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患者为女性，出现肌肉酸痛和僵硬，无关节疼痛，同时伴有发热、体重减轻等全身症状，红细胞沉降率（ESR）升高。以下最可能的诊断是？

患者为胆囊切除术后，出现咳嗽、少量黏液痰、心动过速和显著发热，以下最可能的诊断是？ (缺图)

患者正在服用华法林，出现出血风险，以下最合适的处理措施是？

患者左手掌面出现挛缩畸形，影响小指和拇指，以下最可能的诊断是？ (缺图)

早产儿出生后出现呼吸窘迫，尽管阿普加评分良好，以下最可能的诊断是？ (缺图)

患儿血氧饱和度为85%，呼吸频率为48次/分，以下最合适的处理是？

患者面部出现色素沉着斑，以下最可能的诊断是？ (缺图)

The most important single feature of the assessment of this boy's condition is his oximetry reading in room air of 85%. This, in conjunction with his raised respiratory rate of 48 breaths/min, indicates that he needs urgent attention and immediate administration of continuous oxygen therapy and bronchodilator therapy. Normal oximetry should be over 95%. A reading under 90% indicates significant hypoxia requiring urgent management. It also mandates his urgent referral to hospital by ambulance for ongoing care, with the ambulance officers providing continuous oxygen and bronchodilator therapy (E is correct). His clinical findings also are consistent with impending respiratory failure. All other treatment options listed in this scenario miss the crucial point that the child is severely compromised and that his asthma is life-threatening in this severe attack. Surveys into the cause of death in asthma (childhood and adult) confirm that the primary cause is underestimation of the attack severity by either the patient, the patient's parent or the patient's medical attendant.

All the conditions mentioned could present as long-standing pigmented lesions on the face. A lentigo maligna melanoma (Hutchinson melanotic freckle) is characteristically a pigmented focal macular skin lesion found on the solar-exposed facial skin of elderly individuals. The colour varies from light tan to black, and is often variegated as in this instance (A is correct). Another deeply pigmented example is shown. (缺图)

A successful vaginal delivery should be possible in these circumstances. This is particularly the case where the fetus weighs less than 3800g, is a frank or complete breech presentation, labour progresses at a satisfactory rate, and breech extraction is not required. The current accepted optimal mode of delivery of a fetus presenting by the breech is Caesarean section when labour occurs or close to term, because vaginal delivery is associated with a marked increase in risk to the fetus. Despite this knowledge, some patients would prefer to attempt a vaginal delivery. The accoucheur then has a responsibility to ensure this is not likely to be further complicated by an abnormality which would increase the fetal risks even more dramatically. Providing everything progresses normally, the risks to the fetus during labour and delivery would be low, and therefore awaiting spontaneous onset of labour is the correct response in this situation (E is correct). Ultrasound examination is required to rule out a footling breech or knee presentation, and extension of the fetal head. All of these would be associated with a high risk to the fetus if vaginal delivery was attempted. This test, although advisable, is not mandatory to assess fetal size, as its accuracy is ± 20%. X-ray pelvimetry is not necessary as she has already shown she has an adequate pelvis, having delivered a 3900g baby previously. Induction is best avoided in breech presentation for a number of reasons (cord prolapse, need for augmentation).

The critical points that lead to the diagnosis of infantile hypertrophic pyloric stenosis in this boy are his age, sex and the nature of the vomitus. Vomiting has become forceful and is not bile stained, suggesting that an obstruction is present proximal to the entrance of the bile duct. Small bowel obstructions are likely to present soon after birth in the immediate neonatal period, as they are atresias or stenoses or associated with obstruction to the duodenum as part of volvulus/malrotation of the large gut. Gastroenteritis should usually be associated with diarrhoea and would not have continued for ten days without the child looking unwell. The presentation of intussusception is of sudden onset of colic associated with vomiting over a matter of hours. While brain tumours are associated with vomiting in older children, they are unusual in this age. The pattern of vomiting is usually effortless and in the early morning. A 4-week-old infant has nonfused cranial sutures, so raised intracranial pressure results in an enlarged head rather than vomiting. The vomitus in pyloric stenosis may have a coffee grounds appearance after repeated vomiting due to tearing of the gastric mucosa and associated bleeding into the stomach. Usually the vomitus is of milk or whatever fluid has been taken and is not bile stained. The combination of these features make hypertrophic pyloric stenosis the only possible diagnosis (A is correct). This is a classical story and, as the muscle hypertrophies and obstructs the gastric outlet, vomiting becomes more projectile, the baby loses weight and eventually becomes very ill with gross electrolyte and fluid imbalance. In the early stages, the baby may remain fairly well and appear hungry as small amounts of fluid are retained. Treatment is by Ramstedt pyloromyotomy, splitting the muscle layer to the mucosa.

