## Question 51:

發炎性大腸疾病(inflammatory bowel disease)包括克隆氏症(Crohn's disease 簡稱CD)和潰瘍性腸炎(ulcerative colitis 簡稱 UC)，容易有腸道以外的表現 (extraintestinal manifestation)。下列何種腸道外表現較常見於 CD？ (1)pyoderma gangrenosum (2)ankylosing spondylitis (3)primary sclerosing cholangitis (4)episcleritis (5)peripheral arthritis

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

### Correct Answer: D

詳解 解題：
UC和CD都有很多非腸道的表現，能記得大部分已經很厲害了，考官還要考那些常見於CD，這題真的考得很細。只能死背流行病學上的數據囉！以下延伸閱讀摘自哈里遜內科學。再請各位考前讀一下，增加一些印象。
延伸閱讀： 以下引用自 <Harrison’s Internal Medicine CHP 289> Up to one-third of IBD patients have at least one extraintestinal disease manifestation.

Dermatologic Erythema nodosum (EN) occurs in up to 15% of CD patients and 10% of UC patients. Attacks usually correlate with bowel activity; skin lesions develop after the onset of bowel symptoms, and patients frequently have concomitant active peripheral arthritis. The lesions of EN are hot, red, tender nodules measuring 1–5 cm in diameter and are found on the anterior surface of the lower legs, ankles, calves, thighs, and arms. Therapy is directed toward the underlying bowel disease.
Pyoderma gangrenosum (PG) is seen in 1–12% of UC patients and less commonly in Crohn's colitis. Although it usually presents after the diagnosis of IBD, PG may occur years before the onset of bowel symptoms, run a course independent of the bowel disease, respond poorly to colectomy, and even develop years after proctocolectomy. It is usually associated with severe disease. Lesions are commonly found on the dorsal surface of the feet and legs but may occur on the arms, chest, stoma, and even the face. PG usually begins as a pustule and then spreads concentrically to rapidly undermine healthy skin. Lesions then ulcerate, with violaceous edges surrounded by a margin of erythema. Centrally, they contain necrotic tissue with blood and exudates. Lesions may be single or multiple and grow as large as 30 cm. They are sometimes very difficult to treat and often require intravenous antibiotics, intravenous glucocorticoids, dapsone, azathioprine, thalidomide, intravenous cyclosporine, or infliximab.

Other dermatologic manifestations include pyoderma vegetans, which occurs in intertriginous areas; pyostomatitis vegetans, which involves the mucous membranes; Sweet's syndrome, a neutrophilic dermatosis; and metastatic CD, a rare disorder defined by cutaneous granuloma formation. Psoriasis affects 5–10% of patients with IBD and is unrelated to bowel activity. Perianal skin tags are found in 75–80% of patients with CD, especially those with colon involvement. Oral mucosal lesions, seen often in CD and rarely in UC, include aphthous stomatitis and "cobblestone" lesions of the buccal mucosa.

Rheumatologic

Peripheral arthritis develops in 15–20% of IBD patients, is more common in CD, and worsens with exacerbations of bowel activity. It is asymmetric, polyarticular, and migratory and most often affects large joints of the upper and lower extremities. Treatment is directed at reducing bowel inflammation. In severe UC, colectomy frequently cures the arthritis.

Ankylosing spondylitis (AS) occurs in about 10% of IBD patients and is more common in CD than UC. About two-thirds of IBD patients with AS express the HLA-B27 antigen. The AS activity is not related to bowel activity and does not remit with glucocorticoids or colectomy. It most often affects the spine and pelvis, producing symptoms of diffuse low-back pain, buttock pain, and morning stiffness. The course is continuous and progressive, leading to permanent skeletal damage and deformity. Infliximab reduces spinal inflammation and improves functional status and quality of life.

Sacroiliitis is symmetric, occurs equally in UC and CD, is often asymptomatic, does not correlate with bowel activity, and does not always progress to AS. Other rheumatic manifestations include hypertrophic osteoarthropathy, pelvic/femoral osteomyelitis, and relapsing polychondritis.

Ocular

The incidence of ocular complications in IBD patients is 1–10%. The most common are conjunctivitis, anterior uveitis/iritis, and episcleritis. Uveitis is associated with both UC and Crohn's colitis, may be found during periods of remission, and may develop in patients following bowel resection. Symptoms include ocular pain, photophobia, blurred vision, and headache. Prompt intervention, sometimes with systemic glucocorticoids, is required to prevent scarring and visual impairment. Episcleritis is a benign disorder that presents with symptoms of mild ocular burning. It occurs in 3–4% of IBD patients, more commonly in Crohn's colitis, and is treated with topical glucocorticoids.

Hepatobiliary

Hepatic steatosis is detectable in about half of the abnormal liver biopsies from patients with CD and UC; patients usually present with hepatomegaly. Fatty liver usually results from a combination of chronic debilitating illness, malnutrition, and glucocorticoid therapy. Cholelithiasis is more common in CD than UC and occurs in 10–35% of patients with ileitis or ileal resection. Gallstone formation is caused by malabsorption of bile acids, resulting in depletion of the bile salt pool and the secretion of lithogenic bile.

PSC shows both intrahepatic and extrahepatic bile duct inflammation and fibrosis, frequently leading to biliary cirrhosis and hepatic failure; 1–5% of patients with IBD have PSC, but 50–75% of patients with PSC have IBD. Although it can be recognized after the diagnosis of IBD, PSC can be detected earlier or even years after proctocolectomy. Most patients have no symptoms at the time of diagnosis; when symptoms are present, they consist of fatigue, jaundice, abdominal pain, fever, anorexia, and malaise. The traditional gold-standard diagnostic test is endoscopic retrograde cholangiopancreatography (ERCP) but magnetic resonance cholangiopancreatography (MRCP) is also sensitive and specific. MRCP is reasonable as an initial diagnostic test in children and can visualize irregularities, multifocal strictures, and dilatations of all levels of the biliary tree. In patients with PSC, both ERCP and MRCP demonstrate multiple bile duct strictures alternating with relatively normal segments.

The bile acid ursodeoxycholic acid (ursodiol) may reduce alkaline phosphatase and serum aminotransferase levels, but histologic improvement has been marginal. High doses (25–30 mg/kg per day) may decrease the risk of colorectal dysplasia and cancer in patients with UC and PSC. Endoscopic stenting may be palliative for cholestasis secondary to bile duct obstruction. Patients with symptomatic disease develop cirrhosis and liver failure over 5–10 years and eventually require liver transplantation. Ten percent of PSC patients develop cholangiocarcinoma and cannot be transplanted. Patients with IBD and PSC are at increased risk of colon cancer and should be surveyed yearly by colonoscopy and biopsy. Pericholangitis is a subset of PSC found in about 30% of IBD patients; it is confined to small bile ducts and is usually benign.

資料來源： <Harrison’s Internal Medicine CHP 289>

## Question 52:

急性胰臟炎的嚴重度判斷對患者處置和預後相當重要，過去的 Ranson's sign(≧3)和 APACHE II score (≧8)由於較繁瑣，目前有用 bedside index severity取而代之的趨勢，下列何者不屬於 bedside index severity of acute pancreatitis (BISAP)？

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- A. age>60years
- B. SIRS
- C. pleural effusion
- D. creatinine>2.0mg/dL
- E. impaired mental status

### Correct Answer: D

詳解 解題：
這題也是記憶題，考大家知不知道這個 index了，詳細內容請看延伸閱讀。
延伸閱讀：

資料來源：Uptodate

## Question 53:

藥物引起的肝臟傷害(drug-induced hepatic injury)，反應有direct及idiosyncratic 兩種，下列藥物何者屬於 idiosyncratic 反應？(1)oral contraceptive agents (2)acetaminophen (3)halothane (4)isoniazid (5)chlorpromazine

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

### Correct Answer: C

詳 解題：
解 Direct 和 idiosyncratic 最大的差別在於 Direct 是可以預測的且與藥物劑量相 關，至於哪些藥物屬於何者就要靠記憶了，我想出題者可能是剛好翻到了 Harrison 裡的一張表格如下。
延伸閱讀： As shown in Table 299-1, direct toxic hepatitis occurs with predictable regularity in individuals exposed to the offending agent and is dose-dependent. The latent period between exposure and liver injury is usually short (often several hours), although clinical manifestations may be delayed for 24–48 h. Agents producing toxic hepatitis are generally systemic poisons or are converted in the liver to toxic metabolites. The direct hepatotoxins result in morphologic abnormalities that are reasonably characteristic and reproducible for each toxin. In idiosyncratic drug reactions, the occurrence of hepatitis is usually infrequent (1 in 103–105 patients) and unpredictable, the response is not dose-dependent, and liver injury may occur at any time during or shortly after exposure to the drug. Adding to the difficulty of predicting or identifying idiosyncratic drug hepatotoxicity is the occurrence of mild, transient, nonprogressive serum aminotransferase elevations that resolve with continued drug use. Such "adaptation," the mechanism of which is unknown, occurs in such drugs as isoniazid, valproate, phenytoin, and HMG-CoA reductase inhibitors (statins). Extrahepatic manifestations of hypersensitivity, such as rash, arthralgias, fever, leukocytosis, and eosinophilia, occur in about one-quarter of patients with idiosyncratic hepatotoxic drug reactions; this observation and the unpredictability of idiosyncratic drug hepatotoxicity contributed to the hypothesis that this category of drug reactions is immunologically mediated. More recent evidence, however, suggests that, in most cases, even idiosyncratic reactions represent direct hepatotoxicity but are caused by drug metabolites rather than by the intact compound
資料來源： Harrison’s Internal Medicine, 17ed, CHP 299

## Question 54:

有關胃分泌(gastric secretion)的敘述，何者錯誤？

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- A. 基礎胃酸分泌量在早上最高
- B. 除胃酸外，胃可分泌 pepsinogen
- C. 鐵質和B12 的吸收與胃分泌有關
- D. somatostatin 可抑制胃酸分泌
- E. parietal cell 上有histamine, gastrin 和 acetylcholine受體

