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[.56] Alright, so question 11. A 13-month-old child is brought to the emergency department because of urticaria, | 好了，来看第 11 题。一名 13 个月大的孩子因荨麻疹被送往急诊科，
[.70] swelling of the lips, and difficulty breathing immediately after eating an egg. | 吃完鸡蛋后立即出现嘴唇肿胀和呼吸困难。
[.02] A potential risk for hypersensitivity reaction is posed by vaccination against which of the following illnesses? | 接种针对下列哪种疾病的疫苗可能会带来超敏反应的潜在风险？
[.50] Option A is hepatitis. Option B is influenza. Option C is pertussis. | 选项 A 是肝炎。选项 B 是流感。选项 C 是百日咳。
[.52] Option D is poliomyelitis. Option E is typhoid fever. | 选项 D 是脊髓灰质炎。选项 E 是伤寒。
[.86] For this one, I think I'd go with influenza, right? | 对于这一题，我认为应该选流感，对吧？
[.86] So this person basically has anaphylaxis, probably from an egg allergy, right? | 所以这个人基本上出现了过敏性反应，可能源于鸡蛋过敏，对吧？
[.44] From an egg allergy. | 源于鸡蛋过敏。
[.06] So remember, the influenza vaccine, these are high-yield-to-know-for-you exams, right? | 记住，流感疫苗，这些在考试中都是高频考点，对吧？
[.68] The influenza vaccine and the yellow fever vaccine, those are grown in eggs. | 流感疫苗和黄热病疫苗，它们都是在鸡蛋中培养的。
[.44] So the vaccines may contain ovalbumin. | 因此，这些疫苗可能含有卵清蛋白。
[.52] So if people have a history of egg allergies, they may have some problems with these vaccines, | 所以，如果有人有鸡蛋过敏史，接种这些疫苗可能会出现一些问题，
[.02] influenza and yellow fever. | 比如流感疫苗和黄热病疫苗。
[.64] But the thing is, having an egg allergy is not a contraindication to the influenza vaccine. | 但问题是，鸡蛋过敏并不是接种流感疫苗的禁忌症。
[.28] You know, what may just need to happen is that you give them the vaccine, | 你知道，可能只需要在给他们接种疫苗后，
[.96] and you probably just monitor them for like a half hour or something | 观察大约半小时左右，
[.72] to make sure that they don't develop anaphylaxis symptoms. | 以确保他们不会出现过敏反应症状。
[.58] But actually, it's very high-yield-to-know-this. | 但实际上，了解这一点非常重要。
[.84] An egg allergy is not a contraindication to the influenza. | 鸡蛋过敏不是流感的禁忌症。
[.52] It's a contraindication to the influenza vaccine. | 它是流感疫苗的禁忌症（此处为播讲者口误纠正）。
[.50] And again, remember, the agent that really triggers the hypersensitivity is ovalbumin. | 再次强调，真正引发超敏反应的物质是卵清蛋白。
[.98] O-V-A-L-B-U-M-I-N. | O-V-A-L-B-U-M-I-N。
[.32] Ovalbumin. | 卵清蛋白。
[.90] This is one of those things where you either know it or you don't, right? | 这种知识点，要么知道，要么不知道，对吧？
[.08] So there's, like, the other answers are not grown in eggs, right? | 比如，其他的备选答案都不是在鸡蛋里培养的，对吧？
[.30] But the key egg wants to know influenza and yellow fever. | 但关于鸡蛋过敏，关键要记住流感和黄热病。
[.58] All right, question 12. | 好了，第 12 题。
[.84] A 42-year-old white man is brought to the ED by his same-sex partner. | 一名 42 岁的白人男子由其同性伴侣送往急诊科。
[.80] Because of confusion. | 因为意识模糊。
[.52] Diplopia. | 复视。
[.94] A mild weakness of his right arm. | 右臂轻微无力。
[.34] The patient is somewhat agitated and shows confusion for recent events. | 患者有些烦躁，对近事表现出困惑。
[.74] Temperature is 100.1 degrees Fahrenheit. | 体温为 100.1 华氏度。
