# 103年內專(200題)49-100

## Question 49:

有關膽酸(bile acid)的敘述，何者錯誤？ (應選出所有正確答案)
(1)主要由飲食而來
(2)肝臟合成膽酸與膽固醇代謝有關
(3)膽酸可於空腸(jejum)再吸收，稱為enterohepatic circulation
(4)肝臟合成的膽酸有primary 及secondary 兩種，前者以lithocholic acid 及chenodeoxycholic acid為主
(5)膽酸的 enterohepatic circulation 異常可導致腹瀉，甚至steatorrhea

---

- A. (1)+(2)+(3)
- B. (2)+(3)+(4)
- C. (3)+(4)+(5)
- D. (1)+(3)+(4)
- B. (2)+(4)+(5)

### Correct Answer: D

(1)(2)膽酸可分為
* Primary bile acid: 肝細胞以膽固醇為原料，經多個步驟合成
* Secondary bile acid: primary bile acid經歷了腸道細菌的分解，以及腸肝循環後形成的產物

(3) 錯誤，**回收conjugated bile acids 的地方應為 distal ileum**

(4) 錯誤，**lithocholic acid 為secondary bile acid 的成分**

(5) 正確，**enterohepatic circulation 會導致decrease in duodenal concentration of conjugated bile acids,脂肪消化差，導致steatorrhea**

Ref: Harrison's Principles of Internal Medicine, 18ed, Chapter 311 disease of the gallbladder and bile ducts and chapter 294 disorders of absorption

## Question 50:

一位慢性腹瀉患者，呈現水腫，低蛋白血症(albumin: 2.1g/dL、globulin: 1.8g/dL)，血液的AST/ALT/PT/PTT/BUN/Cr及尿液檢查皆正常。接受小腸內視鏡合併切片檢查，切片組織染色結果如圖，下列敘述何者錯誤？


---

- A. 低蛋白血症與腸道過度流失蛋白有關
- B. 除了低蛋白外，此個案之周邊血液淋巴球數目也可能減少
- C. 可用 α1-antitrypsin clearance協助確認蛋白流失
- D. 脂肪性腹瀉在此種病人也常發生
- E. 治療上除了 low fat diet外，應補充long-chain fatty acids

### Correct Answer: E

圖出自 Harrison’s 18th P.2469 figure 294-4 intestinal lymphangiectasia

Protein-losing enteropathy: 為一群疾病,特色為 hypoproteinemia (蛋白質由腸胃道喪失) and edema，但沒有proteinuria or defects in protein synthesis。依類型可分為


此病人的切片顯示為 intestinal lymphangiectasia (第3項)

A. 診斷protein-losing enteropathy 為low serm albumin, globulin levels 而且沒有肝或腎臟問題,和本題病人符合

B. 此類病人除了會喪失蛋白質外,peripheral lymphocytes 也可能會由淋巴管喪失, 所以也會周邊血液淋巴球數目減少

C. 可利用α1-antitrypsin clearance 協助確認蛋白流失(量測糞便和血液的數值)

D. Lymphatic dysfunction 的病人因為 lymphatic flow 不順, 使乳糜粒跑到腸道中, 而造成steatorrhea

E. **應補充 medium-chain fatty acids 才對, 因為不會經淋巴管跑到腸道,而是藉由門靜脈運送到身體**

Ref: Harrison's Principles of Internal Medicine, 18ed chapter 294 disorders of absorption

## Question 51:

23 歲男性因屢次不明原因腹痛至急診，其腹部電腦斷層結果如圖，全大腸鏡檢查發現右側結腸及末端迴腸有潰瘍，切片病理為granulomatous inflammation，糞便檢查及各項培養並無細菌和結核菌感染。有關此患者之治療何者錯誤？


---

- A. 5-ASA 中的sulfasalazine可於胃、迴腸、結腸釋放及作用，最適合作第一線治療
- B. 類固醇可使 60~70%患者得到緩解
- C. 處方metronidazole或ciprofloxacin 對此位患者能發揮有益效果
- D. azathioprine可用於維持緩解時的治療
- E. 對免疫抑制藥物無效者可考慮用anti-TNF antibody 治療

### Correct Answer: A

圖出自Harrison’s 18th P.2484 Figure 295-7

屢次不明原因腹痛且大腸鏡切片病理為granulomatous inflammation,顯示病人為 Crohn’s disease, 以下是crohn’s disease 和 ulcerative colitis 的比較。


A. 5-ASA 對UC 有效,但對CD效果不好

B. 類固醇對moderate to severe CD病人有效,且可使60~70%患者得到緩解

C. 這兩種抗生素可以用於 first line drugs for short periods of time in active inflammatory, fistulizing and perianal CD

D. Azathioprine 被用於glucocoticoid-sparing agents of UC and CD patient

E. Anti-TNF therapy 可用於CD patient refractory to glucorticoid, 6-MP or 5-ASA

Ref: Harrison's Principles of Internal Medicine, 18ed chapter 295 inflammatory bowel disease

## Question 52:

有關大腸直腸癌(colorectal cancer)篩檢(screening)策略，何者正確？
(1)不論男女，50 歲以上即必需篩檢
(2)有1 個小於1 公分的管狀腺瘤(tubular adenoma)者，應在1年後重做大腸鏡
(3)1 級血親有大腸癌病史者，篩檢年齡為50 歲
(4)目前台灣是使用糞便潛血免疫反應法做篩檢
(5)有遺傳性大腸癌症候群(hereditary nonpolyposis colorectal cancer)家族史者可於30 歲即開始篩檢

---

- A. (1)+(2)+(3)
- B. (2)+(3)+(4)
- C. (3)+(4)+(5)
- B. (1)+(2)+(4)
- E. (1)+(4)+(5)

### Correct Answer: E

(1)(4) 衛生福利部國民健康署自民國99年起全面提供50-69歲民眾每二年1次大腸癌篩檢(糞便潛血免疫反應法)

(2) **tubular adenoma, 所謂大腸直腸瘜肉的惡性機率和大小有關 <1.5cm 的機率很小(<2%),所以三年內追蹤大腸鏡即可**(Harrison’s 18th P.768)

(3) 1 級血親有大腸癌病史者，篩檢年齡應提早,不應和一般人一樣

(5) 這一類病人因其癌病發病率高,出現的早(30-40 歲), 可於30 歲即開始篩檢

Ref:
* 衛生福利部國民健康署-大腸癌篩檢簡介
* 國家衛生研究院-大腸癌臨床診療指引 -
* Harrison's Principles of Internal Medicine, 18ed chapter 91 gastrointestinal tract cancer

## Question 53:

40 歲女性健康一向良好，參加公司健康檢查，超音波發現膽囊有如圖之異常。下列敘述何者錯誤？


---

- A. 因為無症狀，可採追蹤策略
- B. 快速減重是造成此異常可能原因之一
- C. 膽囊蠕動快速(gallbladder hypermotility)也會造成此異常
- D. 此異常與遺傳因子也有關
- E. 慢性膽道感染也是可能病因

### Correct Answer: C

圖出自Harrison’s 18th P.2620 figure 311-2

A. 無症狀膽結石患者發生症狀和併發症的機率很低(1-2%/年),所以追蹤觀察即可。除非出現以下症狀,才會建議 prophylactic cholecystectomy
(1) 多發性或嚴重腹痛導致生活受影響
(2) 之前有因為膽結石造成的併發症,如: acute cholecystitis…etc
(3) 病人本身有underline 造成 Gall bladder stone complication 增加(calcified or porcelain gallbladder and/or a previous attack of acute cholecystitis, very large gallstones(> 3 cm)…etc)

B. weight loss 為prediposing factors of gallstone formation 之一

C. 應為膽囊蠕動過慢(gallbladder hypomotility)會造成此異常

D&E. 皆正確,請看圖表


Ref: Harrison's Principles of Internal Medicine, 18ed chapter 311 disease of the gallbladder and bile ducts

## Question 54:

承上題，上述患者因急性腹痛、發燒至急診，理學檢查發現黃疸，腹部超音波呈現膽管擴張，血液培養有葛蘭氏陰性菌。下列敘述何者錯誤？

---

- A. 單用抗生素治療效果不佳
- B. ERCP with endoscopic sphincteromy 兼具診斷及治療效果
- C. laparoscopic cholecystectomy 為最佳治療方式
- D. 有可能併發急性胰臟炎
- E. 無惡性腫瘤狀況下，膽紅素(bilirubin)很少超過 20mg/dL

### Correct Answer: C

此病人為acute cholangitis relate to passage of gallstones into the Common bile duct

A. 針對acute cholangitis 且有菌血症的病人,單用抗生素的治療效果不佳 (Harrison’s 18th p.2625)

B. 正確( Harrison’s 18th p.2625)

C. ERCP with endoscopic papillotomy and stone extraction is the preferred approach

D. Nonalcoholic acute pancreatitis 最常見的原因即是biliary tract disease

E. CBD stone 造成的maximum bilirubin level 很少超過15 mg/dL, 20mg/dL以上需要考慮腫瘤

Ref: Harrison's Principles of Internal Medicine, 18ed chapter 311 disease of the gallbladder and bile ducts

## Question 55:

患者因上腹痛、體重減輕、黃疸接受如圖(A、B)之檢查。下列何者與此疾的發生較無關聯？


---

- A. 肥胖
- B. 抽煙
- C. 糖尿病
- D. 咖啡
- E. 慢性胰臟炎

### Correct Answer: D

From above image, we can notice there is a pancreatic tumor that cause obstruction. Pancreatic cancer is likely.

(1) ++obesity++ associated with increased risk for pancreatic cancer based on 2 cohort and 2 case-control studies
(2）++cigarette smoking++ may be the cause of up to 20-25% of all pancreatic cancers and is the most common environmental risk factor for this disease. Other risk factors are not well established due to inconsistent results from epidemiological studies, but include ++chronic pancreatitis and diabetes++.

Ref:
* JAMA 2009 Jun 24;301(24):2553 full-text, editorial can be found in JAMA 2009 Jun 24;301(24):2592. commentary can be found in JAMA 2009 Oct 28;302(16):1752
* Harrison Ed18 Chapter 93 Pancreatic cancer

## Question 56:

一位60 歲女性病患被送至急診，主訴為突然感到嚴重腹痛，疼痛指數達到九分（滿分十分）。病人沒發燒。醫師在身體診察時，發現其腹部摸起來並不硬，僅有輕度壓痛，但並無固定部位，其血壓正常。他自述過去有心律不整之現象。下列各項敘述，與此病人密切相關，除了：

---

- A. 應測白血球數目、血液酸鹼度、及血清 lactate 數值
- B. 應趕快安排傳統超音波檢查，因其較方便且診斷效益較高
- C. CT angiography 對診斷有極大助益
- D. 傳統 angiography 是黃金診斷之依據
- E. 立即安排 ECG，必要時也要安排 24 hr Holter monitor recording

### Correct Answer: B

A. In the evaluation of acute intestinal ischemia, routine laboratory tests should be obtained, including complete ++blood count++, serum chemistry, coagulation profile, arterial ++blood gas++, amylase, lipase, ++lactic acid++, blood type and cross match, and cardiac enzymes.

B. 沒有提到傳統超音波

C&D&E. Other diagnostic modalities that may be useful in diagnosis but should not delay surgical therapy include electrocardiogram (ECG), abdominal radiographs, CT, and mesenteric angiography.
The ++ECG++ for arrhythmia, indicating the possible source of the emboli.
A plain abdominal film may show evidence of free intraperitoneal air, indicating a perforated viscus and the need for emergent exploration.

Ref: Harrison Chapter 298. Mesenteric Vascular Insufficiency

## Question 57:

一位50歲男性因皮膚泛黃住院。抽血檢驗結果如下：Bilirubin (T) : 8.5 mg/dL (≦1.0), Bilirubin (D) : 7.0 mg/dL (≦ 0.2), ALT : 70 (≦ 41), AST : 80 (≦ 31), ALP : 380 (≦104), GGT : 500 (≦ 52)。他最近沒有腹痛狀況，食慾尚佳。腹部超音波檢查發現兩側肝內膽管，近肝門區之總膽管及主胰管皆脹大。打顯影劑之電腦斷層攝影 (contrat-enhanced spiral CT) 亦有同樣發現，但未看到任何腫瘤。下列各項進一步之檢查，何者最有效益？

---

- A. 血清CA 199 檢測
- B. 磁振造影 (MRI)
- C. 內視鏡超音波 (EUS)
- D. 正子掃瞄電腦斷層 (PET-CT)
- E. 99mTc HIDA scan

### Correct Answer: C

(1) **multidetector helical computed tomography (CT)** imaging modality of choice for initial evaluation

(2) **endoscopic ultrasound** useful in patients with suspected pancreatic cancer with no visible mass on CT.

