# 109年內專(200題)1-76

## Question 1:

就疾病之預防及處置，請問下列個案的處置，何者是不當之舉？

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- A. 78歲老翁有心電圖呈現 ST-T 變化，病人血壓 128/74 mmHg, 心跳74/min, 正常律動，尚無胸痛或心悸等病狀，可做內科門診治療，不必立刻做經皮冠狀動脈介入治療(Percutaneous coronary intervention)
- B. 32歲婦人每逢月經來臨都有心悶症狀，經冠狀動脈造影及超音波心圖都顯示正常結構及功能，為安全起見仍應請每六個月回診追蹤
- C. 56歲男性公司經理人，有高血壓及高脂血。但為防治心血管病，應做風險評估，並在門診追蹤作生活方式矯正(Lifestyle modification)
- D. 48歲男性從商，胸悶經由理學檢查及實驗室檢查後，並無任何心血管疾病及風險，不必建議作全身健康檢查
- E. 102 歲老婦人30年前因高血壓到門診治療，五年前開始有體力不支、容易疲倦、未有胸悶、眩暈、呼吸困難等症狀，經確診為二尖瓣閉鎖不全，使用藥物治療，症狀改善。應建議這位老婦人每 6或12個月回診評估，如有惡化，才建議住院做外科手術治療

### Correct Answer: B

A. 根據目前ST elevation需要 primary PCI 的適應症(ACC/AHA 2011, Circulation.
2011;124:2574–2609)如下。患者未出現症狀因此非 primary PCI 的適應症。
B. 較少文獻探討經期與胸悶之關聯，不過有文獻討論( J Med Case Reports. 2009; 3: 6618.)認為可能與用月經時 estrogen濃度暫時下降有關，可以考慮補充estrogen治療。停經後因為失去estrogen保護，婦女產生 CAD的風險會大幅上升，因此也建議有此類現象的婦女應該留意。

C&D.應該是常識

E. MVP 為Chronic promary MR常見原因，severe primary MR (stage D)或無症狀但合併systolic dysfunction [LVEF<60%或ESD>40mm (stage C2)]採行外科手術為Class I indication (repair 優於replace)。MVP 可以透過beta blocker 緩解症狀，本選項患者高齡且已無症狀，均暗示患者無立即行 MVR的必要。

## Question 2:

有位38歲林小姐因心悸及失眠多個月而求診，經身體檢查並無重大異常，唯有左胸骨下緣處有輕度(Gr 1-2/6)中期心縮雜音(Mid-systolic murmur)，請問下列何組是確定診斷的必要處置？
(1) 心電圖(Electrocardiogram)
(2) 胸部 X光(Chest X-ray)
(3) 超音波心圖(Echocardiogram)
(4) 心臟磁振造影(Cardiac MRI)
(5) Thallium 201 心肌灌注影像(Thallium 201 Perfusion Scan)
(6) 心臟專科會診

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

### Correct Answer: A

左胸骨下緣=Tricuspid area.
Mid-systolic murmur = systolic ejection murmurs
此患者應該從AS/PS/ASD與 HOCM鑑別。其中HOCM 造成murmur 的原因是LVOT 狹窄及MR所造成，因此根據位置可以判斷是LVOT obstruction 於左胸骨下緣造成的murmur。
*補充 HOCM與AS 的鑑別：HOCM是dynamic 而AS 是fixed。HOCM的murmur 可因為 preload下降(e.g. 站立或Valsalva's maneuver)而變大聲，因preload上升(e.g.蹲踞)而變小聲。而 AS 剛好相反

根據2020 AHA guideline，HOCM的初步檢查方向包含
1. 12 lead EKG: LVH pattern，pseudo-infarction pattern (anterior lateral TWI, dagger-like Q waves in infero-lateral leads)
2. CXR:可能會看到心臟肥大(但是guideline 尚未包含CXR)
3. Heart Echo:最重要的檢查，hypertrophic walls, ASH, septal wall to posterior wall ratio of 1.3:1)。若ehco無法有明確結論再考慮進行Heart MR
4. 完整的理學檢查(包含)與三代 family history taking 初步診斷class I indication

## Question 3:

心衰竭(Heart failure, HF)是臨床很重要的課題，可分成左心室射出比率低退心衰竭(Heart Failure reduced Ejection Fraction,HFrEF)及射出比率正常心衰竭(Heart Failure preserved Ejection Fraction,HFpEF) ，請問下列何項的說法是不正確的？

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- A. 八十五歲以上老人約40%有各種不同程度的心衰竭
- B. 急性心衰竭病人的病況惡化多與原始病因轉劇有關，但不能忽視病人因其他慢性疾病誘發，用藥順從性不佳或藥物交互作用導致
- C. 左心室HFrEF 約佔心衰竭的半數以上
- D. 左心室HFrEF，多見在女性、老年人特別合併有高血壓及糖尿病史者
- E. 左心室HFpEF 之死亡率遠比左心室HFrEF為低，但仍比同年齡的正常人為高

### Correct Answer: D

A. 本選項其實有點爭議。Herrison說>65 歲患者約佔同齡6~10%，美國統計文獻統計80歲以上大約佔同齡 12~14%(Nat Rev Cardiol. 2011 Jan; 8(1): 30–41.)，多數文獻也大概落在10%上下…

B. 常識

C. 本選項其實有點爭議。在Harrison裡面的描述為：約有一半的患者為HFpEF，2016 ACCF/AHA guildeline 則說HfpEF與HfrEF各約佔一半，ESC 2016年則說HfpEF佔比根據定義不同大約佔 22 ~73%...

D. HFpEF常見的特色為：DM, HTN, 高齡, 女性, Atrial fibrillation較多。
(Harrison 20th ed, 2016 ESC)

E. 是的，如常理一般，文獻亦證明如此 (2016 ESC)

## Question 4:

隨著醫療環境及醫學的進步，有關感染性心內膜炎(Infective endocarditis,IE)的臨床實況有許多變化，請問以下的說法何者是不正確的？

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- A. 隨風濕性心臟病盛行之減少，罹患IE 的病人多偏向老齡化
- B. 心臟瓣膜病變產生的心內亂流(Turbulent flow) 與IE 發生贅生物(Vegetation)的形成有關
- C. 二尖瓣脫垂及肥厚性心肌病都有發生IE 的風險
- D. 全身性紅斑性狼瘡(Systemic lupus erythematosus, SLE)的消耗性贅物(Marantic vegetation)不具血管營養, 可是一旦細菌附着感染，不易抗生素治好
- E. 46 歲女性病人主訴感冒、發燒及輕度呼吸困難，有兩週之久，身體檢查有心臟雜音, 手掌有類似的Osler node, 經採血一次,細菌培養有金黃色葡萄球細菌，按Duke criteria，本病例應可確診感染性心內膜炎

### Correct Answer: E

A. 跟據CID期刊，IE 患者於 1940年代平均年齡為35歲，近年過半患者超過60歲。原因為(1)風溼性心臟病盛行率下降及(2)風溼性心臟病及先天性心臟病患者剩命延長
(Clinical Infectious Diseases 2002;34(6):806-12. doi: 10.1086/339045)

B. IE 產生的重要機制如下：先天/後天心臟結構異常產生紊流àendothelial damageà sterile thrombosis formationà暫時性的bacteremia 可能導致細菌沾上thrombosis

C. (Circulation. 2000;102:2842–2848)

D. Nonbacterial thrombotic endocarditis (NBTE, = marantic endocarditis = Libman Sacks Endocarditis)，常發生於hypercoagulable state 之患者(例如SLE, Antiphospholipid syndrome跟adenocarcinoma)，其表現為心臟瓣膜出現小至顯微鏡才可見的血小板聚集斑塊到大塊vagitation，常見於 mitral與aortic valve 且患者無任何感染證據(metabolically inactive, non-growing)。

E.根據modified Duke’s criteria，確診條件為major+minor：2+0或1+3或0+5
本選項關鍵字：感冒、發燒(minor)及輕度呼吸困難，有兩週之久，身體檢查有心臟雜音(不確定是否為新發生), 手掌有類似的 Osler node(minor), 經採血一次,細菌培養有金黃色葡萄球細菌(minor，須採血兩次才符合major)

## Question 5:

心室頻脈(Ventricular tachycardia, VT) 是威脅生命性心律不整(Life-threatening arrhythmia)，有關其診斷及治療的說法，下列何者不正確？

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- A. 有器質性心臟病(Organic heart disease)的持續性(Sustained)VT 時，應置放心內去顫器(Intra-cardiac defibrillator)
- B. 長期使用抗心律不整藥物可治療特發性心室快跳(Idiopathic VT)，唯宜先採 用導管燒灼術(Catheter ablation)
- C. 有VT發作病人，一定有重度器質性心臟病
- D. 寬闊奇異狀QRS 波(Wide,Bizarre QRS waves)，融和跳(Fusion beat) 、捕捉跳(Capture beat) 及房室跳解離 (A-V dissociation)是診斷VT的心電圖條件(Criteria) ，但僅只房室跳解離是唯一可靠的根據
- E. 隨著冠脈血管再通術之發達，ST 波上昇型的急性心肌梗塞(ST elevation acute myocardial infarction)併發 VT多在急性冠心症一週內

### Correct Answer: C

A. ICD在VT secondary prevention的indication如下(2015 ESC)
(1) Vf, hemodynamic unstable VT(無reversable cause 或post-MI 48h之內) (Class I)
(2) 已經嘗試藥物且LVEF 正常但是 Recurrent sustain VT (Class Iia)

B. 當Idiopathic VT 產生症狀或者影響 ventricle function時需要治療，idiopathic VT常見的起源點為 Outflow tract，其中又以RVOT(70%)為主。目前catheter ablation已經成為RVOT-VT一線治療(成功率>95%)，因此應該優先進行。相對之下LVOT-VT比較需要技巧(trasnseptal & retrograde approach)，併發症及風險相對高，因此可以先嘗試class IC (Na+ channel blocker)抗心律不整藥物後再考慮由有經驗的EP 專家進行catheter ablation。(2015 ESC)

C. 錯誤。Idiopathic VT 就是指沒有 structural heart disease 的VT！

D. 本題應該是呼應Brugada criteria (Se:98.7%, Sp:96.5%) (Circulation. 1991; 83(5):1649-59)
有興趣可以參考Curr Cardiol Rev. 2014 Aug; 10(3): 262–276.一文，裡面也提及AV dissosication 或 VA block其specificity趨近100%

E. Post-AMI 造成的VT/Vf在不同時間的機制有所不一。前期的 VT主要肇因於ischemia & reperfusion injury，後期(>2 week)則是scar formation為主，其中多數(85%)發生在前48小時
(Arrhythm Electrophysiol Rev. 2017 Aug; 6(3): 134–139.)

## Question 6:

由於醫療科技的進步及臨床實例的經驗累積，下列有關肥厚性心肌病(Hypertrophic cardiomyopathy) 的臨床特質，何項是不正確的說法？

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- A. 其在人口的盛行率是1/500；死亡率< 1%
- B. 三分之一的年輕人猝死(sudden cardiac deaths) 是因肥厚性心肌病而起，且多見心室頻脈或心室纖維顫動(Ventricular tachycardia or fibrillation)
- C. 利用電氣生理及基因檢測已能預期其猝死之風險
- D. 運動後低血壓、心室中隔厚度>3cm、有眩暈病史或心室快跳之心電圖記錄，都是判定猝死風險的指標
- E. Gadolinium 磁振影像可顯示心肌纖維化(Fibrosis) 程度是嚴重心律不整之可靠預測指標

### Correct Answer: C

A&B. 流行病學敘述正確。HCM為年輕人死亡及心衰竭的主因，年輕診斷者預後較差，成年後診斷者預後較佳，機制上推測是心肌肥厚-> Microinfarction->fibrosis & scar 產生-> ventricular arrhythmias。(Harrison 20th dition)

C. 根據2020 AHA HCM guideline (Circulation. 2020;142:e558–e631.)，目前被證實
HCM-SCD的風險因子包含：
(1) Hx of cardiac arrest or sustained ventricular arrhythmias
(2) Hx of syncope suspected by clinical history to be arrhythmic
(3) Family Hx in close relative of premature HCM-related sudden death, cardiac arrest, or sustained ventricular arrhythmias (first-degree or close relatives≤50 y/o)
(4) Maximal LV wall thickness (≥30 mm), EF (<50%), LV apical aneurysm
(5) Non sustain VT episodes (≥3 times, ≥10 beats, ≥200 bpm) on continuous ambulatory electrocardiographic monitoring

D. 正確，相關預後因子如下：(Harrison 20th ed)

E. HCM症狀多元，最主要的診斷方式為影像學檢查。藉由ECG診斷不易，且一些ECG finding需要排除許多其他原因）。Diffuse and extensive late gadolinium enhancement (≥15% of LV mass)可預測 HCM-SCD。(2020 AHA/ACC)

## Question 7:

病人58歲婦女，主訴運動性呼吸困難、體重一星期間從 84公斤增加至87公斤，雙腳水腫有一週之久，步履難行，初步檢查呈現心臟擴大，乃前往醫學中心診療，在急診初步檢查Chest X-ray、心臟超音波和心電圖(如圖)，旋即住院。病人七年前有左乳癌經切除手術，至今並未完全緩解。病人近五年來，有高血壓及糖尿病，都藥物治療中。生命徵象：T: 36.2°C, P:81/min, R:20/min, BP:150/84mmHg, Pain score:0。病史詢問及身體理學檢查，請問下列何組心血管病理學檢查(Cardiovascular approach)，是您應該觀察的標的？

(1) 消沈的S1 and /or S2
(2) S3 and S4
(3) Pericardial friction
(4) Mid-systolic murmur and pansystolic murmur
(5) Kussmaul sign
(6) Pulsating congestive liver

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

### Correct Answer: C

**EKG**: Sinus rhythm w/ HR≌81bpm, low voltage, no PR abnormality nor STT change
**補充: Definition of low voltage EKG
(1)all limb lead QRS<5 mm, or (2)all precordial leads QRS<10 mm
**CxR**: post left side mastectomy, cardiomegaly w/ water-bottle sign, mild increase of right lower lung infiltration and present of left side pleural effusion
**TTE**: Pericardial effusion(+)(<-present anteriorly and posteriorly ≌1.5~2cm in thickness, moderate~large amount)
**Impression**: Left side pleural effusion and moderate to large amount pericardial effusion, r/o breast CA metastasis w/ malignant effusion +/- acute decompensated heart failure with mild pulmonary edema

(1) 消沈的S1 and /or S2: distant heart sound, r/o pericardial effusion
**Beck's traid of cardiac tamponade: distant heart sound + increase JVP + hypotension
(2) S3 and S4: gallop rhythm, sign of congestive heart failure, r/o ADHF
(3) Pericardial friction: may present in pericarditis
(4) Mid-systolic murmur and pansystolic murmur: r/o AS/PS or MR/TR
**AS/PS: low pitch, early ejection click + mid-systolic crescendo-decrescendo murmur; MR/TR: high pitch, pansystolic murmur
(5) Kussmaul sign-> r/o cardiac tamponade
**Definition: paradoxical rise in jugular venous pressure (JVP) on inspiration or failure in the appropriate fall of the JVP with inspiration
(6) Pulsating congestive liver-> r/o ADHF

這題主要考的是approach of pericardial effusion。第一步是評估病人是否hemodynamic compromise(e.g cardiac tamponade), 需不需要緊急放水, 病患穩定後第二步才會找原因, 評估是否有其他放水的適應症。所以一定要選的話就選跟pericardial effusion 有關的physical examination: (1)、(3)、(5).

