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# System prepended metadata

title: '內專110年 51-96&141 缺78, 80'

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# 內專110年 51-96&141 缺78, 80

## Question 51:

51.患者因看牙醫發現於嘴唇、口腔有深棕色色素沈積，而轉診消化內科，經上、下消化道內視鏡檢查，發現  於胃及大腸有息肉，有關此病症的敘述何者為非? 

---

- A.  息肉病理為hamartoma。 
- B.  比起familial adenomatous polyposis，此種息肉轉成惡性機會較低。 
- C.  與卵巢腫瘤發生有關。 
- D.  與胰臟腫瘤發生有關。 
- E.  與口腔腫瘤發生有關。 

### Correct Answer: E 

詳解:
題目敘述為Peutz-Jeghers syndrome，與STK11突變有關。下圖為Harrison 上關於顯性遺傳為腸道瘜肉疾病的比較圖。

![](https://hackmd.io/_uploads/S1FFDxSHn.png)

Peutz-Jeghers syndrome與口腔腫瘤無關。 
另外，在男性身上，PJS 會增加Sertoli cell testicular tumors的風險 
Reference:  
1.  Harrison 20th ED. Chapter 77. Page 573. 
2.  van Lier MG, Wagner A, Mathus-Vliegen EM, Kuipers EJ, Steyerberg EW, van Leerdam ME. High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations. Am J Gastroenterol. 2010 Jun;105(6):1258-64; author reply 1265. 

## Question 52:

52.有關大腸憩室症(diverticulosis)的敘述，何者為非? 

---

- A.  通常在乙狀結腸(sigmoid colon)，但在亞洲族群，有70%發生在右側結腸。 
- B.  是60歲以上病患發生下消化道出血最常見旳原因。 
- C.  aspirin 及NSAID 不會增加此類患者下消化道出血的風險。   
- D.  以腹痛、發燒、白血球增加為表現的憩室炎可以先用抗生素治療。 
- E.  憩室炎可進展成穿孔及腹膜炎。 

### Correct Answer: C 
 
詳解: 
Aspirin與NSAIDs 會增加diverticulitis與diverticular bleeding的風險 
Reference: Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology. 2011 May;140(5):1427-33. 

## Question 53:

53.患者因腹痛、噁心、嘔吐及發燒到急診，腹部電腦斷層檢查如圖，按壓此病患左下腹時造成右下腹明顯疼痛，此現象稱為?

![](https://hackmd.io/_uploads/HkFJuxHB3.png)

---

- A.  Rovsing’s sign。 
- B.  Obturator sign。 
- C.  Iliopsoas sign。 
- D.  Murphy’s sign。 
- E.  Cullen’s sign。 

### Correct Answer: A 

詳解: 
題幹圖片顯示wall thicking of appendix and peri-appendiceal fat stranding，是典型急性盲腸炎。(Harrison 20th, Chap324, p.2301) (圖片一模一樣) 
 
如果在CT 上看到以下情形，要合理懷疑有急性盲腸炎： 
(1). Enlarged appendiceal diameter > 6mm with an occluded lumen. 
(2). Appendiceal wall thickening (>2mm) 
(3). Peri-appendiceal fat stranding 
(4). Appendiceal wall enhancement 
(5).有盲腸糞石  (Appendicolith) 
(A). Rovsing’s sign：壓左下腹時，右下腹會疼痛。又稱indirect tenderness，暗示有右側局部的peritoneal irritation。 
(B). Obturator sign：屈曲右髖骨和右膝後，接著內轉右髖骨，會造成右下腹痛。因為骨盆腔內的盲腸位於閉口內肌上，內轉造成擠壓疼痛。但這檢查的sensitivity  只有8%，低到沒人想要做這檢查。 
(C). Iliopsoas sign：右髖骨往後伸展(extension)時，腰大肌從後方壓迫盲腸，造成右下腹疼痛。 
(D). Murphy sign：吸氣時，壓迫右上腹，碰觸到發炎的膽囊時造成疼痛。 
(E). Cullen’s sign：肚臍周遭的表皮水腫和瘀青，暗示出血性胰臟炎。 
(Uptodate: Acute appendicitis/clnical manifestation) 


## Question 54: 
 
54.患者因上腹痛反射至背部，合併噁心、嘔吐至急診，血液檢查 amylase和lipase值均有3倍以上的增加，下列何者不屬於判斷此病嚴重度的BISAP score? 

---

- A.  BUN>25mg/dL。 
- B.  Impaired mental status。 
- C.  SIRS:2  ≧  of 4 present。 
- D.  Amylase>2000 IU/L。 
- E.  Pleural effusion。 

### Correct Answer: D 
 
詳解: 
急性胰臟炎的診斷，要符合以下其中二項： 
(1). 典型上腹痛，並輻射痛到背部 
(2). Serum lipase and/or amylase >=3倍以上 
(3). CT 影像符合急性胰臟炎的表現 
 (Harrison 20th, Chap341, p.2440) 

![](https://hackmd.io/_uploads/ByBIulHS3.png)


## Question 55:

55.Statement on management strategy for patients with autosomal dominant polycystic kidney disease (ADPKD), which is incorrect: 

---

- A. Dietary salt restriction may be beneficial in the management of ADPKD。 
- B. Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are the first-line antihypertensive drugs in ADPKD。 
- C. Nonsteroidal anti-inflammatory drugs (NSAIDs) is more effective and safe than acetaminophen or tramadol for cystic pain relief in ADPKD patients。 
- D. Oral tolvaptan can slow the increase in total kidney volume and the decline in kidney function of ADPKD patients。 
- E. ADPKD patients can be a recipient for renal transplantation。 

### Correct Answer: C 
 
詳解:

![](https://hackmd.io/_uploads/ryF3tWSSn.png)

(A) We advise all PKD patients to restrict dietary sodium, with a goal of 2 grams intake per day or less. In order to ensure adherence, the authors measure a 24-hour urine sodium and obtain a nutrition consult at least once during the course of the management. 
Ref:   Uptodate:Autosomal dominant polycystic kidney disease (ADPKD): Treatment 
(A) CRISP study:Adherence to dietary sodium restriction, as reflected by degree of reduction in urinary sodium, was moderate and variable among participants. Higher sodium excretion was associated with an increased risk of kidney growth and eGFR decline 
Ref: Dietary salt restriction is beneficial to the management of autosomal dominant polycystic kidney disease 
(B) ACE inhibitor should be the initial antihypertensive agent. PATHOGENESIS:Increased activity of the renin-angiotensin system (RAS) and extracellular volume expansion are often present early in ADPKD (prior to loss of kidney function) and may play an important role in the rise in blood pressure. It has been suggested that cyst expansion, leading to focal areas of kidney ischemia and enhanced renin release 
Ref: Uptodate:Autosomal dominant polycystic kidney disease (ADPKD): Evaluation and management of hypertension 
(C) No specific treatment is required in most PKD people with dull or persistent flank and abdominal pain; pain medications such as acetaminophen are often recommended. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, is not recommended, 
(D) Tolvaptan is a vasopressin V2-receptor (V2R) antagonist with proven beneficial results in ADPKD Mechanism: In animal models, vasopressin activates the V2R, triggering a cascade of cellular proliferation, thereby leading to cystogenesis. Conversely, sustained suppression of vasopressin production, release, or action results in lower cyst burden, preserved kidney function Candidates for treatment:eGFR) ≥25 mL/min1.73 m2 and who are at risk of rapid progression as below: 
                Mayo classes 1C, 1D, or 1E;   
                Age ≤55 years and an eGFR <65 mL/min/1.73 m2 
                Kidney length >16.5 cm in a patient aged <50 years   
                PROPKD score >6 
Ref: Uptodate:Autosomal dominant polycystic kidney disease (ADPKD): Treatment 
(E) Patients with ADPKD and ESKD have equivalent, or perhaps better, overall outcomes with any kidney replacement therapy compared with non-ADPKD patients. Suitable for kidney transplant 
Intracranial aneurysms occur in approximately 5 to 20 percent of patients with ADPKD. Pre-OP screening was needed 

## Question 56:

56.A 54 y/o diabetic female patient with 4 days of fever, respiratory symptoms and dyspnea. At emergency service, physical examination revealed postural hypotension, tachycardia, and Kussmaul respiration. Laboratory tests were: blood glucose level of 385 mg/dL. The arterial pH is 7.35, pCO₂ is 22 mm Hg,pO₂ 86 mmHg, HCO₃⁻ 14 mEq/L. Serum electrolyte values were: Na 130 meq/L; K 5.1 meq/L; Cl 96 meq/L; Chest x-ray film indicated consolidation of bilateral lower lobe. Which of the following statements is most likely to be true? 
(1)The patient has respiratory acidosis, possibly related to pneumonia 
(2)The patient has metabolic acidosis, possibly related to diabetes 
(3)The patient has respiratory alkalosis, possibly related to pneumonia 
(4)The anion gap is still within normal range 
(5)Be cautious with hyperphospatemia during combined insulin and glucose therapy 

---

- A. (1)+(2)+(5)。 
- B. (1)+(2)+(4)+(5)。 
- C. (2)+(3)+(5)。 
- D. (2)+(3)。 
- E. (2)+(3)+(4)。 
 
### Correct Answer: D 

詳解: 
The arterial pH is 7.35, pCO₂ is 22 mm Hg,pO₂ 86 mmHg, HCO₃⁻ 14 mEq/L 
第一步看PH值  7.35 偏酸 
第二步看代償  HCO₃⁻ 低為代謝酸 
↓PaCO ₂=1.25*△[HCO₃⁻ ] -> 1.25*10=12.5 ± 2 
△  PaCO ₂ =40-22=18>14.5  合併呼吸鹼 
Na 130 meq/L; K 5.1 meq/L; Cl 96 meq/L 第三步看陰離子間隙(AG) 
AG=[Na]-([CI]+[HCO₃⁻])=130-(96+14)=20 
△  AG=20-10=10,  △  [HCO₃⁻]=10,比值為1 
Only High anion gap acidosis 
(5)Increased insulin levels promote the transport of both glucose and phosphate into skeletal muscle and liver. However, in normal subjects the administration of insulin or glucose leads only to a slight decrement of serum Pi levels.
Ref:Medication-induced hypophosphatemia: a review 
In DKA treatment:we do not recommend the routine use of phosphate replacement. However, phosphate replacement should be strongly considered if severe hypophosphatemia occurs (serum phosphate concentration below 1 mg/dL) 
Ref: Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment 

## Question 57:

57.A middle aged woman was referred to renal clinic for evaluation of her renal disorder. She had intermittent pre-tibial swelling for almost 3 months. She has mild hypertension, but no diabetes. Neither viral hepatitis B nor C history. Laboratory tests were: albumin 3.1 g/dL, creatinine 1.7 mg/dL, Both serum complement levels (C3 and C4) are low, with a particularly depressed C4 compared with C3. 
Which of the following should be considered ? 

