21 一位65歲病人最近1個月疲倦、走路呼吸急促、食慾不佳、體重減輕5公斤；30年前診斷為成人型多囊性腎疾，當時的血清肌酐（creatinine）是1.2 mg/dL。他的血清肌酐15年前為2.2 mg/dL，2年前上升至7.2 mg/dL。此次檢查肌酐12 mg/dL, BUN 120 mg/dL，血紅素8.5 g/dL，電解質（單位mmol/L）：Na 139, K 5.5, Cl 103, Ca 1.95, P 8.9 mg/dL；有關此病人的處置下列何者較為適當？

這次可能是急性的腎功能惡化，觀察2個月後再測定腎功能

病人維生素D製造不良，可先用1-alpha-vitamin D3控制磷離子

予胰島素降低血鉀濃度

開始透析治療

start dialysis

normal creatinine os 0.5-1 .this patient is getting worse reaching 12 mg/dL

dialysis should be started========

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24 下列關於Liddle’s syndrome的敘述，何者錯誤？

為自體顯性遺傳，amiloride-sensitive sodium channel發生activating mutations

臨床表現有高血壓，低血鉀及代謝性鹼中毒

血清renin濃度高，aldosterone濃度高

低鈉飲食及amiloride可矯正其高血壓及電解質異常

ans C

Liddle's syndrome, also called Liddle syndrome and pseudoaldosteronism,^[1] is an autosomal dominantdisorder characterized by early, and frequently severe, hypertension associated with low plasma renin activity,metabolic alkalosis due to hypokalemia, and hypoaldosteronism (low secretion of aldosterone).^[2] It is one of several conditions with this unusual set of characteristics known collectively as pseudohyperaldosteronism. Hypertension due to this syndrome often begins in infancy. Liddle syndrome involves abnormal kidney function, with excess reabsorption of sodium and loss of potassium from the renal tubule, and is treated with a combination of low sodium diet and potassium-sparing diuretic drugs (e.g., amiloride). It is extremely rare, with fewer than 30 pedigrees or isolated cases having been reported worldwide as of 2008^[3].

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27 下列何者為正常陰離子隙代謝性酸中毒（normal anion gap metabolic acidosis）？

乳酸中毒（lactic acidosis） 糖尿病酮酸中毒（diabetic ketoacidosis）

第一型腎小管性酸中毒（type1, 即distal RTA） 水楊酸中毒（salicylate poisoning）

type 1 distal RTA

The differential diagnosis of normal anion gap acidosis is relatively short (when compared to the differential diagnosis of acidosis):

• Hyperalimentation
• Acetazolamide and other carbonic anhydrase inhibitors
• Renal tubular acidosis^[1]
• Diarrhea
• Ureteroenteric fistula - an abnormal connection (fistula) between a ureter and the gastrointestinal tract
• Pancreaticoduodenal fistula - an abnormal connection between the pancreas and duodenum

It can be remembered with the mnemonic HARD-UP.^[2]

As opposed to high anion gap acidosis (which involves increased organic acid production), normal anion gap acidosis involves either increased production ofchloride (hyperchloremic acidosis) or increased excretion of bicarbonate.

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28 下列臨床或實驗室之檢查皆為評估類風濕性關節炎活性之指標，那一項最無法反應疾病活性（disease activities）？

Rheumatoid factors C-reactive protein

Number of tender joints Patient’s global assessment of pain

ans A: RF!!!!!!!

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33 減白的血小板（leucocyte-depleted platelet），可降低藉輸血發生下列那一種傳染疾病的機率？

Cytomegalovirus Hepatitis A virus

Human immunodeficiency virus type 1（HIV-1） Hepatitis C virus

CMV human herpes virus 5

http://en.wikipedia.org/wiki/Cytomegalovirus

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34 一位患者的淋巴瘤被發現有染色體轉位t（11;14）並有BCL1的表現，此淋巴瘤最可能的分類為何？

Follicular lymphoma Mantle cell lymphoma

Diffuse large B-cell lymphoma Burkitt’s lymphoma

mantle cell lymphoma

burkittL

Almost by definition, Burkitt's lymphoma is associated with a chromosomal translocation of the c-myc gene. This gene is found at 8q24.

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35 病人輸血時發燒到38℃以上，若臨床上已經完全排除溶血反應或感染，關於此類病人的輸血反應，下列敘述何者錯誤？

常發生於過去多產的女性受血者

因受血者對捐贈者血漿中的蛋白過敏

選擇使用減白的血液製品（leucocyte-depleted RBC or platelet），可以減少發生的機率

對經常發生的受血者，輸血前先口服acetaminophen可改善發燒反應

ans B: not protein, it is leukocyte

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38 一位55歲身體狀況一向良好的女性因左腳腫脹1週就醫。理學檢查發現左下肢腫脹，溫度比右邊稍高且靜脈明顯，但無紅疹或壓痛。此外，左鎖骨上窩處淋巴腺腫大，稍硬且固著。驗血時那一項為陽性的可能性最高？

Alpha-fetoprotein Beta-hCG CEA CA-125

AFP: entertaining liver cancer,

not the cea: although virchows node tells you malignancy is coming from the abdomen.

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