RAPD604 50K

&(B" DP >&(B"2B$W 2B$W  2(4F&LK 2P (4F&LK3C3CGKG2#$%&' 2K #$%&'$()!*+ $()!*+%D1>7. %D1>7.1C13(J. 3C (J.2J#9)*#3#4&1FJOB:Z6  2J#9)*#3#4&1FJOB:Z6   &[&. [D* D* ICU D"#Z6  #Z6   &[&. D*7C [D*7C294" 294"#D<= #D<= O )J1>7.(G" (G"%3#(4F %3#(4F  O  sat. drop N4O-=)J1>7. %18D<#9DC D<#9DC7ND#<7C 7ND#<7C$><" $><" >7. (4F<=N4T N4T  $>\\] $P >\\]#BC #BCD,JZK D,JZK7&9GK 7&9GK7C7216 2C 16& 2

   ) 1. '*%+",   * (4 "BD++) "#$%&'(   1. %+",-.* -.*%/%0"12 %/%0"12  +3445 + ) 3445%67 %67.8/-7 .8/-7901* 901*%.:;  %.:;    =>= < .?0#17 .> ?0#179@0, 9@0,-A%.B8-C?; -A%.B8-C?;   (4 .................................................................................................................................................................    ) 2.'*%+/B86< "#$%&'(   2. %+/B86<0%EE7 0%EE70F%A%.B-7 0F%A%.B-7901* 901*%.@G2 %.@G2   C9I< CH 9I<+C?* +C?*%93E$< %93E$<%:; %:;    =>= < .?-7 .> ?-7901* 901*%. %. maintain airway D1B?796%?8/3-< 96%?8/3-<-(-( (ICG.,J( JD1BK+%-KC90%EE7 D( 1BK+%-KC90%EE70F%-< 0F%-<.? .?) (3 "BD++) ................................................................................................................................................................................. ................................................................................................................................................................................. .................................................................................................................................................................................    ) 3. 617986< "#$%&'(   3. 986<0%EE7 0%EE70F%-7 0F%-79"#$%&'( 9"#$%&'(  2 ) D1<."12 ."12  +3445 + ) 3445%67 %67.8/KC9:;  .8/KC9:;    =>= < >.?017 .?017G&%@=L G&%@=L+=0I, +=0I,D1B D1B vital signs stable '*%+/B86< %+/B86<0%EE7 0%EE70F%C?* 0F%C?*%93EI* %93EI*C3=@M2 C3=@M2  C=5 C ) =5C907 C907+A%.B-7 +A%.B-7901* 901*%.@0, %.@0,-NH  -NH    #KO KO   +C( +H C(0( GC0DI*P2P  C?%3&* C 2) ?%3&*I
!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 3 !"#$ "#$%&'(  ) 1. "#$%&'(  ) 2.

"BD++ ) Direct synchronized cardioversion K+%- 1-2 J/kg ( 3 "BD++, $<%ICGD"* Direct synchronized cardioversion C?*%9@-(?.86< 2 "BD++, $<%ICGD"* cardioversion 6E2C defibrillation DI* 3&*&( Direct synchronize  86<1"BD++) "#$%&'(  ) 3. Lidocaine 6E2C Amiodarone 6E2C Procainamide ICG?%I7.8-0Q 3-<(3"BD++) Ventricular Tachycardia ( 4

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 4  562$7 !"#$%&'$()!*+ ,-.!/$&LK3CG2K #$,$012)*#3#456$*+ )3%789BQK2:#*/ 10 &; <#G1DJ7.D*%1T :P 2 1"#29#*%N4T :P $>BD4C9EXF91FG/9 ZK7&9GK  07*%R)#F <"N":*<=(12 :#9#1%&'$<#9?W    $V %1T :P *A ND3N/<><" >7.  ><"< =>?.  ><"-C9 16    G. DC 7= %D4#B4C3:#9#1JFB#*>& 9":$B$.#$=     V 2 %7T:$%N*>&1C39#11C9E#%1T :P 2>?.&D7?.:!= P 1).-/<-$ B#*%&'$&9GK (4.D $:9$C    $V JF(?82(127=<#G4:7  ><"%N*,-.*#:F>1&1FJO  ><"<=&1FDCG%K -"$$=    ,V $N1:3N1CD G1DJ1"#29#* : T 37 C, HR 90/min, regular, RR 20/min, BP 120/80 mmHg o

good consciousness, not pale, no edema, no cyanosis, no jaundice Heart : no active precordium, normal S 1, S2, pansystolic murmur grade 2/6 at apex and radiate to left axilla Lungs : clear  Abdomen : no hepatosplenomegaly CXR

(4F EKG &9GK (G"<= abnormal movement 1A9L<: VDO 23 4"<$

%DEFF 1.1

[2] 

J2,B.9#1DK$JK RC*U#DF abnormal movement Chorea

1.2

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J#9?.:<64%3T    :V 2G.$ !"#$NK7D"#U#DF7C294"#D$"#JF%9K7J#901N:F>1<#9!= @P 7/  Acute rheumatic fever

2.