---

- A. Cryoglobulinemia。 
- B. Post-streptococcal glomerulonephritis。 
- C. Membranoproliferative glomerulonephritis。 
- D. Lupus nephritis, stage III or V。 
- E. Infectious endocarditis or shunt nephritis。 

### Correct Answer: A 

詳解: 
(A)  題目中  with a particularly depressed C4 compared with C3 為關鍵提示 
Type I cryoglobulins typically produce few serologic complement abnormalities. Mixed cryoglobulinemia sera often demonstrate reduced levels of total hemolytic complement (CH50) and early complement proteins C1q, C2, and C4, particularly in type II cryoglobulinemia. Levels of C3 are generally unaffected or only mildly diminished 
Ref: Uptodate:Overview of cryoglobulins and cryoglobulinemia  

![](https://hackmd.io/_uploads/B1ZoqWrr2.png)

## Question 58:

58.Struvite stones occurs in patients of repeated urinary tract infections (UTI) from bacteria that produce the enzyme urease, including both gram-positive and gram-negative species. Which is the least possible micropathogen causing struvite stone and repeated UTI? 

---

- A. Klebsiella spp。 
- B. Escherichia coli。 
- C. Mycoplasma spp。 
- D. Staphylococcus epidermidis。 
- E. Proteus。 

### Correct Answer: B 
 
詳解: 
Struvite (magnesium ammonium phosphate) stones are a subset of kidney stones that form as a result of UTI with urease-producing pathogens 
Bacteria that produce the enzyme urease, including both gram-positive and gram-negative species from genera such as Proteus, Staphylococcus,    Pseudomonas, Providencia, and Klebsiella 
Ref: Renal struvite stones—pathogenesis, microbiology,    and management strategies 
(C) A genital mycoplasma, is predominantly located in the human genito-urinary tract and produces urease. Its possible role in the formation of infection stones was studied in the rat model described by Friedlander and Braude 


## Question 59: 
 
59.Which are correct statements regarding hyperuricemia and related nephropathy? 
(1)The renal tubular transporters responsible for determining how much of the filtered uric acid is actually excreted are located in the distal nephron 
(2)Renal clearance of uric acid can be inhibited by the angiotensin-converting-enzyme inhibitors or by β-Blockers. 
(3)Initiation of colchicine can induce acute flares of gout 
(4)Initiation of allopurinol or febuxostat can induce acute flares of gout 
(5)Routine use of allopurinol (100-300 mg/day) in patients with stage 3-4 CKD can slow kidney disease progression 

---

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

### Correct Answer: D 

詳解:
(1) Reabsorption 與secretion 都主要在proximal tubule進行 

![](https://hackmd.io/_uploads/rydSs-rH3.png)


![](https://hackmd.io/_uploads/BJa8sZrr3.png)

(2) Current use of diuretics, β blockers, angiotensin converting enzyme inhibitors, and non-losartan angiotensin II receptor blockers among those with hypertension were all associated with an increased risk of developing gout. (Losartan reduces serum uric acid levels by 20-25% by producing a uricosuric effect) 
(3) Colchicine可用於gout flares 以及prophylaxis during initiation of urate-lowering therapy 
(4) An acute fall in serum urate concentration often precipitates a gout flare. A tenable explanation for the mechanism is that urate lowering disrupts the physical state and/or surface chemical composition of preformed crystal deposits and thus makes the component crystals interactive with local cells competent in initiating IL1-mediated acute inflammatory responses emanating from activation of toll-like receptors and the formation of NALP3 inflammasomes (Ref: Uptodate: Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout) 
(5) In patients with chronic kidney disease and a high risk of progression, urate-lowering treatment with allopurinol did not slow the decline in eGFR as compared with placebo.(Ref: Badve SV et al. Effects of allopurinol on the progression of chronic kidney disease. N Engl J Med 2020 Jun 25; 382:2504.) 

## Question 60:

60.A 26-year-old girl of type I diabetes had poor appetite and body weight loss for 3 kg (6%) in recent one month. After admission, she received partial parenteral nutrition due to anorexia and poor oral intake. Hypophosphatemia (0.8 mg/dL) was noticed on the third day of admission. 
The most likely mechanism for her acute hypophosphatemia is: 

---

- A. Acute stage of diabetic ketoacidosis。 
- B. Hungry bone syndrome。 
- C. Primary hypoparathyroidism。 
- D. Renal phosphate wasting。 
- E. Shift of phosphorus into intracellular stores 

### Correct Answer: E 

詳解:

![](https://hackmd.io/_uploads/BkF2oWHBh.png)

(A) In DKA, net (urinary) loss of phosphate occurs because of a transcellular shift, osmotic diuresis and reduced renal phosphate reabsorption by the Na-Pi transporters in the renal proximal tubule (due to acidosis and hyperglycemia). During insulin and fluid repletion in the treatment phase of DKA, phosphate shifts from the extracellular to the intracellular compartment, worsening hypophosphatemia. 
Ref: van der Vaart A et al. Incidence and determinants of hypophosphatemia in diabetic ketoacidosis: an observational study. BMJ Open Diabetes Research and Care 2021;9:e002018. doi: 10.1136/bmjdrc-2020-002018 
(B) Hungry bone syndrome: Parathyroidectomy in patients with preexisting osteopenia can rarely result in marked deposition of calcium and phosphate in bone in the immediate postoperative period. Probably results from acute reversal of the PTH-induced contribution of bone to maintenance of the serum calcium concentration. In the high turnover state associated with hyperparathyroidism, PTH increases bone formation and resorption with a net efflux of calcium from bone. Sudden withdrawal of PTH causes an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption, leading to a marked net increase in bone uptake of calcium, phosphate, and magnesium 
Ref: Uptodate: Hungry bone syndrome following parathyroidectomy in end-stage kidney disease patients 
(C) Most patients with hypoparathyroidism have an elevated serum phosphorus level 
(D) There are several rare syndromes characterized by isolated renal phosphate wasting. The resulting hypophosphatemia is the primary cause of rickets 
(E) Refeeding syndrome: the clinical complications that can occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients. The pathogenesis of hypophosphatemia begins when stores of phosphate are depleted during episodes of anorexia nervosa and starvation. When nutritional replenishment starts and patients are fed carbohydrates, glucose causes release of insulin, which triggers cellular uptake of P (K, Mg) and a decrease in serum phosphorous levels. Insulin also causes cells to produce a variety of molecules that require P (eg, ATP and 2,3-diphosphoglycerate), which further depletes the body’s stores of phosphate 
Ref: Uptodate: Anorexia nervosa in adults and adolescents: The refeeding syndrome 

## Question 61:
 
61.A 50-year-old male visited outpatient clinic due to difficult-to-control hypertension. After initial work up, hypokalemic hypertensive disorder was impressed, Further laboratory evaluation of adrenal hormones including plasma renin, aldosterone, cortisol, and androgen levels were arranged to distinguish among specific diagnoses. The results are: high renin level, high aldosterone level, an aldosterone-to-renin ratio of 10 : 1 ; and a normal serum cortisol level
Which is the most possible diagnosis? 
 
---

- A. ACTH-secreting tumor。 
- B. Bartter syndrome。 
- C. Liddle syndrome。 
- D. Primary hyperaldosteronism。 
- E. Unilateral renal artery stenosis。 

### Correct Answer: E 
 
詳解: 
(A) Cortisol level 應會升高 
(B) Bartter syndrome: result from a defect in sodium chloride reabsorption in the cortical and medullary thick ascending limbs of the loop of Henle. Patients have low to normal blood pressure, despite activation of the renin-angiotensin system. Low to normal blood pressure results from chronic extracellular fluid volume depletion caused by salt wasting along the thick ascending limb and paradoxical vasodilation. Volume-independent production of renin by juxtaglomerular cells contributes to hyperreninemia in patients with the Bartter-like phenotype. Decreased sodium chloride entry into macula densa cells also stimulates renin production. This volume-independent hyperreninemia, in combination with chronic extracellular fluid volume depletion, is responsible for the high circulating levels of angiotensin II and aldosterone. 
Ref: Uptodate: Inherited hypokalemic salt-losing tubulopathies: Pathophysiology and overview of clinical manifestations 
(B) Bartter syndrome: 

![](https://hackmd.io/_uploads/ryAIhZSHh.png)
 
(C) Liddle‘s syndrome: rare genetic disorders associated with abnormalities in the function of the collecting tubule sodium channel. The genetic abnormality in Liddle's syndrome involves gain-of-function mutations to SCNN1A, SCNN1B, and SCNN1G, which encode the alpha, beta, and gamma subunits of the epithelial sodium channel (ENaC), respectively. Deletions or substitutions in a short proline-rich segment of the intracytoplasmic C-terminus cause an inability of these subunits to bind with an intracellular ubiquitin protein ligase (Nedd4) that normally removes the luminal sodium channel from the cell surfac. Failure to remove sodium channels results in an inability to reduce their number in response to low levels of aldosterone that result from the volume expansion-mediated suppression of renin secretion. These mutations result in a "gain-of-function" that mimics the effects of hyperaldosteronism. The consistent findings among such individuals are low plasma renin activity and, in contrast to primary aldosteronism, reductions in both the plasma aldosterone concentration and urinary excretion of aldosterone (Ref: Uptodate: Genetic disorders of the collecting tubule sodium channel: Liddle's syndrome) 
(D) The plasma renin concentration are typically very low (due in part to the associated mild volume expansion) in patients with primary aldosteronism. The mean value for the aldosterone-to-renin ratio in normal subjects and patients with primary hypertension is 4 to 10. In general, a aldosterone-to-renin ratio greater than 20 is considered suspicious for primary aldosteronism, although others use a cutoff criterion of 30 
Ref: Uptodate: Diagnosis of primary aldosteronism 
(E) 

![](https://hackmd.io/_uploads/rJgi2bSr3.png)

## Question 62: 
 
62.Laboratory indices for differentiation of prerenal versus Intrinsic renal azotemia.   
Which of the followings prefers pre-renal azotemia? 

