# 內專105年_51-100

## Question 51:

有關發炎性大腸疾病 (inflammatory bowel disease) 中潰瘍性腸炎 (ulcerative colitis) 和克隆氏病 (Crohn's disease) 的敘述，何者正確 ?
1. 抽煙會增加潰瘍性腸炎的發生
2. 盲腸切除手術( appendectomy ) 可以減少潰瘍性腸炎的發生
3. 使用口服避孕藥 (oral contraceptive) 會增加克隆氏病發生
4. 除了 15-30 歲外，兩者在 60-80 歲有另一好發高峰
5. 克隆氏病女性發生機會高於男性

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

### Correct Answer: A


## Question 52:

60 歲男性一年前接受大腸鏡檢查在乙狀結腸發現一些憩室 ( diverticulum )。因為左下腹疼痛、發燒至急診處，血液檢查 WBC: 15000 /μL Seg: 88% 且腹部及骨盆腔電腦斷層並無游離空氣或膿瘍。下列何項處方較不適合此患者的治療？

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- A. penicillin / clavulanic acid
- B. cephalexin
- C. ciprofloxacin / met ronidazole
- D. piperacillin
- E. trimethoprim / sulfamethoxazole

### Correct Answer: B

1. Complicated diverticulitis includes abscess/perforation/stricture/fistula
2. Symptomatic uncompl icated dive rticular disease with confi rmation of inflammation and i nfection with i n the colon should be treated i n itially with antibiotics and bowel rest.
3. cu rrent recommended antim icrobi al coverage is **trimethoprim/sulfamethoxazole** OR **ciprofloxacin + metronidazole** OR IV **piperacillin** OR oral **penicillin/clavulanic acid** may be effective targeting aerobic **gram-negative rods and anaerobic bacteria**
4. 4. Addition of ampicillin for non-responders is recommended (for enterococcus)

校閱補充：單用 trimethoprim / sulfamethoxazole 也不能 cover anaerobic bacteria

## Question 53:

有關幽門螺旋桿菌 (Helicobacter 檢測，何者正確 ?
1. 呼氣測試 (urea breath 敏感度最高
2. 糞便抗原測試 (stool 價格最昂貴
3. 血清測試可用於殺菌後的早期追蹤
4. 服用bismuth 或 proton pump inhibitor 會使快速尿素酵素測試 (rapid urease 呈現偽陰性結果
5. 二次以上殺菌失敗後可考慮細菌培養測抗藥性

---

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

### Correct Answer: D

2: …The stool antigen test, another simple assay, is more convenient and potentially less expensive than the urea breath test but has been less accurate in some comparative studies

3: … Serology test are not used to monitor treatment success, as the gradual drop in titer of H. pylori specific antibodies is too slow to be of practical use

4.: … Non-invasive test (Serology; Urea bre ath test; Stool antigen test) are dependent on H. pylori load, their use <4 weeks after treatment may yield false negative. Furthermore, these tests are unreliable if performed within 4 weeks of intercurrent treatment with antibiotics or bismuth compounds or within 2 weeks of the discontinuation of PPI treatment.



## Question 54:

急性胰臟炎在 24 小時內有所謂的 bedside index of severity in acute pancreatitis ，簡稱 BISAP來協助嚴重度的判定。下列何項不屬於 BISAP

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- A. BUN>22mg/dL
- B. impaired mental status
- C. hemoconcentration
- D. age>60years
- E. pleural effusion

### Correct Answer: C


## Question 55:

膽結石有膽固醇結石 (cholesterol 和色素結石 (pigment兩種，下列何項不是色素結石之促發因子 (predisposing

![圖片放這]()

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- A. 老年人
- B. 懷孕
- C. 酒精性肝硬化
- D. 惡性貧血 (pernicious
- E. 慢性溶血 (chronic

### Correct Answer: B


## Question 56:

下列何項檢測主要用於 primary biliary cirrhosis

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- A. antinuclear antibody
- B. anti smooth muscle antibody
- C. antimitochondrial antibody
- D. C3/C4
- E. IgG4

### Correct Answer: C

- ANA: Type 1 autoimmune hepatitis
- Anti SM antibody: Type 1 auto immune hepatitis
- Anti LKM: Type 2 autoimmune hepatitis
- Anti mitochondrial antibody: PBC
- C3/C4: Chronic active hepatitis
- IgG4: Type 1 autoimmune pancreatitis, IgG4 related disease

## Question 57:

肝細胞癌（ hepatocellular carcin oma, HCC ）名列國人癌症十大死因前茅，其預防及治療對國人健康影響甚大。下列各項敘述，何者錯誤？

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- A. 罹患 HCC 的病人，其血中 alpha fetoprotein (AFP) 都會異常上升
- B. 定期對高危險群檢驗血中 AFP 數值是必要的
- C. 腹部超音波檢查是發現 HCC 之利器
- D. 肝硬化患者是 HCC 最高危險群
- E. 早期控制慢性Ｂ型肝炎之病情有助於預防 HCC 之發生

### Correct Answer: A

- A:
AFP is a serum tumor marker for HCC, however, it is only inc reased in approximately one half of US patients
台灣高嘉宏醫師 : 利用免疫螢光法分析，只有 82 ％大型細胞癌 (>3cm) 患者的血清甲種胎兒蛋白值會大於 20ng/mL; 而 35 ％小型肝細胞癌 (<3cm) 患者的血清甲種胎兒蛋白值為正常
（<20 ng/mL )
- B, C: Screening in high risk patients:
1. Ultrasound was more sensitive than AFP
2. Most practitioners obtain 6 monthly AFP and CT (or ultrasound) when follow high risk patient
- D:
Factors associated with an increased HCC risk


- E:
HCC risk among HBV carrier is highest in continued high level HBV replication and lower for person high level HBV DNA falls. Thus, treatment is targeted to suppressed the viral replication

## Question 58:

一位慢性肝炎患者，定期接受超音波檢查，最近一次被告知肝內疑似有一個腫瘤，想徵詢您的看法。下列有關肝內腫瘤之敘述，何者錯誤？
1. 肝內血管瘤（ hemangioma ）有惡化之可能，最好予以處理
2. 肝內水泡（ cyst ）通常不需處理
3. 腺瘤（ adenoma ）不具 hormone responsiveness
4. 局部結節增生（ focal nodular hyperplasia ）若大於 5 公分，且患者為年輕女生，未來可能會懷孕，最好予以切除
5. 肝細胞癌（ hepatocell ular carcinoma ）大多為 hypervascular
6. 轉移性肝癌（ metastatic liver cancer ）大多為 hypovascular
7. 肝內膽管癌 cholangiocarcinoma ）預後相當不錯

---

- A. 3+4+5+6
- B. 1+4+5+6
- C. 2+4+5+6
- D. 2+3+6+7
- E. 1+3+4+7

### Correct Answer: E

1: Three common benign tumors occur and all are found predominantly in women. They are hemangiomas, adenomas and focal nodular hyperplasia(FNH). Hemangiomas are most common and entirely benign. Treatment is unnecessary unless their expansion cause symptoms

3: Adenomas are associated with contraceptive hormone use. It has low potential for malignant change and 30% risk of bleeding. Therefore, on
discovery of liver mass, patients are usually advised to stop taking sex steroids, as adenoma regression may then occasionally occur

4: FNH is typically benign and no treatment is needed

7: Cholangiocarcinomas are grouped by their anatomic site of origin, as intrahepatic, hilar(or central 65%) and peripheral(or distal, ~30%). Near 30% of hilar CCC and distal CCC are resectable and survival is approximately 24 months. Unresectable (intra hepatic and 70% of hilar CCC) has poor prognosis Among all unresectable CCC, intra hepatic type has shortest survival

## Question 59:

下列有關 NSAID (Nonsteroidal Anti inflammatory Drugs) induced gastrointestinal complications 之敘述，何者錯誤？

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- A. NSAID 會抑制 prostaglandin synthesis ，因此可用 misoprostol 治療
- B. H. pylori 感染與 NSAID induced 胃部潰瘍毫無關聯
- C. 曾有胃潰瘍出血既往病史者屬於高危險群
- D. 65 歲以上老年病人使用高劑量 NSAIDs ，亦有較高風險會發生此等併發症
- E. 標準劑量 proton pump inhibitors (PPIs) 為預防此等併發症之首選

### Correct Answer: B

A,E:
The mechanism of NSAID induced disease including epithelial effect due to prostaglandin depletion. Prostaglandins play a critical role in maintaining gastroduodenal mucosal integrity and repair.


