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[.52]A 45-year-old woman comes to the office for a full-up examination two weeks after she sustained the vertebral fracture at L1. | 一名 45 岁女性在发生 L1 椎体骨折两周后来诊所进行随访检查。
[.66]The fracture occurred spontaneously and there is no history of trauma to the area or the fractures. | 骨折是自发发生的，该区域没有外伤史或其他骨折史。
[.84]She gained 60 pounds during the six months before the fracture occurred. | 在骨折发生前的六个月里，她的体重增加了 60 磅。
[.86]Her only medication is hydromorphone as needed for pain. | 她唯一的药物是根据疼痛需要服用的氢吗啡酮。
[.26]She is 5:4'' tall and weighs 220 pounds. Her BMI is 38. | 她身高 5 英尺 4 英寸，体重 220 磅。她的 BMI 是 38。
[.26]Her vital signs are completely fine except her blood pressure that's 145 over 98. | 除了血压为 145/98 之外，她的生命体征完全正常。
[.42]Physical examination shows central obesity and purple stri over the abdomen bilaterally. | 体格检查显示向心性肥胖，腹部两侧可见紫色条纹。
[.44]The lower extremities appear thin. | 下肢显得纤细。
[.90]Her blood pressure is 145 over 98. | 她的血压是 145/98。
[.64]Results of lab studies are shown. | 实验室检查结果如下。
[.66]So we see her plasma radian activity is high, a little bit high. | 我们看到她的血浆肾素活性很高，有一点高。
[.10]Metanephrine is fine. Cortisol is elevated. | 变肾上腺素正常。皮质醇升高。
[.96]ACTH activity is a little bit high. | ACTH 活性有点高。
[.82]Aldosterone is fine. | 醛固酮正常。
[.42]Urine 24-hour cortisol excretion is high, right? | 24 小时尿皮质醇排泄量很高，对吧？
[.38]340 micrograms in 24 hours. | 24 小时内为 340 微克。
[.82]Now the most likely cause of the fracture in this patient is an increase in which of the following processes, right? | 现在，该患者骨折最可能的原因是以下哪项过程的增加，对吧？
[.96]So this question is pretty straightforward, right? | 所以这个问题很直接，对吧？
[.16]This person seems to have like Cushing syndrome, right? | 这个人似乎患有库欣综合征，对吧？
[.02]She has the purple striae, has the abdominal obesity, right? | 她有紫色条纹，有腹部肥胖，对吧？
[.54]And we see that she has fractures. | 我们看到她有骨折。
[.84]Because remember, hypercordisolism can cause osteoporosis, right? | 因为请记住，高皮质醇血症会导致骨质疏松症，对吧？
[.60]Basically, whenever a person has high levels of steroids, they basically activate osteoclasts. | 基本上，每当一个人体内类固醇水平较高时，基本上都会激活破骨细胞。
[.50]Remember, osteoclasts can be activated when rank ligand from an osteoblast binds to the rank receptor in osteoclasts. | 记住，当成骨细胞产生的 RANK 配体与破骨细胞中的 RANK 受体结合时，破骨细胞就会被激活。
[.20]And then that activates the osteoclasts. | 然后这会激活破骨细胞。
[.38]And then your bones get resorbed. | 然后你的骨骼就会被吸收。
[.40]And that can weaken your bones. | 这会削弱你的骨骼。
[.80]So steroids, they increase the production of rank ligand, right? | 所以类固醇会增加 RANK 配体的产生，对吧？
[.18]So if you have more rank ligand being produced, you have more of that receptor on the surfaces of your osteoblast. | 因此，如果有更多的 RANK 配体产生，你的成骨细胞表面就会有更多的这种受体。
[.68]That's going to hit your rank receptor on the osteoclasts. | 这将击中破骨细胞上的 RANK 受体。
[.36]And then that's going to cause you to activate them and resorb bones. | 然后这会导致你激活它们并吸收骨骼。
[.90]So the answer here is probably option D. | 所以这里的答案很可能是选项 D。