---

- A. High urine Na concentration >20 (mmol/L)。 
- B. High Urine specific gravity >1.020。 
- C. Low urine osmolality <300 (mosmol/kg H₂O)。 
- D. High renal failure index (UNa/UCr/PCr) >1。 
- E. Urinary sediment analysis reveals a lot of muddy-brown granular casts and casts containing tubular epithelial cells。 

### Correct Answer: B 

詳解: 

![](https://hackmd.io/_uploads/B1IR3WBS3.png)

![](https://hackmd.io/_uploads/H1VJaZSB2.png)


## Question 63:
 
63.下列何種情況會造成高血磷症（Hyperphosphatemia）? (1)維生素D 中毒  (2)代謝性鹼中毒  (3)原發性副甲狀腺機能亢進  (4)嚴重低血鎂症（Severe hypomagnesemia)）  (5)腫瘤溶解症候群(tumor lysis syndrome,TLS) 

---

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


### Correct Answer: E 
 
詳解: 
Ref: Uptodate: Overview of the causes and treatment of hyperphosphatemia 
Ref: J Clin Invest. 1964 Jan;43(1):138-49. doi: 10.1172/JCI104888. 
(1) Vitamin D increases intestinal phosphate and calcium absorption, and the rise in serum calcium concentration diminishes urinary phosphate excretion, both by inhibiting PTH secretion and, in many cases, by impairing kidney function (in part due to direct renal vasoconstriction). 
(2) The fall in partial pressure of carbon dioxide during acute respiratory alkalosis results in intracellular pH stimulates phosphofructokinase activity which in turn stimulates glycolysis and increases the formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle, serum phosphate concentrations fall rapidly. 
(3) Any cause of hypersecretion of PTH can lead to hypophosphatemia. PTH increases phosphate excretion by diminishing activity of sodium-phosphate cotransporters. Most patients with primary hyperparathyroidism have mild hypophosphatemia. 
(4)   Low magnesium levels impair PTH release in response to hypocalcemia. Diminished PTH secretion appears to require more severe hypomagnesemia. Deficient PTH secretion results in increased phosphate reabsorption and leads to hyperphosphatemia. 
(5) The phosphorus concentration in malignant cells is up to four times higher than in normal cells. Thus, rapid tumor breakdown often leads to hyperphosphatemia, which can cause secondary hypocalcemia, leading to tetany or seizures.

![](https://hackmd.io/_uploads/r1PHaWSHh.png)

## Question 64:

64.一位74歲糖尿病女性患者合併慢性腎臟病第四期，長期服用口服降血糖用藥搭配胰島素控制，由於意識不清醒被送到急診就醫，經檢查有代謝性酸中毒(metabolic acidosis)，其陰離子隙(anion gap)為 26mmol/L，經積極使用碳酸氫鈉（sodium bicarbonate)矯正，仍無法控正，下列何種用口服降血糖藥物可能為誘發的原因？ 

---

- A.  二肽基肽酶-4抑制劑（Dipeptidyl peptidase-4 inhibitor）。 
- B.  過氧化物酶體增殖物活化受體γ（PPAR-γ）。 
- C. α-葡萄糖苷酶抑制劑(α-glucosidase inhibitor)。 
- D.  二甲雙胍類降血糖藥物  (Metformin)。 
- E.  磺醯基尿素(sulfonylurea)。 

### Correct Answer: D 

詳解: 

![](https://hackmd.io/_uploads/S1o_T-SS2.png)

Ref: J Nephrol. 2016 Dec;29(6):783-789 
Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA) Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn 

## Question 65:

65.一位 60歲男性高血壓肥胖患者，近幾個月血壓升高以 4種降壓劑控制，血壓為166/92 mmHg。病患無家族高血壓病史，一年前檢查雙側腎在大小一致約 11cm，腎臟功能正常。安排腎臟超音波檢查後發現:  右腎10.6 cm,  左腎 8.6 cm，血液生化檢驗顯示：肌酸酐(Creatinine) 2.0 mg/dL。以下敘述，何者最正確? 

---

- A.  9成以上患者在理學檢查有腹部雜音(bruit)且檢查血鉀[K]通常會升高。 
- B.  如果腹部雜音偏側化或延伸到整個收縮期到舒張期，則它更有可能在血流動力學上具有顯著意義。 
- C.  用核磁共振血管攝影(MRA)影像檢查，如果發現renal artery stenosis，通常以fibromuscular dysplasia (FMD)型最常見。 
- D.  降壓劑中，以ACEI  或ARB類為首選用藥。 
- E.  高血壓的原因屬先天性異常，與血清膽固醇較無關係，無需使用 HMG-CoA還原酶抑制劑(statins)控制膽固醇。 

### Correct Answer: B 

詳解:
Ref: 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases’European Heart Journal, Volume 39, Issue 9, 1 March 2018, Pages 763–816 
(A) Renal hypoperfusion causes a BP increase secondary to activation of the sympathetic nervous systemand the renin–angiotensin–aldosterone system (RAAS), thus increase potassium secretion 
(B) Abdominal bruit is common in normotensive patients aged 15–30 years. high-pitched systolic-diastolic bruit is distinctive for renovascular hypertension and is uncommon in essential hypertension 
(C) Age>50 male, more likely to be atherosclerosis type 

![](https://hackmd.io/_uploads/H1ePCZSH2.png)

(D) 

![](https://hackmd.io/_uploads/B1ku0ZBB2.png)

(E) Statins are associated with improved survival, slower lesion progression and reduced restenosis risk after renal stenting 

## Question 66:

66.有關慢性間質性腎臟病常見之臨床表現，下列敘述何者正確(應選出所有答案) (1)范康尼氏症候群(Fanconi syndrome) (2)寡尿（Oliguria）與等張尿（isosthenuria）(3)貧血  (4)高陰離子間隙代謝性酸中毒合併低血鉀  (5)腎病症候群 

---

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


### Correct Answer: E 

詳解:
Ref: Atlas of Renal Pathology II|Volume 70, ISSUE 1, e1-e2, July 01, 2017 
(1) Chronic interstitial nephritis is a nonspecific diagnosis of a pattern of kidney injury. Patients may present at any age, usually with low-grade proteinuria and slowly progressive decline in glomerular filtration rate, and may reach end-stage kidney disease. Fanconi syndrome may be present, with glycosuria and aminoaciduria. 
(2) increased risk of dehydration secondary to polyuria and enuresis (especially in children), unresponsive to vasopressin 
(3) Early in the course secondary to destruction of erythropoeitin (EPO) producing interstitial cells 
(4) Lack of aldosterone (secondary to hyporeninemic hypoaldosteronism) or tubular unresponsiveness induce hyperkalemia 
(5) Patients usually do not have significant proteinuria, and nephrotic syndrome occurs in <1 percent of patients with CIN 
 
## Question 67:

67.一名45 歲女性患有糖尿病，因明顯疲勞而就診。抽血檢查顯示：血清尿素氮 (BUN) 為100 mg/dL，血清肌酐酸為 2.5 mg/dL。 評估需要哪些初步處置？ 

---

- A. 安排腎臟超音波及腎臟組織切片檢查。 
- B.  葡萄糖耐受試驗。 
- C. 轉介到運動復健中心鍛鍊。 
- D. 血紅素（Hb）及大便潛血檢查。 
- E.  限制病友蛋白攝取。 

### Correct Answer:  D 

詳解: 
Ref: Harrison’s 20e Chap 48 & 304.  
Ref: Uptodate: Etiology, clinical manifestations, and diagnosis of volume depletion in adults 

![](https://hackmd.io/_uploads/H1TCA-rH3.png)

A.腎臟超音波為恰當的初步處置，可排除post-renal lesions, 但侵入性的腎臟切片，非初步處置 
B.葡萄糖耐受試驗用於診斷糖尿病，對於診斷AKI原因沒有幫助 
C.應先釐清AKI原因 
D.BUN/Crea ration: 100/2.5= 40, favor prerenal AKI, hypovolemia should be considered. 

![](https://hackmd.io/_uploads/rywW1GrHh.png)

Otherwise, BUN/serum creatinine ratio increases markedly in upper GI bleeding. Two reasons: the extracellular fluid volume is decreased due to the blood loss, which increases proximal tubule urea reabsorption; and the rate of urea production is increased due to the catabolism and absorption of blood proteins from the gastrointestinal tract. 
E.應先釐清AKI原因

## Question 68:

68.  一名 23 歲的男性研究生，因一次無痛性明顯血尿由學校保健中心轉診到腎臟科門診。他身體健康，沒有明顯的家族史。身體診察時血壓正常，無其他異常。追蹤實驗室檢查顯示生化及血液學正常、腎功能檢查正常，以及尿培養陰性。血清免疫學檢測包括補體、抗核抗體(ANA)、抗中性粒細胞胞漿抗體(ANCA)和肝炎檢測均呈陰性。尿液試紙檢查顯示:潛血(2+)和蛋白質(+)，顯微鏡檢查中有少許型變RBC 但並無RBC cast。他的腎臟超音波檢查是正常的。1 週後重複體檢和實驗室檢查顯示尿液潛血1+ 和紅血球細胞5至8個紅細胞和微量尿蛋白，定量為 150 毫克/天。下列何者是最適當建議 

---

- A. 繼續追蹤觀察。 
- B. 腎臟組織切片檢查。 
- C. 對患者及其家屬進行基因檢測。 
- D. 開始類固醇經驗性治療。 
- E. 泌尿科轉診查明原因。 


### Correct Answer:  A 
 
Ref: Uptodate(Etiology and evaluation of hematuria in adults; Isolated and persistent glomerular hematuria in adults) 
 
-Dysmorphic RBC (+) → Glomerular hematuria

![](https://hackmd.io/_uploads/BJkIJGSS3.png)

-Isolated glomerular hematuria: asymptomatic patient who has a normal rate of albumin excretion, a normal serum creatinine concentration, and normal blood pressure 
-Isolated hematuria should initially be reexamined over a period of one to four weeks to ascertain if the hematuria is persistent, because transient hematuria is a relatively common finding over time in adults and may be induced by factors such as exercise or infection 
-Most adult cases of persistent isolated hematuria due to glomerular disease are attributable to immunoglobulin A (IgA) nephropathy, Alport syndrome, or thin basement membrane nephropathy. Less common causes: mild postinfectious 
glomerulonephritis, C3 glomerulopathy 

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

-§ A kidney biopsy can help to distinguish between the most common causes of isolated and persistent glomerular hematuria. However, the risks of kidney biopsy should be weighed against the potential benefits of establishing a diagnosis (eg, predicting prognosis and genetic counseling in patients found to have Alport syndrome) and potential therapies. Since there are no specific therapies for patients with Alport syndrome, thin basement membrane nephropathy, or IgA nephropathy with isolated hematuria, patients should be informed that conservative monitoring (ie, urinalysis and measurement of serum creatinine and urine protein excretion on an annual basis) is also an option, and a kidney biopsy can be deferred until the patient develops signs of progressive renal disease (eg, increasing serum creatinine or urine albumin excretion >30 mg/day). 

