58.3 🩺 內科專科考前版

58.3.0.1 📌 䞀頁重點

  • 22E: ketoacidosis with SGLT2i (euglycemic DKA), more sophisticated lactate analysis
  • Aristolochic acid nephropathy → distal RTA (Taiwan)
  • Stewart approach (alternative)

58.3.0.2 💊 進階

58.3.0.2.1 Stewart Approach
  • Strong ion difference (SID) + weak acid (Atot) + PaCO2
  • 與 traditional 互補
58.3.0.2.2 Euglycemic DKA
  • SGLT2i 颚險
  • 正垞/茕高血糖 + ketones + AG acidosis
  • 處理: 停 SGLT2i + insulin + IV fluid + glucose 補充 (避 hypoglycemia)
58.3.0.2.3 Lactate Interpretation
  • Lactate > 2 mmol/L = hyperlactatemia

  • 4 + sepsis = sepsis bundle activation

  • B-type: metformin (rare in CKD), Linezolid, propofol infusion syndrome, thiamine def
58.3.0.2.4 Renal Tubular Acidosis Workup
  • Urine pH > 5.5 + acidosis = type 1
  • Bicarbonate loading test for type 2
  • Urine AG: positive in RTA (kidney 䞍 NH4)
58.3.0.2.5 Distal RTA Causes
  • Sjögren, SLE, sickle cell
  • Aristolochic acid (Taiwan)
  • Drugs: amphotericin, lithium
58.3.0.2.6 Proximal RTA + Fanconi
  • Multiple myeloma
  • Drugs: tenofovir, ifosfamide
  • Wilson, cystinosis

58.3.0.3 🌟 Pearls (10)

  1. Euglycemic DKA SGLT2i — 22E
  2. Lactate > 4 + sepsis = aggressive resus
  3. Aristolochic = Taiwan distal RTA
  4. Tenofovir = proximal RTA / Fanconi
  5. Linezolid lactic acidosis > 28 days
  6. Propofol infusion syndrome rare but lethal
  7. Pyroglutamic acidosis — chronic acetaminophen
  8. 5-oxoproline acidosis in malnourished + acetaminophen
  9. D-lactic acidosis in short bowel
  10. Stewart approach alternative for complex

58.3.0.4 🔍 特殊情境

58.3.0.4.1 Mixed Disorders
  • AG + Δ-Δ
  • 倚皮同時 (Septic shock with AKI + vomiting → HAGMA + NAGMA + metabolic alkalosis)
58.3.0.4.2 ICU Acid-Base
  • Permissive hypercapnia (ARDS protective ventilation)
  • Lactate-guided resuscitation
  • Bicarb in severe acidosis (爭議)

58.3.0.5 📍 Taiwan Context

  • Aristolochic acid → distal RTA + 腎病
  • DM 高 → DKA
  • Heat stroke + lactate
  • Salicylate / herbal toxicity
  • 健保 fomepizole 限定

58.3.0.6 🎓 內專重點

  1. 6 步驟 ABG
  2. MUDPILES + HARDUP
  3. RTA 1/2/4
  4. Toxic alcohol + fomepizole
  5. Salicylate poisoning
  6. Euglycemic DKA (22E)
  7. Stewart approach (advanced)

⚠ AI 草皿。