The scenario suggests a unilateral lower limb nerve palsy in this 64-year-old woman. Her symptoms of dragging her foot and numbness and pins and needles in the leg could be due to a peripheral neuropathy or a lesion at a higher level. Muscle weakness and sensory loss are the findings on examination. The details of her motor and sensory findings are required to determine the level of the lesion. Her motor losses are weakness of ankle dorsiflexion (extension) and of inversion/eversion. Ankle extensors, invertors and evertors are all supplied from the L5 nerve root via the lumbosacral plexus, sciatic nerve and common peroneal nerve (lateral popliteal nerve) distribution. No tendon reflex depends on the L5 motor root. The L5 nerve root dermatome involves the outer aspect of the leg below the knee, and extends to the dorsum of the foot, and to the great and inner toes. All the clinical features provided are thus consistent with an L5 nerve root lesion (B is correct). Clearly this is not an L4 nerve root lesion - L4 root fibres are distributed through femoral and obturator nerves, as well as the 'sciatic nerve' and would cause sensory loss on the inner side of the leg below the knee, not on the outer side. The motor weakness from an L4 root lesion could include weakness of the hip and knee extensors, as well as ankle extension and inversion, but not ankle eversion. The knee jerk (L3, L4) may also be affected. The other three responses involving peripheral nerves of the lower limb are also inconsistent with the clinical features. The superficial peroneal nerve (musculocutaneous nerve) is one of the terminal branches of the common peroneal (lateral popliteal) nerve. The common peroneal nerve follows the tendon of biceps femoris to the head of the fibula, winds round the neck of the fibula (where it is very vulnerable to extrinsic compression or trauma), and divides at this site into the superficial and deep peroneal nerves. The superficial peroneal nerve supplies the peroneal muscles longus and brevis, which evert the ankle, and the skin of the outer leg below the knee and virtually all the dorsum of the foot and toes. The ankle and toe extensors (tibialis anterior, extensor hallucis longus, extensor digitorum longus) are supplied by the deep peroneal (anterior tibial) nerve, which is almost entirely motor, with a small terminal sensory contribution to the skin on the dorsum between the great and second toes. The tibial nerve (medial popliteal/posterior tibial nerve) is the second terminal branch of the sciatic nerve, continuing its course down the midline of the posterior calf, supplying the posterior flexor muscles and then the short muscles of the foot, together with sensation to the sole and toes and back of the lower leg. The sciatic nerve is the largest of the main lower limb nerves and gives motor supply to virtually all the lower limb muscles except the extensors of the knee (femoral nerve) and adductors of the hip (obturator nerve). The sensory distribution is correspondingly widespread and covers all but the front and sides of thigh, and the inner side of lower leg to the level of the ankle. The sciatic nerve is vulnerable to trauma from posterior hip dislocations and from misplaced buttock injections, and divides above the popliteal fossa into common peroneal and tibial nerves. It can be seen that the peripheral nerve lesion which most closely could mimic an L5 nerve root lesion would be a lesion of the common peroneal nerve (not given as a distractor), which would give motor and sensory losses involving anterior and peroneal compartment muscular weakness and sensory loss similar to the L5 root lesion. Differentiation between a central L5 nerve root lesion and a peripheral common peroneal nerve lesion is usually apparent from the associated features of the patient's presentation. For example, by a history of back pain and sciatica and other features of radiculopathy (L5 nerve root); or by evidence of a knee injury or iatrogenic compression of the peripheral nerve (common peroneal nerve). Diabetes mellitus is an important contribution both to peripheral nerve neuropathies, and less commonly to lumbosacral plexus neuropathy (diabetic amyotrophy). Following is a summary of the major features of lower limb nerve palsies. • Nerve root lesions (radiculopathies) are usually associated with impingement from intervertebral disc injury of which L5/S1 and L4/L5 are the most common usually causing S1 and L5 radiculopathies respectively. • L4 radiculopathy gives impaired knee jerk reflex and quadriceps strength and impaired ankle inversion with sensory impairment of inner lower leg. • L5 radiculopathy gives no tendon reflex impairment, but causes foot drop and impaired strength of ankle and toe extension, specifically of extensor hallucis longus, with sensory impairment of outer lower leg and inner toes, and a high-stepping slapping gait. • S1 radiculopathy gives impaired ankle jerk and plantar reflex, weakness of ankle plantar flexion and sensory impairment of outer toes and sole. • Sciatic nerve palsy gives impaired knee flexion, and impaired ankle extension and flexion leading to foot drop, and widespread sensory loss. • Common peroneal nerve palsy gives findings very similar to an L5 nerve root impairment but is usually clearly distinguishable by the history of presentation.