## Question 69:

69.一名 68歲患有腎病症候群女性（尿蛋白3 .5 g/天，腎功能正常，血清白蛋白2 .2 g/dL）最近經腎臟切片診斷為膜性腎病變（membranous nephropathy）。血清PLA2R 檢測和腎組織染色呈均為陰性。以下相關的敘述何者「錯誤」 

---

- A. 進一步調查應包括惡性腫瘤檢查。 
- B.  患者應開始交替使用環磷醯胺（cyclophosphamide）和類固醇。 
- C. 發生血栓事件的風險很大，出血風險低的患者可以考慮預防性抗凝劑。 
- D. 她應該接受B 型肝炎篩查，已知B 型肝炎與膜性腎病有關。 
- E.  如果經過 6 個月後其蛋白尿仍保持目前狀況，她的腎臟功能可能出現進行性腎病的風險 


### Correct Answer:  B 
 
詳解:
- A.  A&D: 病人為Non-PLA2R-associated MN，有可能是非PLA2R 的抗體造成的primary MN, 也有可能是Secondary MN, Malignancy & HBV were possible causes of secondary MN 

![](https://hackmd.io/_uploads/SJb1eGBH3.png)

- B.  If primary MN: 此病人為Low risk of progression, 應觀察3-6個月 
If secondary MN: Treat underlying cause 

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

- C.  *Clinically apparent venous thromboembolic events occur in about 7% of patients with membranous nephropathy. Hypoalbuminemia, particularly<2.8 g/dl, is the most significant independent predictor of venous thrombotic risk. (Ref: Clin J Am Soc Nephrol. 2012;7(1):43) 
* If this patient had no other underlying disease and medication, her HAS-BLED score was 1 point(Age >65), and serum Alb < 3g/Dl. Prophylactic anticoagulation was suggested. (Ref: Kidney Int Rep. 2020 Apr; 5(4): 435–447) 

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

- E.  Spontaneous remissions (complete and partial) of proteinuria, usually accompanied by stable renal function, eventually occur in 40% to 50% of patients and the remainder slowly progress to end-stage renal disease (ESRD) or die of complications or from unrelated disease after 5 to 15 years. Factors associated with a progressive course include older age at onset, male gender, persisting hypertension, hyperlipidemia and/or hypoalbuminemia, reduced renal function at discovery, persisting nephrotic range glomerular proteinuria, concomitant tubular proteinuria, and advanced glomerular damage with chronic tubulointerstitial fibrosis. (Ref: Semin Nephrol. 2003;23(4):324. ) 


## Question 70:

70.腎前性氮血症(Prerenal azotemia)的診斷必須經由適當的病史詢問和理學檢查後確立, 下列尿液和血 清檢驗可用於幫助確認腎前性氮血症的診斷? 

---

- A. 尿素氮(BUN)與肌酸酐(creatinine)的比值大於 20。 
- B.  鈉排泄分率(fractional excretion of sodium,FeNa)小於 1% 。 
- C. 尿液滲透壓(urine osmolality)大於500 (mOsm/kg H2O)。 
- D. 尿液鈉濃度大於 20 (mEq/L) 。 
- E.  尿液比重大於1.020。 

### Correct Answer:  B 

詳解:

![](https://hackmd.io/_uploads/rymdlGSS3.png)

A. 尿素氮(BUN)與肌酸酐(creatinine)的比值大於 20。 
B. 鈉排泄分率(fractional excretion of sodium,FeNa)小於 1% 。 
C. 尿液滲透壓(urine osmolality)大於500 (mOsm/kg H2O)。  
D. 尿液鈉濃度大於 20 (mEq/L) 。 
E. 尿液比重大於1.020。  
Ref: Harrison’s 20e Chap 48 

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

C: Urine osmolarity (cid:0) X 
Fractional excretion of sodium (FeNa) was one of the first urine chemistries applied to differentiating pre-renal AKI from acute tubular necrosis (ATN). It is based on the premise that intact tubules reabsorb sodium in the pre-renal setting whereas injured tubules in the context of ATN do not.  
Ref:  Espinel CH: The FENa test. Use in the differential diagnosis of acute renal failure. JAMA. 1976, 236: 579-581. 
Perazella MA, Coca SG: Traditional urinary biomarkers in the assessment of hospital-acquired AKI. Clin J Am Soc Nephrol. 2012, 7: 167-174.  

## Question 71:

71.急性腎損傷後需要緊急透析是嚴重腎臟損傷的指標,患者的合併症和死亡率增加。關於急性腎損傷的透析 治療,下列敘述何者是正確的? 

---

- A. 應該需要高強度的透析頻率和時間,以便為患者提供最合適的體內恆定環境。  
- B. 急性腎損傷患者開始透析的主要原因包括酸中毒、高血鉀和全身體液過多。 
- C. 與間歇性血液透析相比,連續腎臟替代治療已被證明對患者有更好的結果。 
- D. 透析開始時的血清肌酐高低與急性腎損傷患者的預後負相關。  
- E. 敗血症(sepsis)患者早期開始透析可改善預後 
 

### Correct Answer: B 

詳解:
A:應該需要高強度的透析頻率和時間,以便為患者提供最合適的體內恆定環境。  (cid:0) X 在ATN  研究中,將 1124 位需要 腎臟替代療法的急性腎損傷患者隨機分為標準治療組或強化治療組,並比較兩組的亡率和腎功能的恢復結果。 比較結果顯示死亡率或腎功能恢復無明顯差異。 在RENAL  研究中將 1,508 名急性腎損傷患者隨機分為強化治療組(40 mL/kg/h 連續性血液透析過濾術)或標準治療組(25 mL / kg / h 連續性血液透析過濾術),比 較兩組的死亡率和腎功能的恢復。同樣的,本研究中的死亡率或腎功能恢復方 面也未顯示任何顯著差異。 
Ref:  
Palevsky PM. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008;359:7-20.  
Bellomo R Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J 
Med 2009;361:1627-38 
B:急性腎損傷患者開始透析的主要原因包括酸中毒、高血鉀和全身體液過多 (cid:0) O 
Indications for urgent dialysis (when condition refractory to conventional therapy)  
Acid-base disturbance: refractory acidemia 
Electrolyte disorder: hyperK; hyperCa, hyperPO4, tumor lysis syndrome 
Intoxications   
Indicated for: methanol, ethylene glycol, metformin, Li, valproic acid, salicylates, barbiturates, theophylline, thallium 
Consider for: carbamazepine, APAP, dig (Rx Digibind), dabigatran, (Rx idarucizumab) 
Overload: refractory hypervolemia → hypoxemia (eg, CHF)  Uremia: pericarditis, encephalopathy, bleeding 
C:與間歇性血液透析相比,連續腎臟替代治療已被證明對患者有更好的結果。 -> X 
就重症急性透析患者的臨床預後而言,是否連續性腎臟替代療法優於間歇 性腎臟替代療法仍存在爭議。許多系統性回顧發現兩種治療方式,在加護病房死亡率,住院死亡率,住院天數, 皆無顯著差別。

![](https://hackmd.io/_uploads/S1xbZMzSHh.png)

D:透析開始時的血清肌酐高低與急性腎損傷患者的預後負相關。X  
E:敗血症(sepsis)患者早期開始透析可改善預後X 
目前對於啟動透析時間點的研究大都是回溯性和觀察性的研究。近期幾個 前瞻性隨機對照研究結果顯示,早期啟動腎臟替代療法對於急性腎損傷 患者的存活率、住院日數、與腎功能的恢復皆無顯著改善,甚至可能增加低血 磷、出血、與透析導管感染等副作用。僅有一個隨機對照研究結果支持及早 開始透析,針對外科手術病患(尤其是開心手術),早期啟動腎臟替代療法可 能降低死亡率,同時有助於腎功能的恢復 


## Question 72:

72.有關腎小管腎絲球回饋(Tubuloglomerular Feedback,TGF)的敘述何者正確? 

---

- A.  腎小管腎絲球回饋是指遠側腎小管對尿液滲透壓的感覺信號對單個腎元單位腎絲球過濾率(glomerular filtration rate,GFR)的回饋調節 
- B.  糖尿病初期會造成出球小動脈壁中的顆粒細胞將腎素大量釋放到循環中。  
- C.  腎素分泌後,進一步活化腎素-血管收縮素系統(renin-angiotensin system,RAS)收縮入球小動脈。  
- D.  緻密斑(macula densa)細胞,感知到大量鈉/氯離子時,代謝增加腺苷(Adenosine)含量,讓入球小動脈舒張。  
- E.  糖尿病患者使用SGLT-2 抑制劑阻斷葡萄糖與鈉再吸收,會使入球小動脈收縮,從而使同一腎元單位 的腎小球過濾率減少。 

### Correct Answer: E 

詳解: 
Tubuloglomerular Feedback,TGF 
The macula densa is a collection of densely packed epithelial cells at the junction of the thick ascending limb (TAL) and distal convoluted tubule (DCT). 
The macula densa uses the composition of the tubular fluid as an indicator of GFR. A large sodium chloride concentration is indicative of an elevated GFR, while low sodium chloride concentration indicates a depressed GFR.  
Sodium chloride is sensed by the macula densa mainly by an apical Na-K-2Cl cotransporter (NKCC2). The usual situation that causes a reduction in reabsorption of NaCl via the NCC2 at the macula densa (DCT) is a low tubular lumen concentration of NaCl due to low GFR. Reduced NaCl uptake via the NCC2 at the macula densa leads to increased renin release, which leads to restoration of plasma volume, and to dilation of the afferent arterioles, which leads to increased renal plasma flow and increased GFR. 