[.08] There is decreased pulmonary response on the left with paresis of lateral gaze on the right. | 瞳孔对光反射（应为 pupil）左侧减弱，右侧侧视麻痹。
[.70] Peripheral leukocyte count is increased. | 外周白细胞计数升高。
[.18] Which of the following is the most appropriate next step in evaluation of this patient's neurologic signs and symptoms? | 评估该患者神经系统体征和症状的最合适下一步是什么？
[.40] You know, the person has fever. | 你知道，患者有发热。
[.66] The person has altered mental status, right? | 意识状态改变，对吧？
[.80] Is agitated, right? | 表现烦躁，对吧？
[.50] And this person seems to have, like, these neuro deficits, right? | 而且这个人似乎有这些神经功能缺损，对吧？
[.92] So, again, it's maybe hard to say exactly what's going on here. | 所以，目前可能很难准确判断发生了什么。
[.86] But let's look at the answers and then we'll kind of talk through this, right? | 但让我们看看选项，然后我们会详细讨论一下，对吧？
[.40] I think this is a good question. | 我觉得这是一道很好的题目。
[.50] So option A says bilateral carotid arteriography. | 选项 A 是双侧颈动脉血管造影。
[.18] Option B says CT scan of the head. | 选项 B 是头部 CT 扫描。
[.10] Option C says EEG. | 选项 C 是脑电图。
[.14] Option D says LP for examination of CSF. | 选项 D 是腰椎穿刺以检查脑脊液。
[.38] Option E says serum HIV antibody test. | 选项 E 是血清 HIV 抗体测试。
[.58] So the thing is, this guy, you know, same sex, so maybe he has HIV. | 情况是这样，这个人是同性恋，所以他可能患有 HIV。
[.62] But the thing is, he has very acute complaints that we need to address. | 但关键是，他有我们需要处理的非常急性的主诉。
[.86] HIV, you're not going to die from HIV right now. | HIV，你现在不会死于 HIV。
[.26] But he has acute complaints we kind of need to address. | 但他有我们必须处理的急性症状。
[.26] And this acute complaint involves neurologic dysfunction. | 这种急性症状涉及神经功能障碍。
[.04] You know, he probably has meningitis or something like that. | 你知道，他可能有脑膜炎之类的。
[.46] But the thing is, whenever a person, you suspect the person has meningitis or encephalitis. | 但问题是，当你怀疑一个人患有脑膜炎或脑炎。
[.60] And you're seeing all these neuro deficits. | 并且你看到了所有这些神经功能缺损。
[.96] A lumbar puncture initially is contraindicated. | 最初是禁忌进行腰椎穿刺的。
[.68] You want to go ahead and do a CT of the head first. | 你应该先做头部 CT。
[.44] And then if that CT is negative, doesn't show like signs of increased ICP, then you can do a lumbar puncture. | 如果 CT 结果阴性，没有显示颅内压升高的迹象，那么你就可以进行腰椎穿刺。
[.50] So I will say option B, right? | 所以我会说选选项 B，对吧？
[.62] A CT of the head makes sense here. | 在这里做头部 CT 是合理的。
[.76] I will certainly do that before considering option D, which is the lumbar puncture. | 在考虑选项 D（即腰椎穿刺）之前，我肯定会先做这个。
[.94] And then after I fix his acute complaints, then I go, | 在处理完他的急性主诉后，我会，
[.10] I would consider option E, which is the serum HIV antibody test. | 考虑选项 E，即血清 HIV 抗体测试。
[.00] I would not pick option C, EEG, because this person doesn't appear to have seizures. | 我不会选择选项 C 脑电图，因为这个人看起来并没有癫痫发作。
[.52] And I will not pick option A, bilateral carotid and arteriography, because we're not worried about this person having like carotid stenosis or whatever. | 我也不会选择选项 A 双侧颈动脉造影，因为我们不担心这个人有颈动脉狭窄之类的问题。
[.72] So question number 13. | 那么，第 13 题。