[.52]Remember some other things that kind of interact with that rank ligand business, right? | 记住其他一些与 RANK 配体相关的交互作用，对吧？
[.24]So for example, there's this thing called osteoportegrin that binds. | 例如，有一种叫做骨保护素的东西可以结合。
[.24]So rank ligand. | 也就是结合 RANK 配体。
[.24]Obviously, if osteoportegrin binds to rank ligand, then rank ligand will not interact with the rank receptor. | 显而易见，如果骨保护素与 RANK 配体结合，那么 RANK 配体就不会与 RANK 受体相互作用。
[.84]So you'll resorb bone. | 这样你就减少了骨吸收。
[.30]And that can weaken your bones. | 那样会削弱骨质。
[.74]So steroids, they increase the production of rank ligand, right? | 那么类固醇，它们增加了 RANK 配体的产生，对吧？
[.90]That's actually how estrogen is bone protective because estrogen increases osteoportegrin synthesis. | 这实际上就是雌激素具有骨保护作用的原因，因为雌激素会增加骨保护素的合成。
[.04]And then the drug we use for osteoporosis, denosumab. | 还有我们用于治疗骨质疏松症的药物，地舒单抗。
[.76]Denosumab is a rank ligand inhibitor. | 地舒单抗是一种 RANK 配体抑制剂。
[.86]It's a monoclonal antibody. | 它是一种单克隆抗体。
[.08]It grants rank ligand. | 它针对 RANK 配体。
[.96]It binds to rank ligand so it doesn't bind to the rank receptor and cause you problems. | 它与 RANK 配体结合，使其不会与 RANK 受体结合并给你带来问题。
[.04]All right. | 好的。
[.20]So just know that. | 只要知道这一点。
[.20]So the answer here has to be option D. | 所以这里的答案一定是选项 D。
[.10]Really, like. | 真的，就像。
[.18]So steroids do not increase osteoblast proliferation or. | 所以类固醇不会增加成骨细胞增殖或...
[.66]I mean, you know, they decrease calcium absorption. | 我的意思是，如你所知，它们会减少钙的吸收。
[.38]They actually decrease calcium absorption. | 它们实际上减少了钙的吸收。
[.52]So option A doesn't make sense because the question is the most likely cause of the fracture in this patient is an increase in which of the following processes. | 所以选项 A 没有意义，因为问题是该患者骨折最可能的原因是以下哪项过程的增加。
[.96]So steroids cause you to actually decrease calcium absorption. | 类固醇实际上会导致你钙吸收减少。
[.30]So option A is wrong. | 所以选项 A 是错误的。
[.04]Calcium excretion didn't really have much to do with that. | 钙排泄与此关系不大。
[.74]Phosphorus. | 磷。
[.34]Again, steroids don't really do much with phosphorus. | 同样，类固醇对磷并没有太大作用。
[.48]And you may wonder, why does this person have high blood pressure? | 你可能会想，为什么这个人血压高？
[.34]Well. | 嗯。
[.88]Remember that cortisol has some mineralocorticoid receptor activity. | 记住皮质醇具有一定的盐皮质激素受体活性。
[.54]Right. | 对。
[.48]So it can increase blood volume, increase blood pressure. | 所以它可以增加血容量，升高血压。
[.24]The works. | 诸如此类。
[.44]And then we can see this person's urine 24 hour free cortisol excretion is high. | 我们可以看到此人 24 小时尿游离皮质醇排泄量很高。
[.12]Right. | 对吧。
[.24]So that kind of tells you that, again, this person has hyper cortisolism. | 所以这再次告诉我们，这个人患有高皮质醇血症。
[.28]All right. | 好的。
[.70]Now, question 82 says a 25 year old woman comes to the ED because of a three hour history of fever, severe headache, lightheadedness, dizziness, shaking, chills and muscle aches. | 现在，第 82 题说，一名 25 岁女性因发热、剧烈头痛、头晕、眩晕、寒战和肌肉酸痛 3 小时急诊就诊。
