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2025年全國醫(yī)學英語水平考試（METS四級）考前沖刺試題及答案四,更多相關資訊請繼續(xù)查看易考吧全國醫(yī)護英語水平考試
1). Patient Access to Physician Notes Is Gaining Momentum■Family physician Richard Martin， MD， sees many patients with chronic conditions.Among them is a man in his 80s who arrives prepped by Martin′s notes from his last visit.Martin was one of the first physicians at Geisinger Health System， headquartered in Danville， Pennsylvania， to volunteer in 2010 for an OpenNotes pilot program making physician notes readily available through a secure online portal，( ).■Sharing medical notes with patients is a trend more health institutions are adopting they foster transparency in medical records.OpenNotes is an initiative to promote medical note sharing that was launched in 2010 by clinicians and researchers at Beth Israel Deaconess Medical Center in Boston.Funded by the Robert Wood Johnson Foundation and other charitable groups， OpenNotes has developed copyrighted materials that it shares for free with health systems to introduce simple patient access to medical notes.■“My patient contends that reading his medical notes motivated him to maintain his health，” said Martin.( ) According to a recent study， patients who frequently read their physician′s notes reported they better understood their health condition， took better care of their health， and had a better relationship with their physician.■For decades， patients could legally access their medical notes as part of the Health Insurance Portability and Accountability Act of 1996.( )What sets OpenNotes apart is the ease and speed with which patients can access notes.■The OpenNotes initiative was the brainchild of Tom Delbanco， MD， a professor of general medicine and primary care at Harvard Medical School， and Jan Walker， RN，an assistant professor of medicine， also at Harvard.Throughout his 40 years of practice，Delbanco freely shared his notes with patients.When patent portals were introduced，Delbanco realized that patients could email their physicians and schedule appointments，but physician notes were hidden.He and Walker decided to investigate the consequences of inviting patients to view physician notes via online patient portals by setting up a 1-year research and demonstration project， funded by the Robert Wood Johnson Foundation and 2 other organizations.■The project involved 105 primary care physicians and 13，564 patients at 3 sites：Beth Israel， Geisinger， and Harborview Medical Center in Seattle.Both participating patients and participating and nonparticipating physicians completed an online survey at the beginning of the study assessing their attitudes toward medical note sharing.( )At the study′s conclusion， after a year of access to physician notes，participating patients and physicians completed a follow-up online survey， which asked the same questions as the baseline survey， but with the verb tense changed to reflect that patient access to medical notes had been established.The results showed that 99% of responding patients supported continued access to medical notes online， and the majority of responding physicians at each of the 3 sites， ranging from 85% at Beth Israel to 91%at Geisinger， agreed that access was a good idea.■Some physicians were skeptical at first， expressing concerns that giving patients access to medical notes might add to their workload if patients called and emailed with questions based on what they read， Delbanco said.For the most part， those fears were unfounded， he noted.( )■Since the pilot study， other health systems have adopted the OpenNotes concept.Delbanco estimates that about 100 health care institutions are at some stage， from planning to implementation， of sharing medical notes with patients.Some have used the OpenNotes resources， and others have not， Delbanco said.■The medical notes that the patients read are the physician′s notes一the patient′s story - Delbanco emphasized， and not simply the after-visit laundry list of medications and instructions that patients customarily receive.■Despite OpenNotes′ benefits， some concerns remain.One is that patients might find the information they read upsetting.To cushion a potential blow， MD Anderson Cancer Center holds laboratory， radiology， and pathology results for 7 days and Mayo Clinic delays patient access to radiology and pathology results for 3 days so physicians can first speak with patients.■In addition， OpenNotes raises issues of access and fairness for patients who don′t have a computer or have a limited knowledge of English， noted Nancy Berlinger， PhD， a Hastings Center research scholar.■( ) The OpenNotes pilot study found that 28% of participating physicians at Beth Israel， 9% at Geisinger， and 11% at Harborview reported in the poststudy survey that they were less candid in their notes knowing patients could read them， suggesting the concern may be valid.■Steven Malkin， MD， an internist who practices in Arlington Heights， Illinois， is concerned that if his patients routinely read his notes， he would be less forthcoming.“My notes are for me，” Malkin said.“If I knew a patient was going to read them， I would write them differently.′”■Although Geisinger′s Martin said he has not changed the way he writes notes， he has learned that patients may， interpret a word differently than anticipated， citing a patient who took offense to being described as obese.( ).■Despite lingering apprehension， Milliner thinks sharing notes with patients is a good tool for improving communication between patients and physicians.“It is one more way they become part of decision making，” Milliner said.“I view that as a very positive thing.”( )
