本文有兩篇文章，3-4均為呼吸系統(tǒng)疾病，故而放在一起。
CASE 3:
CHRONIC COUGH
慢性咳嗽
History
A 19-year-old boy has a history of repeated chest infections. He had problems with a cough and sputum production in the first 2 years of life and was labelled as bronchitic.
sputum痰液（統(tǒng)稱），粘痰則可以用phlegm，中醫(yī)的痰質(zhì)，可用semha。固定搭配：吐痰spit sputum，咳痰 expectorate sputum
bronchus 支氣管（plu bronchi），trachea 氣管
Over the next 14 years he was often ‘chesty’ and had spent 4–5 weeks a year away from school. Over the past 2 years he has developed more problems and was admitted to hospital on three occasions with cough and purulent sputum. （膿痰）
On the first two occasions, Haemophilus influenzae （流感嗜血桿菌）was grown on culture of the sputum, and on the last occasion 2 months previously Pseudomonas aeruginosa was isolated from the sputum at the time of admission to hospital.
culture表示培養(yǎng)，如培養(yǎng)細(xì)胞，細(xì)菌等，
pseudo—假，mono—單個(gè)（的），pseudomonas aeruginosa 銅綠假單胞菌/綠膿桿菌
isolate 文中表示分離，近似于separate，seclude，insulate等，但也可表示隔離，近似于quarantine，但quarantine本身有檢疫的意思在里面，如用于因?yàn)橐咔槎a(chǎn)生的隔離，更貼切。
He is still coughing up sputum. Although he has largely recovered from the infection, his mother is worried and asked for a further sputum to be sent off.
The report has come back from the microbiology laboratory showing that there is a scanty（少量） growth of Pseudomonas on culture of the sputum.
There is no family history of any chest disease. Routine questioning shows that his appetite is reasonable, micturition （排尿，書面語）is normal and his bowels tend to be irregular.
Examination
On examination he is thin, weighing 48 kg and 1.6 m (5 ft 6 in) tall.
The only finding in the chest is of a few inspiratory crackles over the upper zones of both lungs. Cardiovascular and abdominal examination is normal.
in—在xxx里的，spiratory參考respiratory，所以inspiratory 表示吸氣性的，相反的是expiratory呼氣性的
crackle本身表示劈啪作響，這里表示濕啰音，如粗濕啰音 coarse crackle。與之相對(duì)的，干啰音rhonchi。
呼吸過程中，肺會(huì)收縮擴(kuò)張，進(jìn)行氣體交換，產(chǎn)生呼吸音，通過聽診器聽呼吸聲音來判斷有誤呼吸系統(tǒng)異常。是臨床上常見的初步檢查手法之一。
（因胸片等圖片無法上傳，這里缺失，但不影響上下文）
ANSWER 3
The chest X-ray shows abnormal shadowing throughout both lungs, more marked in both upper lobes （上葉）with some ring shadows and tubular shadows representing thickened bronchial walls.
肺左側(cè)兩葉，右側(cè)三葉
These findings would be compatible with a diagnosis of bronchiectasis（支氣管擴(kuò)張）. The pulmonary arteries are prominent, suggesting a degree of pulmonary hypertension.（肺動(dòng)脈高壓）
The distribution is typical of that found in cystic fibrosis where the changes are most evident in the upper lobes.
cystic 囊的，fibro—纖維的，—sis xxx病變，cystic fibrosis 囊性纖維化
Most other forms of bronchiectasis are more likely to occur in the lower lobes where drainage（引流） by gravity is less effective. High-resolution（高分辨率） computed tomography (CT) of the lungs is the best way to diagnose bronchiectasis and to define its extent and distribution.
In younger and milder cases of cystic fibrosis, the predominant organisms in the sputum are Haemophilus influenzae（流感嗜血桿菌） and Staphylococcus aureus（金黃色葡萄球菌）.
Later, as more lung damage occurs, Pseudomonas aeruginosa is a common pathogen. Once present in the lungs in cystic fibrosis, it is difficult or impossible to remove it completely.
Cystic fibrosis should always be considered when there is a story of repeated chest infections in a young person.