[.94]Five hours ago, she was diagnosed with Lyme disease and began doxycycline therapy. | 五小时前，她被诊断出患有莱姆病并开始多西环素治疗。
[.24]She has no other history of serious illness and takes no other medications. | 她没有其他严重疾病史，也没有服用其他药物。
[.44]Menses are current regular 20 day intervals. | 月经规律，周期为 20 天。
[.58]She's currently menstruating and using a tampon. | 她目前正处于经期并使用卫生棉条。
[.36]She appears anxious. | 她显得很焦虑。
[.62]Temperature is 98.6. | 体温是 98.6 华氏度。
[.74]She's tachycardic, tachypneic, hypotensive. | 她心动过速、呼吸急促、血压低。
[.46]Her pulse ox is 94% on room air. | 在室内空气下，她的脉搏血氧饱和度为 94%。
[.30]She has flushing and diaphoresis. | 她面色潮红，大汗淋漓。
[.42]Cardiopulmonary exam shows no other abnormalities. | 心肺检查未见其他异常。
[.12]Which of the following is the most likely mechanism of this patient's current condition? | 以下哪项是该患者目前状况最可能的机制？
[.86]Again, let's work this out first. | 同样，让我们先分析一下。
[.00]Right. | 对吧。
[.34]So we see this person getting antibiotic therapy for some bug. | 我们看到这个人正在接受针对某种病原体的抗生素治疗。
[.74]And then you notice within hours the person is flushed. | 然后你注意到在几个小时内，这个人面色潮红。
[.48]The person is diaphoretic. | 这个人大汗淋漓。
[.18]The person is hypotensive, tachycardic, tachypneic. | 这个人血压低、心动过速、呼吸急促。
[.44]Right. | 对吧。
[.38]This is pretty classic for the Jarish-Hexheimer reaction. | 这是非常典型的赫氏反应 (Jarish-Hexheimer reaction)。
[.96]The Jarish-Hexheimer reaction. | 赫氏反应。
[.90]Right. | 对。
[.58]We tend to see this with treatment for spirochete infections. | 我们通常在治疗螺旋体感染时看到这种情况。
[.04]But you can also see it with many gram negative infections. | 但在许多革兰氏阴性菌感染中也可以看到。
[.62]Right. | 对。
[.18]So basically, it's like you get an antibiotic. | 所以基本上，就像你使用了抗生素。
[.08]You explode the bug. | 你让病菌“爆炸”了。
[.30]As you explode the bug, the cell soup of the bug is released into the bloodstream. | 当你炸掉病菌时，病菌的“细胞汤”被释放到血液中。
[.42]And then your body mounts a massive immune response. | 然后你的身体会发起大规模的免疫反应。
[.70]You know, you release all this IL-6, TNFR. | 你知道，你会释放所有这些 IL-6、TNFR。
[.76]And that causes that inflammatory reaction. | 这引起了炎症反应。
[.04]That's what causes these symptoms. | 这就是导致这些症状的原因。
[.42]Right. | 对吧。
[.04]Classically on the USMLEs, they test it with spirochetes like treponema pallidum, leptospirant tarragans. | 经典的 USMLE 考点是针对螺旋体，如梅毒螺旋体、问号钩端螺旋体。
[.56]A thing that causes leptospirosis. | 引起钩端螺旋体病的东西。
[.64]Remember, if you go to Hawaii and swim. | 记住，如果你去夏威夷游泳。
[.82]And then we also see this with Borrelia bogdofrii. | 然后我们也在伯氏疏螺旋体中看到这种情况。
[.08]Right. | 对。
[.28]Like in this person. | 就像在这个人身上一样。
[.08]Right. | 对吧。
[.68]So I'm going to say that this is the Jarish-Hexheimer reaction. | 所以我要说这就是赫氏反应。
[.16]And most times, it's going to go away over time. | 大多数情况下，它会随着时间的推移而消失。
[.62]But just go ahead and give the person like an antipyretic, like ibuprofen or something like that. | 但可以直接给患者服用退烧药，比如布洛芬之类的。
[.30]You can also give steroids. | 你也可以给类固醇。
[.30]But I'll say you should probably go with ibuprofen on your exam. | 但我会说在考试中你可能应该选择布洛芬。
