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·π«∑“߇«™ªØ‘∫—µ‘„π‚§√ß°“√À≈—°ª√–°—π ÿ¢¿“æ∂â«πÀπâ“ ‡√◊ËÕß ‰¢â‡©’¬∫æ≈—π„π‡¥Á°‡≈Á° Àπâ“ 2 2 4 4 5 6 6 8 8 8 9 11 11 12 13 14 17 18 7 15 16

§”𑬓¡ °“√«—¥Õÿ≥À¿Ÿ¡‘ “‡Àµÿ ·π«∑“ß°“√«‘π‘®©—¬ ·π«∑“ß°“√√—°…“ °“√¥Ÿ·≈√—°…“∑—Ë«‰ª °“√„À⬓≈¥‰¢â °“√√—°…“Õ◊πË Ê - °“√„Àâ “√πÈ”∑¥·∑π - °“√ªÑÕß°—π·≈–√—°…“°“√™—°®“°‰¢â ‡¥Á°Õ“¬ÿ 0<3 ‡¥◊Õ𠇥Á°Õ“¬ÿ 3 ‡¥◊Õπ - 3 ªï °“√ª√–‡¡‘𧫓¡√ÿπ·√ß °“√µ‘¥‡™◊ÈÕ·Õ∫·Ωß (Occult infection) °“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ °“√√—°…“ ‡Õ° “√Õâ“ßÕ‘ß √“¬™◊ËÕ§≥–∑”ß“π µ“√“ß∑’Ë 1 ¢π“¥¬“ acetaminophen ∑’Ë„™â„π‡¥Á° ·ºπ¿Ÿ¡‘∑’Ë 1 ·π«∑“ß°“√¥Ÿ·≈√—°…“‰¢â‡©’¬∫æ≈—π„π‡¥Á°Õ“¬ÿ 0<3 ‡¥◊Õπ ·ºπ¿Ÿ¡‘∑’Ë 2 ·π«∑“ß°“√¥Ÿ·≈√—°…“‰¢â‡©’¬∫æ≈—π„π‡¥Á°Õ“¬ÿ 3 ‡¥◊Õπ - 3 ªï

·π«∑“߇«™ªØ‘∫—µ‘ „π‚§√ß°“√À≈—°ª√–°—π ÿ¢¿“æ∂â«πÀπâ“

√À— ‡Õ° “√ π«ª. 09-016-01

«—π/‡¥◊Õπ/ªï 01/06/2545

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·π«∑“߇«™ªØ‘∫µ— π‘ ’È ‡ªìπ‡§√◊ÕË ß¡◊Õ à߇ √‘¡§ÿ≥¿“æ¢Õß°“√∫√‘°“√¥â“π ÿ¢¿“æ∑’‡Ë À¡“– ¡°—∫ ∑√—欓°√·≈–‡ß◊ËÕπ‰¢ —ߧ¡‰∑¬ ‚¥¬À«—ߺ≈„π°“√ √â“߇ √‘¡·≈–·°â‰¢ªí≠À“ ÿ¢¿“æ¢Õߧπ‰∑¬ Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ·≈–§ÿ¡â §à“ ¢âÕ·π–π”µà“ßÊ „π·π«∑“߇«™ªØ‘∫µ— π‘ ‰’È ¡à„™à¢Õâ ∫—ߧ—∫¢Õß°“√ªØ‘∫µ— ‘ ºŸ„â ™â  “¡“√∂ªØ‘∫µ— ·‘ µ°µà“߉ª®“°¢âÕ·π–π”π’‰È ¥â „π°√≥’∑ ’Ë ∂“π°“√≥å·µ°µà“ßÕÕ°‰ª À√◊Õ¡’‡Àµÿº≈∑’ Ë ¡§«√ ‚¥¬„™â«‘®“√≥≠“≥∑’ˇªìπ∑’ˬա√—∫„π —ߧ¡ §”𑬓¡ Õÿ≥À¿Ÿ¡‘√à“ß°“¬¡“µ√∞“π : Õÿ≥À¿Ÿ¡‘∑’Ë«—¥∑“ߪ“° ‰¢â : Õÿ≥À¿Ÿ¡‘√à“ß°“¬ «—¥∑“ߪ“° Ÿß°«à“ 37.0 Ì´ Õÿ≥À¿Ÿ¡‘ ∑“ߪ“° ∑“ß°âπ o ‰¢âµË” 37.5 - 38.4 ´ 38.0 - 38.9 o ´ 39.0 - 39.9 o ´ ‰¢âª“π°≈“ß 38.5 - 39.4 o ´ ‰¢â Ÿß > 39.5 o ´ > 40 o ´

∑“ß√—°·√â 37.0 - 37.9 o ´ 38.0 - 38.9 o ´ > 39 o ´

‰¢â‡©’¬∫æ≈—π : ‰¢â ‰¡à‡°‘π 7 «—π Õÿ≥À¿Ÿ¡‘∑“ß∑«“√Àπ—° : Ÿß°«à“∑“ߪ“° 0.5 o ´  Ÿß°«à“∑“ߺ‘«Àπ—ßÀ√◊Õ√—°·√â 1 o ´ ∑“√° : ‡¥Á°Õ“¬ÿ < 12 ‡¥◊Õπ ∑“√°··√°‡°‘¥ : ‡¥Á° Õ“¬ÿ < 30 «—π ¿“«–‰¢â‡©’¬∫æ≈—π„π‡¥Á°‡≈Á° : „π∑’πË À’È ¡“¬∂÷ß ¿“«–‰¢â„π‡¥Á°Õ“¬ÿ‰¡à‡°‘π 3 ªï ∑’‡Ë °‘¥¢÷πÈ ¡“‰¡à‡°‘π 7 «—π ·≈– ‰¡à¡’Õ“°“√·≈–Õ“°“√· ¥ß∑’Ë∫Õ°∂÷ßµ”·Àπàßµ‘¥‡™◊ÈÕ À√◊Õ “‡Àµÿ¢Õ߉¢â ∑’™Ë ¥— ‡®π

