CE2014NU Ans1 PDF

Comprehensive Step II, February 2014 (2557), By MEDNU#15 & NT#7
Comprehensive Step II, February 2014 (2557)

Part
1. () 66 no u/d 2wk.

A.diet control and life style modification
B.pH monitoring
C.PPI and prokinetic drug
D.EGD
E.
--------------------------------------------------------------------------------------------------------------------
D. EGD
40
2wk.
gastroesophageal reflux disease
(GERD) (Dysphagia) GERD alarm symptom
(Esophagogastroduodenoscopy; EGD)
Alarm symptoms
Comprehensive Step II | 1
1. () B 1
High position of the testicle, Transverse lie of the
affected testis, Loss of cremasteric reflex
a. Explore laparotomy
b. Orchiectomy
c. ATB
d. Manual detorsion
--------------------------------------------------------------------------------------------------------------------
Ans A.Explore laparotomy Testicular torsion acute onset
Testicular torsion
Testis High position of the testicle , Transverse lie of the
affected testis , Lose cremasteric reflex
(orchiopexy) Necrosis
12

(Orchiectomy) sign necrosis
scrotum Orchiectomy

3. () B 3 50 1
..... 1
.....
?
a.
b.
c.
--------------------------------------------------------------------------------------------------------------------
hernia ..... complication
Complications of an inguinal hernia include:
Pressure on surrounding tissues. Most inguinal hernias enlarge over
time if they're not repaired surgically. Large hernias can put pressure on
surrounding tissues. In men, large hernias may extend into the scrotum, causing
pain and swelling.
Incarcerated hernia. If the omentum or a loop of intestine becomes
trapped in the weak point in the abdominal wall, it can obstruct the bowel,
leading to severe pain, nausea, vomiting, and the inability to have a bowel
movement or pass gas.
Strangulation. An incarcerated hernia may cut off blood flow to part of
your intestine. This condition is called strangulation, and it can lead to the death
of the affected bowel tissue. A strangulated hernia is life-threatening and requires
immediate surgery.
Ref : http://www.mayoclinic.org
B.
BCuZImAGIRL_KORN
4. . flexion, adduction, internal rotation ()
a. Posterior hip dislocation

b. Anterior hip dislocation
c. Fracture neck of femur
--------------------------------------------------------------------------------------------------------------------
a.
4 ( A ) 29 biopsy caceous
necrosis PPE
1. CMV
2. HIV
3.TB
4.MAC
--------------------------------------------------------------------------------------------------------------------
2. HIV Bx caceous necrosis (
TB) PPE HIV
4. ( B) 65
Pseudoephedrine
a. P
b. Abdominal Palpation
c. Digital Perianal Examination
d. Urine leak test with valsalva maneuver
e. Bulbocavernosus Reflex
--------------------------------------------------------------------------------------------------------------------
d. Urine leak test with valsalva maneuver
Pseudoephedrine
- used as a nasal/sinus decongestant
- treat stress incontinence
- indirect action on the adrenergic receptor muscles contract
vasoconstriction
Adverse effects = CNS stimulation, Allergy
Stress incontinence Stress
incontinence .
. Neurogenic bladder Hx trauma +

. BPH obstructive symptom /
. Full bladder Obstructive Urinary track

continuous incontinence (Empty Bladder) Reflex
. P
iPoweRx
5
27 2 salbutamol 2

. Oral prednisolone
. Inhaled corticosteroids plus long acting 2 agonist
Inhaled corticosteroids plus long acting 2 agonist

step 3 ( step1) low dose Inhaled
corticosteroids plus long acting 2 agonist
6. 2 Cleft palate
--------------------------------------------------------------------------------------------------------------------
Speech therapy 2 Cleft palate
Speech therapy ( Cleft
palate 1 )

6 B () Eng
22 gunshort woud (small community)
chest tube 700 ml trauma center refer refer
BP drop 80/64 Next step ?
a. Clamp chest tube
b. Cancel refer
c. Emergency department thoracotomy
d. Primary survey and refer
e. Delay refer until referring doctor contact thoracis surgeron
Ans d. Primary survey and refer

a. hemothorax clamp tube drain
b. BP drop refer plan OR
c. Emergency thoracotomy

d. Primary survey and refer refer BP unstable
primary survey (ABCDE) BP unstable initial
management bleed , tension pneumothorax,
pericardial tamponade refer
e. BP unstable refer
Management penetrate chest ( BP drop thoracotomy)

http://www.springermedizin.de/immediate-thoracotomy-for-penetrating-injuries-
tenyears-experience-at-a-dutch-level-i-trauma-center/3630120.html
6. A 6. B 119. 65 BP 70/50 mmHg
EKG ()
1. Defibrillation
2. Adrenaline
3. Amiodarone
4. 0.9% Normal saline IV load
B 119. 56 BP 70/40
mmHg pulse monitor EKG
a. Defibrillation
b. Adrenaline IV
c. Amiodarone IV
d. 0.9% NSS load IV
e. Endotracheal tube
--------------------------------------------------------------------------------------------------------------------
a. Defibrillation EKG Ventricular tachycardia no pulse
shock defibrillation ()
pulse Steps for advanced cardiovascular support
(Basic life support,BLS)
1. (Level of consciousness)

2. //(Call for help) .1669
3. (A= Airway)
head tilt-chin lift c-spine injury jaw thrust
4. (Check breathing) 10

5. (B= Breathing) (air
hunger or gasping) ambu bag
6. (check pulse) 10 (carotid pulse)
chest compression (C= circulation)
nipple line effective chest compression :
push hard and fast 1.5-2 100 30 2
1 cycle(ratio 30:2), full chest recoil
, minimize interruption
advanced airway endotracheal tube, combitube, LMA

advanced airway advanced airway
advanced airway 6-8 8-10
algorithm (Advanced cardiovascular life support,
ACLS)

: update
7. ( A 7, B 120.)
stool AFB
a. Albendazole
b. Ceftriaxone
c. Metronidazole
B 120. () 40 1
oral thrush, scaphoid abdomen, PPE +
a. Albendazole
b. Ciprofloxacin
c. Metronidazole
--------------------------------------------------------------------------------------------------------------------
c. metronidazole ()
Treatment: Isosporiasis
Trimethoprim-sulfamethoxazole (TMP-SMX, 160/800 mg four times daily for 10
days; and for HIV-infected patients, then three times daily for 3 weeks) is effective.
For patients intolerant of sulfonamides, pyrimethamine (5075 mg/d) can be used.
Relapses can occur in persons with AIDS and necessitate maintenance therapy with
TMP-SMX (160/800 mg three times per week).
Harrison's internal medicine 18th ed
PSam
Bactrim (co-trimoxazole) choice
Drug of choice Pyrimethamine
Albendazole treat
Ciprofloxacin prophylaxis
Metronidazole treat
( > /|\ <)
Ref Parasitology
Unknown Author
8 ( A )
50 U/D Chronic hepatitis B with cirrhosis
1 . Ascites: Yellow, Clear, SAAG 1.3, Total
protein 2.0, WBC 20 cells/cumm, Lymphocyte 100% management
A. Furosemide 40 mg OD
B. Propanolol 40 mg BID
C. Norfloxacin 40 mg OD
D. Spinololactone 100 mg OD
E. Large volume release with albumin IV ( choice
)
D. Spinololactone 100 mg OD
(Ascites) chart
Uncomplicated cirrhotic ascites
The Management of Cirrhotic Ascites
Diuretics that block aldosterone receptors in the distal convoluted tubule
are preferred because of the presence of hyperaldosteronism in patients with
cirrhosis. Loop diuretics may be used in combination, but are ineffective when
used alone. The initial starting dose of spironolactone is 100 mg once daily
and can be titrated up to a maximum of 400 mg once a day. Absorption of
spironolactone is improved if administered with food. The diuretic effect can be
seen within 48 hours, but the peak onset of action is 2 weeks, due to impaired
metabolism in cirrhotic persons and a half-life of up to 5 days. Therefore, the dose
should be adjusted only once a week. Side effects include hyperkalemia and
painful gynecomastia. Amiloride can be used instead of spironolactone, starting at

5 mg per day. The latter is sometimes preferred because of its shorter half-life and
quicker onset of action. However, it is much more expensive than spironolactone
and has also been shown to be less effective in a randomized, controlled trial

8. () 40 on warfarin ICH INR 3.5
A. FFP
B. Vitamin K
C. Cryoprecipitate
D. Factor 7A
E. Platelet concentration
--------------------------------------------------------------------------------------------------------------------
A. FFP
*** emergency FFP
9B 36 2
PE: Left upper outer quadrant mass 2.5 cm. Movable not tender,
Mammogram: 2.5 cm mass, U/S: An anechoic mass with well circumscribed, with
increased through transmission Diagnosis?
A. Cyst
B. DCIS
C. .
D. Pagets disease
E. Phyllodes tumor
A. Cyst
Acute onset
movable u/s
anechoic mass with well circumscribed, with increased through
transmission cyst
10 A () 60 COPD 10
PE pitting edema
both leg, lung clear and no crepitation, oxygen saturation room air = 88%
A. Furosemide
B. Antibiotic
C. Salbutamol inh
D. Prednisolone
E. Long term oxygen therapy
E.Long term oxygen therapy
COOD
Pitting edema 2 lung clear
right side heart failure Osat =88% criteria long

term oxygen therapy
1. PaO255 mmHg SaO288%
2. PaO2 56-60 mmHg SaO289%
3
- corpulmonale
- dependent edema congestive heart failure
- polycythemia (Hct>55%)
PaO2 = 88%dependent edema
long term oxygen therapy
furosemide heart
10. ( A , B 28)

a. Fixed drug eruption

b. Erythema nodosum
c. Erythema multiforme
d. Steven-Johnson Syndrome
e. Drug hypersensitivity
--------------------------------------------------------------------------------------------------------------------
SJS
Fixed drug eruption describes the development of one

or more annular or oval erythematous patches as a
result of systemic exposure to a drug; these reactions
normally resolve with hyperpigmentation and may
recur at the same site with reexposure to the drug.
Repeated exposure to the offending drug may cause
new lesions to develop in addition to "lighting up" the
older hyperpigmented lesions.
Erythema nodosum (EN) is an inflammatory condition characterised
by inflammation of the fat cells under the skin, resulting in tender red nodules or
lumps that are usually seen on both shins. It can be caused by a variety of
conditions, and typically resolves spontaneously within 36 weeks. It is common in
young people between 1220 years of age.
Erythema nodosum in a person who had recently had streptococcal

pharyngitis
Erythema multiforme (EM) is an acute, self-limited, and sometimes recurring skin

condition that is considered to be a type IV hypersensitivity reaction associated
with certain infections, medications, and other various triggers.
Target lesion of erythema multiforme.

Raised atypical targets and arcuate lesions.
Stevens-Johnson syndrome is an immune-complexmediated hypersensitivity
complex that typically involves the skin and the mucous membranes. Although
several classification schemes have been reported, the simplest classification
breaks the disease down as follows[1] :
Stevens-Johnson syndrome: A minor form of toxic epidermal necrolysis, with
less than 10% body surface area (BSA) detachment
Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis: Detachment
of 10-30% of the BSA
Toxic epidermal necrolysis: Detachment of more than 30% of the BSA
Target lesion of erythema multiforme.
Raised atypical targets and arcuate lesions.
SJS skin lesion mucosal involvement
SJS
Drug hypersensitivity syndrome is sometimes also
called Drug Reaction with Eosinophilia and Systemic
Symptoms (DRESS), and Drug-Induced Hypersensitivity
Syndrome (DIHS).
Drug hypersensitivity syndrome is a severe,
unexpected reaction to a medicine(s), which affects
several organ systems at the same time. It most
commonly causes the combination of a high fever,
a morbilliform skin rash and inflammation of one or more internal organs including
the liver, kidneys, lungs and/or heart. It generally starts two to eight weeks after
taking the responsible medicine.
--
11. ( A , B 24) 35 ( Herpes zoster)
a. Tzanck smear
b. Gram strain
c. Giemza stain
--------------------------------------------------------------------------------------------------------------------
a. Tzanck smear multinucleated giant cell
--
11 chronic hepatitis B
AFP Ultrasound hypoechoic mass 2x2 cm
. Biopsy
. antibiotic IV
. CT multiphase whole abdomen
. ultrasound 3
.
. CT multiphase whole abdomen
Management of chronic HBV infection (HBV carrier)

1. HBeAg +ve 3TC 1-2 yr or PEG-IFN 4-6 mo
2. HBeAg ve HBV DNA > 105 copies/ml3TC >1-2 yr or PEG-IFN 1 yr
3. HCC surveillance U/S + AFP q 6 mo high risk
a. > 40 y(male), >50 y(female)
b. Advanced fibrosis / cirrhosis
c. FH of HCC
HCC criteria Dx 2
1. Radiological criteria : 2 imaging technique +ve (liver mass > 2 cm with
arterial hypervascularization)
2. Combined criteria : 1 imaging technique +ve + AFP >200 ng/ml
CT multiphase whole abdomen
US MRI
13. ( A , B_) 30
stiff neck positive, no neurological deficit (clinical subarachnoid hemorrhage)
CT scan Normal Investigation
a. LP
b. EKG
c. LFT
d. Lab for renal function
e. EEG
a. LP
clinical subarachnoid hemorrhage CT normal
investigation LP RBC CSF
14. A 14
a. Colon ulcer
b. Colon cancer
c. Colon diverticulitis
--------------------------------------------------------------------------------------------------------------------
film apple core appearance CA
colon

15 4
CBC WBC 3000 Lymphocyte 60% Platelet 100,000 Hct 42%
PE Hepatomegaly
A. Scrub Typhus
B. Typhoid fever
C. DHF
D. Melioidosis
C. DHF
16. ( A , B 129) 57 U/D HT 1st Dx. 6 loss F/U

3
PE : BP 156/96 mmHg, generalize edema Dot and blot hemorrhages,

Microaneurysms , hard exudates Blood sugar 400, U/A protein 2+, Blood 2+ U/S
normal appearance, size 10.7, 11.7 cm
a. Diabetic nephropathy
b. Hypertensive nephropathy
c. Ischemic nephropathy
d. Membranous nephropathy
e. RPSGN
1
( A 16. , B 129) 53 right inguinal

hernia Atenolol 6 3
30 / BP 179/96 mmHg
Dot spot hemorrhage, microaneurysm...
UA: protein 2+, blood 2+
FBS: 300 mg/dL Cr 1.7 mg%
U/S KUB: kidney normal size, Lt Kidney 10.4 cm, Rt kidney 11.2 cm
a. Diabetic nephropathy
b. Hypertensive nephropathy
c. Ischemic nephropathy
d. Membranous nephropathy
e. FSGS
--------------------------------------------------------------------------------------------------------------------
diabetic nephropathy (
R/O severe )
DM Harrison
Funduscopy is important in the diabetic patient, as it may show evidence of
diabetic retinopathy, which is associated with nephropathy. DM

blood suger U/A DN CKD HT
() most common CKD DM
Hypertensive nephropathy HT loss FU BP U/A
Membranous nephrotic syndrome