B:
The interplay between H. Pyloti and NSAIDs in pathogenesis of PUD is complex. Meta analysis supports the conclusion that each aggressive
factors are independent and synergistic

C,D:
1. Established risk factor of NSAID GI
2. Advanced age;
3. history of ulcer;
4. concomitant use of glucocorticoids;
5. High dose NSAID;
6. multiple NSAIDs;
7. concomitant use of anticoagulants,
8. clopidogrel and serious or multisystem disease

## Question 60:

一位病人因皮膚發癢而就醫 抽血檢驗之結果如下 ALT=105 U/L (<41), AST=100U/L (<37), ALP (alkaline phosphatase)=700 U/L (<104), GGT (gamma glutamyl transpeptidase)=500 U/L (<50), Bilirubin (total)=1.0 mg/dL (<1.0) 。下列敘述何者正確

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- A. Ｂ型肝炎之可能性很低 (hepatitis
- B. Ｃ型肝炎之可能性很低 (hepatitis
- C. 藥物性肝炎之可能性很低 (drug induced hepatitis)
- D. 膽汁鬱積性肝病之可能性很高 (cholestatic liver
- E. Wilson's disease 之可能性很高

### Correct Answer: D


- 根據此表 以 ALP 跟 GGT 升高為主 伴隨輕微 ALT 異常的表現是 cholestatic liver disease
- Chronic hepatitis B 或 C 就可能表現 mildly elevated serum aminotransferases (<15 times upper limit of normal)
- 表格裡可看到 D rug induced hepatitis 的肝功能異常可以用 hepatitic 或 cholestatic pattern 表現
- Wilson’s disease 主要是 hepatitic pattern.

## Question 61:

有關膽囊疾病之敘述，下列何者正確？

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- A. 無症狀之膽囊結石患者，仍應儘早予以施行膽囊切除
- B. 體外震波碎石術（ extracorporeal shock wave lithotripsy ）僅適用於治療少許病人
- C. 直徑小於 0.5 公分之多發性膽囊息肉，應加以切除
- D. 有直徑大於 3 公分之膽囊結石患者，若無症狀，不必考慮膽囊切除
- E. Choledochal cyst 並非發生膽囊癌之高風險因子

### Correct Answer: B

1. Prophylactic cholecystectomy is not indicated for most patients with asymptomatic gallstones. However, p rophylactic cholecystectomy is indicated for patients with an increased risk of gallbladder cancer Anomalous pancreatic ductal drainage , g allbladder adenomas , porcelain gallbladder , l arge gallstones (particularly if larger than 3 cm) cm)) and may have a role in the treatment of some patients with hemolytic disorders or those who are undergoing a gastric bypass

2. ESWL still has a number of limitations. Several treatment sessions are required and complete ductal clearance is not always achieved, particularly with large or intrahepatic stones.

3. The most useful predictive feature for malignancy is the size of the polyp. Polyps larger than 2 cm are almost always malignant.


4. The risk for gallbladder cancer is higher with larger gallstones (patients with stones larger than 3 cm had a 10 fold higher risk of gallbladder cancer compared with those with stones <1 cm) and longer duration of cholelithia sis (particularly over 40 years

5. Biliary cysts are associated with an increased risk of cancer, particularly cholangiocarc inoma.

## Question 62:

下列有關 gastroesophageal reflux disease (GERD) 之敘述 何者錯誤

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A. Asthma 可能是 GERD 的 extraesophageal syndrome 之一
B. 過度肥胖之 GERD 患者，減肥有助於改善其 GERD 之症狀
C. 若 GERD 已成慢性狀況，長期使用低劑量 proton pump inbihitors (PPIs) 通常需要
D. 加上 metoclopramide （如 Primperan 等）通常 有助於強化 GERD 之治療
E. Barrett's esophagus 之病人應定期接受內視鏡檢查

### Correct Answer: D

1. Clinical manifestations :
a) Esophageal: heartburn, atypical chest pain, regurgitation, water brash, dysphagia .
b) Extraesophageal: cough, asthma (often poorly controlled), laryngitis, dental erosions

2. Treatment:
a) Lifestyle: avoid precipitants, lose weight, avoid large & late meals, elevate head of bed.
b) Medical: PPI achieve relief in 80 90% (titrate to lowest dose that achieves sx control).
c) Refractory: confirm w/ pH testing: if acidic or sx corre late w/ reflux episodes → surgical fundoplication; if nl pH or no sx correlation → TCA, SSRI or baclofen.

3. Screen for Barrett s esophagus if ≥2 of the following risk factors: >50 y, male, white, chronic GERD, hiatal hernia, high BMI.

## Question 63:

一位 50 歲男性之健檢中有關肝炎病毒標記之檢驗結果如下： HBsAg (-), Anti HBs (-), Anti HBc (+), Anti HCV (+) 。下列各項敘述，何者正確 ?
1. 仍可能是Ｂ型肝炎病毒慢性感染者
2. 未曾接觸過Ｂ型肝炎病毒
3. 應儘快接受Ｂ型肝炎疫苗注射
4. 過去可能曾有 Anti HBs(+)，目前濃度已降低至測不到
5. 曾感染過Ｃ型肝炎病毒
6. Ｃ型肝炎可能已痊癒

---

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

### Correct Answer: C


1. 根據 Harrison isolated anti HBc 可能表示下列情形
a) Window period ( 也稱 gap period): HBsAg 消失而 Anti HBs 尚未出現的這段期間 見上圖
b) H epatitis B infection in the remote past: 因為 Anti HBc 存在血液中的時間比 Anti HBs 長
c) L ow level hepatitis B viremia : HBsAg below the detection threshold

2. Recent and remote HBV infections can be distinguished by determination of the immunoglobulin class of anti HBc. IgM anti HBc predominates during the first 6 months after acute infection , whereas IgG anti HBc is the predominant class of anti HBc beyond 6 months.

3. Hepatitis C:
a) Acute hepatitis = HCV RNA (+) ± Anti HCV.
b) Resolved = HCV RNA (-) ± Anti HCV.
c) Chronic = HCV RNA (+), anti HCV (+)

## Question 64:

關於 IBD (inflammatory bowel disease) 之敘述，何者錯誤？

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- A. Ulcerative colitis 患者較常有 proctitis
- B. Ulcerative colitis 患者之症狀較為 acute onset, Crohn disease 患者則較常 indolent onset
- C. Ulcerative colitis 患者較常有 enterocutaneous fistula
- D. Crohn disease 患者較常有 perianal abscess
- E. 兩者之發生皆可能涉及 genetic predisposition, immune dysregulation 及 environmental triggers

### Correct Answer: C

1. Proctitis is a condition in which when the lining tissue of the inner rectum becomes inflamed. UC is idiopathic inflammation of the colonic mucosa
2. Clinical manifestations of UC : s evere colitis (15%): progresses rapidly over 1 2 wk with ↓ Hct, ↑ ESR, fever, hypotension, >6 bloody BMs /day, distended abd absent bowel sounds
3. Complications of CD
a) Perianal disease: fissures, fistulas, perirectal abscesses (up to 30% of Pts)
b) Stricture: small bowel, postprandial abd pain; can lead to complete SBO
c) Fistulas: perianal, enteroenteric, rectovaginal, e nterovesicular, enterocutaneous
d) Abscess: fever, tender abd mass, ↑ WBC; steroids mask sx, nee d high level suspicion
e) Malabsorption: ileal disease/resection: ↓ bile acids abs → gallstones; ↓ fatty acid abs → Caoxalate kidney stones; ↓ fat soluble vitamin abs → vit D deficiency → osteopenia
4. A consensus hypothesis for IBD is that in genetically p redisposed individuals, both exogenous factors (e.g., normal luminal flora) and host factors (e.g., intestinal epithelial cell barrier function, innate and adaptive immune function ) cause a chronic state of dysregulated mucosal immune function that is furt her modified by specific environmental factors (e.g., smoking)