(3) endoscopic retrograde cholangiopancreatography (ERCP) useful in patients with jaundice who require endoscopic stent to relieve obstruction

(4) **magnetic resonance imaging cholangiopancreatography (MRCP)** may also be used staging laparoscopy controversial, useful in patients with large tumors, or other indicators of advanced disease

(5) tissue biopsy may be obtained by ERCP, image-guided fine needle aspiration, or **endoscopic ultrasound-guided fine needle aspiration**

(6) biomarkers including cancer antigen **(CA) 19-9**

Patients who present with clinical features suggestive of pancreatic cancer undergo imaging to confirm the presence of a tumor, and to establish whether the mass is likely to be inflammatory or malignant in nature. Other imaging objectives include the local and distant staging of the tumor, which will determine resectability and provide prognostic information. Dual phase, ++contrast-enhanced spiral CT++ is the imaging modality of choice. It provides accurate visualization of surrounding viscera, vessels, and lymph nodes, thus determining tumor resectability. Intestinal infiltration, and liver and lung metastases are also reliably depicted on CT. There is no advantage of ++magnetic resonance imaging (MRI)++ over CT in predicting tumor resectability, but selected cases may benefit from MRI to characterize the nature of small indeterminate liver lesions and to evaluate the cause of biliary dilatation when no obvious mass is seen on CT. ++Endoscopic retrograde cholangiopancreatography (ERCP)++ is useful for revealing small pancreatic lesions, identifying stricture or obstruction in pancreatic or common bile ducts, and facilitates stent placement.
Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for accurately depicting the level and degree of bile and pancreatic duct dilatation. ++EUS is highly sensitive in detecting lesions less than 3 cm in size, and is useful as a local staging tool for assessing vascular invasion and lymph node involvement++. Positron-emission tomography with fluorodeoxyglucose positron emission tomography (++FDG-PET++) should be considered before surgery or radical chemoradiotherapy (CRT), as it is superior to conventional imaging in detecting distant metastases.
cholescintigraphy scan, also known as: hepatobiliary iminodiacetic acid (HIDA)[沒有提到這檢查]

Ref:
* Harrison 18th edition, Chapter 93 Pancreatic cancer
* Pancreatic cance, Testing overview. Dynamed.

## Question 58:

你的病人懷孕已 26 周，因近期皮膚發癢，甚至癢到影響睡眠而來求醫。她祇有服用vitamin 及folic acid，未服用任何藥物。身體診察發現皮膚有抓痕，沒有petechiae 或 ecchymoses。病人意識清楚，生命徵象正常，沒有發燒。有 mildly icteric sclera。腹部敲診無 shifting dullness。抽血檢驗結果如下：Hb=12.0 (≧10.8); WBC=4800 (≧4000), platelet=280K (≧130K), PT (INR)=1.1 (0.8-1.1), Bilirubin (T)=3.8 mg/dL (≦1.0), Bilirubin (D)=3.2 mg/dL (≦0.3), ALT=38 (≦ 41), AST=29 (≦31), ALP (Alkaline phosphatase)=330 (≦104), GGT=400 (≦52), Albumin=3.5 g/dL (≧3.5)。超音波檢查子宮及胎兒正常。最可能之診斷為下列那一項？

---

- A. HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome
- B. Acute fatty liver of pregnancy
- C. Intrahepatic cholestasis of pregnancy
- D. Hyperemesis gravidarum
- E. Drug-induced liver injury

### Correct Answer: C

Severe preeclampsia: new-onset hypertension and proteinuria accompanied by end organ damage.
* HTN (>160/110 mmHg)
* proteinuria (>5 g/24 h)
* central nervous system (CNS) dysfunction (headaches, blurred vision, seizures, coma)
* renal dysfunction (oliguria or creatinine > 1.5 mg/dL)
* pulmonary edema
* hepatocellular injury (ALT > 2-fold the upper limits of normal)
* hematologic dysfunction (platelet count < 100,000/L or disseminated intravascular coagulation)
* placental dysfunction (oligohydramnios or severe intrauterine growth restriction).

A. The HELLP ( hemolysis, elevated liver enzymes, low platelets) syndrome is a special subgroup of severe preeclampsia and is a major cause of morbidity and mortality

B. Acute fatty liver is a rare complication of pregnancy. Frequently confused with the HELLP syndrome and severe preeclampsia, the diagnosis of acute fatty liver of preg- nancy may be facilitated by imaging studies and laboratory evaluation.
Acute fatty liver of pregnancy is generally characterized by markedly increased levels of bilirubin and ammonia and by hypoglycemia. Management of acute fatty liver of pregnancy is supportive.

C. Cholestasis of pregnancy occurs in the second and third trimesters and resolves after delivery. Its cause is unknown, but the condition is probably inherited and cholestasis can be triggered by estrogen administration

D. Pregnancy is the most prevalent endocrinologic cause of nausea, which affects 70% of women in the first trimester.

Ref: Harrison’s,Chapter 7. Medical Disorders During Pregnancy

## Question 59:

下列各項何者可能是肝硬化的併發症？（請選出全部可能答案）
(1) Esophageal varices
(2) Spontaneous bacterial peritonitis
(3) Hepatic encephalopathy
(4) Hepatic failure
(5) Hepatorenal syndrome
(6) Hepatopulmonary syndrome
(7) Portopulmonary hypertension
(8) Hepatoovary syndrome

---

A. (1)+(3)+(4)+(5)
B. (1)+(2)+(3)+(4)+(5)
C. (1)+(2)+(3)+(4)+(5)+(6)
D. (1)+(2)+(3)+(4)+(5)+(6)+(7)
E. 每項皆可能

### Correct Answer: D


Ref: Harrison’s, chapter 308

## Question 60:

一位55 歲女性病人住院之主訴為腹痛兩天，小便變少。過去病史不清楚。身體診察發現mildly icteric sclera 及shifting dullness with tenderness of abdomen。手臂有2處ecchymoses。體溫 38℃ （耳溫），B.P.=100/60 mmHg, P.R.=90/min, regular. 抽血檢驗結果如下：Albumin=2.5 g/dL (≧ 3.5), Bilirubin (T)=3.8 mg/dL (≦1), ALT=70 (≦ 41), AST=80 (≦31), ALP=380 (≦104), GGT=600 (≦52), Cr=3.0 mg/dL (≦1.3), PT=17" (≦ 11")。腹部超音波檢查發現肝硬化、脾腫大及腹水。有關本病人之敘述，下列何者正確？
(1)應儘快抽腹水送驗白血球總數及分類
(2)應儘快測量FeNa (fractional excretion of sodium)
(3)服用UDCA (ursodeoxycholic acid)對其病情有幫助
(4)應儘快以低劑量Dopamin治療之
(5)注射Albumin 對其病情有幫助
(6)Spironolactone (aldosterone inhibitor)及furosemide (loop diruetics)之使用不必考慮（請選出全部正確答案）

---

- A. (1)+(2)+(3)+(4)+(5)+(6)
- B. (1)+(2)+(4)+(5)
- C. (1)+(3)+(5)+(6)
- D. (2)+(3)+(4)
- E. (1)+(2)+(3)+(5)

### Correct Answer: E

Primary biliary cirrhosis(PBC) is seen in about 100–200 individuals per million, with a strong female preponderance and a median age of around 50 years at the time of diagnosis. The cause of PBC is unknown; it is characterized by portal inflammation and necrosis of cholangiocytes in small- and medium-sized bile ducts. Cholestatic features prevail, and biliary cirrhosis is characterized by an elevated bilirubin level and progressive liver failure. Liver transplantation is the treatment of choice for patients with decompensated cirrhosis due to PBC

1. Fluid management in individuals with cirrhosis, ascites, and AKI is challenging because of the frequent difficulty in ascertaining intravascular volume status.
Administration of intravenous fluids as a volume challenge may be required diagnostically as well as therapeutically. Excessive volume administration may, however, result in worsening ascites and pulmonary compromise in the setting of hepatorenal syndrome or AKI due to superimposed spontaneous bacterial peritonitis. ++Peritonitis++ should be ruled out by culture of ++ascitic fluid++. ++Albumin++ may prevent AKI in those treated with antibiotics for spontaneous bacterial peritonitis.
The definitive treatment of the hepatorenal syndrome is orthotopic liver transplantation. Bridge therapies that have shown promise include terlipressin (a vasopressin analog), combination therapy with octreotide (a somatostatin analog) and midodrine (an 1-adrenergic agonist), and norepinephrine, all in combination with intravenous albumin (25~50 mg per day, maximum 100 g/d).

2. check FeNa<1%


Laboratory findings: an elevation in ++γGT and ALK-P++ along with mild elevations in ++ALT and AST++. Immunoglobulins, particularly IgM, are typically increased.

3. **UDCA has been shown to improve both biochemical and histologic features of the disease. Improvement is greatest when therapy is initiated early**; the likelihood of significant improvement with UDCA is low in patients with PBC who present with manifestations of cirrhosis.

4. Hepatorenal syndroms is often seen in patients with refractory ascites and requires exclusion of other causes of acute renal failure. Treatment has, unfortunately, been difficult, and ++in the past, dopamine or prostaglandin analogues++ were used as renal vasodilating medications. ++Carefully performed studies have failed to show clear-cut benefit from these therapeutic approaches++. Currently, patients are treated with midodrine, anagonist, along with ++octreotide and intravenous albumin++. The best therapy for HRS is liver transplantation; recovery of renal function is typical in this setting. In patients with either type 1 or type 2 HRS, the prognosis is poor unless transplant can be achieved within a short period of time.

Ref: Harrison's manual, Chapter 308. Cirrhosis and Its Complication

## Question 61:

54 歲女性至門診做健康諮詢。她母親在 72 歲罹患大腸癌。她目前已停經，無任何不適。身體診察無異常，一般檢驗（包含CEA 數值）之結果皆正常，大腸鏡檢查無 polyp 及cancer。她希望能服用一些藥物來預防大腸癌之發生。請問下列各種藥物，何者已被證實有效且被應用於民眾？

---

- A. Aspirin
- B. Celecoxib
- C. Estrogen-replacement therapy
- D. Vitmin D
- E. 以上皆非

### Correct Answer: E

Primary Prevention
Several orally administered compounds have been assessed as **possible** inhibitors of colon cancer. The most effective class of chemopreventive agents is ++aspirin and other NSAIDs++, which are thought to suppress cell proliferation by inhibiting prostaglandin synthesis. Regular aspirin use reduces the risk of colon adenomas and carcinomas as well as death from large-bowel cancer; such use also appears to diminish the likelihood for developing additional premalignant adenomas following treatment for a prior colon carcinoma. This effect of aspirin on colon carcinogenesis increases with the duration and dosage of drug use. ++Oral folic acid++ supplements and ++oral calcium supplements++ reduce the risk of adenomatous polyps and colorectal cancers in case-controlled studies. The value of ++vitamin D++ as a form of chemo-prevention is under study. Antioxidant vitamins such as ++ascorbic acid, tocopherols, and -carotene are ineffective++ at reducing the incidence of subsequent adenomas in patients who have undergone the removal of a colon adenoma. ++Estrogen-replacement therapy has been associated with a reduction in the risk of colorectal cancer in women++, conceivably by an effect on bile acid synthesis and composition or by decreasing synthesis of IGF-I. The otherwise unexplained reduction in colorectal cancer mortality rate in women may be a result of the widespread use of estrogen replacement in postmenopausal individuals

Ref: Harrison 18th edition, chapter 91.

