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A 19-year-old white male presents to the emergency department （ED） in Connecticut after an episode of shortness of breath and syncope while at home.He reports having experienced recurrent episodes of palpitations and fatigue in the week before presentation.Yesterday，the patient sought medical attention for these symptoms at his pediatrician's office.An electrocardiogram （ECG） was performed，but it was normal； the patient was sent home wearing a Holter monitor （also known as an ambulatory electrocardiography device）.Today，while mowing the lawn，the patient again felt a sudden onset of palpitations，accompanied by shortness of breath and lightheadedness.He went inside the house，where he suddenly “passed out”（according to the patient's girlfriend）.The girlfriend also stated that he was unresponsive for a couple of minutes and that the patient exhibited no seizure like activity or incontinence.She noted that he was “pretty much himself” once he regained consciousness.He was then brought by ambulance to the ED； a rhythm strip was acquired en route.Prophylactic transcutaneous pacer pads were placed by the emergency medical services （EMS） team.
In the ED，the patient describes his palpitations as irregular，forceful beats，with a sensation of a racing heart.They occur spontaneously，without any clear inciting factors.He denies having any chest pain or shortness of breath at the time of questioning in the ED.He has not experienced any similar events prior to these，and he is usually active and athletic.The patient denies having any recent fevers，upper respiratory infections，cough，or sore throat.He denies having any recent headaches，neck stiffness，tinnitus，vertigo，or focal neurologic deficits.He also denies experiencing any bleeding （e.g.，no hematochezia or melena）.The patient has been eating a regular diet and has not had any weight loss recently.His past medical history is only significant for a cervical spine fracture secondary to a diving accident that occurred 3 years ago.He has no residual deficits or physical limitations.The patient is otherwise healthy，with no known cardiac，neurologic，or pulmonary disease.He has no known family history of sudden death or premature cardiac disease.He does not take any regular medications，and he denies any drug abuse，tobacco use，or alcohol consumption.The Holter monitor had been removed before he began to mow the lawn； therefore，no results were available to ED staff.
On physical examination，the patient appears to be in no acute distress，but he is noted to have moderate anxiety.He is nontoxic-appearing and alert.His vital signs include a temperature of 96.7℉ （35.9℃），a pulse rate between 40-120 bpm，a respiratory rate of 16 breaths/min，and a blood pressure of 102/46 mmHg.His oxygen saturation is 96% while breathing room air.His head and neck examination are unremarkable.No jugular venous distention or carotid bruits are noted.His lungs are clear to auscultation bilaterally.His cardiac examination reveals an irregular，tachycardic rhythm.There is no discernible murmur with or without Valsalva maneuvers or hand clenching.His abdomen is soft，nontender，and non-distended.No clubbing，cyanosis，or edema is noted in his extremities.His neurologic examination is normal.On skin examination，multiple，bilateral macular erythematous lesions with large central pallor are noted on his thighs.
An ECG is obtained.
episode ［ˈepɪsəʊd］ n. something that take place 发作
syncope ［ˈsɪŋkəpi］ n. loss of consciousness resulting from insufficient blood flow to the brain 晕厥
electrocardiography ［elektrəʊˈkɑ：dɪəʊɡrəfɪ］ n. 心电描记法
lightheadedness n. mentally disoriented，dizzy 眩晕
pass out to become unconscious 昏倒，失去知觉
seizure ［ˈsiʒər］ n. sudden occurrence （or recurrence） of a disease 发作
incontinence ［ɪnˈkɒntɪnəns］ n. inability of the body to control the evacuative functions of urination or defecation 大小便失禁
pretty much most completely 几乎全部
en route ［en ru：t］ on the way 在途中
prophylactic ［ˌprɒfɪˈlæktɪk］ a. guarding from or preventing the spread or occurrence of disease or infection 预防疾病的
transcutaneous ［ˌtrænzkjʊˈtenɪəs］ a. passing，entering，or made by penetration through the skin 经皮（性）的；由皮的
incite ［ɪnˈsaɪt］ v. to move on，stir on，urge on 激励；激起
tinnitus ［ˈtɪnɪtəs］ n. a ringing or booming sensation in one or both ears； a symptom of an ear infection or Meniere's disease 耳鸣
hematochezia ［hɛmətəˈkizɪə］ v. bright red blood is found in the feces 便血
melena ［məˈli：nə］ n. abnormally dark tarry feces containing blood （usually from gastrointestinal bleeding）黑粪症
saturation ［ˌsætʃəˈreɪʃ（ə）n］ n. the act of saturating ：the state of being saturated 饱和
macular ［ˈmækjʊlə］ n. of macula 斑疹的，斑的
erythematous［ˌerɪˈθi：mətəs］ a. abnormal redness of the skin due to capillary congestion 红斑的
Decide whether the following statements are true（T） or false（F） according to the passage.