### Correct Answer: A

詳解 解題：
A選項應該是早上最低，晚上最高。這題的答案在 Harrison CHP287 的某一 個段落上都有，考官可能又剛好翻到那一頁。 延伸閱讀： Physiology of Gastric Secretion <Harrison’s Internal Medicine CH287>
Hydrochloric acid and pepsinogen are the two principal gastric secretory products capable of inducing mucosal injury. Acid secretion should be viewed as occurring under basal and stimulated conditions. Basal acid production occurs in a circadian pattern, with highest levels occurring during the night and lowest levels during the morning hours. Cholinergic input via the vagus nerve and histaminergic input from local gastric sources are the principal contributors to basal acid secretion. Stimulated gastric acid secretion occurs primarily in three phases based on the site where the signal originates (cephalic, gastric, and intestinal). Sight, smell, and taste of food are the components of the cephalic phase, which stimulates gastric secretion via the vagus nerve. The gastric phase is activated once food enters the stomach. This component of secretion is driven by nutrients (amino acids and amines) that directly stimulate the G cell to release gastrin, which in turn activates the parietal cell via direct and indirect mechanisms. Distention of the stomach wall also leads to gastrin release and acid production. The last phase of gastric acid secretion is initiated as food enters the intestine and is mediated by luminal distention and nutrient assimilation. A series of pathways that inhibit gastric acid production are also set into motion during these phases. The gastrointestinal hormone somatostatin is released from endocrine cells found in the gastric mucosa (D cells) in response to HCl. Somatostatin can inhibit acid production by both direct (parietal cell) and indirect mechanisms [decreased histamine release from enterochromaffin-like (ECL) cells and gastrin release from G cells]. Additional neural (central and peripheral) and hormonal (secretin, cholecystokinin) factors play a role in counterbalancing acid secretion. Under physiologic circumstances, these phases occur simultaneously. The acid-secreting parietal cell is located in the oxyntic gland, adjacent to other cellular elements (ECL cell, D cell) important in the gastric secretory process (Fig. 287-5). This unique cell also secretes intrinsic factor (IF). The parietal cell expresses receptors for several stimulants of acid secretion, including histamine (H2), gastrin (cholecystokinin B/gastrin receptor), and acetylcholine (muscarinic, M3). Binding of histamine to the H2 receptor leads to activation of adenylate cyclase and an increase in cyclic AMP. Activation of the gastrin and muscarinic receptors results in activation of the protein kinase C/phosphoinositide signaling pathway. Each of these signaling pathways in turn regulates a series of downstream kinase cascades, which control the acid-secreting pump, H+,K+-ATPase. The discovery that different ligands and their corresponding receptors lead to activation of different signaling pathways explains the potentiation of acid secretion that occurs when histamine and gastrin or acetylcholine are combined. More importantly, this observation explains why blocking one receptor type (H2) decreases acid secretion stimulated by agents that activate a different pathway (gastrin, acetylcholine).

The chief cell, found primarily in the gastric fundus, synthesizes and secretes pepsinogen, the inactive precursor of the proteolytic enzyme pepsin. The acid environment within the stomach leads to cleavage of the inactive precursor to pepsin and provides the low pH (<2.0) required for pepsin activity. Pepsin activity is significantly diminished at a pH of 4 and irreversibly inactivated and denatured at a pH of 7.

資料來源：<Harrison’s Internal Medicine CH287>

## Question 55:

11. 長期酗酒的患者因解黑便、吐血到急診處，內視鏡檢查結果(如圖)，下列何種處置不適合急性出血的控制？

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- A. octreotide
- B. propranolol
- C. injection therapy(sclerotherapy)
- D. transjugular intrahepatic portosystemic shunt
- E. somatostatin

### Correct Answer: B

詳解 解題：
Propranolol 應用於治療慢性 portal vein hypertension，預防EV bleeding 延伸閱讀： The medical management of acute variceal hemorrhage includes the use of vasoconstricting agents, usually somatostatin or Octreotide. Vasopressin was used in the past but is no longer commonly used. Balloon tamponade (Sengstaken-Blakemore tube or Minnesota tube) can be used in patients who cannot get endoscopic therapy immediately or who need stabilization prior to endoscopic therapy. When esophageal varices extend into the proximal stomach, band ligation is less successful. In these situations, when bleeding continues from gastric varices, consideration for transjugular intrahepatic portosystemic shunt (TIPS) should be made.
資料來源： Harrison’s Internal Medicine, 17ed, CH:302

## Question 56:

便秘（constipation）可能發生於下列情況，何者除外？

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

### Correct Answer: C

C.應該是 Hypercalcemia
延伸閱讀：

資料來源： Harrison’s Internal Medicine, 17ed, CH:40

## Question 57:

大腸的diverticular diseases 在中老年人相當常見，下列相關敘述，何者錯誤？

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- A. Diverticulitis 之典型症狀包括：左或右下腹痛、發燒及 leukocytosis
- B. 用來治療diverticulitis 之抗生素應包括對抗 aerobic gram-negative 及 gram-positive細菌
- C. Diverticulitis 急性發作期不宜做內視鏡檢查
- D. 若診斷不是很確定，abdominopelvic CT 是首選檢查工具
- E. Diverticula of colon 是血便的常見病因之一

### Correct Answer: B

詳 解題：
解 A: The clinical presentation of acute diverticulitis:
Abdominal pain is the most common complaint in patients with acute diverticulitis. The pain is usually in the left lower quadrant due to involvement of the sigmoid colon. However, patients may have right lower quadrant or suprapubic pain due to the presence of a redundant inflamed sigmoid colon or, much less commonly, right-sided (cecal) diverticulitis which has a higher incidence in Asian populations. The pain is usually constant and is often present for several days prior to presentation.
Nausea and vomiting have been reported in 20 to 62 percent of patients due to a bowel obstruction or an ileus due to peritoneal irritation.Patients may also have a low grade fever.
Hemodynamic instability with hypotension and shock are rare and are associated with perforation and peritonitis.
A tender mass is palpable in approximately 20 percent of patients due to pericolonic inflammation or a peridiverticular abscess. Patients may have localized peritoneal signs with localized guarding, rigidity, and rebound tenderness. Stool may be positive for occult blood. Change in bowel habits, with constipation reported in approximately 50 percent of patients and diarrhea in 25 to 35 percent of patients.
B: Based upon retrospective studies and clinical experience, patients with acute uncomplicated diverticulitis have generally been treated with a course of antibiotics, with the duration depending upon resolution of symptoms (7 to 10 days). However, the routine use of antibiotics for all patients may not be necessary. When antibiotic therapy is chosen, the choice of antibiotics should be based upon the gastrointestinal flora of the affected segment of bowel (principally Gram-negative rods and anaerobes, and particularly E. coli and B. fragilis). Reasonable choices include a quinolone with metronidazole, amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole with metronidazole
C:發炎時不建議做檢查避免感染惡化
D: Computed tomography (CT) findings suggestive of acute diverticulitis include the presence of localized bowel wall thickening (>4 mm), an increase in soft tissue density within the pericolonic fat secondary to inflammation or fat stranding, and the presence of colonic diverticula. The sensitivity and specificity of abdominal CT for the diagnosis of acute diverticulitis are 94 and 99 percent, respectively.
E:A選項解答中就有答案。
資料來源： Up To Date, “Clinical manifestations and diagnosis of acute diverticulitis in adults”, “Nonoperative management of acute uncomplicated diverticulitis”

## Question 58:

一位72歲男性至急診就醫，主訴為過去二周有心窩痛，6小時前有吐出咖啡色物質。他過去曾接受手術換過 mitral valve，也曾有過 transient ischemic attack，現在一直服 用warfarin。過去無肝病史。身體診察發現血壓為 170/88 mmHg，無姿勢性低血壓， 心跳為92/分，呼吸速率 17/分，體溫正常，腹部檢查在心窩處有輕微壓痛。抽血檢 查 INR=2.3 (0.8-1.2), Hb : 13 g/dL (≧ 13.2), Albumin: 3.8 (≧ 3.7) g/dL, Bilirubin (total): 0.9 (≦ 1.0) mg/dL, AST: 31U/L (≦ 31), ALT: 25U/L (≦ 41)。下列何者為最迫 切合宜之處置？

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- A. 輸注Fresh frozen plasma
- B. 輸注Vitamin K
- C. 輸注Platelet
- D. 給予預防性抗生素
- E. 安排內視鏡檢查

### Correct Answer: E

詳解 解題：曾吐coffee ground->懷疑UGI bleeding。長期服用warfarin 造成 INR prolong 更為UGI bleeding的risk factor。Vital signs 相對穩定下應該安排內視鏡檢查同時局部治療。
資料來源： UpToDate, Approach to acute lower gastrointestinal bleeding in adults

## Question 59:

一位60歲女性病人自述近 2個月有逐漸加重的活動性氣促（progressive exertional dyspnea），她並無胸痛或心悸等現象，靜止或睡覺時亦無氣促情況。身體診察僅在 胸前發現spider angiomata，其它無異常發現。抽血檢驗發現：PaO2=62 mmHg，oxygen saturation 90%，AST=110 (≦ 31)，ALT=130 (≦ 41)，Alb=3.5 (≧ 3.7) g/dL，Bil(T)=0.9 (≦ 1) mg/dL，INR=0.95 (0.8-1.2)，WBC=4500 (≧ 3500)，Platelet=103K ( > 140K)， HBsAg (-)，AntiHCV (+)。心電圖及胸部 X光皆正常。下列何種診斷最可能？

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- A. Hepatopulmonary syndrome
- B. Portopulmonary hypertension
- C. Ischemic heart disease
- D. Decompensated liver cirrhosis
- E. Idiopathic portal hypertension

### Correct Answer: A

詳解 解題：
(A) Hepatopulmonary syndrome: HPS is a complication of liver disease, especially portal hypertension. It is most commonly associated with chronic liver disease, although it has also been reported in the context of acute liver disease. The clinical features of HPS are due to both hepatic and pulmonary dysfunction. More than 80 percent of patients present with symptoms of liver disease; the remainder experience dyspnea as their initial symptom. Hypoxemia, platypnea, and orthodeoxia are characteristic findings. The diagnosis of HPS can be made when the following three abnormalities have been identified: liver disease, impaired oxygenation, and intrapulmonary vascular abnormalities (referred to as intrapulmonary vascular dilatations [IPVDs]). The liver disease is already known in most patients who undergo a diagnostic evaluation for suspected HPS. Impaired oxygenation is confirmed when an arterial blood gas demonstrates an alveolar to arterial (A-a) oxygen gradient as ≥15 mmHg or an arterial oxygen tension (PaO2) of <80 mmHg while breathing room air. IPVDs may be identified by contrast-enhanced echocardiography, technetium-99m-labeled macroaggregated albumin scanning, and pulmonary arteriography. Contrast-enhanced echocardiography is generally preferred because it is more sensitive than technetium-99m-labeled macroaggregated albumin scanning and less invasive than pulmonary arteriography.