[.12]Steroids have not been shown to really do much. | 类固醇尚未被证明有很大作用。
[.96]But ibuprofen really helps. | 但布洛芬确实有帮助。
[.06]All right. | 好的。
[.92]So option A says exacerbation of infection by B. bogdofrii. | 选项 A 说是伯氏疏螺旋体感染恶化。
[.86]That's wrong. | 那是错的。
[.62]Right. | 对吧。
[.54]The infection is not getting worse. | 感染并没有变得更糟。
[.82]If anything, you're actually fixing the infection. | 如果说有什么变化的话，那就是你实际上正在解决感染。
[.24]Option B says infection-mediated sepsis. | 选项 B 说是感染介导的败血症。
[.62]No. | 不是。
[.94]Infection-mediated sepsis can arise quickly. | 感染介导的败血症可能会迅速出现。
[.62]But man, the time frame here is a little too fast for that. | 但是天哪，这里的时间框架对于败血症来说有点太快了。
[.66]Right. | 对吧。
[.02]That usually takes a little more time. | 那通常需要更多的时间。
[.80]Right. | 对吧。
[.98]Ig-mediated allergic reaction to doxycycline. | Ig 介导的对多西环素的过敏反应。
[.34]No. | 不。
[.16]The person doesn't have like. | 这个人没有像...
[.10]Airway problems. | 呼吸道问题。
[.50]So that's wrong. | 所以那是错的。
[.82]D says release of bacterial products producing acute inflammation. | D 说是细菌产物的释放引起急性炎症。
[.24]Yeah. | 是的。
[.46]Sounds a lot like what happens with Jarish-Hexheimer's reaction. | 听起来非常像赫氏反应发生的情况。
[.36]And then option E, secretion of bacterial endotoxins. | 然后选项 E，细菌内毒素的分泌。
[.96]I think they're kind of thinking of toxic shock syndrome. | 我认为他们有点在考虑中毒性休克综合征。
[.06]But that's not what's going on here. | 但这不是这里发生的情况。
[.42]Right. | 对。
[.04]So the answer here is going to be option D. | 所以这里的答案将是选项 D。
[.98]All right. | 好的。
[.48]Question 83 says a newborn delivered at 36 weeks gestation to a 22-year-old woman, gravida 1 para 1, has difficulty feeding and listlessness. | 第 83 题说，一名 22 岁女性（孕 1 产 1）在妊娠 36 周产下的新生儿，出现喂养困难和精神萎靡。
[.04]The mother received no prenatal care. | 母亲未接受产前检查。
[.80]Spontaneous vaginal delivery was uncomplicated. | 经阴道分娩顺产，无并发症。
[.14]The mother's only medication. Most of prenatal vitamin. | 母亲唯一的药物，大多是产前维生素。
[.48]The newborn's length is in the 39th percentile. | 新生儿的身长处于第 39 百分位。
[.22]Weight is in the 30th percentile. | 体重处于第 30 百分位。
[.02]Head circumference is in the 12th percentile. | 头围处于第 12 百分位。
[.72]So everything is fine from that perspective. | 所以从这个角度来看一切都好。
[.10]And this newborn, you know, 98.6 for temperature. | 这个新生儿，你知道，体温 98.6 华氏度。
[.06]Pulse is 134 per minute. | 脉搏每分钟 134 次。
[.54]Respirations are 38 per minute. | 呼吸每分钟 38 次。
[.34]And blood pressure is 73 over 50. | 血压是 73/50。
[.74]Physical exam shows ambiguous genitalia. | 体格检查显示两性畸形（模糊外生殖器）。
[.72]Results from several studies are shown. | 几项研究的结果如下。
[.46]Right. | 对。
[.00]So let's interpret these labs. | 让我们解释一下这些化验结果。
[.12]So this child's sodium is pretty low. | 这个孩子的血钠相当低。
[.80]Potassium is normal, I guess. | 血钾正常，我想。
[.30]Chloride is fine. | 氯正常。
[.98]Bicarb is low. | 碳酸氢根低。
[.04]Glucose is pretty low. | 血糖相当低。
[.90]Well, I guess glucose is fine. | 嗯，我想血糖还行。
[.90]And then it says the most appropriate pharmacotherapy for this patient targets which of the following receptors, right? | 然后它问，该患者最合适的药物治疗针对以下哪种受体，对吧？
