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A 17-year-old girl was transferred to this hospital because of chest pain and hemoptysis.She had been well except for mild asthma until 4 months earlier，when pedal edema developed，testing revealed （3+） proteinuria，hematuria，and hyperlipidemia.One month later，a renal biopsy was performed at another facility，and a diagnosis of membranous glomerulonephritis was made.Testing for antibodies to hepatitis B and hepatitis C，as well as anti-ribonuclear protein，anti-topoisomerase I，anti-Smith antibody，anti-Ro （SS-A），anti-La （SS-B），anti-double-stranded DNA，and anti-nuclear antibody was negative.The levels of serum C3 and C4 complement were normal.Enalapril，atorvastatin，and fluid restriction began； after the therapy for several weeks，the patient stopped taking atorvastatin because of muscle pain.After the renal biopsy，she had persistent pain in the back and abdomen.Ultrasonography of the kidney disclosed a small perinephric hematoma.
Over the course of the next 2 months，although imaging studies showed diminution in the size of the hematoma，the patient continued to report severe pain in the back as well as abdominal pain，which lasted despite treatment with oxycodone and acetaminophen and interfered with her activities and sleep，and thus she largely stayed in bed.Bilateral lower leg edema occurred intermittently.During the 2 weeks before admission，pain in the back and abdomen decreased in intensity，but she began to have pain in the chest，radiating to the neck and shoulder，which was exacerbated by coughing and deep inspiration.
Six days before admission，she was seen in a pain clinic at another hospital； a diagnosis of neuralgia of the intercostal nerves was made，and gabapentin and tramadol were prescribed.Over the next several days the pain worsened，cough and hemoptysis developed，and one episode of dyspnea occurred，which was relieved with the use of an albuterol （salbutamol） inhaler.
The day before admission，she went to a second hospital because of increasing chest pain.The temperature was 39.0℃，the blood pressure 115/69 mmHg，the pulse 156 beats per minute （bpm），and the respiratory rate 50 breaths per minute.Oxygen saturation was 98% while the patient was breathing ambient air.On examination，her breathing was shallow because of chest pain.The lungs were clear，and the results of the physical examination were otherwise normal.Two liters of normal saline were administered in the emergency room，and the patient was admitted to the pediatric intensive care unit.Treatment with enoxaparin was begun.The oxygen saturation intermittently fell to 92%～93% and oxygen was administered by nasal cannula at 1～2 liters per minute.Urinalysis results were positive for protein （3+） and for blood （2+），and revealed a specific gravity of 1.041.Chest radiography revealed a patchy density in the left costophrenic angle and electrocardiography showed sinus tachycardia.Morphine sulfate was administered for the patient's pain，and specimens of blood were sent for culture.
The next day，transthoracic echocardiography showed moderate right ventricular dilatation with an estimated pulmonary artery pressure of 60 mm Hg； flattened，paradoxical septal motion； and a small pericardial effusion.No intraatrial or intraventricular clot was identified.After prophylactic treatment with acetylcysteine and bicarbonate，spiral computed tomographic （CT） scanning and CT angiography of the chest were performed.There were emboli in both pulmonary arteries with multiple bilateral pulmonary infarcts and small bilateral pleural effusions.Renal ultrasonography revealed a hematoma around the left kidney； Doppler studies showed no clot in the inferior vena cava，and noninvasive testing of the legs did not reveal deep venous thromboses.Enoxaparin was discontinued，and treatment with heparin was begun； the patient was transferred to this hospital and admitted to the intensive care unit.
She had mild intermittent asthma，which required occasional use of an albuterol inhaler，with upper respiratory infections，but was otherwise well and had not been hospitalized previously.She was a good student in high school and did not use tobacco，alcohol，or illicit drugs.Her mother had multiple sclerosis and asthma，her father had hypertension，and distant cousins had systemic lupus erythematosus.A paternal cousin was receiving dialysis for an unknown cause，her mother and two siblings carried the sickle cell trait，and her fraternal twin was in good health.The patient had taken oral contraceptives for the past 3 years，for treatment of irregular menses.On transfer，her medications included heparin，morphine，ranitidine，albuterol，and dextrose normal saline.
On admission，the temperature was 38.3℃，the pulse 148 beats per minute，the blood pressure 138/72 mmHg，the respiratory rate 34 breaths per minute，and the oxygen saturation 92% while the patient was breathing ambient air.There was decreased inspiratory effort and a prominent second heart sound.Jugular venous pulsations，measured with the patient in a reclining position at 30 degrees，were 7 cm above the sternal angle.A pulmonary artery tap，a right ventricular heave，and a harsh systolic murmur （grade 2/6） over the left lower sternal border were heard.There was tenderness in the right midabdomen and 1+ edema of both legs extending up to the knees.
Electrocardiography revealed an S wave in lead I and Q and T waves in lead Ⅲ.A management decision was made.