°“√«—¥Õÿ≥À¿Ÿ¡‘√à“ß°“¬ «‘∏’∑’Ë¥’∑’Ë ÿ¥ ”À√—∫∑“√° §◊Õ °“√«—¥∑“ß∑«“√Àπ—° ¥â«¬‡∑Õ√å‚¡¡‘‡µÕ√å™π‘¥·°â«∫√√®ÿª√Õ∑ À√◊Õ™π‘¥· ¥ßµ—«‡≈¢ (digital) ‘ “ßÀŸ¥«â ¬‡§√◊ÕË ß«—¥Õÿ≥À¿Ÿ¡‡‘ ¬◊ÕË ·°â«ÀŸ (tympanic thermometer) ∂â“„™â ∂Ÿ°µâÕßµ“¡ ● °“√«—¥Õÿ≥À¿Ÿ¡∑ ∑’Ë√–∫ÿ‚¥¬∫√‘…—∑ºŸâº≈‘µ®–√«¥‡√Á« ‡™◊ËÕ∂◊Õ‰¥â ·≈– –¥«° ·µà∂â“„™âº‘¥‡∑§π‘§ ‡™à𠇥Á°¡’¢’ÈÀŸ¡“° ®–‰¥â§à“∑’˺‘¥ ‡™◊ËÕ∂◊Õ‰¡à‰¥â √«¡∑—Èß¡’√“§“·æß ®÷߉¡à·π–π”„Àâ„™â ● §«“¡ Ÿß¢Õ߉¢â„π∑“√° ‰¡à∫Õ°§«“¡√ÿπ·√ߢÕß‚√§∑’ˇªì𠓇Àµÿ¢Õ߉¢â „π∑”πÕß°≈—∫°—π ∑“√°∑’Ë¡’Õÿ≥À¿Ÿ¡‘√à“ß°“¬µË”°«à“ª°µ‘ (<36 o ´ ) Õ“®¡’°“√µ‘¥‡™◊ÈÕ∑’Ë√ÿπ·√߉¥â  “‡Àµÿ ‡¥Á°∑’Ë¡’‰¢â ‚¥¬‰¡à¡’Õ“°“√º‘¥ª°µ‘Õ◊Ëπ ●  “‡Àµÿ à«π„À≠à‡ªìπ°“√µ‘¥‡™◊ÈÕ‰«√— ´÷ËßÀ“¬‡Õ߉¥â ●  à«ππâÕ¬‡°‘¥®“° - °“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥·Õ∫·Ωß (occult bacteremia) ´÷ËßÀ“°‰¡à‰¥â√—∫ °“√√—°…“Õ“®¥”‡π‘πµàÕ‰ª‡ªìπ°“√µ‘¥‡™◊ÈÕ∑’ËÕ«—¬«– ”§—≠ ‡™àπ meningitis ‰¥â - °“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬∑’Ë∑“߇¥‘πªí  “«– - ‡¬◊ËÕ·°â«ÀŸÕ—°‡ ∫ ●

·π«∑“߇«™ªØ‘∫—µ‘ „π‚§√ß°“√À≈—°ª√–°—π ÿ¢¿“æ∂â«πÀπâ“

√À— ‡Õ° “√ π«ª. 09-016-01

«—π/‡¥◊Õπ/ªï 01/06/2545

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·π«∑“ß°“√«‘π‘®©—¬ ‡¥Á°µâÕ߉¥â√—∫°“√ª√–‡¡‘π®“°·æ∑¬å‚¥¬≈–‡Õ’¬¥√Õ∫§Õ∫ ‡¡◊ËÕ - ∑“√°∑’Ë¡’‰¢â > 38.5 o ´ - ‡¥Á°∑’Ë¡’‰¢â √à«¡°—∫ Àπâ“·¥ß µ—«·¥ß ‡Àß◊ËÕÕÕ° ´÷¡ °√– —∫°√– à“¬ À“¬„®‡√Á« ™—° √âÕ߉À≡àÀ¬ÿ¥ ‡∫◊ËÕÕ“À“√  “‡Àµÿ : ● °“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬À√◊Õ‰«√—  ‡ªì𠓇Àµÿ∑’Ë∫àÕ¬∑’Ë ÿ¥ ●  “‡ÀµÿÕ◊Ëπ Ê ∑’Ëæ∫‰¥âπâÕ¬ ‰¥â·°à - °“√‰¥â√—∫ “√æ‘…À√◊Õ¬“∫“ß°≈ÿà¡ ‰¥â·°à phenothiazine ·≈– anticholinergic - Õ“°“√‰¢â®“°§«“¡√âÕ𠇙àπ Õ¬Ÿà„π∑’Ë¡’Õÿ≥À¿Ÿ¡‘√âÕπ®—¥ À√◊Õ «¡‡ ◊ÈÕºâ“À𓇰‘π‰ª - °“√∑’Ë√–∫∫ª√– “∑ à«π°≈“߉¥â√—∫°“√°√–∑∫°√–‡∑◊ÕπÀ√◊Õ¡’欓∏‘ ¿“æ ¢âÕ¡Ÿ≈∑’˙૬„π°“√«‘π‘®©—¬ ‰¥â·°à 1. ‡«≈“∑’ˇ√‘Ë¡¡’‰¢â 2. ≈—°…≥–¢Õ߉¢â 3. Õ“°“√·≈–Õ“°“√· ¥ßÕ◊Ëπ Ê ∑’Ë¡’√à«¡¥â«¬ ‡™àπ ‰Õ πÈ”¡Ÿ° µ“·©– Õ“‡®’¬π ∑âÕ߇ ’¬ °“√¥÷ß„∫ÀŸ (Õ“®· ¥ß∂÷ßÀŸ™—Èπ°≈“ßÕ—°‡ ∫ ) 4. ª√–«—µ‘°“√§≈Õ¥ ª√–«—µ‘ ÿ¢¿“æ √«¡∂÷ß∫—π∑÷°°“√„Àâ«—§´’π 5. ª√–«—µ‘‡°’ˬ«°—∫ ¿“æ·«¥≈âÕ¡„π∫â“π °“√‡≈’ȬߥŸ ·≈–°“√„ÀâÕ“À“√ °“√ —¡º— ‚√§µ‘¥‡™◊ÈÕ 6. °“√µ√«®√à“ß°“¬‚¥¬≈–‡Õ’¬¥ ¥Ÿ ’¢Õߺ‘«Àπ—ß  —߇°µ≈—°…≥–°“√À“¬„®·≈–√–¥—∫§«“¡√Ÿâ µ‘ §≈”™’æ®√ ¥Ÿ capillary refill ¥Ÿ§«“¡µ÷ߢÕߺ‘«Àπ—ß (skin turgor ) 7. °“√µ√«®ÀŸ ‡æ◊ËÕ¥Ÿ«à“¡’ÀŸ™—Èπ°≈“ßÕ—°‡ ∫À√◊Õ‰¡à °“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ Õ“®®”‡ªìπµâÕßµ√«®∑“ßÀâÕߪؑ∫µ— °‘ “√ À“°°“√µ√«®√à“ß°“¬¬—߉¡à “¡“√∂«‘π®‘ ©—¬ “‡Àµÿ¢Õß ‰¢â‰¥â ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π‡¥Á°∑“√°∑’Ë¡’‰¢âª“π°≈“ß·≈–‰¢â Ÿß∑’˵√«®À“µ”·Àπàßµ‘¥‡™◊ÈÕ‰¡àæ∫

