& * -% * (%& *& 
( & % 
@ 4&MM)+ -*  (%   *1 )

77

Ethics, Preventive & Commed

1. 3) Fasting blood sugar
 % 
&  6 +)3%6  @ -3*! $&
1) CA cervix Pap smear (+- 35, 40, 45, 50, 55)
2) CA breats Breast examination (7  &@ 
&#)
3) DM Hx, if suggest DTX, if 126 mg/dL FBG
4) Hypertension BP (- 35)
5) Thalassemia OFT 54 %  31
6) Congenital hypothyroidism & phenylketonuria TSH, PKU
7) Vaccination % 
2. 4)  #-   MM)@]
3. 60%
Disease
No disease
30
150
Test positive
120
Test negative
80
1770
1850
200
2000
1800
6
1!!" Positive predictive value = 120 100 = 60%
150
 %  $%  8.  @L ) * 6
1

M4&&* !!   150  30 *

  : CXR M4&@%4 @ Test positive ! ,

$@%4 negative $&

4. 4) %M)@]
M)@]+-% % 18 @ 4) .1"$@ !4E4$&&% % 10  @ '4E4M)@]
!M)@]- < 18 @ M)+
4E4# 4&,  & 
5. $
4)  5)
!"&% Ottawa charter   4)  5) %%4&% 4)
&)& * %*%4&

 -) (% #+  
-
 $ -) * % **%4&* $% !" 6(3/M+
%
 1) $$& * 4&4E4M)@] M)@ ] $&  4 -3*6&$ #@P4%4 (4E4 2.)
 2) 4+$@@] - -
 3) @|5@%- !$+*%4&$ -$&
 )*4+%4
   4-3*%VKe::ee4E @P4%4+5 5 @  #
1)   6E .+ #%-3* &  %     4 
&3(  @+@
 1 *#+4& -3*&  $& 6 +4&3"
2)    14+ &+  -3*& 6& - (13*& E %4 "+  6% !#@L M4&
 6&*
@L% &$-E1    4-3*
3)   4  -+ *#+4- )"@L
 & &" -  4&
*"+ *%

78

6.
7.

8.
9.
10.

4)  *(-*#+-3*& @L - *-  6& )  '"(
*#+-3*   4(4%*#+*4+ #@  +
$@) -3*&
5) @ @+ 4 -3* @L 3 4
  4 -3*+* &
 *%%  
E  - -
4) Randomization @L *#+ 
 confounding factor  -& --#+-&
2) Autonomy
@L4E4 M)@]+
$&  ) * **#+ !%&4
 4 (
Biomedical ethics
1) Autonomy  *4E4 M)@]
#  3*- %M)@] "+ *1  *  ! M)@] % 

   M)@] 3%  )

 M)@] *1% + $$@4E4*#M)@]
*#+M)@] !%&4
$& 4 @ '
    @L*#  #+ informed consent
2) Beneficence !#@ 61 M)@]@L
#  @ 61M)@] "+ @L #+ @%4+$@+*1
&)M)@]*#+@ 61 M)@] 
$@!"  @}   #
&% 
4%M)@]& & ( @ 614 teleology "+ &
 @L )@E (.@P4*E1  *1M)@]4& paternalism "+ *1
&)- %
M)@]@ &-
& 4& &&)-%
3) Nonmaleficence (Do no harm) $  +
@LM%M)@]
#  $@L3%M)@] %*1
$4&%  #&
%M)@] $
6&% 

#   #$  &, "+   *#+@L$@% *1
"
 @L%  )
 !@P4%4 * * *#++
$4&%   #+ +
4&% %M)@]
4) Justice @P4%4%M)@]&
 -%4E  6&+$@ !"  
 * $@!"  4  -%4E   %&%+ *  4 % , )
& $* * -  
" @L@|5%  @P4%4
 ) .1
&) 3.
&) 11.
1) Bias
4+ +
  -@*E1M4& (Error) $&
1. Random error M4&*&
 -%  -% $@
$
%%   
 45 (Chance)
2. Systemic error +M4&*&+4&
%-#+ #
 random error  #   %4 (Bias)  3
4&, (%4&,) #
Selection bias M4&*&+4&
% &#@  +'"(+$
Information bias  & exposure  # outcome +$-%4E 
rd
3 variable or confounder @|

+ 3  #% ( % $

&@L bias) @L@|

+M%*E1
 @|

+'"( outcome/disease 6&% -.%4#

o @L%-"+ (Causal relationship)  outcome

79

$*E1@L%- (Non-causal relationship)  exposure

o $@L intermediate step  causal pathway  exposure  outcome

@L Information bias
Contamination =  +-&  #---&-"+ $&  intervention  -"+ $
$&  -
- $&  #-&  $& placebo @L%
Co-intervention =  +-&  #-- $& intervention #+#
+'"(* -& 6&-
$$&  *
&)%4&%MM)@]-& * #+
$&M& "+ !M&
4 

$$&4&
 &%
@LM
 &)+- &
+  $&6& double blind technique
11. 3)  # 4) "&-*44
 @L3  & #$ %&)#
  &
12. 1) Social empowerment
o

80