Although it presents most often below the age of 20 years, diagnosis may be delayed until the 20s, 30s or even 40s in milder cases.
Associated problems occur in the pancreas (malabsorption, diabetes), sinuses and liver.
pancreas 胰腺
mal—xxx不良的，malabsorption 吸收不良
diabetes 糖尿病，diabetes mellitus簡(jiǎn)稱
sinus，竇，竇道，不同器官表示不同竇道，如鼻部，鼻竇，血管中表示（動(dòng)）靜脈竇，心臟表示竇房結(jié)的竇，需要聯(lián)系上下文。
It has become evident that some patients are affected more mildly, especially those with the less common genetic variants.
These milder cases may only be affected by the chest problems of cystic fibrosis and have little or no malabsorption from the pancreatic insufficiency. （胰腺功能不全/分泌不足）
Differential diagnosis
鑒別診斷
The differential diagnosis in this young man would be other causes of diffuse bronchiectasis such as agammaglobulinaemia or immotile cilia.（不動(dòng)纖毛）
a表示與單詞本身相反的，gamma希臘字母γ，可以翻譯為甲乙丙的丙，global—球狀的
——in，表示xxx素，如毒素，toxin，globulin雪球素，但是這么翻譯比較拗口，故常譯作球蛋白
—emia，血液中發(fā)生xxx，如anemia，貧血
所以agammaglobulinaemia表示丙種球蛋白缺乏癥
Respiratory function should be measured to see the degree of functional impairment. Bronchiectasis in the upper lobes may occur in tuberculosis（肺結(jié)核?。?/strong> or in allergic bronchopulmonary aspergillosis （曲霉菌病）associated with asthma. 哮喘
The common diagnostic test for cystic fibrosis is to measure the electrolytes（電解質(zhì)） in the sweat, where there is an abnormally high concentration of sodium and chloride.
At the age of 19 years, the sweat test may be less reliable. It is more specific if repeated after the administration of fludrocortisone.（氟氫可的松）
An alternative would be to have the potential difference across the nasal epithelium measured at a centre with a special interest in cystic fibrosis.
epi— upon，on，over等，這里表示xxx之上，epithelium上皮細(xì)胞
Cystic fibrosis has an autosomal recessive inheritance with the commonest genetic abnormality ΔF508 found in 85 per cent of cases.
The gene is responsible for the protein controlling chloride transport across the cell membrane. The commoner genetic abnormalities can be identified and the current battery of genetic tests identifies well over 95 per cent of cases.
However, the absence ofΔF508 and other common abnormalities would not rule out cystic fibrosis related to the less common genetic variants.
In later stages, lung transplantation（肺移植） can be considered. Since the identification of the genetic abnormality, trials of gene-replacement therapy （基因替代療法）have begun.
CASE 4:
SHORTNESS OF BREATH
氣短
History
A 26-year-old teacher has consulted her general practitioner (GP) for her persistent （持續(xù)性/反復(fù)發(fā)作性）cough.
She wants to have a second course of antibiotics（二級(jí)抗生素） because an initial course of amoxicillin （阿莫西林）made no difference.
The cough has troubled her for 3 months since she moved to a new school.The cough is now disturbing her sleep and making her tired during the day.
She teaches games, and the cough is troublesome when going out to the playground and on jogging.
In her medical history she had her appendix （附器，單獨(dú)出現(xiàn)則表示闌尾）removed 3 years ago. She had her tonsils （扁桃體）removed as a child and was said to have recurrent episodes of bronchitis between the ages of 3 and 6 years.
She has never smoked and takes no medication other than an oral contraceptive.
口服避孕藥。個(gè)人觀點(diǎn)：英語口語使用spoken English表達(dá)，雖然也有袋鼠國(guó)朋友使用oral English，但是總覺得有點(diǎn)奇怪。
Her parents are alive and well and she has two brothers, one of whom has hayfever. 花粉癥
Examination
The respiratory rate（呼吸頻率） is 18/min. Her chest is clear and there are no abnormalities in the nose, pharynx, cardiovascular, respiratory or nervous systems.
INVESTIGATIONS
? Chest X-ray is reported as normal.