·π«∑“ß°“√√—°…“ ‡¥Á°‡≈Á°∑’Ë¡’‰¢â§«√‰¥â√—∫°“√µ√«®«‘π‘®©—¬·≈–¥Ÿ·≈√—°…“‚¥¬‡√Á« ‡æ√“–¿“«–‰¢â‡ÕßÕ“®¡’º≈‡ ’¬ µàÕ‡¥Á°‰¥â 1. °“√¥Ÿ·≈√—°…“∑—Ë«‰ª ¢—Èπ·√°§◊Õ°“√∑”„Àâ∑“√°√Ÿâ ÷° ∫“¬µ—«¢÷Èπ È ÕÕ°∫â“ß ∂Ⓡ¥Á°∑’„Ë  à‡ ◊ÕÈ ºâ“À𓇰‘π‰ª ‡æ◊ÕË „À⺫‘ Àπ—ß√–∫“¬§«“¡√âÕπÕÕ°®“° ● §«√∂Õ¥‡ ◊Õ √à“ß°“¬ °“√‡™Á¥µ—«‡ªìπ«‘∏’∑’Ë∑”„À≢â≈¥≈ßÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ - ‡™Á¥µ—«¥â«¬πÈ”∏√√¡¥“ ‰¡à§«√‡™Á¥µ—«¥â«¬πÈ”‡¬Áπ À√◊Õ·Õ≈°ÕŒÕ≈å - ‡™Á¥¥â«¬ºâ“™ÿ∫πÈ”„Àâ∑—Ë«∑—Èßµ—« ‚¥¬‡©æ“–∫√‘‡«≥¢âÕæ—∫ ‰¥â·°à §Õ √—°·√â ¢“Àπ’∫ ´÷Ëß¡’‡ âπ‡≈◊Õ¥„À≠àºà“π ∑”„Àâ√–∫“¬§«“¡√âÕπ‰¥â¥’ - ‡Õ“ºâ“™ÿ∫πÈ”„À¡à ‡¡◊ËպⓥŸ¥´—∫§«“¡√âÕπ®“°√à“ß°“¬®πºâ“‡ªï¬°π—Èπ√âÕπ 2. °“√„À⬓≈¥‰¢â (µ“√“ß∑’Ë1) ●

·π«∑“߇«™ªØ‘∫—µ‘ „π‚§√ß°“√À≈—°ª√–°—π ÿ¢¿“æ∂â«πÀπâ“

√À— ‡Õ° “√ π«ª. 09-016-01

«—π/‡¥◊Õπ/ªï 01/06/2545

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∂â“¡’‰¢âµË” Õ“®‰¡àµâÕß„À⬓≈¥‰¢â â ‰¢â ߟ ‡°‘π 39.5 o ´ §«√„À⬓≈¥‰¢â„π∑ÿ°Õ“¬ÿ §«√´—°ª√–«—µ°‘ “√°‘π¬“≈¥‰¢â¡“°àÕπ ● ·µà∂“ ‡æ◊ËÕªÑÕß°—π°“√„Àâ´È”·≈–¬“‡°‘π¢π“¥ ● ¬“∑’˧«√„™â≈¥‰¢â§◊Õ acetaminophen ● ¬“≈¥‰¢â∑’Ë¡’°“√„™â ‰¥â·°à 2.1. Acetaminophen - ‡ªìπ¬“≈¥‰¢â∑‡’Ë À¡“– ¡∑’ Ë ¥ÿ „Àâ„π¢π“¥ 10-15 ¡°./°°. „Àâ´È”‰¥âÀ≈—ß 4-6 ™¡. ‰¡à‡°‘π 5 §√—Èß„π 24 ™¡. - ¬“π’ȉ¡à§àÕ¬¡’º≈¢â“߇§’¬ß‡¡◊ËÕ„Àâ„π¢π“¥ª°µ‘ - º≈¢â“߇§’¬ß ”§—≠ §◊Õæ‘…µàÕµ—∫ ´÷ßË ®–‡°‘¥¢÷πÈ ‡¡◊ÕË „™â¬“¡“°‡°‘π‰ª®π√–¥—∫¬“ Ÿ ß ∂÷ß√–¥—∫∑’‡Ë ªìπæ‘… À√◊Õ‡¡◊ÕË „Àâæ√âÕ¡°—∫¬“Õ◊πË Ê ∑’¡Ë æ’ …‘ µàÕµ—∫ ‡™àπ barbiturates, carbamazepine, INH, rifampin, sulfapyrazone. 2.2. Aspirin - ¡’ƒ∑∏‘Ï≈¥‰¢âÕ¬à“ß¡’ª√– ‘∑∏‘¿“懙àπ‡¥’¬«°—∫ acetaminophen ·µà‰¡à§«√„™â‡ªì𠬓≈¥‰¢â ‡æ√“–¡’¢âÕ‡ ’¬À≈“¬Õ¬à“ß - ¡’§«“¡ —¡æ—π∏å°—∫°“√‡°‘¥ Reyeûs syndrome ‡¡◊ËÕ„ÀⷰຟâªÉ«¬∑’Ë¡’°“√µ‘¥‡™◊ÈÕ ‰«√— ‚¥¬‡©æ“–Õ¬à“߬‘ËßÕ’ ÿ°Õ’„  - ∑”„Àâ gastritis ·≈–≈¥ platelet adhesion ∑”„Àâ‡≈◊Õ¥À¬ÿ¥¬“° ‚¥¬‡©æ“–‡¡◊ËÕ ‡ªìπ‰¢â‡≈◊Õ¥ÕÕ° ●

