问题 多项选择题 案例分析题

患者男性,40岁,因高血压15年,双下肢无力且反复间断跌倒4年,低血钾3年就诊。患者15年前开始出现高血压,血压最高190/120mmHg(1mmHg=0.133kPa),服用多种降压药物,效果不佳,一般控制在150~160/90~110mmHg左右。4年前突发双下肢无力、跌倒且反复出现。3年前再次发作,血电解质检测发现血钾低,最低为1.9mmol/L,予以补钾治疗后好转,但低血钾反复出现,难以纠正。多次行腹部及肾上腺超声检查提示双肾、肾上腺等均未见明显异常。该患者既往有多次脑梗死病史2年。查体:体型偏瘦,血压165/110mmHg。

为进一步确诊原发性醛固酮增多症,可以选做下列哪种试验()

A.卧立位试验

B.高盐饮食负荷试验

C.生理盐水滴注试验

D.卡托普利抑制试验

E.氟氢可的松抑制试验

F.可乐定抑制试验

答案

参考答案:B, C, D, E

解析:患者系难治性高血压,相对年轻时起病,下肢无力跌倒、低血钾反复出现且难以纠正等情况提示醛固酮增多症可能,而患者脑梗死发病年龄早也提示原发性醛固酮增多症可能。肾动脉狭窄可引起继发性醛固酮增多症也可引起上述症状。肾素瘤可自主分泌大量肾素,激活肾素-血管紧张素-醛固酮系统(RAA系统)而引起高血压、低血钾。醛固酮增多症可分为原发性醛固酮增多症和继发性醛固酮增多症。肾动脉彩色多普勒超声若发现肾动脉狭窄,可考虑继发性醛固酮增多症。腹部CT薄层平扫+增强可发现醛固酮分泌肾上腺瘤和位于肾脏的肾素瘤。由于肾上腺醛固酮瘤和肾素瘤体积均较小(1~2cm),超声检查容易漏诊,延误诊断,因此当临床怀疑此类疾病时一般不首选超声检查。患者高血压、低血钾、左肾上腺结节约1.6cm×1.3cm,临床高度怀疑原发性醛固酮增多症,在筛查诊断时需检测血钾、24小时尿钾、血浆肾素活性、血管紧张素、醛固酮等。原发性醛固酮增多症患者在低血钾状态下24小时尿钾排泄量增加,内分泌检查表现为低肾素活性、高醛固酮,醛固酮/肾素活性比值是筛查诊断的重要指标。患者血生化及内分泌检查提示低血钾、高尿钾、低肾素,可以排除继发性醛固酮增多症(如肾动脉狭窄、肾素瘤等引起),应考虑原发性醛固酮增多症。而临床表现和影像学检查均不支持嗜铬细胞瘤和皮质醇增多症,后两者肿瘤体积一般较大,多大于3cm。在高盐饮食负荷试验、生理盐水滴注试验、卡托普利抑制试验、氟氢可的松抑制试验中任选一种均可确诊原发性醛固酮增多症。而卧立位试验的目的不在于确诊,而用于分型诊断。原发性醛固酮增多症分为上述6种病因类型。单侧单个醛固酮瘤首选手术治疗,手术方式首选腹腔镜肾上腺肿瘤切除术,尽可能保留正常肾上腺组织。对于增生型、单侧多发肿瘤或结节应考虑行肾上腺全切除术。

阅读理解

第三部分阅读(共两节,满分40分)

第一节阅读理解(共15小题;每小题2分,满分30分)

阅读下列短文,从每题所给的A、B、C和D项中,选出最佳答案。

We’ve talked about snails (蜗牛) and their slow move. But much of the time snails don’t move at all. They are in their shells (壳) —sleeping.

Hot sun will dry out a snail’s body. So at the least sign of hot sun, a snail draws its body into his shell. A snail will die in a heavy rain. So when it rains, a snail does the same thing, too. A snail can sleep for as long as it needs to. It spends all  the winter months in its shell, asleep.

In the spring the snail wakes up. Its body, about three inches long, comes out from the shell. When hungry, the snail  looks for food. Its eyes, at the end of the top feelers (触角), are very weak. But its sense (感觉) of smell is very strong. It helps the snail to find food and the new greens.

A snail’s mouth is no bigger than the point of a pin (大头针). Yet it has 256,000 teeth! The teeth are very small, and you can’t see them. If you put a snail in a hard paper box, it will eat its way out! And if a snail wears out its teeth, it will grow new ones.

51. A snail _________.

A. moves more slowly at night        B. has thousands of  feet

C. doesn’t move at all                     D. sleeps much of the time

52. In the sentence “A snail draws its body into its shell”,  the word “draw” means _____.

A. to make with a pencil        B. to push      C. to pul     D. to move away

53. From the story, we know _________.

A. a snail’s shell is very thin           B. a snail can’t see well

C. a snail’s nose is quite short        D. a snail’s body changes                                    in different seasons

54. A snail goes to sleep when _____.

A. it feels hungry   B. it is put into a paper box  C. spring is coming   D. it rains heavily

55. Which of the following is wrong?

A. In winter the snail doesn’t eat or move. 

B. A snail doesn’t like living under the sun.

C. The snail’s teeth can’t be worn out.      

D. The snail’s nose helps to find food.

单项选择题