______1.The 19-year-old white male patient sought medical attention for his symptoms at his attending physician's office.
______2.The patient's girlfriend states that he just lost consciousness for several minutes and didn't have any seizure like activity or incontinence.
______3.The patient hasn't had any experience of chest pain or shortness of breath prior to this time because he doesn't have the habit of doing exercises.
______4.The Holter monitor had been removed before the patient began to mow the lawn； Therefore，ED staff couldn't get any available results.
______5.The patient's vital signs include a temperature of 96.7℉ （35.9℃），a pulse rate between 80-120 bpm，and a blood pressure of 102/46 mmHg on physical examination.
Answer the following questions according to the passage.
1.What is the most likely diagnosis according to symptoms and lab findings such as multiple，bilateral macular erythematous lesions with large central pallor are noted on his thighs？
_____________________________________________________________________
2.What first-line antibiotics will be used to treat the patient？
_____________________________________________________________________
Use the appropriate form of the words or phrases in the box to complete the following sentences.
respiratory palpitation syncope cyanosis auscultation
erythematous distention prophylactic fracture thigh
pulmonary tinnitus cardiac
1.Inspection，_______________ and olfaction，inquiry and pulse-taking and palpation are the four diagnostic methods to understand the pathological conditions.
2.They suspect he is suffering from a _______________ embolism，basically a blood clot in an artery of the lung that could prove fatal.
3.Shakiness，cold sweating，_______________，and hunger sensation are some of the initial symptoms of hypoglycemia which result from adrenergic effect.
4.A gastric tube is indicated to reduce stomach _______________ and decrease the risk of aspiration.
5.Similarly，most physicians advocate giving _______________ platelet transfusions to reduce the likelihood of bleeding.
6.In these patients，the virus directly infects the lung，causing severe _______________ failure.
7.All patients didn't appear the symptoms of vascular and nerve injury and the situation of _______________ fixation.
8.Zipes said if doctors can figure out how Clark's heart healed itself and develop a treatment from that mechanism，many other _______________ patients could benefit.
9._______________ is the major indication that there is a problem with many newborn babies.
10.A 27-year-old female presented with several annular plaques on the upper back for one month.Other dermatologic findings revealed _______________ plagues with mild scaling on the scalp.
Translation
A.Translate the following expressions into English.
1.反复发作的心悸 2.动态心电描记法装置
3.恢复意识 4.局灶性神经功能缺损
5.猝死家族史 6.体格检查
7.脉搏 8.血压
B.Translate the following sentences or expressions into Chinese.
1.In the ED，the patient describes his palpitations as irregular，forceful beats，with a sensation of a racing heart，which occur spontaneously，without any clear inciting factors.
2.There is no discernible murmur with or without Valsalva maneuvers or hand clenching.
3.He does not take any regular medications，and he denies any drug abuse，tobacco use，or alcohol consumption.
4.The patient has been eating a regular diet and has not had any recent weight loss.
5.Today，while mowing the lawn，the patient again felt a sudden onset of palpitations，accompanied by shortness of breath and lightheadedness.