(B) Most patients with portopulmonary hypertension (PPHTN) present with clinical evidence of portal hypertension and pulmonary symptoms due to pulmonary arterial hypertension (PAH). Patients suspected of having PAH undergo extensive diagnostic testing, which is aimed at identifying the cause of the PAH and confirming the presence of the PAH. PPHTN is confirmed when PAH exists during right heart catheterization, portal hypertension exists during hepatic vein catheterization, and an alternative cause of the PAH cannot be identified. Patients with PPHTN and reduced cardiac output due to right heart failure receive anticoagulant therapy if no contraindications exist. Anticoagulant therapy should be considered on a case by case basis for other patients with PPHTN, after carefully weighing the risks versus the benefits. When anticoagulant therapy is administered, we advocate a goal international normalized ratio (INR) of 1.5 due to the increased risk of hemorrhage in patients with chronic liver disease. Liver transplantation is a possible treatment for PPHTN. Reports describe patients with PPHTN who have successfully undergone liver transplantation with improvement or complete normalization of their PAH. Patients with PPHTN be referred for liver transplantation. In patients who have a good clinical response to advanced therapy, the timing of liver transplantation can be determined by the status of the liver disease. In patients with PPHTN, beta-blockers and transjugular intrahepatic portosystemic shunts (TIPS) are potentially harmful and, therefore, they are not indicated as treatments for PPHTN.

(C) Ischemic heart disease 較可能會有 EKG change、胸悶胸痛等症狀
(D) Decompensated liver cirrhosis 代償不全之肝硬化主要有以下的病徵：肝性腦病 變、黃疸、腹水或消化道出血。正常人的血中膽紅素小於 1.2mg/dL，當肝硬化合併 代償不全時，血中膽紅素會上升並會有皮膚黃，眼白變黃，茶色尿等徵狀。腹水及 胃食道靜脈瘤之主因為肝硬化導致的肝門脈高壓；腹水通常需要超音波檢查確定， 嚴重的腹水會造成腹部的腫脹也可能併發細菌感染稱為自發性腹膜炎。肝門脈高壓 會造成肝門脈的側支循環血管腫大，常見的是胃食道靜脈瘤，肝硬化的病人最常見 的消化道出血是胃食道靜脈瘤出血，常以吐鮮血為表現，是肝硬化的患者最常見且 有可能危及生命的併發症。
(E) The diagnostic approach in a patient suspected of having idiopathic noncirrhotic portal hypertension includes the following: laboratory tests to rule out other causes of liver disease/noncirrhotic portal hypertension, hepatic imaging to rule out portal or hepatic vein occlusion, and liver biopsy to rule out cirrhosis. The differential diagnosis includes portal hypertension due to cirrhosis of any etiology and a variety of pre-, intra-, or postsinusoidal disorders associated with portal hypertension
資料來源： UpToDate “Hepatopulmonary syndrome: Prevalence, causes, clinical manifestations, and diagnosis”,” portopulmonary hypertension”
## Question 60:

一位肝硬化病人最近發生肝性腦病變（hepatic encephalopathy）。住院後並未發現有腸胃道出血、感染及低血鉀等病情，他在家中每天於服用 lactulose 下解便約4次， 生病前亦無進食過多蛋白質。增加下列何者給病人服用，有助於預防未來再發生肝 性腦病變且不會有明顯可預期之副作用？

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- A. Dulcolax
- B. Neomycin
- C. Metronidazole
- D. Rifaximin
- E. Anticholinergic drug

### Correct Answer: D

詳解:
Nonabsorbable antibiotics are also effective for treating hepatic encephalopathy. Rifaximin is currently used most often. The dose of rifaximin is 550 mg orally twice daily or 400 mg orally three times daily. As a general rule, antibiotics are added to rather than substituted for lactulose or lactitol. However, antibiotics all cause alterations in gut flora and some are substantially more costly than nonabsorbable disaccharides. As a result, they may be best suited for patients who cannot tolerate or do not respond sufficiently to disaccharides. A meta-analysis of five randomized trials of rifaximin for hepatic encephalopathy found that it had similar efficacy to nonabsorbable disaccharides for acute and chronic hepatic encephalopathy, but was perhaps somewhat better tolerated. A randomized trial compared the combination of rifaximin and lactulose with lactulose alone in 120 patients hospitalized with overt hepatic encephalopathy. Patients were followed until they were discharged from the hospital or died. Patients who received rifaximin and lactulose were more likely than those who received lactulose alone to have complete resolution of their hepatic encephalopathy (76 versus 44 percent) and lower mortality (24 versus 49 percent). A meta-analysis of 19 trials showed that rifaximin has a beneficial effect on hepatic encephalopathy and may reduce mortality. Neomycin had been used for many years to treat hepatic encephalopathy, but studies reached variable conclusions regarding its efficacy, and there is concern over its association with ototoxicity and nephrotoxicity if used long-term. An early study found neomycin to be as effective as lactulose in 33 patients, and a subsequent randomized trial that compared neomycin with rifaximin in 49 patients with cirrhosis found that both treatments were similarly effective at reducing the neuropsychiatric signs of hepatic encephalopathy and blood ammonia levels. On the other hand, a randomized trial of 39 patients comparing neomycin at a dose of 6 g per day with placebo reported no difference in outcomes between the two treatment groups.
資料來源： UpToDate, “hepatic encephalopathy”—“oral antibiotic”

## Question 61:

下列關於acute intestinal obstruction 之敘述，何者錯誤？ (1) 初期常有陣發性 cramping mid-abdominal pain (2) Strangulation 發生時，腹痛較會固定於某一部位， 且變成持續性，也較不會 cramping (3) Colon obstruction 之腹痛較不嚴重 (4) 身體診 察時，腹部脹氣越厲害，表示其阻塞部位較可能在近端小腸處 (5) 身體診察時，聽 不到bowel sound，可排除 acute intestinal obstruction 之可能性 (6) 身體診察時，聽 不到bowel sound，表示一定是發生 adynamic (paralytic) ileus (7) Barium meal study 是判斷阻塞部位之最好方式

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

### Correct Answer: E

解題： (1)正確。
(2) Strangulation 表示腸道被箝制阻塞住，因此疼痛會固定在腸道卡住的點。
(3) Diseases affecting the proximal colon, such as cecal volvulus or adhesions, are more likely to be confused with acute small bowel obstruction compared with distal disease. In a study of patients with colonic volvulus, the most frequent symptoms were abdominal pain (58 percent) and obstipation (55 percent). Most patients with cecal volvulus presented with abdominal pain, which occurred in 89 percent of patients. The interval at which cramping pain occurs is typically longer with colonic obstruction compared with small bowel obstruction, and occurs lower in the abdomen between the umbilicus and pubic tubercle. 這個答案似乎有點爭議，用嚴重度來分似乎不洽當。
(4) In multiple retrospective reviews, abdominal distension was the most frequent physical finding on clinical examination occurring in 56 to 65 percent of patients. Although nausea and vomiting may be less severe in patients with distal small bowel obstruction compared with proximal obstruction, abdominal distention is greater because the more proximal bowel acts as a reservoir. Swallowed air and gas from bacterial fermentation can also accumulate, adding to the abdominal distention. It is important to remember, however, in patients with a closed-loop obstruction, abdominal distention can be minimal.
(5) Acute mechanical bowel obstruction is characterized by high-pitched “tinkling” sounds associated with the pain. With significant bowel distention, bowel sounds may become muffled, and as the bowel progressively distends, bowel sounds can become hypoactive.
(6) Paralytic ileus occurs to some degree after almost all open abdominal operations and can also be caused by peritonitis, trauma, intestinal ischemia, and medications (eg, opiates, anticholinergics). It is exacerbated by electrolyte disorders, particularly hypokalemia. As the intestine becomes distended, the patient experiences many of the same symptoms as mechanical obstruction. However, on radiologic examination there is air in the colon and rectum, and on abdominal computed tomography (CT) or small bowel series there is no demonstrable mechanical obstruction.
(7) For most patients, we suggest obtaining plain abdominal films to confirm a suspected diagnosis of mechanical small bowel obstruction. Findings on plain film that indicate that small bowel obstruction is present include dilated loops of bowel with air-fluid levels, proximal bowel dilation with distal bowel collapse, or a gasless abdomen. For many patients, no further radiologic tests will be needed because the films may demonstrate findings that indicate the immediate need for urgent decompression (eg, sigmoid volvulus) or surgical intervention (eg, pneumoperitoneum, cecal or midgut volvulus). Abdominal computed tomography (CT) is the imaging modality of choice for identifying the specific site (ie, transition point, small versus large bowel) and severity of obstruction (partial versus complete, or closed-loop obstruction); determining the etiology by identifying hernias, masses, or inflammatory changes; and for identifying complications (ischemia, necrosis, perforation).
資料來源： UpToDate, “Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults”

## Question 62:

下列關於Acute Appendicitis 之敘述，何者正確？
(1) 典型之腹痛是由 periumbilical/epigastric region 移行至 right lower quadrant of abdomen
(2) 常有bowel habit change
(3) 常有 anorexia
(4) 身體診察時，在右下腹沒有發現 tenderness，即可 排除acute appendicitis 之診斷
(5) psoas/obturator sign 對判斷acute appendicitis 之有 無極具價值
(6) 使用CT with contrast agent enhancement診斷acute appendicitis之準 確率（accuracy）相當高，可達90%