A.腎小管腎絲球回饋是指遠側腎小管對尿液滲透壓離子濃度的感覺信號對單個腎元單位腎絲球過濾率(glomerular filtration rate,GFR)的回饋調節 
B.糖尿病初期會造成出球小動脈壁中的顆粒細胞將腎素Ang ll 大量釋放到循環中。
Ref: Hoong Sern Lim; Robert J. MacFadyen Arch Intern Med. 2004;164(16):1737-1748. 
C.腎素分泌後,進一步活化腎素-血管收縮素系統(renin-angiotensin system,RAS)收縮舒張入球小
動脈。
D.緻密斑(macula densa)細胞,感知到大量鈉/氯離子時,代謝增加腺苷(Adenosine)含量,讓入球小動脈舒張收縮。 
E.糖尿病患者使用SGLT-2 抑制劑阻斷葡萄糖與鈉再吸收,會使入球小動脈收縮,從而使同一腎元單位
的腎小球過濾率減少。 
Ref: Andrianesis, Vasileios et al. “The renal effects of SGLT2 inhibitors and a mini-review of the literature.” Therapeutic advances in endocrinology and metabolism vol. 7,5-6 (2016): 212-228. doi:10.1177/2042018816676239  

![](https://hackmd.io/_uploads/r1OkVMrHh.png)

## Question 73:

73.病人82 歲老太太因突漸嚴重性呼吸困難而住院，她三十年前就有心雜音可聞知，唯未曾進一步診療。從五年前開始就有運動難受，伴有運動性心悶，經檢查確認心臟擴大，在以後的歲月，症狀逐漸加劇，特別在運動或攀登樓梯中，休息即可改善。住院前三日，突然在凌晨發作呼吸困難。時，T/P/R：36.4/90/16；  BP，110/62 mmHg；jugular vein engorgement；bilateral basal chest with crackles；heart，normal heart border，Gr.III systolic murmur over RUSB with carotid transmission，S2 diminished；otherwise unremarkable。Chest X- ray & ECG如圖所示。請問病人最可能的診斷是： 

![](https://hackmd.io/_uploads/rk2WXa7S3.png)

![](https://hackmd.io/_uploads/B19GmTQH3.png)

---

- A.  僧帽瓣狹窄(Mitral stenosis)。 
- B.  僧帽瓣閉鎖不全(Mitral regurgitation)。 
- C.  主動脈瓣狹窄(Aortic stenosis)。 
- D.  主動脈瓣閉鎖不全(Aortic regurgitation)。 
- E.  正常心臟。 

### Correct Answer: C

詳解: 
根據前面臨床症狀描述懷疑 valvular heart disease uncontrolled, complicated with chronic heart failure, EF to be determined. 
入急診PE jugular vein engorgement + bilateral basal chest with crackles 懷疑 fluid overload + 左心功能異常 
重點Gr.III systolic murmur over RUSB with carotid transmission，S2 diminished 表示高度懷疑AS. 
複習一下 AS staging,  臨床表現和預後之關係: 

![](https://hackmd.io/_uploads/SJHP7T7B3.png)

![](https://hackmd.io/_uploads/HyP_7aQB3.png)

Reference:
(1)Braunwald E. Aortic Stenosis: Then and Now. Circulation. 2018 May 15;137(20):2099-2100. doi:10.1161/CIRCULATIONAHA.118.033408. Epub 2018 Apr 12. PMID: 29650546. 


## Question 74:

74.臨床上會造成病患的一氧化碳肺瀰散量(diffusion capacity of carbon monoxide，DLCO)下降的常見原因不包括：

---

- A. 肺氣腫。
- B. 肺動脈高壓。
- C. 氣喘急性發作。
- D. 肺纖維化。
- E. 貧血。 

### Correct Answer: C

詳解: 

![](https://hackmd.io/_uploads/r1VKkySrh.png)
 
Ref: Nguyen LP, Harper RW, Louie S. Using and interpreting carbon monoxide diffusing capacity (Dlco) correctly. Consultant. 2016;56(5):440-445 

## Question 75:

75.有關大腸直腸癌(colorectal cancer)篩檢(screening)策略，何者正確? 
(1)不論男女，50歲以上即必需篩檢 
(2)有1個小於1公分的管狀腺瘤(tubular adenoma)者，應在1年後重做大腸鏡 
(3)一級血親有大腸癌病史  者，篩檢年齡為50歲 
(4)目前台灣是使用糞便潛血免疫反應法做篩檢 
(5)有遺傳性大腸癌症候群(hereditary nonpolyposis colorectal cancer)家族史者可於30歲即開始篩檢 

---

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

### Correct Answer: E 

詳解:

![](https://hackmd.io/_uploads/ryQqueBH2.png)


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

(1)：正確。Average rsik從50歲開始定期追蹤 
(2)：錯。1個小於1公分的管狀腺瘤(tubular adenoma)屬於increased risk中的low risk，7-10年後重做大腸鏡即可 
(3)：錯。一級血親有大腸癌病史  者，篩檢年齡應為40歲 
(4)：正確。 
(5)：正確。 

## Question 76:

76.一位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 
 
In pregnant women with nonsevere hypertension, our preference is to start treatment with either labetalol, a long-acting calcium channel blocker (eg, extended-release nifedipine), or methyldopa   
Ref: Chronic hypertension in pregnancy: Preconception, pregnancy, and postpartum issues and management 
It is well accepted that angiotensin-converting enzyme (ACE) inhibitors are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage. 
Ref:Taking ACE inhibitors during early pregnancy Is it safe? 
 
## Question 77: 
 
77.Clostridium difficile 感染，下列敘述何者正確？ 

---

- A. C. difficile 是不會產生孢子的革蘭氏陽性桿菌，故 70%酒精具有此菌良好之殺菌力。 
- B. 以大腸鏡檢查偽膜性腸炎(Pseudomembranous colitis)之敏感性很高，因此腸鏡檢查若無出現病灶則可排除此診斷。 
- C. 致病力可能和 toxin A和toxin B相關，toxin A是cytotoxin, toxin B是 enterotoxin。 
- D. 對於首次輕度 C. difficile 腸炎，首選治療藥物為口服 metronidaozle 治療10到14天。 
- E. 對於首次 C. difficile 腸炎重度患者，首選治療藥物為針劑 vancomycin 治療10到14天。 

### Correct Answer: D

詳解：(此題為 105年隻字未改考古題，106年類似題) 
(A) 困難梭狀芽孢桿菌(Clostridium difficile)是一種革蘭氏陽性、厭氧、會產生內孢子和分泌毒素的桿菌。(Gram-positive, anaerobic, spore-forming, toxin-producing bacillus)。酒精不會破壞孢子，需用肥皂洗手才能預防孢子傳播。 
(B) 內視鏡發現的偽膜性(約直徑兩公分白黃病灶，不規則的分布在正常黏膜組織間，且不會被沖洗掉)不一定出現在每個 CDI 的病患，且無偽膜性腸炎也不能排除感染。例如：反覆CDI 或發炎性腸炎併 CDI 患者幾乎不會有偽膜性腸炎。而偽膜性腸炎也可能源於其他疾病，包含：Behcet’s disease,   inflammatory bowel disease,  其他感染(CMV, Ecoli O157)等。 
(C) 當正常腸道菌叢被破壞時，C. difficile  成為支配並占據大腸的主要菌叢，但僅一部份帶菌的患者產生CDI 症狀，其源於酵素及毒素，以破壞表皮細胞並引起發炎等。其中最主要的兩個毒素(toxin A, B)，雖然傳統上將 toxin A  命名為 “enterotoxin A”；toxin B命名為“cytotoxin B”，因過去動物實驗中 toxin A是最主要的毒素來源，而 toxin B只有在A破壞組織後才有作用，但其實兩者皆具腸毒性(enterotoxic)和細胞毒性(cytotoxic)。另有Clostridium difficile binary toxin(CDT)是部份困難梭狀桿菌產生的另一種毒素。 
(D) (E) 2014 ESCMID 建議口服Metronidazole 為治療CDI 輕症，而口服 Vancomycin  適用於較嚴重CDI。然而，後續的研究及2021 IDSA指引都建議Fidaxomicin>>Vancomycin>>Metronidazole 
(如下圖所示) 
Eur J Clin Microbiol Infect Dis. 2019; 38(7): 1211–1221. 
Clinical Infectious Diseases, Volume 73, Issue 5, 1 Sep. 2021, Pages e1029–e1044 

2021 IDSA Clostridium difficile guideline  建議治療CDI 的選項 

![](https://hackmd.io/_uploads/BkrAVfBS3.png)

![](https://hackmd.io/_uploads/S1dxHzrH2.png)


## Question 79:

79.一位 40歲病人抱怨胃痛，內視鏡檢查發現胃竇(gastric antrum)有一腫瘤，病理切片檢查顯示為mucosa-associated lymphoid tissue lymphoma，CD20陽性及 H. pylori陽性，分期檢查未發現其他異常。下列何者為此病人最適當的第一線治療？ 

---

- A. Eradication of H. pylori。 
- B. Rituximab。 
- C. Chemotherapy。 
- D. Rituximab + Chemotherapy。 
- E. Local irradiation。 

### Correct Answer: A


詳解：(此題為 105年隻字未改考古題) 
Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma)  為一種extranodal marginal zone B cell lymphoma，即在淋巴組織外產生淋巴樣的組織，又分為 gastric 和non-gastric，前者約占三分之一。
治療上，早期(stage I為主，沒有其他nodal involvement)的gastric MALT lymphoma 且H. pylori (+)病人，能透過治療 H. pylori 感染而痊癒(需在三個月追蹤內視鏡檢查和 restage)。而H. pylori (-)患者，則選用放射治療(主要)或Rituximab。 

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

2021 NCCN  guideline: B-cell lymphoma- gastric  MALT lymphoma 

![](https://hackmd.io/_uploads/Sk38rfHS2.png)

## Question 81:

81.有關 COVID-19的治療，以下何者正確，請選出最適當的答案 
(1)單獨使用抗病毒藥 Remdesivir 對疾病輕、重症患者之預後都有極為顯著之效果。 
(2)單株抗體 Bamlanivimab + Etesevimab 主要作用於病毒 spike glycoprotein，對於疾病輕微或中度而有重症危險因素如年紀≥65 歲、肥胖(BMI ≥35)，有慢性腎病、慢性肺病、心血管疾病、高血壓、糖尿病、免疫抑制患者，於發病診斷 3天內使用，可降低住院和死亡之風險。 
(3)單株抗體 Bamlanivimab + Etesevimab 對南非變異株(B.1.351, β)和巴西變異株(P.1, γ)在體外中和試驗效果變差，而單株抗體 Casirivimab + Imdevimab 則對前述病毒變異株之體外中和試驗效果未改變。 
(4)IL-6 receptor blocker 如Tocilizumab 建議與 dexamethasone 合併使用於嚴重肺炎。 
(5)JAK抑制劑 Baricitinib，不可與dexamethasone 合併使用。 

