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# System prepended metadata

title: 內專104年1-50題

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# 內專104年1-50題

## Question 1:

有關心臟聽診(Cardiac auscultation)，請問下列何者說法是不正確的?

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- A. 僧帽瓣閉鎖不全(Mitral regurgitation)、主動脈瓣閉鎖不全(Aortic regurgitation)及心 室中隔缺損(Ventricular septal defect) 等心臟雜音都可因血管擴張劑之靜液注射後而 更加增強
- B. 蹲坐(Squatting)可致肥厚性心肌病變所致心臟雜音更趨強 
- C. 從臥躺而站立後，二尖瓣脫垂(Prolapse of mitral valve)所致心縮期敲擊性心音 (Systolic click)更趨近第一心音(S1) 
- D. 主動脈瓣狹窄(Aortic stenosis) 的心縮期雜音常在蹲坐後心雜音更強化 
- E. 三尖瓣閉鎖不全的心雜音常在深吸氣時更加強化 


### Correct Answer: A

Mitral regurgitation- the murmur is holosystolic, commencing immediately after S1 and continuing up to (and sometime beyond) and obscuring A2, a result of the persistent pressure gradient between the left ventricle and atrium after aortic valve closure. The murmur diminishes after amyl nitrite administration. Aortic regurgitation- The murmur of aortic regurgitation is best heard with the diaphragm of the stethoscope. Low-intensity, high-pitched aortic regurgitation murmurs may not be heard unless firm pressure is applied with the diaphragm of the stethoscope over the left sternal border or over the right second interspace, while the patient sits and leans forward with the breath held in full expiration VSD- Holosystolic murmur if pressure in the right ventricle is lower than the left ventricle throughout systole, resulting in a continuous left-to-right shunt.

延伸閱讀：
![](https://hackmd.io/_uploads/HJu-nhXO2.png)

資料來源： BECK W, SCHRIRE V, VOGELPOEL L, et al. Hemodynamic effects of amyl nitrite and phenylephrine on the normal human circulation and their relation to changes in cardiac murmurs. Am J Cardiol 1961; 8:341. http://www.uptodate.com/contents/auscultation-of-cardiac-murmurs-in-adults?source=mach ineLearning&search=heart+murmur&selectedTitle=1~150&sectionRank=4&anchor=H155 2124#H26

## Question 2:

有關冠心病幾種說法，請問下列何者不是當今實證醫學的說法 ?

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- A 男性比女性較多因心血管病而死亡
- B 近數十年在男性因心血管而死亡人數已大幅度降低，但女性病亡人數卻不減反升
- C 冠心病之發生常與冠脈微循環(Coronary microcirculation)之異常有關，尤於女性病人最為嚴重
- D 女性較男性好發冠心病，研究顯示與肥胖、糖尿病、發炎及代謝症候群等冠心病危險因素之多發有關
- E 女性運動心電圖有較多的偽陽性缺氧變化，以致臨床診療常見誤診

### Correct Answer: A

詳解題：In a survey from Rochester, Minnesota of patients seen between 1960 and 1979, 解 women with angina pectoris as an initial diagnosis had a longer survival and lower risk of subsequent myocardial infarction or cardiac death than age-matched men with the same presentation

延伸閱讀：
![](https://hackmd.io/_uploads/S1sM32Qd3.png)

資料來源： 1. Orencia A, Bailey K, Yawn BP, Kottke TE. Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death. JAMA 1993; 269:2392. http://www.uptodate.com/contents/epidemiology-of-coronary-heart-disease?source=se arch_result&search=coronary+artery+disease+epidemiology&selectedTitle=1~150#H 293274781

## Question 3:

77歲老太太一向健朗，未有任何不適症狀，因主動脈區有心縮性心雜音而轉診內科。理學檢查：Height: 160cm/ Weight: 55kg; BP:142/82 mmHg; T/P/R: 36.2 /60 /20, SpO2: 99% under room air; Pulsus paradoxicus (-),PMI: 5th ICS, around left mid-clavicular line, aortic ejection sound (+),Gr. III/VI Mid-systolic murmur over Aortic area and left lower sternal border, no neck radiation; Lungs: No crackles; No hepatosplenomegaly and no ascites; No legs edema. 其心電圖、胸部X光、心臟超音波 及心導管報告如列。 本病人隨即有下列諸項臨床決策：(1)初步診斷是高血壓及高 血壓性心臟病 (2)初步診斷是主動脈瓣狹窄心臟病 (3)在現階段最好的內科治療是 適量的Beta-blocker,Calcium channel blocker,ACE inhibitors or Angiotensin receptor blocker，以降低血壓 (4)由於未有明顯的心絞痛、眩暈或呼吸困難，在現階段最恰 當的治療是以Statin、Angiotensin receptor blocker及 Beta-blocker為宜 (5)內科及外科 的治療，對其預後無有改進，本病人的唯一選擇是主動脈瓣膜置換手術或經導管主 動脈瓣膜置放手術，請問下列何組決策是正確的 ? 
![](https://hackmd.io/_uploads/BJuXhnXuh.png)

![](https://hackmd.io/_uploads/ryENnhXuh.png)

![](https://hackmd.io/_uploads/SkZBn2md3.png)

![](https://hackmd.io/_uploads/rkDInnXu3.png)


---

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

### Correct Answer: C

詳 解題：
解 Physical examination for aortic stenosis can be characteristic for 1. A slow rate of rise in the carotid pulse 2.mid to late peak intensity of the murmur 3. reduced intensity of the second heart sound The medical treatment options are limited in symptomatic patients with aortic stenosis who are not candidates for surgery. In patients with pulmonary congestion, cautious use of digitalis, diuretics, and angiotensin-converting enzyme (ACE) inhibitors might attempted, whereas beta-blockers might be used if the predominant symptom is angina. In any case, excessive decrease in preload or systemic arterial blood pressure should be avoided. The ESC/EACTS guidelines recommend that patients with heart failure symptoms who are not suitable candidates for surgery or transcatheter aortic valve implantation may be treated with digoxin, diuretics, ACE inhibitors, or angiotensin receptor blockers
延伸閱讀：
![](https://hackmd.io/_uploads/ryrvh27O3.png)

資料來源： http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aortic-sten osis-in-adults?source=machineLearning&search=aortic+stenosis&selectedTitle=1~150 &sectionRank=1&anchor=H112078599#H17

## Question 4:

吳先生現年20歲，一向健壯，從事建築粗工，於3月22日有感冒流鼻水、發燒及咳嗽症狀，三天後更有全身倦怠及暈厥，乃至心疼，因心電圖及胸X光異常(如圖)， 而從急診住院。理學檢查：Consciousness: drowsy, E3VTM4;T:37.5 P:93 R:16及 BP:82/65 mmHg; 頸靜脈怒張; 胸部有濕濁呼吸音; 心臟未有擴大，心音略為微 弱，尚無S3或S4及心臟雜音可聞; 腹部未有腹水或肝脾腫大; 雙腳未見水腫。實驗 室檢查：WBC,8.37 K/uL;RBC,4.35 M/uL;Plt,128 K/uL; Hb, 13.0 gm/dL;CK,514 U/L;CK-MB,43 U/L; Troponin I, 2.6 ug/L; CRP, 5.6 mg/dL。 本病人隨即進行下列臨 床決策： (1) Continuous IV infusion of Dopamine at the dose of 7.8 mcg/kg/min，以 穩定血壓及心跳及血氧 (2) 使用IV Heparin at the dose of 1000 u/hour，以預防血栓 的形成 (3) 3月27日因持續性Ventricular tachycardia，採用Electric cardioversion不盡 有效，而置放V-A ECMO及IABP (4) 3月28日進行Left ventricular assisted device，以 維持左心室功能 (5) 3月29日Myocardial biopsy之病理確診後，使用IVIG，也使用 Prednisolone、Cyclosporine及Azathioprine (6) 病情在3月31日後於焉穩定 從診斷及 處置，本病例的處置尚稱成功。請問下列何者才是Evidence based management?
![](https://hackmd.io/_uploads/BkN_hnXu2.png)


---

- A. 從病史、理學檢查及Troponin I 或CRP的數值可確定診斷
- B. 從胸部X光及心電圖可確定診斷
- C. 從病程血行力學之不穩定，應逕行Myocardial biopsy
- D. 使用Immunosuppressive agents:Prednisolone及Cyclosporine是本例治療 功的重 要因素
- E. 使用IVIG(Intravenous immunoglobulin)才是救命的要訣

### Correct Answer: C

詳 解題：
解 Once other causes of heart failure (such as ischemic heart disease, critical valvular lesions, and restrictive and hypertrophic cardiomyopathies) have been excluded, the need for an endomyocardial biosy should be based upon the likelihood that the results will change management. This will depend upon the time course, severity, and characteristics of the presentation as addressed in the 2007 American Heart Association/American College of Cardiology Foundation/EuropeanSociety of Cardiology (AHA/ACCF/ESC) scientific statement on endomyocardial biopsy.

延伸閱讀：
![](https://hackmd.io/_uploads/Skr9hhXO2.png)

資料來源： http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-myocarditis-in- adults?source=search_result&search=myocarditis+biopsy&selectedTitle=1~150#H23

## Question 5:

病人男性59歲於午夜24時，突因胸悶並有牙床緊疼，乃直往急診部求診，時病人之T/P/R = 35.1/51/18, BP 137/74 mmHg; 理學檢查，未見任何異常。病史追尋，本病人曾經醫師確定高血壓、高脂血、糖尿病及攝護腺肥大，唯僅只服用Bisoprolol 2.5 mg/day。經緊急檢查：其心電圖及胸部X光顯示如圖：生化檢查: CK,96 U/L;CK-MB,20 U/L;TnI <0.0012 ng/ml;Sugar 252 mg/dL; Na,137 mmol/L; K, 3.7 mmol/L; TG,182 mg/dL and Total cholesterol, 222 mg/dL ; 血液檢查: Hb,13.9 g/dl; Platelet, 203 K/uL; WBC,9.45 K/uL; Cre,1.3 mg/dL 請問本病人最可能的急診診斷 是：
![](https://hackmd.io/_uploads/H11p327O2.png)

---

- A Printzmetal's angina
- B Aortic dissection
- C Acute anterior myocardial infarction
- D Hypertension
- E Acute periodontitis disease . 