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

### Correct Answer: C

詳解 解題： 可先用刪去法，先刪除選項(4)，答案從(A),(B),(C)中選，(6)選項也一定對，所 以選(C)。
(1): In the classic presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is typically periumbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses.
(2),(3): classic symptoms: ●Right lower quadrant (right anterior iliac fossa) abdominal pain ●Anorexia ●Nausea and vomiting In many patients, initial features are atypical or nonspecific, and can include: ●Indigestion ●Flatulence ●Bowel irregularity ●Diarrhea ●Generalized malaise Anorexia算在典型症狀，bowel habit change算是不典型症狀。
(4)一眼就看出是錯的選項。
(5) Commonly described physical signs include: ●McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus (sensitivity 50 to 94 percent; specificity 75 to 86 percent). ●Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower quadrant. This sign is also called indirect tenderness and is indicative of right-sided local peritoneal irritation (sensitivity 22 to 68 percent; specificity 58 to 96 percent). ●The psoas sign is associated with a retrocecal appendix. This is manifested by right lower quadrant pain with passive right hip extension. The inflamed appendix may lie against the right psoas muscle, causing the patient to shorten the muscle by drawing up the right knee. Passive extension of the iliopsoas muscle with hip extension causes right lower quadrant pain (sensitivity 13 to 42 percent; specificity 79 to 97 percent). ●The obturator sign is associated with a pelvic appendix. This test is based on the principle that the inflamed appendix may lay against the right obturator internus muscle. When the clinician flexes the patient's right hip and knee followed by internal rotation of the right hip, this elicits right lower quadrant pain, (sensitivity 8 percent; specificity 94 percent). The sensitivity is low enough that experienced clinicians no longer perform this assessment. ->psoas/obturator sign 對診斷沒有到極具價值，obturator sign甚至已不建議使用。
(6)懷疑appendicitis 去掃CT已經是標準反射動作了。
Computed tomography findings — The following findings suggest acute appendicitis on standard abdominal computed tomography (CT) scanning with contrast including:
●Enlarged appendiceal diameter >6 mm with an occluded lumen ●Appendiceal wall thickening (>2 mm)
●Periappendiceal fat stranding
●Appendiceal wall enhancement
●Appendicolith (seen in approximately 25 percent of patients)
資料來源： UpToDate, “Acute appendicitis in adults: Clinical manifestations and differential diagnosis”

## Question 63:

下列關於肝臟局限性病灶（focal lesion）之敘述，何者正確？
(1) 大的cyst 若有 wall irregularity，應考慮切除之
(2) Focal Nodular Hyperplasia (FNH)有malignant potential，故應切除之 (3) 直徑5公分以上的 adenoma可能會spontaneous rupture 或演變成惡性腫瘤，故應切除之
(4) 接觸 ameba至開始有liver abscess 之臨床症狀， 其潛伏期約2-4 weeks
(5) 接受CT scan 檢查，注射顯影劑後，在血管瘤會有所謂 "fill-in"現象，即是顯影劑會隨時間從血管瘤之周邊向其中央滲入。

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

### Correct Answer: E

詳解 解題：
(1) The appearance of an MCN(Mucinous cystic neoplasm) on ultrasonography can usually differentiate it from a simple cyst. On ultrasonography, an MCN typically appears as a hypoechoic lesion with thickened, irregular walls and occasional internal echoes representing debris and wall nodularity. These findings are generally indicative of a complicated cyst, which may represent a simple cyst with previous bleeding, a neoplastic cyst such as an MCN (with or without invasive carcinoma), or rarely, a metastasis. On a computed tomography scan, an MCN appears as a low attenuation mass, which may be uni- or multilocular or may have septations. The cyst wall is usually thickened and/or irregular. This is in contrast to a simple cyst, which is typically devoid of septations and has imperceptible walls Treatment — The preferred treatment for noninvasive MCNs is resection, which should be performed whenever possible, since malignant transformation of the cyst lining has been described in as many as 15 percent of patients.
(2) Focal nodular hyperplasia is a benign liver tumor that is believed to be a hyperplastic response to an anomalous artery. Like hepatic adenoma, focal nodular hyperplasia occurs most commonly in women in their 30s and 40s. In the majority of patients, focal nodular hyperplasia is diagnosed incidentally during imaging studies or laparotomy performed for unrelated reasons. Patients who are suspected of having FNH based upon the evaluation described above should be managed conservatively.
(3) Cystic lesions of the liver represent a heterogeneous group of disorders, which differ in etiology, prevalence, and clinical manifestations. Most liver cysts are found incidentally on imaging studies and tend to have a benign course. A minority can cause symptoms and rarely may be associated with serious morbidity and mortality. Larger cysts (≥4 cm) are more likely to be symptomatic and cause complications such as spontaneous hemorrhage, rupture into the peritoneal cavity or bile duct, infection, and compression of the biliary tree.
(4) Amebic liver abscess is the most common extraintestinal manifestation of amebiasis. Amebae establish hepatic infection by ascending the portal venous system. For travelers returning from an endemic area, clinical presentation usually occurs within 8 to 20 weeks (median 12 weeks), although a longer lag (sometimes years) has been reported.
(5) A non-contrast-enhanced CT scan of a hemangioma usually demonstrates a well-demarcated hypodense mass. Calcifications are seen in approximately 10 percent of cases. Similar to ultrasound, the lesions may appear as hyperdense relative to the surrounding parenchyma in patients with fatty infiltration of the surrounding liver.
The administration of contrast results in a peripheral nodular enhancement in the early phase, followed by a centripetal pattern or "filling in" during the late phase. Peripheral nodular or globular enhancement representing venous lakes is seen in up to 94 percent of hemangiomas >4 cm in size. A pattern of globular enhancement isodense to the aorta is seen in 67 percent of hemangiomas, a feature that helps distinguish them from hepatic metastases.
資料來源： UpToDate, “A Diagnosis and management of cystic lesions of the liver”,” Extraintestinal Entamoeba histolytica amebiasis”,” Hepatic hemangioma”.

## Question 64:

目前已有Ａ型肝炎及Ｂ型肝炎疫苗，年輕一代之國人應接受之。下列相關敘述，何者錯誤？

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- A. 若母親為HBeAg (-)之Ｂ型肝炎帶原者，其新生兒應於 24小時內接受 HBIG (hepatitis B immune globulin) 注射，並於一周內完成第一劑Ｂ型肝炎疫苗注射
- B. 目前之Ｂ型肝炎疫苗，應於六個月內完成三劑注射
- C. 目前之Ａ型肝炎疫苗，應於六個月～一年內完成兩劑注射
- D. 完成三劑注射且產生 anti-HBs 後，60%以上可持續維持具保護性之濃度至少10 年
- E. 完成二劑注射且產生 anti-HAV後，應可持續維持具保護性之濃度至少20年

### Correct Answer: A

詳解可以秒殺直接看到 A選項就知道是錯的。
(A)(B)(D)母嬰間的垂直感染，是臺灣地區Ｂ型肝炎盛行的重要原因，40-50%的帶原 者是經由此途徑傳染。為截斷母嬰間的垂直傳染，孕婦應於姙娠第 12週或第1次 產檢時辦理Ｂ型肝炎產前檢查，檢驗結果若為高傳染性Ｂ型肝炎帶原者（ｓ抗原及 ｅ抗原均為陽性），其所生之嬰兒：不論出生體重亦或早產，如臨床狀況穩定，於 出生後應儘速注射 1劑Ｂ型肝炎免疫球蛋白及Ｂ型肝炎疫苗，越早越好，不要晚於 24小時。出生體重若小於 600公克，其HBIG 於出生後仍儘速接種。至於其第 1劑 Ｂ肝疫苗，建議於臨床狀況穩定且其生命安全無疑慮後再行接種。 ◎接種時程: 第1劑：出生24小內儘速接種，愈早愈好。 第2劑：出生滿1 個月。 第3劑：出生滿6 個月。 ◎新生兒完成B肝疫苗接種後可持續維持具保護性之濃度 15年到 18年。
(C)(E)接種A型肝炎疫苗為預防 A型肝炎病毒感染相當有效的方法之一。目前國內 上市的A型肝炎疫苗有兩種廠牌，均為不活化疫苗，核准的接種年齡為出生滿12 個月以上，接種劑次無論成人或兒童都是 2劑，2劑間隔至少6個月（未滿19歲每 劑疫苗的劑量是0.5 ml，而滿19歲以上的成人則是 1 ml）。接種 1劑後約95%以 上可產生保護抗體，完成 2劑後，可提升抗體效價。一般而言，免疫力約可持續 20 年。
資料來源： 衛生福利部疾病管制署專業人士版網頁--Ｂ型肝炎疫苗 (Hepatitis B)及A型肝炎疫 苗 (Hepatitis A)。 http://www.cdc.gov.tw/professional/info.aspx?treeid=5b0231beb94edffc&nowtreeid=dc 132e275cf714e3&tid=88ADC7445F7182B5 http://www.cdc.gov.tw/professional/info.aspx?treeid=5b0231beb94edffc&nowtreeid=dc 132e275cf714e3&tid=D76D08D4B13EB623

## Question 65:

在日常醫療之情況下，下列何種藥物最不會產生肝臟傷害？

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- A. 降低血中尿酸濃度的 allopurinol
- B. 退燒時使用acetaminophen（酒精成癮者除外）
- C. 治療結核病之isoniazid
- D. 治療足癬之ketoconazole 類藥物
- E. 降低血中膽固醇之 statin 類藥物

### Correct Answer: B

詳 解題：
解 -Allopurinol: Increased liver enzymes, increased serum alkaline phosphatase -Acetaminophen: Increased serum alkaline phosphatase, increased serum bilirubin -Isoniazid: Increased liver enzymes (mild, 10% to 20%), bilirubinuria, jaundice, hepatic insufficiency, hepatitis (may involve progressive liver damage; risk increases with age; 2.3% in patients >50 years), hyperbilirubinemia -Ketoconazole: Jaundice -Statin: 0.5 to 3.0% occurrence of persistent elevations in aminotransferases in patients receiving statins 這五種藥物都會有肝臟方面的 side effects，以 common sense來說，acetaminophen最 常在醫療常規上使用，像發燒是疼痛的給予。一般正常給藥不容易造成副作用，反之overdose才有機會造成副作用

延伸閱讀： The therapeutic dose of acetaminophen is 10 to 15 mg/kg per dose in children and 325 to 1000 mg per dose in adults, given every four to six hours, with a maximum recommended daily dose of 80 mg/kg in children or 4 g in adults. The toxic dose may vary among individuals according to baseline glutathione levels and other factors. Toxicity is unlikely to result from a single dose of less than 150 mg/kg in a child or 7.5 to 10 g for an adult .Toxicity is likely to occur with single ingestions greater than 250 mg/kg or those greater than 12 g over a 24-hour period. Virtually all patients who ingest doses in excess of 350 mg/kg develop severe liver toxicity. The management of acetaminophen overdose is antidotal treatment with N-acetylcysteine.