**Indications of pericardiocentesis**:
1. Symptomatic moderate to large amount pericardial effusion
2. Asymptomatic large amount chronic (>3 months) idiopathic pericardial effusion
3. Suspect bacterial, tuberculous, or neoplastic pericarditis...etc.
A simplified algorithm for pericardial effusion triage and management
Ref: 2015 ESC guideline of Pericardial Diseases

## Question 8:

86歲老太太因有二小時的胸悶前往醫院急診求治。病人在十年前因急性心肌梗塞而住院，在左前降支冠狀動脈(Left anterior descending artery)置放冠狀動脈支架。病人尚有類風濕關節炎及老齡失智診斷。理學檢查發現：BH：156 cm, BW：48 kg；BMI：19.7 kg/m²；T/P/R：36.2/66/22；BP：158/90 mmHg；在急診的其他檢驗尚無重大異常，其系列的生化檢驗、Chest X ray、心電圖如附圖：

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- A. 高血壓性心臟病
- B. 左迴旋冠脈栓塞之Non-STE acute myocardial infarction
- C. 左前降支冠脈栓塞之Non-STE acute myocardial infarction
- D. 左前降支冠脈栓塞之STE acute myocardial infarction
- E. 左迴旋冠脈栓塞之STE acute myocardial infarction

### Correct Answer: D

EKG: sinus rhythm with VPCs, ST elevation in V1~V3
ST-elevation可以localization, 但ST-depression則無法

## Question 9:

有關二尖瓣膜閉鎖不全(Mitral regurgitation, MR) 可分原始性及續發性(Primary and Secondary MR)兩種，從諸多臨床實証，下列何者不是續發性MR的正確說法？

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- A. 左心室射出比率低退的心衰竭(Heart Failure reduced Ejection Fraction, HFrEF) 的病人大有75%的有續發性 MR
- B. 續發性MR多肇因於二尖瓣環擴大(Mitral annular dilatation)及乳頭肌異常，影響二尖瓣閉合，外科復原手術有良好治療成績
- C. 從臨床症狀之惡化及聽診異常之強度不可為MR的嚴重度參考
- D. 二尖瓣膜的病變不是決定續發性MR的關鍵因素
- E. 使用心臟再同步化治療(Cardiac resynchronization therapy) 改善左心室心肌失能，有助續發性MR的嚴重度

### Correct Answer: B

A. Secondary or functional MR is commonly seen in HF with reduced ejection
fraction (HFrEF) patients and is a poor prognostic marker.
Ref: https://academic.oup.com/eurheartj/article/40/27/2189/5475839)

B. Secondary MR 以 CAD Rx, HF Rx, CRT為主來改善症狀, 除非一直惡化到symptomatic(=NYHA 3~4) severe MR 才會考慮手術

C. MR的嚴重度要參考 TTE or TEE result
D. Secondary MR 瓣膜本身通常是正常的

E. LV dyssynchrony can potentially contribute to functional MR by several
mechanisms(e.g. reducing the sphincteric function of the mitral annulus, decreasing the efficiency of LV contraction and closing forces...etc.), 因此CRT 可以改善functional MR.
Ref: Journal of Cardiovascular Medicine: doi: 10.2459/JCM.0b013e3282ef39c5

MR management algorithm
Ref: Harrison’s Principles of Internal Medicine, Twentieth Edition

## Question 10:

依據2016年Taiwan Society of Cardiology有關非瓣膜性心房纖維顫動(Atrial
fibrillation) 病人之預防腦中風的治療指引，請問何種說法是錯誤的？

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- A. Aspirin對腦中風的預防是無療效
- B. 包括台灣在內的亞洲人，臨床實証發現以新式口服抗凝血藥物(New Oral Anti-Coagulants, NOACs)比 Warfarin 對腦中風的預防更具療效
- C. 七十五歲老年人合併有中-重度慢性腎衰竭時，建議可使用低劑量NOAC，但若使用Warfarin，Time in therapeutic range > 70%時，可改用Warfarin
- D. 就亞洲病人而言，使用低劑量NOACs 可作為如Warfarin一樣安全的治療選擇
- E. 亞洲病人使用 Warfarin或 NOAC都有較高腦中風、大出血及顱內出血的發生，是以建議含Aspirin 及Clopidogrel的雙重抗血小板治療(Dual antiplatelet therapy, DAPT) 代替

### Correct Answer: E

A. 整體而言，aspirin 治療在 Af 患者的角色其實有限，除非患者有服用抗凝血劑的禁忌症，才考慮做為抗血栓治療的替代性治療; 對於CHA2DS2-VASc score=1(male) or =2(female)目前已傾向NOAC(class 2a recommendation) or none(<-連ASA都不吃, 因為效果較差且未降低出血風險).

Ref:
* 腦中風危險因子防治指引:心房纖維顫動
* 2016 & 2020 ESC Atrial Fibrillation Guidelines

C. 中重度腎功能不良(<-但仍然要 CCr≥15ml/min)可考慮reduced dose Rivaroxaban/Apixaban/Edoxaban; 但若是 Time in therapeutic range>70% 可考慮使用warfarin達到同等預防中風的效果
Ref: 2020 ESC Atrial Fibrillation Guidelines
B&D&E. CHA2DS2-VASc score≥2(male) or ≥3(female)目前首選就是NOAC, 除非 Valvular heart or Mechanical valve or CCr<15ml/min才會考慮首選Warfarin, 但就算是post-ACS 的病人也會根據bleeding risk/ischemic risk 來決定是否用Triple therapy(NOAC + DAPT) or double therapy(=NOAC + SAPT), 而不應該只用DAPT 來作為stroke prevention.
Ref: 2020 ESC Atrial Fibrillation Guidelines

## Question 11:

有關心肌炎(Myocarditis)的最近進展，下列何則是不正確的說法的？

---

- A. 從人口推估，心肌炎的發生率約萬分之一至十萬分之一，但在年青猝死病人的病理解剖卻高達12%
- B. 病理診斷心肌炎必須心肌無缺血性的細胞損傷、退化或壞死(Injury, degeneration or necrosis)及發炎細胞侵潤變化，但真實的臨床世界裡，大部份心肌炎是臨床診斷，不是病理診斷
- C. 靜脈注射免疫球蛋白(Intravenous immunoglobulin, IVIG)對年青人的急性心肌炎有效，唯其結論有待完整的臨床試驗的驗証
- D. 愛滋病毒及淋巴心肌炎都是預後嚴重的心肌炎
- E. 巨細胞心肌炎多見老年人，時以胸痛、心衰竭、惡性心律不整或傳導阻滯，有賴臨床警覺早期切片診斷，盡早免疫治療有效，唯死亡率高，有賴心臟移植治療

### Correct Answer: E

E. 好發族群為 young and middle-aged adults; Combine immunosuppression Rx
能使約2/3病患達到survival free of transplantation.

**Giant cell myocarditis**(GCM)
(1) Characteristics: a rare, rapidly progressive, and frequently fatal myocardial disease in young and middle-aged adults.
(2) Manifestation: heart failure, ventricular arrhythmias,atrioventricular block, ± acute myocardial infarction or sudden cardiac death
(3) Pathphysiology: T lymphocyte-mediated inflammation of the heart muscle and associates with systemic autoimmune diseases in ≈20% of cases.
(4) Diagnosis: Endomyocardial biopsy(EMB), presence of a widespread inflammatory infiltrate including lymphocytes, histiocytes, and multinucleated giant cells in association with myocyte necrosis and eosinophils.
(5) Treatment: Combined immunosuppression Rx + Heart failure Rx + Arrhythmias Rx (e.g. Corticosteroid + Azathioprine + MMF, or Corticosteroid + Cyclosporine + MMF…etc.)
**註: small prospective study suggest that cyclosporine-based combined immunosuppression may be able to reduce myocardial inflammation and improve clinical outcome)
(6) Prognosis: Current immunosuppression appeared able to arrest the disease process in two thirds of patients with GCM, resulting in clinical remission sufficient for survival free of transplantation.
Ref: “Diagnosis, Treatment, and Outcome of Giant-Cell Myocarditis in the Era of Combined Immunosuppression”, Circ Heart Fail. 2013;6:15-22

## Question 12:

請問下列有關心因性休克(Cardiogenic shock)的說法，何者是不正確的？

---

- A. 急性心肌梗塞的心因性休克發生率已因早期使用再灌注治療(Reperfusion therapy)而減少了5-10%
- B. 有心因性休克的心肌梗塞病人以多條冠狀動脈病變為多，且約80%是以ST波段上昇心肌梗塞（ST elevation myocardial infarction ）的心電圖表現
- C. 在臨床實證上，治療心因性休克以緊急外科冠脈繞道手術為宜
- D. 在諸多的大型臨床試驗，利用血管作用劑（Vasoactive agents) 如Norepinephrine, Dopamine, Dobutamine 治療心因性休克，無助預後之改善
- E. 使用主動脈內氣球幫浦（Intra-aortic balloon pump，IABP）治療心因性休克，在臨床試驗資料並不顯示能改善死亡率

### Correct Answer: C

A&B. 正確
C. MI related cardiogenic shock首選PCI as reperfusion therapy, 除非coronary
anatomy not suitable for PCI or PCI failed, 才會考慮 emergent CABG(Class 1
recommendation).
**註: Complete revascularization if multivessel disease is present(Class 2a
recommendation)

D. Intravenous inotropic agents/vasopressors 無法改善預後, 但當血壓太低時為了
維持vital organ perfusion還是會使用來維持 SBP >90 mmHg.(Class 2b recommendation)

E. IABP 不建議常規使用, 但特殊狀況下(e.g. severe MR or VSD)可以考慮使用。
原文: IABP counterpulsation does not improve outcomes in patients with STEMI and cardiogenic shock without mechanical complications, nor does it significantly limit infarct size in those with potentially large anterior MIs. Therefore, routine IABP counterpulsation cannot be recommended, but may be considered for haemodynamic support in selected patients (i.e. severe mitral insufficiency or ventricular septal defect)(Class 2a recommendation).
Ref: 2017 ESC Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation Guidelines

## Question 13:

高安氏血管炎(Takayasu arteritis)，最常影響的血管為？

---

- A. 腎動脈(renal artery)
- B. 腹主動脈(abdominal aorta)
- C. 鎖骨下動脈(subclavian artery)
- D. 冠狀動脈(coronary artery)
- E. 主動脈弓(aortic arch)

### Correct Answer: C

如圖(Ref: Harrison 20th edition)

## Question 14:

有關章魚壺心肌症(Takotsubo cardiomyopathy)之描述，下列何者錯誤？

---

- A. 臨床表現包括肺水腫，低血壓與典型心絞痛
- B. 心臟收縮功能異常可以在數天到數週後緩解
- C. 患者之心電圖常呈現典型心肌梗塞之變化
- D. 造成之因素常為強烈交感神經刺激或兒苯酚胺毒性(catecholamine toxicity)
- E. 口服抗凝血劑是必要之藥物治療

### Correct Answer: E

Takotsubo cardiomyopathy表現如下圖
主要是交感神經過度活化或Catecholamine 直接作用所導致。口服抗凝血劑在單純Takotsubo的治療上無角色。
Ref: Harrison 20th edition

## Question 15:

有關抗凝血劑的解藥(antidote)下列何者錯誤？

---

- A. Heparin的antidote 是 protamine
- B. Warfarin的antidote 是 vitamin K
- C. Dabigatran的antidote 是 idarucizumab
- D. Rivaroxaban的antidote 是 andexanet
- E. Apixaban的antidote 是 idarucizumab

### Correct Answer: E

Xa inhibitor(Apixaban, Edoxaban, Rivaroxaban)之解毒劑為Andexanet, Thrombin
inhibitor(Dabigatran)之解毒劑為Idarucizumab

## Question 16:

有關肺動脈高壓的敘述，下列何者錯誤？

---

- A. 一氧化碳瀰漫量(Diffusing capacities of the lungs for carbon monoxide DLCO) 在肺動脈高壓患者會下降
- B. 心臟超音波的影像(如附圖)
- C. 在無睡眠呼吸障礙的肺動脈高壓患者,夜間缺氧(nocturnal desaturation)並不常見
- D. 肺動脈高壓患者均應接受抗核抗體 (antinuclear antibody)，類風濕因子(rheumatoid factor)，Scl 70抗體 (anti-scl-70 antibody)檢測
- E. 心音聽診時，第二心音肺動脈瓣成分會加重(accentuated P2)

### Correct Answer: C

A. 因肺高壓使進入肺部的血流受阻，所以導致 dead space 變多（有氣無血），在DLCO檢查上呈現出來就是擴散能力變差
B. RV > LV=RV壓力過大=肺高壓（出題老師直接拿 Harrison的圖來出）

C. Nocturnal desaturation 在PAH病人中十分常見，且可能與疾病的嚴重度有關，發生機轉仍然不明，推測pulmonary vasoconstriction, OSA 是可能的幾轉，但仍需更多研究來證實。
D. RA, SLE, Systemic sclerosis, Sjogren, APS, Polymyositis 均有機會併發pulmonary hypertension，因此需要查出成因並加以治療

E. 肺高壓導致右心壓力提高，而使肺動脈瓣關閉時的壓力差增大，因此造成較大的P2
Ref: Harrison 20th edition

## Question 17:

有關急性腎損傷(acute kidney injury)造成心臟衰竭之描述，下列何者錯誤？

---

- A. 急性腎損傷患者出院後，因心臟衰竭再住院風險明顯增加
- B. 急性腎損傷患者出院後，因心血管疾病死亡或慢性心臟衰竭比率明顯增加
- C. 急性腎損傷重症患者，半乳糖凝集素-3 (galectin 3)與心肌傷害有相關
- D. 在急性腎損傷時，用氨基末端腦鈉肽前體(NT-proBNP)可以診斷心臟衰竭的嚴重度
- E. 嗜中性白血球明膠相關性脂質運載蛋白(neutrophil gelatinase–associated lipocalin /NGAL)與急性腎損傷造成之心肌纖維化有相關

### Correct Answer: D

A&B. AKI 的患者，HF rehospitalization, CV death顯著提高
Ref:
* CJASN , June 2018, 13 (6) 833-841
* JASN , March 2018, 29 (3) 1001-1010)

C: Galetin-3與cardiac remodeling, fibrosis 有關，在AKI 時，會活化Galetin-3的
pathway, 造成心肌損傷
Ref: JACC Basic Transl Sci. 2019 Oct; 4(6): 717–732.

D: 大多數NT-proBNP 預測HF severity的study 都排除CKD或AKI 的病人，且在AKI 時，NT-proBNP 的代謝會減慢，而使數值上升，造成診斷 HF 的價值下降。
Ref: JASN, September 2008, 19 (9) 1643-1652

E: AKI 時會製造NGAL，透過 mineralcorticoid excess 的機轉，造成cardiac fibrosis
Ref: J Mol Cell Cardiol, 2018 Feb;115:32-38.

## Question 18:

有關心臟理學檢查之描述,下列何者正確？
(1) 心房顫動時,聽診時不會出現第四心音(S4)
(2) 聽診時,第三心音(S3)在只在收縮功能異常之心臟衰竭患者出現,收縮功能正常之心臟衰竭患者不會出現
(3) Allen's test是用來偵測肱動脈(brachial artery) 血液循環
(4) 大流量之動靜脈廔管(arteriovenous fistula)可以造成非常低之舒張壓
(5) 在擴張性心肌病變患者,把脈時可以摸到雙峰脈波(bifid pulse)
(6) 主動脈瓣狹窄之收縮期雜音聽診區在胸骨右側第二肋間,心雜音會傳遞至頸動脈

---

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

### Correct Answer: B

(1)(2) S3 出現在early-/mid- diastolic 的心音，為 ventricular gallop sound，有可能為生理性（出現在小於35歲左右的人身上）或病理性。Pathological S3 的成因有ventricular dysfunction（congestive heart failure, post-MI, dilated cardiomyopathy等）
或是rapid early diastolic ventricular filling（MR, VSD or systemic disease such as anemia, thyrotoxicosis 等）。
S4 出現在late diastolic or pre-systolic 的心音，為atrial gallop sound，atrial
fibrillation 時不會出現。

(3) Allen's test是用來偵測尺動脈 (radial artery) 血液循環

(4)正確

(5) 雙峰脈波(bifid pulse / pulsus bisferiens)意指在收縮期出現了兩個peak，它的出
現暗示著低心輸出的狀態，可見於 hypertrophic obstructive cardiomyopathy（如下
圖D）、aortic regurgitation（如下圖 C）的患者。
(6)正確
Ref：Harrison 20th edition Chapter 38, Chapter 110

## Question 19:

下列哪一個乙狀受體阻斷劑(beta-blocker)，除了交感神經抑制外，還具備血管擴張功能(additional vasodilator actions)？

---

- A. Nebivolol
- B. Atenolol
- C. Metoprolol
- D. Propranolol
- E. Bisoprolol

### Correct Answer: A

β-adrenergic blocking agents 臨床上可分為 non-selective beta blockers 及relatively selective β blockers 兩類：
(1) Non-selective beta blockers 包括有：Carvedilol (α-blocking activity), Labetalol (α-blocking activity), Nadolol, Penbutolol, Propranolol, Sotalol, Timolol
(2) Relatively selective β blockers 包括有：Acebutolol, Atenolol, Bisoprolol, Esmolol(ultra short-acting), Metoprolol, Nebivolol

Nebivolol為一外消旋混合物（racemic mixture），由D-nebivolol及L-nebivolol 等量混合而成。其中D-isomer 有著selective β-adrenoreceptor antagonist的特性，而L-isomer 則有vasodilatation 的特性。Nebivolol藉由刺激內皮L-arginine/NO pathway增加內生性vasodilator NO的生體可用率（biovailability）進而促使血管擴張。
**補充:non-selective bB 中的Carvedilol, Labetalol等具有α-receptor blockade 的特性亦有血管擴張的效果。
Ref：Kim C, Abelardo N, Buranakitjaroen P, et al. Hypertension treatment in the Asia-Pacific: the role of and treatment strategies with nebivolol. Heart Asia 2016; 8: 22-26. doi: 10.1136/heartasia-2015-010656