## Question 62:

媽媽帶著19 歲女兒至門診就醫，她自己及兩位年紀較大的孩子皆為B 型肝炎病毒慢性感染者。這個女兒出生時接受過B 型肝炎疫苗注射，目前檢驗結果為：HBsAg (+), Anti-HBs (-), Anti-HBc (+), HBeAg (+), Anti-HBe (-), ALT: 22 (≦41), AST: 25 (≦31), Bilirubin (T) = 2.5 mg/dL (≦1.0), Bilirubin (D)=0.3 mg/dL (≦0.2), Albumin=4.5 g/dL (≦3.5), PT (INR)=1.05 (0.8-1.2)。下列何者是目前最合適之處置？

---

- A. 再追加B 肝疫苗注射
- B. 馬上做肝切片 (liver biopsy)瞭解病情
- C. 儘速以口服B 型肝炎病毒抑制藥物，如：entecavir 或tenofovir，治療
- D. 儘速建議接受 alpha interferon 治療
- E. 定期（二～三個月一次）追蹤血清 ALT及AST即可

### Correct Answer: E



American Association for the Study of Liver Diseases (AASLD) 2009 recommendations on monitoring for patients not considered for treatment initially:
if ++(HBeAg)-positive with normal (ALT)++:
(1) check HBeAg status every 6-12 months (AASLD Grade III)
(2) check ALT level every 6 months, more often if elevated (AASLD Grade III)
(3) if ALT levels are 1-2 times upper limit of normal, recheck every 1-3 months (AASLD Grade III)
* consider ++liver biopsy if > 40 years old and ALT borderline or mildly elevated++ on serial tests
* consider treatment if biopsy shows moderate-to-severe inflammation or significant fibrosis

(4) if ALT > 2 times upper limit of normal for 3-6 months and HBeAg-positive, hepatitis B virus (HBV) DNA > 20,000 units/mL, consider liver biopsy and treatment
(5) consider screening for hepatocellular carcinoma (HCC)

Harrsion’s
1. Liver disease tends to be mild or inactive clinically; most such patients ++do not undergo liver biopsy++
2. According to the EASL guidelines, treat if ++HBV DNA is >2 × 1000 IU/ml and ALT >ULN++.
3. According to EASL guidelines, patients with ++compensated cirrhosis++ and detectable ++HBV DNA at any level, even with normal ALT++, are candidates for therapy. Most authorities would treat indefinitely, even in HBeAg-positive disease after HBeAg seroconversion
4. Because HBeAg seroconversion is not an option, the goal of therapy is to suppress HBV DNA and maintain a normal ALT. ++PEG IFN++ is administered by subcutaneous injection ++weekly for a year++; caution is warranted in relying on a 6-month posttreatment interval to define a sustained response, because the majority of such responses are lost thereafter. Oral agents, ++entecavir or tenofovir++, are administered ++daily++, usually indefinitely or, until as very rarely occurs, virologic and biochemical responses are accompanied by HBsAg seroconversion.

Ref: American Association for the Study of Liver Diseases (AASLD) 2009

## Question 63:

一位慢性C型肝炎患者抽血檢驗之結果為：ALT=53 (≦41), AST=48 (≦31), HCV RNA=380,000 IU/mL。Hb=15 (≧13), WBC=5,000 (≧4,000), Platelet=110,000 (≧ 130,000)。病人過去沒有甲狀腺疾病，也沒有depression。肝切片發現慢性發炎併有fibrosis，無明顯cirrhosis。下列何者是目前最合宜之處置？

---

- A. 未來每年接受一次肝切片檢查，追蹤其fibrosis 進行狀況，決定治療時機。
- B. 未來每6 個月檢查一次血中HCV RNA viral load，決定治療時機。
- C. 未來每2 個月檢查一次血中ALT及AST，決定治療時機。
- D. 未來每3 個月檢查一次complete blood count，決定治療時機。
- E. 積極建議病人開始接受 interfron-based therapy。

### Correct Answer: E


有測到HCV RNA,需開始接受治療.

Complications of IFN therapy include:
* systemic “flu-like” symtoms
* marrow suppression
* emotional lability (irritability, depression, anxiety)
* autoimmune reactions (especially autoimmune thyroiditis)
* miscellaneous side effects such as alopecia, rashes, diarrhea, and numbness and tingling of the extremities. With the possible exception of autoimmune thyroiditis

all these side effects are reversible upon dose lowering or cessation of therapy

Ref: Harrison's Principles of Internal Medicine, 18ed, Chapter 306

## Question 64:

下列有關嘔吐之病因推測，何者錯誤？

---

- A. 嘔吐物主要為未消化之⻝⾷食物，可能有achalasia
- B. 嘔吐物含有膽汁，不可能為gastric obstruction
- C. 嘔吐物帶有糞味，可能有distal intestinal or colonic obstruction
- D. 嘔吐通常發⽣生於飯後1⼩小時內，可能為pyloric stenosis
- E. 嘔吐後腹痛消失，表⽰示可能為acute pancreatitis

### Correct Answer: E

A&B&C.
The vomitus initially contains bile and mucus and remains as such if the obstruction is high in the intestine.
With low ileal obstruction, the vomitus becomes feculent, i.e., orange-brown in color with a foul odor, which results from the overgrowth of bacteria proximal to the obstruction. (Harrison 18, P2514)

D. Pyloric stenosis often causes projectile vomiting — the forceful ejection of milk or formula up to several feet away. Vomiting occurs within 30 minutes after baby eats. Vomiting may be mild at first and gradually become more severe as the pylorus opening narrows.
http://www.uptodate.com/contents/infantile-hypertrophic-pyloric-stenosis

E. acute pancreatitis的腹痛會因前傾(sitting with the trunk flexed and knees drawn up)改善。沒提到會因嘔吐改善。(Harrison 18, p.2636)

## Question 65:

一位病⼈人因急性心窩痛⽽而被送⾄至急診室。心窩痛會延伸⾄至背部。病⼈因難受⽽顯得焦躁不安，呼吸急促。身體診察顯⽰：體溫39.1’C，⾎壓 150/90 mmHg，脈摶 104/分，規律，呼吸速率 24/分。左下肺呼吸⾳較弱。心窩處有輕微壓痛。他最近沒有使⽤新藥。抽血檢驗結果如下：Hb=15.0 (≧13), WBC=16,300 (> 4,000, < 10,000), Amylase=20,000, Lipase=8,000, BUN=68 (≦24), Cr=2.4 (≦1.0)。打顯影劑之CT (contrast-enhanced CT)顯⽰胰臟周遭有⽔腫，無組織壞死、亦無腹水。下列各項，何者最能反映出本病⼈病情之嚴重度？

---

- A. 體溫 (39.1℃)
- B. Amylase 及 Lipase serum level
- C. 胰臟周遭⽔腫
- D. BUN數值
- E. ⼼窩痛且延伸⾄背面

### Correct Answer: D

Hemoconcentration may be the harbinger of more severe disease (i.e., pancreatic necrosis), while azotemia is a significant risk factor for mortality. (Harrison 18, p. 2637)


## Question 66:

一位病⼈因關節炎⽽需使⽤NSAIDs藥物治療，病⼈很怕會有胃腸副作⽤。下列各項有關預防NSAID-induced gastrointestinal (GI) injury之敘述，何者錯誤？

---

- A. Standard-dose proton pump inhibitors (PPI) 為⾸選藥物
- B. Misoprostol (synthetic prostaglandin E1 analogue) 亦可考慮使⽤，但劑量不宜過高以減少腹瀉之副作⽤
- C. High-dose H2 blockers 效果與PPI 或 Misoprostol 相似，故可做為替代藥物
- D. 若病⼈屬low GI risk 且 low cardiovascular (CV) risk 者，使用低劑量單⼀種 NSAID 時不需預防其可能產⽣之 GI 及 CV toxicity
- E. Enteric-coated NSAIDs 及 Aspirin無法有效預防其 GI injury

### Correct Answer: C



C. Only PPIs can heal GUs or DUs, independent of whether NSAIDs are discontinued. High-dose H 2 blockers (famotidine, 40 mg bid) have also shown some promise in preventing endoscopically documented ulcers, although PPIs are superior.

E. A systematic literature review through Medline, Embase, and Index Medicus was made to identify toxicological effects induced by modified release formulations of NSAIDs in the small and large intestine. SR and EC NSAID use has been associated with both small and large intestinal bleeding, anaemia, strictures, ulcerations, perforations, and death.

Ref：
* Harrison 18th edition, p. 2450
* http://www.ncbi.nlm.nih.gov/pubmed/10951657

## Question 67:

中年男性，最近三個月在⾨診剛被確診有⾼⾎壓。為了解高血壓的病因與相關影響，除了一般病史與理學檢查之外，您會建議優先做以下實驗室檢查篩檢，何者除外?

---

- A. Hemoglobin or hematocrit
- B. Urinalysis
- C. Fasting glucose level
- D. HbA1C level
- E. Electrocardiogram (ECG) or chest X-ray

### Correct Answer: D


A. Hematocrit is the most important determinant of whole blood viscosity.
Blood viscosity and vascular resistance affect total peripheral resistance to blood flow, which is abnormally high in the established phase of primary hypertension. ( Hypertension 1992;20-319-32)

B. All disorders of the kidney may cause hypertension
Renal disease is the most common cause of secondary hypertension.
Proteinuria>1000 mg/d and an active urine sediment are indicative of primary renal disease.
In either instance, the goals are to control blood pressure and retard the rate of progression of renal dysfunction. (Harrison 18th edition, p. 2048)

C. Insulin resistance also is associated with an unfavorable imbalance in the endothelial production of mediators that regulate platelet aggregation, coagulation, fibrinolysis, and vessel tone.

Ref: Harrison 18th edition, p. 2048, 2053

## Question 68:

一位49歲男性，外傷後第三天出現尿量減少(350 mL/day)。腎臟超⾳波檢查: 腎臟⼤小無異常，也無水腎(hydronephrosis)。以下數據何者⽀支持ATN (acute tubular necrosis)，⽽⾮腎前性急性腎損傷(pre-renal acute kidney injury)?

---

- A. BUN 78 mg/dL, creatinine 1.8 mg/dL
- B. Urine [Na] 41 mEq/L
- C. Urine osmolality 390 mosmol/L
- D. Plasma [Na] 140 mEq/L, plama [creatinine] 1.8 mg/dL, urine [Na] 28 mEq/L, urine [creatinine] 72 mg/dL
- E. urine sediment normal, occasional hyaline cast. No granular or brown cast

### Correct Answer: B

Ref: Harrison 18th edition, p.337, 2300, 2301


A. BUN/Creatinine: 78/1.8= 43.3>20 pre-renal acute kidney injur

B. Urine [Na]<20 mEq/L pre-renal AKI

C. Elevated Urine osmolality pre-renal AKI



D. FeNa:(28/140)/(72/1.8)= 0.005<1 => pre-renal AKI

E. AKI 尿液檢查思路


## Question 69:

一位58歲⼥女性，例⾏性健康檢查時發現: 尿液檢查報告異常。Urinalysis: protein (-), occult blood (2+), RBC 15-20/(HPF, high power field), WBC cast (-), dysmorphic RBC (-), RBC cast (-). 病⼈人自述無其他不適，理學檢查也無異狀。您接著會優先做以下何種檢查?

---

- A. Urine cytology test
- B. Check serum cryoglobulin, complement (C3, C4)
- C. Check myoglobulinuria
- D. Arrange renal biopsy
- E. Do urine bacterial culture

### Correct Answer: A

Ref: Harrison 18th edition, p.338, 339


A. The suspicion for urogenital neoplasms in patients with isolated painless hematuria and nondysmorphic RBCs increases with age.

B. No dysmorphic RBC, no RBC casts

C. A false-positive dipstick for hematuria (where no RBCs are seen on urine microscopy) may occur when myoglobinuria is present, often in the setting of rhabdomyolysis. But no symptoms or history indicates rhabdomyolysis.

D. Isolated microscopic hematuria can be a manifestation of glomerular diseases. The RBCs of glomerular origin are often dysmorphic.

E. No symptoms, no pyuria => UTI is not likely

## Question 70:

以下是一位ICU病⼈的動脈氣體分析與⾎液電解質報告: pH 7.42, PaO2 88 mmHg, PaCO2 67 mmHg, [Na] 140 mEq/L, [K] 3.5 mEq/L, [Cl] 88 mEq/L, HCO3 42 mEq/L。依據上述數值，最符合以下何種病⼈狀況?

---

- A. Sepsis in ICU
- B. Uremia, long-term use of diuretics
- C. COPD with diuretics
- D. Methanol intoxication, with secondary lactic acidosis
- E. Pneumonia, on ventilator support for pulmonary edema

### Correct Answer: C

呼吸酸+代謝鹼中毒
呼吸酸 => 刪掉ABD
代謝鹼 => diuretics

## Question 71:

以下有關腹膜透析(peritoneal dialysis, 簡稱PD)的敘述，何者正確? (應選出所有正確答案)
(1)PD病⼈發⽣腹膜炎(peritonitis)，最常見的是Staphylococcus aureus
(2)要診斷PD病人發生腹膜炎(peritonitis)，三個最主要的症狀(triad)是: 腹痛(abdominal pain), 透析液混濁(cloudy dialysate), 及混濁的透析液中WBC需 >100 /μL
(3)PD病⼈發⽣腹膜炎(peritonitis)，若是透析液混濁(cloudy dialysate), ⽽混濁的透析液中WBC >100 /μL，且以lymphocyte為主(>50%)時，要考慮TB (tuberculosis)或是fungal peritonitis
(4)⽼年PD病人發⽣腹膜炎(peritonitis)，最常⾒的是Pseudomonas species菌種
(5)PD病⼈人發⽣導管出口(exit-site)感染，最常⾒的是Staphylococcus epidermidis

---

- A. (1)+(2)+(3)+(4)+(5)
- B. (1)+(2)+(3)+(5)
- C. (1)+(2)+(4)
- D. (1)+(2)+(5)
- E. (2)+(3)

### Correct Answer: E

(1) The most common culprit organisms are gram-positive cocci, including Staphylococcus, reflecting the origin from the skin.