資料來源： 1. Uptodate 2. 17th Harrison pg.1951-1955

## Question 66:

一位45歲男性病人因右上腹痛及皮膚癢而就醫，抽血檢驗結果如下：ALT=60U/L (≦ 41)，AST=70U/L (≦31)，ALP=700 (≦104)，r-GT=450U/L (≦50)，Bil(T)=1.2mg/dL， Bil(D)=0.8mg/dL。住院後接受磁振造影及膽胰管攝影（MRCP, magnetic resonance cholangio pancreatography）發現肝內膽管有分布不一之狹窄及擴大現象（segmental stricture with saccular dilatation）。病人接受肝切片，其組織顯現 portal tract expansion with ductular proliferation and lymphocytic infiltration，此病人 之診斷因而已經確立。關於本病人之病情，下列各項敘述，何者錯誤？

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- A. 常合併有慢性發炎性腸道疾病（inflammatory bowel disease）
- B. 應隨時注意其是否併發 cholangiocarcinoma
- C. 高劑量 (25 mg/Kg/d) UDCA (ursodeoxycholic acid) 能有效控制其病情
- D. 若病情惡化，可考慮肝臟移植
- E. MRCP用於診斷此等病人，其準確率可達 90%
詳 解題：
解 此題目要考的疾病就是 primary sclerosing cholangitis（PSC）。

### Correct Answer: B

C 錯的原因在於 UDCA的劑量應該是 15mg/kg/day
延伸閱讀： Primary sclerosing cholangitis (PSC) is a chronic progressive disorder of unknown etiology that is characterized by inflammation, fibrosis, and stricturing of medium and large ducts in the intrahepatic and/or extrahepatic biliary tree. PSC is usually a progressive disorder that ultimately leads to complications of cholestasis and hepatic failure. Median survival without liver transplantation after diagnosis is 10 to 12 years. The majority of patients with PSC have underlying ulcerative colitis (UC); the prevalence of ulcerative colitis may be as high as 90 percent when rectal and sigmoid biopsies are routinely obtained.
Approximately half of the patients with primary sclerosing cholangitis are asymptomatic at the time of diagnosis, despite some already having advanced disease. PSC is often detected as part of the evaluation of abnormal liver tests in patients with inflammatory bowel disease. Among patients who have symptoms, fatigue and pruritus are common. The diagnosis of PSC is made by showing cholangiographic evidence of characteristic bile duct changes (multifocal strictures, segmental dilations) and excluding secondary causes of sclerosing cholangitis. A percutaneous liver biopsy may support the diagnosis of PSC but is rarely diagnostic. In patients with characteristic findings on cholangiography, a liver biopsy is typically not required. However, a liver biopsy is required for patients with suspected small duct PSC. A cholangiogram may be obtained using MRCP, ERCP or percutaneous transhepatic cholangiography (PTC). Because it is noninvasive with comparable diagnostic accuracy to ERCP, MRCP is typically the first test of choice. the sensitivity and specificity of MRCP for diagnosing PSC were 86 and 94 percent. Continued destruction of bile ducts in primary sclerosing cholangitis (PSC) leads to end-stage liver disease. Patients with PSC also may develop a number of other complications, including Fat-soluble vitamin deficiencies (A, D, E, and K), Metabolic bone disease, Dominant biliary strictures, Cholangitis & cholelithiasis, Cholangiocarcinoma, Gallbladder cancer, Hepatocellular carcinoma (in patients with cirrhosis) and Colon cancer (in patients with concomitant ulcerative colitis).
A variety of immunosuppressive and anti-inflammatory agents have been studied in patients with primary sclerosing cholangitis (PSC) . These include: Ursodeoxycholic acid, Glucocorticoids, Cyclosporine, Methorexate, Vancomycin, Azathioprine, Tacrolimus, D-penicillamine and Etanercept. Surgical options for primary sclerosing cholangitis (PSC) include biliary reconstructive procedures, proctocolectomy (in patients with ulcerative colitis), and liver transplantation.

資料來源： 1.Uptodate-Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis 2.Uptodate- Primary sclerosing cholangitis in adults: Management

## Question 67:

24歲女性病人因肌肉抽筋與全身乏力影響打電腦與走路而求診。理學檢查為：血壓 112/70 mmHg; HR 80/min, 呼吸14/min,全身肌力約4分。BUN 13.2 mg/dL, Cre 0.9 mg/dL, Uric acid 9.6 mg/dL, Na 136 mmol/L, K 2.6 mmol/L, Cl 85 mmol/L, Ca 2.38 mmol/L, Mg 0.9 mmol/L. Urine K 33.4 mmol/24/h , TTKG 11.74. Blood gas pH 7.53, PaCO2 49.3 mmHg, PaO2 98.0 mmHg, HCO3- 41.2 mEq/L, BE 15.8 mEq/L. Plasma renin activity 25.8 ng/ml/h (normal <5); Plasma aldosterone 64.4 ng/dL (normal <30)., 腎臟超音波(如圖)。請問何者為正確？

(1) Fanconi syndrome,
(2) Bartter syndrome,
(3) Gilteman syndrome,
(4) 長期過度使用Thiazide,
(5) 長期過度使用 Loop diuretics.

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

### Correct Answer: B

詳 解題： 解 此題目主要是考 hypokalemia 的鑑別診斷。 依據題目給的 data 然後跟著 flow chart走，最終會到右下最後一個表格。 Bartter syndrome跟長期使用 loop diuretic症狀一樣，而 Gilteman syndrome 跟 長期使用 thiazide症狀一樣。因此答案是 B（2+5）

延伸閱讀： Bartter syndrome is an autosomal recessive disorder that often presents in childhood and may be associated with the following clinical features:
－Growth and mental retardation,
－Hypokalemia
－Metabolic alkalosis
－Polyuria and polydipsia due to decreased urinary concentrating ability
－Normal to increased urinary calcium excretion
－Normal or mildly decreased serum magnesium concentration
－Hypophosphatemia in occasional patients ( secondary hyperparathyroidism being a possible mechanism) The clinical features in patients with Bartter syndrome are compatible with a primary defect in sodium chloride reabsorption in the medullary thick ascending limb of the loop of Henle. Mutations in a variety of tubular transport proteins can mimic the effects of chronic therapy with loop diuretics in Bartter syndrome, resulting in hypokalemia and metabolic alkalosis. Patients with classic Gitelman syndrome, which is an autosomal recessive disease, have mutations in the gene coding for the thiazide-sensitive Na-Cl cotransporter in the distal tubule (NCCT, SLC12A3). The most common mutation causes impaired cellular routing of the cotransporter. Reduced NCCT activity will mimic the effects of persistent thiazide diuretic action, which include volume contraction, reduced blood pressure, increased renin activity and aldosterone levels, renal potassium wasting and hypokalemia, renal magnesium wasting and hypomagnesemia, and a fall in urinary calcium excretion.
資料來源： 1.17th Harrison，pg.280-282, pg1801-1802 2.Uptodate- Bartter and Gitelman syndromes

## Question 68:

73歲男性病人因最近五天眼眶周遭自然出現紫斑，自述之前無外傷或跌倒，過去無糖尿病或高血壓，也無服用止痛藥、阿斯匹林、抗凝劑等。理學檢查：全身他 處皮膚無雷同症狀，下肢無水腫。但尿液檢查有尿蛋白 3+,RBC 0-2/HPF，BUN 30 mg/dL, Cre 1.5 mg/dL, Albumin 3.3 gm/dL，.超音波顯示腎臟大小正常，皮質回音 度稍增強，其他無異常。請問在建議做侵襲性檢查前，最好能選擇底下哪幾項檢 查比較能(接近百分之百的靈敏度)來確定臆斷之正確否？

(1) Immunofixation of serum
(2) Immunofixation of urine
(3) Serum protein electrophoresis
(4) Urine Bence Jones Protein detection
(5) Serum immunoglobulin free light chain assay

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

### Correct Answer: D

詳 解題： 解 Raccoon eyes DD: basal skull fracture, disseminated neuroblastoma, amyloidosis. 題目裡提到無跌倒＋protienuria，因此最有可能的疾病就是 amyloidosis。 Amyloidosis 唯有 biopsy才能確診。不過由於 Amyloidosis 有很多 form，例如： AL,AH,ATTR,.....而其中 AL form 是最常見的。因此，一些檢驗可以幫忙區別出 AL跟其他 form 的 amyloidosis. 以下是出自於 17th harrison裡面的關於 amyloidosis 的diagnosis 內容： Identification of a clonal plasma cell dyscrasia distinguishes AL from other types of amyloidosis. More than 90% of patients have a serum or urine monoclonal Ig protein that can be detected by immunofixaton electrophoresis or free light chain assay. The standard serum protein electrophoresis and urine protein electrophoresis are not useful screening tests because the clonal Ig in AL amyloidosis, unlike in multiple myeloma, is often not present in sufficient quantity in the serum to produce a monoclocal “M-spike”by these tests. 所以選項3是錯誤的，至於選項4錯誤的原因在於bences jone protein detection 用來screening for monoclonal gammopathy of undetermined significance （MGUS）and Waldenström's macroglobulinemia
延伸閱讀： Amyloidosis is the general term used to refer to the extracellular tissue deposition of fibrils composed of low molecular weight subunits of a variety of proteins, many of which circulate as constituents of plasma. These deposits may result in a wide range of clinical manifestations depending upon their type, location, and the amount of deposition. There are several major forms of amyloidosis. The principal types of amyloidosis are the AL (primary) and AA (secondary) types. AL amyloid, caused by a plasma cell dyscrasia, is due to deposition of protein derived from immunoglobulin light chain fragments. AA amyloidosis is a potential complication of chronic diseases in which there is ongoing or recurring inflammation that results in the production of serum amyloid A, an acute phase reactant, which can form amyloid deposits. The diagnosis of amyloidosis can be confirmed only by tissue biopsy. Clinical manisfestations: Renal disease — Renal involvement most often presents as asymptomatic proteinuria or clinically apparent nephrotic syndrome. However, primary deposition can be limited to the blood vessels or tubules; such patients present with renal failure with little or no proteinuria. End-stage renal disease is the cause of death in a minority of patients. Cardiomyopathy — Cardiac involvement can lead to systolic or diastolic dysfunction and the symptoms of heart failure Gastrointestinal disease — Hepatomegaly with or without splenomegaly is a common finding in some forms of amyloidosis Neurologic abnormalities — Several forms of neurologic involvement may occur, including peripheral and autonomic neuropathy, central nervous system involvement, and ischemic stroke Hematologic abnormalities — Increased bleeding may occur due to one or more of several causes, including reduced activity of factor X, vascular infiltration with amyloid, and abnormal liver function due to amyloid deposition Pulmonary disease — Pulmonary manifestations of amyloidosis include tracheobronchial infiltration, persistent pleural effusions, parenchymal nodules (amyloidomas), and, rarely, pulmonary hypertension . Tracheobronchial infiltration can cause hoarseness, stridor, airway obstruction, and dysphagia; bronchoscopic or surgical resection of airway abnormalities may be required Skin manifestations — Signs of skin involvement in systemic amyloidosis include waxy thickening, easy bruising (ecchymoses), and subcutaneous nodules or plaques. Purpura, characteristically elicited in a periorbital distribution (raccoon eyes) by a Valsalva maneuver or minor trauma, is present in only a minority of patients but is highly characteristic of AL amyloidosis.
資料來源： 1.17th Harrison pg.2146 2.Uptodate- Overview of amyloidosis