## Question 20:

一位70歲女性，主訴昏厥病史，24 小時Holter ECG(如附圖)，無症狀之心電圖為上圖，發生昏厥之心電圖為下圖。該心電圖之心臟節律正確診斷為？

---

- A. 第一度房室傳導阻斷
- B. 第二度第一型房室傳導阻斷（Mobitz I）
- C. 第二度第二型房室傳導阻斷（Mobitz II）
- D. 第三度房室傳導阻斷
- E. 病竇症候群

### Correct Answer: D

A. 第一度房室傳導阻斷（First-degree AV block）在心電圖上可見PR interval > 200 msec.

B. 第二度第一型房室傳導阻斷（Mobitz type I (Wenckebach) second-degree AV block）因於房室間的傳導延遲，在心電圖上可見到漸行漸遠的PR interval，最終某個QRS complex消失

C. 第二度第二型房室傳導阻斷（Mobitz type II second-degree AV block）因於希氏
束下的阻斷（distal or infra-His conduction system），心電圖上可見到某個p波後面沒有接QRS complex

D. 第三度房室傳導阻斷（Third-degree AV block (complete AV block)）代表房室分離（AV dissociation）， 心電圖上看起來就是心房心室各跳自己的，p波及QRS complex沒有關聯性
Ref：Harrison 20th edition, Chapter 240

## Question 21:

有關心房顫動與低收縮分率心臟衰竭 (heart failure with reduced ejection fraction)之描述何者錯誤？

---

- A. 心房顫動與低收縮分率心臟衰竭兩者合併發生時，會導致心臟衰竭患者預後不良
- B. 在中至重度低收縮分率心臟衰竭患者，使用dronedarone 不會導致死亡率增加
- C. 可以使用dofetilide 來進行節律控制(rhythm control)
- D. 可進行導管燒灼術(catheter ablation and pulmonary vein isolation)
- E. 可以使用 amiodarone 來進行節律控制(rhythm control)

### Correct Answer: B

A&B. 心房顫動與低收縮分率心臟衰竭為彼此預後不良的因子。
B. 在當年ANDROMEDA study (族群主要為heart failure, n=627)，由於dronedarone 組相較於placebo組多出一倍多的死亡率 (HR=2.13; CI 1.07-4.25, p=0.03)，試驗提前結束。另外，在2010-2011 的PALLAS study (族群主要為permanent atrial fibrillation, n=3236)中可見接受dronedarone 治療組中不論是all-cause mortality, CV death, arrhythmic death, stroke, MI, CV hospitalization, hospitalization for heart failure皆較 placebo組為高。

C. Dofetilide 為class III anti-arrhythmic agent

D&E. 對於Afib合併有HFrEF的人，amiodarone 及catheter ablation為建議的治療方式。

Ref：
*2020 ESC guideline for Management of Atrial Fibrillation
*NEJM 2008; 358:2678-2687. Increased Mortality after Dronedarone Therapy for Severe Heart Failure
*Connolly SJ, et al. NEJM 2011;365(24):2268-76. Dronedarone in high-risk permanent atrial
fibrillation.

## Question 22:

有關感染性主動脈炎(infective aortitis)的描述,下列何者錯誤？
(1) 細菌感染性主動脈炎造成感染性動脈瘤(mycotic aneurysm)好發部位在infrarenal abdominal aorta
(2) 細菌感染性主動脈炎造成感染性動脈瘤好發於年輕人
(3) 細菌感染性主動脈炎造成感染性動脈瘤好發於男性
(4) 梅毒性主動脈炎(syphilitic aortitis) 好發於升主動脈(ascending aorta)，尤其是主動脈根部(aortic root)
(5) 梅毒性主動脈炎會造成血管滋養管 (vasa vasorum) 的閉塞性動脈內膜炎
(obliterative endarteritis)

---

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

### Correct Answer: A

(1)(2)(3) 細菌感染性主動脈炎造成感染性動脈瘤的好發部位在suprarenal abdominal aorta，較好發於老人、男性。
Ref：Harrison 20th edition, Chapter 274

## Question 23:

78歲老菸槍，COPD 診斷已經好幾年，因為肺功能不佳及咳喘，長期使用吸入型氣管擴張劑。不幸的是左上肺葉發現一顆腫瘤，切片證實是鱗狀細胞癌，沒有淋巴結及遠端轉移，外科醫師想要開刀切除，你會建議哪種檢查來評估術後的肺功能？

---

- A. 電腦斷層
- B. 核磁共振
- C. 支氣管鏡
- D. 肺臟血流灌注掃描
- E. 胸部超音波

### Correct Answer: D

Indications of V/Q scan:
(1) diagnosis of suspected
(2) monitor pulmonary function following
(3) provide preoperative estimates of lung function in patients, where pneumonectomy is planned.
Perform differential analysis of lung function prior to surgical procedure:
The aim of this indication is to help predict the lung function reduction in the postoperative period following lung resection (e.g. lung cancer). This is particularly important in those patients who already have a reduced function in the preoperative period. The differential function is calculated by drawing regions of interests on each lung in the anterior and posterior views. The lung can also be divided into three equal rectangular regions of interest: top, middle, and bottom. Alternatively, posterior oblique views can be used to assess lobar segmentation, assisting in cases of segmentectomy or lobectomy.
Ref: Semin Nucl Med 2017; 47:671–679

## Question 24:

年輕女性在健檢時胸部 X-ray 有疑似腫瘤的陰影，於是來到大醫院門診進一步檢查。她聽朋友說核磁共振檢查比較昂貴、比較精密，於是要求安排胸部核磁共振檢查，下列何者說明是不合理的？

---

- A. 核磁共振對於肺臟的解析度比電腦斷層佳，可以用來檢測肺腫瘤
- B. 電腦斷層在肺臟的解析度比核磁共振好
- C. 對於胸腔入口腫瘤（pancoast tumor）核磁共振有較佳的解析度
- D. 肺動靜脈畸型，核磁共振能提供足夠的訊息
- E. 脊椎或神經根的侵犯，核磁共振的解析度比電腦斷層佳

### Correct Answer: A

**CT** is considered a sensitive imaging technique, especially in the assessment of **nodes involvement and distant metastasis**.

The advantages **MRI has over CT** include:
(1) better soft tissue contrast, multiplanar imaging capability, and therefore useful for superior sulcus tumours and evaluation of the aortopulmonary window, and cardiac gating which enables excellent delineation of the heart and great vessels and removes cardiac pulsation artefact.
(2) useful in the assessment of mediastinal and chest wall invasion by virtue of its ability to determine fat-stripe invasion and involvement of the diaphragm and spinal canal.
(3) aid in differentiating lymph nodes from hila vessels.
In the specific evaluation of **loco-regional tumor extension** (evaluation of brachial plexus, subclavian vessels, parietal pleura, subpleural fat, neurovertebral foramina, and spinal canal involvement), MR provides a high soft tissue resolution.

**MRI has disadvantages** compared to CT, being slower and more expensive with poorer spatial resolution and providing limited lung parenchyma information.
Ref: European Respiratory Journal 2002 19: 722-742

## Question 25:

下列敘述何者錯誤？

---

- A. 支氣管鏡搭配支氣管超音波幅射型微小探頭檢查可以取得肺周邊的腫瘤組織，診斷準確率依操作者的經驗有所不同
- B. 胸部超音波檢查可以評估肺門附近的病變
- C. 縱膈腔淋巴結取樣檢查，縱膈腔鏡仍然是標準方式
- D. 肋膜腔鏡可以用來評估肋膜病變，不需要進開刀房全身麻醉
- E. 早期的氣管黏膜病變可以用螢光支氣管鏡檢測

### Correct Answer: B

(1) EBUS has developed from a simple observational tool to a helpful method to guide TBNA or transbronchial biopsy(ATS journal)

(2) Transthoracic ultrasound allows the assessment of pleural-based masses. When the pleural abutting is very small, only a part of the tumor can be seen even if it is large.

(3) Mediastinoscopy is the gold standard for evaluating mediastinal nodes. Thus, mediastinoscopy is encouraged as part of the initial evaluation, particularly if the results of imaging are not conclusive and the probability of mediastinal involvement is high.
Ref: 2013 and 2019 NCCN guidelines

(4) Compared with “surgical” thoracoscopy, which is better termed “video-assisted thoracic surgery” (VATS) and is performed in an operating room under general anaesthesia with selective intubation, medical thoracoscopy/pleuroscopy can be performed in an endoscopy suite under local anaesthesia or conscious sedation, using non-disposable rigid or semi-flexible (semi-rigid) instruments. Thus, medical thoracoscopy/pleuroscopy is considerably less invasive and less expensive.
Ref: Breathe 2011 8: 156-167

(5) Combined with the technical developments in bronchoscopic techniques, e.g., laser-induced fluorescence endoscope (LIFE) bronchoscopy, we now have improved methods to localize preinvasive and early-invasive bronchial lesions.
Ref: JTO 2001

## Question 26:

59歲男性因為久咳不癒、大量的黃痰來門診就診。胸部 X 光有 Tram tracks sign，回顧病史，他有慢性鼻竇炎，反覆發作，結婚數十年膝下無子，下列診斷何者最有可能？

---

- A. 囊性纖維化（cystic fibrosis）
- B. 肺氣腫（emphysema）
- C. 氣喘（asthma）
- D. 支氣管擴張，纖毛運動障礙症候群（dyskinetic cilia syndrome
- E. 非結核分枝桿菌（NTM）感染

### Correct Answer: D

下圖為支氣管擴張(Bronchiectasis)危險因子:
(Harrison 20th edition )

Primary ciliary dyskinesia leads to severely impaired mucociliary clearance and a wide variety of symptoms primarily affecting the respiratory system. Productive cough, rhinitis and recurrent infections of the upper and lower respiratory tract have been described as leading symptoms. Manifestations from other systems have also been reported and about half the patients have been described to present with situs inversus. In addition, many males with PCD have immobile spermatozoa or dysfunction of cilia in the epididymal duct, leading to infertility.
(European Respiratory Journal 2016 48: 1081-109 )

## Question 27:

下列疾病的肺功能表現何者為非？

---

- A. 肥胖：胸壁異常導致通氣受限(ventilatory restriction)
- B. 重症肌無力：呼吸肌無力導致通氣受限(ventilatory restriction)
- C. 特發性肺纖維化(idiopathic pulmonary fibrosis)：肺泡壁變厚、回彈力(elastic recoil)增加導致氣流阻塞
- D. 氣喘發作：氣道直徑減小導致氣流阻塞
- E. 嚴重肺氣腫(emphysema) 肺泡壁破壞、回彈力下降導致氣流阻塞

### Correct Answer: C

Restrictive lung syndromes can be caused by:
1. Pulmonary parenchyma diseases (intrinsic causes) : caused by intrapulmonary restriction due to inflammatory processes within the lung tissue by diseases categorized under interstitial lung diseases.
(1) Idiopathic pulmonary fibrosis (IPF)
(2) Non-specific interstitial pneumonia (NSIP)
(3) Cryptogenic organizing pneumonia (COP)
(4) Sarcoidosis
(5) Acute interstitial pneumonia (AIP)
(6) Inorganic dust exposure such as silicosis, asbestosis, talc, pneumoconiosis, berylliosis, hard metal fibrosis, coal worker's pneumoconiosis, chemical worker's lung
(7) Organic dust exposure such as farmer's lung, bird fancier's lung, bagassosis, and mushroom worker's lung, humidifier lung, hot tub pneumonitis
(8) Hypersensitivity pneumonitis
(9) Systemic sclerosis
(10) Pulmonary vasculitis l Pulmonary LangerhANS cell histiocytosis (formerly referred to as histiocytosis
X)
(11)Medications such as nitrofurantoin, amiodarone, gold, phenytoin, thiazides, hydralazine, bleomycin, carmustine, cyclophosphamide, methotrexate
(12) Radiation therapy
2. Extrapulmonary diseases (extrinsic causes) : a result of diseases of the chest wall, such as:
(1) Kyphoscoliosis
(2) Pleural conditions such as effusions, trapped lung, pleural scarring, chronic
empyema, asbestosis
(3) Obesity
(4) Neuromuscular disorders like muscular dystrophy, amyotrophic lateral sclerosis,
polio, and phrenic neuropathies.
(5) Ascites
Ref: StatPearls July 15, 2020.

## Question 28:

關於結核病藥物副作用的處理原則，下列哪些敘述是正確的？
(1) 血中尿酸增高時，同時服用 allopurinol，降尿酸效果通常很顯著
(2) 因嚴重皮膚副作用而中斷治療者，待副作用消失後，應考慮由低劑量至高劑量逐一加入抗結核藥物
(3) 嚴重副作用時，例如肝炎、嚴重視力模糊、嚴重血球降低、嚴重皮膚副作用時，應同時停止所有抗結核藥物治療
(4) 腸胃不適、皮疹、搔癢、關節痠痛等副作用，通常在服用抗結核藥物兩周
後會自然減輕。因此，若症狀不嚴重，應給予病人適當衛教、心理治療，必要時給予藥物症狀治療即可

---

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

### Correct Answer: E

1. 關於抗結核藥物副作用之處置
(1) 高尿酸血症：PZA會干擾尿酸代謝而導致高尿酸血症，一般人血清尿酸濃度小於13 mg/dL時，無症狀時通常不需要藥物治療，也不需停止PZA使用。痛風患者需注意痛風發作情形，或暫時停用 PZA。 與Allopurinol併用會增加血中pyrazinoic acid 濃度，故PZA造成尿酸增加不可使用Allopurinol來治療。若需長期使用PZA，可考慮採用降尿酸藥 Benzbromarone 類藥物治療高尿酸血症

(2) 皮疹反應: 停藥後，先增加單一藥物劑量，再併用其他種類。
一般而言，皮膚不良反應的問題，與腸胃不適的處理方式類似，大約在兩週內會自行減緩或消失，診治醫師只須給予心理支持。

2. 停藥準則：發生此類不良反應時，若非常確定該不良反應是由某一特定結核藥物所致（如pyrazinamide 引發無法改善之高尿酸血症），可以直接停止該藥；否則建議停止所有抗結核藥物，待不良反應消失或減緩後，以逐一嘗試用藥方式 （rechallenge）找出導致此不良反應之藥物，此後不再使用該藥物。
(1) 有肝炎症狀而AST/ALT超過正常上限的三倍；或無肝炎症狀但AST/ALT超 過正常上限的五倍
(2) 嚴重之貧血、血小板下降、紫斑、白血球低下、或甚至泛血球寡少症。
(3) 使用抗結核藥物後，creatinine 上升超過0.5 mg/dL。同時留意是否可能有其他腎功能惡化的原因，例如腎前、或腎後因素。
(4) 嚴重無法緩解之痛風症狀、或已經攝取足夠水分且接受低普林飲食之後血清尿酸值仍高於 13 mg/dL、或高尿酸血症併急性腎功能惡化。
(5) 嚴重無法緩解之皮疹、搔癢、或併發 toxic epidermal necrolysis、 Stevens-Johnson syndrome。
(6) 視力惡化。
(7) 其他任何導致病人無法規則服藥的不良反應、或不適反應。
Ref: 結核病診治指引第六版

## Question 29:

54歲男性有高血壓及糖尿病史，日前與國外回來的朋友聊天喝咖啡，數日後因為呼吸道症狀合併發燒，來醫院急診。胸部 X -ray 顯示兩側肺浸潤(毛玻璃狀為主)，血氧飽和度<90%，立刻被送進加護病房隔離。24小時內，肺浸潤變嚴重，接受氣管插管及開始呼吸器使用。下列處置何者對於病人有幫助?
(1) 為確保足夠血氧濃度，呼吸器潮氣容積要 10 ml/kg 以上
(2) 呼吸器吐氣末期正壓(PEEP)愈低越好
(3) 俯臥通氣(Prone Positioning)可以降低氧氣需求量
(4) 給予鎮靜及神經肌肉阻斷劑
(5) 水分限制(fluid restriction)

---

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

### Correct Answer: C


## Question 30:

72歲海軍退休輪機士官長，長年在軍艦輪機房工作。最近因為喘，在門診就診，胸部X光異常，於是接受胸部電腦斷層檢查如附圖，下列何者敘述為是?