(2) Peritonitis is usually defined by an elevated peritoneal fluid leukocyte count (100/mm3 , of which at least 50% are polymorphonuclear neutrophils) The clinical presentation typically consists of pain and cloudy dialysate, often with fever and other constitutional symptoms.

(3) Gram-negative rod infections are less common; fungal and mycobacterial infections can be seen in selected patients, particularly after antibacterial therapy.

(4) 沒看到這樣的說法

(5) Staphylococcus aureus and Pseudomonas aeruginosa exit-site infections are very often associated with concomitant tunnel infections and are the organisms that most often result in catheter infection-related peritonitis.The most serious and common exit-site pathogens are Staphylococcus aureus and Pseudomonas aeruginosa. As these organisms frequently lead to peritonitis, such infections must be treated aggressively (7,8,19,23–41).
Exit-site and tunnel infections may be caused by a variety of microorganisms, with S. aureus and Pseudomonas aeruginosa being responsible for the majority.
Ref:
* Harrison 18th edition, p.2326
* ISPD GUIDELINES/RECOMMENDATIONS, Peritoneal Dialysis International, Vol. 30, pp.393–423 doi:10.3747/pdi.2010.00049
* CURRENT Diagnosis & Treatment: Nephrology & Hypertension. Chapter 51. Peritoneal
Dialysis.

## Question 72:

一位44歲女性，主述最近六週來兩側脛骨前(pre-tibial)與腳踝(ankle)有間歇性⽔腫(edema)。傍晚時較腫，腳抬高或早晨睡醒時水腫會稍改善。實驗室檢查報告為: albumin 3.0 g/dL, BUN 26 mg/dL, creatinine 1.0 mg/dL, total cholesterol (t-Chol) 284 mg/dL, LDL 168 mg/dL. C3 48 mg/dL (normal range, 75-135 mg/dL)。尿液檢查顯示: protein (2+), occult blood (1+)。依據上述數值，最不符合以下何種診斷?

---

- A. 可能是 lupus nephritis
- B. 可能是 post-infectious glomerulonephritis
- C. 可能是 membranous nephropathy
- D. 可能是 cryoglobulinemia
- E. 可能是 membranoproliferative glomerulonephritis

### Correct Answer: C

C. Levels of complement components C3 and C4 are typically normal in patients with MN.

A&B&D&E: 皆有可能造成C3 level下降

A. SLE會造成C3, C4下降

B. In the first week of symptoms, 90% of patients will have a depressed CH 50 and decreased levels of C3 with normal levels of C4. A subclinical disease is reported in some series to be four to five times as common as clinical nephritis, and these latter cases are characterized by asymptomatic microscopic hematuria with low serum C3 complement levels.

D. Type I MPGN is commonly associated with persistent hepatitis C infections, autoimmune diseases like lupus or cryoglobulinemia, or neoplastic diseases.

E: Low serum C3 levels are common.

Ref:
* Brenner, p.1127
* Harrison 18th edition, p. 2340, 2344

## Question 73:

一位54 歲男性，因為近三周來有呼吸不適(dyspnea)、痰中有⾎血絲(hemoptysis)到急診就醫。實驗室檢查報告為: albumin 3.9 g/dL, BUN 46 mg/dL, creatinine 5.8 mg/dL, Hb 9.4 g/dL. 胸部X-光顯⽰示: 兩側肺有瀰漫型浸潤(diffuse alveolar infiltration)。免疫學檢查，含: anti-GBM antibody, ANCA-antibody, C3, C4, ANA，皆無明顯異常。依據上述數值，病人的肺部與腎臟病因，較可能是?

---

- A. Uremic lung
- B. SLE 合併pulmonary-renal syndrome
- C. Wegener's granulomatosis
- D. Goodpasture's syndrome
- E. Microscopic polyarthritis (是否應為polyarteritis 或polyangiitis?)

### Correct Answer: A

病患有三週的 dyspnea和hemoptysis，需考慮infection、pulmonary edema、以及pulmonary hemorrhage，但選項未提及感染因素。CXR顯⽰示diffuse alveolar infiltration，pulmonary edema 和pulmonary hemorrhage均無法排除。lab data 發現明顯azotemia 和anemia，且autoimmune markers 皆為陰性，因此腎衰竭造成此病人症狀的可能性大於自體免疫相關。

A. The pathogenesis of "uremic lung" is controversial. Hypoalbuminemia, characteristic of chronic renal failure, decreases plasma oncotic pressure and thus fosters movement of fluid out of the pulmonary capillaries. Such movement is also promoted by the increased hydrostatic pressure that occurs in congestive heart failure, which is common in this condition.

B. There are a number of “pulmonary renal syndromes” that affect both the lungs and the kidneys. These disorders most commonly present with hemoptysis from diffuse alveolar hemorrhage, along with renal insufficiency associated with either acute glomerulonephritis or other vasculitis. Three of the most familiar diseases with both pulmonary and renal manifestations are Wegener’s granulomatosis, systemic lupus erythematosus, and Goodpasture’s syndrome. Systemic lupus erythematosus is a multisystem inflammatory disorder of unknown cause. SLE is characterized by the presence of antinuclear antibodies. Pulmonary and renal involvement are very common. Thoracic manifestations include pleuritis, acute lupus pneumonitis, interstitial pulmonary fibrosis, pulmonary vasculitis, diffuse alveolar hemorrhage, pulmonary hypertension, organizing pneumonia, and the “shrinking lung syndrome.” Although these usually occur in patients with an established diagnosis of lupus, either of them, and any of the other intrathoracic processes listed, may be the initial manifestation of the disease.

C. Wegener’s granulomatosis is a clinical syndrome consisting mainly of necrotizing granulomatous vasculitis of the upper and lower respiratory tract, along with glomerulonephritis. Wegener's granulomatosis is characterized by the presence of positive tests for ANCA in at least 90% of affected patients.

D. Goodpasture’s syndrome is a disorder of unknown etiology, manifested by diffuse alveolar hemorrhage and glomerulonephritis. It is also known as anti-glomerular basement membrane antibody disease. Alveolar hemorrhage appears to be more common among patients who smoke.1

E. Microscopic polyangiitis (MPA) is an ANCA-associated small to medium vessel systemic vasculitis. MPA is of a fibrinoid necrotizing vasculitis with few or no immune deposits that primarily affects small vessels such as
capillaries, arterioles, or venules, although spread to include small and medium-sized arteries may occur. The most commonly affected organs are the kidneys and the lungs. It may be severe and acute with rapidly progressive glomerulonephritis and pulmonary hemorrhage, presenting as a pulmonary renal syndrome.

Ref:
* D.J. Pierson, Respiratory considerations in the patient with renal failure, Respir Care, 51 (4) (2006), pp. 413–422
* Gary S. Firestein, Kelley's Textbook of Rheumatology, 9th edition, Chapter 89, 1481-1497.e4

## Question 74:

一位70 歲男性，過去病史有糖尿病、⾼血壓、與慢性腎臟病(CKD)。預定兩天後進行心導管檢查。實驗室檢查報告為: albumin 4.0 g/dL, BUN 42 mg/dL, creatinine 3.1 mg/dL, total cholesterol (t-Chol) 224 mg/dL, LDL 128 mg/dL. 尿液檢查顯示: protein (2+)。目前用藥有: losartan, carvedilol, furosemide, rosuvastatin, aspirin, insulin和 saxagliptin。依據病⼈狀況，為減少或預防contrast-induced nephropathy or acute kidney injury (AKI)，以下何種措施正確? (應選出所有正確答案)
(1)Hydration with isotonic saline, 可加上 sodium bicarbonate
(2)因為serum creatinine⾼，做完心導管當⽇，應安排做預防性⾎液透析(prophylactic hemodialysis)
(3)導管前⼀天與當天各給予N-acetylcysteine (600 mg, bid)
(4)將ARB (losartan)換成cyclosporin-A，以減少腎毒性
(5)如果腎功能尚可(< 1.5 mg/dL)，應該盡量將insulin換回metformin，可以增加腎臟保護作⽤

---

- A. (1)+(2)+(3)+(4)+(5)
- B. (1)+(3)+(4)+(5)
- C. (1)+(3)+(4)
- D. (1)+(3)+(5)
- E. (1)+(3)

### Correct Answer: E

Volume expansion 為已被確認可預防CI-AKI 的⽅式，⽽N-acetylcysteine也因其抗氧化的能⼒被嘗試使用在 CI-AKI。洗腎的效果也仍未明瞭且具風險，目前不建議。而cyclosporin-A 本⾝也會造成AKI，故因避免。metformin 在eGFR⼩於30ml/min 者禁用，小於 60ml/min 使⽤用上也需注意lactic acidosis，在本題病患接受contrast medium 的情況下腎功能極有可能惡化，因此也應避免。

Patients at risk for CI-AKI have comorbidities that will exacerbate the primary pathogenesis of the injury: contrast-induced vasoconstriction leading to diminished blood flow to the renal medulla.1 Diabetes is a risk factor for deterioration in renal function after angiography. Other factors include age over 75 years, periprocedural volume depletion, heart failure, cirrhosis or nephrosis, hypertension, proteinuria, concomitant use of nonsteroidal antiinflammatory drugs, and intraarterial injection.
(1) The administration of fluids is recommended to reduce the risk of contrast-medium–induced nephropathy. It has been hypothesized that alkalinization of tubular fluid might be beneficial by reducing the levels of pH-dependent free radicals.

(2) A single session of HD can effectively remove 60–90% of contrast media from the blood. Generally, several hemodialysis sessions are needed to eliminate all contrast media. A previous meta-analysis and a recent meta-analysis could not demonstrate the benefit of dialysis on the incidence of CI-AKI when compared with routine preventive care. In addition, the risks of dialysis procedures and the much greater cost should be considered. As such, the Contrast Media Safety Committee of ESUR states that there is no need to schedule the dialysis in relation to the injection of contrast media or the injection of contrast agent in relation to the dialysis program.

(3) N-acetylcysteine has the potential to reduce the nephrotoxicity of contrast mediums through antioxidant and vasodilatory effects. Recent meta-analyses suggest some benefit to N-acetylcysteine. Also, the effect of N-acetylcysteine on outcomes other than minor changes in serum creatinine levels is unknown. More data are needed before N-acetylcysteine can be strongly recommended for the prevention of contrast-medium–induced nephropathy.

(4) Nephrotoxicity may be the result of cyclosporine-induced afferent arteriolar vasoconstriction that results in part from an imbalance between the production of prostaglandin E, a vasodilator, and that of thromboxane A, a vasoconstrictor.

(5) Recent studies have recommended the use of metformin for kidney protection and antioxidant. It has been shown that gentamicin-induced renal tubular damage is reduced by metformin.5 Anxieties about the use of iodinated contrast agents in diabetics taking metformin relate to the possibility of producing CIN (contrast-induced nephropathy), thus leading to retention of metformin, with an associated increased risk of lactic acidosis. In the absence of direct studies on the subject, guidelines for radiologists produced since the 1990s have had to be based on the consensus of experts familiar with metformin pharmacokinetics and the pathophysiology of CIN. The 2009 ESUR guideline states that patients with an eGFR of 45 ml/min/1.73 m2 or greater can continue to take metformin normally if they receive intravenous iodinated contrast medium. Patients receiving intra-arterial iodinated contrast medium with an eGFR of 30–59 ml/min/1.73 m2 and patients receiving intravenous contrast medium with an eGFR 30–44 ml/min/1.73 m2 should stop taking metformin 48 h before contrast medium administration. Renal function should be re-assessed 48 h after contrast medium and metformin should only be restarted if it has not deteriorated further.

Ref:
* Solomon R, Dauerman HL. Contrast-induced acute kidney injury. Circulation 2010;122:2451–5.
* Brendan J. Barrett, M.B. Preventing Nephropathy Induced by Contrast Medium. N Engl J Med 2006; 354:379-386
* Susantitaphong P, Eiam-Ong S. Nonpharmacological Strategies to Prevent Contrast-Induced Acute Kidney Injury. BioMed Research International. 2014;2014:463608. doi:10.1155/2014/463608.
* Jean-Louis Vincent, Edward Abraham, Textbook of Critical Care, 6th edition, Chapter 176, 1308-1316
* Rafieian-Kopaie M. Metformin and renal injury protection. Journal of Renal Injury Prevention. 2013;2(3):91-92. doi:10.12861/jrip.2013.29.
* Stacul, Fulvio, et al. "Contrast induced nephropathy: updated ESUR contrast media safety committee guidelines." European radiology 21.12 (2011): 2527-2541.