## Question 69:

請問底下所列降血壓之藥物，哪些可幫忙輸尿管結石之排出？
(1) Thiazide
(2) Loop diuretics
(3) Beta blockers
(4) alpha blockers (tamsulosin)
(5) calcium blockers (nifedipine)

---

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

### Correct Answer: C

詳 解題： 解 Tamsulosin 主要用於 BPH，可是off label use 可以用於Bladder outlet obstruction symptoms; Ureteral calculi (distal) Nifedipine主要用於management of chronic stable or vasospastic angina; treatment of hypertension. Off label use: Hypertensive emergency in pregnancy; Preterm labor; Raynaud phenomenon; Ureteral calculi (distal); High altitude pulmonary edema (prevention and treatment); Pulmonary hypertension
延伸閱讀： 無
資料來源： 1.Uptodate- Tamsulosin: Drug information 2.Uptodate-Nifedipine: Drug information

## Question 70:

58歲男性病人有糖尿病 12年，高血壓與腳部水腫約半年。理學檢查 BMI 29，血壓 154/88 mmHg，脛骨前水腫 +。 尿蛋白 3+, URBC 0-2/HPF。Albumin 3.3 g/dL, BUN 33 mg/dL, Cre 1.8 mg/dL (eGFR 42 ml/min), Na 132 mmol/L, K 5.2 mmol/L, HbA1C 7.3. .請問下列處置何者是錯誤？
(1) 因是慢性腎臟病第 3b期， 尚無須轉診至腎臟專科醫師。
(2) 高血壓之出現代表腎功能將持續繼續惡化。
(3) 若血糖能嚴格控制，亦難以降低心血管疾病之發生。
(4) 若高血壓能嚴格控制(包 括使用ACEI或 ARB)可以減緩糖尿病腎病變與視網膜病變。(5) 病人血糖在高血 壓與尿蛋白出現將更難控制。

---

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

### Correct Answer: A

解題： 解 選項1: CKD stage 3 加上hyperkalemia，常理來說就要去看腎臟科長期追蹤了 選項3: 一樣是common sense，血糖控制好當然可以降低心血管疾病發生
延伸閱讀： 無
資料來源： 無

## Question 71:

請問慢性腎臟病人中使用底下之藥物，何者或哪些不會加重血管鈣化？
(1) Calcium containing phosphate binders;
(2) non-ion based phosphate binders,
(3) Vitamin D,
(4) High calcium dialysate, (5) Warfarin 。

---

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

### Correct Answer: A

詳 解題： 解 Risk factors for Vascular Calcification(VC) include the following:
●Increasing age
●Dialysis vintage for those patients on dialysis ●Hyperphosphatemia
●Positive net calcium and phosphate balance and calcium intake (including calcium-containing phosphate binders) ●High calcium-phosphate product
●Vitamin D therapy
●Diabetes
●Dyslipidemia
●Oral inhibitors of vitamin K (eg, warfarin)
延伸閱讀： Vitamin D frequently result in hypercalcemia and an elevated calcium-phosphate product, which can accelerate extraosseous calcification. The propensity to ectopic/soft tissue calcification is also associated with adynamic bone disease caused by excessive vitamin D dosing. Warfarin prevents the activation of vitamin K-dependent proteins such as matrix Gla protein and growth arrest specific gene 6-encoded protein, which prevent VC and vascular smooth muscle cell apoptosis and movement, respectively. 資料來源： 1.Uptodate-Vascular calcification in chronic kidney disease

## Question 72:

請問底下藥物何者是主要由腎臟排泄且腎功能欠佳時需調整劑量，但在藥物過量時卻無法以血液透析來排除？ (1) Aspirin ; (2) Digoxin ;(3) Lithium (4)Tobramycin; (5)Vancomycin.

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

### Correct Answer: C

解題：Molecular mass of Aspirin: 180.157 g/mol Molecular mass of Digoxin: 780.938 g/mol Molecular mass of Lithium: 6.94Ar (atomic weight) Molecular mass of Tobramycin: 467.515 g/mol Molecular mass of Vancomycin: 1449.3 g/mol Digoxin 跟Vancomycin 的size最大因此無法透過透析膜洗掉
延伸閱讀： Treatment of aspirin poisoning Circulation — Aspirin-poisoned patients may be hypotensive due to sensible and insensible fluid losses and inappropriate systemic vasodilation. Aggressive volume resuscitation is warranted in such patients, unless cerebral edema or pulmonary edema is present. Hypotensive patients who do not respond to fluid resuscitation can be treated with a vasopressor Decontamination — Activated charcoal (AC) effectively absorbs aspirin, and at least one initial dose (1 g/kg up to 50 g PO) should be given to all alert and cooperative patients and all intubated patients via orogastric tube who present within two hours of ingestion Supplemental glucose — Aspirin intoxication may decrease cerebral glucose concentrations despite a normal serum glucose. Thus, supplemental glucose should be given to patients with an altered mental status regardless of the serum glucose concentration. Alkalinization of serum and urine — Alkalinization with sodium bicarbonate is an essential component of management of the aspirin-poisoned patient. The usual initial dose of sodium bicarbonate is 1 to 2 mEq (or mmol) per kg given as an intravenous bolus. This is followed by a sodium bicarbonate infusion of 100 to 150 mEq (or mmol) in one liter of sterile water with 5 percent dextrose. The rate of the infusion is titrated to a urine pH of 7.5 to 8, but is usually 1.5 to 2 times the maintenance dose for intravenous fluids. Hypokalemia must be corrected or prevented for alkalinization to be effective. Hemodialysis — he efficiency of salicylate removal can be enhanced by hemodialysis
. Indications for hemodialysis include the following
●Altered mental status
●Pulmonary or cerebral edema
●Renal insufficiency that interferes with salicylate excretion
●Fluid overload that prevents the administration of sodium bicarbonate
●A serum salicylate concentration >100 mg/dL (7.2 mmol/L) in acute overdose
●Clinical deterioration despite aggressive and appropriate supportive care Treatment of Digoxin poisoning The treatment for any clinically significant arrhythmia from digitalis toxicity, such as those producing hypotension, is digoxin-specific antibody (Fab) fragments. As temporizing measures or if Fab fragments are not immediately available, symptomatic bradycardia or bradyarrhythmia can be treated with atropine (0.5 mg IV in adults; 0.02mg/kg IV in children, minimum dose 0.1 mg) and hypotension with IV boluses of isotonic crystalloid. Life-threatening ventricular arrhythmias are treated according to the algorithms of advanced cardiac life support(ACLS). Fab fragments should be given in all cases of severe digitalis poisoning, as there is no alternative therapy with comparable efficacy and safety. We suggest Fab fragments be given to patients with digitalis toxicity and any of the following: ●Life-threatening or hemodynamically unstable arrhythmia (eg, ventricular tachycardia; ventricular fibrillation; asystole; complete heart block; Mobitz II heart block; symptomatic bradycardia)
●Hyperkalemia (serum potassium >5 to 5.5 meq/L [>5 to 5.5 mmol/L]) ●Evidence of end-organ dysfunction from hypoperfusion (eg, renal failure, altered mental status) Treatment of Lithium poisoning Hydration — Restoration of sodium and water balance in hypovolemic patients with lithium toxicity is essential to maximize lithium clearance. Gastrointestinal decontamination — Oral activated charcoal (AC) does not prevent the absorption of charged particles such as lithium and has no role in the management of an isolated lithium ingestion. Whole bowel irrigation with polyethylene glycol (PEG) solution can be effective in patients with large acute ingestions or ingestions of sustained release preparations of lithium. There is no benefit from whole bowel irrigation in patients with chronic toxicity. Hemodialysis — Lithium is readily dialyzable due to its low molecular weight, negligible protein binding, and small volume of distribution. Therefore, hemodialysis is the treatment of choice for severe lithium toxicity.

Aminoglycosides are effectively removed by both hemodialysis (continuous and intermittent) and peritoneal dialysis. As a result, supplemental doses after hemodialysis are generally required.