(1) 電腦斷層顯示為胸膜斑(pleural plaques)
(2) 與工作環境息息相關
(3) 不會引起肺癌
(4) 與胸腔間皮瘤高度相關
(5) 抽煙對於癌症的發生率不會有加成效果

---

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

### Correct Answer: D

**Asbestos exposure** remains an important public health and clinical problem; industrial use has been significantly reduced but not eliminated. Being exposed to asbestos does increase the risk of developing a serious lung condition such as **asbestosis, malignant pleural mesothelioma (MPM) or lung cancer**.
**Pleural plaques**, or localized thickening of the parietal pleura, are the most common consequence of asbestos exposure. They typically become visible twenty or more years after the inhalation of asbestos fibers. Pleural plaques preferentially involve the parietal pleura adjacent to ribs and they are also common along the diaphragmatic pleura, but absent in the region of the costophrenic sulci and the lung apices. They may be an indicator of a higher risk for cancer such as pleural mesothelioma or asbestos lung cancer. However, there is no scientific evidence that having pleural plaques increases the risk any further.
**Cigarette smoking** is not a risk factor for the development of MPM. But if the patient smokes, quit smoking is suggested due to it will reduce the chances of developing a smoking-related lung disease such as lung cancer.

## Question 31:

40歲男性因為嗜睡、注意力無法集中，朋友建議他來睡眠呼吸暫停(sleep apnea)門診。身體檢查BMI>30，脖子短，下巴內縮，似乎為典型 obstructive sleep apnea/ Hypopnea syndrome(OSAHS)的病人。下列何者為非?

---

- A. OSAHS 常合併其他慢性疾病，例如: 心血管疾病、高血壓、糖尿病等
- B. 可以從症狀及病史來診斷
- C. 得到OSAHS 的病人容易英年早逝
- D. 病人因睡眠品質不佳，長期缺氧，容易造成神經功能的退化
- E. 持續氣道正壓呼吸器治療是目前的主流

### Correct Answer: B

Obstructive sleep apnea (OSA) is characterized by repetitive partial or complete collapse of the upper airway during sleep, resulting in episodic reduction (hypopnea) or cessation (apnea) of airflow despite respiratory effort and leading to acute gas exchange abnormalities.

Risk factors: **Older age, Male gender, Obesity** (the risk of OSA correlates well with **BMI), Craniofacial and upper airway abnormalities** (e.g., retrognathia, deviated nasal septum, low-lying soft palate, enlarged uvula and base of the tongue. It is especially important in **Asian** patients, where obesity is not as major a risk factor compared with the US). Other less well-established risk factors include **smoking and family history** of snoring or OSA.

The prevalence of OSAHS is also increased in patients with a variety of medical conditions, including **T2DM**, Obesity hypoventilation syndrome **(OHS), CHF, ESRD, cardiac dysrhythmias** (eg, atrial fibrillation), **chronic lung disease** (e.g., Asthma, COPD, IPF), **stroke and TIA**,**** acromegaly, hypothyroidism****, etc.
OSA is **not a clinical diagnosis** and objective testing must be performed for the diagnosis. The diagnostic testing for OSA should be performed on patients with **excessive daytime sleepiness (EDS) on most days** and the presence of other clinical features of OSA: **habitual loud snoring, witnessed apnea or gasping or choking during sleep**, and diagnosed systemic hypertension.
**Polysomnography (PSG)** is a monitored, eight-hour sleep study conducted in a laboratory with an established scoring criteria for OSA-related respiratory events. The test can be tailored to a patient’s clinical history to determine the need for supplemental oxygen and positive airway pressure titration, detect elevated carbon dioxide (hypercapnia or hypoventilation) due to shallow breathing, and monitor for seizures or parasomnias. The PSG also records REM and non-REM sleep for REM-related sleep disorders, body position (supine and off supine), and variability in
muscle tone that corresponds to the different stages of sleep.
* Apnea: defined as the absence of airflow for ≥ 10 seconds.
* Hypopnea: defined as ≥ 30% reduction in thoracoabdominal movement or airflow with ≥ 4% oxygen desaturation.
AHI (apnea-hypopnea index) = (apneas + hypopneas / total sleep time in hours)
RDI (respiratory disturbance index) = (apneas + hypopneas + respiratory effort-related arousals [RERAs] / total sleep time in hours)
Generally, AHI ≥ 5 is considered abnormal and the patient is considered to have a sleep disorder. An abnormal AHI accompanied by excessive daytime sleepiness is the hallmark for OSA diagnosis.
There is conjecture that the AHI may correlate better with cardiovascular outcomes, while the RDI may yield more information about daytime sleepiness and symptoms.

## Question 32:

18歲男性無特殊疾病，某天在打籃球時突然胸痛、胸悶來到急診。胸部X光如附圖，下列何者為是:

---

- A. 好發年輕男性身材矮胖
- B. 常是慢性肺部疾病引起
- C. 治療首選是開刀
- D. 與抽菸關係密切
- E. 治療成功後幾乎不會復發

### Correct Answer: D

**Spontaneous pneumothorax**, which occurs in the absence of thoracic trauma, is classified as primary or secondary.
(1) Primary spontaneous pneumothorax (PSP) affects patients who do not have clinically apparent lung disorders.
(2) Secondary pneumothorax (SSP) occur in the setting of underlying pulmonary disease, which most often is COPD.
PSP is associated with low rates of morbidity and mortality, typically affects a young population and has a recurrence rate of between **17% and 54%**. The onset of PSP typically occurs at rest (80%) and is characteristically associated with chest pain (81%) and dyspnea (39%).

Smoking remains the main risk factor of PSP. Routine smoking cessation is advised.
(1) The retrospective study in Stockholm assessed the smoking rates of 138
patients admitted to hospital over a 10-year period and compared their rates of smoking with a large contemporary random sample of people from the same
area. Of the patients with PSP, 88% smoked. Compared with nonsmokers, the
relative risk of a first spontaneous pneumothorax was increased 9-fold in
women and 22-fold in men who smoked.
Cases of PSP have been shown to exhibit clustering, an effect that has been hypothesised to be due to changes in atmospheric pressure or levels of air pollution. Height has been demonstrated to be a risk factor for PSP and recent studies have shown a high prevalence of **low BMI** in patients with PSP. In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, **definitive treatment **including pleurodesis is undertaken.

Ref:
* British Thoracic Society (BTS) guidelines (2010)
* American College of Chest PhysiciANS (ACCP)(2001)

## Question 33:

72歲男性老煙槍一天兩包菸至少 30年，有糖尿病、高血壓，接受口服藥物治療，但順從性不佳。慢性阻塞性肺病已有 10年歷史，雖然使用吸入型長效型乙二型交感神經刺激劑(LABA)及長效型抗膽鹼劑(LAMA)，但常常因為肺炎合併慢性阻塞性肺病急性惡化住院。最近新英格蘭雜誌發表一篇大型研究，認為加上吸入型類固醇可以減少惡化次數，下列何者為是:

---

- A. 吸入型類固醇會增加肺炎機會，不適合此位病人
- B. 低劑量類固醇對於降低急性發作更有幫助，應該使用低劑量吸入型類固醇
- C. 因為糖尿病控制不佳，使用低劑量吸入型類固醇即可
- D. 使用高劑量吸入型類固醇及長效型乙二型交感神經刺激劑效果最佳
- E. 使用高劑量吸入型類固醇及長效型抗膽鹼劑最好

### Correct Answer: A

因反覆肺炎不建議吸入性類固醇使用，維持LABA+LAMA之順應性。

## Question 34:

71歲男性有吸煙史，一天一包 30年，戒了20年。最近因為走路會喘、咳嗽加重來到門診。肺功能檢查顯示侷限性肺功能缺損(restrictive deficit)，胸部X光高度懷疑肺纖維化。下列何者為非?

---

- A. 胸部電腦斷層是必要的檢查
- B. 必須排除結締組織疾病(connective tissue disease)造成的肺纖維化
- C. 切片檢查是必要的，即使是特發性肺纖維化也必須切片證實
- D. 特發性肺纖維化，目前已有抗纖維化療法(pirfenidone 及nintedanib)
- E. 免疫抑制可能會增加死亡率

### Correct Answer: C

Idiopathic Pulmonary Fibrosis (IPF): Adult patients with newly detected interstitial lung disease (ILD) of apparently unknown cause are clinically suspected of having IPF if they have unexplained symptomatic or asymptomatic patterns of bilateral fibrosis on a chest radiograph or chest CT scan, bibasilar inspiratory crackles, and an age typically older than 60 years.
**Diagnosis of IPF** requires the following:
(1) Exclusion of other known causes of ILD (e.g., domestic and occupational environmental exposures, CTD, drug toxicity), and either #2 or #3:
(2) The presence of the HRCT pattern of UIP
(3) Specific combinations of HRCT patterns and histopathologypatterns in patients subjected to lung tissue sampling.
Ref: Am J Respir Crit Care Med Vol 198, Iss 5, pp e44–e68, Sep 1, 2018
Ref: N Engl J Med 2020;383:958-68.

## Question 35:

非侵襲性呼吸器（noninvasive ventilator, NIV）不適合用於下列哪些病人？
(1) 慢性阻塞性肺病急性發作合併二氧化碳蓄積
(2) 神經肌肉疾病所導致的慢性呼吸衰竭
(3) 意識不清無法合作
(4) 心肌梗塞合併肺水腫
(5) 休克的病人

---

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

### Correct Answer: E

NIV contraindications
Ref: AJRCCM 2001 Jan;163(1):283-91

(1) COPD AE
Bilevel NIV may be considered in COPD patients with an acute exacerbation in three clinical settings:
. To **prevent acute respiratory acidosis**, i.e. whe PaCO2 is normal or elevated but pH is normal
. To **prevent endotracheal intubation** and invasive mechanical ventilation in patients **with mild to moderate acidosis and respiratory distress**, with the aim of preventing deterioration to a point when invasive ventilation would be considered
. As an alternative to invasive ventilation in patients with severe acidosis and more severe respiratory distress.
Bilevel NIV may also be used as the **only method for providing ventilatory support in patients who are not candidates for or decline invasive mechanical ventilation**.

(4) Cardiogenic pulmonary edema:
NIV has the ability to improve respiratory mechanics and facilitate left ventricular work by decreasing left ventricular afterload. This is facilitated by the decrease in negative pressure swings generated by the respiratory muscles. We recommend either **bilevel NIV or CPAP for patients with ARF due to cardiogenic pulmonary oedema**.
**BUT!** In patients with **acute coronary syndrome or cardiogenic shock** in studies evaluating NIV for cardiogenic pulmonary oedema, the above recommendation **does not apply to these subgroups**.
Ref: ERJ 2017 Aug 31;50(2):1602426.

## Question 36:

慢性阻塞性肺疾病COPD(Chronic Obstructive Pulmonary Disease)患者在下列
哪些情況會可考慮加上吸入性類固醇(inhaled glucocorticoid)的治療？
(1) 當患者同時有氣喘(asthma)之病史
(2) 當患者一年內有兩次或以上慢性阻塞性肺疾病急性發作之病史
(3) 當患者一年內有一次或以上慢性阻塞性肺疾病急性發作需要住院之病史
(4) 血液嗜酸性白血球計算(eosinophil count)大於150/mm3 (5) 當患者不適合使用長效型支氣管擴張劑時可單獨使用

---

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

### Correct Answer: C
(1) ICS in combination with long-acting bronchodilator therapy:
Moderate to very severe COPD: ICS+ LABA v.s ICS or LABA alone可以改善lung function, health status, reduce AE.
In hospitalization for COPD AE: LABA/ICS vs LABA 可降低AE rate

(2) Blood eosinophil count:
ICS containing regimens have little or no effect at a blood eosinophil count<100 cells/uL. BEC >300 identifies the top of the continuous relationship between eosinophils and ICS, and can be used to identify patients with the greatest likelihood of treatment benefit with ICS.

(3) 單用ICS in COPD?
ICS alone無法改善COPD 患者 FEV1 decline 或改善mortality。
TORCH trial: Fluticasone propionate alone 相較於placebo 或Salmeterol+Fluticasone propionate(LABA+ICS, Seretide)有增加mortality 的trend

(4) LABA/ICS may also be first choice in COPD patients with a history of asthma

(5) ICS Adverse effect:
RCT: ICS using group has higher prevalence of oral candidiasis, hoarse voice, skin bruising and pneumonia
High pneumonia risk: smoker, older(>55y/o), prior AE or Pneumonia Hx, BMI<25, poor MRC dyspnea grade +/- severe airflow limitation
Observational studies: increase risk of DM/ poor control DM, cataracts,
mycobacterial infection
Ref: 2020 GOLD guideline

## Question 37:

王先生40歲有氣喘(asthma)病史，平時不規則使用吸入型類固醇(inhaled corticosteroid, ICS)。最近夜咳以及夜間喘鳴(wheezes)狀況加劇，於是來到急診就醫，血氧飽和度(SpO2)96%(無使用氧氣)，身體診查發現肺部有瀰漫性喘鳴聲(diffuse wheezes)，尖端呼氣流量(peak expiratory flow rate, PEFR)為預測值 的50%，可考慮給予下列哪些處置？
(1) 吸入型短效乙二型交感神經刺激劑 (short-acting β2 agonist, SABA)
(2) 吸入型短效抗膽鹼藥物(short-acting muscuarinic antagonist，SAMA)
(3) 全身性類固醇 (systemic corticosteroids)
(4) 硫酸鎂注射液 (magnesium sulfate)
(5) Azithromycin

---

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

### Correct Answer: D

(1) Def: **Exacerbation of asthma** are episodes characterized by a **progressive increase in symptoms of SOB, cough, wheezing or chest tightness and progressive decrease in lung function**, i.e. they represent a change from the patient’s usual status that is sufficient to **require a change in treatment**.
Peak expiratory flow: <50% compared with severe exacerbation
(2) Treat exacerbations:
Repetitive administration of short-acting inhaled bronchodilators, early introduction of systemic corticosteroids, an controlled flow oxygen supplementation.
* Repeated inhaled SABA(4-10puffs Q20mins for 1st hour; 4-10 puffs Q3-4H-6-10puffs Q1-2hrs)
* SAMA(Ipratropium): both SABA+SAMA associated with fewer hospitalization and greater improvement in PEF and FEV1 compared with SABA alone
* Oxygen therapy: maintain oxygen saturation 93-95%
* Systemic steroid: 1mg prednisolone /kg/day or equivalent up to Max 50mg/day, continued for 5-7 days
* Controller medications: keep and increase dose
* Other Tx:
. Magnesium: NOT routinely use in Asthma AE. However, single 2g infusion over 20 minutes reduces hospital admission in some groups(fev1<25-30%, fail to respond to initial treatment and persistent hypoxemia)
. Antibiotics: NOT recommended
. Aminophylline & Theophylline: NOT be used in Asthma AE due to poor efficacy and safety profile
. Helium oxygen: No role for routine care but may be considered if no respond to standard Tx
. Leukotriene receptor antagonist: limit evidence
. ICS-LABA: in ED or hospital is unclear
. NIV: weak evidence
Ref: 2020 GINA guideline

## Question 38:

有關氣喘(asthma)之治療，下列何者錯誤？

---

- A. 輕度氣喘的病患The Global initiative against asthma (GINA) 2020 不再建議單獨使用吸入型短效乙二型交感神經刺激劑 (short-acting β2 agonist, SABA)作為控制藥物(controller)，需要使用SABA時建議與低劑量吸入型類固醇(inhaled corticosteroid, ICS)並用
- B. 長效型抗膽鹼劑(long-acting muscarinic antagonists; LAMA)於中重度氣喘的控制沒有角色
- C. 白三烯素拮抗劑(leukotriene receptor antagonist)在控制氣喘效果與預防急性發作上較吸入型類固醇(inhaled corticosteroid, ICS)差
- D. 輕度氣喘的病患可於有症狀時間歇性使用budesonide-formoterol
- E. 吸入型類固醇(inhaled corticosteroid, ICS)與吸入型長效乙二型交感神經刺激劑 (long-acting β2agonist, LABA)併用較單獨使用吸入型類固醇於中度氣喘患者可達到較快速的症狀改善

### Correct Answer: B

A&B&D.
C.
E. Combination therapy with a LABA plus an inhaled glucocorticoid did not result in a significantly higher risk of serious asthma-related events than treatment with an inhaled glucocorticoid alone but resulted in significantly fewer asthma exacerbations.
(NEJM 2018 Jun 28;378(26):2497-2505.)
Ref: 2020 GINA guideline

## Question 39:

體外生命支持(Extracorporeal life support, ECLS)使用在呼吸衰竭病患可以達到的效果，以下何者錯誤？

---

- A. 改善低血氧(hypoxemia)
- B. 改善高碳酸血症(hypercapnia)
- C. 減少呼吸器導致肺損傷(ventilator-induced lung injury, VILI)
- D. 減少橫膈膜損傷(diaphragm myotrauma)
- E. 減少泛發性血管內血液凝固症(disseminated intravascular coagulation,DIC)的機會

### Correct Answer: E

(1) Indications and Potential Indications for ECMO and ECCO2R
* Very severe ARDS
* Moderate to Severe ARDS
* Bridge to Lung TrANSplant
* Right heart failure with or without Respiratory Failure
* Acute pulmonary embolism
* Acute decompensated of pulmonary hypertension
* Others for respiratory failure

(2) Contraindication:
The only absolute contraindication to the use of ECLS for respiratory failure is an **irreversible underlying process** when the patient is not a candidate for lung trANSplantation.