## Question 75:

一位34 歲⼥性，過去無重大疾病或慢性病。主述最近兩天有頻尿、排尿疼痛不適(dysuria)，但是沒有發燒或腰痛情形，也沒有vaginal discharge。你查閱病例，發現這是她近六個月來第三度因為相同主述就醫。⽽⼀個月前，醫師曾開予trimethoprim-sulfamethoxazole (TMP-SMX)三日份，當時有效且症狀痊癒。醫師建議以下處置，下列何者除外?

---

- A.⼀一樣開予3-5日份之TMP-SMX 做症狀治療
- B. 如果症狀未緩解或惡化，重新做urine culture，並依結果選擇抗⽣素治療
- C. 安排做IVP或電腦斷層(CT)檢查
- D. 給予預防性抗生素，每天睡前低劑量 TMP-SMX，或cephalexin，約3-6 個⽉為期。之後停藥觀察
- E. ⿎勵多喝水、配合養成適時解尿的習慣

### Correct Answer: C

此年輕女性表現為典型 recurrent cystitis，距離前次感染已間隔⼀個⽉，且前次治療順利，因此應再次使⽤用短期抗⽣素療程。若治療效果不彰或在兩週內復發，應考慮其他菌種或抗藥性菌種，因此需留 urine culture且選擇其他抗⽣素。改變⽣活習慣以及預防性抗⽣素也是現⾏的做法。絕⼤部份recurrent cystitis 或pyelonephritis 並無結構上的異常，接受影像檢查的診斷價值不⾼高，因此不需進⼀步檢查。

Uncomplicated UTI refers to acute cystitis or pyelonephritis in nonpregnant outpatient women without anatomic abnormalities or instrumentation of the urinary tract; complicated UTI is a catch-all term that encompasses all other types of UTI.
Recurrent UTI is not necessarily complicated.1 Cystitis is usually manifested as dysuria with or without frequency, urgency, suprapubic pain, or hematuria. Clinical manifestations suggestive of pyelonephritis include fever (temperature >38°C), chills, flank pain, costovertebral-angle tenderness, and nausea or vomiting, with or without symptoms of cystitis. Dysuria is also common with urethritis or vaginitis, but cystitis is more likely when symptoms include frequency, urgency, or hematuria; when the onset of symptoms is sudden or severe; and when vaginal irritation and discharge are not present. In women who have symptoms of cystitis along with vaginal discharge or irritation, it is reasonable to delay antimicrobial treatment until vaginal examination has been performed and the results of a urine culture are available.

A. Episodes of cystitis that occur at least 1 month after successful treatment of a urinary tract infection should be treated with a first-line short-course regimen.

B. Urinary symptoms that persist or recur within a week or two of treatment for uncomplicated cystitis suggest infection with an antimicrobial-resistant strain or, rarely, relapse. A urine culture should be performed and treatment should be initiated with a broader-spectrum antimicrobial agent, such as a fluoroquinolone.

C. In women with recurrent uncomplicated cystitis or pyelonephritis, routine urologic evaluation (with the use of ultrasonography or computed tomography) has a low diagnostic yield and is not recommended. However, it should be considered in women who have persistent hematuria or multiple early recurrences of cystitis involving the same strain of bacteria.

D. Antimicrobial prophylaxis has been shown to reduce the risk of recurrence by approximately 95%; however, such treatment should be limited to women who have had three or more urinary tract infections in the past 12 months or two or more urinary tract infections in the past 6 months (at least one of which was confirmed by a positive culture) in whom nonantimicrobial strategies have not been effective and who prefer prophylactic antimicrobial
therapy. Continuous antimicrobial prophylaxis daily bedtime dose as Nitrofurantoin 50–100 mg, TMP-SMX 40, 100, 200 mg (3 times weekly is also effective), Cephalexin 125–250 mg, Fosfomycin, 3-g sachet every 10 day had been used.

E. Behavioral counseling as abstinence or reduction in frequency of intercourse were recommanded, and if spermicides are used, recommend changing to another method for contraception or prevention of infection, urinate soon after intercourse, drink fluids liberally, not routinely delay urination, wipe front to back after defecation, avoid tight-fitting underwear, avoid douching.

Ref:
* Gupta K, Trautner BW. Chapter 288. Urinary Tract Infections, Pyelonephritis, and Prostatitis. Harrison's Principles of Internal Medicine, 18e.
* Hooton, Thomas M. "Uncomplicated urinary tract infection." New England Journal of Medicine 366.11 (2012): 1028-1037.
* Hooton, Thomas M. "Recurrent urinary tract infection in women." International journal of antimicrobial agents 17.4 (2001): 259-268.

## Question 76:

一位28 歲男性，主述兩天來尿液顏色深暗(tea-colored urine)，且感覺尿量明顯減少了。病⼈過去無重⼤疾病或慢性病，約5天前先有感冒症狀、輕度發燒、肌⾁肉與腰部酸痛，曾⾃⾏至藥局買感冒成藥服用。但是無嘔吐、腹瀉、或頻尿等症狀。理學檢查發現: ⾎壓 135/86 mm Hg, 喉嚨輕度紅腫，呼吸⾳正常，無⽔腫。實驗室檢查: Hb 9.9 g/dL, WBC 9700/mm3, albumin 4.1 g/dL, BUN 38 mg/dL, creatinine 1.9 mg/dL. C3, C4 數值皆正常。尿液檢查顯示: protein (2+), occult blood (3+)。腎臟超音波顯⽰示: 兩側腎臟⼤小正常，無阻塞情形。病⼈最可能的診斷是?

---

- A. Membranous nephropathy
- B. IgA nephropathy
- C. Microscopic polyarteritis
- D. Membranoproliferative glomerulonephritis
- E. Focal segmental glomerulosclerosis

### Correct Answer: B

此年輕男性表現為上呼吸道症狀後產⽣⾎尿與蛋⽩尿，為IgA nephropathy 的重要線索。此病人蛋⽩尿嚴重程度較低，未造成hypoalbuminemia，不同於典型membranous nephropathy 與FSGS的表現。因C3 正常，MPGN的可能性較低。尿液檢查無cast，雖有發燒和痠痛，但同時也伴隨感冒症狀且未提及體重減輕，與MPA 表現不符。

A. Eighty percent of patients with MGN present with nephrotic syndrome and nonselective proteinuria. Microscopic hematuria is seen in up to 50% of patients but is seen less commonly than in IgA nephropathy or FSGS.

B. IgA nephropathy is one of the most common forms of glomerulonephritis worldwide. There is a male preponderance, a peak incidence in the second and third decades of life. The two most common presentations of IgA nephropathy are recurrent episodes of macroscopic hematuria during or immediately following an upper respiratory infection often accompanied by proteinuria or persistent asymptomatic microscopic hematuria.

C. Renal manifestations of MPA include microscopic hematuria, an abnormal renal sediment with red cell casts, proteinuria that is not usually of nephrotoxic proportions (i.e., is less than 3.5 g per 24 hours), and variable loss of kidney function.2 Disease onset may be gradual, with initial symptoms of fever, weight loss, and musculoskeletal pain; however, it is often acute.

D. Patients with MPGN present with proteinuria, hematuria, and pyuria (30%), systemic symptoms of fatigue and malaise that are most common in children with type I disease, or an acute nephritic picture with RPGN and a speedy deterioration in renal function in up to 25% of patients. Subendothelial deposits with low serum levels of C are typical, although 50% of patients have normal levels of C and occasional intramesangial deposits.

E. FSGS can present with hematuria, hypertension, any level of proteinuria or renal insufficiency.1 Proteinuria is a defining feature of focal segmental glomerulosclerosis, typically accompanied by hypoalbuminemia, hypercholesterolemia, and peripheral edema.

Ref:
* Harrison's Principles of Internal Medicine, 18e. Chapter 283. Glomerular Diseases.
* Gary S. Firestein, Kelley's Textbook of Rheumatology, 9th edition, Chapter 89, 1481-1497.e4
* Harrison's Principles of Internal Medicine, 18e. Chapter 326. The Vasculitis Syndromes.
* D'Agati, V. D., et al. (2011). Focal segmental glomerulosclerosis. New England Journal of Medicine, 365(25), 2398-2411.

## Question 77:

一位慢性腎臟病人，4 年來持續接受規則血液透析治療。某日，因跌倒骨折被送至急診。經診斷有骨質疏鬆，多處⾎管鈣化，與皮膚⾎管病變(calciphylaxis)。造成上述病因與症狀，與何種下列機轉無關?

---

- A. High parathyroid hormone
- B. High [Calcium] x [Phosphate] product
- C. High fetuin-A
- D. High FGF-23 (fibroblast growth factor)
- E. Vascular wall (media and intima) calcification

### Correct Answer: C

⾻質疏鬆、⾎管鈣化、calciphylaxis 皆為CKD病⼈人鈣磷代謝異常的表現，

A. The pathophysiology of secondary hyperparathyroidism and the consequent high-turnover bone disease is related to abnormal mineral metabolism through the following events:
(1) declining GFR leads to reduced excretion of phosphate and, thus, phosphate retention;
(2) the retained phosphate stimulates increased synthesis of PTH and growth of parathyroid gland mass; and
(3) decreased levels of ionized calcium, resulting from diminished calcitriol production by the failing kidney as well as phosphate retention, also stimulate PTH production.

B. Soft-tissue calcifications commonly develop when serum phosphorus levels are markedly elevated or when the calcium–phosphorus ion product in serum is extremely high.

C. Progressive renal impairment is associated with worsening systemic inflammation. Elevated levels of C-reactive protein are detected along with other acute-phase reactants, while levels of so-called negative acute-phase reactants, such as albumin and fetuin, decline with progressive renal impairment.

D. Fibroblast growth factor 23 (FGF-23) is part of a family of phosphatonins that promotes renal phosphate excretion. Recent studies have shown that levels of this hormone, secreted by osteocytes, increases early in the course of CKD. It may defend normal serum phosphorus in at least three ways:
(1) increased renal phosphate excretion;
(2) stimulation of PTH, which also increases renal phosphate excretion; and
(3) suppression of the formation of 1,25(OH)2D3, leading to diminished phosphorus absorption from the gastrointestinal tract.
Interestingly, high levels of FGF-23 are also an independent risk factor for left ventricular hypertrophy and mortality in dialysis patients.

E. Arterial calcifications among patients with CKD involve the medial layer of small- and medium-sized arteries predominantly.

Ref:
* Harrison 18th edition. Chapter 280. Chronic Kidney Disease.
* CURRENT Diagnosis & Treatment: Nephrology & Hypertension. Chapter 20. Renal Osteodystrophy.

## Question 78:

關於慢性腎臟病(Chronic kidney disease)之心⾎管疾病(Cardiovascular disease)，底下各項敘述，何者正確？(請選出所有正確答案之組合)
(1)三到四成以上慢性腎臟病患者在進展至第五期前，已罹患⼼⾎管疾病或已因之死亡
(2)只有在第三⾄第五期慢性腎臟病患者，⼼⾎管疾病才是居前的罹病或致死的原因
(3)透析病⼈⼼血管疾病的死亡率之明顯增加，主要是急性⼼肌梗塞造成
(4)低血清白蛋⽩血症與透析病⼈之死亡率有關
(5)低壓力肺⽔腫 (low-pressure pulmonary edema)常見於晚期慢性腎臟病，係由肺泡壁微血管通透度增加所致,所以透析治療常無效果

---

- A. (1)+(2)+(3)+(4)+(5)
- B. (1)+(2)+(3)+(4)
- C. (1)+(3)+(4)
- D. (1)+(4)
- E. (1)+(4)+(5)

### Correct Answer: D

⼼⾎管疾病在任⼀時期的 CKD皆為主要的morbidity 與mortality 因素，且30 ⾄至45%的CKD病⼈在進展到stage 5 以前已經罹患心血管疾病或因其死亡。其死亡的因素主要為心衰竭，⽽不一定要有急性心肌梗塞。低壓力肺水腫⾒於晚期CKD，但會經由洗腎改善。

(1) Between 30 and 45% of patients reaching stage 5 CKD already have advanced cardiovascular complications. As a result, most patients with CKD succumb to cardiovascular disease before ever reaching stage 5 CKD.

(2) Cardiovascular disease is the leading cause of morbidity and mortality in patients at every stage of CKD.