Nerve traction or compression injuries can occur during anaesthesia and surgery when the anaesthetised patient, usually also receiving muscle relaxant anaesthesia, has prolonged undue stretching or compressive injury. Nerves particularly at risk include the brachial and lumbosacral plexuses, and peripheral limb nerves - radial nerve in the spiral groove, ulnar nerve behind the elbow, and common peroneal nerve at the knee when in the lithotomy position. During surgery the arms are preferably positioned by the side and pronated, to avoid impingement or traction effects. Arm abduction has potential risks of compressive or traction injury to the ulnar nerve at the elbow (D is correct) or to the lower trunk of the brachial plexus (C8/T1) - the risk is greatest if the arm is kept supinated. The epidural anaesthesia, directed below T6 spinal segments, is unlikely to have involved the C8 segmental area by malpositioning or excess volume.

神经牵拉或压迫损伤可发生在麻醉和手术期间，当麻醉患者，通常还接受肌肉松弛麻醉，有 prolonged undue stretching or compressive injury。神经特别处于风险包括臂丛和腰骶丛，以及外周肢体神经 - 腋神经在螺旋沟，尺神经在肘部后方，和腓总神经在膝关节时处于截石位。在手术中，手臂最好置于侧面和俯卧位，以避免压迫或牵拉损伤。手臂外展有潜在风险对肘部的尺神经（D是正确的）或到臂丛的下干（C8/T1）- 风险最大如果手臂保持旋前。硬膜外麻醉，位于T6以下脊髓节段，不太可能涉及C8节段区域由malpositioning或excess volume。

长期高血压患者出现不规则心悸，已间歇性存在八小时，伴有相关头晕，最可能由于心房纤颤伴快速心室反应，如Rhythm strip B所示（B是正确的）。 (缺图)

男性乳房发育是相对常见情况，特别是在年轻男性，当被认为与青春期变化和雌激素相对过剩相关。然而，在大多数情况下，该条件是idiopathic - 明确原因从未被识别（A是正确的）。男性乳房发育如描绘是超出正常生理变化范围。合成类固醇可用于肌肉构建，并常导致男性乳房发育。当患者出现男性乳房发育时，重要的是排除重要病理原因，包括睾丸肿瘤，肾上腺和垂体肿瘤和肝脏疾病。大量药物如大麻，螺内酯，α-甲基多巴，合成类固醇和甲硝哒嗪可引起男性乳房发育。肥胖和老年个体可能看起来有男性乳房发育（'senile' gynaecomastia）。胸部壁变化更多是由于脂肪沉积而非乳腺组织肥大。 (缺图)