### Correct Answer: C

- 詳 解題： 解 This ECG shows hyperacute T waves in precordial leads (V2-V4). Broad, asymmetrically peaked or ‘hyperacute’ T-waves are seen in the early stages of ST-elevation MI (STEMI) and often precede the appearance of ST elevation and Q wave. 

延伸閱讀：
![](https://hackmd.io/_uploads/r1cJ6h7O3.png)

資料來源： http://www.medscape.com/viewarticle/576765_2 

## Question 6:

依據今年1月台灣心臟學會及高血壓學會所公告之高血壓處置指引 (2015 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension)，請問下列何者說法是錯誤的? 

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- A 台灣的高血壓處置指引與最近歐洲及美國的指引不盡相同
- B 80歲以上的老年人降壓以低於150/90 mmHg為治療目標
- C 糖尿病、冠心病、慢性腎病變併有蛋白尿病人之高血壓，以低於140/80 mmHg 為治療目標
- D 服用抗血栓藥物防治腦中風發作之降壓目標，以不高於130/80 mmHg
- E 所有病人(40-80歲)之高血壓治療目標在140/90 mmHg以下 

### Correct Answer: C

詳 解題： 解 TSOC-THS 表示：「我們並不同意 ESH/ESH joint hypertension guidelines 主張『所 有患者的血壓均應控制為 < 140/90 mmHg』的建議。」 • TSOC-THS 表示：「我是說去年 JNC Report 發表的東西是垃... 是讓我們非常不 同意的，其中我們特別反對『 60 - 80 歲患者的血壓控制目標應放寬至 < 150/90 mmHg 』這一段。」 • 對於下列患者，我們認為其血壓控制目標應 < 130/80 mmHg： 1. 糖尿病 (diabetes) 2. 冠心病 (coronary heart disease) 3. 慢性腎病且合併蛋白尿者 (chronic kidney disease with proteinuria) 4. 正使用抗血栓藥物預防中風者 (receiving antithrombotic therapy for stroke prevention) • 年齡超過 80 歲的老人，血壓控制目標可放寬至 < 150/90 mmHg。 • 其餘人等，血壓控制目標應 < 140/90 mmHg。 延伸閱讀： 《 生活型態改變 (Life Style Modification, LSM) 》 對於血壓偏高，但尚無需以降血壓藥治療者，應先進行為期三個月的生活型態改變 (Life Style Modification, LSM) 介入，口訣為 "S-ABCDE"，如未見效果，再評估是否 用藥。 S - Sodium restriction 限鈉*：建議 2 - 4 g/day A - Alcohol limitation 減酒戒癮：♂ < 30 gm/day EtOH, ♀ < 20 gm/day EtOH B - Body weight reduction 減重：BMI 22.5 - 25.0 C - Cigarette smoke cessation 戒菸：全戒掉，不解釋 D - Diet adaptation 飲食調整：DASH diet # E - Exercise adoption 運動：有氧運度，at least 40 min/day & 3-4 days/week ＊ TSOC-THS 建議以低鹽飲食來取代大悲無鹽的飲食方式，且他們認為，過於嚴苛 的限鈉 (< 2 gm/day) 反而是對身體有害的。 ＃DASH diet: rich in fruits and vegetables (8-10 servings/ day), rich in low-fat dairy products (2-3 servings/day), and reduced in saturated fat and cholesterol. 
《 藥物治療 (Drug Therapy) 》 當開始考慮藥物治療時，要考慮的東西很多(廢話!!!)，除了內文有提到的 "Rule of 10"、"Rule of 5" 等觀念外，選擇藥物的部份主要是依據 "PROCEED" 的觀念進行評 估： P - Previous experience 病人過往經驗：若病人之前吃某類藥就會不舒服，為提升順服 性，請避免開立同類藥品。 R - Risk factors 風險因子：患者有共伴疾病時，要避免選用會加重疾病風險的降壓藥。 O - Organ damage 器官損壞：患者本身有器官失能時，可選用能保護該器官、或長期 使用具有延緩疾病惡化之降壓藥。 C - Contraindications or unfavorable conditions 禁忌症：不解釋 E - Expert's or doctor's judgment 專家或是醫師的當面決斷：病人狀況百百種，case by case 還是很重要的。 E - Expenses or cost 藥物價位與花費：$$$ D - Delivery & compliance issue 藥物給藥方式與順從性：不解釋 當患者接受初期治療，仍無法達到理想的血壓治療目標時，可開始考慮以單一錠複方 藥物 (single-pill combination, SPC) 作為治療，並以 "AT GOALs" 的評估流程，調整 病人的治療計畫： A - Adherence 探討病人順服性並提升之 T - Timing of administration 設計服藥的時間 G - Greater doses 是否需使用較高的治療劑量 O - Other classes of drugs 是否需加上另一類的降壓藥 A - Alternative combination or SPC 考慮改以其他複方或 SPC Ls - LSM + Laboratory tests 持續 LSM 並進一步做 lab test 追蹤是否有其他問題 
資料來源：http://www.jcma-online.com/article/S1726-4901(14)00315-3/abstract 

## Question 7:

一向主導全世界高脂血處置之NCEP ATP III，於2013年11月公布新的指引，請問下列何項不是新的規定? 

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- A 有冠心病、腦血管或週邊血管病之病人應服用Statin治療
- B 40-75歲的人只要LDL-C高於190 mg/dL應服用Statin治療
- C 40-75歲糖尿病人應服用Statin治療
- D 所有病人之血脂濃度：LDLC以低於100 mg/dL，而Cholesterol 180 mg/dL為治療 目標
- E 只限定Statin一藥，排除Fibric acid 及Cholestyramine 為降脂血藥物 

### Correct Answer: B

題： 解 B) According to the new guidelines, these patients should start life-style modification and re-assess cardiovascular risks every 4-6 years (Framingham score). 
延伸閱讀：
![](https://hackmd.io/_uploads/HkN76nmdh.png)

www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf 
資料來源： 
www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf 

## Question 8:

臨床處置指引常依據實證修訂，有關感染性心內膜炎(Infective endocarditis) 有下列諸多的記述： (1)血液細菌培養應在24小時內採血三次，在不同血管處採血，且應 相隔至少一小時實施 (2)心臟超音波檢查是必要的診斷工具，經食道心臟超音波檢 查適用於心肌膿腫、瓣膜破洞、心內廔管及人工瓣膜心內脈炎的診斷 (3)二尖瓣脫垂病人接受牙科治療應作預防性抗生素使用 (4)有發紺先天性心臟病人、人工瓣膜 置換手術後病人、曾有心內膜炎病史及換心人有主動脈瓣病變者應預防性抗生素使 用 (5)病人裝置ICD(Intra-cardiac device) 接受大腸鏡檢查應預防性抗生素使用 請 問下列何組是正確的處置指引? 

---

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

### Correct Answer: B

詳 解題： 解 1). Major blood culture criteria for IE include the following: - Two blood cultures positive for organisms typically found in patients with IE - Blood cultures persistently positive for one of these organisms, from cultures drawn more than 12 hours apart - Three or more separate blood cultures drawn at least 1 hour apart 2). Major echocardiographic criteria include the following: Echocardiogram positive for IE, documented by an oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation Myocardial abscess Development of partial dehiscence of a prosthetic valve New-onset valvular regurgitation 3). Common valvular lesions for which antimicrobial prophylaxis is NOT recommended include bicuspid aortic valve, acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation), and hypertrophic cardiomyopathy with latent or resting obstruction 4) and 5). Prophylaxis is warranted only in settings associated with the highest risk of an adverse outcome if IE occurs. This includes patients with: ●Prosthetic heart valves, including bioprosthetic and homograft valves ●A prior history of IE ●Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits ●Completely repaired congenital heart defects with prosthetic material or device during the first six months after the procedure (whether placed by surgery or by catheter intervention) ●Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic patch or prosthetic device ●Valve regurgitation due to a structurally abnormal valve in a transplanted heart 
資料來源： Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736. 

## Question 9:

男性病人現年60歲，於清晨 6時突然胸悶、冷汗，自覺伴有後背及腹部酸疼，病人由家屬急送醫院。病人有多年高血壓及痛風病，服用 Losartan(50mg) 1tabQD; Amlodipine(5mg) 1tabQD;Colchicine(0.5mg)1 tabQD;Benzbromarone(100mg) 1tabQD;Atorvastatin 0.5 Tab /HS 等藥中。身體檢查，呈現急病狀，臉色蒼白，體溫: 36.2℃，脈跳: 66/min，呼吸: 23/min；BP: 252/114mmHg；意識清楚；胸部及腹部尚無 異常，心律正常，S1 及S2正常，未有S3或 S4，無心臟雜音可聞，也無 paradoxical split of S2，神經檢查正常。其時實驗室檢查如圖表。下列何者是正確的診斷?
![](https://hackmd.io/_uploads/BJwNT37d3.png)


--- 

- A. Acute myocardial infarction 
- B. Aortic dissection 
- C. Hypertensive crisis
- D. Pulmonary embolism 
- E. Aortic stenosis 

### Correct Answer: B

詳 解題： 解 Aortic dissection is caused by a circumferential or, less frequently, transverse tear of the intima. It often occurs along the right lateral wall of the ascending aorta where the hydraulic shear stress is high. The dissection usually propagates distally down the descending aorta and into its major branches, but it may propagate proximally. Distal propagation may be limited by atherosclerotic plaque. In some cases, a secondary distal intimal disruption occurs, resulting in the reentry of blood from the false to the true lumen. 
延伸閱讀： There are at least two important pathologic and radiologic variants of aortic dissection: intramural hematoma without an intimal flap and penetrating atherosclerotic ulcer. Acute intramural hematoma is thought to result from rupture of the vasa vasorum with hemorrhage into the wall of the aorta. Most of these hematomas occur in the descending thoracic aorta. Acute intramural hematomas may progress to dissection and rupture. Penetrating atherosclerotic ulcers are caused by erosion of a plaque into the aortic media, are usually localized, and are not associated with extensive propagation. They are found primarily in the middle and distal portions of the descending thoracic aorta and are associated with extensive atherosclerotic disease. The ulcer can erode beyond the internal elastic lamina, leading to medial hematoma, and may progress to false aneurysm formation or rupture. 
資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter 248 