RPSGN cast
---
A. Diabetic nephropathy
FBS 300 30/
dot spot hemorrhage , microaneurysm Cr 1.7 UA
microalbuminuria Diabetic nephropathy
Kidney damage
BUN Cr rising
UA microalbuminuria
Microaneurysm Venous side capillary network inner nuclear
layer , punctate hemorrhage and exudate diabetic retinopathy

Kukkai
17. ( A , B_) 25 Thalassemia B/HbE Bronze
skin 1 Lab : serum ferritin 1,500 Cr 2 FBS 110 complication
a. Folic acid
b. Metformin
c. Desferoxamine
d. Deferasirox
e. Glipizide
--------------------------------------------------------------------------------------------------------------------
2 iron chelator defuroxamine , deferasirox

defuroxamine , serum CR = 2
deferasirox S/E serum cr
thalassemia B thal E complication
iron overload iron
overload bronze impair FBS serum iron =
1,500 [ serum ferritin monitor]
serum feritin 1,000 ../
( Iron chelator )
>>>> Iron chelator
deferasirox
Deferasirox (ICL670, Exjade)
Tridentate iron chelator (highly specific) (
90)
(beta-thalassemia with iron-
overload) deferoxamine
parenteral injection deferiprone iron-chelator
3
deferasirox

(side effects)
1. (gastrointestinal disturbances)
2. (skin rash)
3. Serum creatinine (dose-dependent)
4. Liver transaminases
defuroxamine
Deferoxamine (Desferal, DFO)

DFO infusion pump 8-10 5-7/
serum ferritin 6
(side effects)
1. (swelling ,localized redness
and itchiness)
2. reduced visualacuity, impaired color vision, and night
blindness)
3. (hearing loss)
4.(growth retardation and bonechanges)
defuroxamine serum CR = 2 deferasirox

S/E serum cr
............by P' gloay
17. ( B ) 65

1. Urinary retention
2. Renal deterioration
3. UTI with sepsis
4. Orthostatic hypotension
5. Iron deficiency anemia
1. Urinary retention

()
; CA bladder
50-70
aniline hydrocarbon 75%

- Renal deterioration ;

- UTI with sepsis ; UTI urinary retention sepsis
- Orthostatic hypotension ;

- Iron deficiency anemia ;

(
)
18 B
5
a. respirator
b.
c.
d. High protein diet
e.
c.
pressure sore
c.

1.
1.1
1.2 70 . 1 - 2

1.3

1.4 flaccid spastic
2.

3.

4.
5.
80 - 100 /

6.

7.
8.
Joint NT7
18. ( A 18) 22 Abdominal pain.......

( lab ) BS = 600 , urine ketone + management
A) Water and insulin
B) Normal saline and insulin

--------------------------------------------------------------------------------------------------------------------
B) Normal saline and insulin
lab key word BS = 600 ,
urine ketone + Diabetic Ketoacidosis

1.
2. DKA
metabolic acidosis
3.
4.
5. DKAHHS
6.DKAHHS
DKA
1. : (plasma
glucose) >200 ./. (>11/.)
2. (acidosis): HCO2 <15 /.
venous pH <7.3
3.
(fluid therapy)intravascularextravascular
volume0.9%NSS1 L

24
Serum Osmolality 3 mOsm/kg/hr
20 (Cerebral Edema)
50 ml/kg 4 200
./. 5% D/NSS/2 150-250 .
hypoglycemia
Insulin (Insulin therapy)insulinIV

DKAHHS 0.1unit/kg (Bolus dose)
0.1 unit/kg/hr 5070 mg/dl
50 mg/dl/hr

2 Anion Gap
Potassium DKAHHSpotassium serum
potassium potassiumcell
potassiumcellacidosis
insulin acidosis potassiumcell serum
potassium
Bicarbonate pH6.9 bicarbonate
DKA (Out of DKA)
-Serum glucose< 200 mg/dl -HCO3> 18 mEg/1
-Venous pH > 7. 3 -Anion gap <10mEq/l
By>>> #013
19. ( A , B_) crystal

a. allopurinol
b. colchicine
c. indomethacin
--------------------------------------------------------------------------------------------------------------------
b. Allopurinol
:
acute gout
:
Steven-Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN) drug rash with eosinophilia
and systemic symptoms (DRESS)
( 4 )
allopurinol thiazide
Ref. NLEM
20 ( B)
A .
B. (citrus)
C. > 2g/day
D. low carbohydrate high protein
E. Bariatric surgery BMI > 30
B. (citrus) : citrus
citrate citrate
calcium calcium oxalate (
citrate oxalate
antagonist )
A .

oxalate
C.
1,000 mg/day
D. calcium, oxalate uric acid
E.Bariatric surgery
Bariatric surgery oxalate
B () 21.
60
PE: BP 200/100 mmHg, PR 80 /min, E4M6V5 good consciousness, pupil 3
mm RTLBE, motor grade V all extremities, no neurological deficit, Eye exam: no
papilledema, Stiff neck ve
A. CT brain scan
B. Analgesic
C. Lumbar puncture
D. Adalat sublingual
E. Intravenous mannitol
A. CT brain scan
approach headache secondary headache primary

Worrisome Headache Red Flag signs SNOOP
SYSTEMIC SYMPTOMS (fever, weight loss) or SECONDARY RISK FACTORS
(HIV, systemic cancer)
NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness
or consciousness)
ONSET: sudden, abrupt, or split-second
OLDER: new onset and progressive headache, especially in middle age >50
years
PREVIOUS HEADACHE HISTORY: first headache or different (change in attack
frequency, severity, or clinical features)
60 sudden onset
secondary headache BP 200/100 mmHg
end organ damage
2aneurysmal subarachnoid hemorrhage (SAH)
focal neurological deficit
management CT brain scan without contrast lesion
LP (25% of cases are
missed by CT scanning)
Nifedipine (Adalat) sublingual
hypertensive urgency & emergency
r/o secondary headache SAH BP
compensate cerebral blood flow
I.V. mannitol increase

intracranial pressure brain herniation
21. ( A , B_) 20 + stiff neck

positive LP open 30 close 20 RBC 0 cells/HPF WBC 200 cells/HPF (N 20% L 80%)
protein 50 mg% sugar 30 mg% blood sugar 60 mg% CT-brain bilateral
hypodensity lesion at temporal lobe investigation for diagnosis
a. PCR for TB
b. crypto ag
c. Culture for bacterial
d. PCR for herpes simplex
--------------------------------------------------------------------------------------------------------------------
D. PCR for herpes simplex profile viral meningitis
CT-brain bilateral hypodensity lesion at temporal lobe
In adults, CT scans classically reveal hypodensity in the temporal lobes

either unilaterally or bilaterally, with or without frontal lobe involvement.
Hemorrhage is usually not observed. A gyral or patchy parenchymal pattern of
enhancement is observed. Contrast enhancement generally occurs later in the
disease process.
The herpes virus preferentially involves the temporal lobe and orbital
surfaces of the frontal lobes. This involvement may extend to the insular cortex,
posterior occipital cortex, and cerebral convexity; however, the basal ganglia are
spared. Bilateral involvement is frequent. Involvement of the cingulate gyrus
occurs later in the disease. The classic involvement of the medial temporal and
frontal lobes is consistent with intracranial spread along the small meningeal
branches of the fifth cranial nerve. Cingulate gyrus involvement may arise from
efferent hippocampal connections. A rhomboencephalitis resulting from pontine
involvement may occur and likely arises from retrograde viral transmission along
the cisternal portion of the trigeminal nerve to the brainstem.
22 u/s fibrous tissue

A. Appendix abscess
B. Appendix phlegmon
C. Diverticulitis
B. Appendix phlegmon
24. 30 skin lesion hypopigmented discrete scaly patches

1.skin biopsy
2.Giemsa stain
3.Fungal culture
4.
5.Potassium hydroxide preparation
Potassium hydroxide preparation (KOH) lesion tinea Versicolor

Diagnosed by clinical impression and confirmed by KOH preparation of scale that
reveals a spaghetti and meatballs
24. ( B) ( 160/100) BUN,Cr

U/A profile glomerulonephritis
a. Enalapril
b. Hydralazine
c. Furosemide
--------------------------------------------------------------------------------------------------------------------
Hydralazine renal function
Enalapril, Furosemide hydralazine
vasodilate renal function
25. B GA 41 wk 3,100
PPV with chest compression Apgar score 1, 3 HR 55 bpm complication
A. mental retardation
B. splastic cerebral palsy
C. learning disorder
B. splastic cerebral palsy
birth asphyxia Asphyxia

Apgar score ( 7 5 )
muscle tone
conscious

- capillary refill
-

-
-
plasma glucose, serum electrolyte, calcium, ABG, EEG,
CT, MRI
(The international Classification of
Disease ) 2 severe birth asphyxia
Apgar score 1 0-3 mild or moderate birth asphyxia Apgar
score 1 4-7
birth asphyxia

Epilepsy, Mental Retardation, Cerebral Palsy Learning Disabilities
cerebral palsy
asphyxia 90%
25. ( A. 25) 56 ER V/S : BT 38.9C , PR

130 bpm ,BP 60/40 mmHg, RR 40/min : drowsiness , sings of chronic
liver disease and tense ascites , PR maroon content First-step
management
. NG decompression
. Blood transfusion
. Octreotide
. Call staff, EGD
. IV uid resuscitation and intubation
--------------------------------------------------------------------------------------------------------------------
. IV uid resuscitation and intubation ABC BP 60/40
mmHg, RR 40/min IV + denite airway Endotracheal tube
BY.. Praew-meng
26. ( B) Term NB 7 PE : Central cyanosis, Mild
dyspnea, Heart systolic ejection murmur grade II at LUSB, loud P2 CXR :
decreased pulmonary blood flow
a. PDA
b. ToF
c. Truncus arteriosus with pulmonary stenosis
d. TAPVR
e. large pulmonary stenosis
--------------------------------------------------------------------------------------------------------------------
b. ToF
A. Acyanotic CHD.
Volume load : Lt.-to-Rt. shunt :
VSD, ASD, PDA, ECDs
Pressure load: stenotic lesions :
PS, AS
B. Cyanotic CHD.
PBF : TOF, PA
PBF : TGA, TAPVR, TA
Ref. slide .. .
26. ( A , B_) 56 BMI 35

GERD omeprazole 40 mg OD + Domperidone

a. Weight reduce
b. Barium swallowing
c. omeprazole
d. Ranithedine
e. Fundoplication
b. Barium swallowing alarm symptom of dyspepsia
EGD
By
28.() 53 20 3
neuro normal ,
CT brain :
1. Diazepam
2. Phenytoin
3. Valproic acid
4. Tegretol
5.
1. Diazepam
alcohol withdrawal
benzodiazepine cross-tolerance
alcohol alcohol GABA-facilitatory GABA-benzodiazepine
receptor complex anticonvulsant
delirium alcohol withdrawal benzodiazepine
equivalent diazepam
chlordiazepoxide
lorazepam
conjugate
conjugate Ref...
http://www.ramamental.com/psychiatrist/alcohol-withdrawalsyndromes/
29 7 1 T 37 c, BP 90/60
mmHg, suprapubic tenderness, Lab : UA WBC 10-20 cell, RBC 5-10 cell, nitrate,
gram stain : gram negative bacilli
A. penicillin
B. ofloxacin
C. cef-3
D. gentamycin
E. azithromycin
acute cystitis anatomic & physiologic abnormality,

resistant uropathogen infection limited to lower
urinary tract uncomplicated cystitis gram-
negative organism lab empirical
therapy 2nd-3rd generation cephalosporin E.coli
32. ( B) 10 40
generalized hypotonia, flat occiput,
upslant palpable fissure, transverse simian crease, clinodactyly at fifth finger both
hand
a.
b.
c. 1-2
d.
e.
32. ( B) 40 Well baby clinic PE : Flat
facial, Palmar simian crease, Up-slanting palpebral fissure
a.
b. 1-2
c.
d.
c. 1-2
Down Syndrome


3
46

(holistic approach) , 2
,
2 2
, ,
. 1-2

.

.
95 Trisomy 21
46 46
1
2 .
2
autoimmune disease
pneumococcal vaccine
.
2 2
--
Ans. B
(IQ)
(IQ 50-70) (IQ 35-50)
6-8

a
d d
1-2
1.

2.
3.
4.
Trisomy 21
Translocation

( Down syndrome
Trisomy 21 c. )
5. (Early intervention program)
Stedman

Barry

cognitive adaptive ( b
)
: . 173-181
MED NU 15 52461328
33. ( A 33.) EKG () ( tall

peak T) Mx
--------------------------------------------------------------------------------------------------------------------
10% calcium gluconate
EKG Hyperkalemia
Tall peaked T , P wave , sine , wide
QRS
Management
1. 10% calcium gluconate 10 ml IV drip in 10 min ( Ca threshold
arrhythmia ; EKG change )
2. RI 10 U + 50% glucose 50 ml ( RI shift K cell ; K > 6.5 )
3. Hemodialysis
internal medicine SI117----
35. () A. 35, B 148 25
3 () ( 10 )
10
v/s stable not
pale conjunctivae Heart, Lung, Abdomen : WNL
a. Colorectal cancer
b. Colonic diverticulitis
c. Inflammatory bowel syndrome
d. Irritable bowel syndrome
e. Functional abdominal pain
A. CA Colon
B. Sigmoid volvulus
C. Inflammatory Bowel Disease
D. Irritative Bowel Syndrome
E. Functional Abdominal Pain Syndrome
--------------------------------------------------------------------------------------------------------------------
4. Irritable bowel syndrome
IBS is characterized by the presence of abdominal discomfort or pain
associated with disturbed defecation. Bloating or visible abdominal distention
often is present in patients.
Rome III criteria
Recurrent abdominal pain or discomfort at least three days/months in the
last three months associated with 2 or more of the following
- improvement with defecation
- onset associated with change in frequency of stool
- onset associated with change in form(appearance) of stool
4
tips : IBS
stress mild
distention
By Tae Bizarre

CA Colon : A change in your bowel habits eg. diarrhea, constipation or
consistency of stool
: Rectal bleeding or blood in your stool. Persistent abdominal
discomfort, such as cramps, gas or pain. A feeling that your bowel doesn't empty
completely. Weakness or fatigue. Unexplained weight loss
Sigmoid volvulus : Bowel obstruction, manifested as abdominal distension and
vomiting.
: Ischemia (loss of blood flow).
Inflammatory Bowel Disease
Signs and symptoms can range from mild to severe and develop gradually
or come on suddenly.
: Diarrhea
: Abdominal pain and cramping
: Blood in your stool. Ulcers. Reduced appetite and weight loss
: Other eg. Fever, Fatigue, Arthritis, Eye inflammation, Mouth sores,
Skin disorders, Inflammation of the liver or bile ducts, Delayed growth or sexual
development, in children
Irritative Bowel Syndrome Inflammatory Bowel Disease