A.Nonetheless， that description motivated the patient to lose weight， he said
B.Less than 10% of participating physicians reported increased length of visits or time responding to patient queries
C.Sharing medical notes， he said， appears to engage his patients and refreshes their memory of office conversations
D.But fees or long wait times to receive the records sometimes hampered the process
E.Furthermore， physicians may be inclined to censor themselves because patients can electronically peer over their shoulder
F.The feedback from Martin′s elderly patient illustrates why health systems across the country are making physician notes easily available to patients
G.Although individual physicians can′t opt out of note sharing， certain types of notes， such as confidential psychiatric notes， may be withheld
H.Initially， most patients (92%～97%) at the 3 sites thought patient access to notes was a good idea， although fewer participating physicians thought so (69%～81 % at the 3 sites)

正確答案：D
2). Celiac Sprue■(一)■1.Celiac sprue， also known as celiac disease and gluten-sensitive enteropathy， is characterized by malabsorption resulting from inflammatory injury to the mucosa of the small intestine after the ingestion of wheat gluten or related rye and barley proteins.There is clinical and histologic improvement on a strict gluten-free diet， and relapse when dietary gluten is reintroduced.Accounts of celiac sprue date back to the first century A.D.It was not until the 1940s， however， that the link to gluten ingestion was established； Dickc， a Dutch pediatrician， observed that the condition of children with celiac sprue improved during the food shortages of World War I，only to relapse after cereal supplies were restored.Until fairly recently， celiac sprue was considered uncommon in the United States，with an estimated prevalence of 1 per 3， 000 population.However， greater awareness of its presentations and the availability of new， accurate serologic tests have led to the realization that celiac sprue is relatively common， affecting 1 of every 120 to 300persons in both Europe and North America.■2.The true prevalence of celiac sprue is difficult to ascertain， because many patients have atypical symptoms or none at all A large， multicenter Italian study identified seven new cases of celiac sprue in children for each patient with established disease.The highest reported prevalence is in Western Europe and in places where Europeans emigrated，notably North America and Australia.Celiac sprue is also found in parts of northwest India， and it may be underdiagnosed in South America， North Africa， and Asia.It is rare among people from a purely African-Caribbean， Chinese， or Japanese background.In most series there is a slight female preponderance.■3.Celiac sprue results from an inappropriate T-cell-mediated immune response against ingested gluten in genetically predisposed people.The importance of genetic factors is supported by the approximately 10 percent prevalence of the disease among first- degree relatives.Over 95 percent of patients with celiac sprue express the HLA-DQ(α1 * 501，β1 * 02) heterodimer ( HLA-DQ2)，which preferentially presents gluten derived gliadin peptides on its antigen-presenting groove to stimulate intestinal mucosal T cells.The enzyme tissue transglutaminase is one of the targets of the autoimmune response in celiac sprue.The modification of gliadin by host tissue transglutaminase has a key role in enhancing the gliadin-specific T-cell response， and a single tissue transglutaminase modified peptide is the dominant a-gliadin T cell epitope and may be a target for antigen-specific peptide therapy.■4.Classically， infants with celiac sprue present between the ages of 4 and 24 months with impaired growth， diarrhea， and abdominal distention.Vomiting is common in young .infants， as are pallor and edema.The onset of symptoms is gradual and follows the introduction of cereals into the diet.The velocity of weight gain slowly decreases before weight loss ensues.Some children present with constipation， although diarrhea is more typical.Patients with severe， untreated celiac sprue may present with short statue，pubertal delay， iron and folate deficiency with anemia， and rickets.Atypical celiac sprue is usually seen in older children or adolescents， who often have no overt features of malabsorption.In addition to recurrent abdominal pain， hypertransaminasemia， recurrent aphthous stomatitis， arthralgia， and defects in dental enamel， children may have behavioral disturbances such as depression， may be irritable， and may perform poorly in school.