# Question 65:

目前對慢性Ｃ型肝炎患者之治療，下列敘述何者錯誤？

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A. 以干擾素（ interferon 為基礎之治療已非優先方式
B. 口服不含干擾素之新藥（ direct acting antiviral agents, DAA ）之治癒率大多可達九成以上
C. DAA 之療程多在 12-24 週
D. DAA 之副作用較少且輕微，病人之順從性高
E. DAA 與其它藥物很少有 drug interaction

### Correct Answer: E


1. Interferon free combination 已經成為主流 且 SVR rate 可以達到 9 成以上
2. 目前台灣有的 DAAs 處方 療程大部分為 12 至 24 週 可參閱 2017 年 2 月報告的 GI Minisymposium).
3. DAAs 還是有副作用 疲倦 、 噁心 、頭痛、皮膚癢、拉肚子、失眠 但比起傳統的 IFN 少很多 病人的順從性也增加 可參閱 2017 年 2 月報告的 GI Minisymposium).
4. DAAs 和許多藥物有 drug drug interaction 可直接搜尋 DAAs 的處方籤或參閱 2017 年 2 月報告的 GI Minisymposium). 重要的 DDI 舉例： **Amiodarone, Digoxin, statin, Anticonvulsants, Rifampin, HIV anti retrovirals, PPI, Antifungal (-azole)**
5.
## Question 66:

目前對慢性Ｂ型肝炎患者之治療，下列敘述何者錯誤？
1. Pegylated interferon (PEG interferon) alpha 2 α 已不建議使用
2. Tenofovir 及 Entecavir 是兩種被推薦優先使用之口服抗 Ｂ肝病毒藥物
3. Tenofovir 及 Entecavir 之使用不需因腎功能狀況而調整劑量
4. 對 Tenofovir及 Entecavir 之抗藥性Ｂ肝病毒出現率極低
5. 失代償性（ decompensated ）肝病患者應儘速使用 PEG interferon
6. 若病人對 Entecavir 產生抗藥性，可改用 Tenofovir

---

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

### Correct Answer: E

1. The main role of interferon is primarily treatment of young patients with well compensated liver disease who do not wish to be on long term treatment . Among HBeAg positive patients, HBV genotype A , as well as low HBV DNA and high ALT levels are predictive of response to interferon therapy.
2. Treatment for chronic HBV: 1st line is nucleo(s/t)ide analogues: entecavir or tenofovir; well tolerated & low resistance.
3. For patients with chronic HBV and reduced kidney function (creatine clearance [CrCl] <60 mL/min), tenofovir disoproxil fumarate should be avoided, if possible. For most patients, either entecavir or tenofovir alafenamide can be used . An advantage of tenofovir alafenamide over entecavir is that the dose does not need to be adjusted for renal function. However, tenofovir alafenamide should be avoided if the CrCl is <15 mL/min, given the lack of pharmacokinetic data in this populati on; for such patients, entecavir (with the dose modified for the degree of renal insufficiency) should be used
4. For patients with decompensated cirrhosis, interferon is contraindicated , and either entecavir or tenofovir should be used.
5. For those failing entecavir , we add tenofovir until the HBV DNA becomes undetectable; at that point, we discontinue entecavir and treat with tenofovir alone. Some providers switch to tenofovir without an overlap period since data suggest that monotherapy with tenofovir disoproxil fumarate has similar efficacy compared with combination therapy (ie, tenofovir disop roxil fumarate plus entecavir) entecavir). For those failing tenofovir, we add entecavir until the HBV DNA becomes undetectable; at that point, we discontinue tenofovir.

全民健保慢性B 肝抗藥株處理流程



## Question 67:

54 歲肥胖男子 (BMI 因高血壓一直控制不佳而被轉診 其降壓藥物開始有 Verapamil 、Metoprolol 、 Clonidine 後來調整成 Amlodipine 、 Atenolol 、 Valsartan 、 Doxazosin 、 Minoxidil 五種 但是血壓仍然在 160- 180/100-110 mmHg 。他常因頭痛與關節酸疼服用 Ibuprofen ，最近檢測血清肌酸酐為 2.9mg/dL ；另外有呼吸中止症候群，因配戴儀器睡覺不舒服，沒有每天接受 continuous positive airway pressure (CPAP) 治療。 為了能將血壓好好控制，請問底下處置哪些為正確？
1. 應該改用 Selective COX2 inhibitor ，對血壓較無影響。
2. 應該安排 24 小時動態血壓監測 (24 hour ambulatory blood pressure monitor) 的檢查。
3. 應該加上利尿劑之使用以及篩檢其他次發性高血壓。
4. 應該減重及強調每天使用 CPAP 治療。
5. 應該推薦做腎動脈交感神經燒灼術治療。

---

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

### Correct Answer: D

1:
All NSAIDs in doses adequate to reduce inflammation and pain can increase blood pressure in both normotensive and hypertensive individuals . The average rise in blood pressure is 3/2 mmHg but varies considerably. These effects may contribute to the increase in cardiovascular risk associated with the selective cyclooxygenase 2 (COX 2) inhibitors. The prohypertensive effect is dose dependent and probably involves inhibition of COX 2 in the kidneys, which reduces sodium excretion and increases intravascular volume所有的 NSAID 都會造成高血壓，甚至 COX2 inhibitor 造成腎臟鈉離子排出減少和血管內容積增 加是造成高血壓的機轉。

5:
在尚未排除和治療可能的次發性高血壓前，不應做腎動脈交感神經燒灼術治療

## Question 68:

63 歲男性病人兩天前接受膀胱鏡檢查，逐漸出現畏寒發燒、解尿不易、解尿疼痛、頻尿、會陰處稍微不適；體溫攝氏 38.3 度、其他生命現象穩定， Costophrenic angle 無敲擊痛、尿道口無分泌物；尿液檢查有 10 WBC/HPF 、 Nitrite 1+, Leukocyte esterase 1+ 1+；抽血檢查腎功能正常PSA 升高至 25ng/ml 。 請問底下哪些敘述是正確的？
1. 應該要做尿液與血液細菌培養
2. 因為尿液 Nitrite 呈陽性，極可能是 Pseudomonas 感染
3. 應該安排腎臟膀胱攝護腺超音 波檢查
4. 可給予口服 Fluoroquinolone 二至四週
5. 可給予口服 Nitrofuratoin 二至四週

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

### Correct Answer: B

題幹敘述的是 acute bacterial prostatitis

2:
Only members of the family Enterobacteriaceae convert nitrate to nitrite, and enough nitrite must accumulate in the urine to reach the threshold of detection.
- Enterobacteriaceae : Salmonella, Escherichia coli, Yersinia pe stis, Klebsiella, Shigella, Proteus, Enterobacter, Serratia, and Citrobacter. Pseudomonas 不屬之

4,5: Nitrofurantoin remains highly active against E. coli and most non E. coli isolates. Proteus,Pseudomonas, Serratia, Enterobacter, and yeasts are all intrinsically resistant to this drug . Nitrofurantoin does not reach significant levels in tissue and cannot be used to treat pyelonephritis Since the prostate is involved in the majority of cases of febrile UTI in men, the goal in these patients is to eradicate the prostatic infection as well as the bladder infection. A 7 to 14 day course of a fluoroquinolone or TMP SMX is recommended if the uropathogen is susceptible . If acute bacterial prostatitis is suspected, antimicrobial therapy should be in initiated after urine and blood are obtained for cultures. Therapy can be tailored to urine culture results and should be continued for 2 4 weeks. For documented chronic bacterial prostatitis, a 4 to 6 week course of antibiotics is often necessary .

