完整字幕请关注喜马拉雅：方块块xxl [00:21.52]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。 [00:28.66]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。 [00:33.84]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。 [00:37.86]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。 [00:41.26]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。 [00:46.26]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。 [00:51.42]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。 [00:56.44]The lower extremities appear thin. | 下肢显得纤细。 [00:57.90]Her blood pressure is 145 over 98. | 她的血压是 145/98。 [00:58.64]Results of lab studies are shown. | 实验室检查结果如下。 [00:58.66]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。 [01:00.10]Metanephrine is fine. Cortisol is elevated. | 变肾上腺素正常。皮质醇升高。 [01:00.96]ACTH activity is a little bit high. | ACTH 活性有点高。 [01:05.82]Aldosterone is fine. | 醛固酮正常。 [01:06.42]Urine 24-hour cortisol excretion is high, right? | 24 小时尿皮质醇排泄量很高，对吧？ [01:09.38]340 micrograms in 24 hours. | 24 小时内为 340 微克。 [01:09.82]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？ [01:13.96]So this question is pretty straightforward, right? | 所以这个问题很直接，对吧？ [01:14.16]This person seems to have like Cushing syndrome, right? | 这个人似乎患有库欣综合征，对吧？ [01:16.02]She has the purple striae, has the abdominal obesity, right? | 她有紫色条纹，有腹部肥胖，对吧？ [01:16.54]And we see that she has fractures. | 我们看到她有骨折。 [01:18.84]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？ [01:19.60]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。 [01:21.50]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。 [01:22.20]And then that activates the osteoclasts. | 然后这会激活破骨细胞。 [01:26.38]And then your bones get resorbed. | 然后你的骨骼就会被吸收。 [01:28.40]And that can weaken your bones. | 这会削弱你的骨骼。 [01:30.80]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？ [01:34.18]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。 [01:36.68]That's going to hit your rank receptor on the osteoclasts. | 这将击中破骨细胞上的 RANK 受体。 [01:37.36]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。 [01:40.90]So the answer here is probably option D. | 所以这里的答案很可能是选项 D。 [01:41.52]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？ [01:49.24]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。 [01:49.24]So rank ligand. | 也就是结合 RANK 配体。 [01:56.24]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。 [01:56.84]So you'll resorb bone. | 这样你就减少了骨吸收。 [01:58.30]And that can weaken your bones. | 那样会削弱骨质。 [01:59.74]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？ [01:59.90]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。 [02:01.04]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。 [02:01.76]Denosumab is a rank ligand inhibitor. | 地舒单抗是一种 RANK 配体抑制剂。 [02:05.86]It's a monoclonal antibody. | 它是一种单克隆抗体。 [02:06.08]It grants rank ligand. | 它针对 RANK 配体。 [02:10.96]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。 [02:11.04]All right. | 好的。 [02:14.20]So just know that. | 只要知道这一点。 [02:14.20]So the answer here has to be option D. | 所以这里的答案一定是选项 D。 [02:18.10]Really, like. | 真的，就像。 [02:18.18]So steroids do not increase osteoblast proliferation or. | 所以类固醇不会增加成骨细胞增殖或... [02:19.66]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。 [02:20.38]They actually decrease calcium absorption. | 它们实际上减少了钙的吸收。 [02:24.52]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。 [02:27.96]So steroids cause you to actually decrease calcium absorption. | 类固醇实际上会导致你钙吸收减少。 [02:28.30]So option A is wrong. | 所以选项 A 是错误的。 [02:29.04]Calcium excretion didn't really have much to do with that. | 钙排泄与此关系不大。 [02:29.74]Phosphorus. | 磷。 [02:34.34]Again, steroids don't really do much with phosphorus. | 同样，类固醇对磷并没有太大作用。 [02:34.48]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？ [02:35.34]Well. | 嗯。 [02:35.88]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。 [02:40.54]Right. | 对。 [02:41.48]So it can increase blood volume, increase blood pressure. | 所以它可以增加血容量，升高血压。 [02:44.24]The works. | 诸如此类。 [02:44.44]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。 [02:46.12]Right. | 对吧。 [02:46.24]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。 [02:47.28]All right. | 好的。 [02:48.70]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。 [02:52.94]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。 [02:53.24]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。 [02:53.44]Menses are current regular 20 day intervals. | 月经规律，周期为 20 天。 [02:53.58]She's currently menstruating and using a tampon. | 她目前正处于经期并使用卫生棉条。 [02:54.36]She appears anxious. | 她显得很焦虑。 [02:55.62]Temperature is 98.6. | 体温是 98.6 华氏度。 [02:56.74]She's tachycardic, tachypneic, hypotensive. | 她心动过速、呼吸急促、血压低。 [02:57.46]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%。 [02:58.30]She has flushing and diaphoresis. | 她面色潮红，大汗淋漓。 [03:02.42]Cardiopulmonary exam shows no other abnormalities. | 心肺检查未见其他异常。 [03:03.12]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？ [03:06.86]Again, let's work this out first. | 同样，让我们先分析一下。 [03:07.00]Right. | 对吧。 [03:08.34]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。 [03:14.74]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。 [03:15.48]The person is diaphoretic. | 这个人大汗淋漓。 [03:18.18]The person is hypotensive, tachycardic, tachypneic. | 这个人血压低、心动过速、呼吸急促。 [03:18.44]Right. | 对吧。 [03:19.38]This is pretty classic for the Jarish-Hexheimer reaction. | 这是非常典型的赫氏反应 (Jarish-Hexheimer reaction)。 [03:19.96]The Jarish-Hexheimer reaction. | 赫氏反应。 [03:21.90]Right. | 对。 [03:23.58]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。 [03:24.04]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。 [03:25.62]Right. | 对。 [03:26.18]So basically, it's like you get an antibiotic. | 所以基本上，就像你使用了抗生素。 [03:28.08]You explode the bug. | 你让病菌“爆炸”了。 [03:32.30]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。 [03:33.42]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。 [03:33.70]You know, you release all this IL-6, TNFR. | 你知道，你会释放所有这些 IL-6、TNFR。 [03:35.76]And that causes that inflammatory reaction. | 这引起了炎症反应。 [03:36.04]That's what causes these symptoms. | 这就是导致这些症状的原因。 [03:36.42]Right. | 对吧。 [03:37.04]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。 [03:40.56]A thing that causes leptospirosis. | 引起钩端螺旋体病的东西。 [03:40.64]Remember, if you go to Hawaii and swim. | 记住，如果你去夏威夷游泳。 [03:40.82]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。 [03:44.08]Right. | 对。 [03:44.28]Like in this person. | 就像在这个人身上一样。 [03:45.08]Right. | 对吧。 [03:53.68]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。 [03:54.16]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。 [03:57.62]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。 [03:58.30]You can also give steroids. | 你也可以给类固醇。 [04:01.30]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。 [04:03.12]Steroids have not been shown to really do much. | 类固醇尚未被证明有很大作用。 [04:04.96]But ibuprofen really helps. | 但布洛芬确实有帮助。 [04:07.06]All right. | 好的。 [04:08.92]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。 [04:11.86]That's wrong. | 那是错的。 [04:14.62]Right. | 对吧。 [04:16.54]The infection is not getting worse. | 感染并没有变得更糟。 [04:18.82]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。 [04:22.24]Option B says infection-mediated sepsis. | 选项 B 说是感染介导的败血症。 [04:23.62]No. | 不是。 [04:27.94]Infection-mediated sepsis can arise quickly. | 感染介导的败血症可能会迅速出现。 [04:30.62]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。 [04:31.66]Right. | 对吧。 [04:34.02]That usually takes a little more time. | 那通常需要更多的时间。 [04:34.80]Right. | 对吧。 [04:37.98]Ig-mediated allergic reaction to doxycycline. | Ig 介导的对多西环素的过敏反应。 [04:39.34]No. | 不。 [04:40.16]The person doesn't have like. | 这个人没有像... [04:43.10]Airway problems. | 呼吸道问题。 [04:45.50]So that's wrong. | 所以那是错的。 [04:45.82]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。 [04:48.24]Yeah. | 是的。 [04:49.46]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。 [04:53.36]And then option E, secretion of bacterial endotoxins. | 然后选项 E，细菌内毒素的分泌。 [04:55.96]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。 [04:58.06]But that's not what's going on here. | 但这不是这里发生的情况。 [05:00.42]Right. | 对。 [05:02.04]So the answer here is going to be option D. | 所以这里的答案将是选项 D。 [05:07.98]All right. | 好的。 [05:08.48]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。 [05:10.04]The mother received no prenatal care. | 母亲未接受产前检查。 [05:11.80]Spontaneous vaginal delivery was uncomplicated. | 经阴道分娩顺产，无并发症。 [05:15.14]The mother's only medication. Most of prenatal vitamin. | 母亲唯一的药物，大多是产前维生素。 [05:16.48]The newborn's length is in the 39th percentile. | 新生儿的身长处于第 39 百分位。 [05:20.22]Weight is in the 30th percentile. | 体重处于第 30 百分位。 [05:23.02]Head circumference is in the 12th percentile. | 头围处于第 12 百分位。 [05:26.72]So everything is fine from that perspective. | 所以从这个角度来看一切都好。 [05:27.10]And this newborn, you know, 98.6 for temperature. | 这个新生儿，你知道，体温 98.6 华氏度。 [05:28.06]Pulse is 134 per minute. | 脉搏每分钟 134 次。 [05:30.54]Respirations are 38 per minute. | 呼吸每分钟 38 次。 [05:33.34]And blood pressure is 73 over 50. | 血压是 73/50。 [05:34.74]Physical exam shows ambiguous genitalia. | 体格检查显示两性畸形（模糊外生殖器）。 [05:38.72]Results from several studies are shown. | 几项研究的结果如下。 [05:39.46]Right. | 对。 [05:40.00]So let's interpret these labs. | 让我们解释一下这些化验结果。 [05:41.12]So this child's sodium is pretty low. | 这个孩子的血钠相当低。 [05:42.80]Potassium is normal, I guess. | 血钾正常，我想。 [05:45.30]Chloride is fine. | 氯正常。 [05:47.98]Bicarb is low. | 碳酸氢根低。 [05:51.04]Glucose is pretty low. | 血糖相当低。 [05:53.90]Well, I guess glucose is fine. | 嗯，我想血糖还行。 [05:56.90]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？ [05:58.06]So let's look at this for a second. | 让我们看一眼。 [05:58.92]So you see a child with ambiguous genitalia. | 你看到一个两性畸形的孩子。 [06:03.88]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。 [06:04.26]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？ [06:06.76]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。 [06:09.58]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。 [06:11.46]Well, the most common cause is 21-hydroxylase deficiency. | 嗯，最常见的原因是 21-羟化酶缺乏症。 [06:12.86]21-hydroxylase deficiency. | 21-羟化酶缺乏症。 [06:14.44]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。 [06:19.68]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。 [06:22.76]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？ [06:24.52]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。 [06:26.88]So you have hyponatremia. | 所以你有低钠血症。 [06:28.08]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？ [06:32.72]Right. You have to hold on to it. | 对。你只能留住它。 [06:34.44]So you have hyperkalemia. | 所以你有高钾血症。 [06:36.06]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。 [06:41.46]And then also, you will not be able to excrete acid, right? | 此外，你也无法排酸，对吧？ [06:43.24]So you hold on to that acid. | 所以你留住了那些酸。 [06:44.54]So your acid is actually going to be pretty high. | 所以你的酸度实际上会很高。 [06:45.94]You're going to have a low bicarb. | 你的碳酸氢根会很低。 [06:48.00]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？ [06:49.42]You're going to have a low bicarb. | 你的碳酸氢根会很低。 [06:51.24]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？ [06:53.34]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。 [06:56.48]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？ [07:00.64]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。 [07:02.02]So how are we going to fix this? | 那我们要如何解决这个问题？ [07:04.72]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。 [07:08.20]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。 [07:11.70]So the answer has to be option B, right? | 所以答案一定是选项 B，对吧？ [07:14.76]Option A doesn't really make any sense. | 选项 A 真的没有什么意义。 [07:17.86]Option C doesn't make any sense. | 选项 C 没有意义。 [09:13.40]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。 [09:19.70]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。 [09:22.70]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。 [09:28.50]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。 [09:33.78]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。 [09:39.20]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。 [09:45.46]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。 [09:51.14]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。 [09:55.66]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。 [10:00.54]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。 [10:03.62]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... [10:08.72]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... [10:14.46]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。 [10:19.32]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。 [10:22.64]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。 [10:26.56]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？ [10:31.72]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。 [10:36.24]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。 [10:41.34]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。 [10:45.64]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... [10:50.98]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。

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完整字幕请关注喜马拉雅：方块块xxl [09:44.72] You get a question about a newborn. | 你遇到一道关于新生儿的题。 [09:47.06] Right? | “对吧？” [09:47.22] The newborn had phenomenal abguards at birth. | 新生儿出生时阿普加评分非常好。 [09:50.00] The newborn was completely fine. | 新生儿完全正常。 [09:52.40] Right? | “对吧？” [09:52.96] Newborn was completely fine. | 新生儿非常健康。 [09:54.44] And then. | 然后。 [09:55.84] You know. | 你知道。 [09:56.16] Like 12 hours after birth. | 出生后 12 小时。 [09:57.56] 24 hours after birth. | 出生后 24 小时。 [09:59.46] The child starts sweating with feeds. | 孩子在喂奶时开始出汗。 [10:01.28] Right? | “对吧？” [10:01.62] Or the child starts becoming profoundly hypoxic. | 或者孩子开始出现严重的缺氧。 [10:04.08] And you're giving this child supplemental oxygen. | 你给孩子吸氧。 [10:06.02] And it's not helping. | 但没起作用。 [10:07.18] That's a very classic presentation. | 这是一个非常经典的临床表现。 [10:09.34] Of a cyanotic congenital heart defect. | 发绀型先天性心脏病。 [10:11.74] Right? | “对吧？” [10:12.08] Of a cyanotic congenital heart defect. | 发绀型先天性心脏病的表现。 [10:14.08] The thing is. | 关键在于。 [10:14.76] Why do I put this under the pattern of cloaked questions? | 为什么我把它归类为“隐身题目”？ [10:17.26] The thing is. | 事实是。 [10:17.74] Sometimes. | 有时。 [10:18.22] People are not. | 考生们。 [10:19.16] They don't even pick up. | 他们根本察觉不到。 [10:20.00] On this at all. | 完全意识不到这一点。 [10:20.90] Because they're like. | 因为他们觉得。 [10:21.44] Oh. | “噢。” [10:21.60] Everything seemed fine. | “一切看起来都挺好。” [10:22.88] Right? | “对吧？” [10:23.70] And then. | 然后。 [10:24.02] Why did things go bad? | “为什么情况变糟了？” [10:25.22] That's a cloaked question. | 这就是隐身题目。 [10:27.06] That's a cloaked question. | 这就是隐藏了考点的题目。 [10:28.42] Another classic cloaked question example is. | 另一个经典的隐身题目例子是。 [10:31.00] The inborn errors of metabolism. | 先天性代谢异常。 [10:33.38] Right? | “对吧？” [10:33.88] So you notice. | 你会注意到。 [10:34.74] You know. | 你知道。 [10:35.00] The baby is completely fine at birth. | 婴儿出生时完全正常。 [10:37.40] They go home. | 他们回了家。 [10:38.70] Right? | “对吧？” [10:39.18] And then a few days. | 然后过了几天。 [10:40.10] Few weeks later. | 几周后。 [10:41.08] The baby just starts crashing and burning. | 婴儿的情况突然急转直下。 [10:42.80] Right? | “对吧？” [10:43.16] They start becoming lethargic. | 他们开始变得萎靡不振。 [10:44.44] They start having poor feeding. | 他们开始喂养困难。 [10:45.54] They start having vomiting. | 他们开始呕吐。 [10:46.34] They start having seizures. | 他们开始抽搐。 [10:48.04] Right? | “对吧？” [10:48.50] Many times. | 很多时候。 [10:48.96] They'll have a distinct. | 他们会有一个明显的特征。 [10:50.00] Fail. | 衰竭。 [10:50.52] Right? | “对吧？” [10:50.92] When you see this. | 当你看到这种情况。 [10:52.36] Think of an inborn error of metabolism. | 要想到先天性代谢异常。 [10:54.34] It's a kind of cloaked question. | 这也是一种隐身题目。 [10:56.76] Right? | “对吧？” [10:57.10] So the fact that. | 事实上。 [10:57.98] Something starts off right. | 事情一开始很顺利。 [10:59.46] For a child. | 对一个孩子来说。 [11:00.32] Does not mean that. | 并不意味着。 [11:01.58] Things are going to stay right. | 情况会一直好下去。 [11:03.20] Right? | “对吧？” [11:03.62] Because the thing is. | 原因是。 [11:04.60] When you're in the womb. | 当你在子宫里时。 [11:05.88] Mom. | 妈妈。 [11:06.68] Does a lot of the heavy lifting. | 承担了大部分的代谢工作。 [11:08.18] For you. | 为你。 [11:08.84] Right? | “对吧？” [11:09.30] Literally. | 事实上。 [11:09.88] Her metabolism handles. | 她的代谢处理了。 [11:11.38] Practically everything. | 几乎所有事情。 [11:12.58] Right? | “对吧？” [11:13.22] If the baby cannot process things. | 如果宝宝不能处理某些物质。 [11:14.88] Guess what? | 你猜怎么着？ [11:15.30] Just outsource your problem. | 把问题“外包”给。 [11:16.74] To the placenta. | 胎盘。 [11:17.46] The placenta is going to deal with it. | 胎盘会处理它。 [11:18.68] For you. | 为你。 [11:19.30] Right? | “对吧？” [11:20.00] But once the baby starts. | 但一旦宝宝开始。 [11:21.52] Feeding independently. | 独立进食。 [11:22.72] Metabolizing independently. | 独立代谢。 [11:23.60] Then that inborn error of metabolism. | 那么那种先天性代谢异常。 [11:25.16] That enzyme defect they have. | 他们所携带的酶缺陷。 [11:27.18] It becomes apparent. | 就会变得显而易见。 [11:28.90] It begins to show up. | 就会开始显现出来。 [11:31.68] Right? | “对吧？” [11:32.12] It begins to show up. | 开始发病。 [11:33.14] Right? | “对吧？” [11:33.50] So like. | 所以。 [11:34.08] Just keep this in mind. | 请记住这一点。 [11:35.32] This is something that. | 这就是。 [11:36.46] Like this cloaked question business. | 这种隐身题目的套路。 [11:38.82] Is something that shows up a lot in pediatrics. | 在儿科题目中经常出现。 [11:41.08] Right? | “对吧？” [11:41.64] So like. | 比如。 [11:42.20] You know. | 你知道。 [11:42.42] Like PKU. | 比如苯丙酮尿症（PKU）。 [11:43.04] A child that has PKU. | 一个患有 PKU 的孩子。 [11:44.34] Is going to. | 将会。 [11:44.86] Is going to be completely fine in the hospital. | 在医院里会完全正常。 [11:47.18] But it's a few days. | 但在几天后。 [11:48.42] A few weeks after they've gone home. | 在他们回家几周后。 [11:49.82] You're going. | 你将会。 [11:50.00] To start seeing problems. | 开始看到问题。 [11:51.18] Right? | “对吧？” [11:51.54] Same thing with maple syrup urine disease. | 枫糖尿病也是一样。 [11:53.66] Right? | “对吧？” [11:53.92] Where you have an issue with branching. | 当你的支链。 [11:55.24] Ketoacetic dehydrogenase. | α-酮酸脱氢酶出现问题。 [11:56.80] Right? | “对吧？” [11:57.00] Again. | 再次。 [11:57.70] Child's going to be completely normal at birth. | 孩子出生时完全正常。 [11:59.86] But as they go home. | 但当他们回家后。 [12:01.00] As they stay home for a few days. | 当他们在家里待了几天。 [12:02.22] You start seeing problems. | 你就开始看到问题。 [12:03.22] Galactosemia. | 半乳糖血症。 [12:05.00] Same deal. | 也是一样的情况。 [12:05.50] Same deal. | 也是一样。 [12:06.78] Right? | “对吧？” [12:07.08] Same deal. | 也是同理。 [12:08.24] Galactosemia is going to be the exact same deal. | 半乳糖血症也是完全一样。 [12:10.12] Right? | “对吧？” [12:10.72] Galactos 1. | 半乳糖-1-。 [12:11.34] Phosphate urinal transferase deficiency. | 磷酸尿苷酰转移酶缺乏症。 [12:13.16] Again. | 再次。 [12:13.78] They start off fine. | 他们起初没事。 [12:15.32] And then they get a few. | 然后他们喝了几。 [12:18.06] You know. | 你知道。 [12:18.70] Rounds of breast milk under their belt. | 几顿母乳下肚。 [12:20.00] And then they start having problems. | 然后他们就开始出现问题。 [12:21.70] Right? | “对吧？” [12:21.98] So again. | 所以。 [12:23.26] Baby is fine at birth. | 宝宝出生时很好。 [12:25.14] Right? | “对吧？” [12:25.66] Baby is fine at birth. | 宝宝出生时完全健康。 [12:26.88] Right? | “对吧？” [12:27.32] And then things start deteriorating. | 然后情况开始恶化。 [12:28.72] When you see those things like that. | 当你看到这类情况。 [12:30.22] Think of. | 想到。 [12:31.16] An inborn error of metabolism. | 先天性代谢异常。 [12:33.36] Right? | “对吧？” [12:34.04] The thing is. | 事实是。 [12:34.68] The USML is. | USMLE 在。 [12:35.38] When they want to cloak things in adults. | 当他们想在成人题目中隐藏考点时。 [12:37.58] Many times. | 很多时候。 [12:38.50] They will give you. | 他们会给你。 [12:39.40] Like an offshoot presentation. | 某种非典型的表现。 [12:40.58] Of a main disease. | 某种主要疾病的分支表现。 [12:42.10] Right? | “对吧？” [12:42.74] In fact. | 事实上。 [12:43.26] Let me just. | 让我。 [12:44.02] Maybe make this. | 或许把这个。 [12:45.74] Pattern number three. | 归为模式三。 [12:47.04] Cloak presentation. | 隐藏的表现形式。 [12:48.48] Right? | “对吧？” [12:49.30] Offshoot presentation. | 衍生出来的表现。 [12:50.00] Of a main disease. | 某种主要疾病的非典型表现。 [12:51.04] Let me explain what I mean. | 让我解释一下我的意思。 [12:52.06] By offshoot presentation. | 所谓的衍生表现。 [12:53.76] Of a main disease. | 即主要疾病的某种分支表现。 [12:54.20] By offshoot presentation. | 所谓的衍生表现。 [12:55.26] Of a main disease. | 某种主要疾病的表现。 [12:55.96] I mean that. | 我的意思是。 [12:56.64] Hey. | 嘿。 [12:57.22] There is a main disease. | 存在一种主要疾病。 [12:59.02] But. | 但是。 [12:59.64] They take an offshoot of it. | 他们提取了它的一个分支。 [13:01.32] And test just that offshoot. | 并且只考那个分支。 [13:02.66] That's a very good way. | 这是一个非常好的方式。 [13:03.94] To cloak a concept. | 去隐藏一个概念。 [13:04.96] And make people not realize that. | 并让人们意识不到。 [13:06.76] Oh. | “噢。” [13:06.94] This is what this person is testing. | “这才是考题真正要考的内容。” [13:09.02] Right? | “对吧？” [13:09.52] Like I give you a classic example. | 我给你举一个经典的例子。 [13:11.02] Of this. | 关于这个。 [13:12.30] A good classic example. | 一个很好的经典例子。 [13:14.18] Will be testing. | 将会测试。 [13:17.36] Let's see. | 让我看看。 [13:17.98] Let me try to think of an example. | 让我试着想一个例子。 [13:19.16] Again. | 再次。 [13:19.42] Sorry. | 抱歉。 [13:19.74] This is kind of off the cuff. | 这是临时想到的。 [13:20.74] So. | 所以。 [13:21.14] I'm trying to. | 我在试着。 [13:22.56] You know. | 你知道。 [13:22.96] Think of an example here. | 在这里想一个例子。 [13:24.88] But a good example. | 但一个好例子。 [13:25.78] Will be something along the lines of. | 大概会是这样的。 [13:29.02] Okay. | 好了。 [13:29.58] So let's say for example. | 假设举个例子。 [13:31.18] A person has. | 一个人患有。 [13:35.68] A person has. | 一个人患有。 [13:37.34] Giant cell arteritis. | 巨细胞动脉炎。 [13:39.10] Right? | “对吧？” [13:39.52] A person has giant cell arteritis. | 一个患有巨细胞动脉炎的人。 [13:41.32] And then. | 然后。 [13:42.44] They get in an accident. | 他们出了一场事故。 [13:43.84] And become profoundly hypotensive. | 并且出现了严重的低血压。 [13:46.44] Right? | “对吧？” [13:47.36] And they tell you that. | 题目告诉你。 [13:48.34] Hey. | “嘿。” [13:48.46] This person has been given fluids. | “这个人已经补液了。” [13:49.64] And they have been given. | “并且已经给予了治疗。” [13:50.42] And all that stuff. | 等等。 [13:50.54] And it's not. | 但没起作用。 [13:51.40] Their blood pressures are just not. | 他们的血压就是。 [13:53.14] Budging at all. | 完全没有回升。 [13:54.36] Right? | “对吧？” [13:55.34] And then you notice that the right answer is. | 然后你发现正确答案是。 [13:57.00] Adrenaline sufficiency. | 肾上腺功能不全。 [13:57.96] And you're like. | 然后你会想。 [13:58.68] What in the world is this? | “这到底是什么鬼？” [14:01.22] Well. | 好的。 [14:02.16] That's where you need to start making links. | 这就是你需要开始建立联系的地方。 [14:04.36] Right? | “对吧？” [14:05.16] The concept was cloaked. | 这个概念被隐藏了。 [14:06.90] By GCA. | 被巨细胞动脉炎（GCA）隐藏了。 [14:07.98] Right? | “对吧？” [14:08.40] Because our friends at the NBMEs. | 因为 NBME 的出题老师。 [14:10.26] They know that. | 他们知道。 [14:10.48] Oh. | “噢。” [14:10.96] People think. | “人们会想。” [14:11.24] Oh. | “噢。” [14:11.66] GCA. | “GCA。” [14:12.22] You know. | 你知道。 [14:13.26] One over 50. | 50 岁以上的女性。 [14:15.34] Right? | “对吧？” [14:15.78] She has like. | 她有。 [14:16.44] Unilateral eye pain. | 单侧眼痛。 [14:17.72] Unilateral headache. | 单侧头痛。 [14:18.66] Right? | “对吧？” [14:19.30] Sometimes. | 有时。 [14:19.54] You may see the association. | 你可能会看到这种关联。 [14:20.50] With polymyalgia rheumatica. | 与风湿性多肌痛的关联。 [14:22.10] Right? | “对吧？” [14:22.86] That's what most people know about GCA. | 这是大多数人对 GCA 的了解。 [14:24.58] And hey. | 而且。 [14:25.08] You know. | 你知道。 [14:25.56] They can go blind. | 他们可能会失明。 [14:26.68] It's a large vessel vasculitis. | 这是一种大血管炎。 [14:30.14] People know those things. | 人们知道这些。 [14:30.56] That's fine. | 没问题。 [14:31.60] Right? | “对吧？” [14:32.10] But. | 但是。 [14:32.10] They can use it as a way to test. | 他们可以利用它来测试。 [14:34.40] Adrenaline sufficiency. | 肾上腺功能不全。 [14:36.34] Where. | 在哪里。 [14:36.76] Where's the link? | 联系在哪里？ [14:37.46] Well. | 好的。 [14:38.22] Think about it. | 想想看。 [14:38.28] When a person has GCA. | 当一个人患有 GCA 时。 [14:39.52] They have to be on high dose steroids. | 他们必须服用大剂量的类固醇。 [14:40.94] For months. | 长达数月。 [14:42.36] Right? | “对吧？” [14:43.32] That's going to suppress. | 那会抑制。 [14:44.48] ACTH production. | ACTH（促肾上腺皮质激素）的产生。 [14:45.26] If you suppress ACTH production. | 如果你抑制了 ACTH 的产生。 [14:47.82] That is literally going to stop your adrenal cortex from being stimulated. | 那实际上会停止对肾上腺皮质的刺激。 [14:52.28] Right? | “对吧？” [14:53.18] But again. | 但是。 [14:53.90] That's not a problem. | 只要你的生活压力水平没变，这就不是问题。

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完整字幕请关注喜马拉雅：方块块xxl [00:32.56] 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， [00:40.70] 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。 [00:47.02] 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？ [00:54.50] 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。 [00:59.52] Option D is poliomyelitis. Option E is typhoid fever. | 选项 D 是脊髓灰质炎。选项 E 是伤寒。 [01:03.86] 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？ [01:07.86] 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？ [01:13.44] From an egg allergy. | 源于鸡蛋过敏。 [01:15.06] 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？ [01:19.68] 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。 [01:26.44] So the vaccines may contain ovalbumin. | 因此，这些疫苗可能含有卵清蛋白。 [01:29.52] 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， [01:36.02] influenza and yellow fever. | 比如流感疫苗和黄热病疫苗。 [01:37.64] 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。 [01:44.28] 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， [01:47.96] and you probably just monitor them for like a half hour or something | 观察大约半小时左右， [01:50.72] 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。 [01:53.58] But actually, it's very high-yield-to-know-this. | 但实际上，了解这一点非常重要。 [01:55.84] An egg allergy is not a contraindication to the influenza. | 鸡蛋过敏不是流感的禁忌症。 [01:59.52] 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）。 [02:01.50] 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。 [02:05.98] O-V-A-L-B-U-M-I-N. | O-V-A-L-B-U-M-I-N。 [02:10.32] Ovalbumin. | 卵清蛋白。 [02:12.90] 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？ [02:16.08] 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？ [02:20.30] 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。 [02:23.58] All right, question 12. | 好了，第 12 题。 [02:24.84] 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。 [02:28.80] Because of confusion. | 因为意识模糊。 [02:29.52] Diplopia. | 复视。 [02:31.94] A mild weakness of his right arm. | 右臂轻微无力。 [02:34.34] 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。 [02:38.74] Temperature is 100.1 degrees Fahrenheit. | 体温为 100.1 华氏度。 [02:42.08] 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。 [02:47.70] Peripheral leukocyte count is increased. | 外周白细胞计数升高。 [02:50.18] 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？ [03:01.40] You know, the person has fever. | 你知道，患者有发热。 [03:03.66] The person has altered mental status, right? | 意识状态改变，对吧？ [03:07.80] Is agitated, right? | 表现烦躁，对吧？ [03:11.50] 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？ [03:14.92] 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。 [03:18.86] 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？ [03:22.40] I think this is a good question. | 我觉得这是一道很好的题目。 [03:23.50] So option A says bilateral carotid arteriography. | 选项 A 是双侧颈动脉血管造影。 [03:27.18] Option B says CT scan of the head. | 选项 B 是头部 CT 扫描。 [03:29.10] Option C says EEG. | 选项 C 是脑电图。 [03:31.14] Option D says LP for examination of CSF. | 选项 D 是腰椎穿刺以检查脑脊液。 [03:34.38] Option E says serum HIV antibody test. | 选项 E 是血清 HIV 抗体测试。 [03:37.58] 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。 [03:43.62] 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。 [03:47.86] HIV, you're not going to die from HIV right now. | HIV，你现在不会死于 HIV。 [03:50.26] 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。 [03:53.26] And this acute complaint involves neurologic dysfunction. | 这种急性症状涉及神经功能障碍。 [03:56.04] You know, he probably has meningitis or something like that. | 你知道，他可能有脑膜炎之类的。 [03:59.46] 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。 [04:04.60] And you're seeing all these neuro deficits. | 并且你看到了所有这些神经功能缺损。 [04:06.96] A lumbar puncture initially is contraindicated. | 最初是禁忌进行腰椎穿刺的。 [04:09.68] You want to go ahead and do a CT of the head first. | 你应该先做头部 CT。 [04:12.44] 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。 [04:17.50] So I will say option B, right? | 所以我会说选选项 B，对吧？ [04:19.62] A CT of the head makes sense here. | 在这里做头部 CT 是合理的。 [04:21.76] 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。 [04:26.94] And then after I fix his acute complaints, then I go, | 在处理完他的急性主诉后，我会， [04:29.10] 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。 [04:33.00] 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。 [04:37.52] 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。 [04:47.72] So question number 13. | 那么，第 13 题。 [04:49.18] 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。 [04:54.34] He is disoriented and complains about his vision. | 他神志不清并抱怨视力有问题。 [04:56.88] 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。 [05:00.16] 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。 [05:05.60] You last saw him two weeks ago at that visit. | 你两周前在那次就诊中见过他。 [05:10.08] 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。 [05:15.92] 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）。 [05:20.98] His pulse is 110 and his blood pressure is 190 over 70. | 脉搏 110 次/分，血压 190/70 mmHg。 [05:25.12] On physical examination, | 体格检查显示， [05:28.32] 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。 [05:32.58] Which of the following is the most appropriate test at this time? | 此时最合适的检查是什么？ [05:35.22] Option A says blood cultures. | 选项 A 是血培养。 [05:36.66] Option B says chest x-ray. | 选项 B 是胸部 X 光检查。 [05:38.02] Option C says hemoglobin A1c. | 选项 C 是糖化血红蛋白 A1c。 [05:40.80] Option D says HIV antibody titer. | 选项 D 是 HIV 抗体滴度。 [05:43.86] Option E says plasma radian activity. | 选项 E 是血浆肾素活性（renin）。 [05:49.22] So what do we think this guy has? | 我们认为这个人得了什么病？ [05:54.22] We see this weird phondoscopic exam. | 我们看到了这个奇怪的眼底检查。 [06:00.04] We see that he has a history of IV drug use. | 我们看到他有静脉吸毒史。 [06:06.82] He has a fever. | 他有发热。 [06:08.52] He's tachycardic. | 心动过速。 [06:10.12] He has a white pulse pressure. | 他有脉压增宽（wide pulse pressure）。 [06:15.12] Just so many things here are pointing to endocarditis. | 这里的许多迹象都指向内膜炎。 [06:19.42] 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。 [06:26.88] Well, look at this hemorrhage in his eye. | 瞧，他眼底有出血。 [06:29.48] And he has all these punctates, you know, like whitish. | 还有这些点状物，白色的。 [06:36.62] Those are rough spots. | 那些是 Roth 点（Roth spots）。 [06:38.14] This guy has endocarditis. | 这个人患有内膜炎。 [06:40.62] 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。 [06:49.08] 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。 [06:58.80] 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。 [07:07.66] So I'd go with option A here. | 所以这里我选选项 A。 [07:15.10] 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。 [07:33.26] Oh, you know, his blood pressure is 190 over 70. | 哦，你知道，他的血压是 190/70。 [07:50.78] 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。 [07:53.86] 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。 [08:07.94] 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）， [08:17.12] 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。 [08:26.12] 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。 [08:28.92] 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。 [08:33.44] 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。 [08:41.78] He drinks two to three beers daily. | 他每天喝两到三瓶啤酒。 [08:52.76] So, his anti-HEV is positive. | 他的抗-HAV 阳性（HAV 为 A 型肝炎）。 [08:56.20] Anti-HPS, anti-AV surface is negative. | 抗-HBs（乙肝表面抗体）阴性。 [08:58.38] Hebisophis antigen is positive. | 乙肝表面抗原（HBsAg）阳性。 [08:58.68] Hebe antigen is positive. | HBeAg（E抗原）阳性。 [09:03.06] Which of the following is the most appropriate next step? | 以下哪项是最合适的下一步？ [09:05.80] Option A says, begin interferon-alpha therapy. | 选项 A 是开始干扰素-α 治疗。 [09:07.82] Option B says, begin corticosteroid therapy. | 选项 B 是开始皮质类固醇治疗。 [09:08.70] 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。 [09:13.38] Option D says, order hep B virus PCR tests. | 选项 D 是订购乙肝病毒 PCR 检测。 [09:17.76] Option E says, schedule liver biopsy. | 选项 E 是安排肝活检。 [09:24.26] So, this guy definitely has active hep B. | 所以，这个人肯定患有活动性乙肝。 [09:59.28] 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。 [10:21.90] Chronic hep B, if you want to manage it. | 慢性乙肝，如果你想治疗的话。 [10:40.62] 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。 [11:00.22] 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。 [11:05.86] 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。 [11:29.62] 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。 [11:53.24] So, I'm going to go with option C for that. | 所以我选选项 C。 [11:56.22] Let's go to question number 15. | 来看第 15 题。 [11:58.08] A 75-year-old white woman returns to the office. | 一名 75 岁的白人妇女回到诊所。 [12:01.80] 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。 [12:06.96] 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。 [12:16.34] 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。 [12:26.94] She says, I'm doing fine except for shakiness in my hands. | 她说，除了手抖外，我一切都好。 [12:32.60] She also says her mood is a little depressed. | 她还说她的心情有点抑郁。 [12:38.66] 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）。

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完整字幕请关注喜马拉雅：方块块xxl 00:13 A 57-year-old man who manages his own accounting firm has a 5-year history of malignant melanoma | 一位经营自己会计师事务所的 57 岁男性，有 5 年的恶性黑色素瘤病史， 00:18 that has been treated with local excision and immunotherapy. | 曾接受过局部切除和免疫治疗。 00:22 He now is admitted to the hospital for evaluation of constant pain in his back and left hip | 他现在住院以评估背部和左髋部的持续疼痛， 00:28 and an 11-kilogram or 24-pound weight loss. | 以及 11 公斤（24 磅）的体重减轻。 00:33 He and his wife of 35 years are worried that the cancer may be back. | 他和结婚 35 年的妻子担心癌症可能复发了。 00:38 Pelvic and abdominal CT scans show multiple bony metastases. | 盆腔和腹部 CT 扫描显示多处骨转移。 00:42 He tells you, I just want to die. I can't bear this. | 他告诉你，“我只想死。我受不了了。” 00:46 Which of the following is the most appropriate initial intervention? | 以下哪项是最合适的初始干预措施？ 00:49 A. Adjust his analgesic regimen. | A. 调整他的止痛方案。 00:52 B. Arrange for him to be transferred to a psychiatric service. | B. 安排将他转至精神科。 00:56 C. Begin antidepressant medication. | C. 开始服用抗抑郁药物。 00:59 D. Initiate hyperalimentation. | D. 开始高营养治疗（全静脉营养）。 01:01 E. Refer him to a cancer patient support group. | E. 推荐他参加癌症患者支持小组。 01:05 So for this personally, we see this guy, the melanoma seems to spread | 就我个人而言，我们看到这个人，黑色素瘤似乎已经扩散了， 01:11 and he just has constant pain and he says, I can't bear this, right? | 他一直处于持续的疼痛中，并说 “我受不了了”，对吧？ 01:15 So let's maybe fix his pain. | 所以，我们也许应该先解决他的疼痛。 01:17 So I'm going to go with option A here. Adjust his analgesic regimen. | 所以我选 A。调整他的止痛方案。 01:21 This guy does not seem to have any psychiatric problems, right? | 这家伙似乎没有任何精神问题，对吧？ 01:25 Fix the pain first. | 先解决疼痛。 01:26 If he's still having this, I just want to die. | 如果他在疼痛得到控制后， 01:28 If he's still having this type attitude, you know, after the pain has been taken care of, | 仍然有这种 “我只想死” 的态度， 01:33 then maybe you want to, you know, refer him for like some psych thing, right? | 那么你可能想把他转诊到精神科，对吧？ 01:36 But I think option A is the best answer here. | 但我认为选项 A 是这里的最佳答案。 01:40 Again, antidepressant medication, it does not meet the 5 out of 9 CIGICAPS criteria for depression. | 再说抗抑郁药，他并不符合抑郁症 SIGECAPS 标准中 9 项中的 5 项。 01:46 Hyperalimentation is for weight loss, but this guy can probably eat just fine. | 高营养治疗是针对体重减轻的，但这个人可能吃得还行。 01:51 And then cancer patient support group. No, fix the pain, right? | 至于癌症患者支持小组。不，先解决疼痛，对吧？ 01:53 That's the problem that is propounded in the question. | 那是题目中提出的核心问题。 01:55 All right, question 48 says, | 好了，第 48 题说， 01:58 So for this, anorexia, can it be linked to the cancer? | 那么对于这个，食欲不振，它是否与癌症有关？ 02:16 Yeah, cancer makes people cachectic, makes people not want to eat, right? | 是的，癌症会让患者出现恶病质，让人不想吃东西，对吧？ 02:20 So I don't think I would chalk that up to a major depressive syndrome in the patient, right? | 所以我不认为我会把它归咎于患者的重度抑郁综合征，对吧？ 02:25 Expressions of discouragement. | 气馁的表现。 02:27 Right. Could it be linked to the cancer? | 对。它可能与癌症有关吗？ 02:30 Yeah, it could. It could. But I guess let's keep that. | 是的，有可能。有可能。但我想我们先保留这个选项。 02:33 Although, yeah, it could. Although expressions of discouragement, right? | 虽然，是的，它有可能。尽管气馁的表现，对吧？ 02:37 It could be linked to the cancer, but it could also be a sign of major depressive syndrome. | 它可能与癌症有关，但也可能是重度抑郁综合征的征兆。 02:41 C says insomnia. | C 选项是失眠。 02:43 Well, the person has cancer. The person is in a lot of pain. | 嗯，这个人患有癌症。这个人非常痛苦。 02:47 Could that be attributed to the cancer? | 这能归因于癌症吗？ 02:49 Yes, it could, right? | 是的，可以，对吧？ 02:50 So I don't know if I would say that that's most suggestive of a major depressive syndrome. | 所以我不知道我是否会说那是重度抑郁综合征最典型的表现。 