µ“√“ß∑’Ë 1 ¢π“¥¬“ acetaminophen ∑’Ë„™â„π‡¥Á° Dosage Form ¢π“¥¬“ µàÕ °°./«—π - Tablet 350, 500 ¡°. - Syrup 120 ¡°./5¡≈ - Concentrated syrup: 100 ¡°/¡≈.

- 10 ¡°/°°/§√—Èß - 0.3-0.4 ¡≈/°°/§√—Èß - 0.1 ¡≈/°°/§√—Èß

·π«∑“߇«™ªØ‘∫—µ‘ „π‚§√ß°“√À≈—°ª√–°—π ÿ¢¿“æ∂â«πÀπâ“

¢π“¥°“√„™â 10¡°/°°/§√—Èß Àà“ß°—π >4 ™¡ Õ“¬ÿ ¡°. 0-3 ‡¥◊Õπ 40 4-11 ‡¥◊Õπ 40 1 - < 2 ªï 120 2-3 ªï 160 4-5 ªï 240 6-8 ªï 320 9 -10 ªï 400 11 ªï 480 12-14 ªï 640 > 14 ªï 650

√À— ‡Õ° “√ π«ª. 09-016-01

«—π/‡¥◊Õπ/ªï 01/06/2545

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2.3 Ibuprofen - ¡’√–¬–°“√ÕÕ°ƒ∑∏‘Ïπ“π°«à“ acetaminophen ·≈– aspirin - µâÕß°‘πæ√âÕ¡Õ“À“√À√◊Õπ¡‡æ◊ÕË ≈¥º≈¢â“߇§’¬ßµàÕ∑“߇¥‘πÕ“À“√ ‰¥â·°à ª«¥∑âÕß §≈◊Ëπ‰ â ª«¥¡«π„π∑âÕß À√◊Õ ‡≈◊Õ¥ÕÕ°„π°√–‡æ“–®“°°“√‡°‘¥·º≈ - ‰¡à¡’√“¬ß“π«à“‡°’ˬ«¢âÕß°—∫ Reyeûs syndrome ·µà¡’√“¬ß“π«à“¡’æ‘…µàÕ‰µ - §«√À≈’°‡≈’ˬ߰“√„™â‚¥¬‡©æ“–„π‡¥Á°‡≈Á° 3. °“√√—°…“Õ◊Ëπ Ê ‰¥â·°à 3.1 °“√„Àâ “√πÈ”∑¥·∑π „π‡¥Á°∑’Ë¡’‰¢â §«√„À⇥Á°¥◊Ë¡πÈ”‡æ’¬ßæÕ 3.2 °“√ªÑÕß°—π·≈–√—°…“°“√™—°®“°‰¢â ● ‡¥Á°∑’Ë¡’‰¢â§«√‰¥â√—∫°“√¥Ÿ·≈„°≈♑¥ ≈¥‰¢â‚¥¬°“√‡™Á¥µ—«À√◊Õ„À⬓‡¡◊ËÕ ¡’‰¢â Ÿß √–«—ßÕ“°“√™—°®“°‰¢â ( febrile seizure ) ´÷Ëßæ∫‰¥â„π‡¥Á°Õ“¬ÿ 6 ‡¥◊Õπ ∂÷ß 5 ªï √—°…“Õ“°“√™—°„π¢≥–π—Èπ¥â«¬ ● „π‡¥Á°Õ“¬ÿ 30 «—π - 5 ªï - diazepam 0.2-0.5 ¡°./°°./§√—Èß (‰¡à‡°‘π 5 ¡°./§√—Èß) ∑“߇ âπ‡≈◊Õ¥¥” (IV) „Àâ´È”∑ÿ° 15-30 π“∑’ (‡¥Á°Õ“¬ÿ > 5 ªï „Àâ 5-10 ¡°./§√—Èß) - ∂â“·∑߇ âπ‡≈◊Õ¥‰¡à‰¥â„Àâ diazepam  «π‡¢â“∑“ß∑«“√Àπ—° ‚¥¬‰¡àµâÕß ‡®◊Õ®“߉¥â ‚¥¬„™â¢π“¥ 0.5 ¡°./°°./§√—Èß „ à„π insulin syringe ¢π“¥ 1 ¡≈. „ à∑“ß∑«“√Àπ—°≈÷° 3-4 ´¡. ®–‰¥â¢π“¥¬“∑’Ë∂÷ß√–¥—∫„π 10-15 π“∑’ ·≈–¡’ƒ∑∏‘Ïπ“π 4 ™¡. ● ‡¥Á°∑’Ë™—°‡¡◊ËÕ¡’‰¢â µâÕߧ‘¥∂÷ß “‡Àµÿ®“°°“√µ‘¥‡™◊ÈÕ¢Õß√–∫∫ª√– “∑  à«π°≈“ß ‡ ¡Õ ‚¥¬‡©æ“–Õ¬à“߬‘Ë߇¡◊ËÕ‡ªìπ‡¥Á°Õ“¬ÿπâÕ¬°«à“ 6 ‡¥◊Õπ À√◊Õ‡¥Á°∑’ˉ¡à‡§¬¡’ ª√–«—µ‘™—°®“°‰¢â À√◊Õ‰¡à¡’§«“¡º‘¥ª√°µ‘∑“ß ¡Õß¡“°àÕπ