- Acute bacterial prostatitis 的首選藥物是 fluoroquinolone 或 TMP SMX Nitrofurantoin 較不適合的原因可能是一部份常見的致病菌具有內生抗藥性，同時該藥的組織穿透性也不好。 Acute bacterial prostatitis 治療時間建議二到四週。

## Question 69:

58 歲男性病人有高血壓、高血脂、慢性腎臟病、痛風 近半年發作三次，最後一次為三周前，在手指、腳趾、手肘、耳朵等多處關節有 Subcutaneous tophi) 。目前抽血檢查血清肌酸酐
2.1 mg/dL(eGFR 33) 33)；尿酸 9 mg/dL 。其目前服用藥物有 Thiazide 、 Losartan 、 Amlodipine 、
Fenofibrate 、 low dose aspirin 。 請問下列哪些處置為恰當？
1. 開始使用 Allopurinol 或Febuxost at ，但須降低劑量。
2. 停用 Thiazide ，因為會加尿酸而且增加 Allopurinol 的毒性。
3. Losartan 、 Amlodipine 、 Low dose aspirin 均會促進尿酸排泄。
4. 已非急性痛風期，不必再使用Colchicine 。
5. 此病人降低尿酸之預期目標為 6 mg/dL 以下。

---

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

### Correct Answer: C

3:
Medications with uricosuric properties (Table 431e 1) include aspirin (at doses >2.0 g/d), losartan, fenofibrate, x ray contrast materials, and glyceryl guaiacolate . 應該是
high dose aspirin (>2g/d) 才會促進尿酸排泄 。Table 431e 1 有表格整理其他可降尿酸的藥物 Amlodipine 雖然未列在其中，但一些文獻搜尋是有降尿酸的效果。

4:
Colchicine anti inflammatory prophylaxis in doses of 0.6 mg one to two times daily should be given along with the hypouricemic therapy until the patient is normouricemic and without gouty attacks for 6 months or as lo ng as tophi are present .

5: Ultimate control of gout requires correction of the basic underlying defect: the hyperuricemia. Attempts to normalize serum uric acid to <300 360 μmol/L (5.0 6.0 mg/dL) to prevent recurrent gouty attacks and eliminate tophaceou s deposits.

## Question 70:

62 歲女姓，過去無高血壓或糖尿病，近五年雙手手指碰冷水會變紅紫，最近四個月逐漸出現以下症狀：面孔與手指浮腫、吞嚥不順、說話遲緩、下肢腫脹、血壓變高、呼吸急促、呼吸困難、端坐呼吸。 BP160/83 mmHg, Urine protein 3+, RBC 40 50/HPF;Hb 7.4 gm/dL,Alb 2.8 gm/dL,Cre 2.8 mg/dL( 半年前 1.2 mg/dL) 。( 如圖示 ) 請問下列何者為正確？


---

- A. 馬上住院並開始類固醇的治療。
- B. 若在發病前給予 ACE inhibitor ，即可有效地預防此病之發作。
- C. 若病人沒有出現高血壓即Normotensive)Normotensive)，其病情與預後會較好。
- D. 若病人之 autoantibody against topoisomerase I (Scl70) 呈陽性，其預後較好。
- E. 若兩年後仍無法脫離透析治療，可建議病人接受腎臟移植，因為其存活率還好且很少復發。

### Correct Answer: E

題幹所述雙手手指碰冷水會變紅紫Raynaud phenomenon, 吞嚥不順暗示esophageal dysmotility, 以及圖片中出現的sclerodactyly及telangiectasia，以及腎功能衰竭、蛋白尿等，暗示為systemic sclerosis或scleroderma。

A:
Because there is an association between glucocorticoid use and scleroderma renal crisis , prednisone should be used in high risk SSc patients only when absolutely required and at low doses (<10 mg/d). 要馬上住院沒錯，但是類固醇的使用與 scleroderma renal crisis 有相關性， SSc 的病人要使用類固醇必須要有足夠的臨床需要，且必須使用低劑量。 (Scleroderma renal crisis 的第一線治療是ACEI)

B:
ACE inhibition alone does not prevent scleroderma renal crisis , but it does reduce the impact of hypertension. 無法預防

C:
Approximately 10% of patients with scleroderm a renal crisis present with normal blood pressure. Normotensive renal crisis is generally associated with a poor outcome. 預後較差

D:
The outcome of scleroderma renal crisis is worse in patients with antibodies to topoisomerase 1 compared to those with antibod ies to RNA polymerase III. 預後較差

E:
Kidney transplantation is appropriate for those unable to discontinue dialysis after 2 years. Survival of transplanted SSc patients is comparable to that of patients with other connective tissue diseases, and recurrence o f renal crisis is rare

## Question 71:

追蹤糖尿病病人血糖控制情形的糖化血色素 (Glycosylated hemog lobin, HbA1C) HbA1C)，請問有哪些狀況會假性增高 (false high)?
1. Hemolytic anemia
2. Iron d e ficiency anemia.
3. High dose Vitamin A or C
4. Chronic kidney disease
5. Chronic liver dsease.

---

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

### Correct Answer: C

- HbA1c 的數值與紅血球的壽命及turnover rate有關。所以falsely high HbA1c通常代表紅血球處於low turnover的狀態，像是iron, vitamin B12, folate缺乏造成的貧血就會出現這種情形。

- 反之，falsely low HbA1c通常代表紅血球處於high turnover的狀態，像是溶血性貧血，以及iron, vitamin B12, folate缺乏之貧血有在接受治療的，以及打過EPO的。

- **另外，慢性腎臟病(chronic kidney disease)則可能falsely high或falsely low**

## Question 72:

關於攝護腺特定抗原 (Prostate specific PSA) 之測量與篩檢，底下何者為正確？
1. PSA 之篩檢具極佳之敏感度 ( Sensitivity )與特異性 ( Specivisity )。
2. PSA 之血中濃度跟攝護腺癌之發生機率及預後無明顯 相關。
3. PSA 之篩檢建議只在年齡 55 到 69 歲的男性，才有利多於弊。
4. PSA 之篩檢建議只在預估壽命有超過 15 年的男性才需考慮。
5. PSA 之篩檢若包括測量 free PSA ，可增加測得攝護腺癌的機率。

---

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

### Correct Answer: E

1. 以American Cancer Society的systemic review來看，若以傳統4ng/mL作為cutoff，則PSA對攝護腺癌的敏感度只有21%，對high-grade攝護腺癌敏感度只有51%。特異度則高達91%。所以PSA有很好的特異性但缺乏敏感度，此項錯誤。
2. PSA濃度與癌症發生機率有關（0-2ng/mL: 發生率<1%; 2-4ng/mL: 15%; 4-10ng/mL: 25%; >10ng/mL: 42~64%），且PSA數值偏高(>4ng/mL)的病患，預後也會比較好。故此項錯誤。
3. Uptodate原文：screening should be discussed with average-risk men beginning at the age of 50, though not with men who have a comorbidity that limits their life expectancy to less than 10 years. 後面又說：ERSPC (European Randomized Study of Screening for Prostate Cancer) initially found a screening survival benefit only among the core group of men ages 55 to 69. 故此項正確。
4. 同上，uptodate說10年，題幹說15年，沒有明顯錯誤。
5. 一篇multicenter,包含700多位病人的prospective trial顯示，只用PSA的cancer detection rate 約25%，但若加進PSA的free to total ratio<10%，則cancer detection rate 可增加到56%。故此項正確。

## Question 73:

當紫斑症 Purpura 出現時，其重要的鑑別診斷為是否 Palpable ，請問底下那些腎臟疾病出現的 purpura 是為 Palpable?
1. Uremia
2. Thrombotic thrombocytopenic purpura
3. Henoch Schon lein Purpura
4. Waldenstrom's hypergammaglobulinemic purpura 5. Polyarteritis nodosa

---

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

### Correct Answer: E

Palpable purpura 的主要成因有 vasculitic 和 embolic ( 主要是 septic emboli 造成的；若是 cholesterol 和 fat 的，則是 nonp alpable) 。本題的兩個答案 HSP 和 polyarteritis nodosa 都屬於前者。

palpable purpura 包括：
(1) Vasculitis: cutaneous small-vessel vasculitis (又稱leukocytoclastic vasculitis, LCV; Henoch- Schonlein Purpura is a subtype of acute LCV), polyarteritis nodosa

(2) Emboli: acute meningococcemia, disseminated gonococcal infection, Rocky Mountain spotted fever, Ecthyma gangrenosum.