Figure 2. Selected Complications Associated With Adult Respiratory Extracorporeal Membrane Oxygenation (ECMO)

Ref: JAMA. 2019;322(6):557–568

## Question 40:

65歲男性有高血壓、糖尿病病史。因為發燒，咳嗽有黃痰來到急診。在急診時意識清楚，血壓120/80mmHg，心跳速率100/min，體溫38.8°C，呼吸速率26/min，血氧飽和度(SpO2)95%(無使用氧氣)，身體診查發現右下肺野有粗爆裂音(coarse crackles)。胸部X光顯示右下肺葉浸潤，無明顯肋膜積水。以下處置何者錯誤？

---

- A. 可考慮給予口服抗生素門診治療
- B. 流行性感冒流行季節應進行流感檢測
- C. 可考慮單獨給予azithromycin或clarithromycin
- D. 可考慮給予Amoxicillin-clavulanate加上macrolide
- E. 可考慮單獨給予respiratory fluoroquinolone

### Correct Answer: C

Pneumonia severity 可以CURB-65評估，此患者1分(age)可門診治療。
另依據是否具有PsA, MRSA, Aspiration PNA or Anaerobic risks 考量調整抗生素使用。
Ref: 2018 台灣肺炎診治指引

## Question 41:

下列何者不是進展成為嚴重新型冠狀肺炎(severe coronavirus disease 2019, Covid-19)的危險因子？

---

- A. 年齡小於65歲
- B. 慢性肺疾病
- C. 糖尿病
- D. 肥胖
- E. 末期腎病(End Stage Renal Disease, ESRD)

### Correct Answer: A

根據美國CDC網站，以下疾病與severe COVID-19相關：
Cancer, **CKD, COPD**, Down syndrome, 心臟疾病(heart failure, CAD, cardiomyopathy), 器官移植者, **obesity** (BMI >30), 懷孕, sickle cell anemia, 抽菸, **type 2 DM**
以下疾病可能與severe COVID-19相關：
Asthma, cerebrovascular disease, cystic fibrosis, hypertension, 免疫不全者, dementia, 肝臟疾病, overweight (BMI>25), 肺纖維化, thalassemia, type 1 DM

A. 經age-related risk factor 校正後的risk severity 隨年紀增加上升2.7%
(Int J Environ Res Public Health. 2020; 17(16): 5974.)

## Question 42:

下列造成濾出性肋膜積水(TrANSudative pleural effusion) 之病因，何者根據Light's criteria 最常被誤判為滲出液(Exudate)？

---

- A. 鬱血性心臟衰竭(Congestive heart failure)患者使用利尿劑治療
- B. 肝硬化(cirrhosis)
- C. 腎病症候群(nephrotic syndrome)
- D. 低白蛋白血症(hypoalbuminemia)
- E. 肺塌陷(atelectasis)

### Correct Answer: A

A. Heart failure 病人在用利尿劑治療後肋膜積液 transudate容易變成pseudoexudate，Protein (fluid/serum ratio)平均由0.34 +/- 0.09上升到0.47 +/- 0.13 (p < 0.01) ，LDH (fluid/serum ratio)平均由 0.39 +/- 0.16 上升到 0.64 +/- 0.28 (p < 0.01)
Ref: Chest. 1989;95(4):798-802.

## Question 43:

50歲男性因為發燒，咳嗽有黃痰伴隨左側胸痛來到急診。在急診時意識清楚，血壓130/70 mmHg，心跳速率110/min，體溫39°C，呼吸速率28/min，血氧飽和度(SpO2)95%(無使用氧氣)，身體診查發現左下肺野有粗爆裂音(coarse crackles)且呼吸音減少。胸部X 光顯示左下肺葉浸潤，同時有肋膜積水。下列敘述何者錯誤？

---

- A. 抽出的肋膜積液在革蘭氏染色(Gram stain)下看到細菌就可診斷為膿胸
- B. 胸腔超音波是評估肋膜積液是否有隔間(septations)最佳的工具
- C. 若感染性肋膜積液有隔間(septations)，及早進行影像輔助胸腔鏡手術(Video-Assisted Thoracoscopic Surgery ,VATS)可減少手術併發症
- D. 若抽出的肋膜積液為膿(frank pus)，使用胸管引流加上tissue plasminogen activator (t-PA)以及DNase比上單純胸管引流可降低死亡率
- E. 如果病患不適合開刀，引流膿胸使用 14-French 胸管(chest tube)或豬尾導管(pigtail catheter)即可

### Correct Answer: D

MIST2 trial (N Engl J Med 2011; 365:518-526) 在pleural infection (即目前對empyema 的定義：外觀為pus, culture或gram stain (+), pH< 7.2，合併系統性感染如發燒、leukocytosis 及CRP 高等)的病人使用**intrapleural t-PA + DNase combination therapy** 對影像學上 pleural effusion 減少的量、surgical referral 的減少、hospital stay 縮短、CRP level下降都有顯著差異，(但t-PA 或DNase單用的兩個group 則都沒有達到統計學上的顯著改善)，但**對死亡率則無明顯改善**。

## Question 44:

下列何種狀況於晚期發小細胞肺癌第一線治療適合單一使用 pembrolizumab注射？

---

- A. EGFR mutations
- B. ALK gene rearrangements
- C. 病患有控制不佳的自體免疫疾病
- D. PD-L1 tumor proportion score less than 1%
- E. PD-L1 tumor proportion score of 50% or greater

### Correct Answer: E

題目應為**非**小細胞肺癌。
Single-agent pembrolizumab is recommended (category 1; preferred) as first-line therapy for eligible patients with metastatic NSCLC regardless of histology, **PD-L1 expression levels of 50% or more**, and with **negative test results for EGFR, ALK, ROS1, and BRAF V600E**(specific molecular) variants.
The NCCN NSCLC Panel also recommends single-agent pembrolizumab as a first-line therapy option in eligible patients with metastatic NSCLC regardless of histology, **PD-L1 levels of 1-49%** (category 2B; useful in certain circumstances).
根據KEYNOTE-024 trial，NSCLC PD-L1>50%第一線使用 pembrolizumab monotherapy
Ref: NCCN guideline for non-small cell lung cancer v3. 2020

## Question 45:

病人因感到倦怠而就醫，其抽血檢驗如下：AST=70 (<31) U/L，ALT=35 (<41) U/L，ALP (Alkaline phosphatase)=105 (<104) U/L。下列病況何者不能解釋其結果？

---

- A. 溶血 (hemolysis)
- B. 心肌梗塞 (myocardial infarction)
- C. 重訓 (heavy muscle exercise)
- D. 酗酒 (alcoholism)
- E. 健康的B型肝炎病毒慢性感染者（健康帶原者）

### Correct Answer: E

A. 細胞內較高濃度之鉀，磷，AST，LDH在紅血球破裂時會進入週邊的血漿。
Ref: Biochem Med (Zagreb)2011;21(1):79-85

B. AST 以及 ALT 之升高在STEMI 皆可以見到，兩者與CK-MB之濃度皆有相關性，並且與較差之臨床預後與較高之死亡率有關。AST 又比ALT 更加與CK-MB關係成正相關。
Ref: Coron Artery Dis . 2012 Jan;23(1):22-30

C. 運動廣泛可能導致健康人ALT，AST 短暫上升，強度，運動類型以及時間皆有相關。有相關研究顯示在運動後七天都可能仍然上升，且一開始抽血常見為AST/ALT>1 之型態。
Ref: 2008 Feb; 65(2): 253–259

D. 酗酒 (AST:ALT ratio >2:1 is suggestive, whereas a ratio >3:1 is highly suggestive, of alcoholic liver disease. (Harrison 20th, chapter 330, p2339)

E. B肝患者通常可以處在四期，健康的 B肝帶原者(Chronic infection)，通常指的是在immune-tolerant時期(HBeAg(+))或者是指inactive carrier(HBeAg(-))，肝切片下這兩個時期通常顯示幾乎沒有肝臟壞死與發炎，這時 ALT 與AST 應該為正常
Ref: Journal of Hepatology 2017 vol. 67

## Question 46:

病人因上腹疼痛一天被送至急診室，抽血檢驗 Amylase 上升至1000 U/L。住院第三天，血清 amylas 降至正常。下列敘述何者正確？
(1) 檢測血清 triglyceride 濃度可能 >1000 mg/dL
(2) 要釐清有無膽結石
(3) 身體診察可能有Obturator sign
(4) 住院後24小時需注意 serum Creatinine level
(5) 需排除 perforated peptic ulcer
(6) 需排除 mesenteric vascular occlusion
(7) 每天做腹部超音波檢查是最佳判斷 severity 之方式

---

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

### Correct Answer: E


此題符合急性胰臟炎的診斷原則，因此就可以依此邏輯來解題。
(1) Hypertriglyceridemia is the cause of acute pancreatitis in 1.3–3.8% of cases; serum triglyceride levels are usually >1000 mg/dL.
Ref: Harrison 20th chapter 341, p2438

(2) 常見原因為喝酒以及膽結石導致 Gallstones and alcohol account for 80–90% of the acute pancreatitis cases in the United States. Gallstones continue to be the leading cause of acute pancreatitis in most series (30-60%).
Re: Harrison 20th chapter 341, p2438

(3) Obturator sign是在檢查急性闌尾炎常見之檢查。

(4) 急性胰臟炎根據2012 Revised Atlanta Criteria 分為早期與晚期，其中建議早期（通常一到二週）的器官衰竭使用 modified Marshall scoring system 來定義，如果其中一個系統（呼吸，腎臟，心血管）分數大於兩分則定義為器官衰竭。早期通常為嚴重之發炎反應導致多重器官衰竭，也因此像是BISAP score其中一項 BUN>25mg/dL，以及早期預後指標住院時BUN>22mg/dL都象徵著嚴重度較重。由此可知早期腎功能之指標(Serum Creatinine)往往也暗示著之後疾病的嚴重度。
Ref: Harrison 20th chapter 341, p2441 Gut. 2013 Jan;62(1):102-11

(5)(6) 下表為常見hyperamylasemia 之原因。兩者歸在other abdominal disorders.
Reference: Harrison 20th chapter 341, p2436

(7) 目前急性胰臟炎之嚴重度之評估分為輕度，中重度，重度，一般以是否有器官衰竭，以及是否有局部或系統性併發症。超音波對於胰臟之解析度一直都不好，電腦斷層一般建議在住院支持治療後三到五天仍沒有改善時來偵測是否有局部併發症如壞死或感染的發生，其與死亡率相關。
Contrast-enhanced CT scan (CE-CT scan) is the standard radiographic imaging in detecting acute pancreatitis.
Ref: Open Access Maced J Med Sci. 2019 Aug 30;7(19):3319-3323.

## Question 47:

病人最近因關節炎而需服用NSAID (Non-steroidal Anti-inflammatory Drug)。某天半夜突然感到劇烈的胸 骨後疼痛而醒來。關於這個病人的病情，下列敘述何者錯誤？

---

- A. Anti-secretory drugs 常被用來加速病情之改善
- B. 服藥後要喝足夠的水且避免於 30 分鐘內躺平睡覺
- C. 最容易發生於食道中段
- D. 服用 potassium chloride 及 quinidine 亦可能造成類似病情
- E. 此種病情僅會持續幾天，且不會有後遺症

### Correct Answer: E

A. Anti-secretory drugs 常常用來短期改善症狀，同時可減少GERD造成之食道損傷。
Short-term treatment with proton pump inhibitors (PPIs) and antacids. PPIs are found to be very useful with their acid-inhibiting properties as gastric acid reflux may contribute further to the worsening of esophageal injury.
Ref: StatPearls Publishing; 2020 Jan.2020 Jun 23.
B. 預防發生的方式包含，服藥搭配足夠的水分（至少200-250ml），避免服藥時躺著，吃藥後至少要過 30分鐘後才躺床，服藥後搭配食物。
Ref: StatPearls Publishing; 2020 Jan.2020 Jun 23.
C. 食道中段在2014的一篇觀察性研究(N=78人)顯示為最常影響之解剖部位(61/78, 78.2%)，原因是中段為生理性狹窄處，起因於主動脈弓以及擴大的心房壓迫處。
Ref: World J Gastroenterol . 2014 Aug 21;20(31):10994-9
D. 常見造成之藥物有如下表，其中potassium chloride and quinidine 屬於persistent esophageal injury 這組，且容易有併發症如狹窄等的發生。
Ref: Dis Esophagus . 2009;22(8):633-7
E. 症狀通常在吃藥後的幾小時到一個月都可能發生。大部分的個案症狀在7-10天內就會緩解，但是有一些病人症狀在藥物停止後仍然持續幾個禮拜。少數病患也可能會發生食道狹窄，食道黏膜內血腫，食道破裂，或者甚至出血死亡，因此不會有後遺症明顯錯誤。
Ref: StatPearls Publishing; 2020 Jan.2020 Jun 23.

## Question 48:

一個病人被診斷肝硬化已有三年，最近肚子逐漸鼓漲，就醫時醫師在身體診察其腹部時發現有shifting dullness。下列敘述何者錯誤？

---

- A. 應儘可能安排上消化道內視鏡檢查
- B. 血液檢驗很可能發現 thrombocytosis
- C. 病人每日所食用的鈉應低於 2 gm
- D. 必要時需開立 spironolactone +/- furosemide
- E. 要檢測其血清 Albumin 濃度

### Correct Answer: B

由題目可了解此題要考的觀念為 Cirrhosis with ascites formation, acute decompensated liver 之情境。因此，可參照cirrhosis guideline AASLD 2015, 以及2018 decompensated cirrhosis EASL，以下節錄文獻重點。

A. 此族群為高風險產生靜脈曲張，因此建議之前沒做過胃鏡者應該安排內視鏡排除食道靜脈曲張。

B. 肝硬化病患大部分因為門脈高壓而合併脾臟腫大，而導致sequestration related thrombocytopenia

C&D. 根據AASLD guideline，腹水之第一線治療包含限鈉與口服利尿劑之使用。
AASLD: The mainstays of first-line treatment of patients with cirrhosis and ascites include
(1) Education regarding dietary sodium restriction (2000 mg per day [88 mmol per day])
(2) Oral diuretics.
The usual diuretic regimen consists of single morning doses of oral spironolactone and furosemide. Starting with both drugs appears to be the preferred approach in achieving rapid natriuresis and maintaining normokalemia. An alternative approach would be to **start with single-agent spironolactone**, in particular in the outpatient setting.