[6] [2]

J23:9($D!#29#11C9E#@OB1C3Z6    &. [D*1#*$=     V P *#!= ,P -. ,$9#11C9E#U#DF abnormal movement 7C294"#D =< 1 /M 4( 2.1 3:9-T : Hadol, Benzodiazepine, Phenothiazine, Pimozide,

[4]

2.2

3:9($D!#2,$9#176(41C9E#01N!= %P &'$@#%BG/ ,$Z6    &. [D*1#*$=     V =< 2 *+( 1. Antibiotic prophylaxis for recurrent rheumatic fever : Penicillin 2. Advise IE prophylaxis if indicated

%1T :P 2 cardiac problem : MR *C2><"G:. 2,B.*#%)1#FD"# regurgitation $.:* CXR + EKG  ><")3BCD,J0G %)=*2,B.G7K G#<76%&'$1F*F

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 5  562$7 !"#$%&'$()!*+ ,-.!/$::9G1DJ!=  P OPD  012)*#3#4!C DP >& )3%789:#*/ 3 &; <#1C9E#7.D* skin lesion 1A9BC-

!"#$$

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J2,B.9#1DK$JK RC*(*901N =< 3 5B% 1. Stevens - Johnson syndrome 2. Erythema multiforme 3. Kawasaki syndrome 4. Bullous LE

[3]

2.

!"#$G.:29#1?.:<64!= @P ONCQ:F>13.#2 J#9&1FDCGK(4FG1DJ1"#29#*%)T :P -"D*,$9#1DK$JK RC*01N )(@=< 3 ($8<9 K #1,-.*# %-"$*#(9.:C9%@3 *#9C$-C9 *# NSAIDS 1.   &1FDCG9 K #1GK7%-T    :V %-"$ Mycoplasma, Infectious mononucleosis, Adenovirus, Coxackie, 2.   &1FDCG9 etc 3.

4C9EXF?:2ZT $P %1K 

4.

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3.

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J23:9U#DF(!19H.:$!= )P 3>7. ,$01N$=     V =< 4 ($8<9 1. Secondary bacterial infection 2. Fluid and electrolyte imbalance 3. Pneumonia / Renal failure 4.

31K%DX%*T :P 3/:#J%9K79#1GK79C$

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 6  562$7 !#19%)5-#*:#*/ 6 @C&7#B+ :#%J=*$)/ 2" 3":*A B4C29K$$<<# 2 @C&7#B+ %&'$<#9?W    $V %1T :P *A :#%J=*$ %&'$$<  ><"%N*<=$  V O@=%?=*D&$ Z6    &. D[ *9K$$<<#17#:*"#2%7=*D S"#*:/JJ#1FDC$4FN1C    2V $V  OB$C9(19%9K7 3,000 91C< G1DJ1"#29#* : BW 3,400 g, mild dehydration  ><")3ND#
!"#$>7.@"2 upper GI study  >7.Z47C2,$16& J=<$!J'0 ** <=1&6

%DEFF [2]

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J23:9ND#
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[2]

2.

J2(&4Z4 serum electrolytes

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1. Hypokalemia

[1]

2. Hypochloremia

[2]

3. Metabolic alkalosis

3.

J2,B.9#1DK$JK RC*01N Hypertrophic pyloric stenosis

[2]

4.

J23:9Specific treatment (BD)0;K? @3
G+<'() Surgery  ,B. 1 NF($$

!"#$%&'()*+(,() CRQ -. 6  562$7 !"#$%&'$()!*+%)K 

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J2,B.9#1DK$JK RC*(*901N<# 3 5B% 1. Herpes simplex infection 2. Cheilitis angularis 3. Impetigo

(7

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1. Wet dressing

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2.

S.#%&'$,$  ,B.:<$V  O%94T:4.#2(Z4(4F3.D$]":*A 3. !#7.D* Xylocaine viscous 4. Paracetamol (9.&D7

[1] [1]

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2.2

@BN3G<+ >C  +-;O $=3L=C ?%  +=0 @AF)@:B8(9 ()(@@
%R4*?.:@:3 Constructed Response Question (CRQ) $5).&; 6 -/7!=  P 5/2550 ?.:!=  P 8

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%&G<= 1. J2311*#* Skin lesion

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erythematous patch at both cheeks with fine scale 2.

J2,B.9#1DK$KJRC*(*901N <# 3  01N

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atopic dermatitis seborrheic dermatitis tinea facii 3.

J2,B.9#11C9E#!= %P B<#F@<,$Z6    &. D[ *1#*$=     V mild topical steroid; 1% hydrocortisone

antihistamine (2) emoilliant (1)

!#ZT $P

bid (2)

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 9  562$7 %789BQK2:#*/ 7 %7T:$ <= >?.<# 3 DC$  ><"<:= #9#1>:  ><"<$=   V O<69>B4  >?.@26 G4:7!C    2V  3 DC$ DC$$=    ?.@26 <#9 (4F-C9%9182 G#%B4T:9 &1FDCGK immunization : <#17#%)K 2P $O>&R=7DCNH=$%<")3 Koplik’s spot, neuro signs : &9GK, W Brudzinski-negative, AF   ><"G2 o

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Z6    &. [D*1#*$=    $V #" JF%&'$01N:F>1<#9!= @P 7/ Roseola infantum

[3]

2.

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Paracetamol

 ,B.*#9C$-C9( Diazepam)  ><"G:. 2(*9Z6    &. [D* (No need for isolation)

[1] [1]

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[1]

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GC    2V (G"D$C (19!= 1P C3>D. !"#$JF,B.9#11C9E#Z6    &. [D*1#*$=    :V *"#2>1

3.