## Question 10:

女性病人現年47歲，G2P2，主訴近來一個月間時有頭昏，並有漸進式呼吸困難。住院前四天症狀更形惡化，是乃經急診住加護病房。理學所見: 身高 163cm; 體重 . 67.4kg; BMI = 25.37; 體溫:36.5℃ ;BP(mmHg): 128/60; PR(/min): 104; RR(/min): 24; 臉 血蒼白; 心跳快速但正常律動, 在三尖瓣區有 Grade 3/6 systolic murmur 可聞 ，其他尚 無重大異常。其心電圖及胸部 X光和Computer tomography如圖。 D-Dimer, 3.56 mg/L;Blood gas:pH,7.534;PaO2,57 mmHg;PaCO2,20.9 mmHg;HCO2 std 22.0 mmol/L;病 人住院後隨即靜注大方劑量(Bolus dose) Unfractionated Heparin 3000u 及每小時1000u 靜脈輸注。病程中先後進行下列處置： (1)通知心臟科啟動 PCI團隊 (2) 查Protein C ，Protein S 和anti-thrombin III, 和Anticardiolipin IgG (3)Tumor biomarkers :CEA, CA-199,CA-125,CA-153 (4)Heparin bolus 3000 unitIV stat and then IV pump 6~12 U/kg/hr according to the aPTT (5)Digoxin o.25 mg + 20% glucose in water for IV to control tachycardia 請問下列何組處置才是正確的? 
![](https://hackmd.io/_uploads/HkIranQu2.png)


--- 

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

### Correct Answer: D

詳 解題： Thrombophilia contributes to the risk of venous thrombosis. Antithrombin, protein C, and 解 protein S are naturally occurring coagulation inhibitors. Deficiencies of these inhibitors are associated with VTE but are rare.Other common predisposing factors include cancer, systemic arterial hypertension, chronic obstructive pulmonary disease, long-haul air travel, air pollution, obesity, cigarette smoking, eating large amounts of red meat, oral contraceptives, pregnancy, postmenopausal hormone replacement, surgery, and trauma. 
![](https://hackmd.io/_uploads/B1zqanm_3.png)

延伸閱讀： 
![](https://hackmd.io/_uploads/SkeoT2Qd3.png)
![](https://hackmd.io/_uploads/r1lh6nQdn.png)

資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter 262 

## Question 11:

病人是位47歲家庭主婦，自 7歲起就診斷有心臟病，18歲懷孕生有一子，過程尚稱順利，近十年來偶有心悸及胸悶，近二年曾有五次昏厥，因此住院。 理學檢查及生化檢驗都正常。胸 X光及心電圖(如圖)。本病人最有可能的診斷是： 
![](https://hackmd.io/_uploads/r1Jp6nmOn.png)


--- 

- A. Supraventricular tachycardia
- B. WPW syndrome with AVRT
- C. Long QT syndrome with Torsade de pointes
- D. Monomorphic ventricular tachycardia from outflow tract
- E. Polymorphic ventricular tachycardia with Torsade de pointes 

### Correct Answer: D 

![](https://hackmd.io/_uploads/SJBCT2Qdn.png)

Monomorphic VT suggests a stable tachycardia focus in the absence of structural heart disease or a fixed anatomic abnormality that can create the substrate for a stable reentrant VT circuit when structural disease is present. Monomorphic VT tends to be a reproducible and recurrent phenomenon and may be initiated with pacing and programmed ventricular stimulation. 
資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter 233 

## Question 12:

38歲女性因為很容易出現運動喘而來檢查，下列哪一個身體檢查的發現最容易懷疑是否有肺 動脈高壓？ 

---

- A. 頸靜脈鼓脹，心音 S1，S2正常。在右上胸骨緣有 II/VI等級的舒張期心雜音。
- B. 頸靜脈鼓脹，大聲的 S2心音。在左下胸骨緣有 II/VI等級的收縮期心雜音。
- C. 頸靜脈鼓脹， 大聲且固定而分裂的 S2 心音。在左下胸骨緣有 III/VI等級的收縮期心雜 音。 
- D. 頸靜脈鼓脹，吐氣時 S2心音分裂。在左上胸骨緣有 大聲而尖銳的 II/VI等級的收縮期 心雜音。 
- E. 頸靜脈鼓脹，桶型胸腔變形。呼吸週期的吐氣期特別長。 

### Correct Answer: B

詳 解題： 解 signs of pulmonary hypertension : 1. right ventricular lift 2. loud and single or closely split S2 3. Narrow physiologic splitting, and both A2 and P2 are heard during expiration at a narrow splitting interval because of the increased intensity and high-frequency composition of P2. 
![](https://hackmd.io/_uploads/BydJRhQ_2.png)

4.The physical examination typically reveals increased jugular venous pressure, a reduced carotid pulse, and a palpable RV impulse. Most patients have an increased pulmonic component of the second heart sound, a right-sided fourth heart sound, and tricuspid regurgitation. 5. tricuspid regurgitation : A prominent RV pulsation along the left parasternal region and a blowing holosystolic murmur along the lower left sternal margin, which may be intensified during inspiration and reduced during expiration or the strain of the Valsalva maneuver, are characteristic findings. 延伸閱讀： The neck veins are distended with prominent v waves and rapid y descents, marked hepatomegaly, ascites, pleural effusions, edema, systolic pulsations of the liver, and a positive hepatojugular reflex. 
資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter e13, 227, 237, 250 

## Question 13:

60歲女性因為逐漸出現的喘氣造成無法行走正常距離而到急診，他沒有胸痛、支氣管哮喘、痰或是發燒。胸部 X光檢查發現雙側肺動脈擴張，左心房擴大，雙側肺部 沒有浸潤現象。心電圖出現 V1導極有高的 R 波，心軸右偏。此時幫患者進行心臟超 音波檢查，最可能會出現下面哪一種變化？ 

---

- A. 主動脈瓣迴流 
- B. 主動脈瓣狹窄
- C. 左心室收縮功能低下
- D. 二尖脈（僧帽瓣）瓣狹窄
- E. 二尖脈（僧帽瓣）瓣迴流 

### Correct Answer: D

詳 解題： 解 When the mitral valve opening is reduced to <1 cm2, often referred to as "severe" MS, a LA pressure of >25 mmHg is required to maintain a normal cardiac output (CO). The elevated pulmonary venous and pulmonary arterial (PA) wedge pressures reduce pulmonary compliance, contributing to exertional dyspnea. The first bouts of dyspnea are usually precipitated by clinical events that increase the rate of blood flow across the mitral orifice, resulting in further elevation of the LA pressure. An increase in heart rate shortens diastole proportionately more than systole and diminishes the time available for flow across the mitral valve. Therefore, at any given level of CO, tachycardia, including that associated with rapid AF, augments the transvalvular pressure gradient and elevates further the LA pressure. ECG In MS and sinus rhythm, the P wave usually suggests LA enlargement. It may become tall and peaked in lead II and upright in lead V1 when severe pulmonary hypertension or TS complicates MS and right atrial (RA) enlargement occurs. The QRS complex is usually normal. However, with severe pulmonary hypertension, right-axis deviation and RV hypertrophy are often present. CHEST X-RAY The earliest changes are straightening of the upper left border of the cardiac silhouette, prominence of the main pulmonary arteries, dilation of the upper lobe pulmonary veins, and posterior displacement of the esophagus by an enlarged LA. Kerley B lines are fine, dense, opaque, horizontal lines that are most prominent in the lower and mid-lung fields and that result from distention of interlobular septae and lymphatics with edema when the resting mean LA pressure exceeds approximately 20 mmHg. 
延伸閱讀： The LV diastolic pressure and ejection fraction (EF) are normal in isolated MS. In MS and sinus rhythm, the elevated LA and PA wedge pressures exhibit a prominent atrial contraction pattern (a wave) and a gradual pressure decline after the v wave and mitral valve opening (y descent). In severe MS and whenever pulmonary vascular resistance is significantly increased, the pulmonary arterial pressure (PAP) is elevated at rest and rises further during exercise, often causing secondary elevations of right ventricular (RV) end-diastolic pressure and volume. The clinical and hemodynamic features of MS are influenced importantly by the level of the PAP. Pulmonary hypertension results from: (1) passive backward transmission of the elevated LA pressure; (2) pulmonary arteriolar constriction (the so-called "second stenosis"), which presumably is triggered by LA and pulmonary venous hypertension (reactive pulmonary hypertension); (3) interstitial edema in the walls of the small pulmonary vessels; and (4) at end stage, organic obliterative changes in the pulmonary vascular bed. Severe pulmonary hypertension results in RV enlargement, secondary tricuspid regurgitation (TR) and pulmonic regurgitation (PR), as well as right-sided heart failure. 資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter e13, 237 

## Question 14:

高血鉀的心電圖變化，請在下列項目中選擇最適合的發現：(1) P 波變平而可能消失 (2) ST segment 延長 (3) U波明顯變大 (4) QRS 波變寬 (5) T波變高 (6) PR interval 縮短

---

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

### Correct Answer: D

詳 解題：
解 The earliest ECG change with hyperkalemia is usually peaking ("tenting") of the T waves. With further increases in the serum potassium concentration, the QRS complexes widen, the P waves decrease in amplitude and may disappear, and finally a sine-wave pattern leads to asystole unless emergency therapy is given.
![](https://hackmd.io/_uploads/SymU0hQu2.png)


延伸閱讀： Hypokalemia prolongs ventricular repolarization, often with prominent U waves.
![](https://hackmd.io/_uploads/Skb20hQu2.png)


資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter e13, 237 

## Question 15:

所謂「完整的心臟病診斷」(Complete cardiac diagnosis) 應依序包括哪些項目組合?