Functional Abdominal Pain Syndrome

Key features in the diagnosis
: Abdominal pain that is present for at least 6 months and is not
related to gut function.
: The patient will often have a decrease in daily activity with time.
The principal criterion differentiating FAPS from other GI disorders, such as
pancreatitis, is the lack of symptom relationship to food intake or defecation.
Psychological disturbances are more likely when pain has persisted for a long
period and manifests as symptom-related behaviors that dominate a patients life.
BCuZImAGIRL_KORN
35. ( B) 3 respiratory difficultly 2 hr PTA
URI symptom no fever
PE: Patient is respiratory distress, RR 44/min (vital signs ) ,
O2 sat 92%, Lungs: expiratory wheezing and decrease breath sound at Rt. basal
lung & retraction
What is Management?
a. Bronchoscopy
b. Adrenaline IM
c. Bronchodilator Nebulizer
d. Intubation and Mechanical ventilator
e. Bronchodilator Nebulizer and steroid
--------------------------------------------------------------------------------------------------------------------
e. Bronchodilator Nebulizer and steroid
Diagnosis: Asthma with exacerbation severe RR 3 yr
RR 44 (normal rate < 40 ) + retraction ,wheezing
36. () B 36 5 3 cotrimoxazole
mild pale mild jaundice , no hepatosplenomegaly Hb 9 Hct 27 MCV 80 , UA blood
+ve rbc 1-2
a. B thal major
b. B thal E
c. DIC
d. HbH with hemolysis
e. G6PD with hemolysis
36. ( B) 5 co-trimoxazole
PE:no hepatosplenomegaly Hb 9 mg/dl Hct 29% MCV 89 WBC 8500 Neu 70, Lym
30 diagnosis
a. DIC
b. B-thal major
c. B-thal E
d. G6PD with intravascular hemolysis
e. Hb H with intravascular hemolysis
--------------------------------------------------------------------------------------------------------------------
G6PD jaundice
hemolysis D E Hb H
--
: G6PD with hemolysis
Picture acute blood loss

intravascular hemolysis dark urine , UA blood +ve, mild jaundice
HbH c hemolysis G6PD c hemolysis

acute hemolysis
lab

41. () B 41, 100 diazepam 100
antidote
--------------------------------------------------------------------------------------------------------------------
Flumazenil

Flumazenil

Flumazenil (Anexate) 0.3
. 1 2
. Flumazenil

43. ( A) 28
PR 110 BP 120/70 RR 24 Paradoxical chest movement CXR
segmental fracture of 3rd 6st ribs most serious complication
a. Atelectasis
b. Bleeding
c.
d. Ventilation failure
e.
--------------------------------------------------------------------------------------------------------------------
D. Ventilation failure
Dx fail chest syndrome
keyword Paradoxical chest movement segmental fracture of 3rd
6st ribs complication Ventilation failure lung
contusion
--
45. ( A) valvular heart disease 10 on warfarin
intracerebral hemorrhage lab PT prolong INR 3.5
management
a. FFP
b. Vit K
c. cryoprecipitate
d. platelet concentration
e. recombinant factor VII A
--------------------------------------------------------------------------------------------------------------------
A FFP
INR vitamin
K1 10 . fresh frozen plasma prothrombin
complex concentrate recombinant factor VIIa
vitamin K1 12

(urgent) oral intravenousvitamin K 2.5-5.0 .

(emergency) fresh frozen plasma prothrombin complex
concentrate low-dose IV oral vitamin K
vitamin K

46. () ( A 46, B 9) 32 ( 38 )
2
PE: left upper outer well-defined mass of left breast, moveable, not tender, no
lymphadenopathy.
Mammogram: well circumscribed mass 2.5 cm
U/S: anechoic ( Hypoechoic) well circumscribed mass, increased

through transmission
Diagnosis
a. Cyst
b. CA breast
c. DCIS
d. Phylloides tumor
e. Pagets disease
--------------------------------------------------------------------------------------------------------------------
a. cyst cyst ()
[Noppon]
a. Cyst
36 W/U
U/S anechoic mass

cystic lesion ^_____^*
( 35 yr U/S mammogram
cut point 40-50 yr)
BY My MiiM
Breast cyst mammogram
: mass 2.5 cm, well circumscribe mass ultrasound cystic
lesion

- DICS proliferative epithelium lining minor ducts

- Pagets disease CA nipple
nipple
- CA breast nipple discharge , mass ill
defined, fixation mammograme ultrasound solid
mass
- Phyllodes tumor : tumor benign, borderline, malignant
mammograme calcification necrosis benign
CA breast ultrasound mixed gelatinous, solid, and
cystic ( >,,<)
Borderline tumors have a greater potential for local recurrence.
Mammographic evidence of calcifications and morphologic evidence of
necrosis do not distinguish between benign, borderline, and malignant
phyllodes tumors. Consequently, it is difficult to differentiate benign
phyllodes tumors from the malignant variant and from fibroadenomas.
Phyllodes tumors are usually sharply demarcated from the
surrounding breast tissue, which is compressed and distorted.
Connective tissue composes the bulk of these tumors, which have mixed
gelatinous, solid, and cystic areas. Cystic areas represent sites of
infarction and necrosis. These gross alterations give the gross cut tumor
surface its classical leaf-like (phyllodes) appearance. The stroma of a
phyllodes tumor generally has greater cellular activity than that of a
fibroadenoma. (ref. schwartz's principles of surgery ed 9)
Mammography
mammography
(screening)
mammogram
2 40
40 4-5%
(dense breast tissue) mammogram
mammogram
35 synchronous nonpalpable
lesion
premenopause

30 mammogram
85-90%
mammogram
1. 1 cm.
(positive predictive value for cancer 2%)
2. breast dense
positive predictive value for cancer 5%
3. spiculated, stellate knobby mass
(positive
predictive value for cancer 74%)

Ultrasonography
cystic solid
ultrasonography
(ultrasound guide)
(biopsy) aspiration
...

Ref. http://www.surgeons.or.th/view.php?group=8&id=206

48 ( A) 45
2 V/S BT 38.7C
Abd: mild distention, marked tenderness RUQ, guarding, rebound
positive CVA negative
a. Acute cholecystitis
b. Liver Abscess
c. Symptomatic gallstone
--------------------------------------------------------------------------------------------------------------------
a. Acute cholecystitis
a

49. ( A) 2 cleft palate 6
a. Rhinoplasty
b. Speech therapy
c. LeFort I advancing
d. Nasoalveolar molding
e. Alveolar bone grafting
--------------------------------------------------------------------------------------------------------------------
1. Rhinoplasty rhinoplasty speech therapy
guideline () rhinoplasty nose
repair

(Protocol of treatment in cleft lip/palate patients)
Counseling (
3 )
3 6 Lip repair ()
9 -15 Palate repair, myringotomy (
)
3 5 Nose repair ()
5 -7 Speech therapy & Dental care ( )
8 -11 Alveolar bone graft ()
12 -18 Orthodontic treatment (), Orthognathic surgery (
)
Ref: http://www.ramacleft-craniofacial.org/newdetails6.php?news_id=00007

49. () B 49 GA
FHR 80 /min Dx. (
)
a. Vasa previa
b. placenta previa
c. abruptio placenta
--------------------------------------------------------------------------------------------------------------------
1.vasa previa (painful)
FHR drop Vasa previa
Vasa previa
( velamentous insertion)
(synchronous)

fetal distress
10
2
2.placenta previa
Risk factors Advanced maternal age, Multiparity, prior cesarean section, prior
uterine curettage, Smoking, Multifetal gestation, Succenturiate lobe
3.abruptio placenta
Risk Factors Prior abruption, Thrombophilia, Preterm ruptured membranes,
Preeclampsia, Chronic hypertension, Multifetal gestation, Hydramnios, Cigarette
smoking, Increased age and parity, Cocaine use and leiomyoma
Placenta Abruptio Uterine Rupture of Vasa
Clinical & Lab
previa placenta rupture previa
Clinical Painless Painful Painful Painful
Presentation & Abnormal Normal Normal Normal
lie No Normal Loss of station Normal
Engagement Normal Fetal distress Fetal distress Fetal distress
Fetus(FHR) Normal Abnormal Normal Normal
Coagulogram
PongPang
50. ( A) Case 65 1
Vital signs: BP 90/65 mmHg X-ray: free air under right diaphragm
Vital signs
a. Internal bleeding
b. 3rd space loss
--------------------------------------------------------------------------------------------------------------------
b. 3rd space loss
Peptic ulcer perforate 3
1. Early stage (first 2 hours)
peptic ulcer perforation duodenal content
peritoneal irritation (Sudden onset)
epigastrium right lower quadrant gastric
content right paracolic gutte
2. Intermediate stage(2-12 hours)
peritoneal irritation fluid
gastric content delusion phase
Hypovolemic shock fluid
3. Late stage(After 12 hours)
12 bacteria growth bacterial peritonitis
sign septic shock distend abdomen
52. () A. 52, B 15 25 12

a. Ofloxacin
b. Ceftriaxone
c. Doxycycline
d. Clindamycin
e. Cotrimoxazole
()
25 15

a. Ceftriaxone
b. Ofloxacin
c. Gentamicin
d. Cotrimazole
e. Cloxacillin
--------------------------------------------------------------------------------------------------------------------
acute epididymo-orchitis
Orchitis epididymitis

vas deferens spermatic cord
gram-
negative bacilli
Chlamydia trachomatis Neisseria gonorrhea
E.coli Pseudomonas spp.

Treatment
sexually transmitted pathogen:
Ceftriaxone 500 mg intramuscularly single dose, plus
Doxycycline 100 mg by mouth twice daily for 10-14 days
chlamydia non-gonococcal organisms (negative for

Gram negative intracellular diplococci risk gonorrhea)
Doxycycline 100 mg by mouth twice daily for 10-14 days, or
Ofloxacin 200 mg by mouth twice daily for 14 days
(2010 United Kingdom national guideline for the management of epididymo-
orchitis)

(Gonorrhea and chlamydia)
Ceftriaxone Doxycycline
Ceftriaxone ()
(Jib 050)
1. Ceftriaxone
epididymo-orchitis empirical
antibiotic 35 sexually transmitted
pathogen guideline Ceftriaxone 500mg IM single dose (III, B) plus
Doxycycline 100mg PO BID for 10-14 days (III, B) Ceftriaxone
??
STI-associated epididymo-orchitis more Urinary or enteric pathogen-associated

likely if epididymo-orchitis more likely if
< 35 years > 35 years
> 1 partner in past 12 months Low risk sexual history
Urethral discharge present Previous urological procedure or UTI
No urethral discharge
Positive urine dipstick for leucocytes
+ nitrites
Ceftriaxone 500mg IM single dose plus Ofloxacin 200mg PO BID for 14 days or
Doxycycline 100mg PO BID for 10-14 Ciprofloxacin 500mg PO BID for 10
days days
NUH
53. () B 53 48 conization patho CIN III
surgical margin negative prognosis [
]
a. She still has CIN I, II
b. CIN maybe recurrent
c. She has not been cervical carcinoma
d. She has invasive cervical carcinoma
e. HPV is eradicated from her
--------------------------------------------------------------------------------------------------------------------
Ans. B. C.
reference
B conization CIN III adequate method

CIN III CIN III
conization pap smear pap smear + colposcope
CIN III new disease recurrent
Conclusion: CKC for CIN3*

1. Long term efficacy ok CKC for CIN3 with clear margin is high with NS
in recurrence rate
2. The reappearance of CIN3 after CKC with clear margins appeared to
be new disease rather than recurrence
* CKC with clear margins is adequet method to definitely treat CIN3
C. cervical carcinoma (has
+ V3 Present Perfect tense ) CIN III HSIL
cervical carcinoma cervical carcinoma 30-70%
choice
A. patho CIN III CIN I II
D. CIN III HSIL cervical carcinoma
E. CIN III persistant HPV infection conization
F/U lesion
ref :: Preinvasive & invasive cervical cancer 5
. - .
... [] #108#
54. ( A) 65 1 dPTA
?
a. Urinary retention
b. Renal deterioration
c. UTI with septic shock
d. Iron deficiency
e. Orthostatic hypotension
--------------------------------------------------------------------------------------------------------------------
A. Urinary retention ()

Duration blood clot bladder Urinary
retention
55. ( A) 30 5
a. wean ventilator
b.
c.
d. high protein IV
e.
--------------------------------------------------------------------------------------------------------------------
c
56. () A. 56 22 Appendectomy 2
+
red, thick and rise at boundaries of surgical
wound (limit in border)
a. Keloid
b. Hypertrophic scar
c. Mature scar
d. Infected wound
e. Immature scar
--------------------------------------------------------------------------------------------------------------------
e. hypertrophic scar
--
ANS Keloid on set
Hypertrophic scar
- 3
1. 2
- hypertrophic scar :

- :
2. depressed scar
3. scar contracture :
hypopigmentation
hyperpigmentation
..
Faculty of Medicine Siriraj Hospital

57. ( A)
--------------------------------------------------------------------------------------------------------------------
1. 2-3 / 10-16 /

2.

3.

4.

5.

6.
7.