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%DEFF 1.

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J2:MK3#*%)T :P ?:ND#<*K$*:P 7.13C 9#13:994"#D (informed consent) (9"3K7#<#17#?:2%789 51$Q=8 I/+R:A 27E:2$7 P B/    <. @<:2:C9%@3 HW 2P %&'$  01N1.#*(12J$%@=*-=DKG>7. 1. (J.23K7#<#17#@2@C*D"#%789JF%&'$%*T : S.#><"1C9E#:*"#21=37"D$(4FS69G.:2 P G1DJ76D#" %&'$%-T    :V :F>1 (4F,B.*#>7.S96 2. 9":$!O9#11C9E# JO%&'$JFG.:2%J#F$V  O>?@C$B4C2%)T :

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!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 11  562$7 '( 6 ) C< 9IE./RSKA%M@-Q0-( &%E-%M%GSIEP%?C%?S 1 T =U&%IE./I%&+7- D1B E7G.7"N(+ RSKA%ME*%90%?DKQ9DE9   3&*@"?@/QG=>.?I
!"#$%&'()*+(,() CRQ -. 6  562$7 @<-#*:#*/ 10 &; <#)3!"#$7.D*&IQB#%&'$BDC73":* %N*)3()!*+ >7.13C 9#1DK$JK RC*D"#%&'$  Allergic rhinitis
%DEFF [4]1.

J23:9SW2:#9#1!= @P ONCQ (Typical symptoms) 4 :#9#1?:2 Allergic rhinitis (4 NF($$)

KEY Itching

1

Sneezing

1

Clear rhinorrhea

1

Nasal blockage

1

J2,B.NO($F$O!= SP 69G.:2(9"Z   &6  . [D*,$9#147/B4=9%4= *P 2@K 2P G"#2 A != %P &'$9":,B.%9K7:#9#1 NF($$) 2.

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& Z6    &. [D*%789BQK2:#*/ 1 &; %&'$  01NBCD,J1C DP -$K7 ventricular septal defect (4F<= chronic heart failure HW 2P -"D2$=    <"N":* B:3%B$T :P * (G"$  V OB$C9?W    $V $.:*  >7.13C 9#11C9E#7.D**# furosemide, lanoxin (4F captopril (ACEI) 1"D<9C3 JO9C7$V  O (4F27:#B#1%N8< PE: T 36.8oC, PR 100/min, RR 30/min, BP 90/60 mmHg, BW 7.5 kg, Ht 70 cm. Heart : Mild active precordium, PMI at 5 th ICS lateral to MCL, normal S 1, S2, pansytolic murmur grade 3/6 at LPSB  Abdomen : liver 1 cm below Rt costal margin Extremities : no edema, fair skin turgor Serum electrolytes : Na 130, K 3.0, Cl 100, CO2 35 mmol/L Urine pH 7.5

%DEFF 1.

[5] [3] [2]

2.

[5] [2] [2] [1]

J23:9ND#?U#DF electrolytes != ZP K7&9GK$   =  V 47?$#7*# furosemide  ,B. potassium supplement  ,B.Z   6  &. [D*7T 

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 14  562$7 %789-#*:#*/ 3 &; Q#GK$OGCD@"2012)*#3#4 %$T :P 2J#97T 

%DEFF 1.

[2]

J2,B.9#1DK$JK RC*,$Z6    &. [D*1#*$=     V Hydrocarbon ingestion

[3]

2.

[5]

3. [2]

!"#$N#7D"#@#1!= %P 78994T$%?.#>&:#J%9K7Z491F!3B1T::C$G1#*G":1F33:DC*DF,7>7.3.#2 '()=< 3 BD)) )1.:<*9GCD:*"#2:#9#1(4F:#9#1(@72!#2N4K$9K != )P 3

S.#!"#$%&'$()!*+%D1!= BP .:2R/9%RK$ (ER) P %GK13.#2'()Q=8!@?F 3 ($8<9 3.1 !"#$JF@"2G1DJ%)K < - Bun, creatinine - Serum electrolytes, Ca, PO4, Mg - Liver profile / AST, ALT - Chest X-ray

[3]

3.2 [1]

!"#$JFD#2(Z$,B.9#176(41C9E#Z6    &. [D*1#*$=    :V *"#2>1 %7. P 0<2 S.#><"<= respiratory problem (4F Chest X-ray &9GK  ,B.94C33.#$ - Observe 6 -C D

 >7. [2]

-

S.#<= respiratory symptoms B1T: Chest X-ray ZK7&9GK  ,B. Admit G+<'() syrup of ipecac, gastric lavage, activated charcoal and cathartics '?1#) 2 %DEFF

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 15  562$7 %789-#*:#*/ 6 &; <#17#)#<#)3()!*+7D. *%1T :P 2&D7!.:2%&'$A B#*A <# 3 %7T:$ &D731K%DX 4K    $V &;    %c &'$)C9A &012%1=*$ %D4#B#*DK 2P %4"$>7.7=  ><":#%J=*$  >&1C9E# Clinic (4F  012 )*#3#4B4#*(B"2><"7?=    $W  V <#17#<=ND#<"%N*%J83&[D*1.#*(12 V  ><"9$K %Z87 - )Cd$#9#1:*6 ," $%9XY+&9GK 9K$:#B#1G12%D4# N13 3 <"N:" *>7. >&012%1=*$ - %1=*$:*6 GC    2V (G"%&a7%!:< :*6 3" .#$<#99D"#012%1=*$ <#17#@C2%9GD"#S.#,B.:*6 3" .#$JF><"<= :#9#1&D7!.:2 (4F><"%N*GT $P &D7!.:2G:$94#2NT$ DC$%@#1+:#!KG*+ ><"%N* 3"$&D7!.:2 PE : T 36.8oC, PR 90/min, RR 24/min, BP 90/60 mmHg, BW 20 kg, Ht 110 cm  Abdomen : soft, not tender, no hepatosplenomegaly

%DEFF 1.