E. 肝硬化之預後評分最常使用Child-Pugh score，五項中其中包含albumin，可評估肝臟之合成功能，用來評估慢性肝病之預後。

Ref:
* J Hepatol . 2018 Aug;69(2):406-460 (EASL)
* Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012 (AASLD)

## Question 49:

有關C型肝炎之治療，下列敘述何者錯誤？

---

- A. 肝功能失代償之患者，不能服用含 Protease Inhibitor (PI) 類之藥物
- B. eGFR < 15 之末期腎病患者，不宜服用含NS5B 抑制劑之藥物
- C. 目前台灣健保給付規範，祇要病人血中測到C肝病毒，即可接受 Direct Acting Antivirals (DAAs) 之治療
- D. 目前 DAAs 之療程，多在 12~24週
- E. 台灣過去兩年使用 DAAs 治療C肝病人，只要病情尚佳（無肝硬化或僅有代償性肝硬化），其 SVR12 ( sustained virologic response at 12 weeks after end of treatment) 機率高達 98%。

### Correct Answer: D

A. protease-inhibitor-containing combinations have been associated with **potential hepatotoxicity** and hepatic decompensation and are contraindicated in this patient subset.
Ref: Harrison 20th chapter 334, p2395

B. in patients with severe renal impairment (creatinine clearances <30 mL/minute), data are limited on the use of sofosbuvir-containing combinations Sofosbuvir: a pan-genotypic NS5B nucleoside polymerase inhibitor
Ref: Harrison 20th chapter 334, p2395
以上兩題在 Harrison chronic hepatitis C treatment 章節最後的精華總結為:

C. 就最新健保給付條件(update 2020/9/23)顯示:
(1) Sofosbuvir/ledipasvir（如 Harvoni）:
限使用於HCV RNA為陽性之下列病患。
病毒基因型第1型、第2型、第 4型、第5型或第6型成人病患。
12歲(含)以上且未併有失代償性肝硬化之病毒基因型第 1 型兒童患者。
(2) Glecaprevir/pibrentasvir（如 Maviret）:
限使用於HCV RNA為陽性及無肝功能代償不全之病毒基因型第1型、第2型、第3型、第4型、第5型或第 6型12歲(含)以上病患。
(3) Sofosbuvir/velpatasvir（如 Epclusa）:
限使用於HCV RNA為陽性之病毒基因型第1型、第2型、第3型、第4型、第5型或第6型成人病患。

台灣自己的guideline(2020) 也表示: HCV treatment is recommended for all HCV viremic patients with life expectancy 1 year. (Moderate evidence, strong recommendation) (J Formos Med Assoc . 2020 Jun;119(6):1019-1040)
**因此廣義來說針對最廣效基因型的三個藥，HCV RNA(+)就可申請 DAA 之藥物使用。(不論肝腎功能狀況下)。**

D. 大部分DAA之療程為**12週**，**在一些狀況可能少到只需要八週**，而24週通常為有抗藥性(RAS: resistance-associated substitutions)必須使用ribavirin combination治療下而其不能使用時才需要到24週。

E. 這題題目描述有點太粗糙，因為沒有描述使用的DAA類型。需要為過去兩年使用DAA之病患，且為non-cirrhosis or compensated cirrhosis 之SVR rate之data。目前只有找到一篇相關的 real world data。 根據台灣發表於2020的這篇cohort study顯示SVR rate大多落於97-100%之間，而這篇study收入的時間為2013-2018年。不過以整體來說SVR rate很高。
Ref: J Microbiol Immunol Infect . 2020 Aug;53(4):569-577

## Question 50:

關於肝細胞癌 (hepatocellular carcinoma, HCC) 之下列各項敘述，何者正確？
(1) 在台灣，B型肝炎病毒和C型肝炎病毒是引發 HCC 的主要危險因子
(2) 新生兒全面B型肝炎疫苗接種，已明顯降低 HCC 之發生率
(3) 慢性C型肝炎患者體內之C肝病毒被口服抗C肝病毒藥物 (Direct Acting Antirivrals) 根除之後，HCC 之 發生率已明顯降低
(4) Statins 及 Metformin 已被證實可降低 HCC 之發生率
(5) 直徑大於 2 公分之 HCC，在 contrast-enhanced computed tomography (CECT) 中呈現典型的表現，即可確診，不需做切片檢查
(6) BCLC (Barcelona-Clinic-Liver-Cancer) staging system 0期者，以 RFA ( Radiofrequency Ablation) 治 療的成功率與開刀切除差不多

---

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

### Correct Answer: E

我自己解後給在刪除法4後答案只剩下E 但是我認為選項五應該也可以算錯。
1(O), 2(O), 3(X), 4(X), 5(?), 6(O)
1. Chronic viral infection accounts for more than 90% of HCC etiology in Taiwan, where 3.50 million people are (HBV) carriers and around 1.70 million subjects have (HCV) infections. Consequently, **HCC and are the major public health threats in Taiwan. **
2. **Vaccination for hepatitis B virus (HBV) has been reportedly associated with reduced occurrence of hepatocellular carcinoma (HCC)**.
3. **根據 2018 年文獻認為是可以的，但之後有一些研究也顯示沒有減少，如2020 之文獻，因此此選項應該不正確**。
**Antiviral therapy for HBV or HCV could reduce the risk of HCC**。
(J Formos Med Assoc. 2018 May;117(5):381-403 )
In most of the studies reviewed, **SVR by DAAs in HCV patients does not appear to have an impact on the occurrence and recurrence rate of HCC **in the short-term post-viral clearance, suggesting that careful surveillance of HCC in patients with cirrhosis should be mandatory.
(J Formos Med Assoc.2020 Jun; 12(6): 1351.)
4. 從兩篇文獻中皆顯示兩藥皆與特定族群降低 HCC發生率有關，但是因為研究等級皆處在觀察性回溯性研究等級，實證等級薄弱因此此題此選項是較不好之答案。
(1) Metformin: 根據2020的一篇 systemic review，主要收入文獻為case-control study(4) and cohort study(4)，結論為: The systematic review found evidence that the use of **metformin might reduce the risk of HCC in diabetic patients** (Ann Hepatol. May-Jun 2020;19(3):232-237)
(2) Statin: 根據2020的一篇meta-analysis，收入12篇observational study，結論: Statin use was independently associated with a **reduced risk of HCC in patients with HBV or HCV infection**. (BMC Gastroenterol . 2020 Apr 9;20(1):98)
5. 此題題意有些微不清楚，根據台灣 2018的guideline 我認為應該要加上在肝硬化或慢性B型肝炎患者才符合可以直接診斷的可行性。
For nodules >1 cm in **cirrhosis or chronic hepatitis B**, characteristic vascular patterns on a 4-phase or MRI, HCC could be diagnosed without biopsy. (characteristic vascular patterns: arterial and venous or delayed phase washout) However, tissue proof is encouraged
Ref: J Formos Med Assoc . 2018 May;117(5):381-403
6. RFA also provides survival rates equivalent to those seen with surgical resection for small HCC. As a result, RFA has been advocated as a first-line curative therapy for very early stage (BCLC stage 0) or un-resectable early stage (BCLC stage A) HCC.
Ref: J Formos Med Assoc . 2018 May;117(5):381-403

## Question 51:

關於大腸癌與大腸息肉之敘述，下列何者正確?
(1) 老年人約 50% 有 adenomatous polyp 於其大腸中，其中 < 1% 會演變成大腸癌
(2) 有大腸息肉者，約 20% 會驗出糞便有潛血反應
(3) Sessile villous adenomas 衍生癌變之機率約為 tubular adenoma 之 3 倍
(4) 發炎性腸道疾病 (Inflammatory Bowel Disease) 患者發病後，前10年發生大腸直腸癌之機率相當低
(5) 罹患大腸直腸癌之患者，約 50% 其糞便潛血為陰性反應
(6) < 1 cm 之 sessile serrated polyp 被切除後，其後應每年檢查一次大腸鏡

---

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

### Correct Answer: B

(Ref: Harrison 20, chapter 77 Oncology and Hematology, p572)
(1) 正確，中年人約30%有 adenomatous poly，約 50% 老年人有adenomatous poly，其中只有1%會變惡性
(2) 錯誤，<5%的大腸息肉患者的大便會有潛血反應
(3) 正確
(4) 正確，IBD病人發病後，前10年發生大腸直腸癌機率很低，10後每年增加機率約0.5-1%，發病後25年約8-30%病人會得大腸直腸癌
(5) 正確，只有50%大腸直腸癌之患者的糞便潛血為陽性
(6) 錯誤，最頻繁應每3年檢查一次大腸鏡

## Question 52:

下列關於胃腸道疾病之敘述，何者正確?

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- A. Hypocalcemia 可能造成 constipation
- B. 治療急性大腸憩室炎 (diverticulitis) 目前最常使用對抗 aerobic gram-negative rods 及 anaerobic bacteria 之抗生素，包括第三代 cephalosporin 及 metronidazole
- C. 急性胃腸道出血病人有心搏過速現象 (tachycardia) 時，應使用 β blockers 控制之
- D. Secretory diarrhea 病人之大便量通常小於 1L/天，禁食即會停止腹瀉
- E. Chronic mesenteric ischemia (intestinal angina) 病人之腹痛通常與進食無關

### Correct Answer: B

A. 錯誤，Hypercalcemia 造成便秘
Hypercalcemia from any cause can result in fatigue, depression, mental confusion, anorexia, nausea, vomiting, constipation, reversible renal tubular defects, increased urine output, a short QT interval in the electrocardiogram, and, in some patients, cardiac arrhythmias.
(Harrison 20th p2029)

B. 根據acute diverticulitis management guideline，抗生素的使用可以為第三代 cephalosporin 合併 metronidazole.
Ref: World J Gastrointest Pharmacol Ther. 2010 Feb 6;1(1):27-35

C. Acute GI bleeding出現tachycardia 代表出血量達到stage II(blood loss 750cc-1500cc)，應儘快補充volume及輸血，而不是用藥物控制心跳

D. Secretory diarrhea並不會因為禁食而停止腹瀉，是osmotic diarrhea 才會因食而停止腹瀉
E. Intestinal angina 的病人常常進食後，因為腸子需要更多血流，但血管出現血栓，腸子缺血而出現腹痛

## Question 53:

關於幽門螺旋桿菌 (H. pylori) 之下列敘述，何者錯誤?

---

- A. Eradication of H. pylori 減少十二指腸潰瘍復發達 80% 以上
- B. 血清 H. pylori 之 IgG antibody test 可用來判斷 H. pylori eradication 之效果
- C. 胃部 H. pylori 被根除後，再感染率甚低
- D. NSAID (Nonsteroidal Anti-inflammatory Drugs)- induced 胃潰瘍與 H. pylori 有關
- E. H. pylori eradication 需使用組合療法，抗生素為其中重要項目，常用者包括 clarithromycin、amoxicillin

### Correct Answer: B

A. 達到H. pylori 完全清除的病人, 只有2%的病人在6個禮拜後再次出現duodenal ulcer，而沒有達到H. pylori 完全清除的病人，有85%的病人在6個禮拜後再次出現duodenal ulcer
Ref: N Engl J Med. 1993 Feb 4;328(5):308-12
B. 追蹤是否達到Eradication，會在完成抗生素治療後至少4週且PPI 停用2週後進行，可以使用的檢查包括 urea breathing test，fecal antigen test或biopsy
Ref: Am J Gastroenterol. 2017 Feb;112(2):212-239
C. 達到H. pylori 完全清除的病人, 只有2%的病人在6個禮拜後再次出現duodenal ulcer
Ref: N Engl J Med. 1993 Feb 4;328(5):308-12
D. NSAID的使用是否與增加H. pylori感染或是有直接的關係目前還是controversial，不過在1997年登在lancet的一篇RCT 證明使用NSAID前進行H. pylori 根除可減少NSAID-induced peptic ulcers
Ref: Lancet. 1997 Oct 4;350(9083):975-9
E. 各種不同治療H. pylori的 regimen都包括抗生素，一線治療就包括clarithromycin amoxicillin, metronidazole
Ref: Am J Gastroenterol. 2017 Feb;112(2):212-239

## Question 54:

病人過去有慢性肝炎病史，但一直沒有獲得明確診斷。此次就醫抽血檢驗所得結果如下:AST=100 (<31) U/L，ALT=100 (<41) U/L，ALP=500 (<104) U/L，GGT=450 (<50) U/L，Bil (T)/(D)=4.0/3.1 mg/dL，PT INR=1.05。請問其診斷最不可能為下列何者?

---

- A. Primary Biliary cholangitis
- B. Primary Sclerosing Cholangitits
- C. Drug-induced liver injury
- D. Hepatic failure
- E. Stone impaction at common bile duct

### Correct Answer: D

A. Primary biliary cholangitis 常見的血液異常為ALP, GGT升高，以conjugated type為主的黃疸，如果進展到 cirrhosis, INR 就有可能會升高
Ref: J Hepatol. 2017 Jul;67(1):145-172

B. Primary Sclerosing Cholangitits 為膽管發炎，也會出現ALP, GGT升高，以conjugated type 為主的黃疸
Ref: J Hepatol. 2017 Dec;67(6):1298-1323

C. 根據EASL Drug-induced liver injury guideline, DILI 的biomarkers case definitions 包括以下條件之一
(1) ≥5 ULN elevation in ALT
(2) ≥2 ULN elevation in ALP (particularly with accompanying elevations in concentrations of gamma-glutamyltransferase (GGT) in the absence of known bone pathology driving the rise in ALP level)
(3) ≥3 ULN elevation in ALT and simultaneous elevation of TBL concentration exceeding 2 ULN
Ref: J Hepatol. 2019 Jun;70(6):1222-1261

D. 根據EASL hepatic failure guideline, 達到liver failure 的定義 INR>1.5
Ref: J Hepatol. 2017 May;66(5):1047-1081

E. 在CBD的膽結石可引發膽管發炎導致 ALP, GGT上升，因為cholestasis 導致conjugated type 黃膽, ALT AST 上升

## Question 55:

病人自訴倦怠、噁心、食慾不振已有五天，抽血檢驗結果發現:ALT=300(<41) U/L，AST=210 (< 31) U/L。請問下列敘述何者錯誤?

---

- A. 若抽血檢驗 IgM Anti-HAV 呈陰性，就不是急性A型肝炎
- B. 若抽血檢驗 HBsAg 呈陽性，就可確定是急性B型肝炎或B肝病毒慢性感染者併急性肝炎發作
- C. 若抽血檢驗 Anti-HCV 呈陽性，不一定是急性C型肝炎
- D. 若最近有因灰指甲服用 Ketoconazole，應立即停藥，通常停藥後 1~2 週，ALT值可能會明顯下降
- E. 若最近有右上腹痛，需注意膽結石是否掉至總膽管中

### Correct Answer: B

A. 急性A型肝炎 IgM Anti-HAV為陽性，得過 HAV癒後為 IgG Anti-HAV陽性

B. B肝病毒慢性感染急性肝炎發作以EASL 定義的確是符合(ALT >5xULN during chronic HBV infection)，但實際還是要排除其他原因，檢查 viral load，才能確定是HBV flare。
Ref: J Hepatol. 2017 Aug;67(2):370-398

C. Anti-HCV陽性也可以出現在慢性C型肝炎

D. Ketoconazole可能會引起idiosyncratic drug induced liver injury，所以停藥後是有可能讓ALT下降
Ref: J Hepatol. 2019 Jun;70(6):1222-1261

E. CBD stone 因為cholestasis，也可以引發liver injury讓ALT、AST升高

## Question 56:

60歲女性因吞嚥疼痛(odynophagia)接受上消化道內視鏡檢查，結果如附圖，建議用下列何種藥口服治療?

---

- A. Acyclovir
- B. Valganciclovir
- C. Fluconazole
- D. Ganciclovir
- E. Dexlansoprazole

### Correct Answer: C

該圖為candida esophagitis，典型的病灶為白色plaque，可能會帶一點點黃，用水irrigation是不會被沖走。

## Question 57:

50歲中年男性有胸痛症狀，心臟檢查無異常，因為吞嚥困難接受鋇劑食道攝影，結果如附圖。下列敘述何者正確？
(1) 食道壓力(esophageal manometry)可呈現hypotense lower esophageal sphincter 及poor peristaltic activity
(2) 可以合併逆流(reflux)症狀
(3) 可以進展成食道弛緩不能(achalasia)
(4) 可以用calcium channel blockers 治療
(5) 不能用botulinum toxin injections 治療

---

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

### Correct Answer: B

此圖為Diffuse esophageal spasm，主要特徵為cockscrew appearance

(1) 主要是食道上中下段無法有效推進食物(各自蠕動)，主要manometry特徵如下：>20%有simultaneous contraction, 吞入液態物質(wet swallow)後>30%的時間不蠕動(aperistalsis)
Ref: Diffuse Esophageal Spasm. StatPearls 2020 Jan

(2) 可以合併胃食道逆流，其他常見症狀包含 non-cardiac pain and dysphagia
Ref: Diffuse Esophageal Spasm. StatPearls 2020 Jan

(3) 根據許多研究結果，Diffuse esophageal spasm 雖然可以進展至achalasia，但
是發生機會並不高(約10%)
Ref: Diseases of the Esophagus, Volume 26, Issue 5, 1 July 2013, Pages 470–474

(4)(5)治療包含以下幾種選項，第一線通常使用 calcium channel blocker, nitrate類藥物，第二線通常使用 Endoscopic botulinum toxin injection and pneumatic dilation
Ref: Diffuse Esophageal Spasm. StatPearls 2020 Jan

## Question 58:

55歲男性，長期有胃酸逆流及胸口灼熱症狀，BMI:30，接受上消化道內視鏡檢查，結果(如附圖)。下列敘述何者錯誤？

---

- A. 抽煙增加罹病風險
- B. 多吃蔬果可減少罹病風險
- C. 每年有0.12~0.5%罹癌風險
- D. 增加食道上皮細胞癌(esophageal squamous cell carcinoma)風險
- E. 抗逆流手術(antireflux surgery)無法預防其進展成癌症

### Correct Answer: D

此圖為Barrett’s esophagus，正常來說食道內的上皮為squamous cell較多，在內視鏡下為白色(pale pearl)，胃內上皮為columnar 內視鏡下的特徵為salmon-colored，兩者交界處稱為Z-line，正常會位於Gastroesophagus junction(GEJ)，Barrett’s esophagus 會讓Z-line 位於distal esophagus，圖中箭頭處為salmon-colored columnar epithelium。
Ref: 2016 ACG guideline Diagnosis and management of Barrett’s esophagus
Ref: International Journal of Oncology, 41, 414-424.