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- A. 病因、病理、生化及功能異常(Functional disability)的診斷
- B. 咳血生理、解剖、病理及功能異常的診斷
- C. 病理、生理、功能及生化異常的診斷
- D. 病因、解剖、生理及功能異常的診斷
- E. 病因、病理、生理及功能異常的診斷

### Correct Answer: D

詳 解題：
解 As outlined by the New York Heart Association (NYHA), the elements of a complete cardiac diagnosis include the systematic consideration of the following: 1 The underlying etiology. Is the disease congenital, hypertensive, ischemic, or inflammatory in origin? 2 The anatomical abnormalities. Which chambers are involved? Are they hypertrophied, dilated, or both? Which valves are affected? Are they regurgitant and/or stenotic? Is there pericardial involvement? Has there been a myocardial infarction? 3 The physiological disturbances. Is an arrhythmia present? Is there evidence of congestive heart failure or myocardial ischemia? 4 Functional disability. How strenuous is the physical activity required to elicit symptoms? The classification provided by the NYHA has been found to be useful in describing functional disability

延伸閱讀：
![](https://hackmd.io/_uploads/SJ0TRhQO3.png)

資料來源： 1. Harrison’s Principles of Internal Medicine , 18th edition , Chapter 226 

## Question 16:

當心房纖維顫動出現，下列哪一些因子會加重患者的腦血管血栓事件的可能性？(1) 糖尿病 ; (2) 左心房 4.2公分 ; (3) 曾經有暫時缺血性腦中風發作 ; (4) 高血脂 ; (5) 鬱血性心衰竭 ; (6) 年齡62歲

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

### Correct Answer: A

詳解題：
![](https://hackmd.io/_uploads/Sybkkpmu2.png)

延伸閱讀：
![](https://hackmd.io/_uploads/BkZx1pm_h.png)

資料來源： 2014 AHA/ACC/HRS Guideline for the Management of
Patients With Atrial Fibrillation 

## Question 17:

門診時有位擔心的母親來向你詢問有關他兒子的問題，兒子在國一的新生入學檢查中發現有心房中隔缺損。關於如果沒有修復心房中隔缺損，在成年或多年之後，最不可能出現下列哪一種情況？

---

- A. 因為醫療目的而進行中心靜脈管置入術（CVC）而產生氣栓（Air emboli）
- B. 不穩定性狹心症
- C. 栓塞性腦血管事件
- D. 肺高壓
- E. 運動中氧動脈分壓隨之下降

### Correct Answer: B

詳 解題：
解 Increased blood flow to the lungs due to the VSD causes high blood pressure in the lung arteries (pulmonary hypertension), which can cause permanently damage including cyanosis due to shunt, in situ pulmonary artery thrombosis, syncope, atrial and ventricular arrhythmias, and right heart and left heart failure. 
延伸閱讀： Eisenmenger syndrome is a congenital heart disease and with triad of systemic-to-pulmonary cardiovascular communication, pulmonary arterial disease, and cyanosis 
資料來源： http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/ uptodate 

## Question 18:

42歲女性在成人健檢中發現有收縮中期異常心音- Mid-systolic click，沒有發現心雜 音。除此之外的身體檢查正常，血液檢查項目數值正常，平日也沒有不舒服。她還 是擔心相關的發現，依照上述情況，下列哪一相敘述較適當？

---

- A. 說明大多數的這類患者存有結締組織疾病，進行檢查
- B. 解釋並告知病人針對感染性心內膜炎進行相關防範措施
- C. 大部分此種發現會一直存在，但不需治療
- D. 建議她使用Aspirin 100mg/day 來預防血栓事件
- E. 這類問題無法從心臟超音波檢查，不要要求做超音波檢查

### Correct Answer: C

詳 解題：
解 mitral valve prolapse without symptom has benign prognosis. Antibiotic prophylaxis for the prevention of infective endocarditis during procedures that carry a risk for bacteremia is recommended in most patients with a definite diagnosis of MVP. Whether patients with an isolated systolic click and no systolic murmur should receive endocarditis prophylaxis has not been established. 
延伸閱讀： Daily aspirin therapy (80 to 325 mg per day) is recommended for patients with MVP who have a history of focal neurologic events and who are in sinus rhythm but have no atrial thrombi. The diagnosis of mitral valve prolapse (MVP) was previously based upon a combination of clinical exam findings and echocardiographic criteria; the current definition relies on imaging alone. 
資料來源： Current Management of Mitral Valve Prolapse Am Fam Physician. 2000 Jun 1;61(11):3343-3350. uptodate

## Question 19:

下列哪一些身體檢查的發現會懷疑嚴重的主動脈瓣迴流？ (1) Corrigan's pulse ; (2) Pulsus bigeminus ; (3) Quincke's pulse ; (4) Traube's sign ; (5) Pulsus parvus et tardus ; (6) Pulsus paradoxus

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

### Correct Answer: C

詳 解題：
解 aortic regurgitation: Corrigan's pulse :A “water hammer” or “collapsing” pulse is characterized by a rapidly swelling and falling arterial pulse Quincke's pulses: Capillary pulsations in the fingertips or lips. Traube's sign: A pistol shot pulse (systolic and diastolic sounds) heard over the femoral arteries
延伸閱讀： Pulsus bigeminus: groups of two heartbeats close together followed by a longer pause Causes Include 1. Electrolyte imbalance e.g. Hypo or hyperkalemia 2. Hypothyroidism 3. Beta blocker therapy 4. Digoxin 5. Myocardial Infarction 6. Destruction or degeneration of the cardiac conduction system or heart muscle cells 7. Infection Pulsus parvus et tardus :slow-rising pulse, is a sign where, on palpation of the pulse, the pulse is late (tardus) (relative to contraction of the heart) and weak/small (parvus). Classically, it is seen in aortic valve stenosis. Pulsus paradoxus: abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus. It is a sign that is indicative of several conditions cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma,COPD).[1] 
資料來源： uptodate 

## Question 20:

78歲男性，有長期吸菸，肥胖和十年左右的第二型糖尿病。他因為最近兩個月出現的運動喘前來門診。目前他使用的藥品包含 aspirin, metformin 和偶爾會因為關 節疼痛服用 ibuprofen。他的身體檢發現延遲出現-- 脈搏尖峰（delayed peak in peripheral pulse），left ventricular heave。他的心跳規則，在心臟基底部位(cardiac base) 有 VI/VI 級的收縮期心雜音，此雜音會傳向頸動脈區域。同時出現第四心音，心 臟超音波只有嚴重的主動脈瓣狹窄。請問依據病史與相關發現，造成這個病人心臟變化的最可能原因是？

---

- A. 先天性二瓣的主動脈瓣膜（bicuspid aortic valve）
- B. 糖尿病
- C. 風濕性心臟病
- D. 病人有潛藏的結締組織疾病
- E. 以上皆非

### Correct Answer: B

詳 解題：
解 Diabetes mellitus is associated with enhanced inflammation within AS valves, measured by CRP expression, which may contribute to faster AS progression. 
延伸閱讀： Three primary causes of valvular aortic stenosis (AS): 1.A congenitally abnormal valve with superimposed calcification (unicuspid or bicuspid) 2.Calcific disease of a trileaflet valve 3. Rheumatic valve disease 4.Rarely cause metabolic diseases (eg, Fabry's disease), systemic lupus erythematosus, and alkaptonuria. 資料來源： uptodate http://link.springer.com/article/10.1007%2Fs10753-011-9384-7 

## Question 21:

當患者的心臟超音波檢查發現有嚴重的二尖瓣迴流，考量手術適應症，併發症與手術預後，下面哪一個敘述的患者會有最佳的術後進步和手術治療效果？

---

- A. 52歲男性，LVEF=25%，心衰竭症狀 NYHA class III，左心室收縮末期內徑 60mm。
- B. 54歲男性，LVEF=30%，心衰竭症狀 NYHA class II，有肺高壓。 
- C. 63歲男性，竇性規則心律，LVEF=65%，沒有臨床症狀，右心室導管檢查壓 力正常。
- D. 72歲女性，沒有臨床症狀，新發現陣發性心房纖維顫動，LVEF=60%， 左心 室收縮末期內徑 35mm。
- E. 66歲女性，LVEF=50%，沒有臨床症狀，左心室收縮末期內徑 45mm。

### Correct Answer: E

詳 解題：
解 Predictors of poor outcome include age, atrial fibrillation, severity of MR, pulmonary hypertension, LA dilatation, increased LV end-systolic diameter and low LV ejection fraction. poor prognosis when presenting of heart failure symptom and dilatation of Left ventricular.
E is better than C due to the evidence of not dilation of left ventricular
延伸閱讀： surgical indication for asymptomatic MR 1. heart failure symptom 2. LVESD>50mm，LVEDD>70mm
3. Pulmonary hypertention
4. Atrial fibrillation 
資料來源： Long-term outcome after mitral valve repair. Heikkinen J1, Biancari F, Uusimaa P, Satta J, Juvonen J, Ylitalo K, Niemelä M, Salmela E, Juvonen T, Lepojärvi M. http://patient.info/doctor/mitral-regurgitation-pro 

## Question 22:

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？

---

- 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

詳 解題：
解 hypertention and hypokalemia was mentioned above. Should check PRA and PAC ratio to differentiate among different causes of hypertension and hypokalemia.
延伸閱讀：
![](https://hackmd.io/_uploads/S1T-yaQOn.png)

資料來源： uptodate 

## Question 23:

關於肺部聽診的敘述,下列何者正確? (1)哮鳴音(wheezes)代表氣道阻塞 (2)囉音 (crackles)代表肺泡疾病 (3)肺間質纖維化(interstitial fibrosis)會出現 egophony (4)肺實 質化(consolidation)不會出現 whispered pectoriloquy (5)肺氣腫(emphysema)可出現呼 吸音降低

---

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

### Correct Answer: C

解題：
(2)Pneumonia, atelectasis, pulmonary fibrosis, acutebronchitis, bronchiectasis, interstitial lung disease or post thoracotomy or metastasis ablation.Pulmonary edema secondary to left-sided congestive heart failure can also cause crackles
(3)Egophony is most sensitive sign of lung consolidation and may be present along the top of a pleural effusion. It may also be present over a massive pleural effusion caused by significant lung compression. Extensive pulmonary fibrosis can also produce egophony.
(4)Whispered pectoriloquy evaluate for the presence of lung consolidation, which could be caused by cancer (solid mass) or pneumonia (fluid mass). 
資料來源： uptodate Geriatric Physical Diagnosis: A Guide to Observation and Assessment

## Question 24:

關於氣喘階梯式治療(stepwise therapy)的敘述,下列何者正確? (1)每周使用緩解藥物 (reliever medication)大於兩次以上, 就需規律使用控制藥物(controller medication) (2) 控制藥物的首選為吸入型類固醇(inhaled corticosteroids) (3)第一階病人僅使用吸入型 短效之乙型交感神經刺激就可以 (4)吸入型類固醇的起始劑量為中劑量(相當200 μg BID/day beclomethasone dipropionate ) (5)使用控制藥物後兩個月就可評估治療效果

---

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

### Correct Answer: B

詳 解題：
解 (1) For mild persistent asthma, the preferred long-term controller is a low dose inhaled glucocorticoid. As definition of mid persistent asthma, you should also take normal activity, lung function, and night awakening into consideration.
(5) step down if asthma is well controlled at least three moths 
延伸閱讀：
![](https://hackmd.io/_uploads/rJQXkp7On.png)

![](https://hackmd.io/_uploads/rklVkTQu2.png)

資料來源： uptodate

## Question 25:

關於特殊因子和社區性肺炎可能病原菌的組合,下列何者錯誤?