J2@1/&-VWJ
[1]

#

1. School refusal

[2]

#

2. Functional abdominal pain

[3]

[2] [1] [1] [1]

G+<'() Peptic ulcer  IJ+ 1 %DEFF P %GK1%)K < V 276 4C9EXF$K@*C ND#<%&'$:*6 ," $N1:3N1CD 1. 9#1%4=     * 2. 9#1>&012%1=*$ &IQB#!= 0P 12%1=*$ 3. !"#$JF@"2 investigation :F>1 '()=< 1 ($8<9 CBC / UA / stool exam

[4]

4.

!"#$JF<=($D!#2,$9#1(9.&IQB#?:2Z6    &. [D*1#*$=    :V *"#2>1 - :MK3#*:*"#2-C7%J$SW2:#9#1(4F9#17O%$K$?:201N94CD012%1=*$  07*<=%&]#B<#*1"D<9C$ 1FBD"#2Z6    &. 9N1:2 (4FN/XN16D#" '+(9IJ+!1X@Q1+ Q-5B9!B3$F20@;AF  07* . 9N1:2JFG.:2><"(@72!"#!=%&'$9C2D4 B"D2,*%789<#9%9K$>&  ,B.<" ,B.<9= #194"#D4.:%4=*$ B1T:%)"2%482@$,J 2.   B#N/XN16J7  ,$:#9#1?:2%789  ><"@2" %78994C33.#$B1T::$/Q#G,B.B*/7%1=*$ S.#*K 2P ,B.9#1-"D*%B4T:-.# JF!O,B.9#1>&012%1=*$?:2%789*#9<#9?W    $V %)1#F%789JF>7. " 3#*!= 3P .#$ secondary gain J#99#1G#<,J (4F:*6 @

!"#$+,-'.%&'/'. CRQ 01 6 234() * 5/2550 %&'() * 16

 562$7 !"#$%&'$()!*+%D1&1FJO 1)-.(B"2B$W 2P )3%789BQK2:#*/ 3 %7T:$ <#17#GK7%-T    :V  HIV ?XFGC    2V !.:2><" >7.`#9N11U+ ?XF$=    %V 789(?82(127=  ><"%N*%J83&[D*1/$(12 BW 7 kg 9K$$<"

%DEFF 1.

[4]

!"#$JF,B.NO&1W9E#($F$O(9"<#17#:*"#2>1 %1T :P 29#1%4=    *V 276 (4F9#1G1DJ*T$*C$9#1GK7%-T    :V

HIV

($F$O,B.<#G1DJ%&'$1F*F 9#1JF3:9D"#%789GK7%-T    :V B1T:><"G7K %-T    :V 07*,-. K    /  <. 9C$:#JG.:21:SW218 %7T:$ - 9#1G1DJU6
[1]

-

[1] [1] [1]

[1]

%$T :P 2J#9%789><"%N*>7.1C3DCNH=$ !"#$JF($F$O9#1,B.U61 ()(@/F?1*(9;A%Y3F23 4%;BQ1+ IF*NDF3   U) %789&9GK ><"<=:#9#1 @#<#1S,B.DNC H=$G#<&9GK  ,B. BCG

[0.5]

DPT

[0.5]

OPV

[1]

Hepatitis B vaccine

2.

[3]

[3]

[1] [1] [1]

3.

!"#$NK7D"#JO%&'$G.:2&]:29C$01NGK7%-T    :V RD*0:9#@B1T:><" S.#JO%&'$ BD)0/ 4(M $< *F<1 E#D;?K3)B?J
U#NDK-#9/<#1%D-5#@G1+ ?.:@:3 Constructed Response Question (CRQ) $5).&; 6 -/7!=  P 5/2550 ?.:!=  P 17 DC$!=  P ............................... -T :P Z6    @. :3 ................................................

 562$7 !"#$%&'$()!*+%)K 

7.13C &1W9E#J#93K7# <#17#!= 

%&G<= P 2B4C99#1`e9BC7 9#1?C3S"#* (5 NF($$) 1. J2,B.NO($F$O)":(<" %1T :

2.

•

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

J2($F$ODKM9= #1,$9#1`e99#1ND3N/<9#1?C3S"#* (5 NF($$) •

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

•

…………………………………………………………………………………………………………

•

................................................................................................................................................