## Question 74:

65 歲女性因腎病症候群 膜性腎病變 過去曾接受類固醇與利尿劑已有五年時間，但目前為緩解狀況，類固醇仍維持 (Prednisolone 10mg 請問關於病人骨質疏鬆方面，底下處置
那些視為恰當？
1. 類固醇劑量很低不會有影響，不必考慮停用。
2. 應該確定每天有口服足量的鈣片與維他命 D 。
3. 可考慮給予 Bisphosphonate 來預防骨折。
4. 應該不用每年安排檢測骨密度 ( DXA )之檢查
5. 如有骨質疏鬆，可考慮施打合成的副甲狀腺素。

---

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

### Correct Answer: E

1:
類固醇劑量不論多低都有影響尤其如果 >=7.5mg/ 所以應考慮停用 ; 另外 GN guideline 並未提及 MGN 有 steroid maintenance therapy 的概念 , initial Tx 如下 接受下面治療後應觀察 >6 months ( 因為 Cre, nephrotic syndrome 可能慢慢改善 , 未馬上改善不代表無效 ), 如若復發 , 考慮相同治療或 shift to calcineurin inhibitor with Steroid ( 一樣未提及 maintenance, 而用 6 月左右的 steroid)


2:
50 歲 以上成人每日至少需攝取飲食鈣量 1,200 毫克 包括必要鈣劑量 和維生素 D3 800 至1,000IU

3 & 5:
guideline如下 , 但國外建議各國應建立自己的 介入性閾值 台灣目前未建立 但題目很聰明 , 都寫可考慮 ; 目前在 steroid osteoporosis 只有 bisphosphonate and 副甲狀腺素有 evidence



4:
一般兩年一次 DXA 即可 , 但 GIOP(Glucocorticoid induced osteoporosis) 會 rapid bone loss, 要較frequent (但 guideline 未說多 frequent)


## Question 75:

30 歲男性初次參加馬拉松賽跑後不支倒地，肌肉痠疼且尿液呈棕紅色，送至急診初步檢查量得體溫為 38.8 度( 攝氏 )，血壓正常，尿液試紙檢查有潛血 2+ 但離心沉渣無紅血球，肌酸
酐 1.3mg/dL CPK 13000u/L 請問 底下敘述何者為正確？
1. 像熱中暑，因此發生急性腎衰竭機率大。
2. 必須依靠血液或尿液 myoglobin 的定量檢查才可確定是橫紋肌溶解症。
3. 其上述尿液試紙檢查結果代表可能會發生急性腎衰竭。
4. 應該積極補充大量體液，維持尿液 3ml/kg/hr ，直到尿液試紙潛血反應呈陰性。
5. 如果尿液 pH<6.5 ，一定要點滴加上 Bicarbonate 鹼化尿液。

---

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

### Correct Answer: B

1:
約15-50%橫紋肌溶解症患者會導致急性腎衰竭
2:
Myoglobin在橫紋肌溶解症時被受傷肌肉釋放出來,因不易與蛋白質結合,而自尿液排出,因此可見紅棕色尿液.但由於半衰期只有2-3小時及大量尿液排出,血液中濃度約6-8小時候就會完全回到正常範圍,且約有一半患者到院時尿液已無法用urine dipstick檢測myoglobinuria,因此不適合作為確診工具
3:
尿液試紙檢查有潛血2+表示heme pigment cast的存在,可能造成tubular obstruction AKI
4:
需大量補充isotonic saline 1-2 L/hour以避免腎衰竭,雖無確切目標,但一般建議維持尿量3ml/kg/hr直到urine CK<1000U/L或myogluria消失
5:
理論上鹼化尿液可能減少pigment cast formation, myoglobin釋放free iron, vasoconstricting F2-isoprostanes及uric acid沈積,但目前仍無足夠臨床證據顯示bicarbonate溶液會比saline更能避免橫紋肌溶解症導致的AKI. 在AKI病患要維持尿液pH>6.5是非常困難的,且可能附帶著鹼化血液的副作用導致鈣磷沈積

## Question 76:

Which patient may have the highest risk and progression of CKD

---

- A. CKD stage 1, with normal albuminuria
- B. CKD stage 3b, with normal albuminuria
- C. CKD stage 2, with severely increased albuminuria
- D. CKD stage 3a, with moderately increased albuminuria
- E. CKD stage 3, no matter the status of albuminuria, will have similar risk of CK D progression

### Correct Answer: D


## Question 77:

Systemic diseases may induce thrombotic microangiopathy in the kidney, with the pathological picture of secondary focal segmental glomerulosclerosis. Which does not belong to this category ?

---

- A. hemolytic uremic syndrome (HUS)
- B. Hepatitis B virus infection
- C. Malignant hypertension
- D. Antiphospholipid syndrome
- E. Radiation nephropathy after bone marrow transplantation

### Correct Answer: B

- Thrombotic microangiopathy (TMA) describes a pathological process of microvascular thrombosis, consumptive thrombocytopenia and microangiopathic haemolytic anaemia (MAHA), leading to end-organ ischaemia and infarction affecting particularly the kidney and brain.


- HBV相關的腎病變是membranous nephropathy (一般認為HBV不會造成TMA,除了零星的case report案例)
## Question 78:

A 38 year old woman who had been diagnosed as membranous nephropathy with heavy proteinuria (4.5 g/day). One day she presented with flank pain, tenderness, hematuria, and rapid
decline in renal function. Whi ch is the most likely diagnosis

---

- A. Renal stone with urinary tract infection
- B. Renal vein thrombosis
- C. Renal artery stenosis
- D. Malignant hypertension
- E. Thrombotic microangiopathy

### Correct Answer: B

- Nephrotic syndrome asscociated with hypercoagulation 易有靜脈血栓 ; 其中以 MGN 特別多 , 尤其 Alb<2g/dL, proteinuria>10g/day 者 , 靜脈血栓又以 renal vein thrombosis 最常見
- MN患者易發生venous thromboembolism and spontaneous vascular thrombosis, 建議serum albumin < 2.5且具其他thrombosis risk病患可prophylactic oral warfarin. 其他NOAC目前還未有足夠數據佐證. Renal vein thrombosis clinical presentations: flank pain, microscopic or gross hematuria, marked elevation of LDH, increase in renal size Gold standard diagnostic test: renal venography

## Question 79:

Several nutrients have bee n implicated to increase risk for ne phrolithiasis formation. Except ?

---

- A. Higher intake of animal protein
- B. Higher intake of potassium rich or magnesium rich food
- C. Higher sodium intake
- D. Vitamin C supplement is associated with an increased risk of calcium oxalate stone
- E. Higher consumption of sugar sweetened carbonated beverage

### Correct Answer: B

- Risk of calcium stones:
Diet: increased animal proteins, sucrose, sodium, vitamin C intake decreased K, fruit/vegetables/calcium intake

- Vitamin C 會被代謝成 oxalate ; decreased calcium intake 會使 GI 吸收 oxalate 上升而上升 calcium stone risk 喔

## Question 80:

A 48 y/o male was found to develop acute renal failure after 7 days of drug therapy. His clinical presentation s were: fever, rash, peripheral eosinophilia, and oliguric renal failure, but without proteinuria. Which statement is correct?
1. A possible etiology of acute interstitial nephritis (AIN)
2. His manifestation is compatible with nonsteroidal anti inflammatory drug (NSAID) induced AIN
3. Peripheral blood eosinophilia is common in most of AIN patients
4. Urinary eosinophils are sensitive and specific for diagnosis of AIN, therefore, this testing is highly recommended
5. Renal biopsy is generally not required for diagnosis of AIN

---

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

### Correct Answer: B

- Acute interstitial nephritis是發炎性浸潤interstitium而造成腎功能下降的疾病. 最常見是因為藥物所造成,另也有可能是來自自體免疫疾病(eg, systemic lupus erythematosus, Sjögren's syndrome, sarcoidosis)或感染(eg, Legionella, leptospirosis, and streptococcal organisms). 病史上AIN患者常有allergic-type reaction症狀,如rash (15%), fever (27%), and eosinophilia (25%), or triad of rash, fever, and eosinophilia (10%)
- 尿液檢驗：
ATN- granular and epithelial cell casts and free epithelial cells acute glomerulonephritis- red cell casts, as well as red and white cells AIN or renal atheroemboli- white cells, white cell casts w/wo eosinophiluria, 但renal atheroemboli的skin lesion為reticular (livedo reticularis) with digital infarcts.
- 最常見藥物包括:
1. Nonsteroidal anti-inflammatory agents (NSAIDs), including selective cyclooxygenase (COX)-2 inhibitors
2. Penicillins and cephalosporins
3. Rifampin
4. Antimicrobial sulfonamides, including trimethoprim-sulfamethoxazole
5. Diuretics, including loop diuretics such as furosemide and bumetanide, and thiazide-type diuretics
6. Ciprofloxacin and, perhaps to a lesser degree, other quinolones Cimetidine (only rare cases have been described with other H-2 blockers such as ranitidine)
7. Allopurinol
8. Proton pump inhibitors (PPIs) such as omeprazole and lansoprazole
9. Indinavir
10. 5-aminosalicylates (eg, mesalamine)
- 患者的症狀通常非常non-specific, 甚至是沒症狀的. Nephrotic syndrome非常少見,唯一的例外是NSAID造成的AIN (90% with proteinuria),可能還同時造成membranous nephropathy or minimal change disease.
- 患者的腎功能損傷常能找到相關藥物史,所以Biopsy並非必要,除非:
1. 患者有AIN表現(病史及尿液檢驗),卻沒有使用任何AIN藥物
2. 患者有使用AIN藥物,但尿液分析不似典型AIN (NSAID有時可造成其他AKI)
3. 有時患者不適合接受renal biopsy,會直接被投予類固醇治療,但治療效果不如預期時,需考慮biopsy
4. AIN藥物停用後腎損傷無恢復者

## Question 81:

Which statement regarding Lithium associated nephropathy is not correct ?