(3) The largest increment in cardiovascular mortality rate in dialysis patients is not necessarily directly associated with documented acute myocardial infarction but, instead, presents with congestive heart failure and all of its manifestations, including sudden death.

(4) Hypoalbuminemia is associated with both cardiac and noncardiac mortality in hemodialysis patients.

(5) A form of "low-pressure" pulmonary edema can also occur in advanced CKD, manifesting as shortness of breath and a "bat wing" distribution of alveolar edema fluid on the chest x-ray. This finding can occur even in the absence of ECFV overload and is associated with normal or mildly elevated pulmonary capillary wedge pressure. This process has been ascribed to increased permeability of alveolar capillary membranes as a manifestation of the uremic state, and it responds to dialysis.

Ref:
* Harrison 18th edition. Chapter 280. Chronic Kidney Disease.
* Foley, R. N., et al. (1996). Hypoalbuminemia, cardiac morbidity, and mortality in end-stage renal disease. Journal of the American Society of Nephrology, 7(5), 728-736.

## Question 79:

某49 歲男性病人因慢性腎絲球腎炎致尿毒症，於⾎液透析五年後接受由親妹妹捐贈腎臟的腎臟移植⼿術，但於移植⼿術三個月後發生尿量減少及⾎清肌酸酐上升(1.1mg/dL -> 2.9 mg/dL),在超⾳波排除無血管或尿道問題後，腎臟穿刺病理如圖(A、B、C) 顯⽰C4d之螢光免疫染色為陽性，請問最好如何處置？ (請選出所有適當組合的答案)




(1) Plasmapheresis
(2) Immunoglobulin infusion
(3) OKT3 monoclonal antibody
(4) Daclizumab
(5) Anti-CD20 monoclonal antibody

---

- A. (1)+(2)+(3)+(4)+(5)
- B. (1)+(2)+(3)
- C. (2)+(3)+(5)
- D. (1)+(3)+(4)
- E. (1)+(2)+(5)

### Correct Answer: E

依據腎臟移植的病史以及排除結構上的異常，需懷疑此病⼈為排斥現象，且切⽚顯⽰C4d螢光免疫染⾊為陽性，表⽰示病⼈為antibody-mediated rejection，需積極使用plasmapheresis、immunoglobulin infusions、 anti-CD20 monoclonal antibody 來治療。

(1)(2)(5) Early diagnosis of rejection allows prompt institution of therapy to preserve renal function and prevent irreversible damage. Clinical evidence of rejection is rarely characterized by fever, swelling, and tenderness over the allograft. Rejection may present only with a rise in serum creatinine, with or without a reduction in urine volume. The focus should be on ruling out other causes of functional deterioration.
Diagnostic ultrasound is the procedure of choice to rule out urinary obstruction or to confirm the presence of perirenal collections of urine, blood, or lymph. When renal function has been good initially, a rise in the serum creatinine level is the most sensitive and reliable indicator of possible rejection and may be the only sign.
Biopsy may be necessary to confirm the presence of rejection; when evidence of antibody-mediated injury is present with endothelial injury and deposition of complement component C4d is detected by fluorescence labeling, one can usually detect the antibody in recipient blood. The prognosis is poor, and aggressive use of plasmapheresis, immunoglobulin infusions, or anti-CD20 monoclonal antibody that targets B lymphocytes is indicated.

(3) Muromonab-CD3 (OKT3) directed against the CD3 molecule on the surface of human T cells can be useful in the treatment of renal transplant rejection. It is approved for the treatment of acute renal allograft rejection and steroid-resistant acute cardiac and hepatic transplant rejection.

(4) Daclizumab is a humanized IgG that binds to the alpha subunit of the IL-2 receptor. It function as IL-2 antagonists, blocking IL-2 from binding to activated lymphocytes, and is therefore immunosuppressive. Daclizumab is indicated for prophylaxis of acute organ rejection in renal transplant patients and either may be used as part of an immunosuppressive regimen that also includes glucocorticoids and cyclosporine A.

Ref:
* Harrison 18th edition. Chapter 282. Transplantation in the Treatment of Renal Failure.
* Lake DF, et al. Chapter 55. Immunopharmacology. Basic & Clinical Pharmacology, 12e.

## Question 80:

某66 歲病人因尿蛋白3+，血清白蛋白 2.9 gm/dL，BUN 27 mg/dL, Cre 1.5 mg/dL，經腎臟穿刺檢查為膜性腎病變，其病理如附圖(A、B、C、D)， 請問其腎臟病與下列何者沒有關聯？





---

- A. 梅毒
- B 型或C型肝炎
- C. 抗Phospholipase A2 receptor 抗體
- D. 抗Soluble urokinase plasminogen activator receptor 抗體
- E. 惡性腫瘤

### Correct Answer: D

Membranous nephropathy 和感染、自體免疫、癌症、藥物、以及特定疾病有關。包括梅毒、HBV、HCV、惡性腫瘤。

A&B&C&E. In 25–30% of cases, membranous nephropathy is associated with a malignancy (solid tumors of the breast, lung, colon, stomach, kidney, esophagus, neuroblastoma), infection (hepatitis B and C, syphilis, malaria, schistosomiasis, leprosy, filariasis), rheumatologic disorders (systemic lupus erythematosus, rheumatoid arthritis, primary biliary cirrhosis, dermatitis herpetiformis, bullous pemphigoid, myasthenia gravis, Sjögren's syndrome, Hashimoto's thyroiditis), drugs (gold, mercury, penicillamine, nonsteroidal anti-inflammatory agents, probenecid), or other systemic diseases (Fanconi's syndrome, sickle cell anemia, diabetes, Crohn's disease, sarcoidosis, Guillain-Barré syndrome, Weber-Christian disease, angiofollicular lymph node hyperplasia).

Ref: Harrison 18th edition. Chapter 283. Glomerular Diseases.

## Question 81:

就全世界而言，與感染相關之腎絲球炎中，最主要與最常見的為哪兩個？
(1) 瘧疾(Malaria)
(2) ⾎吸蟲(Schistosomiasis)
(3) ⼈類免疫缺陷病毒(HIV)
(4) B型肝炎
(5) C型肝炎

---

- A. (1)+(2)
- B. (3)+(4)
- C. (4)+(5)
- D. (3)+(4)
- E. (1)+(3)

### Correct Answer: A

感染相關的腎絲球腎炎主要原因為瘧疾與⾎血吸蟲，其次才是HIV、HBV、HCV。

Within Glomerular syndromes, infectious disease-associated syndrome is most important if one has an international perspective. Save for subacute bacterial endocarditis in the Western Hemisphere, malaria and schistosomiasis may be the most common causes of glomerulonephritis throughout the world, closely followed by HIV and chronic hepatitis B and C. These infectious diseases produce a variety of inflammatory reactions in glomerular capillaries, ranging from nephrotic syndrome to acute nephritic injury, and urinalyses that demonstrate a combination of hematuria and proteinuria.

Ref: Harrison 18th edition. Chapter 283. Glomerular Diseases.

## Question 82:

34 歲男性剛去東南亞旅遊兩週並承認其間有性交易行為數次，回國一週後出現小便時疼痛與尿道口有分泌物，經尿道分泌物抹片檢查有看到白血球內有格蘭氏陰性之雙球菌，請問下列者為錯誤?

---

- A. 疾病管制署規定為第三類法定傳染病
- B. FDA 已通過可用Nucleic acid amplification tests 來確定診斷
- C. 很可能同時有披衣菌之感染,故最好同時給Doxycycline或Azithromycin 來治療
- D. 此菌因高度突變性,導致其抗藥性相當高
- E. CDC不建議給予Quinolone類抗生素來治療

### Correct Answer: D

Sexual transmitted disease且為格蘭氏陰性之雙球菌，應是Gonococcal Infection

A. 是第三類法定傳染病無誤

B. As of May 2013, five manufacturers had commercially available and **FDA-cleared NAAT** assay platforms for the detection of C. trachomatis and N. gonorrhoeae in the United States.

C. 2010 STD Treatment Guidelines
**Patients infected with N. gonorrhoeae frequently are coinfected with C. trachomatis**; this finding has led to the recommendation that patients treated for gonococcal infection also be treated routinely with a regimen that is effective against uncomplicated genital C. trachomatis infection. Because most gonococci in the United States are susceptible to doxycycline and azithromycin, routine cotreatment might also hinder the development of antimicrobial-resistant N. gonorrhoeae. Limited data suggest that dual treatment with azithromycin might enhance treatment efficacy for pharyngeal infection when using oral cephalosporins.

D. Uptodate的描述
The era of antibiotic resistance began in the 1940s with the emergence of sulfonamide resistance. Subsequently, gonococcal infections were treated with penicillins, but by 1989, >5 percent of cases of gonorrhea were caused by strains that produced a plasmid-mediated beta-lactamase and >17 percent were associated with chromosomally-mediated resistance. N. gonorrhoeae has uniformly developed increasing minimum inhibitory concentrations (ie, decreasing susceptibility) to antibiotics employed for treatment, followed by frank resistance, thus progressively reducing available therapeutic options.
由此段文字判斷與突變無關，resistant strain存活下來並散布

E. CDC不建議使用，因抗藥性 Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop
resistance to antimicrobial therapies. **Quinolone-resistant N. gonorrhoeae strains are now widely disseminated** throughout the United States and the world. As of April 2007, quinolones are no longer recommended in the United States for the treatment of gonorrhea and associated conditions, such as PID. Consequently, only one class of antimicrobials, the cephalosporins, is recommended and available for the treatment of gonorrhea in the United States.

Ref:
* 疾病管制署網站
http://www.cdc.gov.tw/professional/submenu.aspx?treeid=beac9c103df952c4&now
treeid=F811D601B49E2955
* CDC 網站
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6302a1.htm 檢驗
* Uptodate
http://www.uptodate.com/contents/treatment-of-uncomplicated-gonococcal-infection
s?source=search_result&search=Gonorrhea&selectedTitle=1%7E150#H7889004

## Question 83:

20 歲男性學生其兄弟與父親的腎臟超音波檢查顯示兩側腎臟均有腎臟囊腫(Renal cysts)與血管平滑肌脂肪瘤(Angiomyolipoma)，請問下列敘述中何者為錯誤?

---

- A. 告訴學生與其父兄們須要定期超音波，電腦斷層，或核磁共振的追蹤檢查
- B. 告知其父兄其腎功能極可能會衰退到須要透析治療
- C. 當腫瘤大於三公分以上，建議最好處理掉
- D. 有可能也會有CNS的問題
- E. 有可能會有 Pheochromocytoma

### Correct Answer: B

由題文中Angiomyolipoma 此關鍵字，此疾病應為Tuberous sclerosis complex，而不是polycystic kidney disease

A. 再怎麼說這個選項也不可能是錯的

B. 此為陷阱，polycystic kidney disease才是極可能會衰退到ESRD
依據uptodate的敘述，並無提及多數病人會演變至ESRD而是某些病人。
**Some patients** develop significant renal impairment, including end-stage renal disease (ESRD), due to destruction of renal tissue related to extensive bilateral renal AMLs.

C. uptodate是寫4cm~
We generally suggest prophylactic surgery to prevent hemorrhage among patients with renal AMLs larger than 4 cm in diameter, particularly those with high vascularity and/or an aneurysm measuring ≥5 mm in diameter. However, some authors have recommended conservative management of asymptomatic renal AMLs 4 to 8 cm in diameter if close follow-up (at six months and then yearly, if stable) is feasible. If a conservative approach is chosen to follow large tumors, the patient should be instructed to seek prompt medical attention if symptoms develop and to avoid contact activities in which flank or abdominal impact is likely to occur.

D. 有可能有 brain lesion 以及seizure等等

E Tuberous sclerosis complex是Pheochromocytoma的 risk factor 因此類病人易於生tumor

Ref:
* Uptodate
http://www.uptodate.com/contents/tuberous-sclerosis-complex-genetics-clinical-feat ures-and-diagnosis?source=search_result&search=Tuberous+sclerosis+complex& selectedTitle=1%7E79#H140867425

http://www.uptodate.com/contents/renal-manifestations-of-tuberous-sclerosis-complex?source=search_result&search=Tuberous+sclerosis+complex&selectedTitle=3%7E79

## Question 84:

底下關於慢性腎臟病與 Vitamin D的敘述，何者為錯誤?

