新英格兰双语病例讨论2VIP免费

Bilingualcasediscussion2015-09-11A35-year-oldmanwithdyspnea,anemia,andrenalfailure•severalweeksago,thepatientfeltfatigue.Twodaysbeforeadmission,dyspneadeveloped,decreasedurination,withoutfever,cough,orchestpain,nohemoptysis咯血,chills,nightsweats,headaches,visualloss,dryeyes,drymouth,orjointpain.•Hewastransferredbyambulancetotheemergencydepartmentatthishospital•Fouryearsbeforeadmission,hehadbeenevaluatedbecauseofbackpain,fatigue,andatemperatureof38.6°C.Urinalysisshowedhematuria血尿andproteinuria；testingforrapidplasmareagin(RPR快速血浆反应素)waspositiveforantibodiestoTreponemapallidum（梅毒螺旋体）.•Duringtheprevious6months,thepatienthadhadepisodesofbilateralfinger,ankle,andfacialswelling,withoutpainorchangeincolor.•Hehadnohistoryofrecenttravel,exposuretosickpersons,bloodtransfusions,orprevioussurgery.Hedidnotsmoke,drinkalcohol,oruseillicitdrugs.Onexamination,•T36.9°C,BP173/89mmHg,P95b/m,R36b/m,andS0288%(ambientair).•Theskinandconjunctivae结膜werepale,andtherewerehypopigmentedmacules色素减退斑ontherighttempleandbothlowercheeksandhyperpigmentedmacules色素沉着斑onthebridgeofthenose.Therewerebibasilarrales双肺底湿罗音inthelungs,andtheremainderoftheexaminationwasnormal.•totalanddirectbilirubintotalanddirectbilirubin胆红素胆红素,liver-functi,liver-functiontestsandlactatewerenormal.testingforontestsandlactatewerenormal.testingforrheumatoidfactor,screeningofthebloodarheumatoidfactor,screeningofthebloodandurinefortoxinswerenegative;Testingfondurinefortoxinswerenegative;TestingforhepatitisBandCvirusesandautoantibodirhepatitisBandCvirusesandautoantibodiesagainsthistonesesagainsthistones组蛋白组蛋白wasnegative.Swasnegative.Serumproteinelectrophoresiserumproteinelectrophoresis电泳电泳revealerevealedadiffusedadiffuseincreaseintheIgGlevel.increaseintheIgGlevel.Transthoraciccardiacultrasonographyrevealednormalglobalcardiacfunctionandright-ventricularsize,noevidenceofapericardialeffusion心包积液,andfindingsthatwereconsistentwithpulmonaryEdema.Ultrasonographyoftheabdomenrevealednormalrenalsize,position,andechotexture回声特性andnormalarterialbloodflow.Anelectrocardiogram(Anelectrocardiogram(ECGECG)showedsinustachycardia,cou)showedsinustachycardia,counterclockwiserotationnterclockwiserotation逆钟向逆钟向,andnonspecificST-segme,andnonspecificST-segmentandT-waveabnormalities.ntandT-waveabnormalities.onadmissionground-glassopacitiesGGO•Bronchoscopicexaminationrevealedthick,redmucusinthemain-stemandright-lower-lobebronchi;airwaysoftheleftlungwerenormal.Bronchoalveolarlavageontheright,with300and24,500redcellspercubicmillimeter(inthefirsttube),975and1475whitecellspercubicmillimeter(infourthtubes)•Inthefourthtube,thewhite-celldifferentialcountrevealed84%leukocytes白细胞.•Onthesecondday,thesputumculturegrewveryfewklebsiella克雷伯whatdoyouthink••Pulmonaryhemorrhage？•PCP卡氏肺孢子？（梅毒阳性、HIV）•pulmonaryembolism肺栓塞？•Rapidlyprogressiveglomerulonephritis•PulmonaryhemorrhageErnestW.Goodpasturereportedin1919ontheautopsyfindingsinthecaseofan18-year-oldmanwhohaddiedofmassivelunghemorrhageandcrescenticglomerulonephritisduringtheheightoftheinfluenzapandemicThetermGoodpasture’ssyndromeisappliedtothecombinationoflungpurpuraandnephritis,regardlessoftheunderlyingpathogenesis.(一)anti-GBMdisease•anti–glomerularbasementmembrane(GBM)antibodies(anti-GBMdisease)•anti-GBMantibody•（...