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- A. Bronchiectasis--P.aeruginosa
- B. 肺膿瘍--oral anaerobes
- C. 流感(influenza)--Klebsiella pneumoniae
- D. COPD--Haemophilus influenzae
- E. 鳥類接觸--Chlamydia psittaci

### Correct Answer: C

詳 解題：
解 (A)Bronchiectasis- common pathogens are P. aeruginosa, Burkholderia cepacia, Staphylococcus aureus (B)Lung abscess- CA-MRSA, oral anaerobes, endemic fungi, M. tuberculosis, atypical mycobacteria (C)Influenza-Influenza virus, S. pneumoniae, S. aureus (D)COPD- Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp., S. pneumoniae, Moraxella catarrhalis, Chlamydophila pneumonia (E)鳥類接觸- Chlamydophila psittaci 
延伸閱讀： Streptococcus pneumoniae is most common pathogen of CAP. The frequency and importance of atypical pathogens such as M. pneumoniae and C. pneumoniae in outpatients and Legionella in inpatients. P. aeruginosa may also infect these patients as well as those with severe structural lung disease.
Risk factors for Legionella infection include diabetes, hematologic malignancy, cancer, severe renal disease, HIV infection, smoking, male gender, and a recent hotel stay or ship cruise. Risk factors for pneumococcal pneumonia include dementia, seizure disorders, heart failure, cerebrovascular disease, alcoholism, tobacco smoking, chronic obstructive pulmonary disease, and HIV infection. Anaerobes play a significant role only when an episode of aspiration has occurred days to weeks before presentation for pneumonia. The combination of an unprotected airway (e.g., in patients with alcohol or drug overdose or a seizure disorder) and significant gingivitis constitutes the major risk factor. Anaerobic pneumonias are often complicated by abscess formation and significant empyemas or parapneumonic effusions. S. aureus pneumonia is well known to complicate influenza infection. Recently, however, MRSA strains have been reported as primary causes of CAP.
![](https://hackmd.io/_uploads/S1yBk6Quh.png)


資料來源： Harrison’s Principles of Internal Medicine , 17 edition p1621, table 251-3

## Question 26:

關於呼吸器相關肺炎(ventilator-associated pneumonia)病理機轉和相關預防策略的組合, 下列何者錯誤?

---

- A. 正常菌的減少(elimination of normal flora)--避免抗生素使用時間過長
- B. 下呼吸道抵抗力改變(altered lower respiratory host defense)--降低輸血時血紅素的閾值(hemoglobin transfusion threshold)
- C. 氣管內管周圍物質的吸入(microaspiration around endotracheal tube)--加強鎮靜
- D. 呼吸器使用時間過長--呼吸器脫離流程(weaning protocols)
- E. 胃食道逆流--prokinetic agents

### Correct Answer: C

詳 解題：
(A)Elimination of normal flora- Avoidance of prolonged antibiotic courses(B)Altered lower respiratory host defenses-Tight glycemic control; lowering of(C)hemoglobin transfusion threshold; specialized enteral feeding formula(D)Microaspiration around endotracheal tube, Endotracheal intubation -Noninvasive ventilation
(E)Gastroesophageal reflux- Postpyloric enteral feeding; avoidance of high gastric residuals, prokinetic agents 
延伸閱讀： Three factors are critical in the pathogenesis of VAP: colonization of the oropharynx with pathogenic microorganisms, aspiration of these organisms from the oropharynx into the lower respiratory tract, and compromise of the normal host defense mechanisms. Most risk factors and their corresponding prevention strategies pertain to one of these three factors.
The most obvious risk factor is the endotracheal tube (ET), which bypasses the normal mechanical factors preventing aspiration. While the presence of an ET may prevent large-volume aspiration, microaspiration is actually enhanced by secretions pooling above the cuff. The ET and the concomitant need for suctioning can damage the tracheal mucosa, thereby facilitating tracheal colonization. In addition, pathogenic bacteria can form a glycocalyx biofilm on the ET surface that protects them from both antibiotics and host defenses. The bacteria can also be dislodged during suctioning and can reinoculate the trachea, or tiny fragments of glycocalyx can embolize to distal airways, carrying bacteria with them. In a high percentage of critically ill patients, the normal oropharyngeal flora is replaced by pathogenic microorganisms. The most important risk factors are antibiotic selection pressure, cross-infection from other infected/colonized patients or contaminated equipment, and malnutrition. How the lower respiratory tract defenses become overwhelmed remains poorly understood. Almost all intubated patients experience microaspiration and are at least transiently colonized with pathogenic bacteria. However, only around one-third of colonized patients develop VAP. Severely ill patients with sepsis and trauma appear to enter a state of immunoparalysis several days after admission to the ICU—a time that corresponds to the greatest risk of developing VAP. The mechanism of this immunosuppression is not clear, although several factors have been suggested. Hyperglycemia affects neutrophil function, and recent trials suggest that keeping the blood sugar close to normal with exogenous insulin may have beneficial effects, including a decreased risk of infection. More frequent transfusions, especially of leukocyte-depleted red blood cells, also affect the immune response positively.
![](https://hackmd.io/_uploads/HksDJaXuh.png)

資料來源：
Harrison’s Principles of Internal Medicine , 17 edition p1625, table 251-6 

## Question 27:

關於造成肋膜積液(pleural effusion)的原因,下列何者是漏出液(transudate)?

---

- A. Meig's syndrome B. ovarian hyperstimulation syndrome
- C. myxedema
- D. uremia
- E. rheumatoid pleuritis

### Correct Answer: C

詳 解題：
解 (A)Meig's syndrome- exudate (B)ovarian hyperstimulation syndrome- exudate (C)myxedema- transudate (D)uremia- exudate (E)rheumatoid pleuritis- exudate

延伸閱讀： A transudative pleural effusion occurs when systemic factors that influence the formation and absorption of pleural fluid are altered. The leading causes of transudative pleural effusions in the United States are left ventricular failure and cirrhosis. An exudative pleural effusion occurs when local factors that influence the formation and absorption of pleural fluid are altered. The leading causes of exudative pleural effusions are bacterial pneumonia, malignancy, viral infection, and pulmonary embolism. The primary reason to make this differentiation is that additional diagnostic procedures are indicated with exudative effusions to define the cause of the local disease. Transudative and exudative pleural effusions are distinguished by measuring the lactate dehydrogenase (LDH) and protein levels in the pleural fluid. Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none: 
1.pleural fluid protein/serum protein >0.5 
2.pleural fluid LDH/serum LDH >0.6 
3.pleural fluid LDH more than two-thirds normal upper limit for serum
資料來源：
![](https://hackmd.io/_uploads/BJFqJTmu2.png)

Harrison’s Principles of Internal Medicine , 17 edition p1660, table 257-1 th 6. . 

## Question 28:

下列狀況最適合使用非侵襲性呼吸器(noninvasive ventilation)者為?

---

- A. 心跳停止
- B. 嚴重腸胃道出血
- C. 不穩定心絞痛
- D. 慢性阻塞性肺病急性惡化
- E. 上呼吸道阻塞

### Correct Answer: D

詳 解題：
解 Noninvasive positive-pressure ventilation using a mechanical ventilator with a tight-fitting face or nasal mask that avoids endotracheal intubation can often stabilize these patients. This approach has been shown to be beneficial in treating patients with exacerbations of chronic obstructive pulmonary disease. Noninvasive ventilation has been tested less extensively in other types of type II respiratory failure, but may be attempted nonetheless, in the absence of contraindications (hemodynamic instability, inability to protect airway, respiratory arrest). 
延伸閱讀：
![](https://hackmd.io/_uploads/S1uT1amd2.png)

資料來源： Harrison’s Principles of Internal Medicine , 17 edition p1676 th Principles and practice of mechanical ventilation, 2nd edition p437 table 19-1 7.

## Question 29:

關於阻塞性睡眠呼吸中止症(obstructive sleep apnea)的敘述下列何者錯誤?

---

- A. 可增加心肌梗塞的危險
- B. 可引起肝功能異常
- C. 可造成胰島素抗性(insulin resistance)
- D. 治療阻塞性睡眠呼吸中止症可改善中風病人的預後
- E. 會增加麻醉風險

### Correct Answer: D

詳 解題：
解 (A) observational studies suggest an increase in the risk of myocardial infarction and stroke in untreated OSAHS (Obstructive sleep apnea/hypopnea syndrome) (B)Hepatic dysfunction has also been associated with irregular breathing during sleep. Non-alcohol drinking subjects with apneas and hypopneas during sleep were found to have raised liver enzymes and more steatosis and fibrosis on liver biopsy, independent of body weight. (C)Recent data suggest that increased apneas and hypopneas during sleep are associated with insulin resistance independent of obesity. In addition, uncontrolled trials suggest that OSAHS can aggravate diabetes and that treatment of OSAHS in patients who also have diabetes decreases their insulin requirements (D)Patients with recent stroke have a high frequency of apneas and hypopneas during sleep. These seem largely to be a consequence, not a cause, of the stroke and to decline over the weeks after the vascular event. There is no evidence that treating the apneas and hypopneas improves stroke outcome. (E)Patients with OSAHS are at increased risk perioperatively as their upper airway may obstruct during the recovery period or as a consequence of sedation. 
延伸閱讀： Randomized controlled treatment trials have shown that OSAHS causes daytime sleepiness; impaired vigilance, cognitive performance, and driving; depression; disturbed sleep; and hypertension. Daytime sleepiness may range from mild to irresistible, and the sleep attacks can be indistinguishable from those in narcolepsy. The sleepiness may result in inability to work effectively and may damage interpersonal relationships and prevent socializing. The somnolence is dangerous when driving, with a three- to sixfold risk in accidents on the road or when operating machinery. Experiments with normal subjects repeatedly aroused from sleep indicate that the sleepiness results, at least in part, from the repetitive sleep disruption associated with the breathing abnormality. The possible contribution from the recurrent hypoxemia requires further evaluation.Other symptoms include difficulty concentrating, unrefreshing nocturnal sleep, nocturnal choking, nocturia, and decreased libido.Partners report nightly loud snoring in all postures, which may be punctuated by the silence of apneas. Partners often give a markedly different assessment of the extent of sleepiness. 
資料來源： Harrison’s Principles of Internal Medicine , 17 edition p1666 th 8. 