58. () skin tag, hypertrophic

anal papillae
1. Hight fiber and life style
2. Sclerosing agent
3. Rubberband ligation
4. Reassure
5. LIS
5. LIS chronic anal fissure

58. ( A) 50

V/S BP 200/100 P 80
Neuro signs: E4V5M6 good consciousness pupil 3 mm RTLBE
Motor Grade V all extremities Stiff neck negative
management
a. Lumbar puncture
b. CT-Brain
c. Adalat sublingual stat
d. D/C
--------------------------------------------------------------------------------------------------------------------
c. Adalat sublingual stat ( !!! )
Hypertensive urgency Encephalopathy
BP ( subarachnoid
hemorrhage (SAH) SAH stiff neck positive)
Rapid BP reduction is indicated in neurologic emergencies, such as
hypertensive encephalopathy, acute ischemic stroke, acute intracerebral
hemorrhage, and subarachnoid hemorrhage
In hypertensive encephalopathy, the treatment guidelines are to reduce
the MAP 25% over 8 hours. Labetalol, nicardipine, esmolol are the preferred
medications; nitroprusside and hydralazine should be avoided
labetalol, nicardipine, esmolol
hypertensive encephalopathy nitroprusside and hydralazine
choice Adalat sublingual nifedipine Ca

channel blocker nicardipine

choice >>> Lumbar puncture CT-Brain SAH
, D/C Primary headache
BP
(Medscape Hypertensive Emergencies)
http://emedicine.medscape.com/article/1952052-overview#a30
by
59. ( A 59, B 92) 50 4
1
: BT 38C,
Abdomen: ill - defined mass size 5 cm with tender and guarding at RLQ, rebound
positive
CBC: Hct 38% WBC 16,500 cells/L ( WBC 15,600 cells/L)
Ultrasound abdomen: Mixed echogenic-soft tissue mass surrounded by inflamed
echogenic fat. The appendix cannot be identified.
?
a. Diverticulitis
b. Torsion ectopic testes
c. Appendiceal abscess
d. Appendiceal phlegmon
e. Inflammatory bowel disease
a. Appendicitis
b. Appendiceal abscess
c. Appendiceal phlegmon
--------------------------------------------------------------------------------------------------------------------
d. appendiceal phlegmon
lab appendicitis a. b. e.
abscess phlegmon ultrasound ...
Appendiceal abscess
hypoechoic lesion in the appendicular region which may be well
circumscribed and rounded or ill-defined and irregular in appearance
Appendiceal phlegmon
phlegmon wall
off intestine omentum ultrasound
Mixed echogenic fat
(omentum) soft tissue (bowel)
by :D
c Appendiceal phlegmon
Keyword RLQ mass DDx 2 Abscess phlegmon
ultrasound fluctuation abscess appendiceal abscess
peritoneal wall off abscess
--
60. ( A) U/D cardiovascular disease on ASA 3
1 . . Generalize tender and guarding
investigation
a. MRI
b. CT whole abdomen
c. U/S abdomen
d. film acute abdomen series
61. ( A) newborn
V/S : BT 37.8 RR 40 BP 80/60 , LN : preauricular lymphnode
enlargement , eye : cataract both eye , ear : deafness both ears , lung : clear ,
heart : systolic murmur at upper left sterna border , skin found blueberry muffin

a. Congenital syphilis
b. Congenital rubella
c. Congenital CMV
d. Congenital toxoplasmosis
e. Neonatal herpes simplex virus
--------------------------------------------------------------------------------------------------------------------
B. Congenital rubella
Congenital Rubella Syndrome
The classic triad presentation of congenital rubella syndrome consists of the
following:
Sensorineural hearing loss is the most common manifestation of congenital
rubella syndrome.
Ocular abnormalities including cataract, infantile glaucoma, and pigmentary
retinopathy
Congenital heart disease including patent ductus arteriosus (PDA) and pulmonary
artery stenosis
= deafness / = cataract /
= cardiac defect
Other findings in congenital rubella syndrome include the following:
Intrauterine growth retardation, prematurity, stillbirth, and abortion
CNS abnormalities, including mental retardation, behavioral disorders,
encephalographic abnormalities, hypotonia, meningoencephalitis, and
microcephaly
Hepatosplenomegaly
Jaundice, Hepatitis
Skin manifestations, including blueberry muffin spots that represent dermal
erythropoiesis and dermatoglyphic abnormalities
Bone lesions, such as radiographic lucencies
Endocrine disorders, including late manifestations in congenital rubella syndrome
usually occurring in the second or third decade of life (eg, thyroid abnormalities,
diabetes mellitus)
Hematologic disorders, such as anemia and thrombocytopenic purpura
61. .. 2 2 PTA 3 PTA

6 Diagnosis?
--------------------------------------------------------------------------------------------------------------------
Ans. Pertussis

5-10
(Whooping cough)
2-3
>> Bordetella pertussis (B. pertussis)
nasopharynx 1-2 paroxysmal
3
1)
Catarrhal stage 1-2
10

2) Paroxysmal stage 3
5-10
(whoop)

6

2-4

3) (Convalescent stage) 2-3

6-10
>>> B. pertussis (Catarrhal
stage) erythromycin 50 ././
14

3-4

>>> B. pertussis (Whole

cell vaccine) diphtheria tetanus toxoids (Triple vaccine, DTP)
2 2 2
4 6 4 18 (Primary immunization)
5 (booster dose) 4 7

62. () A. 62, B 125 GA 41 wk breech

cyanosis PPV + tube 1 20
a. Chronic renal failure

b. Adrenal insufficiency
c. brachial plexus injury
d. spastic cerebral palsy
B () 125 meconium
ppv and intubation apgar 1 to 3
asphyxia
a. Cerebral palsy
b. Brachial plexus
--------------------------------------------------------------------------------------------------------------------
D. spastic cerebral palsy
(Cerebral Palsy)

4

3-5

63. ( A) 7
PE : V/S no fever, RR 60 /min, O2sat 70% central cyanosis, systolic ejection
murmur gr.III left upper parasternal border
CXR : no cardiomegaly, decrease pulmonary blood flow
a. PDA
b. TGA
c. TOF
d. Pulmonary atresia with VSD
--------------------------------------------------------------------------------------------------------------------
TOF
congenital cyanotic heart
disease 3 TOF , Pulmonary atresia with VSD TGA (
TGA increase pulmonary blood flow ) TOF
Pulmonary atresia with VSD decrease pulmonary blood flow 2

TOF Pulmonary atresia with VSD
systolic ejection murmur at continuous murmur PDA
LUPSB pulmonary stenosis ( PDA Shunt

pulmonary valve )
TOF
By golf #095
63. ( B) OF + DCIP- A2 =4.5
OF + DCIP+ A2 = 25 (
alfa neg)
a. B trait
b. E trait
c. B thal E
d. . . alfa
--------------------------------------------------------------------------------------------------------------------
c. B thal E
A2 >> 3.5-10 B trait
A2 >> 10-40 E trait
A2 >> 80-90 Homo E
B trait E trait B trait E trait B thal
E B 25 B thal E
64. ( A) GA37 weeks, BW 1800 g, APGAR 7,10

HC 31 cm, opacity bilateral cornea, ( bilateral opacity of eyes,
microcephaly)
Heart: systolic ejection murmur gr III at left parasternal border
Skin: blueberry muffin spots
?
A. Congenital CMV
B. Congenital rubella
C. Congenital toxoplasmosis
D. Congenital syphilis
E. Congenital herpes
--------------------------------------------------------------------------------------------------------------------
B. congenital rubella The classic triad presentation
of congenital rubella syndrome consists of the following: 1. Sensorineural hearing
loss 2.Ocular abnormalities including cataract, infantile glaucoma 3. Congenital
heart disease including patent ductus arteriosus (PDA) and pulmonary artery
stenosis Skin manifestations blueberry muffin spots
--
b. Congenital rubella
Congenital Rubella Syndrome
The classic triad presentation of congenital rubella syndrome consists of the

following:
Sensorineural hearing loss is the most common manifestation of
congenital rubella syndrome. Hearing impairment may be bilateral or

unilateral and may not be apparent until the second year of life.
Ocular abnormalities including cataract, infantile glaucoma, and
pigmentary retinopathy. Both eyes are affected in 80% of patients, and the
most frequent findings are cataract and rubella retinopathy. Rubella
retinopathy consists of a salt-and-pepper pigmentary change or a mottled,
blotchy, irregular pigmentation, usually with the greatest density in the
macula.
Congenital heart disease including patent ductus arteriosus (PDA) and
pulmonary artery stenosis is present in 50% of infants infected in the first 2

months' gestation.
Other findings in congenital rubella syndrome include the following:
Intrauterine growth retardation, prematurity, stillbirth, and abortion
CNS abnormalities, including mental retardation, behavioral disorders,
encephalographic abnormalities, hypotonia, meningoencephalitis, and

microcephaly
Hepatosplenomegaly
Jaundice
Skin manifestations, including blueberry muffin spots that represent
dermal erythropoiesis and dermatoglyphic abnormalities

Bone lesions, such as radiographic lucencies
Hematologic disorders, such as anemia and thrombocytopenic purpura
http://emedicine.medscape.com/article/968523-clinical#aw2aab6b3b4

65. ( B) de Quervain syndrome rehab
a. Paraffin
b. Whirl pool
c. TEN
d. U/S
--------------------------------------------------------------------------------------------------------------------
Physical Therapy
Various forms of physical therapy (PT) or occupational therapy (OT) may be
used in the treatment of patients with de Quervain tenosynovitis. In the acute
stage, the therapist may use cryotherapy (eg, cold packs, ice massage) to reduce
the inflammation and edema. Local inflammation also can be treated with topical
corticosteroids (eg, hydrocortisone), which are driven into the subcutaneous tissues
using ultrasound (ie, phonophoresis) or electrically charged ions (ie,
iontophoresis).[16]
PT or OT also may be indicated for individuals who have undergone surgical
correction at the first dorsal compartment. Once the patient has recovered, the
goals of therapy are to strengthen and regain range of motion (ROM) at the thumb,
hand, and wrist.[17]
medscape
46 2
Non operative treatment 70-80 %

2
- thumb spica splint

- steroid injection 60-70% anatomical variation
sheath 2 1 3-6
2 2
: dexamethazone, kenacort
1.5 No 27 distal 1st compartment

retinaculum subcutaneous
depigmentation , subcutaneous fat atrophy, thin skin

50 % 1-2

2
web surgical note

(steroid)
2-3

web

NSAID
ultrasound
steroid
siam health
ortho rehab
ultrasound
medscape iontophoresis phonophoresis choice

66. A , B 29 4 .
PE: BT , CVA no tenderness , tenderness at suprapubic

UA : WBC 50-100 cells/HPF , RBC 5-10 cells/HPF
Gram stain: Gram negative bacilli
a. Penicillin
b. Ofloxacin
c. Ceftriaxone
d. Azithromycin
B () 29. 7 Clinical Suprapubic tender ,
, CVA ve
UA : wbc 10-20 , RBC 5-10 , epithelium 0-1 , Nitrite +ve
Urine gram : numerous gram negative bacilli
Management
a. Penicillin
b. Ofloxacin
c. Ceftriazone
d. Azithomycin
--------------------------------------------------------------------------------------------------------------------
Ans B. Ofloxacin
# UTI lower tract
# UA [ (urinalysis)
> 5-10 /HPF (3+ - 4+)
(
) 1 /Oil Field
]
# nitrite test : nitrate nitrite
# E.coli [gram negative bacilli]

Ampicillin 50-100 ././
Gentamicin 3-5 ././ 3rd generation
Cephalosporins
aminoglycosides
Gentamicin 5 ././ () 3rd
generation Cephalosporins Cefotaxime 100-200 ././, Ceftriaxone 50-
100 ././
/

Nitrofurantoin,Fosfomycin
Pyelonephritis
TMP-SMX,Fluoroquinolone(Ciprofloxacin, levofloxacin, ofloxacin)
beta-lactam Amoxicillin, Coamoxiclav
fluoroquinoloneTMP-SMX
first-line drug
>> 48-72 .
>> 10-14 acute pyelonephritis
7-10

>> circumcision phimosis
()
(> 3 //) prophylaxis Cotrimoxazole

1-2 . trimethoprim/ Nitrofurantion 1-2 ././
6-12 , ,
double-void, , ,
perineum
--
A.Penicillin
Cystitis
: Admit
Oral antibiotic Oral ATB
- Amoxicillin 40 ././ 3
- Co-trimoxazole (TMP-SMX) 6-10 . TMP/./ 2
- Cephalexin 50-100././ 4
- Cefuroxime 20-40././ 2
...Ambulatory PED3 Patsawee
67. A, B 30 18 4
BT 37.7 c BP 80/60 mmHg right pleural effusion (
)
a. IgE
b. decrease vascular permeability
c. antigen antibody enhancement
B () 67. 8 4 .

Good consciousness, Flush face
V/S: BT 37 C, RR 30 /min, PR 130/min (weak), BP 80/60 mmHg
Lung: Decrease breast sound Rt. lung
Abdomen: Liver 2 BRCM, tenderness, no splenomegaly, active bowel sound
Extremities: Petechiae both arm, no edema
A. IgE mediated reaction

B. Increase oncotic pressure
C. Decrease vascular permeability
D. Antibody dependent enhancement
E. Enterotoxin producing inflammatory cytokine
--------------------------------------------------------------------------------------------------------------------
Antigen antibody

6-
9 dengue antibody
(non-neutralizing antibody) enhancing antibody
Antibody dependent
enhancement
serotype
enhancing antibody serotype
monocyte
dengue by pimmy
68. () A. 68 () B 142
LFT: AST 1800, ALT , ALP 150, Total/direct bilirubin
Hepatitis profile: Anti HCV+, Anti HBcIgM+,Anti HBcIgG-, HBsAg+, Anti HAV+
a. Acute hepatitis A
b. Chronic hepatitis B
c. Acute hepatitis B
d. Chronic hepatitis C
e. Acute hepatitis C

() 2
liver 2 FB BRCM , spleen cant palpated , tender at RUQ ,
LFT: AST 1350, ALT 1650, ALP 145
Hepatitis profile: Anti HAV IgG positive, Anti HAV IgM negative
Anti HCV IgG positive
HBsAg positive, Anti HBV IgM positive, Anti HBV IgG negative
a. Acute HAV infection
b. Acute HBV infection
c. Acute HCV infection
d. Chronic HBV infection

e. Chronic HCV infection
--------------------------------------------------------------------------------------------------------------------
68. [] A., B 31 12 4 kg
..1 . () 70 kg ()

PE; Obesity
Vital sign; stable
Acanthrosis nigrican at neck and axillary
Lab; FB 245 mg/dl, electrolyte normal [],
UA; urine protein 1, urine sugar 2, urine ketone negative, urine pH 7.0
a. Hyperglycemic hyperosmolar syndrome

b. diabetic ketoacidosis
c. DM type 1
d. DM type 2
e. immature hyperglycemia ()
B. () 31. 12 4 kg
3
sign of dehydration acanthosis nigricans
Lab : Random plasma glucose 245 mg%
Electrolyte : normal
UA : spec 1.020 pH 7, protein trace, sugar2+, ketone negative
a. Hyperglycemic crisis
b. DM type I
c. DM type II
d. DKA
--------------------------------------------------------------------------------------------------------------------
d. DM type 2
hyperglycemic crisis
lab criteria 2 a and b
2
1 (type 1 diabetes)
46
""
46

30

2 (type 2 diabetes)
46

46

60-90
Ref;
http://www.vachiraphuket.go.th/index.php?name=knowledge&file=readknowledge&
id=12 By Mink
Ans : Acute hepatitis A Acute hepatitis B

1. hepatitis A : anti-HAV antibodies
IgM anti-HAV
- Anti HAV IgM 4-6

- Anti HAV total Ab/IgG

2. hepatitis B
- HBsAg
- Anti HBs

- Anti HBc IgM

- Anti HBc total Ab/IgG
- HbeAg
- Anti HBe

3. hepatitis C
- Anti HCV IgG

Anti HCV

http://webdb.dmsc.moph.go.th/ifc_nih/a_nih_2_002c.asp?info_id=994
by
70. () A. 70 7 . 2
skin : crop of clear vesicle at bilateral palm and lateral aspect
of finger, itchy, no erythema surrounding Dx.?
A. Dyshidrosis
B. Herpes simplex
C. Bullous impetigo
D. Contact dermatitis
E. Erythema multiforme
70. A Thai girl 10 years old come to clinic with recurrent itching rash both palms.
Physical examination : Afebrile, crops of clear, tense cystic papule at palm and
lateral aspect of finger both hands. The otherwise normal.
Whats the most likely diagnosis?
A. Dyshidrosis
B. Herpes simplex
C. Bullous Pemphigoid
D. Erythema Multiforme
E. Cutaneous drug eruption
--------------------------------------------------------------------------------------------------------------------
A Dyshidrosis
E
A. Dyshidrosis
sudden onset deep-seated
pruritic vesicles excessive
sweating
B. Herpes simplex group of vesicle
C. Bullous impetigo Staphylococcal scalded skin syndrome