[.06]So let's look at this for a second. | 让我们看一眼。
[.92]So you see a child with ambiguous genitalia. | 你看到一个两性畸形的孩子。
[.88]And you notice that this child has like hyponatremia, you know, has metabolic acidosis. | 你注意到这个孩子有低钠血症，你知道，还有代谢性酸中毒。
[.26]You probably want to think about congenital adrenal hyperplasia, right? | 你可能想到了先天性肾上腺皮质增生症 (CAH)，对吧？
[.76]Congenital adrenal hyperplasia is probably one of the most common causes of ambiguous genitalia in a newborn. | 先天性肾上腺皮质增生症可能是新生儿两性畸形最常见的原因之一。
[.58]And remember, what's the most common cause? It's the cause of CAH. | 记住，最常见的原因是什么？CAH 的原因。
[.46]Well, the most common cause is 21-hydroxylase deficiency. | 嗯，最常见的原因是 21-羟化酶缺乏症。
[.86]21-hydroxylase deficiency. | 21-羟化酶缺乏症。
[.44]So when you have 21-hydroxylase deficiency, remember, you're going to have an increase in your 17-hydroxyprogesterone. | 记住，当你患有 21-羟化酶缺乏症时，你的 17-羟孕酮会增加。
[.68]And one other thing you're going to notice is that you're not going to be able to make cortisol and you will not be able to make aldosterone. | 另一件事你会注意到的是你将无法产生皮质醇，也无法产生醛固酮。
[.76]So because you're not able to make aldosterone, you lose aldosterone effects, right? | 因为无法产生醛固酮，你会失去醛固酮的作用，对吧？
[.52]So instead of being able to reabsorb sodium in your kidneys, you can't. | 所以本该在肾脏重新吸收钠，你却做不到。
[.88]So you have hyponatremia. | 所以你有低钠血症。
[.08]Instead of being able to excrete potassium in your kidneys, you can't, right? | 本该在肾脏排出钾，你却做不到，对吧？
[.72]Right. You have to hold on to it. | 对。你只能留住它。
[.44]So you have hyperkalemia. | 所以你有高钾血症。
[.06]Although this person in this question does not have hyperkalemia, but we can see the potassium is at the upper range. | 虽然本题中的这个人没有高钾血症，但我们可以看到血钾处于上限。
[.46]And then also, you will not be able to excrete acid, right? | 此外，你也无法排酸，对吧？
[.24]So you hold on to that acid. | 所以你留住了那些酸。
[.54]So your acid is actually going to be pretty high. | 所以你的酸度实际上会很高。
[.94]You're going to have a low bicarb. | 你的碳酸氢根会很低。
[.00]Because you have a lot of acid, you're going to have a low bicarb, right? | 因为你有很多酸，所以你的碳酸氢根会低，对吧？
[.42]You're going to have a low bicarb. | 你的碳酸氢根会很低。
[.24]And many times, you're going to be hypotensive because, again, remember, aldosterone increases your blood volume and blood pressure, right? | 很多时候，你会出现低血压，因为再次记住，醛固酮会增加你的血容量和血压，对吧？
[.34]And because these people are not making cortisol, there's no negative feedback. | 因为这些人不产生皮质醇，所以没有负反馈。
[.48]So their ACTH levels will actually be high, right? | 所以他们的 ACTH 水平实际上会很高，对吧？
[.64]So this person has congenital adrenal hyperplasia. | 所以这个人患有先天性肾上腺皮质增生症。
[.02]So how are we going to fix this? | 那我们要如何解决这个问题？
[.72]So we're going to fix this by giving steroids to replace the cortisol they are not making and fludrocortisone to replace the aldosterone that they're not making. | 我们要通过给予类固醇来补充他们缺失的皮质醇，并给予氟氢可的松来补充他们缺失的醛固酮。