## Question 30:

實行身體檢查時,於肺部聽診,發現呼吸音減少,扣診時為dullness 者,最可能為下列何者?

---

- A. 氣胸(pneumothorax)
- B. 肋膜積液(pleural effusion)
- C. 大葉性肺炎(lobar pneumonia)
- D. 肺氣腫(emphysema)
- E. 縱膈氣腫(pneumomediastinum)

### Correct Answer: B

詳 解題：
解 Pleural effusion: percussion dullness, Fremitus decreased, breathing sound decreased, Voice transmission decreased, Adventitious Sounds absent or pleural friction rub. 
延伸閱讀：
![](https://hackmd.io/_uploads/Hyfyg6Xd2.png)

資料來源： Harrison’s Principles of Internal Medicine , 17 edition p1584, table 245-1 th 9.

## Question 31:

關於結核性肋膜炎(tuberculous pleuritis)的敘述,下列何者錯誤?

---

- A. 經常與 primary TB 有關
- B. 為淋巴球為主的滲出液(exudate)
- C. 對結核菌蛋白(tuberculous protein) 的一種過敏反應(hypersensitivity reaction)
- D. 肋膜積液為 adenosine deaminase >40 IU/L 或interferon- r<140pg/ml - E. 肋膜切片對診斷有幫助 

### Correct Answer: D

詳 解題： 解 (A)(C)- Tuberculous pleural effusions are usually associated with primary TB and are thought to be due primarily to a hypersensitivity reaction to tuberculous protein in the pleural space. (B)- the most common cause of an exudative pleural effusion is tuberculosis (D)- adenosine deaminase > 40 IU/L, interferon γ > 140 pg/Ml (E)- diagnosis can be established by culture of the pleural fluid, needle biopsy of the pleura, or thoracoscopy 
延伸閱讀： In many parts of the world, the most common cause of an exudative pleural effusion is tuberculosis (TB), but tuberculous effusions are relatively uncommon in the United States. Tuberculous pleural effusions are usually associated with primary TB and are thought to be due primarily to a hypersensitivity reaction to tuberculous protein in the pleural space. Patients with tuberculous pleuritis present with fever, weight loss, dyspnea, and/or pleuritic chest pain. 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, interferon γ > 140 pg/mL, or positive polymerase chain reaction (PCR) for tuberculous DNA). Alternatively, the diagnosis can be established by culture of the pleural fluid, needle biopsy of the pleura, or thoracoscopy.
資料來源： Harrison’s Principles of Internal Medicine , 17 edition p1666 th 10 

## Question 32:

關於肺炎嚴重度評估 CURB-65的項目,下列何者錯誤?

---

- A. 年齡
- B. 意識不清
- C. BUN
- D. CRP(C-reactive protein)
- E. 呼吸次數

### Correct Answer: D

詳 解題：
解 (A)age ≥ 65 years (B)conscious change
(C)BUN >20mg/dl (7mmol/L) (E)RR>30/min, SBP< 90, DBP<60 **The single most useful clinical sign is RR>30/min 
延伸閱讀： CURB-65 approach, modified from the British Thoracic Society (BTS) rule, is a simple and accurate way to address this issue. CURB-65, an acronym for the clinical features used to assess pneumonia severity and prognosis,18 assigns 1 point, on a 5-point scale, to confusion, blood urea 7 mmol/L (19.6 mg/dL), respiratory rate ≥30 breaths/min, blood pressure <90 mm Hg systolic or ≤60 mm Hg diastolic, and age ≥ 65 years. In one study, when the score was 0 to 1, the mortality rate was 0%, whereas mortality was more than 20% for a score of 3 or higher, and those with a score of 2 had a mortality of 8.3%. Use of the CURB-65 rules may be a problem in the elderly, reflecting the altered clinical presentations of pneumonia in this population. In one study, a rule similar to CURB-65 had a 66% sensitivity and a 73% specificity for predicting mortality in a population that included 48% of patients who were at least 75 years of age. Interestingly, although the rule was not optimal in an elderly population and did not work as well as it did in other populations, it had a higher sensitivity for predicting mortality than the Prognostic Scoring Index (PSI) derived from the PORT study. Some studies have compared the PSI and CURB-65 and found them to be similar for identifying low-risk populations, but the CURB-65 may be more discriminating for identifying poor prognosis in those with severe illness, compared to the PSI 
資料來源： Textbook of critical care 6th edition, part 3 pulmonary 

## Question 33:

關於氣喘的敘述,下列何者錯誤?

---

- A.吸入型類固醇是治療的主要藥物
- B.合併治療(ICS+LABA,inhaled corticosteroid+long acting beta adrenergic agonist)建議於step2 (含)以上之病人使用
- C.抗白三烯素(antileukotrienes)可作為controller 藥物
- D.急性惡化時可使用全身性類固醇(systemic steroid)
- E.少部分嚴重病人可使用anti-IgE

### Correct Answer: B

詳解題： 
(A)Asthma是慢性發炎的疾病,故第一線治療是吸入型類固醇(inhaled corticosteroid, ICS)
(B)GINA 2015 guideline Step2 建議使用 ICS, Step 3(含)以上才建議用ICS+LABA
![](https://hackmd.io/_uploads/rJIgg67u3.png)

(C)
如上圖,leukotriene modifier 也可用在 controller,通常會用這類藥物當controller的病人有以下幾種:
1.病人不接受ICS,或使用 ICS的side effect 太大
2.病人是aspirin sensitive asthma
3.病人combine有allergic rhinitis
(E)少數asthma病人(10-20%)對傳統治療無效,進展至Step5, 可使用Anti-IgE

## Question 34:

下列哪一個不是乙二型交感神經刺激劑的作用？

---

- A.放鬆呼吸道的平滑肌
- B.減緩咳嗽
- C.抑制慢性發炎反應
- D.增加呼吸道纖毛運動
- E.增加呼吸道黏液分泌

### Correct Answer: C

詳解題： 
Effect of β-adrenergic agonists on Airway
1)Relaxation of airway smooth muscle(proximal and distal airways)
2)Inhibition of mast cell mediator release
3)Inhibition of plasma exudation and airway edema
4)Increased mucociliary clearance
5)Increased mucus secretion
6)Decreased cough

## Question 35:

下列關於過敏性肺炎(hypersensitivity pneumonitis)臨床表徵的敘述何者不正確？

---

- A.成因是當具有特異體質的人，吸入過敏有機性物質時所致
- B.可能出現發冷、發熱
- C.在接觸過敏原後的一到兩個小時內出現呼吸困難症狀
- D.支氣管肺泡灌洗液中的CD4與CD8淋巴球細胞的比例常小於1
- E.支氣管肺泡灌洗液中肥大細胞的量可能和疾病嚴重度成正比

### Correct Answer: C

詳解題：
(A)過敏性肺炎成因:Inhaled organic agents + host susceptibility
(B)常見症狀:Cough, fever, chills, dyspnea, even cyanosis
(C)Hypersensitivity pneumonitis 主要是cell-mediated hypersensitivity, 其臨床症狀的表現可以分為3大類:
1)Acute:症狀在接觸過敏原後6-8小時出現
2)Subacute:接觸過敏原幾週後慢慢出現症狀
3)Chronic:可能由acute或subacute轉變而來,長期持續有症狀
(D)正常的支氣管肺泡灌洗液中:85% macrophage,10-15%lymphocyte,<3% neutrophil...若BAL中的lymphocyte增加,可能原因有
1)Hypersensitivity pneumonitis, organizing pneumonia(CD4/CD8<1)
2)Sarcoidosis(CD4/CD8>4)
3)Lymphoma,Lymphoid interstitial pneumonitis, collagen vascular disease...
(E)BAL mastocytosis may correlate with disease severity

## Question 36:

下列何者是目前國際間做單肺肺臟移植最常見的適應症？

---

- A.慢性阻塞性肺病(COPD)
- B.囊腫纖維化(cystic fibrosis)
- C.原發性肺纖維化(idiopathic pulmonary fibrosis)
- D.類肉瘤(sarcoidosis)
- E.原發性肺動脈高壓(idiopathic pulmonary hypertension)

### Correct Answer: A or C

根據2015年International society for heart and lung transplantation(ISHLT) 的資料 Single lung transplant(上圖左邊)的數量;最多是COPD(綠色,箭頭),第二名是IPF(黃色,斜線)
![](https://hackmd.io/_uploads/SJWzlp7dn.png)


## Question 37:

下列何者不是阻塞性呼吸睡眠中止症有關的誘發因子？

---

- A.肥胖
- B.男性
- C.下巴較小
- D.甲狀腺功能低下
- E.鼻息肉

### Correct Answer: E

Sleep apnea 成因:upper airway striated muscle relax(decreased
muscle tone) during sleep => airway narrow => snoring, hypopnea, apnea Factor predisposing to obstructive sleep apnea: Male, Obesity (BMI>30),middle age(40-65y/o), shortening of mandible/maxilla, hypothyroidism, Acromegaly, myotonic dystrophy,smoking(perhaps)

## Question 38:

下列有關原發自發性氣胸(primary spontaneous pneumothorax)的描述何者不正確？

---

- A.病患無過去肺部疾病
- B.常是肺尖的bleb破裂所致
- C.初次發生後，約有10%的機會再復發
- D.初次發生的一般治療原則是simple aspiration
- E.病患常有吸菸史

### Correct Answer: C

原發性氣胸發生的原因常是因為apical pleural blebs(指的是在visceral pleural 內或之下小的cystic space) 的破裂，幾乎只發生在吸菸者，暗示著這些患者含有潛藏的肺病(subclinical lung disease)。約有一半的患者會復發，最剛開始建議的治療是simple aspiration；若肺部沒有在aspiration後張開，或者患者有復發性的氣胸，則建議使用胸腔鏡(thoracoscopy)做stapling of blebs或pleural
abrasion，使用胸腔鏡或者是thoracotomy來pleural abrasion幾乎可以100%的預防復發。

## Question 39:

下列何者不是後縱隔腔腫瘤常見的原因？

---

- A.neurogenic tumor
- B.meningocele
- C.gastroenteric cyst
- D.bronchogenic cyst
- E.esophageal diverticulum