hemoptysis ［hɪˈmɔptəsɪs］ n. expectoration of blood from some part of the respiratory tract 咳血
pedal ［ˈped（ə）l］ a. of or relating to the feet 足的，脚的
proteinuria ［prəʊti：ˈnjʊərɪə］ n. the presence of excess protein in the urine 蛋白尿
hematuria ［ˌhiməˈtjurɪə］ n. the presence of blood or blood cells in the urine 血尿
hyperlipidemia ［ˌhaɪpərlɪˈpidi：miə］ n. the presence of excess fat or lipids in the blood 高脂血症
glomerulonephritis ［gləʊmerjʊləʊnefˈraɪtɪs］ n. nephritis marked by inflammation of the capillaries of the renal glomeruli 肾小球肾炎
enalapril ［eˈnælæprɪl］ n. an antihypertensive drug C 20 H 28 N 2 O 5 that is an ACE inhibitor administered orally in the form of its maleate 依那普利
atorvastatin ［ətɔ：rˈvɑ：steɪtɪn］ n. 阿托伐他汀（降血脂药）
ultrasonography ［ʌltrəsəˈnɒgrəfɪ］ n. a test in which high-frequency sound waves （ultrasound） are bounced off tissues and the echoes are converted into a picture （sonogram）超声波检查
hematoma ［ˌhi：məˈtəʊmə］ n. a mass of usually clotted blood that forms in a tissue，organ，or body space as a result of a broken blood vessel 血肿
oxycodone ［ˌɒksɪˈkəʊdəʊn ］ n. 羟考酮（药）
acetaminophen ［əˌsiːtəˈmɪnəfən］ n. 对乙酰氨基酚
intercostal ［ɪntəˈkɒstl］ n. situated or extending between the ribs 肋间的
tramadol ［ˈtræmædɔl］ n. a synthetic opioid analgesic administered orally in the form of its hydrochloride C 16 H 25 NO 2 ·HCl to treat moderate to severe pain 曲马多
gabapentin ［ˌgæbəˈpentin］ n. a new kind of anti-convulsion medicine with good tolerance 加巴喷丁
enoxaparin ［eˈnɒksəpərɪn］ n. 依诺肝素
cannula ［ˈkænjʊlə］ n. a small tube for insertion into a body cavity or into a duct or vessel 插管，套管
transthoracic ［ˌtrænsθəˈræsɪk］ n. done or made by way of the thoracic cavity 经胸廓的
tomography ［təˈmɒgrəfi］ n. X线体层照相机；X线断层照相装置
acetylcysteine ［æsɪtɪlˈsɪsti：ɪn］ n. 乙酰半胱氨酸
lupus ［ˈlupəs］ n. one of several diseases that affect the skin and joints 狼疮
erythematous ［ˌerɪˈθi：mətəs］ n. a disorder characterized by skin inflammation 红斑狼疮
inspiratory ［ɪnˈspaɪrətərɪ］ a. of，relating to，used for，or associated with inspiration 吸入的，吸气的
sternal ［ˈstɜ：nəl］ a. of or relating to the sternum 胸骨的；近胸骨的
Decide whether the following statements are true （T） or false （F） according to the passage.
______1.The girl，transferred to this hospital because of chest pain and hemoptysis，had been well except for glomerulonephritis until 14 months earlier.
______2.Before admission，the patient had pain in the low back and abdomen which was decreased in intensity，then the patient began to have chest pains.
______3.One episode of dyspnea occurred to the patient，which was relieved with the use of an albuterol inhaler.
______4.There were no emboli in both pulmonary arteries with multiple bilateral pulmonary infarcts and small bilateral pleural effusions before admission.
______5.The patient's mother and two siblings carried the sickle cell trait，and her fraternal twin was in good health.
Answer the following questions according to the passage.
1.What medicine was prescribed when a diagnosis of neuralgia of the intercostal nerves was made six days before admission？
_____________________________________________________________________
2.How many hospitals did the patient go before she was admitted in the intensive care unit？
_____________________________________________________________________
3.What were the patient's vital signs on admission？
_____________________________________________________________________
Use the appropriate form of the words or phrases in the box to complete the following sentences.
contraceptives dialysis oxycodone cavity ultrasonography
thromboses intermittent specimens glomerulonephritis
dilatation hematuria pediatric gabapentin and tramadol
1.If you have _______________，a urine test will show up blood and protein in the urine.
2.Serious potential consequences of over-dosage with _______________ are central nervous system depression，respiratory depression and death.
3.The patient continued to report severe pain in the back as well as abdominal pain，which lasted despite treatment with _______________ and acetaminophen and interfered with her activities and sleep.
4.Two liters of normal saline were administered in the emergency room，and the patient was admitted to the _______________ intensive care unit.
5.Morphine sulfate was administered for the patient's pain，and _______________ of blood were sent for culture.
6.The next day，transthoracic echocardiography showed moderate right ventricular _______________ with an estimated pulmonary artery pressure of 60 mmHg.
7.Doppler studies showed no clot in the inferior vena cava，and noninvasive testing of the legs did not reveal deep venous _______________.
8.She had mild _______________ asthma，which required occasional use of an albuterol inhaler，with upper respiratory infections.
9.A paternal cousin was receiving _______________ for an unknown cause，her mother and two siblings carried the sickle cell trait.
10.The patient has taken oral _______________ for treatment of irregular menses for the past 3 years.
Translation
A.Translate the following expressions into English.
1.肾活检 2.背部和腹部持续疼痛
3.氧气饱和度 4.肺动脉压
5.下腔静脉 6.上呼吸道感染
7.双腿水肿 8.向上延伸至膝盖
B.Translate the following sentences or expressions into Chinese.
1.Enoxaparin was discontinued，and treatment with heparin was begun； the patient was transferred to this hospital and admitted to the intensive care unit.
2.A pulmonary artery tap，a right ventricular heave，and a harsh systolic murmur （grade 2/6） over the left lower sternal border were heard.
3.After prophylactic treatment with acetylcysteine and bicarbonate，spiral computed tomographic （CT） scanning and CT angiography of the chest were performed.
4.Chest radiography revealed a patchy density in the left costophrenic angle and electrocardiography showed sinus tachycardia.
5.The patient began to have pain in the chest，radiating to the neck and shoulder，which was exacerbated by coughing and deep inspiration.