2
newborn bullae Staphylococcus

aureus exfoliative toxins pyogenic superficial infection ( non-
bullous impetigo strep staph ) lesion diaper
region, axilla neck
D. Contact dermatitis
irritant, allergic, phototoxic contact dermatitis lesion

E. Erythema multiforme immune target lesion ()
wide spectrum major minor
= =
A. Dyshidrosis
Dyshidrotic eczema is a type of eczema (dermatitis) of unknown cause that is

characterized by a pruritic vesicular eruption on the fingers, palms, and soles. The
condition affects teenagers and adults and may be acute, recurrent, or chronic. A
more appropriate term for this vesicular eruption is pompholyx, which means
bubble. The clinical course of dyshidrotic eczema can range from self-limited to
chronic, severe, or debilitating. The condition's unresponsiveness to treatment can
be frustrating for the patient and physician
History
Patients report pruritus of the hands and feet with a sudden onset of
vesicles. Burning pain or pruritus occasionally may be experienced before vesicles
appear. Tiny vesicles erupt first along lateral aspects of the fingers and then on the
palms or soles. Palms and soles may be red and wet with perspiration. The
vesicles usually persist for 3-4 weeks. Vesicle outbreaks may occur in waves. A
photo-induced form of hand dermatitis resembling dyshidrotic eczema has been
described.[11]
Physical Examination
Symmetrical crops of clear vesicles and/or bullae on the palms and lateral
aspects of the fingers characterize dyshidrotic eczema. The feet, the soles, and the
lateral aspects of toes also may be affected.
Ref : Diagnosis and treatment of hand dermatitis.
http://www.ncbi.nlm.nih.gov/pubmed/22820963
Dyshidrotic Eczema http://emedicine.medscape.com/article/1122527-
clinical#a0256
73. ( A) epidemic disease
. 22 2
. 521
158
. 50,000
. Leishmaniasis 1
. 110

--------------------------------------------------------------------------------------------------------------------
. leishmenia 1 .
Epidermic disease ()
endermic

..

5
+ 5
2-3 2-3
2
1
. leishmenia 1 .
--
. By
From http://www.cdc.gov/osels/scientific_edu/ss1978/lesson1/section11.html
Sporadicrefers to a disease that occurs infrequently and rregularly.
Endemic refers to the constant presence and/or usual prevalence of a disease or
infectious agent in a population within a geographic area.
Hyperendemic refers to persistent, high levels of disease occurrence.
Occasionally, the amount of disease in a community rises above the expected
level.
Epidemic refers to an increase, often sudden, in the number of cases of a disease

above what is normally expected in that population in that area.
Outbreak carries the same definition of epidemic, but is often used for a more
limited geographic area.
Cluster refers to an aggregation of cases grouped in place and time that are
suspected to be greater than the number expected, even though the expected
number may not be known.
Pandemic refers to an epidemic that has spread over several countries or
continents, usually affecting a large number of people.
--
74. () A. 74, B 37. 6 , 2 wk PTA
Amoxicillin 4-5 (-- 10 days PTA)
4-5 / 10
perianal redness
PE: BT 38.3 C signs of dehydration, abdominal distension, active bowel sound
Electrolyte: Na 140, K 3.5, Cl 100, HCO 3 15
diarrhea
a. Salmonella diarrhea
b.
c. Drug induced diarrhea
d. Secondary lactase deficiency
e. Cow milk protein allergy
a. Shigella infection
b. Bile acid diarrhea
c. Secondary lactase deficiency
d. Cow milk allergy
e. Antibiotic related diarrhea

( B ) 9 2 wkPTA amoxicillin 10 dPTA
4-5 10 PE : BT 38.3 vital sign dry
lip Abd: abdominal distension ,active bowel sound, no mass, perianal redness.
Stool: WBC 1-2/HPF no RBC. Electrolyte: Na 130 K3.5 Cl 100 Co2 14
1
a. Shigella infection
b. secondary lactase def
c. ATB associate diarrhea
d. Cows milk allergy
--------------------------------------------------------------------------------------------------------------------
b acute viral infection brush border villi
secondary lactase def diarrhea, stomach pains and
bloating
--
D. Secondary lactase deficiency
Watery diarrhea non-invasive diarrhea
Rotavirus, Norwalk virus
tip villi crypt

osmotic diarrhea (osmotic + secretory
diarrhea) pH<6 reducing substance >1+
Rotavirus diarrhea
Secondary lactase deficiency perianal redness
Lungtao ^^
E amoxicillin
MintLove
74. ( B)
a. Justice
b. Autonomy
c. Do no harm
d. Beneficence
e. Confidentiality
--------------------------------------------------------------------------------------------------------------------
c. Do no harm
75. (() A 75 B 38)
PTT
prolong, PT ( factor 8 activity
type )
A. FFP
B. Cryoprecipitate
C. Cryo removed plasma
D. Platelet con.
E. PRC
--------------------------------------------------------------------------------------------------------------------
B. Cryoprecipitate
Dx. Hemophilia A factor VIII
Cryoprecipitate

1 cryoprecipitate Factor VIIIc 80-100 , fibrinogen 225 . vWF (von

0
Willebrand factor)
cryoprecipitate
0
1. Hemophilia A
1 . F VIIIc 2%
Cryoprecipitate 1 F VIIIc 100
2. vWD (von Willebrand disease) desmopressin
(DDAVP)
3. fibrinogen 100 ..
By Nurse MED NU XV
Cryoprecipitate
Hemophilia A factor VIII
X-linked recessive clotting factor concentration
cryoprecipitate
BY..#084
77. () A. 77 B 40 2 HIV

a.
b. Rota virus
c. PCP
d. Follow up 4
e. Isoniazid prophylaxis
--------------------------------------------------------------------------------------------------------------------
. PCP
//
//

//

- HIV
- PCP TB
Tipkamol NUH
c. PCP
1. PCP

PCP 2-3 (
) PCP
CD4 co-
trimoxazole (TMP-SMX) 150 mg/m2 TMP 1-2 3
TMP-SMX
46 PCP

6
12
2.

PPD skin test
Lungtao ^^
D PCR 4 4 wk
MintLove

3) F/U 4
Reference
- 2

-guideline
<48hr

- >48hr

- 1)

- HIV
DNA-PCR 2

1-2
Anti HIV 12
-
2
DNA-PCR 1
-
4
DNA-PCR 2
- Vaccine rota , TB,

pneumocystis jiroveci pneumonia

contact TB
By Bell
77. ( B) 30 3
Film TL spine (anterior and middle column ) mechanism of injury
a. Axial load
b. Rotation injury
c. Translation injury
d. Hyperflexion injury
e. Hyperextension injury
--------------------------------------------------------------------------------------------------------------------
a. Axial load Film TL spine anterior and
middle column burst fracture mechanism of injury axial load
78. ( B)

a. Massage
b. Observe and follow up
c. Spica cast
d. Achilis tenotomy
e. Long leg cast and manipulation
--------------------------------------------------------------------------------------------------------------------
79. A B 42. A 9 mo. girls mother concern about enlarge head of her
daughter.
Physical examination : V/S BT 37.0 BP 100/70 PR 140 RR 20 Head circumferences
55 cm.
HEENT: enlarge and tense anterior fontanelle, AF 5x4 cm., sunset eyes, scalp vein
dilate, babinski dorsiflex, clonus positive, stiff neck negative. Which is
pathophysiology of the disease?
A. CSF is absorbed by the choroid plexus.
B. CSF is primality produced by arachnoid villi.

C. CSF flow is depended on ventricular flow and vascular channel.

D. Aqueductal stenosis is cause of communicating hydrocephalus.
E. Lesion or anatomical obstruction of posterior fossa is the most important
cause of non-communicating hydrocephalus.
--------------------------------------------------------------------------------------------------------------------
C CSF flow is depended on ventricular flow and vascular channel.
( C )
- CSF is primality produced by the choroid plexus and absorbed by
subarachnoid villi.
- Aqueductal stenosis is cause of noncommunicating hydrocephalus.
- Lesion or anatomical obstruction of posterior fossa is the most
important cause of communicating hydrocephalus.
(Hydrocephalus)
Choroid plexus
500 ( 0.35 /)

C horoid plexus :Lateral ventricle
foramen of monro ,3rd ventricle,aqueduct of sylvius, ,4th ventricle
Foramen of Lushka Foramen of Magendie 4th
ventricle ( Subarachnoid space)
Subarachnoid space Cicterna magna
Cerebellum(Posterior fossa), Basal cistern
Subarachnoid spaceSuperior sagittal sinus
Arachnoid villi ,Pachionion granulation
1. Choroid plexus(Choroid plexus papilloma)

2. 2
1.Obstructive hydrocephalusNon communicating hydrocephalus

(Subarachnoid space)
,,
(Aqueductal stenosis), (Neurocysticcercosis)
(Subarachnoid
space)
Cerebellum
Foramen of magnum (Lumbar
puncture)
2.Communicating hydrocephalus
(Subarachnoid space )
(Subarachnoid space :Cistern) ,Arachnoid villi
(Subarachnoid hemorrhage)

3. (Venous sinus thrombosis),

Arachnoiditis Communicating
hydrocephalus
(Clinical manifestation)
Hydrocephalus in infant
1. (Cranium enlargement)
2.Growth curve (Disproportion Head
circumference:chest circumference,height development )
3.(Suture separation)
4.(Fontanelle bulging)
5.(Enlargement &engorgement of scalp vein)
6.(Macewen sign Cracked pot sound)
7.(Sign of increase intracranial
pressure) ,,

8. (Setting Sun sign(Impaired upward gaze)

Mid brain Superior colliculs
9.CN 6TH Palsy (Diplopia)
10. (Hyperactive reflex)
11. (Irregular respiration)
12. (Poor development ,failure to achieve milestones)
13., (Mental retardation )
14. (Failure to thrive)
Ref : PATHOLOGY OF THE NERVOUS SYSTEM
http://www.med.nu.ac.th/pathology/405314/book54/Nervous.pdf
Som-O NUH
- Noncommunicating hydrocephalus
cerebrospinal fluid ventricular system congenital inflammation
bleeding aqueduct
of Sylvius ventricular system embryonic
development
- Communicating hydrocephalus arachnoid
granulation
subarachnoid hemorrahge ,,
subarachnoid space
--
80. ( A) BT 38 C
Hepatosplenomegaly WBC Neutrophils
--------------------------------------------------------------------------------------------------------------------
1.Widal Test
Typhoid fever; Enteric fever 4
1

(Widal test)
40 C
6-8
(transaminases) (Widal
test) antiO antiH
()
81. () A. 81 10 7 amoxicillin
vital signs : BT 38.8 c , PR 80 bpm , RR 35 /min , BP 100/60 mmHg

HEENT : cervical lymph node enlarged 1.5 cm. in diameter bilateral ,
injected pharynx and tonsils ,
tonsils enlargement gr. II with white milky patch
Abdomen : Spleen 2 FB BLCM, liver cant be palpated
Skin : multiple maculopapular rash on chest and abdomen
a. Measle
b. Rubella
c. Scarlet fever
d. Kawasaki disease
e. Infectious mononucleosis
B 44 3 7 2
c linic amoxicillin
Physical examination V/S : BT 38 c, HEENT tonsil enlargement with milky patch
cervical lymph node 1.5 cm both, Heart&Lung: WNL, Abdomen spleen 2 cm BCM
no hepatomegaly, Skin: generalized MP rash,
What is your diagnosis. ()

a. Malaria
b. Scrub typhus
c. Dengue
d. Infectious mononucleosis
e. Diphtheria
--------------------------------------------------------------------------------------------------------------------
E. Infectious mononucleosis
A. Measle 2-3 3C (cough)
(coryza) (conjunctivitis) MP
rash 72
hyperpigmentation
course 7-10 measle

B. Rubella
suboccipital, retroauricular, posterior cervical MP rash
2

C. Scarlet fever exudative pharyngitis , fever
scarlatiniform rash MP rash (scarlet fever
scartiniform rash scarlatiniform rash scarlet
Kawasaki scarlatiniform )
D. Kawasaki disease 5 4/5 exclude
kawa


E. Infectious mononucleosis

MP rash penicillin
80% CBC monocytoid atypical lymphocyte
Ref http://www.med.cmu.ac.th/dept/pediatrics/06-interest-cases/ic-79/Ped401-
Exanthemotous%20Fever-thanyawee.pdf
= =
Key word tonsil enlargement with milky patch
lymph node penicillin MP rash Infectious
mononucleosis
Choice
Malaria
Scrub typhus eschar
Dengue 7
Diphtheria dirty tonsil
OHM NUH
81. ( B) 60 3
. steriod 1
.
A.
B. steriod
C. Electromyography
D. steriod
E. Electromyography 3
--------------------------------------------------------------------------------------------------------------------
A.

Dx Carpal tunnel syndrome

Electromyography steroid

. steroid 3
references 3
82. ( B)
wartenbergs sign positive Froment's sign
positive, Rooss negative test
a. Wartenbergs syndrome
b. Cubital tunnel syndrome
c. Ulnar nerve syndrome
d. C8
e. Thoracic outlet syndrome

83. () A 83 ER

a.
b.
c.
d.
e. _
--------------------------------------------------------------------------------------------------------------------

Ans

..

()
()

()

http://www.thailandlawyercenter.com/index.php?lay=show&ac=article&Id=538973
871&Ntype=19

by
84. 32 GA 12 wk PV : os close 1
cm bloody per os TAS gestational sac 23 mm no fetal heart beat
a. admit observe
b.
c. antibiotic
d. TAS 1
--------------------------------------------------------------------------------------------------------------------

incomplete abortion

20
500 1
(spontaneous abortion)
80 2
1.
trisomy 13,16,18 21
2. Gardanella vaginalis
bacterial vaginosis 2
3. hypothyroidism ,

4. luteal phase defect corpus
luteum
5.