02:55 D, low energy. | D，缺乏活力。 02:56 Low energy can definitely be from the cancer, right? | 缺乏活力绝对可以源于癌症，对吧？ 02:58 So again, it could be from depression, but it could be from the cancer. | 所以，它可能源于抑郁，但也可能源于癌症。 03:01 So it's probably not most suggestive, right? | 所以它可能不是最具有暗示性的，对吧？ 03:03 It's just not as specific. | 它只是不够特异。 03:05 And then option E says withdrawal from family. | 然后选项 E 是疏远家人。 03:07 I think I'll take that one, right? | 我想我会选这一个，对吧？ 03:09 Withdrawal from family, right? | 疏远家人，对吧？ 03:12 Withdrawing from your family is not as a result of the cancer, right? | 疏远你的家人通常不是癌症直接导致的结果，对吧？ 03:15 It can be a result. Basically, that's anhedonia, right? | 它可能是一个结果。基本上，那就是兴趣缺失（anhedonia），对吧？ 03:18 So like, you know, you want to hang with your family, right? | 就像，你知道，你原本是想和家人待在一起的。

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完整字幕请关注喜马拉雅：方块块xxl [00:16] A 35-year-old white man with spina bifida is admitted to the hospital for a urologic procedure. | 一名患有脊柱裂的 35 岁白人男子因泌尿外科手术入院。 [00:22] He has been functionally independent in activities of daily living | 他在日常生活活动中一直能够功能性自理， [00:25] and is employed doing inventory control in a local sporting goods store. | 并在当地一家体育用品商店从事库存控制工作。 [00:28] He has maintained continence through periodic self-catheterization. | 他通过定期的自我导尿来维持排尿自制。 [00:32] The patient is paraplegic, has recurrent calcium oxalate kidney stones, | 该患者截瘫，患有复发性草酸钙肾结石， [00:36] and recent onset of incontinence secondary to detrusor and bladder neck dysfunction. | 近期出现继发于逼尿肌和膀胱颈功能障碍的尿失禁。 [00:40] Vital signs are normal. | 生命体征正常。 [00:41] Physical examination shows a well-developed, well-nourished man in no acute distress. | 体格检查显示一名发育良好、营养良好、无急性病容的男子。 [00:45] Aside from paraplegia, lower extremity muscle atrophy, and lower abdominal surgical scars, | 除截瘫、下肢肌肉萎缩和下腹部手术瘢痕外， [00:50] the physical examination discloses no abnormalities. | 体格检查未发现异常。 [00:53] He had an episode of anaphylaxis secondary to latex allergy | 他曾在一次利用肠道吻合术 [00:56] during a previous operation for functional expansion of his bladder. | 进行的膀胱功能性扩大手术中，发生过继发于乳胶过敏的过敏性休克。 [00:58] Through a bowel anastomosis. | （通过肠道吻合术）。 [01:00] Which of the following is most important to consider in the care of this patient? | 在护理该患者时，以下哪项是最重要的考虑因素？ [01:04] A. Administration of injectable medications with disposable syringes. | A. 使用一次性注射器注射药物。 [01:08] B. Preparation of food by outside contractors. | B. 由外部承包商准备食物。 [01:10] C. Type of cleaning agents used to sterilize bed linens. | C. 用于消毒床单的清洁剂类型。 [01:14] D. Use of rubber urethral catheters. | D. 使用橡胶导尿管。 [01:17] E. Use of topical moisturizing agents for skin care. | E. 使用局部保湿剂进行皮肤护理。 [01:21] For this, I'm going to go ahead and say D, right? | 对于这题，我会选 D，对吧？ [01:23] And again, that makes sense. | 这显然是合理的。 [01:25] Why? | 为什么？ [01:25] Because this person, they've had anaphylaxis with, | 因为这个人，他们曾发生过过敏性休克， [01:28] the person has latex allergy. | 该患者有乳胶过敏。 [01:29.79] And remember, latex allergy can absolutely positively cause anaphylaxis, right? | 记住，乳胶过敏绝对会引起过敏性休克，对吧？ [01:33] So, you don't want to be exposed to latex ever again. | 所以，你不想再让他接触乳胶。 [01:36] And I wouldn't be surprised that this guy developed his sensitivity to latex | 我对他产生乳胶敏感并不感到意外， [01:39] because he's been heavily involved with the healthcare system, right? | 因为他一直频繁地接触医疗系统，对吧？ [01:42] When people have these like neurological disorders, | 当人们患有这些神经系统疾病， [01:45] or they were born preterm or whatever, right? | 或者是早产儿之类的， [01:47] They tend to be in the hospital for a while. | 他们往往会在医院待很长时间。 [01:48] They tend to be in and out of the hospital a lot, right? | 他们往往会经常进出医院，对吧？ [01:50] So, those people may develop a sensitivity to latex | 所以，由于接触了这么多医护人员（戴乳胶手套）， [01:53] because so many healthcare workers have touched them | 这些人可能会产生乳胶过敏。 [01:55] and they've developed a latex sensitivity. | 从而产生了乳胶敏感性。 [01:57] All right. | 好的。 [01:57] Question 38. | 第 38 题。 [01:58] A 14-year-old boy is brought to the walk-in clinic by his father | 一名 14 岁男孩在周六下午晚些时候 [02:01] late on a Saturday afternoon | 由他的父亲带到急诊诊所， [02:02] because his left ear is swollen and painful. | 因为他的左耳又肿又痛。 [02:05] The ear has been black and blue | 自从三天前在摔跤比赛中受伤后， [02:06] since he injured it in a wrestling match three days ago. | 耳朵就一直青一块紫一块的。 [02:09] Symptoms have increased significantly | 在三小时前的一场比赛中再次受伤后， [02:10] following a repeat injury during a match three hours ago. | 症状显著加重。 [02:13] Vital signs are normal. | 生命体征正常。 [02:15] The left ear is markedly swollen and tender to palpation. | 左耳明显肿胀，触痛明显。 [02:18] Which of the following is the most appropriate next step in management? | 以下哪项是最合适的下一步处理措施？ [02:20] A, reassure him and start aspirin. | A，安抚他并开始服用阿司匹林。 [02:22] B, reassure him and start codeine. | B，安抚他并开始服用可待因。 [02:24] C, recommend that he apply cold packs to the ear | C，建议他在接下来的 12 小时内 [02:26] for the next 12 hours. | 对耳朵进行冷敷。 [02:27] D, recommend that he apply hot packs to the ear | D，建议他在接下来的 12 小时内 [02:30] for the next 12 hours. | 对耳朵进行热敷。 [02:31] E, refer him to a surgeon for immediate drainage of the lesion. | E，转诊给外科医生立即对病变进行引流。 [02:34] Hmm. | 嗯。 [02:35] Okay. | 好的。 [02:36] So, look at what's going on here, right? | 看看这里发生了什么，对吧？ [02:38] So, this kid seems to have like a problem with the ear, right? | 这个孩子的耳朵似乎出了问题，对吧？