‡¥Á°Õ“¬ÿ 0-<3 ‡¥◊Õπ 1. À≈—°°“√∑—Ë«‰ª ª√–°Õ∫¥â«¬ : ● „Àâ°“√√—°…“µ“¡ “‡Àµÿ´÷Ëß à«π„À≠à‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ ● ·°â‰¢·≈–ªÑÕß°—π¿“«– dehydration ·≈–¿“«–™—° ·≈– ● ¥Ÿ·≈„À⇥Á°‰¥â√—∫§«“¡ ∫“¬ ‡™à𠇙Á¥µ—« „À⬓≈¥‰¢â 2. ‡¥Á°Õ“¬ÿ 0-<3 ‡¥◊Õπ∑’Ë¡’‰¢â > 38.5o ´ ● §«√√—∫‰«â„π‚√ß欓∫“≈‡æ◊ËÕª√–‡¡‘π·≈– —߇°µÕ“°“√ µ≈Õ¥®πµ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ Õ¬à“ß≈–‡Õ’¬¥ ‰¥â·°à CBC, UA, blood culture ·≈–Õ“®∑” urine culture ¥â«¬ ∂â“ ß —¬ UTI ‚¥¬‡©æ“– Õ¬à“߬‘Ëß∂â“®–„À⬓ªØ‘™’«π– ● §«√µ√«®≈–‡Õ’¬¥‡™àππ’È ‰¡à«à“®–√—°…“·∫∫§π‰¢âπÕ° À√◊Õ√—∫‰«â„π‚√ß欓∫“≈ ●  à«π°“√∑” chest X-ray π—È𠧫√∑”„π√“¬∑’Ë¡’Õ“°“√· ¥ß§«“¡º‘¥ª°µ‘¢Õß√–∫∫∑“߇¥‘π À“¬„® ‡™àπ ‰Õ À“¬„®‡√Á«º‘¥ª°µ‘ øí߇ ’¬ßªÕ¥‰¥â¬‘π‡ ’¬ßº‘¥ª°µ‘ ‡ªìπµâπ 3. √–À«à“ß√Õº≈‡æ“–‡™◊ÈÕ ● °≈ÿà¡ low-risk Õ“®®– —߇°µÕ“°“√°àÕπ‰¥â ●  à«π°≈ÿà¡ high-risk §«√„À⬓ªØ‘™’«π–‰ª°àÕπ‡≈¬ ¬“ªØ‘™’«π–∑’Ë„À⇪ìπ empiric §◊Õ ampicillin √à«¡°—∫ gentamicin

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4. °√≥’∑’ˇ¥Á°´÷¡ À√◊Õ¡’°√–À¡àÕ¡‚ªÉß À√◊Õ¡’ abnormal neurological sign §«√æ‘®“√≥“‡®“– À≈—ß ∂⓺≈µ√«®πÈ”‰¢ —πÀ≈—߇¢â“‰¥â°—∫ bacterial meningitis §«√„À⬓ªØ‘™’«π– ¥—ßπ’È ● Cefotaxime 200 ¡°./°°./«—π À√◊Õ Ceftriaxone 100 ¡°./°°./«—π 5. °“√√—°…“·∫∫§π‰¢âπÕ° ● Õ“®æ‘®“√≥“„π°√≥’∑’Ë - ‡¥Á°¥Ÿ¥’ (nontoxic) ·≈– - µ√«®√à“ß°“¬‰¡àæ∫µ”·Àπàß∑’Ë ß —¬«à“¡’°“√µ‘¥‡™◊ÈÕ ·≈– - ‰¢â‰¡à Ÿß°«à“ 38.5o ´ - º≈°“√µ√«® CBC ·≈– urine ‰¡à¡’≈—°…≥–∑’Ë™’È·π–«à“‡ªìπ bacterial infection - ºŸâª°§√Õ߇¢â“„®  “¡“√∂擇¥Á°¡“µ‘¥µ“¡Õ“°“√‰¥â ● °“√µ√«®·≈–√—°…“ -  àß CBC, UA (æ‘®“√≥“ àß bacterial culture µ“¡§«“¡‡À¡“– ¡) - æ‘®“√≥“°“√„À⬓ªØ‘™’«π–µ“¡ “‡Àµÿ∑’˧‘¥∂÷ß ‡™àπ ➔ Viral infection, dengue infection : ‰¡à„À⬓ªØ‘™’«π– ➔ Bacterial upper respiratory tract infection ‡™àπ otitis media : „Àâ amoxycillin À√◊Õ co-amoxiclav ➔ Urinary tract infection : gentamicin 3-5 ¡°./°°./«—π IM «—π≈–§√—Èß À√◊Õ oral co-trimoxazole 6 ¡°./°°./«—π ( àß urine culture °àÕπ‡√‘Ë¡¬“) ➔ Occult bacteremia : ceftriaxone 50 ¡°./°°./§√—Èß IM «—π≈–§√—Èß ( àß blood culture °àÕπ‡√‘Ë¡¬“) - Õ∏‘∫“¬„À⺟⥟·≈‡¥Á°∑√“∫∂÷ß ➔  ‘Ëß∑’Ë·æ∑¬å§‘¥·≈–∑’Ë∑” „π°“√«“ß·ºπ°“√¥Ÿ·≈√—°…“‡¥Á° ➔ °“√¥Ÿ·≈‡¥Á°∑’Ë∫â“π ·≈– ➔ Õ“°“√∑’˵âÕß擇¥Á°¡“æ∫·æ∑¬å°àÕπ«—ππ—¥ È „π 1-2 «—π µàÕ¡“ ➔ °“√π—¥°≈—∫¡“¥ŸÕ“°“√Õ’°§√—ßÈ æ√âÕ¡∑—ßÈ øíߺ≈°“√‡æ“–‡™◊Õ - ∂⓺≈°“√‡æ“–‡™◊ÈÕ„π‡≈◊Õ¥°≈—∫¡“„Àâº≈∫«° §«√®–√—∫‰«â„π‚√ß欓∫“≈ ·≈– „Àâ ¬“ªØ‘™’«π–∑“߇ âπ‡≈◊Õ¥∑’ˇÀ¡“– ¡µ“¡º≈§«“¡‰«¢Õ߇™◊ÈÕ∑’ˉ¥â 6. °√≥’∑’Ë√—∫‰«â„π‚√ß欓∫“≈ ·≈–„À⬓ªØ‘™’«π–‰ª°àÕπ ● ∂⓺≈°“√‡æ“–‡™◊ÈÕ®“°‡≈◊Õ¥°≈—∫¡“æ∫«à“‡ªìπ true bacteremia °Á„Àâ°“√√—°…“‰ªµ“¡‡™◊ÈÕ∑’Ë æ∫π—πÈ È „π‡≈◊Õ¥‰¥âº≈≈∫·µà„À⬓·≈â«Õ“°“√¥’¢π÷È ·π–π”„À⬓µâ“π®ÿ≈™’æµàÕ®π§√∫ ● ∂â“°“√‡æ“–‡™◊Õ 10 «—π À√◊Õ®π¡’Õ“°“√ª°µ‘ 5 «—π ‡π◊ËÕß®“°°“√∑’˺≈‡æ“–‡™◊ÈÕ„π‡≈◊Õ¥‡ªìπ≈∫‰¡à “¡“√∂ exclude occult bacteremia ‰¥â