---

- A. 慢性腎臟病病人若血中 25-hydroxyvitamin D偏低，其全原因死亡率(all-cause mortality)會增加
- B. Fibroblast growth factor-23 (FGF-23)會促進腎臟磷的排泄與vitamin D的製造
- C. Vitamin D欠缺會增加罹患糖尿病，心臟病，高血壓等之機率
- D. 慢性腎臟病因Vitamin D不足，會減少副甲狀線上Vitamin D receptor而使副甲狀腺素增加
- E. Vitamin D 是在腎臟近端腎小管的1 alfa-hydroxylase將25-OH cholecalciferol 活化

### Correct Answer: B

A. 基本上這種描述也不太可能會錯

B. Fibroblast growth factor-23 (FGF-23)作用是降低vitamin D 1,25-dihydroxyvitamin D的製造，此選項中敘述的是 PTH，FGF-23 的作用uptodate敘述如下:
FGF23 inhibits renal production of 1,25-dihydroxyvitamin D limiting 1-alpha-hydroxylase activity in the renal proximal tubule and by simultaneously increasing expression of 24-alpha-hydroxylase and production of
24,25-dihydroxyvitamin D (an inactive metabolite)

C. 正確

D. 正確，PTH會促進vitamin D分泌，vitamin D會抑制PTH分泌，藉此形成負向回饋

E. 正確

Ref: Uptodate
http://www.uptodate.com/contents/overview-of-vitamin-d?source=preview&search=vitamin+d&language=en-US&anchor=H22930365&selectedTitle=2~150#H2293036
http://www.uptodate.com/contents/vitamin-d-deficiency-in-adults-definition-clinical-manifestations-and-treatment?source=see_link

## Question 85:

下列何者是突發性夜間血紅素尿中的最罕見的臨床表現?

---

- A. 後天形成的溶血性貧血(Acquired hemolytic anemia)
- B. 再生不良性貧血 (aplastic anemia)
- C. 急性骨髓性白血病(Acute myeloid leukemia)
- D. 靜脈血栓 (venous thrombosis)
- E. Hemoglobinuria and hemosiderinuria

### Correct Answer: C

paroxysmal nocturnal hemoglobinuria
C. 發生可能性最低，lifetime risk is 5 percent or less

Uptodate敘述
Some patients with PNH develop acute leukemia. The lifetime risk is 5 percent or less. The leukemia may evolve from either the PNH clone or a non-PNH clone.
Acute myeloid leukemia (AML) is most common, especially acute erythroleukemia (M6 in the French American British [FAB] classification). Some reports have suggested that AML arose from an abnormal PNH clone. Lymphoid leukemias have also been reported.

Harrison’s Ch. 106敘述
The natural history of PNH can extend over decades. Without treatment, the median survival is estimated to be about 8–10 years. In the past, the **most common** cause of death has been **venous thrombosis**, followed by infection secondary to severe neutropenia and hemorrhage secondary to severe thrombocytopenia. **PNH may evolve into aplastic anemia (AA)**, and PNH may manifest itself in patients who previously had AA. **Rarely (estimated 1–2% of all cases), PNH may terminate in acute myeloid leukemia**.
**The most consistent blood finding is anemia**, which may range from mild to moderate to very severe. The anemia is usually normo-macrocytic, with unremarkable red cell morphology; if the MCV is high, it is usually largely accounted for by reticulocytosis, which may be quite marked (up to 20%, or up to 400,000/L). The anemia may become microcytic if the patient is allowed to become iron-deficient as a result of chronic urinary blood loss through hemoglobinuria. Unconjugated bilirubin is mildly or moderately elevated, LDH is typically markedly elevated (values in the thousands are common), and haptoglobin is usually undetectable. All these findings make the diagnosis of HA compelling.
**Hemoglobinuria, the telltale sign of intravascular hemolysis**, may be overt in a random urine sample. If it is not, it may be helpful to obtain serial urine samples, since hemoglobinuria can vary dramatically from day to day, and even from hour to hour

Ref: Uptodate
http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-paroxysmal-nocturnal-hemoglobinuria?source=search_result&search=paroxysmal+nocturnal+hemoglobinuria&selectedTitle=1%7E52#H17

## Question 86:

關於糖尿病人顯微尿蛋白出現之意義,下列何者為錯誤?

---

- A. 顯微尿蛋白的出現, 代表腎絲球超高過濾(glomerlar hyperfiltration)已經存在並從此開始衰退
- B. 顯微尿蛋白的出現, 代表病人發生心血管疾病之罹病或死亡機率已經增加
- C. 顯微尿蛋白的出現, 代表至少有五成以上的病人其眼底有糖尿病視網膜病變
- D. 顯微尿蛋白之出現, 並不具遺傳性.
- E. 顯微尿蛋白的出現, 代表至少有五成以上的病人有高血壓

### Correct Answer: D

Microproteinuria，當作是DM nephropathy progression 的一項指標
A. 依據uptodate描述glomerlar hyperfiltration 存在於DM early course，故A 正確
Elevations in the glomerular filtration rate (GFR) are seen early in the course in many patients with diabetes mellitus

B. Both microalbuminuria and macroalbuminuria in individuals with DM are associated with increased risk of cardiovascular disease.

C 正確，Individuals with diabetic nephropathy **commonly** have diabetic retinopathy.

D. DM 並非完全不具遺傳性，One known risk factor is a family history of diabetic nephropathy.

E. 正確，hypertension more **commonly** accompanies microalbuminuria or macroalbuminuria in type 2 DM.

基本上，Harrison’s 並沒有提到確切比例會發生retinopathy 與hypertension

Ref:
* Harrison 18th edition,Ch. 344
* Uptodate
http://www.uptodate.com/contents/mechanisms-of-glomerular-hyperfiltration-in-diabetes-mellitus

## Question 87:

關於心腎症候群的敘述,下列何者為錯誤?

---

- A. 心腎症候群很少發生在左心室收縮功能正常的病人
- B. 心臟衰竭病人可能因腎靜脈壓力增加, 致使腎絲球過濾率下降
- C. 心臟衰竭病人抗利尿激素(Anti-diuretic hormone,ADH)分泌增加
- D. 慢性腎臟病中維他命D的缺乏會造成心肌肥厚
- E. 心臟衰竭病人血液中 adenosine上升,會造成腎絲球過濾率下降, 鈉回收增加

### Correct Answer: A

A. Cardiorenal syndrome major factors: neurohumoral adaptations, reduced renal perfusion, increased renal venous pressure, and right ventricular dysfunction，左心室功能正常與否與是否心腎症候群無關

B. 病理機制無誤

C. 病理機制無誤

D. **Administration of activated forms of vitamin D to patients with end-stage renal disease and secondary hyperparathyroidism has resulted in decreased left ventricular hypertrophy** along with a decrease in
cardiovascular mortality.

Ref: Robert U. Simpson, et al. Circulation. Selective Knockout of the Vitamin D Receptor in the Heart Results in Cardiac Hypertrophy- Is the Heart a Drugable Target for Vitamin D Receptor Agonists?

E. Adenosine-A1 receptors are found in afferent arterioles, juxtaglomerular cells, the proximal tubule, and thin limbs of Henle, and **GFR and urine output could improve by countering the effects of adenosine. Indeed, adenosine concentrations are increased in patients with HF**. 反之adenosine有保鈉功能.

Ref:
* Jeremy S Bock, et al. Circulation. Cardiorenal Syndrome.
* Gottlieb SS, et al. Circulation. 2002; 105: 1348–1353. BG9719 (CVT-124), an A adenosine receptor antagonist, protects against the decline in renal function observed with diuretic therapy.
* Uptodate
http://www.uptodate.com/contents/cardiorenal-syndrome-definition-prevalence-diagnosis-and-pathophysiology?source=search_result&search=cardiorenal+syndrome&selectedTitle=1%7E10

## Question 88:

某30 歲女性因高血壓(BP 210/130 mmHg)與低血鉀(K =2.8 mmol/L), 動脈血氣體分析為pH 7.45, PaCO2 53mmHg , HCO3 32.7mEq/L. 其基準的血漿腎素活性(Plasma renin activity, PRA 0.07 ng.mL/hr); 血漿留鹽激素(Plasma aldosterone; PA 43.7 ng/mL);經四小時二公升生理鹽水輸注後: PRA 為0.2 ng/mL/hr, PA 為19 ng/mL);請問最可能之診斷為何?

---

- A. Diuretic use
- B. Congenital adrenal hyperplasia
- B. Primary aldosteronism
- D. Cushing syndrome
- E. Licorice ingestion

### Correct Answer: C

正常濃度
Renin: 1 to 4 ng/mL per h
Aldosterone: 5 to 30 ng/dL (140 to 830 pmol/L)
依照uptodate flow chart，正解為C


## Question 89:

(100考古)下列有關心內膜炎(Infective Endocarditis)的說法，何者是錯誤的？

---

- A. 先進國家的心內膜炎近年增多，因非法使用禁藥、多用心內器械(intracardiac device)、增加退化性心瓣膜病人、及醫護相關的感染病也增多
- B. 贅生物(vegetation)集血小板、纖維素、病菌及少數的發炎細胞，多見於低壓腔室的心臟結構
- C. 口腔、胃腸息肉或憩室(diverticuli)常是鏈球菌株的來源，而大腸球菌(enterococci)常來自泌尿道
- D. 社區感染心內膜炎多因草綠色鏈球菌(viridans streptococci)、staphylococci及HACEK病菌而起
- E. 食道超音波心圖檢查可提高心內膜炎的診斷

### Correct Answer: A

A. 依據uptodate的敘述，IE的epidemiology 並不明確
The precise incidence of IE is difficult to ascertain because case definitions have varied over time, between authors and between clinical centers.

B. 正確
A mature vegetation consisting of an amorphous collection of fibrin, platelets, leukocytes, red blood cell debris, and dense clusters of bacteria Vegetations tend to occur when blood travels from an area of high pressure through a narrow orifice into an area of lower pressure. The explanation for this phenomenon can be deduced from in vitro experiments that demonstrate the physics of turbulent flow.

C. 正確
Streptococcus bovis originates from the gastrointestinal tract, where it is associated with polyps and colonic tumors, and enterococci enter the bloodstream from the genitourinary tract.

D. 正確
Microbiology: A variety of microorganisms can cause infective endocarditis (IE); staphylococci and streptococci account for the majority of cases.
Staphylococcal IE is a common cause of healthcare-associated IE; streptococcal IE is a common cause of community-acquired IE.
Among 2781 patients with IE in a large cohort, the distribution of pathogens was as follows: S. aureus(31%), Viridans group streptococci(17%), Enterococci(11%), Coagulase-negative staphylococci(11%), Streptococcus bovis(7), Other streptococci(5%), Non-HACEK gram-negative bacteria(2%), Fungi(2%), HACEK(2%).

*HACEK: include a number of fastidious gram-negative bacilli, e.g. Haemophilus aphrophilus (subsequently called Aggregatibacter aphrophilus and Aggregatibacter paraphrophilus); Actinobacillus actinomycetemcomitans (subsequently called Aggregatibacter actinomycetemcomitans); Cardiobacterium hominis; Eikenella corrodens; and Kingella kingae

E. 正確
The sensitivity of TEE is substantially higher than the values achieved with the transthoracic approach (92 versus 62 percent in the seven studies mentioned above). A similar difference was noted in five studies that compared the sensitivity of the two methods for detecting definite vegetations as defined below (93 versus 46 percent); the specificity was not different (96 versus 95 percent).

Ref: Uptodate
http://www.uptodate.com/contents/epidemiology-risk-factors-and-microbiology-of-infective-endocarditis?source=search_result&search=infective+endocarditis&selectedTitle=3%7E150
http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-infective-endocarditis?source=search_result&search=infective+endocarditis&selectedTitle=1%7E150
http://www.uptodate.com/contents/role-of-echocardiography-in-infective-endocarditis?source=see_link#H11

## Question 90:

(100考古)下列關於MDR-TB 的敘述哪一個不正確？

---

- A. MDR-TB 指至少對isoniazid 及rifampicin 具抗藥性的患者
- B. MDR-TB 的病患以一開始即感染具抗藥性的菌株為最常見的原因
- C. 至少需使用4種有效的藥物治療18個月以上，且需會診具治療多重抗藥結核有經驗的醫師
- D. 病患不規則服藥、服藥期間不足即自行停藥是造成MDR-TB 的原因之一
- E. 對於 MDR-TB 病人之親密接觸者，isoniazid 不適用於治療潛伏期結核菌感染(latent tuberculosis)

### Correct Answer: B

A. 正確
Drug-resistant tuberculosis (MDR-TB), defined as resistance to at least isoniazid and rifampin (also known as rifampicin in many countries)
Ref: Murray and Nadel's Textbook of Respiratory Medicine, 5th ed.: Mycobacteria.