### Correct Answer: D

在大部分的狀況下，CT 是最有價值也是唯一需要做的檢查，而腸胃道的
barium study在後縱膈腔腫瘤的評估也是可以考慮的，因為後縱膈腔腫瘤的鑑別診斷包括了 hernia, diverticula,以及achalasia，而iodine-131 scan則可以用來診斷intrathoracic goiter。而在前縱膈腔以及中縱膈腔腫瘤的患者，確切的診斷可以藉由mediastinoscopy或者anterior mediastinotomy來得到，在大部分的個案組織學的確診可以使用percutaneous fine-needle aspiration biopsy, endoscopic transesophageal biopsy或者endobronchial ultrasound-guided biopsy；治療上，大部分的個案可以藉由video-assisted thoracoscopy來移除腫瘤。
![](https://hackmd.io/_uploads/Hk47xpXO2.png)


## Question 40:

下列關於原發性肺纖維化(idiopathic pulmonary fibrosis)的描述何者錯誤？

---

- 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

[Idiopathic pulmonary fibrosis(IPF)]
IPF 是 idiopathic interstitial pneumonia 中最常見的形式，在間質性患者的評估中，區分出來IPF是相當重要的一個步驟，IPF對治療反應特別差並且預後也不佳。
<Clinical Manifestations>
在理學檢查上，可以看到exertional dyspnea, nonproductive cough, inspiratory crackles，另外digital clubbing可有可無。而典型的HRCT可以看到patchy,predominantly basilar, subpleural reticular opacities，常伴隨有traction bronchiectasis以及honeycombing(如下圖)。在HRCT 上de finite UIP pattern可以精準預測在外科的lung biopsy上實際的UIP pattern。而影像上的extensive ground-glass abnormality, nodular opacities(upper or midzone predominance)以及明顯的hilar/mediastinallymphadenopathy，都是一些影像上非典型的表現，需考慮其他鑑別診斷。肺功能檢查常見的restrictive pattern, DLCO 降低以及運動下產生的arterial hypoxemia。
![](https://hackmd.io/_uploads/B1fNx67d3.png)

<Treatment>
IPF患者若沒有接受治療疾病會逐漸惡化且含有高死亡率，然而目前並沒有針對IPF的有效治療。Thalidomide在這類患者可以改善咳嗽的症狀，其中因為GERD造成的microaspiration在IPF的病理成因以及自然病程是有角色的，因此治療GERD對IPF是有好處的。若在IPF的患者施以下列three-drug regimen，包含了prednisone, azathioprine 以及N-acetylcysteineor warfarin，證據上顯示會增加住院率以及死亡率。IPF患者若同時產生emphysema(combined pulmonary fibrosis and emphysema[CPFE])比較容易需要長期的氧氣治療，並且容易產生肺高壓，故合併emphysema的患者其預後是相當差的。
有IPF的患者可能會因為感染、肺栓塞或者是氣胸造成次發性的惡化，在這些患者中，有1/3是死於心衰竭以及缺氧性心臟病。而這些患者常常經歷快速惡化期(Acute exacerbations of IPF)，其定義是在數天到4周間呼吸窘迫惡化；新產生且瀰漫性的ground-glass abnormality; 以及/或是在原本線狀/蜂巢狀的UIP型態上再加上新的實質化;低血氧惡化;並且在臨床上沒有肺炎、心衰竭以及敗血症。快速惡化期發生的機率約在10-57百分比。在快速惡化期後常可看到瀰漫性的肺泡損傷，目前沒有在此時其合適的治療，呼吸器支持相當常見，3/4的患者會在住院期間死亡。存活的患者仍然時常復發且伴隨著高死亡率，故應及早開始肺臟移植的評估，因為快速惡化期是無法預測的。

## Question 41:

62歲男性，過去無吸菸史，此次因咳嗽三個月都沒改善，故至門診就醫，胸部 X 光檢查顯示右側有中量肋膜積液，以細針抽吸後檢驗發現肋膜積液的 total protein 為4.8 g/dL，LDH為298 U/L，同時病患血液中的 total protein為 5.8 g/dL(正常範圍 為6.4 - 8.4 g/dL)，LDH為273 U/L(正常範圍為 131 - 250 U/L)；肋膜積液中的白血 球總數為2300 /cumm，嗜中性球為3%，淋巴球為 97%，細胞學及抗酸性染色檢查 皆為陰性。請問下列敘述何者最不適當？

---

- A. 根據 Light's criteria，此肋膜積液應為 exudate
- B. 若細胞學標本中的間皮細胞(methoselial cell)比例不到 3%，則結核性肋膜積液 的機會很大
- C. 因為要在肋膜積液中直接找到結核菌的敏感性不到 10%，所以抗酸性染色檢 查為陰性，並不能排除結核性肋膜積液的診斷
- D. 因為要在肋膜積液細胞學檢查中發現惡性細胞的敏感性超過 90%，所以細胞 學檢查為陰性，應可排除惡性肋膜積液的診斷
- E. 可考慮做肋膜切片以幫助診斷 

### Correct Answer: D

詳解題： 
A. Light’s criteria: LDH PF/Ser:273/298 exudate
B. Ｍesothelial cell 是lining pleural cavity的細胞.正常情況下是可以出現在 pleural effusion 內, 如果完全沒有表示 pleural diffuse injury or fibrin cotting. TB 不常出 現mesothelial cell除非在疾病初期,所以exudate中出現>5% mesothelial cell可以 exclude TB.
C. AFB are seen on direct smear in only 10–25% of cases
D. Pleural fluid cytology is positive in 60% of cases. However, in the remaining cases, pleural biopsy is required. Image guided biopsy and thoracoscopy have largely replaced blind biopsy due to their greater sensitivity and safety profile. CT guided biopsy has a sensitivity of 87% compared to Abrams' needle biopsy, which has a sensitivity of 47%. 
E. yes 
延伸閱讀： Tumor markers — No single pleural fluid tumor marker is accurate enough for routine use in the diagnostic evaluation of pleural effusion . Measuring a panel of tumor markers (eg, carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 125, CA 15-3, CA 19-9, cytokeratin fragment CYFRA 21-1) in pleural fluid has also been examined . At levels that provide 100 percent specificity, individual sensitivities are less than 30 percent and a combination of four markers (CEA, CA 125, CA 15-3, and CYFRA 21) only reached 54 percent sensitivity in one study. Similar results were reported in a meta-analysis that looked at various combinations . Mesothelin is a glycoprotein that is highly over expressed in malignant mesothelioma cells . Elevated levels of soluble mesothelin-related peptides (SMRPs), cleaved or unbound peptide fragments of mesothelin, have been found in pleural fluid and/or serum of patients with mesothelioma, ovarian, and pancreatic cancer. The role of SMRPs in the diagnosis of pleural mesothelioma is discussed separately.
資料來源： 1. Harrison’s Principles of Internal Medicine , 17th edition , Chapter 257, 158 2. Uptodate 3. "Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial". Lancet 361 (9366): 1326–30.doi:10.1016/S0140-6736(03)13079-6 

## Question 42:

20. 下列何處有咳嗽接受體(cough receptor)？ (1)上眼瞼，(2)鞏膜，(3)額頭，(4)口腔，(5)咽，(6)喉，(7)外耳道，(8)食道，(9)細支氣管

---

- A. (4)+(5)+(6)+(8)+(9)
- B. (2)+(5)+(6)+(8)+(9)
- C. (1)+(5)+(6)+(7)+(9)
- D. (5)+(6)+(7)+(8)+(9)
- E. (2)+(5)+(6)+(7)+(9) 

### Correct Answer: D

詳解 解題：
The cough reflex has both sensory (afferent) mainly via the vagus nerve and motor (efferent) components. Pulmonary irritant receptors (cough receptors) in the epithelium of the respiratory tract are sensitive to both mechanical and chemical stimuli. The bronchi and trachea are so sensitive to light touch that slight amounts of foreign matter or other causes of irritation initiate the cough reflex. The larynx and carina are especially sensitive, and the terminal bronchioles and even the alveoli are sensitive to chemical stimuli such as sulfur dioxide gas or chlorine gas. The rapidly moving air usually carries with it any foreign matter that is present in the bronchi or trachea. Stimulation of the cough receptors by dust or other foreign particles produces a cough, which is necessary to remove the foreign material from the respiratory tract before it reaches the lungs.
RARS, C-fibers, and SARs have been identified in the distal esophageal mucosa
延伸閱讀： Cough Reflex: http://www.healthhype.com/cough-reflex-physiology-process-ear-cough-reflexes.html 
Ganong WF, "Chapter 36. Regulation of Respiration" (Chapter). Ganong WF: Review of Medical Physiology, 22nd Edition: http://www.accessmedicine.com/content.aspx?aID=706628
資料來源：
Hall, John (2011). Guyton and Hall Textbook of Medical Physiology with Student Consult Online Access (12th ed.). Philadelphia: Elsevier Saunders.
Jump up ^ Hegland, K. W.; Bolser, D. C.; Davenport, P. W. (2012). "Volitional control of reflex cough". Journal of Applied Physiology
The cough reflex and its relation to gastroesophageal reflux. Am J Med. 2000 Mar 6;108 Suppl 4a:73S-78S.