---

- A. Most of the patients presented as oliguric acute renal failure
- B. Prolonged (>10 20 years) lithium use, or those experienced repeated episodes of toxic lithium levels, may develop chronic tubulointerstitial nephritis
- C. The most prudent approach is to monitor lithium levels frequently and adjust dosing to avoid toxic levels
- D. In patients with significant proteinuria, ACEI or ARB treatment should be helpful
- E. typical findings on renal biopsy are interstitial fibrosis and tubular atrophy

### Correct Answer: A

Lithium造成的nephropathy最主要的危險因子為duration of lithium expose和accumulation dose. 所造成的腎損傷則程度不一,切片下可見interstitial fibrosis且程度與lithium使用時間和累計劑量相關. 腎損傷一般來說在不知不覺中進展,因造成ADH resistance增加而有nephrogenic diabetes insipidus (NDI)傾向. 嚴格監控lithium濃度是必須的,且一旦有發現有腎損傷,常是以NDI或chronic tubulointerstitial nephropathy表現,應盡可能停藥.

## Question 82:

Which statement regarding mineral metabolism in CKD is correct?
1. increased production of parathyroid hormone
2. reduced production of fibroblast growth factor 23 (FGF 23)
3. increased renal excretion of phosphate
4. reduced produce of 1,25 dihydroxyvitamin D3 [1,25(OH)2D3]
5. reduction in serum calcium

![圖片放這]()

---

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

### Correct Answer: E

CKD:
- Phospha te retention
- Decreased free ionized calcium concentration
- Decreased 1,25 dihydroxyvitamin D (calcitriol) concentration
- Increased fibroblast growth factor 23 (FGF23) concentration
- The reduced expression of vitamin D receptors (VDRs), calcium sensing receptors (CaSRs), fibroblast growth factor receptors, and klotho in the parathyroid glands
- Secondary hyperparathyroidism
-

## Question 83:

Primary glomerular diseases with reduced complement levels is:

---

- A. Cryoglobulinemia
- B. Minimal change disease
- C. IgA nephro pathy
- D. focal segmental glomerular sclerosis
- E. Wegener's granulomatosis

### Correct Answer: A

B,C,D,E complement level 為正常 但近期有 paper 指出 FSGS 會 c omplement Activation 而上升


## Question 84:

Which test has the highest sensitivity of screening renovascular hypertension ?

---

A. Duplex ultrasonography
B. Computed tomography angiography
C. Captopril renogram
D. Magnetic resonance angiography (MRA)
E. Captopril plus diuretics renogram

### Correct Answer: D

The gold standard for diagnosing renal artery stenosis is renal arteriography MR angiography is a highly sensitive technique for detecting proximal renal artery stenosis, as noted by the following studies:

- In a series of 37 patients with hypertension who underwent both MRA and digital subtraction arteriography, 12 had renal artery stenosis of at least 50 percent. Using arteriography as the gold standard, MRA had a sensitivity of 100 percent and specificity of 96 percent (one false positive) for the detection of stenosis of the main renal arteries. However, MRA missed stenosis in 9 of 12 accessory renal arteries.
- Similar findings were noted in another report of 30 patients: sensitivity of 100 percent and specificity of 71 percent for proximal renal artery stenoses of more than 50 or 75 percent occlusion

## Question 85:

For diagnosis of acute renal failure, which urinary indices indicating prerenal azotemia rather than acute tubular necrosis or obstruction ?

---

- A. Urine Na > 40 mEq/L
- B Urine osmolarity < 400
- C. Urine/plasma creatinine ratio < 20
- D. Renal failure index < 1
- E. FENa > 2%

### Correct Answer: D


- Prerenal azotemia
記憶法：身體缺水，腎臟藉由回收鈉離子、尿素(Urea)，將水一起吸回來；所以血中尿素(BUN)高、尿中鈉低；又水吸收的較鈉多，所以尿液的滲透壓高
- Intrinsic renal azotemia (Acute tubulat necorsis、ATN)
記憶法；身體缺水到引起腎臟缺血性壞死，致腎臟無法回收鈉離子、尿素、也無法吸水回身體而濃縮尿液；所以尿中高鈉，尿液滲透度低。
**口訣：Pre-renal的尿中只有鈉低，其他都高**

## Question 86:

A 52 year old man with a 20 year history of cigarette smoking is admitted to the hospital because of cough and weakness. On admission, his serum electrolyte levels are: serum [Na] 112 mEq/L; [K] 4.5 mEq/L; [Cl] 80 mEq/L ; and HCO3-, 26 mEq/L. The BUN was 8 mg/dL , serum creatinine 0.8 mg/dL and serum uric acid 3.0 mg/dL. These data are most consistent with which of the following?

---

- A. SIADH (syndrome of inappropriate antidiuretic hormone secretion)
- B. Congestive heart failu re
- C. Cirrhosis and ascites
- D. Severe salt and water depletion
- E. Adrenal insufficiency

### Correct Answer: A

**考題重點 Hyponatremia approach**
邏輯 ：由於題目未提供血糖、血脂數值，姑且當作正常因此屬於 hypotonic hyponatremia ；接著判斷 volume status ，但是因為沒有提供 PE 資訊 以及尿液檢驗 所以只能由 BUN 及 uric acid 偏低 來猜測 偏向 SIADH ，因此選項 B 、 C 、 D 可以排除（皆為 effective volume 不足， BUN 及 uric acid 應該偏高 RAAS 活化， K 應該偏低 ）；另外病患有 長期吸煙的 history ，屬於 COPD 以及 Lung cancer 的高風險族群，因此 SIADH 相較於 adrenal insufficiency 應該是機會較高的診斷。

## Question 87:

A 28 y/o young male visited your outpatient clinic with an elevated blood pressure of 148/100mmHg. He denies taking any medications, but has a family history of hypertension. His laboratory values were: [Na] 140 mEq/L, [K] 3.1 mEq/L, [Cl] 98 mEq/L, BUN 25 mg/dL, Creatinine 0.9 mg/dL, Glucose: 85 mg/dL. The arterial blood gas (ABG) test reveals: Arterial pH: 7.48, PC O2: 46 mm Hg, HCO3-: 34 mEq/L. What is the most appropriate characterization of his acid base disorder?

---

- A. Metabolic alkalosis
- B. Metabolic alkalosis and respiratory acidosis
- C. Respiratory alkalosis and metabolic acidosis
- D. Metabolic alkalosis and respir atory alkalosis
- E. Respiratory alkalosis

### Correct Answer: A

pH: 7.48 --> 偏鹼 , --> HCO3 高 metabolic alkalosis, CO2 代償 : 40 + 0.7 (34 24) = 47 ( 跟 46 文中相差不遠 ) --> Metabolic alkalosis with compensation

## Question 88:

相較於血液透析 (HD, hemodialysis)，有關腹膜透析 (PD, peritoneal 的敘述與長期合併症，何者不正確 ?