[.18] A 35-year-old man is brought to the ED because of altered mental status. | 一名 35 岁的男子因意识状态改变被送往急诊科。
[.34] He is disoriented and complains about his vision. | 他神志不清并抱怨视力有问题。
[.88] You have been his physician for the past three years. | 在过去的三年里，你一直是他的医生。
[.16] He has type 1 diabetes mellitus and a known history of intravenous drug use. | 他患有 1 型糖尿病，并有静脉吸毒史。
[.60] You last saw him two weeks ago at that visit. | 你两周前在那次就诊中见过他。
[.08] At that visit, his serum glucose concentration was 150 milligrams per deciliter. | 在那次就诊中，他的血清葡萄糖浓度为 150 mg/dL。
[.92] Today, vital signs are a temperature of 38.1, that's 100.5 degrees Fahrenheit. | 今天，生命体征为：体温 38.1 摄氏度（即 100.5 华氏度）。
[.98] His pulse is 110 and his blood pressure is 190 over 70. | 脉搏 110 次/分，血压 190/70 mmHg。
[.12] On physical examination, | 体格检查显示，
[.32] Phondoscopic examination of the left eye following dilation is shown. | 展示了散瞳后左眼的眼底镜检查结果。
[.58] Which of the following is the most appropriate test at this time? | 此时最合适的检查是什么？
[.22] Option A says blood cultures. | 选项 A 是血培养。
[.66] Option B says chest x-ray. | 选项 B 是胸部 X 光检查。
[.02] Option C says hemoglobin A1c. | 选项 C 是糖化血红蛋白 A1c。
[.80] Option D says HIV antibody titer. | 选项 D 是 HIV 抗体滴度。
[.86] Option E says plasma radian activity. | 选项 E 是血浆肾素活性（renin）。
[.22] So what do we think this guy has? | 我们认为这个人得了什么病？
[.22] We see this weird phondoscopic exam. | 我们看到了这个奇怪的眼底检查。
[.04] We see that he has a history of IV drug use. | 我们看到他有静脉吸毒史。
[.82] He has a fever. | 他有发热。
[.52] He's tachycardic. | 心动过速。
[.12] He has a white pulse pressure. | 他有脉压增宽（wide pulse pressure）。
[.12] Just so many things here are pointing to endocarditis. | 这里的许多迹象都指向内膜炎。
[.42] If we even look at this phondoscopic exam image, it's kind of worrisome. | 即使看这个眼底镜检查图像，也挺令人担忧的。
[.88] Well, look at this hemorrhage in his eye. | 瞧，他眼底有出血。
[.48] And he has all these punctates, you know, like whitish. | 还有这些点状物，白色的。
[.62] Those are rough spots. | 那些是 Roth 点（Roth spots）。
[.14] This guy has endocarditis. | 这个人患有内膜炎。
[.62] And whenever a person has endocarditis, you always want to get a blood culture first. | 当怀疑心内膜炎时，你总是应该先进行血培养。
[.08] So please, I'll say for purposes of the USMLE exams, do not begin endocarditis management if you have not gotten blood culture. | 所以请记住，为了应对 USMLE 考试，如果没有进行血培养，不要开始内膜炎的治疗。
[.80] Get blood cultures because, again, the person is likely going to have to be on long-term antibiotic therapy. | 进行血培养，因为患者可能需要接受长期的抗生素治疗。
[.66] So I'd go with option A here. | 所以这里我选选项 A。
[.10] Hemoglobin A1C, again, this guy has more pressing issues. | 糖化血红蛋白 A1c，再说一次，这家伙有更紧迫的问题。
[.26] Oh, you know, his blood pressure is 190 over 70. | 哦，你知道，他的血压是 190/70。
[.78] So the white pulse pressure may actually indicate that he has like aortic regurg. | 脉压增宽实际上可能表明他患有主动脉瓣反流。
[.86] Remember, aortic regurg has a very strong association with white pulse. | 记住，主动脉瓣反流与脉压增宽（wide pulse pressure）有很强的关联。