■5.The diagnosis of celiac sprue is increasingly being made in adults.Approximately50 percent of adult patients do not have clinically significant diarrhea.iron- deficiency anemia is now the most common clinical presentation in adults with celiac sprue.Other laboratory abnormalities include macrocytic anemia due to folate (or， rarely， vitamin B12)deficiency， coagulopathy resulting from vitamin K deficiency， or vitamin D deficiency leading to hypocalcemia and an elevated alkaline phosphatase level.Other increasingly recognized extraintestinal manifestations include bone fractures， infertility， psychiatric syndromes， and various neurologic conditions ，including peripheral neuropathy， ataxia，and seizures.■6.The availability of highly sensitive and specific serologic markers greatly facilitates the diagnosis of celiac sprue.These serologic tests are used to evaluate patients with suspected disease， monitor adherence and response to a gluten- free diet， and screen patients with atypical， extraintestinal manifestations.IgA antiendomysial antibodies are usually detected by indirect immunofluorescence with the use of sections of human umbilical cord or，less commonly， monkey esophageal smooth muscle.The reported sensitivity and specificity of antiendomysial antibodies are 85 to 98 percent and 97 to 100percent， respectively.■7.Histologic examination of a biopsy specimen of the small intestine remains the diagnostic gold standard for celiac sprue.In current practice， most biopsies in children and adults are performed during upper endoscopy.Endoscopy is more reliable than previous capsule biopsy techniques， because it allows multiple specimens to be obtained， thus reducing sampling error， and because， in many cases， examination of the upper gastrointestinal tract may in itself be indicated (e.g，in iron deficiency anemia ).Specimens should be obtained from the distal duodenum ( second or third part) to avoid the architectural distortion produced by Brunner′s glands or peptic duodenitis.Absent，flattened， or scalloped duodenal folds are not specific for celiac sprue.■8.Because a gluten-free diet represents a lifetime commitment， is more expensive than a normal diet， and may limit patients socially， especially children and teenagers， it should never be recommended unless the diagnosis of celiac sprue is firmly established.There is no role for an empirical therapeutic trial of gluten withdrawal because a patient′s response is often equivocal and because the abnormal findings on both the serologic tests and small-bowel biopsy may revert to normal， making subsequent definitive diagnosis difficult.■(二)■Celiac sprue is a relatively common enteropathy which is correlated with the ingestion of dietary ( )It is difficult to determine the real prevalence of the disease because of ( )symptoms in the patients.An ( )immune response against ingested gluten is likely to result in celiac sprue.Children and adults with celiac sprue present with a wide ( )of clinical manifestations.Methods for the diagnosis of celiac sprue include serologic tests and biopsy of the small intestine taken as diagnostic( )standard.A gluten free diet will not be recommended to the patients until a definite ( )is made.Choose the correct heading for Paragraph 3 ( )
A.Pathogenesis of celiac sprue
B.Clinical presentations of celiac sprue in adults
C.Treatment of celiac sprue with a gluten-free diet
D.Causes and diagnosis history of celiac sprue
E.Treatment of celiac sprue with multivitamin intake
F.Diagnosis of celiac sprue with serologic tests
G.Clinical manifestations in children with celiac sprue
H.Diagnosis of celiac sprue with biopsy of the small intestine
I.Epidemiological features of celiac sprue
J.Refractory sprue and enteropathy-associated T-cell lymphoma

正確答案：A
3). Celiac Sprue■(一)■1.Celiac sprue， also known as celiac disease and gluten-sensitive enteropathy， is characterized by malabsorption resulting from inflammatory injury to the mucosa of the small intestine after the ingestion of wheat gluten or related rye and barley proteins.There is clinical and histologic improvement on a strict gluten-free diet， and relapse when dietary gluten is reintroduced.Accounts of celiac sprue date back to the first century A.D.It was not until the 1940s， however， that the link to gluten ingestion was established； Dickc， a Dutch pediatrician， observed that the condition of children with celiac sprue improved during the food shortages of World War I，only to relapse after cereal supplies were restored.Until fairly recently， celiac sprue was considered uncommon in the United States，with an estimated prevalence of 1 per 3， 000 population.However， greater awareness of its presentations and the availability of new， accurate serologic tests have led to the realization that celiac sprue is relatively common， affecting 1 of every 120 to 300persons in both Europe and North America.