‡¥Á°Õ“¬ÿ 3 ‡¥◊Õπ-3 ªï °“√ª√–‡¡‘𧫓¡√ÿπ·√ß 1. „Àâ¥∑Ÿ ß—È ‘ßË ∑’«Ë ¥— ‰¥â·≈–«—¥‰¡à‰¥â ‰¥â·°à°“√¥Ÿ≈°— …≥–°“√√âÕß ªØ‘°√‘ ¬‘ “¢Õß∫‘¥“¡“√¥“ §«“¡µ◊πË µ—«¢Õ߇¥Á°  ’ ¿“«–°“√¢“¥πÈ” °“√µÕ∫ πÕßµàÕ ‘Ë߇√â“

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2. ‡¥Á°∑’Ë¥ŸÕ“°“√¬‘Ëߪɫ¬¡“°‚Õ°“ ∑’Ë®–‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬√ÿπ·√ß®–¬‘Ëß Ÿß ∂Ⓡ¥Á°¥Ÿ ∫“¬ ( Well appearing ) ‚Õ°“ µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬√ÿπ·√ß√âÕ¬≈– 3 ¥ŸªÉ«¬ ( Ill appearing ) ‚Õ°“ µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬√ÿπ·√ß√âÕ¬≈– 26 ¥ŸÕ“°“√Àπ—° ( Toxic ) ‚Õ°“ µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬√ÿπ·√ß√âÕ¬≈– 92 3. °“√µÕ∫ πÕßµàÕ¬“≈¥‰¢â‰¡à‰¥â‡ªìπ ‘Ëß∫Õ°§«“¡√ÿπ·√ߢÕß‚√§ °“√µ‘¥‡™◊ÈÕ·Õ∫·Ωß (Occult infection) ºŸâªÉ«¬∑’˵√«®‰¡àæ∫ “‡Àµÿ¢Õ߉¢â Õ“®¡’°“√µ‘¥‡™◊ÈÕ·Õ∫·Ωß (occult infection) µàÕ‰ªπ’È 1. Urinary tract infection „π°“√ª√–‡¡‘πºŸªâ «É ¬‡¥Á°∑“√°∑’¡Ë “¥â«¬‰¢â ∑’°Ë “√´—°ª√–«—µ·‘ ≈–µ√«®√à“ß°“¬‰¡à “¡“√∂∫Õ°·À≈àß ¢Õß°“√µ‘¥‡™◊ÈÕ‰¥â (fever of uncertain source) §«√‡°Á∫ªí  “«– ‡æ◊ËÕµ√«®·≈–‡æ“–‡™◊ÈÕ∑—Èß„π‡¥Á°‡≈Á°·≈– ‡¥Á°‚µ 2. Pneumonia ● Pneumonia  à«π„À≠à¡—°· ¥ßÕ“°“√™—¥‡®π ·µà„π‡¥Á°‡≈Á°Õ“®¥Ÿ¬“° ● ‡¥Á°∑’ˇªìπªÕ¥Õ—°‡ ∫®“°·∫§∑’‡√’¬¡—°¡’‰¢â Ÿß°«à“ 39 Ì´ ·≈– WBC  Ÿß°«à“ 20,000 ‡´≈≈å/ ¡≈. ● „π‡¥Á°Õ“¬ÿµË”°«à“ 2 ªï  “‡Àµÿ¢Õߪե∫«¡∑’Ëæ∫¡“°∑’Ë ÿ¥ §◊Õ°“√µ‘¥‡™◊ÈÕ‰«√—  3. Bacterial gastroenteritis ● °“√µ‘¥‡™◊ÈÕ„π√–∫∫∑“߇¥‘πÕ“À“√ ¡—°¡’Õ“°“√∑âÕ߇¥‘π·≈–Õ“‡®’¬π√à«¡¥â«¬ 4. Meningitis ● Bacterial meningitis „π‡¥Á°‡≈Á° Õ“°“√Õ“®‰¡à™—¥ ·µà‡¥Á°¡—°¥ŸªÉ«¬ Ë ”„Àâ ß —¬ bacterial meningitis ‰¥â·°à ´÷¡ °√–À¡àÕ¡ Àπâ“‚ªÉß ● °“√µ√«®√à“ß°“¬„π‡¥Á°‡≈Á° ∑’∑ („π√“¬∑’Ë°√–À¡àÕ¡¬—߉¡àªî¥) Õ“‡®’¬π §Õ·¢Áß ™—° Ë ·≈–‡¥Á°‰¡à√Õâ ß ∂Ⓡªìπ¡“°®–‰¡à¡’ ● °“√µ√«®«à“°√–À¡àÕ¡Àπâ“‚ªÉßÀ√◊Õ‰¡à §«√µ√«®„π∑à“π—ß pulsation ∑’Ë°√–À¡àÕ¡Àπâ“ ● À“° ß —¬ °“√µ√«®πÈ”‰¢ —πÀ≈—ß®–™à«¬„Àâ«‘π‘®©—¬‰¥â 5. Occult bacteremia ● æ∫‰¥âπâÕ¬ ‡¥Á°Õ“¬ÿµË”°«à“ 3 ªï ∑’Ë¡’‰¢â ¡’‚Õ°“ ¡’·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥πâÕ¬°«à“√âÕ¬≈– 3 ∑—Èßπ’È¢÷Èπ°—∫Õ“¬ÿ¢Õ߇¥Á°·≈–§«“¡ Ÿß¢Õ߉¢â Ÿ >38.5 ´Ì ‚¥¬∑’‰Ë ¡à¡Õ’ “°“√· ¥ß‡©æ“–∑’Ë ‡¡◊ÕË ‰¥â≈¥‰¢â·≈⫬—ß´÷¡À√◊Õ ● „π°√≥’∑‡’Ë ¥Á°‡≈Á°¡’‰¢â ß √âÕß°«πº‘¥ª°µ‘§àÕπ¢â“ß¡“° ·≈–¬—߉¡à “¡“√∂«‘π‘®©—¬‡ªìπ‚√§Õ◊Ëπ - æ‘®“√≥“ àß blood culture - „À⬓ªØ‘™«’ π– - Occult bacteremia ª√–¡“≥√âÕ¬≈– 80 ‡°‘¥„π‡¥Á°Õ“¬ÿ‰¡à‡°‘π 24 ‡¥◊Õπ ·≈–  “‡Àµÿ‡°◊Õ∫∑—ÈßÀ¡¥ §◊Õ Streptococcus pneumoniae, Haemophilus influenzae ·≈– non-typhoidal Salmonella °“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ ● ‡¥Á°∑’Ë¡’‰¢â·≈–¥Ÿ‰¡àªÉ«¬ - ‡ªìπ„π°≈ÿà¡∑’Ë¡’§«“¡‡ ’ˬߵ˔ ‰¡à®”‡ªìπµâÕßµ√«®∑“ßÀâÕߪؑ∫—µ‘°“√∑—π∑’