[.94] Now, question 14 says a 38-year-old white man, white letter career, | 第 14 题，一名 38 岁的白人男性，邮递员（letter carrier），
[.12] returns to the office for a follow-up of abnormal results of a liver chemistry profile, | 回到诊所随访三周前常规检查中异常的肝功能结果。
[.12] At that time, physical examination disclosed no abnormalities, but serum EST concentration was 70%. | 当时体检未见异常，但血清 AST 浓度为 70。
[.92] Serum bilirubin and ALK-FOS concentrations were within the reference ranges. | 血清胆红素和碱性磷酸酶浓度在参考范围内。
[.44] Medical history is significant for an episode of hepatitis A at age 22. | 病史显示他在 22 岁时患过甲型肝炎。
[.78] He drinks two to three beers daily. | 他每天喝两到三瓶啤酒。
[.76] So, his anti-HEV is positive. | 他的抗-HAV 阳性（HAV 为 A 型肝炎）。
[.20] Anti-HPS, anti-AV surface is negative. | 抗-HBs（乙肝表面抗体）阴性。
[.38] Hebisophis antigen is positive. | 乙肝表面抗原（HBsAg）阳性。
[.68] Hebe antigen is positive. | HBeAg（E抗原）阳性。
[.06] Which of the following is the most appropriate next step? | 以下哪项是最合适的下一步？
[.80] Option A says, begin interferon-alpha therapy. | 选项 A 是开始干扰素-α 治疗。
[.82] Option B says, begin corticosteroid therapy. | 选项 B 是开始皮质类固醇治疗。
[.70] Option C says, instruct him to cease alcohol consumption and retest him in two months. | 选项 C 是嘱其戒酒并在两个月后复查。
[.38] Option D says, order hep B virus PCR tests. | 选项 D 是订购乙肝病毒 PCR 检测。
[.76] Option E says, schedule liver biopsy. | 选项 E 是安排肝活检。
[.26] So, this guy definitely has active hep B. | 所以，这个人肯定患有活动性乙肝。
[.28] You know, so he seems like he probably has acute hep B. | 你知道，他看起来可能患有急性乙肝。
[.90] Chronic hep B, if you want to manage it. | 慢性乙肝，如果你想治疗的话。
[.62] And, again, we use it for managing chronic hep B. | 再次强调，我们用它来治疗慢性乙肝。
[.22] It doesn't look like this guy in this question has chronic hep B. | 这道题里的这个人看起来不像有慢性乙肝。
[.86] Because the thing is, more than 90% of adults that have hep B, they do clear the infection. | 因为事实是，超过 90% 的成年乙肝患者能够自行清除病毒。
[.62] Again, like I said, more than 90% of adults, they spontaneously clear hep B. | 正如我所说，超过 90% 的成年人会自动清除乙肝。
[.24] So, I'm going to go with option C for that. | 所以我选选项 C。
[.22] Let's go to question number 15. | 来看第 15 题。
[.08] A 75-year-old white woman returns to the office. | 一名 75 岁的白人妇女回到诊所。
[.80] After six months of missed appointments, she says she's feeling depressed. | 在错过六个月的预约后，她说她感到抑郁。
[.96] You have been treating her for years for a variety of disorders, including bipolar disorder, hypothyroidism, AFib, peptic ulcer disease, and hypertension. | 多年来你一直治疗她的多种疾病，包括双相情感障碍、甲减、房颤、消化性溃疡和高血压。
[.34] She takes daily lithium carbonate, levothyroxine, haloperidol, cetraline, benztropine, digoxine, propranolol, ranitidine, and warfarin. | 她每天服用碳酸锂、左旋甲状腺素、氟哌啶醇、舍曲林、苯扎托品、地高辛、普萘洛尔、雷尼替丁和华法林。
[.94] She says, I'm doing fine except for shakiness in my hands. | 她说，除了手抖外，我一切都好。
[.60] She also says her mood is a little depressed. | 她还说她的心情有点抑郁。
[.66] Vital signs are a pulse of 78 per minute with an irregularly irregular rhythm. | 生命体征显示脉搏 78 次/分，节律绝对不齐（房颤）。