A&B. 抽菸會增加Barrett’s esophagus 的風險，其他risk 包含GERD, central obesity, 蔬果intake 過少, 年紀>50yr…
Ref: 2016 ACG guideline Diagnosis and management of Barrett’s esophagus

C. 根據2016 ACG guideline，統計出來的malignant progression 機率約為0.3%/year

D. 常見的malignancy應為esophageal adenocarcinoma
Ref: 2016 ACG guideline Diagnosis and management of Barrett’s esophagus

E. 依照目前的evidence 來說，只有一個小的RCT 證實說使用藥物(PPI) or 手術(Anti-reflux surgery)對於之後產生 tumor progression的機率沒有差異，Meta-analysis 則是有些說有幫助，有些則否，2016 ACG Guideline 並不建議 Anti-reflux surgery當成是預防之後產生癌症的治療方式。

## Question 59:

有關幽門螺旋桿菌(Helicobacter pylori)感染的敘述，下列何者錯誤？
(1) 世界衛生組織定其為definite carcinogen
(2) 與胃黏膜相關淋巴組織(gastric mucosa-associated lymphoid tissue-MALT)淋巴癌的發生有關
(3) 與胃食道逆流性疾病的發生有關
(4) 與不明原因血小板減少紫斑症(idiopathic thrombocytopenic purpura)的發生有關
(5) 第一線治療應用標準劑量 proton pump inhibitor twice daily 加上levoflaxacin 500mg/d及 amoxicilliin 1000mg twice daily

---

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

### Correct Answer: D

(1) 1994年International Agency for Research on Cancer, World Health Organization(IARC/WHO)把 H.pylori定義為class I carcinogen(唯一一個是class I carcinogen的細菌)，以下附上WHO carcinogen classification
Ref: Nat. Rev. Cancer 2, 28–37 (2002)

(2) H.pylori 會導致胃部慢性發炎，慢性發炎導致免疫細胞(B、T 細胞)清除H.pylori，導致lymphoid hyperplasia，進而影響許多signalling pathway，導致malignant clone proliferation，進而導致 MALTOMA
Ref: World J. Gastroenterol. 2014;20:684–698

(3) H.pylori 和GERD有無確切相關目前仍無定論，目前確定與H.pylori 有相關的疾病有Gastric cancer, peptic ulcer 以及atrophic gastritis…，目前根據2017 Maastricht V/Florence Consensus 的共識，H.pylori 對於胃酸並無明顯影響，以下附上內文
(4) 目前有許多假說來解釋有關於 H. pylori和ITP 的關係，目前仍被認為應該有許多因素影響導致ITP，以下研究解釋，ITP 會產生IgG anti-platelet autoantibody 並形成一個pathologic loop，有些病人在根除H.pylori後，這個pathologic loop 會停止，並使血小板恢復。另外2019 ASC ITP guideline 也建議如果是H. pylori associated ITP 建議H. pylori eradication
Ref: World journal of gastroenterology, 20(3), 714–723
(5) 根據2017 American College of Gastroenterology (ACG) clinical guideline，第一線治療為Clarithromycin 500mg BID + PPI(standard dose or double dose) + Amoxicillin 1000mg BID or Bismuth quadruple(PPI + Bismuth + Tetracycline + Metronidazole

## Question 60:

下列有關胃息肉(gastric polyp)的敘述，何者錯誤？

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- A. Sporadic fundic gland polyp(FGP)與proton pump inhibitor使用有關，息肉數目小於10，大小在 1-5mm，毋需切除
- B. 遺傳性FGPs 息肉數目常大於 30，與 familial adenomatous polyposis(FAP)或MYH-associated polyposis 有關，易有不良化生(dysplasia)
- C. 懷疑FAP 或MYH-associated polyposis 必須進行大腸鏡檢查
- D. Hyperplastic polyps 不會有不良化生(dysplasia)
- E. Adenomatous polyps 與萎縮性胃炎(atrophic gastritis)、腸化生(intestinal metaplasia)、及幽門螺旋桿菌感染有關

### Correct Answer: D

A. FGP 通常與PPI 使用有關，手術 indication包含：直徑>1cm, ulcerated polyps or在antrum 的polyp
Ref: Gastroenterol Hepatol(N Y). 2013;9(10):640-651.

B. FGP 數目如果>20需考慮polyposis syndrome可能性，常見有familial adenomatous polyposis(FAP) & MUTYH-associated polyposis (MAP) & gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS)，有這些疾病的FGP 比較容易有dysplasia
Ref: Gastroenterol Hepatol(N Y). 2013;9(10):640-651.

C. 典型FAP 大腸內會有數百至數千的 polyp，MAP 則是會有數十至一百個polyp，所以皆須大腸鏡檢查。
Ref 1:
* N Engl J Med 2003; 348:791.
* Appl Clin Genet. 2015 Apr 16;8:95-107

D. 約有20%左右的機率會有 dysplasia
Ref: N Engl J Med 2003; 348:791.

E. 目前已被證實和atrophic gastritis 和intestinal metaplasia 相關，H. pylori目前資料有限(但是這題應該有很明顯的答案)
Ref: N Engl J Med 2003; 348:791.

## Question 61:

55歲男性因急性腹痛、噁心和嘔吐至急診處就醫，6週內他有兩次飯後的右上腹痛，除此外他過去並無任何醫藥史。身體檢查體溫 36.8℃、血壓130/75 mmHg、脈搏 89/min、呼吸速率17/min、BMI:29，鞏膜有黃疸，腹部檢查有tenderness，但並無guarding或 rebound pain，腸音呈現hypoactive。住院後，給予fluid resuscitation 後，實驗室數據(如附表)：腹部超音波有膽結石但並無膽囊壁增後或積水現象，總膽管並無擴張。下列何者為最適當處置？

---

- A. 出院前進行Cholecystectony
- B. 進行cholecystokin hepatobiliary (CCK-HIDA) scintigraphy
- C. 進行endoscopic retrograde cholangiopancreaticography with bitiary sphincterotomy
- D. Intravenous imipenem
- E. Total parenteral nutirition

### Correct Answer: A

這題診斷應為early cholecystitis(有gallstone 但無wall thickening)，Acute cholecystitis 的治療方向會根據 choleystitis severity 跟病人的general status evaluation來決定，根據2018Tokyo guideline, severity分成三個grade:
病人的general status evaluation, 2018 Tokyo guideline 建議使用ASA(American Society of Anesthesiologists. Physical Status Classification System)或CCI(Charlson comorbidity inde)來評估整體身體狀況。Guideline 也強調開始治療後要反覆再評估severity。這個病人根據2018Tokyo guideline, severity grading應屬於grade I cholecystitis，根據2016 WSES guidelines on acute calculous cholecystitis, 其實症狀的onset時間對於要不要手術也很重要, 如果是症狀持續超過十天以上, 並不建議early cholecystectomy, 根據ASA屬於這個病人屬於Low risk,可以做early laparoscopic cholecystectomy(定義很廣，3-7天內皆屬於early)，以下附上2018 tokyo guideline 的figure

## Question 62:

43歲女性因為4天的腹痛至急診處，一週前她接受腹腔鏡膽囊切除術(laparoscopic cholecystectomy)，手術很順利，並無明顯併發症，她於同日出院。手術後3天開始有持續30分鐘至 2小時的上腹痛，合併噁心。身體檢查：體溫:36.8℃，血壓106/60 mmHg、脈搏82/min、呼吸速率16/min，腹部檢查並無異常現，手術傷口復原良好，實驗室檢查 ALT: 84U/L、AST: 62U/L、CBC、ALP和amylase 數值均於正常範圍。腹部超音波檢查並無腹水，肝內及肝外膽管有擴張現象。24小時後AST 及 ALT恢復正常。下列何者為最可能的診斷？

---

- A. Acute pancreatitis
- B. Bile leak
- C. Cholangitis
- D. Choledocholitihiasis
- E. Sphincter of Oddi dysfunction

### Correct Answer: D

這題應該就是cholangitis 和Choledocholithiasis 選擇(沒提到amylase, lipase，pancreatitis 可以排除，Bile leak會有 peritonitis 症狀，此病人無上述症狀。

Sphincter of Oddi dysfunction之診斷須符合Rome IV criteria (須完全符合以下三點1-3)
(1) Criteria for biliary pain: Pain located in the epigastrium and/or right upper quadrant and all of the
following:
. Builds up to a steady level and lasting 30 minutes or longer
. Occurring at different intervals (not daily)
. Severe enough to interrupt daily activities or lead to an emergency department visit
. Not significantly (<20%) related to bowel movements
. Not significantly (<20%) relieved by postural change or acid suppression
(2) Elevated liver enzymes or dilated bile duct, but not both
(3) Absence of bile duct stones or other structural abnormalities
此病人不符合，Sonogram 看到 IHD, CBD dilation)，Choledocholithiasis 為膽道結石(Gallstone in common bile duct)，此病人 lab data 除了liver enzyme 微升外，其他膽道指數並無升高。Acute cholangitis 的診斷臨床症狀為Charcot triad: Fever,
jaundice, RUQ pain，Lab data 應看到ALP elevation，因此可排除是acute cholangitis。

## Question 63:

80歲男性過去3個月有間歇性解黑便(intermittent melena)，入院時身體檢查：體溫:37℃，血壓135/80mmHg、脈搏80/min、呼吸速率18/min，Hb: 8.2 g/dL。上消化道內視鏡及全大腸鏡檢查並無異常發現。膠囊內視鏡(Capsule endoscopy)檢查發現proximal jejunum 有鮮血，並有一些angiodysplasia。下一步最適當的處置為何？

---

- A. Intraoperative endoscopy
- B. Push enteroscopy
- C. Repeat upper endoscopy
- D. Repeat colonoscopy
- E. Technetium labeled nuclean scan

### Correct Answer: B

(1) **Incidentally found lesions**: Angiodysplasia that is detected during screening colonoscopy should n’t be treated (as long as there is no history of GI bleeding or unexplained iron deficiency anemia).
(2) **Angiodysplasias in patients with GI bleeding**: actively bleeding lesions require treatment
(3) **Treatment of angiodysplasia**
* Medical: Estrogen, thalidomide, octreotide
* Endoscopy: enteroscopy with Argon plasma coagulation/ Electrocoagulation/Mechanical hemostasis/ Injection sclerotherapy
* Survery: Surgery can be considered for patients with large transfusion requirements or life-threatening hemorrhage from a clearly identified site. Preoperative or intraoperative enteroscopy or angiography may be helpful for localizing lesions.
* Angiography

內視鏡意外發現的angiodysplasia 不需要治療，本題的 angiodysplasia 持續出血則需要處理，使用膠囊內視鏡診斷後，可使用標準的小腸鏡進行止血，若需要大量輸血或life-threntening出血，則需考慮手術處理，術前使用內視鏡或是intraoperative enteroscopy可幫助定位，故本題應優先考慮**標準小腸鏡**進行處置。
Ref: Angiodysplasia of the gastrointestinal tract(uptodate)

## Question 64:

38歲男性潰瘍性腸炎患者10天前開始每日服用prednisolone 60mg，但是仍每日有6至9次的血便合併腹痛，因為進食加重疼痛和腹瀉，他主動減少經口進食。身體檢查：體溫:37℃，血壓110/56 mmHg、脈搏96/min，腹部有diffuse tenderness但並無guarding或rebound pain現象。實驗室檢查顯示Hb: 9.7g/dL、WBC: 6300/μL，糞便培養和Clostridium difficile檢查皆為陰性。下列何者為此患者目前最適當的治療？

---

- A. 增加prednisolone至每日80mg
- B. 使用adalimumab
- C. 使用ciprofloxacin和metronidazole
- D. 使用mesalamine
- E. 使用sulfasalazine

### Correct Answer: B

1. **Defining overall disease activity**
* **Mild**: Patients with mild clinical disease have ≤4 stools per day with or without small amounts of blood, no signs of systemic toxicity (eg, no tachycardia), and a normal C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR). Mild crampy abdominal pain, tenesmus, and periods of constipation are also common, but
severe abdominal pain, profuse bleeding, fever, and weight loss are not part of the spectrum of mild disease.
* **Moderate**: Patients with moderate clinical disease may have frequent (four to six per day) loose, bloody stools, mild anemia not requiring blood transfusions (hemoglobin >10 g/dL [100 g/L]), and abdominal pain that is not severe. Patients have no or minimal signs of systemic toxicity. Adequate nutrition is usually maintained and weight loss is not associated with moderate clinical disease.
* **Severe**: Patients with severe clinical disease typically have frequent loose bloody stools (≥6 per day) with severe cramps and evidence of systemic toxicity as demonstrated by a fever (temperature ≥37.8°C), tachycardia (heart rate ≥90 beats per minute), anemia (hemoglobin <10.0 g/dL [100 g/L]), and/or an elevated CRP or ESR. Patients may have weight loss.

2. **Management of moderate to severe ulcerative colitis in adults**
(1) **Goals of therapy**: The treatment goal for patients with active UC is to achieve glucocorticoid-free remission
(2) **Induction therapy**: For the patient with moderate to severe UC, **first-line** induction therapy options include **biologic agents** (with or without an immunomodulator[eg, azathioprine]) or **glucocorticoids**.
* **Anti-tumor necrosis factor (TNF)**
* **Vedolizumab**: anti-integrin antibody
* **Ustekinumab**: anti-interleukin 12/23 antibody
* **Glucocorticoids**: Systemic oral glucocorticoids are used for inducing remission in patients with moderate to severe UC or may be given to provide more immediate symptom relief for patients who are started on a biologic agent for induction therapy.( typically start oral prednisone at a dose of 40 mg daily)

3. **Medical management of low-risk adult patients with mild to moderate ulcerative colitis**
(1) **Ulcerative proctitis or proctosigmoiditis**: mesalamine as first-line treatment, or topical steroid or oral 5-ASA
(2) **Left-sided or extensive colitis**: combination of an oral 5-ASA agent plus rectal

本題病人排便次數超過六次且合併貧血以及 tachycardia，為severe UC的case，應當考慮使用生物製劑或是口服的類固醇
Ref:
* Management of moderate to severe ulcerative colitis in adults(uptodate)
* Medical management of low-risk adult patients with mild to moderate ulcerative colitis (uptodate)

## Question 65:

28歲女性因8週的下腹絞痛合併腹瀉病史，接受進一步評估，她每天排便6至10次，其中有一至二次在半夜，大便特徵為loose to watery with intermittent blood streaking。另外她有噁心及食慾變差現象，但無嘔吐、發燒，也無服用藥物病史。身體檢查：體溫:37.8℃，血壓100/54 mmHg、脈搏96/min，腹部呈現diffuse tenderness但無rigidity, guarding或rebound pain。大腸鏡檢查在升結腸、橫結腸及降結腸有如附圖之發炎病灶，但是terminal ileum及rectum並無發炎現象，下列何者為最可能之診斷？

---

- A. Collagenous colitis
- B. Crohn colitis
- C. Ischemic colitis
- D. Ulcerative colitis
- E. Tuberculous colitis

### Correct Answer: B

此圖為 Crohn disease 的 endoscopy.

A. Collagenous colitis is a chronic inflammatory disease of the colon that is characterized by chronic, watery, non-bloody diarrhea. Evaluation of a patient with suspected microscopic colitis should include stool cultures and a colonoscopy, with mucosal biopsy to establish the diagnosis of microscopic colitis and to exclude other inflammatory diseases. Collagenous colitis is classically characterized by colonic subepithelial collagen band >10 micrometers in thickness. The Mucous membrane of the colon typically looks normal.
Ref: Microscopic (lymphocytic and collagenous) colitis: Clinical manifestations, diagnosis, and management(uptodate)

B. The cardinal symptoms of CD include crampy abdominal pain, chronic intermittent diarrhea (with or without gross bleeding), fatigue, and weight loss.
**Endoscopic findings in Crohn disease: three major endoscopic findings that are specific for the diagnosis of Crohn disease
* **Aphthous ulcers**: Deeper ulcers involve the entire wall of the colon
* **Cobblestoning**: This type of ulceration results in the typical cobblestoning lesions; the deep linear ulcers are the "cracks" between the stones, while areas of inflamed or normal tissue form the "stones".
* **Discontinuous lesions**: Crohn disease lesions are typically discontinuous. They can be adjacent to normal tissue, resulting in "**skip areas**". In contrast, UC tends to be continuous and taper out gradually. If a biopsy taken from endoscopically normal tissue adjacent to an ulcer shows normal histology, the ulcer is probably due to Crohn disease
Ref:
* Endoscopic diagnosis of inflammatory bowel disease(uptodate)
* Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults(uptodate)

C. Findings include edematous, friable mucosa, erythema with interspersed pale areas, scattered hemorrhagic erosions or linear ulcerations.