6. 14 2

7. 2
2
8. 5
9. antiphospholipid syndrome
10. 2
incompetent cervix
1. (threatened abortion)
20
2. (inevitable abortion)

20
3. (complete abortion)
20
4. (incomplete abortion)
20
5. (missed abortion)

GA 12 wk
1 cm incomplete abortion tx

PV os close u/s FHS negative incomplete

abortion GA 12 wk D&C
Ref By pimmy
85. () 30 G1P0 33 GDMA2
polyhydramnios
6 .
2

A. Ruptured uterus
B. Placenta abruption
C. Ruptured vasa previa
D. Placenta insufficiency
E. Placenta precia with hemorrhage
--------------------------------------------------------------------------------------------------------------------
B. Placenta abruption
Polyhydramnios is associated with:

Premature birth
Pregnancy-induced hypertension
Urinary tract infections during pregnancy
Premature rupture of membranes when your water breaks early
Excess fetal growth
Placental abruption when the placenta peels away from the inner wall
of the uterus before delivery
Umbilical cord prolapse when the umbilical cord drops into the vagina
ahead of the baby
C-section delivery
Stillbirth
Heavy bleeding due to lack of uterine muscle tone after delivery
87. () A 87 B 83 13 heavy bleeding from vagina with

anemic symptom, history of massive menstruation since first period, most likely?
A. Cervicitis
B. Endometrial polyp
C. Submucous myoma
D. Coagulopathy
E. Ovulatory DUB
A 87. 15 ( 13 )
10

( heavy bleeding from vagina with anemic symptom, history of
massive menstruation since first period)

markedly pale, no jaundice

?
a. Cervicitis
b. Endometrial polyp
c. Submucous myoma
d. Coagulation defect
e. Ovulation dysfunction
a. Cervicitis
b. Endometrial polyp
c. Submucous myoma
d. Coagulopathy
e. Ovulatory DUB
[] A 18 year old nulligravid women come to ER with
brist bleeding per vagina and anemic symptoms
[
]
Physical examination ; looked pale, vital sign; BP drop, PR 120/min
Pelvic examination ; NIUB normal, bleeding per os, normal cervix and vaginal
mucosa, uterus normal, adnexa unremarkable
UPT negative
What is the diagnosis?
a. Ovulatory DUB
b. Anovulatory DUB
c. Endometrial hyperplasia
d. Endocervical polyps

e. CA endometrial
--------------------------------------------------------------------------------------------------------------------
E. ovulatory DUB Dysfunctional uterine bleeding (DUB)

18
hypothalamic-pituitary axis
ovulatory DUB
--
c. Coagulation defect
Coagulation Disorder
Blood loss in the normal menstrual cycle is self-limited due to the action
of platelets and fibrin. Individuals with thrombocytopenia or coagulation deficiency
may have excessive menstrual bleeding. Several studies of the incidence of
coagulopathy in teenagers admitted or evaluated for menorrhagia found
coagulopathies in 12 to 33% in all admissions for menorrhagia. The most common
coagulation disorders include thrombocytopenia, due to idiopathic
thrombocytopenic purpura (ITP), von Willebrand's disease, which affects up to 1%
of the population, and platelet function defects. Of the adolescents presenting
with severe menorrhagia or hemoglobin less than 10 g/dL, 25% were found to
have a coagulation disorder. In those presenting with menorrhagia at the first
menses, 50% were found to have a coagulation disorder.
http://www.medscape.com/viewarticle/456474_3
menorrhagia
( = =)


88. ( B)

--------------------------------------------------------------------------------------------------------------------

91. ()
DX. ()
a. Nabothian cyst
b. Cervical polyp
c. CA Cervix
--------------------------------------------------------------------------------------------------------------------
D. Cervical polyp
pt
A. nabothian cyst
C. CA cervix diag lesion
malignancy

91. ( B) 3 1
viral conjunctivitis chloramphenicol eye drop
6

A.
B.
C. chloramphenicol
D. Chlamydia spp.
E. acyclovir ointment
--------------------------------------------------------------------------------------------------------------------
B.
- viral conjunctivitis viral prodrome
muco-purulent
bacteria viral conjuncitvits 7 antibiotic
prophylaxis chloramphenicol secondary
bacterial infection qid
- Chlamydia neonate
kikky
59. ( A, B 56, 88, 89, 92) A thai woman 20 years old present with
genitalia itching
PE : cauliflower lesion size 2-3 mm at posterior fourchette and hymen
Other normal
Most likely diagnosis is
a. Condyloma lata
b. Herpes genitalia
c. Condyloma acuminata
89. () A 89 multiple cauliflower
( 92,96 96 )
a. condyloma lata
b. condyloma acuminata
c. Herpes simplex
d. Candida vaginalis
e. Trichomonas vaginalis
92. ( A 92, B 96) A 20 year-old woman was present genital
itching The pelvic examination; 2-5 mm ( 2-5 cm), is size, around
posterior fourcheutte and hymen. , not tender
What is likely diagnosis?
a. Condyloma lata
b. Herpes genitalis
c. Vaginal candidiasis
d. Condyloma acuminate
e. Tricomonas vaginitis

88. () 28 vulva vulva mass

4 cm, redness, tenderness, fluctuate at labia minora
A. Skenes gland abscess

B. Bartholin abscess
C. Condyloma accuminata
--------------------------------------------------------------------------------------------------------------------
B. condyloma acuminata
Condyloma is a wart which caused by Human Papilloma Virus. Condyloma
is a sexually transmitted disease and have adverse effects for both partners. The
incubation period can occur up to several months without any signs and
symptoms of the disease. Usually more during pregnancy and when there is
excessive discharge from the vagina.
Although a bit, set to grow cauliflower and as a result is an accumulation of
purulent material in parts of the hemisphere, usually malodorous, gray, pale
yellow or pink. Condyloma acuminata bumps that are cauliflower-shaped,
pointed or small warts, which grow flowers, to form a group that develops, then
transmitted sexually. Condylomata acuminata found in area parts of the penis or
through sexual contact usually obtained through the rectal canal around the anus,
in women encountered on the mucosal surface of the vulva, cervix, perineum or
around the anus.
Condyloma acuminatum [condylomata acuminata] also known as:
1. Genital warts 2. Verruca acuminata
3. Venereal wart 4. Cock's comb
Treatment
Cryotherapy Electrodesiccation
Curettage Surgical excision

Carbon dioxide laser treatment

Reference http://emedicine.medscape.com/article/781735-treatment#a1126

c. Condyloma acuminate
condyloma lata secondary syphilis
large, grayis lesions found in moist areas.
--
d. Condyloma acuminata
Condyloma Acuminata
HPV type 6 or 11

(cauliflower-like)

laser podophyllin,
cantharidin, phenol, silver nitrate, trichloracetic acid or iodine
Cryotherapy
Vaginal candidiasis : curd-like, , genitalia

Trichomonas vaginitis : , , strawberry cervix
Condyloma lata : syphilis (secondary syphilis)
painless, mucosal, warty erosion genitalia
Herpes genitalis HSV type 2 genitalia

by :D
93. () 30 No U/D 4 PTA
DMPA 3
1. Chronic endometritis
2. Proliferative endometrium
3. Secretory endometrium
4. Atrophic endometrium
4. Atrophic endometrium DMPA
Mechanism DMPA
- DMPA inhibit GnRH -> decrease FSH,LH -> Inhibit follicular development
and LH surge -> no ovulation
- Cervical mucus is profoundly thickened by DMPA, which blocks sperm
entry into the upper genital tract.
- Inhibition of ovarian function during DMPA use causes the endometrium to
become thin and atrophic.

93. () 30 DMPA 3
3 2

--------------------------------------------------------------------------------------------------------------------
choice
DMPA
1.

2.
3.
4.
(DMPA)
Progesterone breakthrough bleeding

( choice
)
Novak Irregular bleeding with DMPA may be related to the
downregulation of endometrial estrogen receptors it produces
1
Berek & Novaks gynecology. 14th ed
by
95. ( B) 18
2-3
Secondary sex characteristics

a. Estrogen withdrawal bleeding
b. Estrogen breakthrough bleeding
c. Progesterone withdrawal bleeding
d. Progesterone breakthrough bleeding
---------------------------------------------------------------------------
Ans. . Estrogen breakthrough bleeding
anovulatory DUB
ANOVULATORY DYSFUNCTIONAL UTERINE BLEEDING
Anovulatory Dysfunctional Uterine Bleeding ( Anovulatory DUB )
283
42 35-80 ml (9) Anovulatory DUB

(early menarche period )
(perimenopaussal period) (9) /
(5)
hypothalamus-pituitary-ovary
axis Polycystic ovary syndrome(PCOS) (4, 5, 9, 10)
Anovulatory DUB
endometrium estrogen
- fragility endometrium endometrium -
endometrium
- endometrium - PG
PGE > PGF
- endometrium
Anovulatory DUB

Anovulatory DUB - Metrorrhagia,
Menometrorrhagia , Amenorrhea followed by bleeding (
6 )
Treatment Anovulatory DUB estrogen,
progestogen
1. Estrogen (3) conjugated estrogen 25
. 2-4 .
24 . estrogen 10 .
21-25 progestogen (oral medroxyprogesterone
acetate10 mg/d ) 7-10
2. Progestogen anovulatory DUB progestogen
progestogen
15
- Norethindrone acetate 2.5 - 10 mg 5 - 10

- Medroxyprogesterone acetate 5 - 10 mg 5 - 10
3. (1, 2, 11) anovulatory DUB
-
- androgen (
progestogen androgen androgen)
20-35 mcg ethinyl estradiol plus progestin 1
35 mcg 2-4 5-7
1 28 3-6
95. ( B) 16
13 cystic mass ~10 cm suprapubic area
tense bluish membrane hymen abdominal ultrasound
hypoechic mass at vagina hypoechoic cyst ~10cm Left ovary right ovary :
normal patophysiology cyst left ovary
--------------------------------------------------------------------------------------------------------------------
Retrograde menstruation
16 primary
amenorrhea Endometrium outflow tract, Ovary, Anterior
pituitary gland hypothalamus Outflow tract
obstruction
hymen imperforate
hymen ultrasound
hypoechoic cyst 10 cm
cyst hypoechic cyst Endometriotic cyst
(chocolate cyst), serous cystadenoma, mucinous cystadenoma, dermoid cyst
functional cyst chocolate cyst (cyclic

pain) endometriosis pathophysiology
1. Sampson ()

(, cul de sac),
( imperforate hymen ),
,

2.

3. (Coelomic metaplasia)
4.
Ref
by ~ 104*
95. () A 95 B 90 16
3-4 13 cystic mass p ubic symphysis
PV purplish mass at toitus TAS hypoechoic mass left ovaries
pathophysiology lesion left ovarian
--------------------------------------------------------------------------------------------------------------------
ANS choice T_T

96. () 36 G2P1 GA 38 wks FHS

150 bpm External fetal monitoring

a. Cord compression
b. Head compression
c. Uteroplacental insufficiency
d. Uterine hyperactivity
e.
--------------------------------------------------------------------------------------------------------------------
a. Cord compression Variable deceleration
46
FHR baseline 15 bpm 15 2

onset ,
(Cord compression)
97. ( A 97, B 60.) . 4

episiotomy wound chromic cat gut 2

a. Film pelvic
b. CT abdomen
c. Film Lower abdomen
d. Transvaginal ultrasound
e. Explore episiotomy wound

--------------------------------------------------------------------------------------------------------------------
E. Explore episiotomy wound ( A E)

Film pelvic
--
D. explore episiotomy wound investigaition
kikky
97.() 18 C/S 2
v/s BT 38.5 C PR 100 RR 20 BP 120/80
mild pale conjunctiva,tender at suprapubic , discharge foul smell, PV = bloody
per os , adnexa not tender management
a. Curettage
b. Endometrial sampling
c. Observe bleeding
--------------------------------------------------------------------------------------------------------------------
a. curettage stop bleed tissue pathology
98. () A, B 60 20
() ( 2
)

a. Chancroid
b. Primary syphilis
c. Secondary syphilis
d. Herpes simplex
e. Lymphogranuloma venereum

a. Soft chancre
b. Primary syphilis
c. Secondary syphilis
--------------------------------------------------------------------------------------------------------------------
b primary syphilis

1 chancroid 35

35

2 primary syphilis
10-90 21
3 secondary syphilis

4 Herpes simplex 2-3
24
2-3
5 lymphogranuloma vevereum
2-3

--
2 Primary syphilis
1 Soft chancre = chancroid

2 Primary syphilis
Chancre =

Primary syphilis Chancre
10-90 21
1-5
30

3 secondary syphilis
17 - 6
2-6
Condylomata lata
1-3
(Jib 050)
primary syphilis Treponema
pallidum

4
Primary ,Secondary ,Latent Tertiary (or late) Penicilli
6
Stage of Disease Preferred Treatment Alternative Treatments
Doxycycline 100 mg orally
Primary infection,
Benzathine penicillin twice per day for 14 days
secondary infection, or
injection 2.4 million units or tetracycline 500 mg
latent infection (for less
(single dose) orally four times per day
than 1 year)
for 14 days
Late latentinfection(for>1 Benzathine penicillin G Doxycycline 100 mg orally
year),cardiovascular injection 2.4 million units twice per day for 28 days
disease, or gumma every week for 3 weeks or tetracycline 500 mg

orally four times per day
for 28 days
Procaine penicillin injection
Aqueous crystalline
2.4 million units each day
penicillin G18-24 million
Neurosyphilis with probenecid 500 mg
units intravenously per day
orally four times per day,
for 10-14 days
both for 10-14 days
98. () B 98 otalgia + hearing loss 3 dPTA

PE - Lt ear : tender at tragus, swelling EAC, mild mucous discharge, TM intact
- Rt ear : normal
treatment [ ]
a. aural toilet + oral cloxacillin
b. aural toilet + oral
c. aural toilet + oral ketoconazole
d. aural toilet + topical ATB
e. aural toilet + topical acetic acid
--------------------------------------------------------------------------------------------------------------------
Ans D.
diagnosis : acute otitis externa
- symptoms : pruritis, otalgia, fullness, hearing loss
- signs : edema, tenderness of tragus, foul smell secretions, cellulites
- treatment : clean EAC, topical antibiotic+wick, supportive care
ref :: CE&NLII . ..
... [] #108#

101. () GA 35 week BP 200/180

mmHg, Urine dipstick: albumin 3+

a.
b.
c.
d.
--------------------------------------------------------------------------------------------------------------------
c.
(severe preeclampsia) preeclampsia
- SBP 160 (mmHg) DBP

110 (mmHg) 2 6
- proteinuria 5 24 3+
2 4
- pulmonary edema cyanosis
- 400 24 (oliguria)
- (persistent headache)
- (epigastric pain) / (impaired
liver function)
- (thrombocytopenia)
- (Oligohydramnios), (decreased fetal
growth) (placental abruption)
Management of Preelcampsia


(mild preeclampsia)
37
expectant management corticosteroids
(lung maturity)
(severe preeclampsia)
34

o non-reassuring fetal status
o (ruptured membrane)
o in labor maternal distress
32 steroids
102. ( A) 33 PID 3

6
a. Uterosalpingography
b. urine LH surge
c. Uteroscope examination
d. FSH 3
e. progesterone mid cycle
--------------------------------------------------------------------------------------------------------------------
a. Uterosalpingography PID

102. () B 102 50 5 no dysphagia,

no odynophagia pedunculated mass (
) right true vocal cord, smooth surface
a. Surgery
b. stop smoking
c. speech therapy
--------------------------------------------------------------------------------------------------------------------
1. Sugery ( ..)
vocal cord polyp pedunculate
Typically the result of trauma to the SLP and microvasculature
Commonly found in the middle portion of the musculo-membranous region
Size
Small: 0-3mm
Medium: 3-6mm
Large: >6mm
Excision
Cold instruments for small and medium polyps
Microspot CO2 laser for large polyps
PongPang
103. () A 103. B 111. Car accident + unstable c-spine
airway maneuver maintain airway
a. Chin tilt
b. Head tilt
c. Sniffing position
d. Jaw thrust
e. Open mouth
--------------------------------------------------------------------------------------------------------------------
. Jaw thrush
The jaw thrust is a technique used on patients with a suspected spinal injury
and is used on a supine patient. The practitioner uses their index and middle
fingers to physically push the posterior (back) aspects of the mandible upwards
while their thumbs push down on the chin to open the mouth. When the
mandible is displaced forward, it pulls the tongue forward and prevents it from
occluding (blocking) the entrance to the trachea, helping to ensure a patent
(secure) airway.
--
d. Jaw thrush "jaw
thrust maneuver"
--
3) Jaw thrust
(Airway Maneuver)
Airway maneuver , , ,

,
(Basic life support) 2

Head tilt-Chin lift

(Sniffing position)


Head tilt-chin lift

Jaw-thrust
(Angle of mandible)

(Positioning)
sniffing

1. 10 . flex

2. extend atlanto occipital
joint ( PA = pharyngeal axis , OA = oral axis , LA = laryngeal axis )
By Bell
105. () 5 2 , ,
a. .
b.
c.
d.
e.
--------------------------------------------------------------------------------------------------------------------
e.
()

[Noppon]
(~~) c,
d

0-3
2
.. ,..
46 46 46 46

BY My MiiM
106. () 25 PCU, .