[.20]So we need to find an answer choice that targets either steroid receptors, like glucocorticoid receptors, or aldosterone receptors. | 因此，我们需要找一个针对类固醇受体（如糖皮质激素受体）或醛固酮受体的答案。
[.70]So the answer has to be option B, right? | 所以答案一定是选项 B，对吧？
[.76]Option A doesn't really make any sense. | 选项 A 真的没有什么意义。
[.86]Option C doesn't make any sense. | 选项 C 没有意义。
[.40]the drug i know that really targets a growth hormone is like growth hormone receptor antagonists | 我知道的真正针对生长激素的药物是生长激素受体拮抗剂。
[.70]you can use those for like gigantism or acromegaly that's big visumant big visumant (Pegvisomant) | 你可以将它们用于治疗巨人症或肢端肥大症，那是培维索孟。
[.70]again this person doesn't have a growth hormonal issue so the answer here is going to be option b all right | 同样，这个人没有生长激素问题，所以这里的答案将是选项 B，好的。
[.50]question 84 says a 60 year old woman is brought to the ed because of a 40 history of fever joint aches and rash | 第 84 题说，一名 60 岁女性因发热、关节痛和皮疹 4 天急诊就诊。
[.78]three weeks ago she was admitted to the hospital for treatment of staph virus endocarditis | 三周前，她因治疗金黄色蛋白球菌心内膜炎入院。
[.20]she has received 21 days out of a prescribed 42-day course of intravenous oxacillin | 在规定的 42 天静脉注射苯唑西林疗程中，她已接受了 21 天。
[.46]currently she appears to be mild distress temperature is 100.4 she's tachycardic | 目前她表现为轻度不适，体温 100.4 华氏度，心动过速。
[.14]she's tachypneic blood pressure is fine her pulse ox is fine she has a diffused maculopapular rash | 她呼吸急促，血压正常，脉搏血氧正常，有弥漫性斑丘疹。
[.66]over the trunk and upper and lower extremities no posterior thema at the skin insertion site | 累及躯干及四肢，皮肤置管处无红肿。
[.54]of the peripherally inserted central catheter line initially placed on the day of hospital discharge | 该经外周静脉穿刺中心静脉置管 (PICC) 是在出院当天放置的。
[.62]and then we'll look at her lab studies right so hemoglobin is | 然后我们看看她的实验室检查，血红蛋白是...
[.72]it's kind of low monocrate is kind of low looks like count is kind of high and you see that | 有点低，血细胞比容有点低，白细胞计数似乎有点高，你可以看到...
[.46]oh the eosinophils really jump out right nine percent okay | 哦，嗜酸性粒细胞非常显眼，对吧，9%，好的。
[.32]and then we look at her serum labs and her creatinine is is high creatinine is high | 然后我们看她的血清化验，她的肌酐很高，肌酐很高。
[.64]and then urine microscopy shows eosinophils and white blood cell cast | 尿液显微镜检查显示嗜酸性粒细胞和白细胞管型。
[.56]so which of the following is the most likely underlying cause of this patient's condition right | 那么，以下哪项是该患者状况最可能的潜在原因，对吧？
[.72]so what do we think is going on here again let's work this out we see a person | 那么我们认为这里发生了什么，让我们再次分析一下。
[.24]that got antibiotics especially like these mssa covering antibiotics like oxacillin | 一个人使用了抗生素，特别是像苯唑西林这样覆盖 MSSA 的抗生素。
[.34]dicloxacillin nafcillin and then now this person has like the classic classic fever | 双氯西林、萘夫西林，然后现在这个人出现了经典的...经典的发热。
[.64]right they have a rash sometimes they'll have joint pain and many times you're going to see | 对吧，他们有皮疹，有时会有关节痛，很多时候你会看到...
[.98]eosinophilia and sometimes you're going to see eosinophiluria right so elevated eosinophils in | 嗜酸性粒细胞增多，有时你会看到嗜酸性粒细胞尿，对吧，也就是尿中嗜酸性粒细胞升高。