骨髓炎由发热，腿部疼痛和局部骨部压痛提示（D是正确的）。无关节受累迹象，结合无先前发热性疾病和游走性多关节炎（该病的特征性表现），否定急性风湿热作为该表现的原因。杂音最可能与发热相关，在这种情况下，杂音在儿童发热消退后复查时不会明显。过敏性紫癜（Henoch-Schönlein purpura）与皮疹和关节周围肿胀相关而非关节炎，关节炎不是该男孩的特征。骨痛可发生于白血病，但通常无特定压痛点，且儿童通常会有其他全身症状数周以及其他体征，如苍白。虽然瘀伤可能与血小板减少和白血病相关，但该男孩瘀伤位置否定此诊断。7岁男孩小腿瘀伤是预期正常发现。有跌倒史，可考虑骨折，但不会与发热相关，且通常涉及不同骨骼部位。近期创伤史在儿童中很常见，出现骨髓炎，可能反映活跃儿童中轻微创伤频率。任何出现发热，骨痛和点状压痛的儿童都应考虑骨髓炎。创伤史伴皮肤破损允许细菌进入，但并非总是存在，且无感染来源可被发现。该临床场景因此需要骨髓炎确定性检查 - 核素骨扫描，血液培养和全血检查及急性期反应物测量（红细胞沉降率[ESR]和C反应蛋白）。抗生素应静脉启动，一旦血培养已采集。

手术推迟十天对预后或治疗有效性无影响。常被患者及其家属忽视的一点是，医生的职责 - 特别是程序性医生 - 超越手术本身。术后立即期可能比手术本身引起更多焦虑。许多程序性医生 - 特别是进行重大干预如本案例计划手术 - 努力确保如果他们离开工作，他们不留下任何潜在问题未受关注。这可能在大医院不是问题，因为其他专科人员可用，但它仍然是良好医疗实践提供患者进入医院直到他们离开时刻的直接护理。因此，转诊医生能给予的最佳建议是支持专科医生的conscientiousness并让患者确信10天延迟对其治疗影响最小，最不可能影响其预后（E是正确的）。严格来说，专科医生建议是正确的，但为何它对患者产生如此负面效果并引起如此多怨恨？外科医生是否以不同方式对待患者以实现更好结果？该场景基本是关于向焦虑患者传达坏消息，其初始对立即治疗的期望被延迟和手术推迟粉碎。诊断和现实是癌症是毁灭性和极度焦虑引发对大多数患者及其支持网络。失眠，厌食和灾难性恐慌想法在早期调整期是通常反应。许多患者对疾病器官产生一种复仇感并想立即移除。该男子对治疗延迟反应表明其外科医生，虽然谨慎和善意，无意中进一步创伤患者并添加感知伤害。有六类临床医生沟通风格：inexperienced；emotionally burdened；rough and ready；benevolent but tactless（可能该外科医生风格在此场景）；distant；和empathic professional。大多数患者偏好最后品质在其临床医生，他们期望诚实，鼓励和希望。他们想要与其专科医生，无论外科医生或医生，建立良好关系，他们希望医生关注其警报和恐惧并以尊重和同情对待其担忧。作为转诊医生，你应提供关注和rapport。外科医生自身可能需要学习更多关于患者中心沟通和向患者传达坏消息以更巧妙方式刺激希望并减轻焦虑。所有其他回答都可能干扰患者与外科医生关系并强化焦虑。

临床表现为复发性胆道疼痛，伴有发热和腹部体征，提示急性胆囊炎。无肾移植并发症似乎可能，最适当治疗应为早期laparoscopic cholecystectomy（B是正确的）。

中心静脉置管程序目的是将导管插入锁骨下静脉。若患者仰卧且头低，空气栓塞可能性低。若针头在锁骨中线内侧端下方1cm处，沿锁骨中线向胸骨上切迹方向，紧贴锁骨后方，可直接进入锁骨下静脉，对周围结构损伤风险最低。锁骨下静脉走行于第一肋上方，位于锁骨前，由前斜角肌分隔。若针头方向足够靠前，可避免动脉穿刺，尽管动脉穿刺是锁骨下静脉置管已知但不常见并发症。胸膜顶位于第一肋颈水平，约高于第一肋软骨胸骨端3cm，因此胸膜存在相当风险损伤，导致pneumothorax，特别是若针头未向头侧方向（D是正确的）。锁骨下静脉置管期间臂丛神经损伤已被描述，但罕见，如损伤交感链（导致Horner综合征）或胸导管。

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