A. Develop personal skill

B. Reorient health service
C. build healthy public policy
D. Strengthen community action

E. Create supportive environment

--------------------------------------------------------------------------------------------------------------------
D
(Ottawa Charter for HealthPromotion)

1. (Build healthy public policy)

2. (Create supportive environment)

3. (Strengthen community action)

4. (Develop personal skills)

5. (Reorient health services)


107. () (.)

A. Justice
B. Fidelity
C. Autonomy
D. Non-maleficent
E. Benefit
--------------------------------------------------------------------------------------------------------------------
. E. Benefit
(Beneficence)

A. Justice

B. Fidelity :

C. Autonomy

(informed consent)

D. Non-maleficent

108. Immunization for elderly?

--------------------------------------------------------------------------------------------------------------------

Influenza (Flu) for all adults ever year
Shingles (Herpes Zoster) 60
Diphtheria for all adults ever 10 year
Tetanus for all adults ever 10 year
Pneumococcal 65


108.
.
.
.
.
.
--------------------------------------------------------------------------------------------------------------------
^^
1. (Active Surveillance)

2. (Passive surveillance)

2
--

From 201
1. Active surveillance


2. Passive surveillance

109 A () 28
5 2
CXR: Normal
A. Silicosis
B. Byssinosis
C. Asbestosis
D. Berylliosis
E.
B.Byssinosis
Byssinosis
:

:

(anti inflammatory drug)

Silicosis



Beryllosis berylium Be
(phosphor)
Asbestosis

109 ( B) 22
a.
b.
c. Diazepam
d.
e.
--------------------------------------------------------------------------------------------------------------------
111. 5 .

()
a. ADHD
b. Autistic
c. Asperger's syndrome
d. Mental retardation
e. Learning disorder
--------------------------------------------------------------------------------------------------------------------

key word
Autistic ( )
Autistic
Choice
ADHD
Asperger's syndrome Spectrum autistic
Mental retardation
Learning disorder
OHM NUH
112. ( ) 65 Hematochezia
Barium enema : Multiple diverticulum
a.
b. Sigmoidectomy
c. Coloscopy stop bleed
--------------------------------------------------------------------------------------------------------------------
diverticulosis High-fiber diet
diverticular bleeding Colonoscopy for identify
location and stop bleeding
diverticular bleeding with complication bleeding does
not stop Colon resection
multiple diverticular
114. ( B) 60 2 wk

a. Colonoscopy
b. test and treat H.pylori
c. Oral PPI and prokinetic drug
d. diet and life style modification
e. EGD
--------------------------------------------------------------------------------------------------------------------
e 55 EGD guideline dyspepsia 2012
115. () B 115 25 2 moderate pale mild

jaundice Liver span 10 cm Spleen 2 cm BCM Hb 9 Hct 28 MCV 89

a. rituximab
b. Prednisolone
B 115. () 23 2 wk no hepatosplenomegaly direct-
antiglobulin positive Hb 9 mg/dl Hct 28% MCV 80 treatment
a. Prednisolone
b. Splenectomy
c. PRC
d. IVIG
e. Rituximab
--------------------------------------------------------------------------------------------------------------------
A Prednisolone
diagnosis AIHA direct-antiglobulin positive (direct coombs test)
Prednosolone
Glucocorticoids prednisolone
1-2 ././ 60 ./
100 ./
dexamethasone 5-10 . 6
prednislone
(Immunosuppressive drugs) azathioprine 2-2.5
././, cyclophosphamide 1-2 ././ AIHA

glucocorticoids
hemolytic crisis acute hemolytic relapse
hemolytic crisis
(splenectomy) glucocorticoids
AIHA
glucocorticoids

AIHA IgG warm

antibody type 50-70% CHAD
IgM
(blood transfusion) AIHA

, (AIHA with
reticulocytopenia),
Intravenous immunoglobulin (IVIg) IgG IVIg FcR

receptors Fc
IVIg ITP AIHA FcR
B prednisolone
AIHA underlying secondary cause
corticosteroid prednisolone dose 1 MKD
rituximab monoclonal Ab CD20 cancer non-Hodgkins
lymphoma Rheumato

116. () A 116 3,250

Apgar score 9,10
Barlow test positive, Otolani test positive

( )
a. Clubfoot and .
b. Clubfoot and Developmental dysplasia of the hip
c. Metatarsus adductus and .
d. Metatarsus adductus and Developmental dysplasia of the hip
e. Congenital vertical talus and Metatarsus adductus
--------------------------------------------------------------------------------------------------------------------
4. Metatarsus adductus and developmental dysplasia of the hip
Metatarsus adductus
Metatarsus adductus is a foot deformity. The front of the foot is bent or
angled in toward the middle of the foot. The back of the foot and the ankles are
normal. About half of children with metatarsus adductus have the problem in
both feet. Metatarsus adductus is thought to be caused by the infant's position
inside the womb. Risks may include:
The baby's bottom pointed down
in the womb (breech position)
The mother had a condition
called oligohydramnios, in which
she did not produce enough
amniotic fluid

There may also be a family history of the condition.

Metatarsus adductus is a fairly common problem. It is one of the reasons
why people develop "in-toeing."
Newborns with metatarsus adductus may also have a problem called
developmental dysplasia of the hip (DDH).
Developmental dysplasia of the hip
Developmental dysplasia of the hip (DDH) is a dislocation of the hip joint
that is present at birth. The condition is found in babies or young children.
The most common method of identifying the condition is a physical exam
of the hips. Two maneuvers commonly employed for diagnosis in neonatal exams
are the Ortolani maneuver and the Barlow maneuver.
By Tae Bizarre
116. ( B) 30 patechiae 3 .
PE: Generalize petechiae, , lymphadenopathy, ,
FH:
Lab: Hb 12 Hct 36 WBC 6500 PMN 70% lym 30 % Plt 2500
ANA-ve HB profile -ve Bone Marrow E:M 3:1 normal myelocyte lymphocyte
,minimal increase megakaryocyte
a. Azathioprine
b. Transamine
c. Prednisolone
d. Splenectomy
e. Plt concentration
--------------------------------------------------------------------------------------------------------------------
.Prednisolone

ITP Isolated thrombocytopenia BM

increase in the production of megakaryocytes
2 2
antibodies against platelets (platelet membrane glycoproteins IIb-IIIa or Ib-IX)

35
Initial treatment usually consists of the administration of

corticosteroids, a group of medications that suppress the immune system.
. Azathioprine for immunosuppressive therapy to prevent rejection
(organ transplantation), autoimmune diseases, including rheumatoid
arthritis, pemphigus, SLE, Behet's disease and other forms of vasculitis
.Transamine Tranexamic acid for treat or prevent excessive blood
loss during surgery and in various other medical conditions. (antifibrinolytic )
117 ( B) 23 3 lymph node

2 pruritic papular eruption 2 lymph node biopsy
reactive lymphoid hyperplasia ,
no granulomatous
A. HIV
B. EBV
C. RSV
D. CMV
E. HSV
--------------------------------------------------------------------------------------------------------------------
HIV pruritic papular eruption
HIV ( CD4 < 75 cell/ml)

reactive lymphoid hyperplasia

HIV Persistent generalized lymphadenopathy

1 . 2
Blue =^o^=
121. ( B) 50 U/D chronic HBV infection with ascites
1 . ascites: yellow,
clear, SAAG 1.3, ascites total protein 2.0, WBC 20 cell/cu.mm, Lymphocyte 100%
(choice dose ....)

A. Furosemide
B. Norfloxacin
C. Propranolol
D. Spironolactone
E. Large volume paracentresis with albumin replacement
--------------------------------------------------------------------------------------------------------------------


Uncomplicated cirrhotic ascites

choice dose ()
1. small amount ascites

< 2 gm/day
2. moderate ascites spironolactone at 100200 mg/d
as a single dose furosemide 4080 mg/d peripheral
edema
ascites spironolactone 400600 mg/d
furosemide 120160 mg/d
3. diuretics max dose ascites (Refractory ascites)
Large volume paracentesis with albumin replacement (Ref.
Harrison ed 18)
( E
propranolol ( role ascites) Norfloxacin (
uncomplicated ascites) A, D, E U/D chronic HBV
infection with ascites ascites
refractory ascites +albumin
dose 2 diuretic
dose)

122 35 AIDS, CD4 50/L, floater and burr vision rt. Eye
fundoscopy : cotton wool exudate
rt. Eye
A. antiparasite + early treat HAART
B. antibiotic + early treat HAART
C. ganciclovir + early treat HAART

D. consult ophthalmologist + early treat HAART
E. early treat HAART
CMV (Cytomegalovirus) HIV
cd 4 50
(CMV Retinitis) (floating)
(visual field loss)
122. ( B) 35 U/D AIDs blurr vision CD4 = 50

: cotton wool spot
A. Antifungal then early start HARRT regimen

B. IV antibiotic then early start HARRT regimen
C. IV Acyclovia then early start HARRT regimen
D. Consult eye then early start HARRT regimen
E. early start HARRT regimen
--------------------------------------------------------------------------------------------------------------------
Ans c. IV Acyclovia then early start HARRT regimen
AIDs CD4 100 cell/mm3 HIV 46
Retinopathy HIV Retinopathy

1. Cotton-wool spots [
Retinal nerve fiber layer
HIV]
2. Intra retinal hemorrhages 3. Retinal microaneurysms
CD 4 = 50 cell/mm35 CMV
Cotton-wool spots 750
Cytomegalovirus (CMV Retinitis)
induction
CMV
maintenance
(induction therapy)
# Ganciclovir 2-3
3-6
# Valganciclovir 14-21
CMV maintenance
# CMVCMV
maintenanceganciclovir5// 1
maintenance
inductionmaintenance
# Valganciclovir450 1 14-21
CMV
CD4
100/ 6
maintenance
123.() Finkelstein's test +, radial styloid tender
1.Paraffin bath
2. TENS
3. Microwave
4.
5.
1. Paraffin bath de Quervains disease

radial deviation first MCP joint IP joint
corticosteroid
6
Ref..
http://www.med.md.kku.ac.th/site_data/mykku_med/701000019/HAND.DOC
125. ( B) 60 U/D COPD

Salbutamol, Beradual MDI,Theophylline loud P2, Oxygen sat 88
% RA, Lung fine crepitation both lungs, edema both legs
1. Furosemide IV
2. Long term oxygen therapy
--------------------------------------------------------------------------------------------------------------------
2. long term oxygen therapy
Indication long term oxygen therapy
1. PaO2 < 55 mmHg or SaO2 < 88%
2. Cor pulmonale
3. Erythrocytosis ,Hct >55%
4. Pulmonary hypertension

127.50 VA 20/200 20/20

ciliary injected , pupil fix semi dilated , IOP (20 )
1.Conjuntivitis
2.Acute uveitis
3.Corneal abration
4.Acute angle closure glaucoma
5.
Acute angle closure glaucoma

- : halo vision (rainbow-colored around light)
- High IOP , Mid-dilate , Sluggish , Irregular pupil , Corneal epithelial
edema , Congested episcleral & conjunctival blood vessel , Shallow AC , Mild
amount of aqueous flare & cell
128. ( A 128, B 89,126)

a.
b.
c.

d. .
e. .
.
130. () PE: corneal edema, shallow ant.

chamber, pupil 6 mm. no reactive, IOP 40 mmHg , Hx : asthma
a. Atropine

b. Beta-blocker
c. miotic drug
d. alpha2-agonist
e. carbonic anhydrase inhibitor
--------------------------------------------------------------------------------------------------------------------
B. Beta-blocker
133 B
80 crystal in PMN
conjunctivitis, desquamation of oral
mucosa, discrete target-like papule and bullae on trunk WBC 11,200
PMN 60% L 19% Eo 21%
a. Colchicine
b. Allopurinol
c. Probenecid
d. Prednisolone
e. NaHCO3
b. allopurinol

allopurinol xanthine oxidase inhibitor (purine analog)

xanthine oxidase enzyme
hypoxanthine xanthine xanthine uric acid
uric acid gout attack
Anti-inflammatory, analgesic, uricosuric activity
allopurinol allopurinol
3
hypersensitivity syndrome TEN, SJS,
high grade fever, liver involvement, renal failure, leukocytosis with eosinophillia
Uricosuric
Probenecid, Benzbromarone, Sulfinpyrazone
Joint NT7
133. () A 133, B 96 68 elective aortic valve

repair severe aortic stenosis on anti-platelet ( anti-
coagulant ) () CT-Scan
()
a. Acute Middle cerebral artery infarction

b. Acute Anterior cerebral artery infarction

c. Acute Posterior cerebral artery infarction
d. Chronic Middle cerebral artery infarction
e. Chronic Anterior cerebral artery infarction
--------------------------------------------------------------------------------------------------------------------
Acute Middle cerebral artery infarction
Stroke
CT lesion Hypodensity at left
frontotemporal region Middle territory Acute
CT ( Chronic lesion
CSF ventricle)
lesion edema Cytotoxic edema mass effect
region
supply MCA

By>>>
#013
134 A(). 65 bowel habit change hematochezia 8 . 2

PE: abdomen normal barium enema () diagnosis
A. Colon diverticulitis
B. Crohn 's disease
C. Colon polyposis
D. Colon cancer
D. Colon cancer
bowel habit change Malignancy
Carcinoma colon barium enema
lesion over Hanging edge 2 lesion
CA colon apple core appearance
apple core appearance ............by P' gloay