? Spirometry is carried out at the surgery and she is asked to record her peak flow rate （峰值流速）at home, the best of three readings every morning and every evening for 2 weeks.
spiro—參考respiratory，—ometry xxx測(cè)量術(shù)，spirometry 肺功能測(cè)定
Spirometry results are as follows:
| 項(xiàng)目 | 實(shí)際值 | 參考值 |
|---|---|---|
| Actual （實(shí)際值） | Predicted （參考值） | |
| FEV1 (L) | 3.9 | 3.6–4.2 |
| FVC (L) | 5.0 | 4.5–5.4 |
| FER (FEV1/FVC) (%) | 78 | 75–80 |
| PEF (L/min) | 470 | 440–540 |
| FEV1: | forced expiratory volume in 1 s; | 第1秒用力呼氣容積 |
| FVC | forced vital capacity | 用力呼氣量 |
| FER | forced expiratory ratio | 用力呼氣比值 |
| PEF | peak expiratory flow | 最大呼氣流速 |
（圖表上傳不能顯示，所以用表格表示，但不影響上下文）
ANSWER 4
The peak flow pattern shows a degree of diurnal（日間的） variation. This does not reach the diagnostic criteria for asthma but it is suspicious.
The mean daily variation in peak flow from the recordings is 36 L/min and the mean evening peak flow is 453 L/min, giving a mean diurnal variation of 8 per cent.
There is a small diurnal variation in normals and a variation of ＞15 per cent is diagnostic of asthma. In this patient the label of ‘bronchitis’ as a child was probably asthma.
The family history of an atopic condition (hayfever in a brother), and the triggering of the cough by exercise and going out in to the cold also suggest bronchial hyper-responsiveness （高反應(yīng)）typical of asthma.
Patients with a chronic persistent cough of unexplained cause should have a chest X-ray. When the X-ray is clear the cough is likely to be produced by one of three main causes in non-smokers.
Around half of such cases have asthma or will go on to develop asthma over the next few years. Half of the rest have rhinitis（鼻炎） or sinusitis （鼻竇炎）with a post-nasal drip.鼻后滴漏
In around 20 per cent the cough is related to gastro-oesophageal reflux.胃食管反流
A small number of cases will be caused by otherwise unsuspected problems such as foreign bodies,（異物） bronchial ‘adenoma’, sarcoidosis or fibrosing alveolitis.（肺泡炎）
adeno—腺有關(guān)的，如adenine腺嘌呤，oma—瘤，adenoma腺瘤
sarco—肉有關(guān)的，
oid 像xxx的，如Android，andr，人有關(guān)的，Android就是像人一樣的
所以sarcoidosis類肉瘤
Cough is a common side-effect （副作用）in patients treated with angiotensin-converting-enzyme (ACE) inhibitors.血管緊張素轉(zhuǎn)化酶抑制劑
angio—血管有關(guān)的，tense緊張，in xxx素，angiotensin血管緊張素
In this patient the diagnosis of asthma was confirmed with an exercise test which was associated with a 25 per cent drop in peak flow after completion of 6 min vigorous exercise.
Alternatives would have been another non-specific challenge such as methacholine or histamine, or a therapeutic trial of inhaled （吸入）steroids.
methyl甲基，acetyl 乙?；?，choline膽堿，methacholine乙酰甲膽堿
histamine 組胺，histology組織學(xué)，amine 胺，amino acid 氨基酸
After the exercise test, an inhaled steroid was given and the cough settled after 1 week. The inhaled steroid was discontinued after 4 weeks and replaced by a β2-agonist（β2（受體）激動(dòng)劑） to use before exercise.
However, the cough recurred with more evident wheeze and shortness of breath, and treatment was changed back to an inhaled steroid with aβ2-agonist as needed.
If control was not established, the next step would be to check inhaler technique and treatment adherence and to consider adding a long-acting（長(zhǎng)效）β2-agonist.
In some cases, the persistent dry cough associated with asthma may require more vigorous treatment than this.
Inhaled steroids for a month or more, or even a 2-week course of oral steroids may be needed to relieve the cough.
The successful management of dry cough relies on establishing the correct diagnosis and treating it vigorously.