·π«∑“߇«™ªØ‘∫—µ‘ „π‚§√ß°“√À≈—°ª√–°—π ÿ¢¿“æ∂â«πÀπâ“

√À— ‡Õ° “√ π«ª. 09-016-01

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- “¡“√∂„Àâ°“√¥Ÿ·≈√—°…“∑’∫Ë “â π‰¥â À“°ºŸªâ °§√Õ߇¢â“„®·≈– —߇°µÕ“°“√‡Õ߉¥â ·≈–擇¥Á° ¡“µ√«®‡æ◊ËÕµ‘¥µ“¡Õ“°“√„π«—πµàÕ Ê ‰ªµ“¡§«“¡‡À¡“– ¡ ● ∂Ⓡ¥Á°¥ŸªÉ«¬ ·≈–·æ∑¬å‰¡à·πà„®„𧫓¡‡ ’Ë¬ß - §«√ àßµ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ ‚¥¬µ√«® CBC, UA, urine culture, - ∂â“ WBC >15,000 -20,000 ‡´≈≈å/ ¡≈. §«“¡‡ ’ˬߵàÕ bacteremia ª√–¡“≥ √âÕ¬≈– 3-4 - ∂â“ WBC >20,000 / ‡´≈≈å/ ¡≈. §«“¡‡ ’ˬߵàÕ bacteremia ª√–¡“≥√âÕ¬≈– 8-10 - Absolute neutrophil count (ANC) ¡’§«“¡‰«·≈–§«“¡®”‡æ“– Ÿß°«à“ WBC À√◊Õ absolute band count „π°“√§âπÀ“ bacteremia ANC > 10,000 / ‡´≈≈å/ ¡≈. ¡’§«“¡‡ ’¬Ë ß ¢Õß bacteremia ‡ªìπ√âÕ¬≈– 8-10 ● √âÕ¬≈– 6-10 ¢Õ߇¥Á°∑’Ë¡’·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥ ®–‡°‘¥°“√µ‘¥‡™◊ÈÕ√ÿπ·√ß É ¬ „Àâ∑” blood culture ‚¥¬‡©æ“–Õ¬à“߬‘ßË ‡¡◊ÕË æ‘®“√≥“«à“®”‡ªìπµâÕß„À⬓µâ“π®ÿ≈™’æ ● ∂Ⓡ¥Á°¥Ÿª« „Àâ∑” blood culture °àÕπ‡ ¡Õ Ë ‡™àπ °“√∂à“¬¿“æ√—ß ’ªÕ¥ ‡æ“–‡™◊ÕÈ Õÿ®®“√– À√◊Õ µ√«®πÈ”‰¢ —πÀ≈—ßπ—πÈ ‰¡à®”‡ªìπ ● °“√µ√«®Õ◊π µâÕß∑”∑ÿ°√“¬ ‡≈◊Õ°∑”µ“¡§«“¡‡À¡“– ¡ ‡¡◊ÕË  ß —¬«à“®–¡’ª«¥∫«¡ µ‘¥‡™◊ÕÈ ∑“߇¥‘πÕ“À“√ À√◊Õ‡¬◊ÕË Àÿ¡â  ¡Õß Õ—°‡ ∫ µ“¡≈”¥—∫ °“√√—°…“ ‡¥Á°∑’¥Ë ‰Ÿ ¡àª«É ¬ ¡’§«“¡‡ ’¬Ë ߵ˔  “¡“√∂¡“µ√«®´È”‰¥â‰¡à¬“°π—°  “¡“√∂„Àâ ß— ‡°µÕ“°“√∑’∫Ë “â π‰¥â ‚¥¬‰¡àµâÕß„À⬓µâ“π®ÿ≈™’æ ®“°°“√´—°ª√–«—µ‘·≈–°“√µ√«®√à“ß°“¬ ● ‡¥Á°∑’Ë¡’§«“¡‡ ’ˬߠŸß„π°“√‡°‘¥ occult bacteremia §«√ àß CBC, blood culture, UA, urine Gram-stain, urine culture Õ“®„À⬓µâ“π®ÿ≈™’æ‚¥¬‰¡àµÕâ ß√Õ º≈°“√‡æ“– ‡™◊ÈÕ ‚¥¬‡©æ“–∂â“ WBC >15,000 ‡´≈≈å/¡≈.À√◊Õ absolute neutrophil > 10,000 ‡´≈≈å/¡≈. ● ¢âÕ¡Ÿ≈¢Õßµà“ߪ√–‡∑»·≈–ª√–‡∑»‰∑¬ · ¥ß«à“‡™◊ÈÕ∑’Ëæ∫‡ªì𠓇Àµÿ¢Õß occult bacteremia „π‡¥Á° à«π„À≠à §◊Õ S.pneumoniae ·≈– H.influenzae ®÷ß·π–π”„Àâ „Àâ amoxicillin À√◊Õ„Àâ ceftriaxone „π°√≥’∑‡’Ë ¥Á°‡§¬‰¥â√∫— ¬“ªØ‘™«’ π–„π 3 ‡¥◊Õπ°àÕπ À√◊Õ ‰¥â√∫— °“√¥Ÿ·≈„π ∂“π√—∫‡≈’¬È ߇¥Á° ´÷ßË ∑”„À⡧’ «“¡‡ ’¬Ë ß  Ÿß¢÷ÈπµàÕ°“√µ‘¥‡™◊ÈÕ¥◊ÈÕ¬“ ’ π–·≈⫇¥Á°¥’¢π÷È ·π–π”„Àâ„À⬓ªØ‘™«’ π–®π§√∫√–¬–‡«≈“ ∂÷ß·¡â°“√‡æ“–‡™◊ÕÈ ®– ● ∂â“„À⬓ªØ‘™« ‰¡à¢÷Èπ À“°º≈‡æ“–‡™◊ÈÕ„π‡≈◊Õ¥„Àâº≈∫«° °“√ª√–‡¡‘πºŸâªÉ«¬„À¡à«à“°“√µ‘¥‡™◊ÈÕ‡©æ“–∑’ËÕ¬ŸàÀ√◊Õ‰¡à ‡™àπ meningitis, pneumonia ●