## Question 43:

請問下列哪些情況導致呼吸困難的機轉和呼吸功(work of breath)增加無關？(1)慢性阻塞性肺病，(2)氣喘，(3)肺動脈高壓，(4)貧血，(5)心因性肺水腫，(6)非心因性 肺水腫，(7)間質性肺病，(8)去條件化(deconditioning)

---

- A. (4)+(6)+(8)
- B. (3)+(4)+(8)
- C. (2)+(5)+(7)
- D. (3)+(4)+(5)
- E. (1)+(2)+(7) 

### Correct Answer: B

詳解 解題：
On inspection, the rate and pattern of breathing as well as the depth and symmetry of lung expansion are observed. Breathing that is unusually rapid, labored, or associated with the use of accessory muscles of respiration generally indicates either augmented respiratory demands or an increased work of breathing. Asymmetric expansion of the chest is usually due to an asymmetric process affecting the lungs, such as endobronchial obstruction of a large airway, unilateral parenchymal or pleural disease, or unilateral phrenic nerve paralysis. Visible abnormalities of the thoracic cage include kyphoscoliosis and ankylosing spondylitis, either of which can alter compliance of the thorax, increase the work of breathing, and cause dyspnea. 
延伸閱讀： 
![](https://hackmd.io/_uploads/ryWreaQOn.png)

資料來源： 1. Harrison’s Principles of Internal Medicine , 17th edition , Chapter 245 

## Question 44: 

請問下列哪些原因造成的肋膜積液通常是transudate？(1)鬱血性心衰竭，(2)肝硬化，(3)肺栓塞，(4)藥物，(5)乳糜 胸，(6)上腔靜脈阻塞，(7)Dressler's syndrome，(8)Meigs' syndrome

---

- A. (1)+(2)+(3)+(6)
- B. (1)+(2)+(6)+(7)
- C. (1)+(3)+(5)+(6)
- D. (2)+(5)+(6)+(8)
- E. (1)+(2)+(5)+(6)

### Correct Answer: A

![](https://hackmd.io/_uploads/BkSUxTX_3.png)

![](https://hackmd.io/_uploads/ryK_VjID2.png)

## Question 45: 

患者主訴為吞嚥困難(dysphagia)，而且一開始發生即包括固體(solid)和流質(liquid)食物皆有問題，下列何者最不可能是此位患者吞嚥困難的原因？

---

- A. achalasia
- B. scleroderma
- C. gastroesophageal reflux disease with weak peristalsis
- D. Schatzki ring
- E. diffuse esophageal spasm 

### Correct Answer: D

![](https://hackmd.io/_uploads/Hy0g-pmd2.png)

延伸閱讀：
![](https://hackmd.io/_uploads/H1s--pQ_h.png)


資料來源： Harrison’s Principles of Internal Medicine , 17th edition , Chapter 38, chapter 286

## Question 46: 

病患主訴腹瀉3個月，糞便檢查顯示無白血球、脂肪則為陽性。下列何者最有可能是造成此位患者腹瀉的病因？

---

- A. 大腸激燥症(irritable bowel syndrome)
- B. 甲狀腺功能亢進(hyperthyroidism)
- C. 大腸絨毛性腺瘤(villous adenoma)
- D. 愛迪生氏病(Addison's disease)
- E. 細菌過度增生(bacterial overgrowth)

### Correct Answer: E

詳 解題：
由於IBS是沒有確定異常病症，其診斷主要依靠臨床特點和消除其他器質性疾 病。仔細的病史和體格檢查是確立診斷通常非常有幫助。On the other hand, the appearance of the disorder for the first time in old age, progressive course from time of onset, persistent diarrhea after a 48-h fast, and presence of nocturnal diarrhea or steatorrheal stools argue against the diagnosis of IBS. Steatorrheal causes Intraluminal maldigestion (pancreatic exocrine insufficiency, bacterial overgrowth, bariatric surgery, liver disease)
Mucosal malabsorption (celiac sprue, Whipple's disease, infections, abetalipoproteinemia, ischemia)
Post-mucosal obstruction (1° or 2° lymphatic obstruction) 
延伸閱讀：
![](https://hackmd.io/_uploads/SJjGW67d3.png)

資料來源：
Harrison’s Principles of Internal Medicine , 17th edition , Chapter 40, chapter 289
UptoDate : Approach to the adult with acute diarrhea in resource-rich countries 

## Question 47: 

患者在嘴唇有黑色的色素沈澱(如圖)，下列敘述何者錯誤？

---

- A. 腸胃道容易有息肉發生
- B. 息肉的病理型態為腺瘤(adenoma)
- C. 為自體顯性遺傳(autosomal dominant)
- D. 發生卵巢腫瘤機會增加
- E. 發生胰臟腫瘤機會增加
![](https://hackmd.io/_uploads/HJFm-aXd3.png)


### Correct Answer: B

詳 解題：
解 Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps in association with a distinct pattern of skin and mucosal macular melanin deposition. Patients with Peutz-Jeghers syndrome have a 15-fold increased risk of developing intestinal cancer compared with the general population. 
延伸閱讀： PJS is associated with an increased risk of gastrointestinal and nongastrointestinal malignancies . The most common sites for malignancy were colorectal, followed by breast, stomach, small bowel, and pancreas. Gastrointestinal cancers — Individuals with PJS have an estimated lifetime risk of gastrointestinal cancer of 38 to 66 percent. The lifetime cancer risk by organ site is as follows: 
●Colorectal – 39 percent 
●Stomach – 29 percent 
●Small bowel – 13 percent 
●Pancreas – 11 to 36 percent Other gastrointestinal tumors that have been associated with PJS include cancers of the biliary tree, gallbladder, and esophagus . The distribution of gastrointestinal cancers in PJS is similar to that of the hamartomatous polyps and carcinoma arising in hamartomas has been clearly documented . The reason for the increased risk of gastrointestinal cancer is uncertain, but does not appear to be due to increased oncogene expression, known to be involved in the adenoma-carcinoma sequence in colorectal cancer.
資料來源：
Harrison’s Principles of Internal Medicine, 17th edition, Chapter 54
UptoDate: Peutz-Jeghers syndrome 

## Question 48: 

老年患者主訴為服用藥物後，有急性發作的胸痛合併吞嚥疼痛(odynophagia)，內視鏡檢查在食道發現如圖的變化(如圖)。下列敘述何者錯誤？

---

- A. 起因於不良的服藥習慣
- B. 最容易發生於食道下端
- C. 服用nonsteroidal anti-inflammatory drugs 是可能的病因
- D. 服用bisphosphonates 也可以造成
- E. 可以處方antisecretory medications
![](https://hackmd.io/_uploads/SyO4WpXOn.png)


### Correct Answer: B

詳 解題：
解 關鍵字：藥物、急性、胸痛、吞嚥痛、胃鏡：diffuse ulcer
A. 沒錯
B. 使用NSAIDs藥物產生的消化道潰瘍以胃及 十二指腸潰瘍最多
C. 沒錯
D. 最常見ulcerogenic drugs 為NSAID, Aspirin 占絕大多數，其餘有 Cocaine, methamphetamine, Bisphosphonates, Glucocorticoids in combination with NSAIDs
E. Peptic ulcer management 
延伸閱讀：
![](https://hackmd.io/_uploads/ry2rZaQdh.png)

資料來源： 1. Harrison’s Principles of Internal Medicine , 17th edition , Chapter 42, Chapter 287 2. UptoDate :Peptic ulcer disease 

## Question 49: 

幽門螺旋桿菌(Helicobacter pylori)是造成慢性胃炎，消化性潰瘍和胃癌的主要原因，下列何項藥物不適合用於除菌的合併治療？

---

- A. omeprazole
- B. bismuth subsalicylate
- C. erythromycin
- D. metronidazole
- E. amoxicillin 

### Correct Answer: C

詳 解題：
解 在麻州手冊(第四版)建議的治療分為 Triple Rx(clarith 500 bid + amox 1g bid + PPI)和Quadruple Rx (MNZ + TCN +bismuth +PPI)，故 Erythromycin 是錯誤選項。 
延伸閱讀：
![](https://hackmd.io/_uploads/SkzDZTQuh.png)

Harrison Internal Medicine 17ed 附的表格 資料來源： Harrison Internal Medicine 17ed Pocket Medicine 4ed

## Question 50: 

有關膽酸(bile acid)的敘述，何者正確？(1)飲食成分中不含膽酸(2)腸子合成的膽酸為初級膽酸(primary bile acid) (3)經由腸子吸收的膽酸會回到肝臟，此過 程有問題會導致 steatorrhea (4)cholestyramine 可用於bile acid diarrhea (5)deoxycholic acid 和lithocholic acid 為初級膽酸

---

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

### Correct Answer: D

詳解 解題：
(2)次級膽酸 (5) deoxycholic acid 和lithocholic acid 為次級膽酸
延伸閱讀： “The primary bile acids, cholic acid and chenodeoxycholic acid (CDCA), are synthesized from cholesterol in the liver, conjugated with glycine or taurine, and secreted into the bile. Secondary bile acids, including deoxycholate and lithocholate, are formed in the colon as bacterial metabolites of the primary bile acids. However, lithocholic acid is much less efficiently absorbed from the colon than deoxycholic acid. Another secondary bile acid, found in low concentration, is ursodeoxycholic acid (UDCA), a stereoisomer of CDCA. In healthy subjects, the ratio of glycine to taurine conjugates in bile is ~3:1.”<Harrison’s Internal Medicine 17ed, CHP 305> “Ileal dysfunction caused by either Crohn's disease or surgical resection results in a decrease in bile acid reabsorption in the ileum and an increase in the delivery of bile acids to the large intestine. The resulting clinical consequences—diarrhea with or without steatorrhea—are determined by the degree of ileal dysfunction and the response of the enterohepatic circulation to bile acid losses (Table 288-2). Patients with limited ileal disease or resection will often have diarrhea but not steatorrhea. The diarrhea, a result of bile acids in the colon stimulating active Cl secretion, has been called bile acid diarrhea, or cholorrheic enteropathy, and responds promptly to cholestyramine, an anion-binding resin. Such patients do not develop steatorrhea because hepatic synthesis of bile acids increases to compensate for the rate of fecal bile acid losses, resulting in maintenance of both the bile acid pool size and the intraduodenal concentrations of bile acids. In contrast, patients with greater degrees of ileal disease and/or resection will often have diarrhea and steatorrhea that do not respond to cholestyramine. In this situation, ileal disease is also associated with increased amounts of bile acids entering the colon; however, hepatic synthesis can no longer increase sufficiently to maintain the bile acid pool size. As a consequence, the intraduodenal concentration of bile acids is also reduced to less than the CMC, resulting in impaired micelle formation and steatorrhea. This second situation is often called fatty acid diarrhea. Cholestyramine may not be effective (and may even increase the diarrhea by further depleting the intraduodenal bile acid concentration); however, a low-fat diet to reduce fatty acids entering the colon can be effective. Two clinical features, the length of ileum removed and the degree of steatorrhea, can predict whether an individual patient will respond to cholestyramine. Unfortunately, these predictors are imperfect, and a therapeutic trial of cholestyramine is often necessary to establish whether an individual patient will benefit from cholestyramine. Table 288-2 contrasts the characteristics of bile acid diarrhea (small ileal dysfunction) and fatty acid diarrhea (large ileal dysfunction).” <Harrison’s Internal Medicine 17ed, CHP 288>

資料來源： Harrison’s Internal Medicine 17ed