!"#$%&'()*+(,() CRQ -. 6 *+(23 4 18  562$7 !#19%)5-#*%9K79":$9OB$7 $V  OB$C9(19%9K7 1,580 91C< 1C3>D. ,$B:Z6    &. D[ *!#19(19%9K7 &1FDCGK<#17# : GC    2V N11U+ 32 @C&7#B+ Z4G1DJ%4T:7,$N4K$9K  ANC <= HBsAg positive !"#$JFD#2(Z$9#1,B.U61

!"#$ 6 KN   
'() :

Hepatitis B vaccine

(4

!= :P #*/ 0, 2, 4, 6 %7T:$

1.2 Passive immunization

'() :  1.3

2.

(2

NF($$)

(2

NF($$)

(2

NF($$)

U#*,$ 24 -C DP 0<2B4C2N4:7 (S.#G:3 HBIG %R*A   >7. 1 NF($$) HBIG

9#1$C7G1DJGK7G#<%)T :P 76Z49#1@1.#2U6
9#1,B.U<6 KN   :91$-3#7!F*C9 (4F0&4K 0: :#*/!  $=P C7<#1C3DCNH=$N1C    2V (19 '() : 2 %7T:$

NF($$)

!"#$+,-'.%&'/'. CRQ 01 6 234() * 5/2550 %&'() * 19

 562$7 %789BQK2:#*/ 8 &; GCD%B4T:2G#%B4T:2<# 1 %7T:$ NC$G#
%DEFF [3]

1.

1F3/-  :TP 01N!= %P &'$@#%BG/?:2 jaundice  ,$Z6    &. D[ *1#*$=     V =< 3 5B% - Cholelithiasis (gallstone) - Choledochal cyst - Wilson disease

[7]

2.

!"#$G.:29#1?.:<64%)K 

13.#2J#9&1FDCGK (4F investigations G:3<#01N4F Q=8!@?F 2 NOG:3

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 20  562$7 !"#$%&'$()!*+-7,-.!/$!= 0P 12)*#3#456$*+(B"2B$W 2P <#17#)#3/G1-#*:#*/ 3 &; <#)37.D*:#9#1  >?.%1T    :V 1C2<# 1 %7T:$ 1"D<9C3<=:#9#1&D7G#<(?$?# %3T :P :#B#1 $V  OB$C947 'B;6B8<9@<$: BT 38.5°C, PR 98/min, RR 28/min, BP 135/85 mmHg HEENT :

mild pale, no jaundice

Lymphnode :

impalpable

Heart + Lung : normal  Abdomen:

%&G<=23 4 1

Liver + Speen impalpable

J2,B.9#1DK$JK RC*(*901N<# 4  01N (4 NF($$) 1. Acute leukemia (1 NF($$) 4. Juvenile rheumatoid arthritis (1 NF($$) 2. Neuroblastoma (1 NF($$) 5. lymphoma (0.5 NF($$) 3. Wilms’ tumor (1 NF($$) 6. Connective tissue disease (0.5 NF($$) 7. Langerhancell histiocytosis (0.5 NF($$) %&G<=23 4 2 !"#$JF@"2G1DJ!#2B.:2&LK3GC K9#1,73.#2 %)T :P -"D*,$9#1DK$JK RC* (6 NF($$) 1. CBC (1 NF($$) 2. U/S abdomen (1.5 NF($$) 3. Bone survey (1 NF($$) 4. Bone scan (1.5 NF($$) 5. Bone marrow aspirate / biopsy (1.5 NF($$) 6. Urine VMA (1.5 NF($$) 7. CT abdomen (1 NF($$) 8. LE, FANA, RF (1 NF($$)

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 21  562$7 !"#$%&'$()!*+ ,-.!/$012)*#3#456$*+(B"2B$W 2P <#17#)#3/G1@#D:#*/ 6 &;<#G1DJ Z6    &. [D*  >7.1C39#1DK$JK RC*D"#%&'$ Acute lymphoblastic leukemia %7.13C *#%N<=3O3C7(4F $:$012)*#3#4:*6  " 14 DC$ %)K 2P 94C33.#$>&>7. 5 DC$ Z6    &. [D*<= >?.@26 <# 2 DC$ :":$%)4=* 9K$>7.$:. * &I@@#DF:/JJ#1F&9GK  ><"<=:#9#1ZK7&9GK:  T$P A 'B;6B8<9@<$ : T 39.5 C, PR 110/min, RR 35/min, BP 110/80 mmHg, o

Mild pallor. Other : WNL CBC : Hct 25%, WBC 1,200/cu mm, PMN 15, L 80, M 2, E 2, B 1%, platelets 82,000/cu mm

%DEFF 1.

[3]

!"#$JF@"2G1DJ!#2B.:2&fK3CG9K #1%)K 

13.#2 '()Q=8!@?F 4 ($8<9

[1]

1. Hemoculture

[1]

2. Urine c/s

[0.5]

3. U/A

[0.5]

4. Gram stain 2.

[3] [2]

[1] [4]

[1]

[1] [1] [1] [1] [1]

[0.5] [0.5] [0.5] [0.5]

!"#$JF,B.9#11C9E#:*"#2>1 (S.#<=9#1,-.*#,B.3:9?$#7*# + 9#131KB#1*#7.D*) 1. Ceftazidime 100-150 mg/kg/day

DG*986<'0S 8 P&.+ Amikacin 15 mg/kg/day DG*986<'0S  12 P&.