---

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

### Correct Answer: B

詳解: 
(1) Remdesivir 適合住院且有氧氣需求的病人，其中僅需些微氧氣治療的病人可以考慮單用，重症(如使用葉克膜、呼吸器，HFNC)不建議單用，在插管病人上可考慮 Remdisivir 和類固醇併用。 

![](https://hackmd.io/_uploads/rkusrGrS2.png)

(2) 此選項在 2021 年12月前都還在CDC指引上。bamlanivimab+ etesevimab  為anti-SARS-CoV-2 單株抗體(mAbs)，選項中敘述的族群為當初收錄在臨床試驗中的對象(BLAZE-1)，為 mild to moderate COVID-19 且高風險進展為嚴重疾病的族群，於發病診斷 3 天內使用，可降低住院和死亡之風險。
但針對 2022目前美國主流的 Omicron，因其spike protein有眾多的突變，因此 CDC已經不建議使用 bamlanivimab + etesevimab 或 casirivimab + imdevimab。針對未來 Omicron 大勢，只能期待以下單株抗體：Sotrovimab(2003 SARS分離出來)，Tixagevimab+ cilgavimab(in vitro 有效但盛行率高時不得而知)，並建議在此一高風險族群上，加上 3天IV針劑的 Remdesivir 使用。 
(3) 如下圖，bamlanivimab + etesevimab 對(B.1.351, β)和 (P.1, γ)在體外中和試驗效果變差，而casirivimab + imdevimab 未改變。 

![](https://hackmd.io/_uploads/Hk_3LfHS2.png)

(4) Tocilizumab 與類固醇併用於嚴重肺炎(HFNC,  呼吸器等) (5) JAK inhibitor如aricitinib 或tofacitinib，併用類固醇以治療COVID 肺炎需氧氣治療的患者。CDC不建議併用 JAK inhibitor 和IL-6 receptor blocker  
Ref: Coronavirus Disease  2019 (COVID-19)  Treatment Guidelines (CDC, 2022) 
 
## Question 82:

82.接種腺病毒載體 SARS-COV-2疫苗偶發血栓性血小板低下(thrombotic thrombocytopenia)，以下描述何者錯誤? 

---

- A. 大多發生於接種疫苗後 5至30天。 
- B. 常見腦靜脈血栓、腹腔內靜脈血栓或肺栓塞。 
- C. 表現與 heparin-induced thrombocytopenia很像，與病人最近有使用heparin有關。 
- D. 病人血清中可測到對抗血小板第 4因子(platelet factor 4)的血小板活化抗體，該抗體可經由與血小板Fcγ接受器而活化血小板。 
- E. 治療建議以 nonheparin 抗凝血劑或IVIG。 

### Correct Answer: C

詳解： 
Thrombosis with Thrombocytopenia Syndrome (TTS)，又名 Vaccine-induced Thrombotic Thrombocytopenia(VITT)  較易發生於腺病毒載體 SARS-COV-2 疫苗COVID 後，並需符合以下5項診斷條件：接種 4-42天內、動靜脈血栓(常見於腦部或腹部)、血小板低下、血清中可測到對抗血小板第4 因子(platelet factor 4, PF4)的血小板活化抗體、D-dimer 上升大於正常值上限四倍。病生理機轉和 autoimmune heparin-induced thrombocytopenia(aHIT )  類似，可檢驗到如同 HIT表現的強陽性 antiPF4/heparin（polyanion）抗體。 
若發現血栓即血小板低下且懷疑此疾病，需避免使用 heparin (直到能完全排除 VITT)，避免輸注血小板並建議以 nonheparin抗凝血劑或 IVIG治療。 

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


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

## Question 83:

83.一位 58歲男性因為髖骨骨折接受手術，手術後發生 MRSA 感染，於住院後接受清創手術及vancomycin 注射，治療三週進步後出院。出院時使用口服 linezolid治療，請問在門診追蹤下列哪一項較不重要? 

---

- A. Linezolid不可與單胺氧化酶抑制劑(monoamine oxidase inhibitor)或selective serotonin re-uptake inhibitor 共同使用。 
- B. 要注意是否有乳酸中毒現象。 
- C. 會造成 QTc prolongation。 
- D. 使用超過 2週有骨髓抑制風險。 
- E. 使用超過 4週有視神經和周邊神經病變之風險。 

### Correct Answer: C

詳解： 
Linezolid為oxazolidinone 類抗生素，resistent Enterococcus Faecium，Staphylococcus aureusStreptococcus 等革蘭氏陽性菌。副作用可能造成腹瀉、嘔吐或頭痛，其他重要仿單警語如下： 
  超過兩周可造成骨髓抑制 
  超過四周可能出現週邊神經及視神經病變 
Linezolid 本身即為一單胺氧化酶抑制劑(monoamine oxidase inhibitor，因此不可與其他單胺氧化酶抑制劑(monoamine oxidase inhibitor)併用。而與 selective serotonin re-uptake inhibitor 共同使用，易引發Serotonin syndrome，也需避免和腎上腺素類(adrenergic)共同使用。 
(C)QT prolongation 的抗生素常見於quinolone 及macrolide 類。 
 
## Question 84:

84. 一位 35歲男性到急診就醫，主訴腹部不適、嘔吐和稀大便 5天，發燒也越來越嚴重，也有頭痛和皮膚疹。身體診察體溫 40°C，血壓 100/70mmHg，心搏 62/分，呼吸 20/分，BMI 26，明顯生病樣。在下胸和上腹部有變淡的紅斑疹，他的鞏膜變黃，結膜充血，咽部較紅，而觸診有肝脾腫大和壓痛。CBC血色素12 g/dl，白血球4500/cumm，多形核白血球 68%，band form 10%，淋巴球 16%，單核球 6%，血小板90000/cumm，AST 120u/L，ALT 240u/L，二套血液培養為格蘭氏陰性菌。最可能的診斷及其治療? 

---

- A.  鈎端螺旋體感染，ciprofloxacin。 
- B. 傷寒，ceftriaxone。 
- C. 退伍軍人病，ciprofloxacin。 
- D. 李斯特菌感染，ampicillin。 
- E. 布氏桿菌病 (brucellosis)，doxycycline。 

### Correct Answer: B

詳解： 
關鍵字：高燒但心跳慢(relative bradycardia)，且血液培養出GNB，腸胃道症狀、肝脾腫大、紅疹。 
(A) 鉤端螺旋體(Leptospirosis)為人畜共通疾病，鼠類、野生哺乳動物或家畜其腎臟慢性感染後，由尿液排大量菌至水及土壤，人類經皮膚黏膜傷口接觸到汙染的水或土壤而感染。鉤端螺旋體為革蘭氏陰性螺旋菌(Spirochetes)。輕症似感冒症狀(占80-90％常被忽略而自癒)，重症(10～20％，致死率高)則導致衛氏病(Weil syndrome)，包含黃疸、腎炎、多器官出血。潛伏期通常為 10天(2～30天)。 
臨床症狀包含：急性發燒、頭痛、肌肉痛（尤其常見小腿肚痛）、腹痛、腹瀉、倦怠，結膜出血，無菌性腦膜炎（aseptic meningitis），無尿、少尿或蛋白尿，黃疸，急性腎功能不全，腸道或肺出血。 
治療最好是在發病 5天之內。不必等實驗室檢查的結果，因病發大約 1週血清學檢查才會出現陽性，培養鑑定鉤端螺旋體更需要花上數週的時間。症狀嚴重應用高劑量靜脈注射青黴素Aqua Penicillin 1.5-3 MU Q6H至少7日。症狀較不嚴重選用doxycycline(最佳)，Amoxicillin、Ampicillin。第三代 Cephalosporins，例如 Ceftriaxone，Cefotaxime，及  Quinolone 類抗生素也有效。需注意 Jarisch - Herxheimer reaction 可能在使用青黴素治療之後短暫時間因細菌大量死亡釋放出內毒素，出現病情暫時惡化之現象。 
(B) 沙門桿菌(Salmonella)為革蘭氏陰性腸道桿菌，依多醣體抗原可再區分為數類。根據致病的嚴重度分為 
a. Typhoid fever: S. typhi(傷寒)、S.paratyphi A(副傷寒) 
b. Nontyphoid salmonellosis. typhimurium, S. enteritidis 
患傷寒或副傷寒常見症狀有：持續性發燒、頭痛、不適、厭食、腹痛、便祕或腹瀉、相對性心律減慢、肝脾腫大、身軀出現紅疹(Rose spot)等。發病初期可由患者血液中分離出病菌，1週後可由尿液及糞便中分離(非腸內正常菌叢)。骨髓培養之敏感性最高，以抗生素治療後，仍可能由骨髓中分離病菌。血清學 Widal Test 之靈敏度及特異性有限，檢驗結果僅供參考。 因食物、飲水被患者、帶菌者糞便及尿所污染而傳染。感染者約有2~5％成為帶菌者(較好發於中年婦女及膽道病變者)。傷寒潛伏期 8-14天（3-60天不等）；副傷寒潛伏期 1- 10天。 治療首選為 Ceftriaxone，輕症可考慮 Azithromycin，重症(腸穿孔、mycotic aneurysm, 休克等)加上Meropenem。Ciprofloxacin 在美國、伊拉克、巴基斯坦因抗藥性漸增應避免經驗性使用。 
(C) 退伍軍人菌(Legionella)為革蘭氏陰性呼吸道桿菌，培養時需要半胱胺酸（L-cysteine）及其他營養素，以血清型第一型最常引起疾病。臨床上區分： 
a. 退伍軍人病（Legionnaires’ disease）：開始時有共同的明顯症狀：厭食、身體不適、肌痛與頭痛等。通常在 1天之內會快速發燒 39.0～40.5℃且伴隨畏寒，乾咳、腹痛及下痢等症狀，胸部Ｘ光會出現肺部實質化且可發展至肺兩側，最後則呼吸衰竭，死亡率可高達 15.0％，若患者免疫能力有障礙，死亡率會更高。 
b. 龐提亞克熱（Pontiac fever）：開始的共同症狀外，不會引起肺炎或死亡，病人通常在1週內會自癒，多半因吸入病原菌而產生。 
主要存於水溶液中，經由吸或嗆入帶菌的氣霧或水滴而致病。治療首選為Levofloxacin/Moxifloxacin  或 Azithromycin, doxycycline 亦為選項之一，療程7-10天，嚴重疾病或免疫不佳的病人可延長至 14-21 天。 
(D) 李斯特菌症（Listeriosis）由單核細胞增多性李斯特菌（Listeria monocytogenes）感染，為一革蘭氏陽性桿菌。疾病嚴重程度取決於受感染者的免疫狀況，分為以腸胃炎自限性症狀的非侵襲性感染，及可導致敗血症及中樞神經系統的侵襲性感染（腦膜炎最為常見），主要發生在孕婦、胎兒、新生兒、免疫力低下者及年長者。傳染途徑是食物，亦可由孕婦胎盤傳染給胎兒。治療選用Ampicillin 及Penicillin，或合併Gentamicin 加成，若對Penicillin過敏可考慮 TMP/SMX 
(E) 布氏桿菌病 (brucellosis)  致病菌為人畜共通的革蘭氏陰性球桿菌。臨床症狀為發燒(波浪式的反覆性發燒(undulant fever))、全身倦怠、出汗、頭痛、肌肉酸痛、腹痛等。有時候僅出現不明原因發燒或伴隨發燒之慢性關節炎。較少見包括鞏膜炎、神經炎、腦膜炎、主動脈炎或心內膜炎等。常見於畜牧業發達的國家，人經由接觸感染動物組織、食入乳製品而感染。根據台灣 CDC，2011年前台灣已有30年未有感染案例，此後僅零星境外移入病例。治療選用Doxycycline+Gentamycin 或 Rifampin，療程至少六週，偶有復發(通常發生在停藥六個月內)，通常是有病灶未完全解除，而非抗藥性。 
 