---

- A. PD 病人使用高糖透析液是為了要達到透析清除尿毒素 (uremic toxin) 的效果
- B. PD 病人容易出現 hypertriglyceridemia ，是因為使用高糖透析液
- C. 相較於血液透析 ( HD)，腹膜透析 (PD) 病人較容易發生腹膜炎 ( Peritonitis )
- D. 相較於血液透析 ( HD)，腹膜透析 (PD) 病人每日蛋白質流失量較高
- E. 相較於腹膜透析 ( PD)，血液透析 (HD) 病人較出現透析中低血壓

### Correct Answer: A

PD 的葡萄糖濃度越高越能 脫水


## Question 89:

30 歲，BMI=23，在建築工地工作的男性高血壓患者，因為已經服用四種藥物之後仍出現 180/110mmHg 的血壓前來門診。依患者所說，他從 17 歲就發現有高血壓，雖然醫師在過去給他四種控制血壓的藥物，他並沒有覺得特別不舒服。平日不常量血壓，只在偶爾發現血壓很高時從藥房加買藥物服用。門診時身體檢查沒有異常，抽血的數據如下： Na: 145mEq/L; Cl: 110mEq/L; K: 3.0mEq/L; HCO3: 30 mEq/L; Glucose: 90mg/dL。請問接下來如何處置較洽當？
(原 104 年 CV 第 22 題)

---

- A. 加第五種藥物，請患者密切追蹤血壓
- B. 測量尿液中的 VMA; metanephrines; catecholamines
- C. 安排雙側腎動脈的都卜勒超音波檢查
- D. 檢查 plasma renin activity (PRA) 與 plasma aldosterone concentration (PAC)
- E. 安排睡眠醫學檢查

### Correct Answer: D

Suspect secondary hypertension (primary hypertension 好發年齡為 25-55 years) 下表附上 TSOC的 secondary hypertension 常見的 cause. 其中病人的 data 裡面看到鈉高鉀低的情況, 與 hyperaldosteronism 相符合；另外 HCO3 30mEq/L 似乎也暗示 metabolic alkalosis, 合併 hypertension 要考慮 hyperaldosteronism, 第一步篩檢要測 PRA/PAC tests。

A 選項: 因為病人未規則服用前四種藥物所以不適合加上第五種

B 選項: 病人沒有 classic triad (headache, sweating, and tachycardia), (雖然 symptomatic 病人僅占半數); 二來也沒有 paroxysmal hypertension 的證據, 題目中也沒有看到像是 family history,
cardiomegaly/heart failure 的 hint. 雖然無法明確地 rule out 但是考試當下 D 的選項仍是較好的選擇

C 選項: 若有 renal artery stenosis, 理論上 PE 會有 bruits; (sensitivity 39-78%), 也未提及其餘的 renal dysfunction 的證據; Differential 的流程應該是先檢測 PRA, PAC 篩檢 hyperaldosteronism 後再根據 renin/aldosterone level 進一步 survey 1st or 2nd; 若確診 2nd hyperaldosteronism 才進一步排 duplex (小麻 7-8)

E 選項: Obstructive sleep apnea 主要的症狀應該是 nocturnal choking or gasping (sensitivity 52% specificity 84%), 此外的症狀有 daytime sleepiness, headache, snore 等症狀也並未被提及; PE 未發現 narrow or "crowded" airway, gas 也沒有特別提及 hypercapnia。


## Question 90:

下列關於原發性肺纖維化(idiopathic pulmonary fibrosis)的描述何者錯誤？ (原 104 年 Chest 第 18 題)

---

- A. 典型的病理變化是 usual interstitial pneumonia
- B. 典型的高解析度電腦斷層變化是週邊下肺野的蜂窩狀線條影像
- C. 典型的肺功能變化是侷限型氣體交換障礙
- D. 吸入性類固醇是藥物治療的首選
- E. 是肺臟移植的適應症之一

### Correct Answer: D

A 選項: The histopathologic pattern associated with the clinical diagnosis of IPF is referred to as "usual interstitial pneumonia" (UIP).

B 選項: The characteristic HRCT features of IPF include peripheral, bibasilar reticular opacities associated with architectural distortion, including honeycomb changes and traction bronchiectasis


C 選項: PFTs typically demonstrate a restrictive pattern, a reduced DLCO

D 選項: Systemic glucocorticoid monotherapy, combination therapy with azathioprine, prednisone, and (N) acetylcysteine are no longer part of the routine maintenance care for patients with IPF, as there is no demonstrated efficacy and they may be harmful. No medication has been found to cure IPF, but two medications, **nintedanib** (intracellular inhibitor that targets multiple tyrosine kinases) and **pirfenidone** (inhibitor for TGF-β production and TGF-β  anti-fibrosis), appear to slow disease progression.

E 選項: IPF is the the second most frequent disease (28%) for which lung transplantation is performed (first: COPD 34%);
**Criteria for placing on transplant list include the following**
1. Decline in FVC ≥10 percent during six months of follow-up
2. Decline in DLCO ≥15 percent during six months of follow-up
3. On six-minute walk test: oxygen desaturation to <88 percent or distance walked <250 meters or >50 meter decline in distance walked over six months
4. Pulmonary hypertension on right heart cath or transthoracic echocardiogram
5. Hospitalization because of respiratory decline, pneumothorax, or acute exacerbation

## Question 91:

便秘（constipation）可能發生於下列情況，何者除外？
(原 104 年 GI 第 12 題)

---

- A. Hypothyroidism
- B. 服用 Bismuth
- C. Hypocalcemia
- D. 服用 calcium channel blockers
- E. 服用 opiates

### Correct Answer: C

**選項 A**: Decreased gut motility results in constipation, one of the most common complaints of patients with hypothyroidism. When euthyroid patients who already have constipation become hypothyroid, their constipation worsens.

**選項 B**: bismuth subsalicylate 並不只是刺激腸道內水分及電解質的再吸收，還可藉由水解後的水楊酸，抑制發炎物質前列腺素合成，可當止瀉劑使用。

**選項 C**: 理論上 constipation 應該想到 hypercalcemia (GI symptoms 有 nausea, anorexia, constipation, or pancreatitis)，而 hypocalcemia 會降低 action potential 的 threshold，一般引起的是 increased neuromuscular irritability，造成 tetany, paresthesias, usually of the fingers, toes, and circumoral regions。相對於 hypercalcemia, 書上及文獻較少提到ＧＩ症狀。

**選項 D**: calcium channel blockers 阻止 Ca 進入細胞內，使細胞內 Ca 濃度降低，進而降低平滑肌收縮強度或放鬆的效果。constipation 是常見的併發症，in vitro 或是 in vivo 都有 evidence。

**選項 E**: These gastrointestinal effects arise from opioid-mediated actions on the both central nervous system (CNS) and gastrointestinal tract. Centrally, opioids agonise four receptor subtypes: μ, δ, κ, and
ORL-1 (opioid receptor-like-1). In addition to inducing analgesia, centrally acting opioids may reduce gastrointestinal propulsion, possibly by altering autonomic outflow from the CNS. Nevertheless, the high density of μ receptors in the enteric system appears to mediate most of opioid agonists’ gastrointestinal effects, by reducing bowel tone and contractility, which prolongs transit time

## Question 92:

一位 30 歲女性，過去有 IgA nephropathy 與輕度蛋白尿，定期在門診就醫。最近懷孕並出現高血壓，以下高血壓相關藥物處置，何者最不適合? (原 104 年 Nephro 第 12 題)

---

- A. 使用 methyldopa
- B. 使用 ACEI 類降低蛋白尿，預防發生 pre-eclampsia
- C. 使用 labetalol
- D. 使用 Long-acting nifedipine
- E. 使用 hydralazine

### Correct Answer: B

JNC 8 建議在 pregnancy 的病人用藥順序: labetolol (first line), nifedipine, methyldopa


ACE inhibitors, ARBs and direct renin inhibitors are contraindicated at all stages of pregnancy because they are associated with significant fetal renal abnormalities

不建議 Hydralazine 做為第一線使用

## Question 93:

病人 67 歲男性，自 7 月起有輕度咳嗽及間斷性發燒高達 38 度，坊間診所診斷為上呼吸道感染。爾後，發燒仍舊起伏變動，偶有寒顫(chillness)，並有全身倦怠及二公斤體重減輕，直到11 月才到院求診。病人僅有高血壓病史，服藥中。理學檢查：血壓，132/70 mmHg；心跳，78/分，正常律動；心臟有 Gr II/IV Systolic murmur over left lower sternum border；其他尚無異常所見。Blood cultures 送檢中。請問本病人的診斷以何項檢查最恰當? (原 103 年 CV 第 4 題)