資料來源： 1.Uptodate-Salicylate (aspirin) poisoning in adults 2.Uptodate-Digitalis (cardiac glycoside) poisoning 3.Uptodate-Lithium poisoning 4.Uptodate-Aminoglycosides

## Question 73:

45歲女性曾接受腎臟移植，正在服用 Tacrolimus 及Sirolimus，此外有服用避孕藥及 因冠狀動脈阻塞曾放支架而服用 Clopidogrel，請問此病人容易罹患底下哪一種腎臟 疾病？ (1) Thrombotic thrombocytopenic purpura ; (2) Hemolytic uremic syndrome ; (3) Goodpasture syndrome ; (4) Henoch-Schonlein purpura ; (5)Microscopic polyangitis

---

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

### Correct Answer: A

詳 解題：
解 Thrombotic thrombocytopenic microangiopathies are a group of disorders characterized by thrombocytopenia, a microangiopathic hemolytic anemia evident by fragmented RBCs , including TTP and HUS. TTP and HUS were previously considered overlap syndromes. Medication-related TTP may be secondary to antibody formation (ticlopidine and possibly clopidogrel) or direct endothelial toxicity (cyclosporine, mitomycin C, tacrolimus, quinine)
資料來源： Harrison 17th edition Thrombotic Thrombocytopenic Purpura and Hemolytic Uremic Syndrome

## Question 74:

63歲女性病人有高血壓、退化性關節炎之過去史，因腎功能欠佳求診經檢查有尿蛋白++與尿紅血球 5-10/HPF。血清肌酸酐 2.2 mg/dL，血紅素10 gm/dL。超音波顯示 兩側腎臟均輕度萎縮各約9公分(如圖)，請問不可能之診斷為？ (1) Myeloma kidney ; (2)nephropathy ; (3)DM nephropathy; (4) Chinese herb nephropathy ; (5)Lithium nephropathy

---

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

### Correct Answer: B

詳 解題：
解 It takes time for kidneys to shrink as a result of chronic disease, the finding of bilaterally small kidneys supports the diagnosis of CKD of long-standing duration, with an irreversible component of scarring. If the kidney size is normal, it is possible that the renal disease is acute or subacute. The exceptions are diabetic nephropathy (where kidney size is increased at the outset of diabetic nephropathy before CKD with loss of GFR supervenes), amyloidosis, and HIV nephropathy, where kidney size may be normal in the face of CKD.
延伸閱讀：
 normal sized kidneys:
o acute tubular necrosis
o acute obstruction
o myeloma
o amyloidosis
o polyarteritis
 bilateral small kidneys:
o chronic renal failure
 bilateral large kidneys:
o amyloidosis
o renal vein thrombosis
o bilateral hydronephrosis
o polycystic disease of the kidney
o acute glomerulonephritis
o acute interstitial nephritis
 kidneys of unequal size (>1.5 cm difference):
o proximal urinary obstruction
o reflux nephropathy
o papillary necrosis (rare)
o renal vascular disease (rare)
網路資料: General Practice Notebook
資料來源： Harrison 17th edition Evaluation and Management of Patients with CKD

## Question 75:

依據目前之臨床證據，於第四期紅斑性狼瘡之誘發期，建議如何選擇免疫抑制劑而能有較佳療效且較少副作用？
(1) Monthly i.v. high dose cyclophosphamide;
(2) Monthly i.v. high dose methylprednisolone,
(3) Monthly i.v. Rituxumab, anti-CD20 monoclonal antibody.
(4) Daily oral mycophenolate mofetil
(5) Daily oral cyclosporine (6) Daily oral azathioprine

---

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

### Correct Answer: B

詳 解題：
解 Class IV lupus nephritis(proliferative LN,) In patients with proliferative LN, the preferred immunosuppressive therapy to induce a renal response is either a combination of glucocorticoids plus cyclophosphamide or glucocorticoids plus mycophenolate mofetil.
資料來源： Uptodate Therapy of diffuse or focal proliferative lupus nephritis

## Question 76:

病人因Transient Ischemia attack 正長期服用低劑量 Aspirin, 請問與下列哪些藥物會有交互作用？ (1) naproxen (2) Ibuprofen (3) COX-2 inhibitor (4) Acetaminophen (5) Diclofenac

---

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

### Correct Answer: A

詳 解題：
解 Aspirin produces its antithrombotic effect by irreversibly acetylating and inhibiting platelet cyclooxygenase (COX)-1, a critical enzyme in the biosynthesis of thromboxane A . At high doses (~1 g/d), aspirin also inhibits COX-2, an inducible COX isoform found 2 in endothelial cells and inflammatory cells. 故本題要選出COX-1 inhibitor: Ibuprofen、Naproxen; Diclofenac: Weakly COX-2 selective;
資料來源： Harrison 17th edition Antiplatelet, Anticoagulant, and Fibrinolytic Drugs: Introduction

## Question 77:

66歲婦人因憂鬱症吞服鈣離子阻斷劑與乙型交感神經阻斷劑(不知道幾粒)，經急診後篩檢發現血壓 70/50 mmHg, 心跳 45/min，心電圖有AV block 現象。請問底下哪 些是不適當的特殊治療或處置？
(1) 給予大量生理鹽水
(2) Glucacon
(3) Vasopressors or inotropic agents
(4) Magnesium
(5) Electric pacing
(6) High dose insulin (with glucose and potassium)
(7) 需要隨時檢測血糖及鉀離子

---

- A. (1)+(2)+(7)
- B. (2)+(6)+(7)
- C. (1)+(4)
- D. (6)+(7)
- E. (1)+(2)+(6)

### Correct Answer: C

詳 解題：
解 The treatment for both CCB and BB toxicity is similar. ABCs should always be assessed first and addressed appropriately. If patients are evaluated within one hour, activated charcoal can be administered. IV fluids and atropine are given to treat hypotension and bradycardia. Patients should then be given IV glucagon and calcium salts. If patients remain hypotensive vasopressors can be started. If the patient is refractory to these interventions, high dose insulin therapy should be considered and utilized. Typical treatment may not be effective because glucagon has a transient increase in inotropy but is not maintained, vasopressors increase systemic vascular resistance which can decrease cardiac output, and perfusion and atropine is short lived. Considering failure of these treatments, increasing evidence demonstrates that patients may have better outcomes with administration of HDI. Insulin has positive inotropic properties while being inexpensive with a minimal adverse effect profile. The mechanism of action is not well defined but it is theorized that during shock myocardium utilizes glucose as a substrate for energy instead of free fatty acids and insulin increases intracellular glucose transport in the myocardium. HDI also produces vasodilation, which improves systemic perfusion.
資料來源： Evidence for High Dose Insulin Therapy Justin Yuan, MD http://www.emdocs.net/wp-content/uploads/2015/08/HighDoseInsulinCCB-Yuan -.pdf

## Question 78:

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?

---

- 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

詳 解題：
解 For women with severe preeclampsia, aggressive management of blood pressures > 160/110 mmHg reduces the risk of cerebrovascular accidents. Intravenous labetalol or hydralazine are the drugs most commonly used to manage preeclampsia. Intravenous hydralazine may be associated with more episodes of maternal hypotension than labetalol. Alternative agents such as calcium channel blockers may be used. Elevated arterial pressure should be reduced slowly to avoid hypotension and a decrease in blood flow to the fetus. Angiotensin-converting enzyme (ACE) inhibitors as well as angiotensin-receptor blockers should be avoided in the second and third trimesters of pregnancy because of their adverse effects on fetal development. Pregnant women treated with ACE inhibitors often develop oligohydramnios, which may be caused by decreased fetal renal function.
資料來源： Harrison 17th edition Medical Disorders during Pregnancy: Introduction Hypertension

## Question 79:

一位52歲男性，有三年的 nephrotic syndrome病史，定期在門診就醫。最近一個月出現雙下肢水腫，體重增加了 4公斤，尿蛋白從 2.8 g/day增加到 10.6 g/day。醫師懷疑有venous thromboembolism 合併症。以下敘述，何者不正確?

---

- A. 可能是發生 deep vein thrombosis 或renal vein thrombosis
- B. 原因通常是 platelet 數目增加或antithrombin III activity增加所致
- C. 可能原因是 protein C 或protein S 減少所致
- D. 通常先以超音波做篩檢(screening test)，必要時再安排 CT 或MRI檢查
- E. 使用 heparin 或 warfarin 治療

### Correct Answer: B

詳 解題：
解 Deficiencies of antithrombin, protein C or protein S, and activated protein C resistance (APCR) are very well-established coagulation defects predisposing to venous thromboembolism (VTE). 故C 選項明顯錯誤 資料來源： Harrison 17th edition Venous thrombosis

## Question 80:

一位24歲外表健康女性，健康檢查發現: urine protein (2+)，urine occult blood test (2+), Hb 9.4 g/dL，WBC 7,650/mm3，serum creatinine 1.8 mg/dL，補體 C3與C4較正常值 偏低。病人最可能是以下何種腎絲球腎炎(glomerulonephritis)?

---

- A. IgA nephropathy
- B. Henoch-Schonlein purpura
- C. Acute poststreptococcal nephritis
- D. Mesangial proliferative glomerulonephritis
- E. Focal segmental glomerulosclerosis (FSGS)

### Correct Answer: C

詳 解題：
解 IgA nephropathy: 好發年輕男性,C3 正常…nephritis Henoch-Schonlein purpura: C3 正常…nephritis Acute poststreptococcal nephritis:C3,CH50 在兩週下降,6-8週回復,C4 正常…nephritis Mesangial proliferative glomerulonephritis: type I: 緩慢惡化,常伴有高血壓和腎功能失 調,C3,C4 皆下降; type II: 侵襲性多以急性腎炎表現,C3 下降較C4 明顯…nephritis 和nephrotic syndrome 都可能 Focal segmental glomerulosclerosis (FSGS):大多原因為 idiopathic(和 HIV、heroin有關) 預後不佳…nephrotic syndrome 依題幹描述,此病患較像 acute nephritis 而非 nephrotic syndrome; 答案以 C 為最適合
資料來源： First choice; Harrison 17th edition Glomerular Diseases

## Question 81:

一位多囊腎(polycystic kidney disease)的病人，因發燒、腰痛住院，診斷為 cystic infection。考量抗生素對個別腎臟囊泡(cyst)的穿透性，以下何種抗生素較不適用?

---

- A. Aminoglycoside
- B. Clindamycin
- C. Ampicillin 或Erythromycin
- D. Fluoroquinolone
- E. Metronidazole

### Correct Answer: A

詳 解題：
解 對個別腎臟囊泡(cyst)的穿透性佳且可拿來治療 UTI的抗生素有 fluoroquinolones (ciprofloxacin, levofloxacin), trimethoprim-sulfamethoxazole,及 chloramphenicol。穿透性不佳的有 aminoglycosides 及penicillins。 通常第一線選擇為 ciprofloxacin 及levofloxacin,替代方案有cefotaxime 或者是 ampicillin plus gentamicin。若urine culture 有streptococcal or staphylococcal infection, 則可加上 Vancomycin 或 erythromycin。若為厭氧菌則可加上 Metronidazole 或 clindamycin。
延伸閱讀：

資料來源： 1. Uptodate Urinary tract infection in autosomal dominant polycystic kidney disease 2. Clin J Am Soc Nephrol. 2009 Jul; 4(7): 1183–1189. Cyst Infections in Patients with Autosomal Dominant Polycystic Kidney Disease

## Question 82:

一位住院病人，抽血發現[Na] 120 mmol/L，針對低血鈉症(hyponatremia)，進一步檢查尿液滲透壓(urine osmolality) 大於 280 mOsm/L，尿液的鈉離子濃度 32 mmol/L。病人的低血鈉症最可能是以下何種病因?