 ,B.*#47>?. paracetamol,  ,B. IV fluid K CD(9"Z   6  &. [D*1#*$=    :V *"#2>1 2. !"#$JF,B.NO($F$O,$9#1&LK3CGG 6  . 6(4Z6    &. [D*9":$!= JP F,B.Z   &6  . [D*94C33.#$,$N1C    2V 9":$) (S.#!"#$%&'$()!*+Z   7 P 2U#DF!= %P @= *P 2G":9#1GK7%-T    :V %-"$  ><"%?.#,94.N$&[D* 1. B4=9%4= *  ><":*6 ," $!= 

?.G.:21=3>&)3()!*+!$ P 2G":9#1<=%4T:7::92"#* ND1JO9C79KJ911
)C9Z":$,B.%)=*2): . 2Z69 %)1#F:#J%9K7`;!  =9P $. 8.   ><"ND1,B.!: C  V %@<: &]:29C$9#1%9#(4.D%9K73#7(Z4 9. ND1GC7%483,B.@    $ K %-T    :V >7. 10. ND11C9E#@/?U#) (4F\I$,B.7= %)1#F:#J%&'$(B4"2,B.G7 7.

!"#$%&'()*+(,() CRQ -. 6 *+(23 4 22  562$7 !"#$%&'$()!*+%)K 

<"< =>?. (4F<=:#9#1B#*,J7C2N1T7N1#7 <#G4:7 1 %7T:$%-"$9C$ Z6    &. [D*%&'$3/G1N$(19 N4:7&9GKN139OB$7 $V  O B$C9(19%9K7 3,000 91C< 9K$$<(<":*"#2%7=*D<# 3 %7T:$ ):%7T:$!=  P 4 G.:2%&4= *P $<#,B.$&!O2#$ 9":$B$.#$=    %V 789@3#*7=<#G4:7 'B;6B8<9@<$ : Active boy, BW 5 kg, length 60 cm. Mild pallor, no jaundice, no fever, eczematoid dermatitis of faces and extremities, secretion sound on chest examination Others : within normal limit.

%DEFF K RC*(*901N=< 2 5B% [4] 1. J2,B.9#1DK$J [2]

1. Cow milk allergy

[2]

2. Infectious diarrhea

[1]

3. Malabsorption syndrome

[1]

!"#$JF@"2G1DJ!#2B.:2&LK3GC K9#1:F>1!= JP F,-.@$C3@$/$9#1DK$JK RC*01N )(@=< 2 ($8<9 1. Skin test / RAST test G": cow milk

[1]

2. Stool culture

[0.5]

3. Stool examination

[0.5]

4. Stool occult blood

[0.5]

5. Stool clinitest

2.

[2]

3.

[4] [2]

J2,B.9#176(41C9E#Z6    &. [D*1#*$=     V 3.1 Specific treatment

[1/1] [1]

[2]

 ,B.B*/7$
3.2 Patient education

B4=9%4= *P 2:#B#1!= (P ).2#" *,$1F*F?D3&;(19 ( >?", SC DP , :#B#1!F%4) V %7. [0.5/0.5/0.5] - 3:9<#17#D"#%789%&'$01N().$
-

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 23  562$7 !"#$%&'$()!*+ ,-.!/$ ::9G1DJ!=  P OPD 1).!C DP >& %789BQK2:#*/ 13 &; <=:#9#1&D7?.:%?"# (4F?.:%!.#H.#* 1"D<9C3<= >?.%&'$A B#*A <# 1 %7T:$ %D4#S69(77JF<=Z  T$P (7231K%DX(9.
Moderate pallor, no jaundice, bilateral multiple cervical lymph nodes, diameter 1 cm. Heart and lungs : normal  Abdomen : Liver 3 cm below right costal margin Extremities : mild swelling and tenderness at left knee and ankle joints CBC : Hb 8 g/dL, Hct 24%, WBC 2,000/cu mm, (N 80, L20%), platelets 120,000/cu mm, RBC morphology : anisocytosis 2+, poikilocytosis 2+, hypochromia 1+ Direct Coomb’s test : positive UA : sp gr 1.020, protein and blood – negative, WBC 0-1/HPF, RBC 0-1/HPF ANA titer: 1 : 360

%DEFF 1.

[2]

!"#$NK7D"#Z6    &. [D*%&'$01N:F>1<#9!= @P 7/ SLE

2.

[8]

J2,B.NO($F$O%9= *P D9C301N!= ZP    6  &. [D*%&'$ (4F,B.NO($F$O,$9#1&LK3CGKGDC %9= *P D9C3@/?U#)?:2Z6     .

&[D* [4] [2]

%&EFDF&!@3 4$;@A)5B% : P =9#1:C9%@3?:2:DC*DF>7.B4#*1F33 %-"$ 1F33ZKDB$C2 ?.:(4F94.#<%$T    :V 1F33 1. %&'$01N!= <

%4T:7 [2] [4]

[2] [1]

[1]

%-T    :V

(4F1F33G":<$V  O%B4T:2 %&'$G.$ V , )C$M/911<, g:1+ 0<$%)5BQK2 (4F(@2(77 2. %9K7J#9B4#*&IJJC*1"D<9C$   >7.(9" 9#1GK7%-T     : %&EFDF&IF@
BA)-BD2<"ND1B*/7*#%:2 (4F<#G1DJG#<$C7 V (?$*#D 9#2%92?#*#D !#N1=<9C$(77 2. J#3@!#3 4$9E,9E11  07*@D<"ND1:*6 ," $!= -P
1.