---

- A. Cardiac MRI
- B. Chest CT
- C. Gallium Scan
- D. Transesophageal echocardiography
- E. Exploratory chest operation

### Correct Answer: D

FUO 鑑別診斷
1. Infection
2. Noninfectious Inflammatory Diseases
3. Neoplasm
4. Miscellaneous
5. Thermoregulatory Disorders

**病人已符合 IE 1major (tricuspid valve regurgitation)及 1minor (fever)的診斷，排 TEE 確認有無超音波證據證實 IE**

理論上應該要一個一個找 …..要有更多證據….而且我怎麼看都想要先驗個 TB ….而且 grade II murmur 應該不會太少見 …..阿算了
Left lower sternal border 應該是 tricuspid area ->TR ?
假設之前知道沒有但這時候出現新的 murmur，加上 FUO，應該考慮 IE 可能 Modified Duke Criteria 其實連 1major+1minor 或 3minor 的 possible IE 都湊不到 (小麻 6-12)
好…就算這時候強烈懷疑是 IE, 要來排檢查了，首選檢查項目應該是 TTE(Se 70%)，應該在 TTE negative 仍強烈懷疑 IE 的時候我們才排 TEE(Se 96%)。

其他的選項
Cardiac MRI/CT 並不做為診斷的首選，guideline 裡面反而著墨較多的 cerebral MRI 去做 early detect thromboembolic events; PET 或 FDG 也僅被拿來做為 supplement 而非第一時間診斷工具。

## Question 94:

下列關於結核性肋膜炎造成的肋膜積水生化及鏡檢之敘述何者錯誤? (原 103 年 Chest 第三題)

---

- A. lymphocyte predominant exudate
- B. adenosine deaminase>40 IU/L
- C. Interferon gamma (INF-r) >140 pg/ml
- D. mesothelial cell 的比率高
- E. smear 的 acid fast stain 陽性率 <5%

### Correct Answer: D

根據 **Harrison's Principles of Internal Medicine, 19e,Chap. 316 Disorders of the Pleura: Tuberculous Pleuritis**
The pleural fluid is an exudate with predominantly small lymphocytes. The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL).

另外根據 **Diagnosis and Treatment of Tuberculous Pleural Effusion in 2006, Chest 2007;131;880-889**
Direct examination of pleural fluid by Acid-fast staining requires bacillary densities of 10,000/mL and, therefore, detects acid-fast bacilli (AFB) in <10% of cases. Besides, The older literature suggested that 5% mesothelial cells in pleural fluid were rarely compatible with TB pleural effusions. This finding is most likely the result of chronic pleural inflammation that prevents exfoliation of mesothelial cells into pleural cavity

## Question 95:

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. 嘔吐通常發生於飯後 1 小時內，可能為 pyloric stenosis
- E. 嘔吐後腹痛消失，表示可能為 acute pancreatitis

### Correct Answer: E

根據進食時間:
1. Pyloric obstruction and gastroparesis produce vomiting within one hour of eating -(D)
2. Intestinal obstruction: Later

根據嘔吐物內容:
1. Gastroparesis: food residue ingested hours or days previously
2. Hematemesis raises suspicion of an ulcer, malignancy, or Mallory-Weiss tear
3. Feculent emesis: distal intestinal or colonic obstruction --- (C)
4. Bilious vomiting excludes gastric obstruction ---(B)
5. Emesis of undigested food: a Zenker's diverticulum or achalasia.---(A)

根據嘔吐與腹痛的關係
1. Relief of abdominal pain by emesis characterizes intestinal obstruction
2. Vomiting has no effect on pancreatitis or cholecystitis pain---(E)

## Question 96:

一位 30 歲男性，在參加喜宴後 3 小時開始發生上吐下瀉之症狀，請問最有可能與下列何種病原相關？

---

- A. Staphylococcus aureus
- B. Shigella spp.
- C. Vibrio cholera
- D. Salmonella spp.
- E. Enterohemorrhagic E.coli

### Correct Answer: A


## Question 97:

48 歲女性因健檢發現甲狀腺腫來求診，身體檢查發現病人甲狀腺呈第一度腫大，抽血檢查︰free T4 1.07 ng/dl、hsTSH 7.5μU/ml、thyroglobulin 100 ng/ml、antiTPO 400 IU/ml。下列處置及其理由何者正確？

---

- A. 病人甲狀腺機能低下即刻給予甲狀腺素補充
- B. 病人甲狀腺腫給予甲狀腺素治療
- C. 病人 antiTPO 高給予甲狀腺素治療以減少發炎
- D. 病人 thyroglobulin 高給予甲狀腺素治療
- E. 甲狀腺素治療無益，觀察即可

### Correct Answer: E

此狀況為 subclinical hypothyroidism
(normal thyroid hormone levels are maintained by a rise in TSH. Though some patients may have
minor symptoms, this state is called subclinical hypothyroidism)

There are no universally accepted recommendations for the management of subclinical hypothyroidism, but the most recently published guidelines do not recommend routine treatment when TSH levels are below 10 mU/L. It is important to confirm that any elevation of TSH is sustained over a 3-month period before treatment is given

There is a risk that patients will progress to overt hypothyroidism, particularly when the TSH level is elevated and TPO antibodies are present. If thyroxine is not given, thyroid function should be evaluated annually.

內文看來雖然有 Anti-TPO 會增加進展成 overt hypothyroidism 的機會,但並不是一定要開始治療的條件!


## Question 98:

37 歲女性為第 1 型糖尿病 19 年，因左足無法背屈 ( dorsiflex ) 來診，最近追蹤除了眼底有一些小血管瘤以外無其他併發症，體檢發現甲狀腺 2 度腫大，左足無法背屈，感覺也喪失，右下肢則為正常； 膝反射二側皆正常，下列那一項檢查最恰當?

---

- A. 甲狀腺功能檢查
- B. 神經傳導檢查
- C. 腦脊髓液蛋白電泳
- D. 腰部核磁共振
- E. 類風濕因子測定

### Correct Answer: B


**The electrodiagnostic (EDx) evaluation : nerve conduction studies (NCS) and needle electromyography (EMG).**

依據題幹敘述可診斷為 diabetic peripheral polyneuropathy
下肢末端感覺及運動障礙、無神經節分布排除 radiculopathy，不對稱分布及兩側膝反射正常排除 spinal cord 以上 lesion

Electromyography (EMG)/nerve conduction velocities (NCV) may aid diagnosis in patient with atypical clinical presentation, such as
- rapidly progressive course
- weakness (motor greater than sensory involvement)
- marked asymmetry
- upper extremity greater than lower extremity involvement

Magnetic resonance imaging of the brain and spine would be expected to be ordered rarely in this population, Unlike electrodiagnostic tests, MRI has little role in the evaluation of DSP given that it primarily evaluates the central nervous system.

## Question 99:

一位中年女性，有蛋白尿(+)， creatinine 1.8 mg/dL，倦怠，與 serum C3 level 降低。尚未做腎臟病理檢查前，最可能是以下哪一種腎炎疾病?

---

- A. Focal segmental glomerulosclerosis (FSGS)
- B. cryoglobulinemia
- C. Henoch-Schonlein purpura
- D. Wegner's granulomatosis
- E. IgA nephropathy

### Correct Answer: B

符合 C3 下降的為 Cryoglobulinemia


## Question 100:

有關僵直性脊椎炎的血液及血清學檢查數據如下，請問何者最為正確?
(1) ANA(+)
(2) ESR上升
(3) CRP 上升
(4) RF (+)
(5)Anti-CCP (-)
(6) HLA-B27(+)
(7) ANCA(+)

---

- A. 1+2+3
- B. 4+5+6
- C. 2+4+7
- D. 3+4+5
- E. 3+5+6

### Correct Answer: E

In most ethnic groups, HLA-B27 is present in 80–90% of patients. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are often, but not always, elevated.

Rheumatoid factor, anti-cyclic citrullinated peptide (CCP), and antinuclear antibodies (ANAs) are largely absent.