D. The endoscopic findings in UC begin at the anal verge and extend proximally.
Endoscopy in ulcerative colitis (UC) typically reveals the following:
* Erythema
* Edema/loss of the usual fine vascular pattern
* Granularity of the mucosa
* Friability/spontaneous bleeding
* Pseudopolyps
* Erosions
* Ulcers
Ref:Endoscopic diagnosis of inflammatory bowel disease(uptodate)

E. Clinical manifestations reflecting intestinal ulcero-constrictive disease; these include intestinal colic, abdominal distension, chronic diarrhea, nausea, vomiting, constipation, and bleeding.
Tuberculosis of the terminal ileum and cecum can mimic Crohn disease by producing a narrowed lumen and nodularity. The presence of caseating granulomas, positive culture, or acid fast bacilli on colonoscopic biopsy specimens establishes the diagnosis of tuberculosis
Ref: Endoscopic diagnosis of inflammatory bowel disease(uptodate)

本題的病人內視鏡有發炎病灶，linear inflammation and discontinuous lesions，直腸無病灶，因此較可能為Crohn disease

## Question 66:

有關COVID-19的胃腸與肝臟異常表現敘述，下列何者正確？
(1) 噁心(nausea)比食慾不振(anorexia)常見
(2) 腹瀉是最常見的胃腸表現
(3) 以嗅覺或味覺做為預測COVID-19表現，敏感度比特異度高
(4) 輕度AST/ALT上昇為最常見之肝臟異常
(5) 胃腸異常較肝臟異常更常見

---

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

### Correct Answer: E

(1)(2) 此題統計數據在不同的meta-analysis 和期刊報導的數字都不盡相同.
The most common gastrointestinal symptom is lack of appetite, followed by nausea and vomiting.
The pooled prevalence of diarrhoea was 9%, nausea or vomiting 6%, loss of appetite 21%, and abdominal pain 3%
In a US study of 318 confirmed COVID-19 cases, 61.3% of patients reported at least one gastrointestinal symptom, with loss of appetite (34.8%), diarrhea (33.7%), and nausea (26.4%) being the most common.

Ref:
* Mao R. Lancet Gastroenterol Hepatol. 2020 Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis.
* Luo, S., Zhang, X. & Xu, H. Clin. Gastroenterol. Hepatol. 18, 1636–1637
(2020). Don’t overlook digestive symptoms in patients with 2019 novel coronavirus disease (COVID-19).
* Redd, W. D. et al. Gastroenterology. Prevalence and characteristics of Gastrointestinal symptoms in patients with SARS-CoV-2 infection in the United States: a multicenter cohort study.

(3) The symptom “sudden smell loss” can be attested a high specificity (97%) and a sensitivity of 65% with a positive predictive value of 63% and negative predictive value of 97% for COVID-19.
Ref: Haehner A. ORL 2020;82:175-180. Predictive Value of Sudden Olfactory Loss in the Diagnosis of COVID-19.

(4) The pooled prevalence of liver injury was 19%. The pooled prevalence of increased ALT was 18% , increased AST was 21% , and increased total bilirubin was 6%. The pooled prevalence of decreased albumin was 6%
Ref: Mao R. Lancet Gastroenterol Hepatol. 2020. Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis.

(5) the pooled prevalence of digestive symptoms was 15%, The pooled prevalence of abnormal liver functions was 19%
Ref: Mao R. Lancet Gastroenterol Hepatol. 2020 Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis.
這題的數據在各期刊的數據差異甚大，大型 meta-analysis也有不同結論

## Question 67:

49歲男性因近幾年重覆排出尿路結石，此外，明顯無其他臨床症狀與系統疾病，經檢查有血清肌酸酐 1.4 mg/dL (eGFR 57 ml/min/1.73m2)、高血鈣(13mg/dL)、及高副甲狀腺iPTH (150 pg/mL)，technetium-99m sestamibi scintigraphy (MIBI)顯示在右甲狀腺處位置有intense uptake，請問其之處置何者為正確
(1) 建議宜低鈣高磷的飲食
(2) 建議宜使用Thiazide 預防尿路結石
(3) 建議宜使用Biphosphate預防骨質疏鬆
(4) 建議宜使用cinacalcet 降低血鈣濃度
(5) 建議宜接受副甲狀腺切除

---

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

### Correct Answer: E

(1) Deficiencies in vitamin D and dietary calcium worsen hyperparathyroidism, so patients should have a calcium-sufficient diet (1000 to 1200 mg per day) and maintain a serum 25-hydroxyvitamin D level in the range of 20 to 30 ng per milliliter, with the use of vitamin D supplements as necessary
Ref: J Clin Endocrinol Metab 2014;99:1072-80

(2) In a retrospective analysis involving 72 patients, hydrochlorothiazide (12.5 mg to 50 mg daily) was found to significantly reduce urinary calcium and parathyroid hormone levels with no increase in serum calcium
雖然可以降尿鈣跟PTH，但未被列入 guideline 中
Ref: J Clin Endocrinol Metab 2017; 102:1270-6.

(3) A meta-analysis of 25 observational studies and 8 randomized, controlled trials evaluating surgery as compared with bisphosphonate therapy showed similar increases in bone mass in the spine and femoral neck at 1 year in the two treatment groups
Ref: J Clin Endocrinol Metab 2010;95:1653-62.

(4) In a double-blind, randomized trial, after 1 year of treatment, the serum calcium level was 1 mg per deciliter lower and the mean PTH level 19% lower among patients with hyperparathyroidism who received cinacalcet than among those who received placebo, but cinacalcet had no significant effect on bone loss.
Ref: J Clin Endocrinol Metab 2009; 94:4860-7.

(5) surgical indications
Ref: Primary hyperparathyroidism: Management-uptodate

## Question 68:

於慢性腎病之分期中，底下哪些為可能迅速嚴重惡化(即紅色警戒)的狀況？
urinary albumin to creatinine ratio (UACR)
(1) eGFR 45-59 + UACR 100 mg/g
(2) eGFR 45-59 + UACR > 300 mg/g
(3) eGFR 30-44 + UACR < 30 mg/g
(4) eGFR 30-44 + UACR 100 mg/g
(5) eGFR 15-29 + UACR < 30 mg/g

---

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

### Correct Answer: A

紅色區塊範圍為 very high risk
Ref: KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

## Question 69:

72歲男性有多年高血壓、高膽固醇血症、慢性腎病第三期(穩定無惡化)，近半年因輕微血尿eGFR 46 mL/min/1.73m2，做腎臟超音波發現左側腎臟(長徑8公分)比右側小 2公分，進一步的MR angiography (如圖) 發現 在左側腎動脈入口處有一狹窄，請問底下敘述，何者為正確？
(1) 其高血壓與慢性腎病極可能為動脈硬化引起腎動脈狹窄所造成
(2) 可安排做captopril renogram 看左側腎臟血流是否有減少
(3) 因腎功能已不正常，應建議放支架或氣球擴張術來改善
(4) 若都卜勒超音波顯示左側腎臟之 resistive index 小於80，應該要需要進一步檢查
(5) ACEi/ARB 與 Statins 的藥物治療即可

---

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

### Correct Answer: C

(1) Renal function deterioration is rare with unilateral RAS but more evident with bilateral RAS or with a single functioning kidney (3%, 18% and 55%, respectively, at 2 years)
因此慢性腎病可能跟RAS 比較不相關
Ref: QJM 1994;87:413–421

(2) Captopril renogram
The diagnostic criteria for RAS are
* delayed time to maximal activity (TMax. greater than or equal to 11 minutes after captopril administration)
* significant asymmetry of peak activity of each kidney
* marked cortical retention of the radionuclide after captopril administration, and
* marked reduction in calculated glomerular filtration rate of the ipsilateral kidney after ACE.
When captopril renography was compared with catheter angiography in a clinical practice setting, the sensitivity was only 74%, and the specificity was only 59%.
Thus, captopril renography may not be a very useful test for screening most patients for RAS but may retain some value in the assessment of renal artery stenoses of borderline angiographic severity for which the physiological
functional significance is unclear
現今guideline不再建議安排 Captopril renogram 來診斷
Ref: Circulation 2006;113:e463–e654.

(3) Regarding renal function, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions. trial reported no benefit from endovascular therapy over best medical therapy
Ref: Am J Med 2003;114:44–50.

(4) 正常RRI 為60-70%，low RRI (<60) can reflect a RAS >70%，high.
RRI (>70) can reflect vasoconstriction, arteriolosclerosis, increased interstitial and increased venous pressure
Ref: Intern Emerg Med 2015;10:893–905.

(5) ACEIs and ARBs have shown benefits in reducing mortality and morbidity in patients with RAD; Statins are associated with improved survival, slower lesion progression
Ref:
* Am Heart J 2008;156:549–555.
* Eur Heart J 2011;32:598–610.

## Question 70:

關於常用的氫離子幫浦阻斷劑對腎臟的不良作用中，下列何者為非？

---

- A. Chronic kidney disease
- B. Acute kidney injury
- C. Acute interstitial nephritis
- D. Metabolic alkalosis
- E. Hypomagnesemia

### Correct Answer: D

A. Substantial evidence has accumulated from multiple large cohort studies suggesting that PPI use is associated with increased risk for CKD outcomes (incident CKD, CKD progression, and kidney failure)
Ref: Am J Kidney Dis. 75(4):497-507

B&C. The associations between PPI use and risk for AIN and AKI have since been consistently reproduced in multiple studies.
Ref: Am J Kidney Dis. 75(4):497-507

D. 應該是造成metabolic acidosis
The risk of metabolic acidosis is higher in the PPI group than in the control group, but
the difference did not reach statistical significance (aHR, 1.83; 95% CI, 0.88-3.82)
Ref: The effect of proton pump inhibitor use on the development of metabolic acidosis and decline in kidney function in patients with CKD stages G3a to G4.

E: Evidence suggests that PPI use is associated with increased risk for hypomagnesemia, the risk is amplified in patients concomitantly using diuretics, and the risk is increased with prolonged duration of PPI exposure.
Ref: Am J Kidney Dis. 75(4):497-507

## Question 71:

底下不同測量血壓之方式，其高血壓的定義何者不正確？

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- A. 診間水銀血壓計 收縮壓 ≥140 and/or 舒張壓 ≥90 mmHg
- B. 自量診間自動血壓計 收縮壓≥140 and/or 舒張壓≥90 mmHg
- C. 居家血壓量測 收縮壓≥135 and/or 舒張壓≥85 mmHg
- D. 24 小時動態血壓監測 (全天) 收縮壓≥130 and/or 舒張壓≥80 mmHg
- E. 24 小時動態血壓監測 (夜間) 收縮壓≥120 and/or 舒張壓≥70 mmHg

### Correct Answer: B

A&C&D&E.
Ref: Hypertension. 2020;75:1334–1357

B. AOBP 的高血壓定義應為 135/85 mm Hg
Ref: Can Fam Physician 2014; 60: 127-32

## Question 72:

關於痛風流行病學與臨床表徵，底下哪一項描述為不正確？

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- A. 台灣原住民每十人至少有一人有痛風，即盛行率超過10%
- B. 痛風病人九成是因為腎臟無法排出尿酸所造成
- C. 女性較少罹患痛風，且常在停經之後就鮮少發作
- D. 若25歲前就有痛風發作，可能有尿酸代謝之基因異常
- E. Thiazide、low dose aspirin、人工甜味劑，都會增加痛風之發作

### Correct Answer: C

A. 台灣原住民痛風盛行率在 40 歲以上男性約 15.2%，女性約 4.8%
Ref: J Rheumatol 1997;24:1364-9.

B. 絕大多數(約 90%)的病患，其高尿酸血症是尿酸排泄過低所引起
Ref: Taiwan Guideline for the Management of Gout and Hyperuricemia

C. 女性在停經前尿酸值 較男性低，但停經後尿酸會增高
Ref: Taiwan Guideline for the Management of Gout and Hyperuricemia

D. Hyperuricemia in an adolescent might prompt concern over an underlying lymphoproliferative or myeloproliferative state, a previously unappreciated congenital cardiac or pulmonary disorder, or a previously undiagnosed inherited enzyme defect resulting in urate overproduction.
Ref: Asymptomatic hyperuricemia-uptodate

E. 部分藥物會影響尿酸排泄
Ref: Harrison’s Principles of Internal Medicine. 20th Chapter 410

## Question 73:

有位39歲女性因多日腹瀉、全身無力、呼吸短促而到急診，過去史有經常性便秘使用瀉劑及與小便困難自行服用利尿劑。理學檢查：稍嗜睡但可清醒、血壓85/55,心跳75/min.皮膚張力稍差，其他無甚異常。實驗 室檢查：Na+ 125 mmol/l, K+ 2.8 mmol/l, Cl- 101mmol/l, Glucose 94mg/dL, BUN 34 mg/dL, Cre 1.6 mg/dL。Arterial Blood Gases (pH 7.29; pCO2 25.6 mmHg; pO2 111 mmHg;
HCO3⁻ 14.0 mmol/l)。就其Blood gas 方面而言，請問下列何項為正確？

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- A. 應為 High anion gap metabolic acidosis
- B. 應為 High anion gap acidosis + metabolic alkalosis
- C. 明顯為Lactic acidosis 造成，應檢測 serum lactate level
- D. 應繼續檢測 Urine Anion Gap (UAG)
- E. 應繼續檢測 Osmolar gap 及 Delta ratio

### Correct Answer: D

A&B. PH 值7.29，為酸中毒。加上HCO3為14，應為代謝性酸中毒。根據代償公式PaCO2=(1.5xHCO3)+8 => 29，此病人PaCO2為25.6，有過度代償情形。Anion gap(Na-Cl-HCO3)=10 => non-anion gap metabolic acidosis
綜合上述結果，應為Non-anion gap metabolic acidosis + respiratory alkalosis

C. lactic acidosis 應為 high anion gap acidosis

D&E. 若為Non-anion gap metabolic acidosis，下一步應為檢查urine anion gap
Ref: Pocket medicine 7th edition

## Question 74:

關於顯影劑相關急性腎傷害(Contrast-associated AKI)，近年文獻回顧指出底下描述何者為不正確？

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- A. 嚴重慢性腎病是發生顯影劑相關急性腎傷害之最強烈之獨立風險因子
- B. 若非合併慢性腎病，糖尿病本身並不是顯影劑相關急性腎傷害之獨立風險因子
- C. 顯影劑相關急性腎傷害雖然程度輕微，但也會增加病人之死亡率
- D. 顯影劑相關急性腎傷害之嚴重程度，與隨後腎功能持續惡化有關
- E. 慢性腎病病人因顯影劑導致嚴重急性腎傷害或導致透析的機率還是明顯高出很多

### Correct Answer: D

A. An analysis of data from 985,737 patients undergoing PCI confirmed that severe chronic kidney disease was the strongest independent risk factor for contrast-associated acute kidney injury
Ref: JACC Cardiovasc Interv 2014; 7:1-9

B: Iohexol Cooperative Study showed that diabetes mellitus was not an independent risk factor but rather amplified susceptibility in patients with underlying chronic kidney disease.
Ref: Kidney Int 1995;47:254-61.

C: Many studies have shown that contrast-associated acute kidney injury, defined by small decrements in kidney function, is associated with increased mortality
Ref: N Engl J Med 2019; 380:2146-2155

D: The odds of rapid progression of kidney disease during the long-term follow-up period increased in a
graded manner with increasing severity of AKI
AKI的嚴重度跟後續腎功能惡化有相關?
Ref: Kidney International(2010)78,803–80

E: With increasing severity of baseline CKD, the incidence of AKI and AKI-D increased significantly.
Ref: JACC Cardiovasc Interv. 2014 Jan; 7(1): 1–9.

## Question 75:

70 y/o 女性高血壓病人，因中風長年臥病在床且須靠鼻胃管餵食，平常只有服用降壓藥(Thiazide、Beta/calcium blocer) (亦無其他精神科藥物)，近日連續天氣高溫而家中沒有空調且通風欠佳且未被看護好好照顧；家屬探望才發現有發燒、意識呆滯反應遲鈍、心悸呼吸急促等而被送至急診，初步檢查：肛溫攝氏41度，血壓90/66, 心跳110/min, Resp: 22/min, 皮膚無發汗、排尿減少。初步亦無明顯感染跡象，請問其可能之初步診斷為？

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- A. Heat cramps
- B. Heat edema
- C. Heat syncope
- D. Heat stroke
- E. Heat exhaustion

### Correct Answer: D

熱傷害當中，只有heat stroke體溫會大於40度，此時會伴隨意識狀態變化。
Ref: Ohio Pediatrics, Summer 2015, 19-20

## Question 76:

底下哪一個抗生素藥物當使用劑量較大時，有可能產生肌肉毒性甚至發生肌肉溶解症之不良後果？

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- A. Erythromycin
- B. Colistin
- C. Quinolone
- D. Daptomycin
- E. Vancomycin

### Correct Answer: D

A. 腸胃道副作用、耳毒性、心律不整
B. 腎毒性、神經毒性
C. 心律不整
D. 肌肉毒性
E. Red-neck syndrome、DRESS、腎毒性
Ref: Stanford Guide Antimicrobial Therapy