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 24  562$7 !"#$%&'$()!*+%)K 

& <=<#17#$O%789BQK2:#*/ 5 &; <#1C39#1 G1DJ%$T :P 2J#9<=:#9#1G#%B4" (4FB$C2G#G9%&'$A B#*A <#$#$ 3 @C&7#B+  ><"< =>?. 1C3&1F!#$:#B#1>7. G#<&9GK  ><"<:= #9#1@O4C9 9":$B$.#$=    &V 9GK(?82(127=  ><" >7.13C 9#11C9E#,7A <#9":$ 'B;6B8<9@<$ : T 37 C, HR 90/min, RR 24/min, BP 90/60 mmHg, o

BW 20 kg, Ht 100 cm. Good consciousness, not in distress, not pale, no jaundice Cranial nerves : pupils 4 mm, reactive to light bilaterally, mild ptosis right eye, complete ptosis left eye, totally ophthalomoplegia bilaterally, no facial weakness, decreased gag reflex, tongue in midline, no fasciculation Motor : normal gait and tone, power 5/5 all Sensory : grossly intact DTR : 2 + all; Babinski : absent

!"#$$

1.

[4]

!"#$NK7D"#:#9#1?:2Z6    &. [D*1#*$=    %V 9K7J#901N:F>1!= %P &'$>&>7.<#9!= @P /7 Myasthenia gravis

2.

[4]

!"#$JF!O9#1G1DJ!#2B.:2&LK3CGK9#1,7!= JP O%&'$,$9#1,B.9#1DK$JK RC*01N '()=< 2 ($8<9

[2]

1. Chest X-ray

[2]

2. Thyroid function tests

[2]

3. Edorphonium hydrochloride test / neostigmine test

G+<'() ESR  IJ+ 1 %DEFF 3.

[2] [1] [1]

!"#$JF,B.9#11C9E#Z6    &. [D*1#*$=    :V *"#2>1 )(@!":<"G:. 23:9?$#7 1. Pyridostigmine ( Mestinon 2. Prednisolone

! )

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 25  562$7 %789BQK2:#*/ 6%7T:$ <= >?.  >: B:3<# 3DC$  ><"%N*B:3<#9":$  ><"< =,N1,$N1:3N1CD%&'$B:3BT7 'B;6B8<9@<$ : T 38 C, RR 50 /min, PR 120 /min, mild dehydration, mild cyanosis o

(oxygen saturation at room air = 89%), Lungs: expiratory wheezing both sides, no crepitation. Heart : no murmur, others: unremarkable CXR : hyperaeration, no pulmonary infiltration CBC : Hct 35 %, WBC 12,000/cu mm, PMN 50, L 50 %, platelets 120,000/cu mm

%DEFF 1.

[4]

J21F3/ 01N!= $P #" JF%&'$<#9!= @P 7/ =< 2 5B%

[2]

1. Asthma

[2]

2. Acute bronchiolitis

[2]

3. Wheezing associated respiratory illness ( WARI)

[2]

4. Hyper reactive airway disease

[2]

2.

[4]

3.

[1]

$:9J#99#1@"2G1DJ!#2B.:2&LK3CGK9#1(4.D !"#$JF!O:*"#2>1G":!=  P ER %)T :P %&'$9#1DK$JK RC* (*901N,$?.:!= 1P  IJ+'()=
[0.5]

with humidity

[1]

2. Hydration

[0.5]

3. Antipyretic drug

[1]

4.

)"$ bronchodilator (ventolin)  ><"JO%&'$G.:2,B. antibiotic

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 26  562$7 !"#$%&'$()!*+%)K 

<"<= :#9#1:#%J=*$ B1T:G#)1"#
BW 28 kg, Ht 130 cm

G1DJ1F33G"#2A :*6 ," $%9XY+&9GK

%DEFF 1.

[4]

!"#$NK7D"#Z6    &. [D*%&'$01N:F>1>7.3.#2 (Differential diagnosis) )(@=< 4 5B%

[1]

1. Renal scar / chronic pyelonephritis

[1]

2. Glomerulonephritis

[1]

3. KUB anomaly / renal hypoplasia / UPJ obstruction / cystic kidney disease

[1]

4. Renal artery stenosis

[1]

5. Coarctation of aorta

[1]

6. Pheochromocytoma / adrenal tumor

[1]

7. Hyperthyroidism

[1]

8. Increase intracranial pressure

2.

[6]

[4] [1] [1] [1] [1]

!"#$JF'B;6B8<9@<$%)K 

13.#2%)T :P 9#1DK$JK RC*01N (4F%)T :P &1F%G (4F1F33!#2%7K$&I@@#DF(4F:DC*DF,$-":2!.:2 4. Doppler ultrasound 76 renal artery stenosis

[1]

5. Serum electrolytes / BUN & creatinine

[1]

6. Urine VMA

[1]

7. DMSA scan

[1]

8. TFT

[1]

9.