B&D. 發生抗藥性主要是病人服藥compliance 差為主要原因，此選項錯誤
抗藥性結核病是結核病治療失敗的重要因素之一，發生抗藥性的原因很多，除了少部分病患是因為直接被具有抗藥性的結核菌株感染致病以外，大部分是人為因素所造成，主要為病患的服藥順從性、處方錯誤、藥物供應不規律、藥物品質不良及個案管理不佳等。發生因素尤其是和病患的服藥順從性與規律性關聯性最大。
Ref: 行政院衛生署疾病管制局九十八年度自行研究計畫,計畫編號：DOH98-DC-2025

C. 正確
抗藥（尤其是多重抗藥）結核病人必須使用含二線藥物的特殊處方，至少應使用4種已知有效或推定有效（按：指經藥敏試驗確定有效，或雖未經藥敏試驗鑑定，但病人從未用過的新藥）的結核藥物，治療至少18個月。必須採行以病人為中心直接觀察治療的措施來確保服藥順服度。同時必須照會對治療多重抗藥結核病有經驗的專家協助診治。
Ref: 行政院衛生署疾病管制局

E. 正確
曾經接觸過抗藥結核病個案的患者（如抗藥性結核病個案的家屬）如不幸發病時很可能具有抗藥性。如果多重抗藥性的可能性極高，應送 INH/RMP 藥物感受性快速測試,可在 3~5 日(cid:0)取得報告，不要等待傳統的藥物感受性試驗的結果取得後,才增加使用治療的藥物。
Ref: 行政院衛生署疾病管制局

## Question 91:

(100考古)下列關於diarrhea之敘述，何者正確？

---

- A. 檢查大便中的fat乃是篩檢malabsorption最佳方式
- B. Malabsorption患者一定會有diarrhea
- C. Non-inflammatory chronic watery diarrhea中，secretory diarrhea於fasting後會停止
- D. Irritable bowel syndrome患者之diarrhea於fasting後會持續
- E. 對severe diarrhea患者，應儘快給予opiates藥物治療

### Correct Answer: A

A. Most, but not all, malabsorption syndromes are associated with steatorrhea, an increase in stool fat excretion of >6% of dietary fat intake.

B. 不一定，根據 uptodate整理之表格


C. The secretory diarrhea is characterized clinically by watery, large-volume fecal outputs that are typically painless and persist with fasting.

D. Nocturnal diarrhea does not occur in IBS. Diarrhea may be aggravated by emotional stress or eating. The appearance of the disorder for the first time in old age, progressive course from time of onset, persistent diarrhea after a 48-h fast, and presence of nocturnal diarrhea or steatorrheal stools argue against the
diagnosis of IBS.

E. In moderately severe nonfebrile and nonbloody diarrhea, antimotility and antisecretory agents such as loperamide can be useful adjuncts to control symptoms. Such agents should be avoided with febrile dysentery, which may be exacerbated or prolonged by them.

Ref:
* Harrison 18th edition, Ch.40, 294, 296

## Question 92:

(100考古)有一位65 歲男性, 懷疑腎結石, 接受IVU ( intravenous urography) 檢查, 第三天發現BUN由33 mg/dL升至60 mg/dL, 血中creatinine由2.1 mg/dL升至4.6 mg/dL, 下列描述何者正確？

---

- A. 顯影劑乃由血管擴張之機轉導致腎損傷.
- B. 心臟衰竭（congestive heart failure）病人較容易發生此併發症
- C. 顯影劑之劑量與腎損傷之程度通常無關.
- D. 顯影劑可經過 reactive oxygen species 之機轉, 主要傷害腎小球（glomerular cells).
- E. 通常為不可逆性, 大約2 星期後進展至需透析治療

### Correct Answer: B

A.
(1) hypoxia in the renal outer medulla due to perturbations in renal microcirculation and occlusion of small vessels;
(2) cytotoxic damage to the tubules directly or via the generation of oxygen free radicals, especially since the
concentration of the agent within the tubule is markedly increased; and
(3) transient tubule obstruction with precipitated contrast material.

B. More severe, dialysis-requiring AKI is uncommon except in the setting of significant preexisting chronic kidney disease, often in association with congestive heart failure or other coexisting causes for ischemia-associated AKI.

C.如A.顯影劑劑量越高，血中濃度越高，越易發生腎損傷

D.如A，主要傷害腎小管與腎臟小血管

E. beginning 24–48 hours following exposure, peaking within 3–5 days, and resolving within 1 week.

Ref: Harrison 18th edition, Ch.279

## Question 93:

(99考古)下列有關皮膚軟組織感染的敘述何者為非？

---

- A. 在台灣，致病菌 Klebsiella pneumoniae的比例比歐美國家高出許多
- B. 壞死性筋膜炎是沿著 fascia 快速蔓延的一種皮膚及皮下組織感染，死亡率可達26%
- C. 壞死性筋膜炎的治療需要儘早的手術清創及有效的抗生素治療
- D. 發生在肢體的壞死性筋膜炎又稱為Fournier's gangrene
- E. Primary pyomyositis 是指骨骼肌內的發炎反應並且形成膿瘍，最常見的致病菌種是 Staphylococcus aureus

### Correct Answer: D

A&B&C&E. 皆正確

D. Fournier’s gangrene consists of cellulitis involving the scrotum, perineum, and anterior abdominal wall, with mixed anaerobic organisms spreading along deep external fascial planes and causing extensive loss of skin.

Ref: Harrison 18th edition, Ch.164

## Question 94:

(99考古) 65 歲男性因倦怠、食慾不振、多尿二個月，今早昏迷來急診，6 個月前病人被診斷肺癌，身體檢查：血壓 88/60 mmHg、PR 108/min、regular，RR20/min，此外無特別異常，抽血檢查 BUN 66 mg/dL、Cr 2.9 mg/dL、Ca 13 mg/dL。經過食鹽水輸液治療後清醒，iPTH測不到，要維持血鈣正常，下列那一藥物最佳?

---

- A. Calcitonin
- B. Bisphosphonate
- C. Diuretic
- D. Prednisolone
- E. EDTA

### Correct Answer: B

A. Calcitonin 因tachyphylaxis 無法”維持”血鈣正常

C. Diuretic 病人CR2.9mg/dL效果可能不佳

D. Prednisolone只對某些癌症有用，包括multiple myeloma, leukemia, Hodgkin’s disease, breast cancer(Harrison 18th edition, Ch.353)，並不包括肺癌

E. EDTA 金屬螯合劑，不用再治療高血鈣

故最佳解為 B.雙磷酸鹽，多可持續一週以上，potancy 亦佳。

## Question 95:

(99考古)30 歲女性平常身體健康，因 2 個月來常早上無法叫醒被送來急診，身體檢查除血壓90/60 mmHg、 PR 120/min， regular、 盜汗外，無特殊異常。經葡萄糖注射恢復正常，注射前抽血檢查血糖 56 mg/dL、 insulin level 18 μU/mL ，下列那一措施在診斷上最恰當？

---

- A. 腹部電腦斷層
- B. 住院做 72 小時空腹試驗
- C. 家中葡萄糖監測
- D. 全身正子掃描
- E. 胰臟內視鏡超音波檢查

### Correct Answer: B

面對低血糖的病人要先確定有無糖尿病使用胰島素或降血糖藥，若無則需考慮有無使用藥物包括：酒精、ACEI, ARB, b blocker, quinolone antibiotics…，若無則再考慮病人有無critical illness(ex: organ failure, sepsis…)、hormone deficiency (ex: cortisol or growth hormone，這些是避免低血糖重要的荷爾蒙)、non-beta-cell tumor (ex: hepatoma, adrenocortical carcinomas, carcinoids 這些腫瘤可能產生類似胰島素的物質，而導致低血糖，故病人血中胰島素會是偏低)，當以上都被排除最後才是考慮endogenous hyperinsulinemic disorders (ex: insulinoma)，通常這類病人會發生fasting hypoglycemia 故可先住院做72 小時空腹試驗，若懷疑insulinoma(較不常見) 則可再考慮電腦斷層或是腹部超音波排除，最具有敏感性的檢查則為胰臟內視鏡超音波檢查，然而較為侵入性

Ref: Harrison 18th edition, Ch.345

## Question 96:

(99考古)手部關節侵犯的位置對一些風濕病之鑑別診斷具有不錯的價值.譬如大拇指的Carpometacarpal joint (1st CMC)之侵犯最可能的風濕病為何?

---

- A. Psoriatic arthritis
- B. Rheumatoid arthritis
- C. Osteoarthritis
- D. Pseudogout
- E. Gonococcal arthritis

### Correct Answer: C

Ref: Harrison 18th edition, Ch.331


## Question 97:

(98考古)23 歲男性患者早晨睡醒時有下背僵硬及稍微疼痛。另外，肩關節及頸部亦時常有僵硬發生，經稍微運動之後僵硬會緩解。有時走路會有兩側鼠蹊部疼痛。請問下列何種檢查對疾病的診斷最有幫助？

---

- A. Pelvis X-film (AP view)
- B. Sonogram of neck and bilateral shoulder joint areas
- C. HLA-B27
- D. C-spine X-film (AP and lateral view)
- E. Autoimmune profile

### Correct Answer: A

The widely used modified New York criteria (1984) are based on the presence of definite radiographic sacroiliitis and are too insensitive in early or mild cases. In 2009, new criteria for axial SpA were proposed by the Assessment of Spondyloarthritis International Society (ASAS). 新的criteria 包括Sacroiliitis on imaging plus 1 SpA feature以及HLA-B27 plus 2 other SpA features. 然而Harrison 有提到需要與其他原因包括腫瘤、感染、受傷等等做鑑別診斷，因此仍以 pelvis x-film為最佳解。
Ref: Harrison 18th edition, Ch.325

## Question 98:

(98考古)下列容易引發栓塞之遺傳性缺陷中，何者在台灣最常見？

---

- A. Antithrombin III deficiency
- B. Protein C deficiency
- C. Protein S deficiency
- D. FactorＶ Leiden mutation
- E. Prothrombin 20210A mutation

### Correct Answer: C

這篇多年前關於台灣的研究供參考，內文：
A further striking findingwas the high overall prevalenceof AT 111, PC and PS deficiency, i.e., 50 among 85 cases, 58.8%; the respective figures were 3 (s.s~.) had an AT HI deficiency, 16 (18.8VO)had a PC deficiency, 28 (32.9%) had a PS deficiency and 3 (3.5%) had a combined deficiency, one with AT 111 and PS deficiency, two with PC and PS deficiency

Ref: Shen MC, et al. High prevalence of antithrombin III, protein C and protein S deficiency, but no factor V Leiden mutation in venous thrombophilic Chinese patients in Taiwan. 1997

## Question 99:

(98考古) Gefitinib (Iressa)與Erlotinib (Tarceva)是二個重要的非小細胞肺癌(NSCLC, non-small cell lung cancer)的標靶藥物，對東方女性，非吸菸之腺癌(adenocarcinoma) 患者，尤其有效。以藥物基因學的觀點，此一上皮生長因子接受體 (EGFR, epidermal growth factor receptor)酪胺酸磷酸化激-(TK, tyrosine kinase)的小分子抑制劑，當「EGFR基因」產生何種變異時，很可能會表現對Gefitinib或Erlotinib 藥物之"抗藥性" (resistance)？

---

- A. L858R (第858 胺基酸位點之Lysine 被Arginine取代)
- B. L747-S752 之一段胺基酸之基因被刪除(deletion)
- C. T790M (第790 胺基酸位點之Threonine被Methionine取代)
- D. E746-A750 之一段胺基酸之基因被刪除(deletion)
- E. 以上EGFR之基因變異，均對Gefitinib或Erlotinib 具高敏感性，並無抗藥性

### Correct Answer: C


A 選項為L858R，而B和C選項皆屬於exon 19 del 之一，故皆對TKI有敏感性，唯T790M 對TKI有抗藥性

## Question 100:

(98考古)42 歲女性，突發左頸部疼痛，左臉與右側肢體麻木，左側肢體失調（dysmetria）與構音困難（dysarthria），則最有可能那一條動脈阻塞？

---

- A. 基底動脈（basilar artery）
- B. 椎動脈（vertebral artery）
- C. 前下小腦動脈（anterior inferior cerebellar artery）
- D. 後大腦動脈（posterior cerebral artery）
- E. 前脊動脈（anterior spinal artery）

### Correct Answer: B

對側肢體及同側臉麻痛，應考慮腦幹內側中風；Dysarthria，應考慮CN9 and CN10；dysmetria應考慮 lateral medullary symdrom，故綜合以上，最有可能為left vertebral artery的問題。

Ref: 外側延隨脊椎症候群(lateral meddulary syndrome)
http://www2.cmu.edu.tw/~cmcmd/ctanatomy/clinical/lateralmedullarysyndrome.html