Ref: 台灣CDC各傳染病核心教材 

## Question 85:

85. 被動物咬傷時有所聞,當病患被咬傷後到醫院就醫,你除了處理傷口外,下列敘述何者不正確? 

---

- A. 狗咬和貓咬的致病菌包括金黃色葡萄球菌、巴士德桿菌(Pasteurella multocida)和厭氧菌。 
- B. 優先考慮的抗生素是 amoxicillin/clavulanate 或ampicillin/sulbactam。 
- C. 如病人有 penicillin過敏史,可用clindamycin + trimethoprim-sulfamethoxazole 或fluoroquinolone。 
- D. 需考慮狂犬病預防。 
- E. 被猴子咬傷也是選擇 amoxicillin/clavulanate 治療, 無需考慮抗病毒藥的使用。

### Correct Answer: E

詳解： 
(A)狗咬傷的致病菌常混合多種，包含 Pasteurella species、β-hemolytic streptococci、Staphylococcus species (含methicillin-resistant Staphylococcus aureus(MRSA)和Staphylococcus intermedius)、Neisseria species (常為 Neisseria weaveri, 以前叫CDC group M-5)、Eikenella corrodens、Capnocytophaga canimorsus，也可能有厭氧菌如Actinomyces、Fusobacterium、Prevotella、Porphyromonas species。貓咬傷的致病菌則和狗咬傷的致病菌類似，以 Pasteurella multocida 占大宗，除上述致病菌外，貓咬傷也可能造成狂犬病(rabies)、破傷風(tetanus)、貓抓病(cat-scratch disease，致病菌為 Bartonella henselae)、兔熱病(tularemia，致病菌為Francisella tularensis)、孢子絲菌病(sporotrichosis，致病菌為Sporothrix schenckii)。    Ref: Harrison 20e Ch. 136 
(B)(C)針對狗咬傷和貓咬傷的抗生素，如果能有 Gram’s stain 和培養最好。經驗性抗生素要能對(A)裡面提到的細菌有效，首選藥物為廣效 penicillin 和β-lactamase 抑制劑的複方藥如amoxicillin/clavulanic acid、ticarcillin/clavulanic acid、ampicillin/sulbactam。第二、第三代cephalosporin 如cefuroxime、cefoxitin、cefpodoxime 再加上能殺厭氧菌的 clindamycin 或metronidazole 也可以考慮。如果對penicillin過敏(尤其是immediate-type hypersensitivity讓使用cephalosporin 也有疑慮時)，可以使用clindamycin 加trimethoprim-sulfamethoxazole 或fluoroquinolone的處方。Azithromycin 對多數致病菌也有效，但對 P. multocida、E. corrodens、
地區抗藥性不同而差異很大，所以只有在沒有其他替代藥物時才考慮使用。抗生素通常會使用 10-14
天。    Ref: Harrison 20e Ch. 136 
(D)動物抓咬傷後的狂犬病免疫球蛋白和狂犬病疫苗使用原則依各地流行病學和公衛政策有所不同。
根據台灣疾管署的使用規範如下

![](https://hackmd.io/_uploads/B1q1KfHBn.png)

(E)被Macaca 屬的舊世界猴咬傷時可能會感染 B virus(=Macacine herpesvirus 1=Herpesvirus simiae=Cercopithecine herpesvirus)，人類感染此病毒後會在傷口出現水泡、潰瘍，局部淋巴結會腫脹，10天候出現發燒、頭痛、肌肉痛、腹痛等症狀，嚴重者可能會侵犯中樞神經系統。此病毒無疫苗，若醫師評估有感染疑慮，可考慮投予抗疱疹病毒藥物(valacyclovir、acyclovir、ganciclovir)。  
Ref: Harrison 20e Ch. 136、皰疹B病毒感染症防治工作手冊 

## Question 86:

86.病史詢問可提供敗血症病原重要線索, 以下哪些狀況要想到鉤端螺旋體病之風險? 
(1)洪水氾濫後 
(2)在溪流河川活動 
(3)廚師 
(4)從事農田、獸醫或畜牧工作 
(5)到三溫暖泡足部溫泉 

---

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

### Correct Answer: D

詳解： 
鉤端螺旋體病(leptospirosis)為依人畜共通疾病，可存於幾乎所有哺乳類動物，傳染途徑為接觸被感染動物的尿液、血液、組織，最常見的感染途徑為暴觸到汙染環境。接觸動物或被動物尿液汙染的水源、土壤就有可能被感染。高風險職業含獸醫、農場工人、汙水處理工人、地下水道工人、屠宰場員、漁業員、畜牧業者、軍人。水上娛樂活動如獨木舟、風帆、游泳、滑水、泛舟，或洞穴探險、叢林探險、野營也會增加感染機會。洪水氾濫後常見大流行。   
(3)廚師會頻繁接觸動物體液和屍體所以有感染風險，但 Harrison、疾管署網站、uptodate的高風險職業內並未提到廚師。 
Ref: Harrison 20e Ch. 179、鉤端螺旋體病傳染病防治手冊 

## Question 87:

87.考量抗生素的特性及抗藥性問題, 在台灣目前經驗性抗生素在下列哪些情況不建議以fluoroquinolone  當作第一線治療?(1)急性化膿性扁桃炎(2)急性膀胱炎(3)足癬合併下肢蜂窩組織炎(4)急性腦膜炎(5)急性腹瀉 

---

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

### Correct Answer: D

詳解： 
(1)急性化膿性扁桃炎常見致病原為 group A, C, G streptococci，病毒如HSV也可能會有化膿。針對group A streptococci 可以用penicillin 或cephalosporin，fluoroquinolone、tetracycline、sulfonamide 類抗藥性都很高故不適合  
Ref Harrison 20e Ch. 31、熱病 App ver 5.1.2 
(2)第一線 TMP-SMX、nitrofurantoin，第二線 beta-lactam、fosfomycin，fluoroquinolone 易養出抗藥性細菌且藥價高故能不用則不用 
Ref Harrison 20e Ch. 130 
(3)常見致病菌為 S. aureus 和group A, B, C, G streptococci，首選藥物為beta-lactam們、clindamycin 
(4)腦膜炎致病菌為 GNB且對beta-lactam全抗藥或有過敏史時可以考慮 ciprofloxacin、moxifloxacin 
Ref 熱病  App ver 5.1.2 
(5)台灣和東亞的 E. coli、shigella、salmonella 對fluoroquinolone的抗藥性高，有需要使用抗生素時，可考慮口服 azithromycin 或針劑三代 cephalosporin 
Ref 熱病  App ver 5.1.2、uptodate 

## Question 88:

88.有一位 23歲男性因高燒不退一週而來住院, 他於三週前全身長滿水痘, 於二週前水痘已漸結痂。住院身體診察體溫 40°C, 血壓140/50mmHg,  心跳136/min,呼吸22/min,  結膜發紅, 胸部X光檢查沒有明顯肺浸潤現象, CBC呈現Hgb 12 gm/dL, WBC18000/cumm, neutrophil 82%, band form 6%, lymphocyte 10%, monocyte 2%,  尿液檢查呈現 RBC10-20, WBC5-10,  蛋白(-), 以下哪一項不正確? 

---

- A. 應行完整的身體診察。 
- B. 可能會有心雜音。 
- C. 應行至少兩套血液培養。 
- D. 應行心臟超音波檢查。 
- E. 病人最可能有腦膜炎。

### Correct Answer: E

詳解： 
此病人應該是感染 group A streptococcus 後併發acute rheumatic fever 和poststreptococcal glomerulonephritis，時序上後兩者會在感染後 1-6週發生。Acute rheumatic fever 會有關節炎、心臟炎、舞蹈症、皮膚疹的表現，最常見的瓣膜疾病為 MR和AR；PSGN則會有血尿、蛋白尿、水腫、高血壓、腎衰竭等表現。懷疑 acute rheumatic fever 時要做的檢查如下表  

![](https://hackmd.io/_uploads/ByHsYzrB3.png)

診斷會用 revised Jones criteria  
 
![](https://hackmd.io/_uploads/ByO3KMBS3.png)
 
## Question 89: 

89.一位 65歲病人住院進行膽結石手術，術後 3天發生院內感染肺炎，請問下列敘述何者最不適當？ 

---

- A. 造成病人發生院內肺炎主要來自於口咽嗆咳(oropharyngeal aspiration)。 
- B. 進行上腹部手術(upper abdominal surgery)增加此病人發生院內肺炎的風險。 
- C. 此病人為發生早發性（early onset）肺炎，致病原主要為呼吸道常在菌，如肺炎球菌或感冒桿菌。 
- D. 若此病人插管使用呼吸器，在培養未發現特定抗藥致病原且病人臨床改善，建議抗生素短期治療（8天）以減少後續抗藥性菌移生。 
- E. 術前使用預防性抗生素 72小時可以降低手術病人發生院內感染的機會。 