[2]

2.2

G1DJ eyeground, film skull

!:M 4(-BD!=?FL<;DE2B@Y+(F ('() 2 ($8<9)

[1]

1. Chest film - PA

[1]

2. EKG

[1]

3. Bun, Cr 

G+<'() Fundoscopic exam / 76 eye ground IJ+ bonus +1

!"#$%&'()*+(,() CRQ -. 6 /0123 4 5/2550 *+(23 4 27  562$7 !"#$%&'$()!*+ ,-.!/$&1FJO012)*#3#456$*+ Z6    &. [D*%789-#*:#*/ 6 &; <#G1DJ9C3!"#$%$T :P 2J#9 B#*,J(12<# 1 @C&7#B+ Z6    &. [D*%&'$&9GK7=%?.3":* 9K$*#&LK-=D$F *#(9. >?. %&'$&1FJO 1D<"N:" *0G%<" 0G G1DJ1"#29#*:*"#2:T $P ><")3ZK7&9GK CBC : Hb 6 g/dL, Hct 18%, WBC 7,800/cu mm (PMN 70, L 30%), platelets 182,000/cu mm; normochromic, normocytic RBC UA :

pH 6, sp gr 1.010, WBC 3-5/HPF, RBC 3-5/HPF, coarse granular casts 3-4 /LPF, and broad granular casts 2-3/LPF.

Serum electrotytes : Na+ 128, K+ 5.7, Cl- 87, CO2 10 mmol/L BUN / Cr = 60/5 mg/dL 1.

[4]

J2,B.9#1DK$JK RC*01N )1.:
[1]

Chronic renal failure (CRF)

[3]

!J'0># 1.  ><" 0G, H=7, 3D< (4F%N*<= >?.%&'$A B#*A 2. UA : sp gr 1010, broad granular cast 3. BUN & creatinine 2.

[3] [1]

[1] [1]

@62, hyperkalemia, metabolic acidosis

J2(@72DKMN= O$DX anion gap 1DP 7. (4F:MK3#*@#%BG/ @# : high anion gap ,G><"

 >7. [3]

3.

:MK3#*(4F($F$O<#17#%9= *P D9C301N (4F($D!#2,$9#176(41C9E#Z6    &. [D*1#*$=     V . [D*%&'$01N>GD#*%1T    :V 1C2 / 1F*F@/7!.#* @#%BG/:#JJF%9K7J#99#1GK7%-T    :V %1T    :V 1C2!= >P G B1T: 1. Z6    & J#99#1!#$*#&LK-D= $F3":*A V @CGD+(4F>?&G1DJG#<()!*+$7 V ()!*+:#J)KJ#1X#4.#2>G (4F / B1T:%&4= *P $>G,B. ,B<" 6. S.#:#9#1<#9?W     $

!"#$%&'()*+(,() CRQ -. 6 *+(23 4 28  562$7 <#17#)#!#19:#*/ 6 DC$ <#)3!"#$7.D*%1T :P 2%B4T:2, $V  OB$C9(19%9K7 3,200 91C< !"#$G1DJ 1"#29#*)3 Moderate jaundice , not pale, active no cephal hematoma BW = 3,150 91C< &1FDCGK<#17#91/     & h %4T:7 AB, !#199K$$<(<":*"#2%7=*D S"#*:/JJ#1F@=%B4T:2DC$4F 4-5 N1C    2V Z49#1G1DJ!#2B.:2&LK3CGK9#1 MB = 17 CBC : Hct = 40

WBC 15,800

PMN = 35%

plt = 150,000 Normochromic, no hemolytic

Reticount = 2.5%, Inclusion body = negative, Heinz body = negative G6PD = normal, blood group AB, coomb’s test negative

%DEFF [4]

1. [4]

[6]

J2,B.9#1DK$JK RC*@#%BG/?:2%B4T:2,$Z6    &. D[ *1#*$=     V - Breast milk jaundice

2.

J2,B.9#176(41C9E#(4F,B.NO($F$O(9"<#17#

[2]

- Reassure

[2]

-

[2]

-

 ,B.9$K $<(<"G":>7. $C7 Follow up :#9#1%B4T:2

!"#$%&'()*+(,() CRQ -. 6 *+(23 4 29  562$7 !#19(19%9K7:#*/N11U+ 40 @C&7#B+ $V  OB$C9(19%9K7 = 3000 91C< - Apgar score 7, 10, N4:7 normal labor Z49#1`#9N11U+&9GK G1DJ1"#29#* Vital sign : HR = 160/min, RR = 60/min, BP = 55/35 (42), ((19%9K7) not distress -

Moderate pale, no jaundice heart no murmur lung : clear  Abdomen : soft, normal contour liver 1 cm

" RCM

spleen impalpable no evidence of bleeding

(191C3 : Hct = 38%, DTX = 60%

%DEFF [2]

1.

J23:9 Problem list  ,$Z6    &. [D*1#*$=     V

 Anemia

[5]

2.

J23:99#1G1DJ!#2B.:2&LK3GC K9#1%)T :P B#@#%BG/ - anemic work up

[1 ]

- CBC blood smear

[0.5]

- blood group

[0.5]

- coomb test

[0.5]

- G-6PD level

[0.5]

- Reticylocyte count

[0.5]

- Inclusion body

[0.5]

- Heinz body

[1]

- acid elusion test (Fetal cell)

3.

[3]

J23:99#176(41C9E#%3T    :V 2G.$

[1]

- observe sign of bleeding, vital sign

[1]

-

[1]

-

S.# Hct drop 42 B1T: vital sign change )KJ#1X#,B.%4T:7 %G1=*<%4T:7 (PRC) B1T: Fresh whole blood  >D.

0

BT = 37.0 C