新英格兰双语病例讨论2.ppt

A 35-year-old man with dyspnea, anemia, and renal failure several weeks ago,the patient felt fatigue . Two days before admission, dyspnea developed , decreased urination,without fever, cough, or chest pain,no hemoptysis咯血,chills, night sweats, headaches, visual loss, dry eyes,dry mouth, or joint pain. He was transferred by ambulance to the emergency department at this hospital Four years before admission, he had been evaluated because of back pain, fatigue, and a temperature of 38.6°C.Urinalysis showed hematuria血尿 and proteinuria；testing for rapid plasma reagin(RPR快速血浆反应素) was positive for antibodies to Treponema pallidum（梅毒螺旋体）. During the previous 6 months, the patient had had episodes of bilateral finger, ankle, and facial swelling, without pain or change in color. He had no history of recent travel, exposure to sick persons, blood transfusions, or previous surgery.He did not smoke, drink alcohol, or use illicit drugs. On examination, T 36.9°C, BP 173/89 mm Hg, P 95b/m, R36 b/m, and S02 88% ( ambient air). The skin and conjunctivae 结膜were pale, and there were hypopigmented macules 色素减退斑on the right temple and both lower cheeks and hyperpigmented macules 色素沉着斑on the bridge of the nose.There were bibasilar rales双肺底湿罗音 in the lungs, and the remainder of the examination was normal. total and direct bilirubin胆红素, liver-function tests and lactate were normal .testing for rheumatoid factor ,screening of the blood and urine for toxins were negative; Testing for hepatitis B and C viruses and autoantibodies against histones组蛋白 was negative.Serum protein electrophoresis 电泳revealed a diffuse increase in the IgG level. Transthoracic cardiac ultrasonography revealed normal global cardiac function and right-ventricular size, no evidence of a pericardial effusion心包积液, and findings that were consistent with pulmonary Edema. Ultrasonography of the abdomen revealed normal renal size, position, and echotexture回声特性 and normal arterial blood flow. An e