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‡Õ° “√Õâ“ßÕ‘ß 1. Finkelstein JA, Christiannsen CL, Platt R. Fever in pediatric primary care : occurrence, management and outcomes. Pediatrics 2000;105:260-6. 2. °¡≈«‘™ ‡≈“ª√– æ«—≤π“ ª√–‡¡‘π°“√„™â Rochester criteria „π°“√®”·π°ºŸâªÉ«¬‡¥Á°‰¢â Ÿß‡©’¬∫ æ≈—π∑’Ë¡’§«“¡‡ ’ˬߵ˔µàÕ°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬√ÿπ·√ß  ß¢≈“π§√‘π∑√凫™ “√. 3. Silpapojakul K, Chupuppakarn S, Yuthasompob S, et al. Scrub and murine typhus in children with obscure fever in the tropics. Pediatr Infect Dis J 1991;10:200-3. 4. Washington LJ, Holder MS, Kirksey OW, Palm DE. Fever in infants. Clinician Reviews 1999; 9:51-53, 57-58, 63-64, 66-68. 5. Childrenûs Hospital Medical Center(Cincinnati, OH). Evidence based clinical protocol guideline for fever of uncertain source in infants 60 days of age or less. Available at: http://www.guidelines.gov/VIEWS/ 6. Hay W,Hayward A, Levin M,et al.Current Pediatric Diagnosis and Treatment. 14th ed. Stanford, Conn: Appleton & Lange;1998. 7. Childrenûs Hospital Medical Center(Cincinnati, OH);2000: Evidence based clinical practice guideline of fever of uncertain source. Outpatient evaluation and management for children 2 months to 36 months of age. Available at: http://www.guidelines.gov/VIEWS/ 8. McCarthy PL, Jekel JF, Dolan TF Jr. Temperature greater than or equal to 40oC in children less than 24 months of age: Aprospective study. Pediatrics 1997;59:663-8. 9. McGrown JE Jr, Braton L, Klein JO,et al. Bacteremia in febrile children seen in a çwalk-iné pediatric clinic. N Eng J Med 1972;288:1309-12. √“¬™◊ËÕ§≥–∑”ß“π 1. æ—π‡Õ° ·æ∑¬åÀ≠‘߃¥’«‘‰≈  “¡‚°‡»» «‘∑¬“≈—¬·æ∑¬»“ µ√åæ√–¡ß°ÿƇ°≈â“ 2. √Õß»“ µ√“®“√¬å ·æ∑¬åÀ≠‘ß ¬¡æ√ »‘√‘π“«‘π §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’ 3. 𓬷æ∑¬å∑«’ ‚™µ‘æ‘∑¬ ÿππ∑å  ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ 4. ·æ∑¬åÀ≠‘ߪ¿√≥å ∫«√°’√µ‘¢®√ ‚√ß欓∫“≈‡®√‘≠°√ÿߪ√–™“√—°…å 5. √Õß»“ µ√“®“√¬å ·æ∑¬åÀ≠‘ߺ°“°√Õß ≈ÿ¡¿‘°“ππ∑å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ 6. √Õß»“ µ√“®“√¬å ·æ∑¬åÀ≠‘ß«‘¡≈¡“≈¬å æß…åƒ∑∏‘Ï»—°¥“ ‚√ß欓∫“≈¡À“√“™ π§√√“™ ’¡ 7. ·æ∑¬åÀ≠‘ß ÿ°—≠≠“ æ‘∑—°…廑√‘æ√√≥ ‚√ß欓∫“≈π§√≈”ª“ß 8. ‡¿ —™°√À≠‘߬ÿæ‘π ≈“«—≥¬åª√–‡ √‘∞  ”π—°ß“π§≥–°√√¡°“√Õ“À“√·≈–¬“ 9. ‡¿ —™°√À≠‘ß¿√≥å«’≥“ ¬—Ë߬◊π

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