### Correct Answer: E

詳解： 
選項A-D都來自於Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults 這篇2008年的論文 
(A)HAP最常見的感染途徑為在口咽移生的菌叢，其他途徑如吸入被汙染的空氣(如細菌活在呼吸器管路、氣管內管、氣切管、蒸氣用水)、菌血症 
(B)手術病人的危險因子包含抽菸、術前住院天數長、手術時間長、胸部手術、上腹手術 
(C)early onset 定義為住院不到96小時發生，需要考慮的菌種有 Streptococcus pneumoniae、Streptococcus species、Haemophilus influenzae、Enterobacteriaceae 如Escherichia coli、Klebsiella species、Enterobacter species、Proteus species、Serratia marcescens、methicillin-susceptible Staphylococcus aureus。Late onset 則要考慮 P. aeruginosa、MRSA、acinetobacter species、S. maltophilia。 
(D)論文中提到除了致病菌為 NF-GNB外，使用 8天或14天的抗生素對死亡率或感染復發率無影響，故若臨床改善也無抗藥性菌種，抗生素用 8天即可。 
(E)目前沒有證據顯示預防性抗生素可以降低院內感染肺炎的機會 


## Question 90:

90.根據美國疾病管制局的建議，對於懷孕者，包括高風險感染之懷孕婦女，下列何者是不建議接種的疫苗組合？選項：(1)B型肝炎疫苗（HBV vaccine）(2)帶狀皰疹疫苗（Varicella-zoster vaccine）(3)麻疹、德國麻疹、腮腺炎疫苗（MMR vaccine）(4)流感疫苗（Influenza）(5)白喉、百日咳、破傷風（Td/Tdapvaccine） 

---

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

### Correct Answer: B

詳解 
美國CDC 網站有建議孕婦施打的疫苗包含 Tdap(每次孕程的27-36週施打以預防新生兒得百日咳)、流感、COVID-19、B肝、A肝(慢性肝病者) 
(2)(3)VZV和MMR皆為活性減毒疫苗，孕婦不能打，理論上孕婦打了會讓小孩有得到先天性水痘症候群、先天性德國麻疹症候群的風險 
Ref: 美國 CDC網站、uptodate-immunizations during pregnancy 

## Question 91:

91.一位接受血液幹細胞移植(Hematopoietic Stem Cell Transplantation)的病人，在移植後 100天發
生感染，請問在此時期之常見之致病原組合，下列何者為最正確?(1)Escherichia 
coli(2)Aspergillus(3)Cytomegalovirus(4)Clostridium difficile(5)Encapsulated 
bacteria(6)Toxoplasma(7)Varicella zoster virus 

---

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

### Correct Answer: A

詳解： 

![](https://hackmd.io/_uploads/rJIdcGBB3.png)


## Question 92:

92.下列有關於 Herpesvirus 產生之疾病配對，何者最不適當? 

---

- A. Herpes simplex virus type 1：Herpangina。 
- B. Varicella-zoster virus : Ramsay Hunt syndrome。 
- C. Epstein-Barr virus : B cell lymphoma。 
- D. Human herpesvirus type 8 : Kaposi’s sarcoma。 
- E. Epstein-Barr virus : Oral hairy leukoplakia。  HSV-1 常見於唇部感染，產生唇皰疹(Cold sores or Herpes labialis)。 

### Correct Answer: A

詳解： 
A.  (X)HSV-1 常見於唇部感染，產生唇皰疹(Cold sores or Herpes labialis) ，而通過口交傳染亦可造成生殖器皰疹，herpangina 是由腸病毒引起的的一種急性傳染性、發熱性疾病，其病毒主要是Coxsackie A virus。  

![](https://hackmd.io/_uploads/HkmaqMBH2.png)

Reference:  
Uptodate, Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection 
Harrison's Principles of Internal Medicine, 20th Edition 
B. (O) Ramsay Hunt syndrome 典型症狀合併耳痛(otalgia)、耳朵及周圍皮膚水泡及患側顏面神經麻痺。又稱為帶狀皰疹病毒耳症(Herpes zoster oticus)。部分病患也會有味覺受到影響、眩暈、耳鳴、聽力損傷及患側易流淚等症狀。 
Reference: Epidemiology, clinical manifestations, and diagnosis of herpes zoster 
C、Ｅ. (O)

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

oral hairy leukoplakia 是HIV感染最常見的口腔病灶，由 Epstein–Barr virus導致，可以作為HIV感染的早期徵兆。長在單側或是雙側而且界線不明顯的白斑。主要好發在舌頭邊緣，但是舌背和舌底也有可能發生。 
Reference: Harrison's Principles of Internal Medicine, 20th Edition 
D. (O) Kaposi 肉瘤屬於血管惡性腫瘤，與 HHV-8感染密切相關。而HHV-8 可通過唾液、性交、血液製品、器官移植傳播。 
Reference: Harrison's Principles of Internal Medicine, 20th Edition 

## Question 93:

93.下列有關於抗生素與其他藥物產生之交互作用配對，何者最不適當? 

---

- A. Metronidazole 併用Ethanol 發生disulfiram-like reaction。 
- B. Macrolides 併用Fluoroquinolones會增加心律不整(arrhythmias)的風險。 
- C. Tetracyclines 併用Warfarin 會加強 Warfarin 抗凝血功能增加出血的風險。 
- D. Rifampin 會加強荷爾蒙作用，口服避孕藥(oral contraceptive)應減量使用。 
- E. Linezolid會增加adrenergic 升壓藥的作用，發生不易控制的高血壓。  

### Correct Answer: D

詳解:
(D) Rifampin 若與口服避孕藥併用,由於Estrogen代謝之增加可能會降低口服避孕藥的作用，導致月經不規則，非計畫性懷孕的病患在投與藥品期間應勸告使用其他避孕方法（如保險套或避孕凝膠）。 

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

## Question 94:

94.有關新冠肺炎 (Coronavirus disease 2019, COVID-19)之敘述，下列何者最不適當? 

---

- A. 致病原 SARS-CoV-2屬於RNA病毒，人類感染冠狀病毒以呼吸道症狀為主。 
- B. SARS-CoV-2潛伏期一般介於2至14 天，大部分為4到5天。 
- C. 臨床症狀發生前極少具有傳染性，大多數感染者是接觸到有症狀者而發生傳染。 
- D. 約有 5%患者會發生呼吸衰竭或敗血性休克等極嚴重感染，需加護治療。 
- E. 實驗室檢查淋巴球減少(lymphopenia)合併D-dimer 升高與死亡率呈正相關。 

### Correct Answer: C

詳解： 
新型冠狀病毒 SARS-CoV-2屬冠狀病毒科（Coronavirinae）之beta亞科（betacoronavirus），人類感染冠狀病毒以呼吸道症狀為主，包括鼻塞、流鼻水、咳嗽、發燒等一般上呼吸道感染症狀，但嚴重急性呼吸道症候群冠狀病毒（SARS-CoV）、中東呼吸症候群冠狀病毒（MERS-CoV）與新型冠狀病毒SARS-CoV-2感染後比一般人類冠狀病毒症狀嚴重，部分個案可能出現嚴重的肺炎與呼吸衰竭等，報告指出，約有 14%出現嚴重症狀需住院與氧氣治療，5%需加護病房治療。新冠肺炎的潛伏期約為 1～14天（多數為 5～6天），目前研究指出確診患者在發病前 2天就可能具有傳染力，傳染途徑包括飛沫傳染以及近距離的接觸感染。 
COVID-19 病人常見的實驗室檢查異常包括淋巴球減少 (lymphopenia)，肝指數(aminotransaminase)升高，LDH (lactate dehydrogenase) 升高，發炎指數 (C-reactive protein，ferritin) 升高。其中淋巴球減少 (lymphopenia) 最常見，約占 90%。嚴重淋巴球減少合併D-dimer 升高與死亡率呈正相關。 
Reference:  
台灣CDC 
新冠肺炎之流行病學、臨床表現及診斷; 內科學誌 2020：31：234-238 

## Question 95:

95.有關呼吸器相關肺炎之預防措施，下列何者為非? 

---

- A. 床頭抬高，以減少嗆入機會。 
- B. 常規制酸劑使用，增加胃 pH值以減少上消化菌叢。 
- C. 長期插管病人，評估鎮靜劑每日中斷。 
- D. 人員落實手部衛生及無菌操作。 
- E. 控制血糖以改善宿主免疫。 

### Correct Answer: B

詳解： 
預防呼吸器相關肺炎的發生，主要著重於呼吸器相關肺炎組合式照護（VAP bundles）感染控制措施，包含： 
1.  床頭抬高 
2.  每日鎮靜藥物中斷 
3.  每日評估是否可以拔管 
4.  聲門下分泌物抽吸 
5.  每日口腔氯己定（chlorhexidine）護理 
6.  使用腸道不能吸收的口服抗生素做選擇性消化道的減菌 
7.  益生菌使用 
8.  手部衛生和氣管導管袖口壓力監測。 
Reference: 台灣 2018肺炎診治指引 

## Question 96:

96.下列有關抗生素的主要抑制機轉配對，何者最不適當？ 

---

- A. Cephalosporin–抑制細胞壁（Cell wall）合成。 
- B. Clindamycin– 抑制蛋白質（Protein synthesis）合成。 
- C. Macrolide– 抑制DNA合成。 
- D. Sulfonamide– 抑制葉酸（Folate）合成。 
- E. Rifampin - 抑制RNA合成。 

### Correct Answer: C

詳解：  

![](https://hackmd.io/_uploads/rJXQnGHB2.png)


## Question 141:

141.58歲女性病人，罹患轉移性肺腺癌(NSCLC, adenocarcinoma)，已接受第一線carboplatin、paclitaxel，合併 bevacizumab 治療，有效”緩解”(partial response)一段期間之後”惡化”(disease progression)。病人的ECOG體能狀態 (performance status, PS)為1，針對病人周邊肺野的較大病灶安排重新切片，分子檢測發現ROS1 基因rearrangement陽性。你建議下一步的治療，何者最為適宜? 

---

- A. Pemetrexed。 
- B. Docetaxel。 
- C. Gemcitabine。 
- D. Erlotinib。 
- E. Crizotinib。 
 
### Correct Answer: E 

詳解: 

![](https://hackmd.io/_uploads/Sk-AykBHh.png)

Ref: NCCN guideline 2022 ver. 1 