---

- A. SIADH (Syndrome of inappropriate antidiuretic hormone secretion)
- B. Primary polydipsia
- C. Liver cirrhosis
- D. Heart failure
- E. Nephrotic syndrome

### Correct Answer: A

詳解 解題：
Primary polydipsia 通常驗尿 urine osmolality會小於 100 mOsm/L；而選項CDE 的成因皆是Effective arterial blood volume(EAV) 下降而造成的ADH 分泌上升， 因此驗尿Na(U)<10 mmol/L或FENa<1%。 SIADH須在排除 hypovolemia, decreased EAV, 及Endocrinopathies (Hypothyroidism, Adrenal insufficiency)等原因之後才能被診斷。
資料來源：小麻

## Question 83:

一位54歲病人，一年前因為蛋白尿，接受腎臟切片(renal biopsy)病理檢查，診斷是Membranous nephropathy (MN)，之後持續於門診追蹤。最近實驗室檢查結果(和 一年前類似)，為: [Albumin] 3.8 g/dL，[creatinine] 1.2 mg/dL，蛋白尿 1.6 g/day。 病人有輕度高血壓，但是沒有水腫。現階段針對此病人的處置，何者較合適?

---

- A. 使用低劑量prednisolone，約2.5 mg/kg/day，預防疾病惡化
- B. 應該使用 Cyclosporine 或 tacrolimus，可以促進緩解(remission)
- C. 單獨使用 Mycophenolate mofetil (MMF)，可以更降低蛋白尿，保護腎臟
- D. 尚無需使用prednisolone 或其他免疫抑制劑，可以使用 ACEI類藥物控制血壓
- E. 應該再安排一次腎臟切片(renal biopsy)，追蹤病理變化

### Correct Answer: D

詳解 解題： 因為病人蛋白尿的程度較輕微而且追蹤腎功能沒有惡化的狀況，屬於Low risk of progression 這個 group，並不需要用到immunosuppressive therapy。
延伸閱讀： Membranous nephropathy依照病人 progression 的risk分為：
＃Low risk of progression – Protein excretion remains less than 4 g/day and creatinine clearance remains normal for a six-month follow-up period.
＃Moderate risk of progression – Protein excretion is between 4 and 8 g/dayand persists for more than six months, and creatinine clearance is normal or near normal and remains stable over 6 to 12 months of observation.
＃High risk of progression – Protein excretion is greater than 8 g/day and persists for three months and/or creatinine clearance is reduced (and considered due to MN) or declines over three months of observation.
治療：
1.Nonimmunosuppressive therapy is given to almost all patients with idiopathic MN 包括ACEI/ARB, blood pressure control, dyslipidemia treatment
2.Immunosuppressive therapy：
Low risk：observation
Moderate risk and High risk：initiation of immunosuppressive therapy
資料來源： Uptodate Treatment of idiopathic membranous nephropathy

## Question 84:

一位48歲慢性腎臟病人(CKD stage IV, eGFR 18)，因為有疑似腹部腫瘤，接受核磁共振(MRI, with Gadolinium-contrast)，兩日後出現寡尿(oliguria)，全身肌肉與皮膚 疼痛。此病人最可能是發生哪種病狀?

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- A. Acute tubular necrosis
- B. Rhabdomyolysis
- C. Nephrogenic systemic fibrosis
- D. Obstructive acute kidney injury
- E. Dehydration-induced acute kidney injury

### Correct Answer: C

詳解 解題：
Nephrogenic systemic fibrosis (NSF) is a recently identified fibrosing disorder seen only in patients with moderate to severe kidney failure, particularly patients on dialysis. NSF is characterized by skin involvement in all patients and systemic involvement in some. Among patients with gadolinium exposure, the latent period between exposure and disease onset is usually two to four weeks. 資料來源： Uptodate Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced renal failure

## Question 85:

有關chronic tubulointerstitial nephritis 病人的尿液檢驗，以下敘述組合何者最正確? (1) 用Hansel stain 可以見到eosinophiluria (2) 沒見到WBC cast (3) 見到 granular cast (4) 蛋白尿(proteinuria) > 1-2 g/day (5) 有潛血反應[occult blood test (+)], 及WBC 40-50/HPF，但是病人並無泌尿道不適症狀

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

### Correct Answer: B

詳 解題： 解 (1) Hansel's stain detects urine eosinophils, a marker of acute interstitial nephritis. (2)WBC casts are indicative of interstitial or, less classically, glomerular inflammation. (3)Granular casts are considered characteristic of ATN
延伸閱讀： Chronic tubulointerstitial nephritis is usually asymptomatic, presenting with slowly progressive renal impairment. Urinalysis may be normal or show low-grade proteinuria (<1.5 g/day) and/or pyuria. Diagnosis depends on renal biopsy, which reveals variable cellular infiltration of the interstitium, tubular atrophy, and fibrosis. There are many causes including sarcoidosis, drugs (prescribed and nonprescribed), irradiation, toxins, and metabolic disorders.
資料來源： Uptodate> Urinalysis in the diagnosis of kidney disease http://oxfordmedicine.com/

## Question 86:

一位52歲女性，主訴發燒、噁心嘔吐、胃口變差和腹痛持續了一個星期。病人因紅斑性狼瘡腎炎及尿毒症，接受腹膜透析約 15年。透析液外觀清澈，腹水化 驗白血球小於100 cells/uL。臨床上出現腸阻塞之症狀，腹部電腦斷層(CT)可看 到有腸道擴張及腸壁鈣化，且被鈣化的臟層腹膜包覆起來。以下敘述，何者正確?
(1) 可能是腹膜透析發生細菌性腹膜炎(bacterial peritonitis), 或黴菌性腹膜炎 (fungal peritonitis)
(2) 可能是發生包囊性腹膜硬化症(encapsulating peritoneal sclerosis)
(3) 可以用 tamoxifen，或免疫抑制劑(如類固醇，corticosteroid)治療
(4) 可以用乙型阻斷劑(beta-blocker)治療
(5) 使用高糖濃度透析液，增加灌洗次數， 可預防腹腔內沾黏，並補充營養

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

### Correct Answer: C

解題：
(1)腹水化驗白血球小於 100 cells/uL代表不像是細菌感染。
(2,3,4)EPS 治療包括中 止腹膜透析, Bowel rest, immunosuppressive therapy and/or surgery。 Immunosuppressive therapy可以單用 corticosteroids 或corticosteroids 合併 azathioprine/Tamoxifen 治療。
(5)一般PD使用高糖濃度透析液是為了更好脫水， 但缺點是造成血糖不易控制。
延伸閱讀： Encapsulating peritoneal sclerosis(EPS) is characterized by extensive intraperitoneal fibrosis and encasement of bowel loops. It is typically associated with a progressive loss of ultrafiltration, resulting in fluid retention and edema. The treatment of EPS often entails cessation of peritoneal dialysis with transfer to hemodialysis (although the disorder may develop or worsen after stopping peritoneal dialysis), bowel rest with total parenteral nutrition(TPN), and (possibly) immunosuppressive therapy, (possibly) antifibrotic therapy, and/or surgery.
資料來源： Uptodate: Problems with solute clearance and ultrafiltration in continuous peritoneal dialysis

## Question 87:

一位51歲男性，身材微胖，兩個月前例行性健檢發現有高血壓(152/94 mm Hg)。病人至你的門診就醫，測得血壓值 148/90 mm Hg，依照2015年出版的台灣高血 壓指引，除了檢查 serum creatinine，urinalysis 等，及lipid parameters 之外，建議 安排以下實驗室例行檢查，何者除外?

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- A. Renal ultrasonography
- B. Hemoglobin or hematocrit
- C. Serum uric acid level
- D. Fasting glucose level
- E. Electrocardiogram (ECG) or chest X-ray

### Correct Answer: A

詳解 解題：
For patients presenting with office BP 140/90 mmHg (or 130/ 80 mmHg in special patient groups, i.e. diabetes, CHD, and proteinuric CKD), physical examination and routine laboratory tests should be performed, and a medical history obtained.

資料來源： 2015 中華民國心臟學會暨台灣高血壓學會高血壓指引

## Question 88:

低血鉀的原因可以大致歸類為 Thyrotoxic periodic paralysis (TPP)與hypokalemic non-periodic paralysis (HNPP)兩類。這些病人在補充鉀的輸液治療中，血清鉀濃 度有時反而更低，這稱之為"Paradoxical hypokalemia". 以下有關 Paradoxical hypokalemia的敘述，何者正確?

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- A. 一般而言，當要矯正低血鉀，TPP 比 HNPP 的病人需要補充更多的鉀
- B. 一般而言，當矯正低血鉀時，TPP 比 HNPP 的病人更常發生 rebound hyperkalemia.
- C. 一般而言，當矯正低血鉀時，TPP 比 HNPP 的病人更常發生 Paradoxical hypokalemia
- D. TPP 的病人發生 Paradoxical hypokalemia 的原因，通常與體液容積不足 (hypovolemia)或 renin-aldosterone 活性過高有關
- E. HNPP 的病人發生 Paradoxical hypokalemia 的原因，通常與血壓高有關，所以 可以使用 beta-blocker 來預防

### Correct Answer: B

詳解 解題：
不管是TPP 還是 HNPP 在補充KCl 之後都有可能發生血鉀越補越低的情況， 稱為Paradoxical hypokalemia。發生率HNPP 高於TPP。 在acute attack of thyrotoxic periodic paralysis(TPP)發生時，建議以 KCl 補充，而 通常發生paradoxical hypokalemia會有較高的thyroxine level，可能需要更多的KCl 補充及無效時再加上 propranolol；而在治療過後容易發生 rebound hyperkalemia。 預防TPP 發生則以 Restoration of euthyroidism 為主。 HNPP 造成 paradoxical hypokalemia 機轉與 TPP 的不同，在 higher urinary potassium excretion rates, higher renin levels, and higher volumes of saline resuscitation 的情況下較常發生。
延伸閱讀：