136 Recurrent otitis media

1.
1.
2.
136. B 55
1 3
a. Phenytoin
b. Diazepam
c. Sodium valproate
d. Topiramate
e. Levetiracetam
--------------------------------------------------------------------------------------------------------------------
2. Diazepam
Alcohol withdrawal seizure
46
Diazepam
46
NUH
137. () A 137, B 127.
no spleenomegaly CBC : Hct 20% WBC 3500 Plt. 1500 bone marrow biopsy
cellular 20% decrease proper management
a. bone marrow transplantation
b. blood component transfusion
B 127.() CBC: Hb 7 Hct 21 WBC 3000 Plt
20000 (pancytopenia)
A. Bone marrow transplantation
--------------------------------------------------------------------------------------------------------------------

138. () 40 . 4 .
.
a. Assist ventilation
b. Emergency radiation
c. Neoadjuvant chemotherapy
d. Laryngoscope
139 A () ( key word -_-)

45
IDL : Unilateral pedunculated mass at anterior part of vocal cord;
Management
1. Speech therapy
2. Surgery
3. Chemotherapy
2.Surgery

Unilateral pedunculated
mass at anterior part of vocal cord Vocal polyp
Vocal polyp voice abuse
collagen type IV basement membrane
hoarseness peducunculated polyp
anterior one third of vocal cord
microsurgical removal voice or
speech tharepy
Vocal nodules ()

Vocal nodules (Singers nudules) voice abuse

nodules anterior one third posterior two third vocal cords
voice or speech tharepy
Vocal polyp
Vocal nodules
By OJ: Ref. , , Disease of ear nose and

throat, Elsavier
140. ( A, B 103) 80

?
B 103. () 2

a. delirium
b. delusion

--------------------------------------------------------------------------------------------------------------------
diag aplastic anemia severe non
severe peripheral / bone marrow criteria
PBS criteria (2/3)
severe
1. Absolute neutrophil count < 500/mm3
2. Plt count < 20000/mm3
3. Reticulocyte count < 1%
Very sevrer
Absolute neutrophil count < 200/mm3
Bone marrow criteria
Severe
Hrmatopoietic cell < 30%

Non severe - symptomatic support (blood component
transfusion)
Severe bone marrow transplantation, ATG+cyclosporin
severe bone marrow criteria Hrmatopoietic
cell < 30% PBS criteria
severe BM criteria severe BM
transplantation

141( A ) Bipolar I
(By pang NT 7)
.Vaproic acid
.Olanzapine
............
.Chlorpromazine
.Carbamazipine
Carbamazipine Bipolar Mood Stabilizer 3 Lithium ,
Carbamazipine ,Na Valproic acid Side effect
SJS Carbamazepine
A 142 schizophrenia 1

A. Propanolol
B. Lithium
C. Trihexyphenadyl
D.TCA
A. Propanolol
antipsychosis EPS Akathisia
high
potency haloperidol Dopamine antagonist
propranolol

Lithium bipolar mania recurrent
Trihexyphenadyl EPS parkinsonisim
TCA antidepressant reuptake NE 5HT

By P Tigg NT7 Ref. NL 2 ..
142B A 35 years old woman with 2 days of anorexia, fatigue and jaundice.
Examination: no chronic liver stigmata. Liver function tests AST 1350 ALT 1450 ALP
145, Hepatitis profile: anti-HAV IgM-negative, anti-HAV IgG-Positive, HBsAg-positive,
Anti-HBs IgG-Negative, anti-HBs IgM-positive, anti-HCV-Positive, Diagnosis?
A. Acute HAV hepatitis

B. Acute HBV hepatitis
C. Acute HCV hepatitis
D. Chronic HBV hepatitis
E. Chronic HCV hepatitis
B. Acute HBV hepatitis
acute 2 anti-HBs IgM-positive
acute


143.() 18

anorexia laba
anorexia nervosa
143. ( B) 50 2 wks HEENT:not pale,no

jaundice Abdomen:Spleen 4 FB, lab Hb 12, Hct 36, WBC 253,000 (shift to the left)
PMN 22% Lym 14%, Plt 543,000
a. AML
b. CML
c. Leukemoid reaction
d. MDS
--------------------------------------------------------------------------------------------------------------------
B.CML leukocytosis +shift to the left
-MDS lab series
-Leukemoid reaction CML Alkaline phosphatate
Leukemoid reaction :high ALP
CML:low ALP()
144). A () 3

1. ADHD 2. Autistic
2.) Autistic
A. 6 (1) (2) (3) 2
(1) (2) (3) 1

1. 2
1.1. (
)
1.2.
1.3.
( )
1.4.
2. 1
2.1.
( )
2.2.
2.3.
2.4.
3.
1
3.1. (stereotyped) 1

3.2.
3.3. (mannerism) ( )
3.4.
B. 3
(1)
(2)
(3)
C. Rett's Disorder Childhood Disintegrative Disorder

18 4
2

(lack of pretend play)
(lack of protodeclarative pointing)
(lack of social interest)
(lack of joint attention)
Attention-deficit hyperactivity disorder (ADHD)
3
1) (inattention) 2) (hyperactivity)
3) (impulsivity)

Ref.http://www.google.co.th/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&c
d=2&cad=rja&ved=
BYGeneii nt7 med NU
144. 3

a. Autistic disorder
b. Mental retardation
c. Communication disorders
--------------------------------------------------------------------------------------------------------------------
a. autistic disorder
Autistic Disorder
A. 6 (1) (2) (3) 2
(1) (2) (3) 1
(1) 2

(a)

(b)
(c)
(
)
(d)
(2) 1
(a) (
)
(b)
(c)
(d)

(3)
1
(a) (stereotyped)

(b)
(c) ( mannerism ) ( )
(d)
B. 3 (1) (2)
(3)
C. Retts Disorder Childhood Disintegrative Disorder
http://www.ramamental.com/dsm/autistic_disorder.htm
145 B ()
case Diag DKA & pyelonephritis DTX 420 PH 7.05 NaHCO3 12

NSS 250 ml/hr x3 hr insulin 7.5 U/hr Ceftriaxone 2 g OD

3 hr DTX 400 PH 7.05, NaHCO3 12 Next step?
a. NaHCO3 50 ml
b. Insulin 10 U sc
c. Insulin 10 U/hr
d. antibiotic Cefotaxime
e. NSS 1000 ml/hr
Ans c. Insulin 10 U/hr

a. NaHCO3 Indication NaHCO3 pH <6.9 ( pH7.05)
b. Insulin sc plasma glucose 250 mg% sc
c. insulin 7.5 u/hr DTX insulin
glucose ( 50 mg/dl 1 hr)
d. antibiotic Antibiotic
24-48
e. DKA NSS 250-500 ml/hr specific
treatment insulin
145. 35 1 day PTA

a. Heroin
b. Amphetamine
c. Alcohol
d. Cannabis
e. Ketamine
--------------------------------------------------------------------------------------------------------------------
1. Heroin
146. () 18
(Hyperventilation)
a.
b.
c.
--------------------------------------------------------------------------------------------------------------------
a.
147 ( A ) DIAZEPAM OVER DOSE ANTIDOTE ?

FLUMAZENIL
(147). gloving and stocking

opthalmopathy megaloblastic anemia, Investigation
a. vitamin B12
b. thiamine pyrophosphate
c. transketolase
b. gloving and stocking paresthesia with

opthalmopathy Wernicke korsakoff [ Vitamin B12 deficiency
beefy glossitis] thiamine pyrophosphate
147. ( B) 85 Dx CA Lung

Vital Sign : Temp = 37, BP 120/80, RR = 18, PR = 90
Heart : Regular rhythm, S1 S2 S3 gallop, No murmur, JVP = 3 cm
Lung: Fine Crepitation and Decrease Breath Sound RLL
CXR : Pleural Effusion Right lung

Lab Electrolyte: Na = 124, K = 5.0, Cl = , CO2 =25

BUN = 20, Cr = 0.6, Urine Na = 60, Urine Osmo = 300,
Na
. HCTZ
. Restrict water intake
. 3% NSS
. 0.9% NSS
. 0.45% NSS
--------------------------------------------------------------------------------------------------------------------
. .
Euvolemic Hyponatremia JVP
Hypervolemic
Hyponatremia HF (S3 Gallop = Ventricle HF),
Pleural effusion
Urine osmolality < 100 (BUN Cr )
Serum osmolality True/Pseudo Hyponatremia
Urinary sodium concentration SIADH U.Na 20-40 ( = 60)
Symptomatic SIADH Heart Failure Hypovolumic
The goal is to correct hyponatremia at a rate that does not cause neurologic
complications, as follows:
Raise serum sodium by 0.5-1 mEq/hr, and not more than 10-12 mEq in the first
24 hours
Aim at maximum serum sodium of 125-130 mEq/L
In an acute setting (< 48 hours since onset) where moderate symptoms are
noted, treatment options for hyponatremia include the following:

3% hypertonic saline (513 mEq/L)

Loop diuretics with saline
Vasopressin-2 receptor antagonists (aquaretics, such as conivaptan)
Water restriction
In a chronic asymptomatic setting, the principal options are as follows:

Fluid restriction
Vassopressin-2 receptor antagonists
If vasopressin-2 receptor antagonists are unavailable or if local experience with
them is limited, other agents to be considered include loop diuretics with
increased salt intake, urea, mannitol, and demeclocycline
By iPoweRx
148. 25

10 Vital signs : normal , Other PE: normal. What is her diagnosis?
1. GERD
2. Anxiety disorder
4. Giardiasis
5. Colon cancer


Vital
signs : normal , Other PE: normal.
REF: http://romecriteria.org/assets/pdf/19_RomeIII_apA_885-898.pdf
NT7
Colorectal CA
stool occult blood
Diverticulitis fever, anorexia, left lower quadrant
abdominal pain, and obstipation appendicitis

Imflammatory bowel syndrome
o Ulcerative colitis Glossly bloody diarrhea, lower abdominal
cramps, tenesmus ()
o Crohns deisease mucus-containing, non-grossly bloody
diarrhea, n/v, bloating, obstipation

. .
149( ) 62 gemfibrocil TURP

GA lithotomy 1 loss dorsiflex of Lt foot
A. Common peroneal nerve injury
choice common peroneal nerve injury

rehab foot drop
common peroneal nerve, sciatic nerve, L-S plexopathy L5-S1radiculopathy
By
NT7
150. () B 150 Oral thrush CD4+ 100
a. Fluconazole Oral
b. Clotrimazole
--------------------------------------------------------------------------------------------------------------------
Ans A.Fluconazole Oral HIV CD4+ 100 Candida
esophagitis Fluconazole Oral

(150 B ) 45 known case HIV CD4 = 100 cell/mm3
5 kg. 3 oral thrush with
abrasion ulcer
. Fluconazole
. Itraconazole
. Amphotericin B
. Nystatin solution
. Cotrimazole troche

. Nystatin solution HIV

esophageal candidiasis

CD4 < 100
CD 4 <75 fluconazole 100-200 mg oral OD
(ref. , emedicine)
150 () 70 u/d COPD .

40
O2sat 94% on simple oxygen mask c bag
A.oxygen toxicity
B.CNS toxicity
C.decrease hypoxic drive
C.decrease hypoxic drive CO2 narcosis

40
(-) Vaginal prolapsed

1. Menopause
2. Chronic cough
3. Chronic hypertension
4. Chronic constipation
5. Multiple vaginal childbirth
3. Chronic hypertension
Common factors that may cause a vaginal prolapse include the
following:
1. Having multiple vaginal deliveries
2. Having a prolonged labor
3. Giving birth to a large baby

4. Being post- Menopause

5. Being of advanced age
6. Being Overweight
7. Having a chronic Cough
8. Tobacco Use Disorder
9. Having chronic Constipation
(-) Aortic valve 5 wk CT

1. Acute left ACA infarction
2. Acute left MCA infarction
3. Acute left PCA infarction
4. Chronic left ACA infarction
5. Chronic left MCA infarction
5. Chronic left MCA infarction


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Comprehensive Step II, February 2014 (2557), By MEDNU#15 & NT#7

Comprehensive Step II, February 2014 (2557)

a. Posterior hip dislocation

. Neurogenic bladder Hx trauma +

. Full bladder Obstructive Urinary track

Inhaled corticosteroids plus long acting 2 agonist

Ans d. Primary survey and refer

Management penetrate chest ( BP drop thoracotomy)

painful gynecomastia. Amiloride can be used instead of spironolactone, starting at

8. () 40 on warfarin ICH INR 3.5

*** emergency FFP

right side heart failure Osat =88% criteria long

a. Fixed drug eruption

Fixed drug eruption describes the development of one

Erythema nodosum in a person who had recently had streptococcal

Erythema multiforme (EM) is an acute, self-limited, and sometimes recurring skin

Target lesion of erythema multiforme.

Management of chronic HBV infection (HBV carrier)

16. ( A , B 129) 57 U/D HT 1st Dx. 6 loss F/U

PE : BP 156/96 mmHg, generalize edema Dot and blot hemorrhages,

( A 16. , B 129) 53 right inguinal

diabetic retinopathy, which is associated with nephropathy. DM

Membranous nephrotic syndrome

2 iron chelator defuroxamine , deferasirox

Deferoxamine (Desferal, DFO)

defuroxamine serum CR = 2 deferasirox

............by P' gloay

18. ( A 18) 22 Abdominal pain.......

B) Normal saline and insulin

Insulin (Insulin therapy)insulinIV

approach headache secondary headache primary

I.V. mannitol increase

21. ( A , B_) 20 + stiff neck

In adults, CT scans classically reveal hypodensity in the temporal lobes

22 u/s fibrous tissue

Potassium hydroxide preparation (KOH) lesion tinea Versicolor

24. ( B) ( 160/100) BUN,Cr

25. ( A. 25) 56 ER V/S : BT 38.9C , PR

26. ( A , B_) 56 BMI 35

acute cystitis anatomic & physiologic abnormality,

33. ( A 33.) EKG () ( tall

Functional Abdominal Pain Syndrome

Picture acute blood loss

U/S: anechoic ( Hypoechoic) well circumscribed mass, increased

U/S anechoic mass

- DICS proliferative epithelium lining minor ducts

49. ( A) 2 cleft palate 6

chlamydia non-gonococcal organisms (negative for

STI-associated epididymo-orchitis more Urinary or enteric pathogen-associated

B conization CIN III adequate method

Conclusion: CKC for CIN3*

58. () skin tag, hypertrophic

choice Adalat sublingual nifedipine Ca

61. .. 2 2 PTA 3 PTA

>>> B. pertussis (Whole

62. () A. 62, B 125 GA 41 wk breech

a. Chronic renal failure

64. ( A) GA37 weeks, BW 1800 g, APGAR 7,10

The classic triad presentation of congenital rubella syndrome consists of the

congenital rubella syndrome. Hearing impairment may be bilateral or

pulmonary artery stenosis is present in 50% of infants infected in the first 2

CNS abnormalities, including mental retardation, behavioral disorders,

encephalographic abnormalities, hypotonia, meningoencephalitis, and