■2.The true prevalence of celiac sprue is difficult to ascertain， because many patients have atypical symptoms or none at all A large， multicenter Italian study identified seven new cases of celiac sprue in children for each patient with established disease.The highest reported prevalence is in Western Europe and in places where Europeans emigrated，notably North America and Australia.Celiac sprue is also found in parts of northwest India， and it may be underdiagnosed in South America， North Africa， and Asia.It is rare among people from a purely African-Caribbean， Chinese， or Japanese background.In most series there is a slight female preponderance.■3.Celiac sprue results from an inappropriate T-cell-mediated immune response against ingested gluten in genetically predisposed people.The importance of genetic factors is supported by the approximately 10 percent prevalence of the disease among first- degree relatives.Over 95 percent of patients with celiac sprue express the HLA-DQ(α1 * 501，β1 * 02) heterodimer ( HLA-DQ2)，which preferentially presents gluten derived gliadin peptides on its antigen-presenting groove to stimulate intestinal mucosal T cells.The enzyme tissue transglutaminase is one of the targets of the autoimmune response in celiac sprue.The modification of gliadin by host tissue transglutaminase has a key role in enhancing the gliadin-specific T-cell response， and a single tissue transglutaminase modified peptide is the dominant a-gliadin T cell epitope and may be a target for antigen-specific peptide therapy.■4.Classically， infants with celiac sprue present between the ages of 4 and 24 months with impaired growth， diarrhea， and abdominal distention.Vomiting is common in young .infants， as are pallor and edema.The onset of symptoms is gradual and follows the introduction of cereals into the diet.The velocity of weight gain slowly decreases before weight loss ensues.Some children present with constipation， although diarrhea is more typical.Patients with severe， untreated celiac sprue may present with short statue，pubertal delay， iron and folate deficiency with anemia， and rickets.Atypical celiac sprue is usually seen in older children or adolescents， who often have no overt features of malabsorption.In addition to recurrent abdominal pain， hypertransaminasemia， recurrent aphthous stomatitis， arthralgia， and defects in dental enamel， children may have behavioral disturbances such as depression， may be irritable， and may perform poorly in school.■5.The diagnosis of celiac sprue is increasingly being made in adults.Approximately50 percent of adult patients do not have clinically significant diarrhea.iron- deficiency anemia is now the most common clinical presentation in adults with celiac sprue.Other laboratory abnormalities include macrocytic anemia due to folate (or， rarely， vitamin B12)deficiency， coagulopathy resulting from vitamin K deficiency， or vitamin D deficiency leading to hypocalcemia and an elevated alkaline phosphatase level.Other increasingly recognized extraintestinal manifestations include bone fractures， infertility， psychiatric syndromes， and various neurologic conditions ，including peripheral neuropathy， ataxia，and seizures.■6.The availability of highly sensitive and specific serologic markers greatly facilitates the diagnosis of celiac sprue.These serologic tests are used to evaluate patients with suspected disease， monitor adherence and response to a gluten- free diet， and screen patients with atypical， extraintestinal manifestations.IgA antiendomysial antibodies are usually detected by indirect immunofluorescence with the use of sections of human umbilical cord or，less commonly， monkey esophageal smooth muscle.The reported sensitivity and specificity of antiendomysial antibodies are 85 to 98 percent and 97 to 100percent， respectively.■7.Histologic examination of a biopsy specimen of the small intestine remains the diagnostic gold standard for celiac sprue.In current practice， most biopsies in children and adults are performed during upper endoscopy.Endoscopy is more reliable than previous capsule biopsy techniques， because it allows multiple specimens to be obtained， thus reducing sampling error， and because， in many cases， examination of the upper gastrointestinal tract may in itself be indicated (e.g，in iron deficiency anemia ).Specimens should be obtained from the distal duodenum ( second or third part) to avoid the architectural distortion produced by Brunner′s glands or peptic duodenitis.Absent，flattened， or scalloped duodenal folds are not specific for celiac sprue.■8.Because a gluten-free diet represents a lifetime commitment， is more expensive than a normal diet， and may limit patients socially， especially children and teenagers， it should never be recommended unless the diagnosis of celiac sprue is firmly established.There is no role for an empirical therapeutic trial of gluten withdrawal because a patient′s response is often equivocal and because the abnormal findings on both the serologic tests and small-bowel biopsy may revert to normal， making subsequent definitive diagnosis difficult.■(二)■Celiac sprue is a relatively common enteropathy which is correlated with the ingestion of dietary ( )It is difficult to determine the real prevalence of the disease because of ( )symptoms in the patients.An ( )immune response against ingested gluten is likely to result in celiac sprue.Children and adults with celiac sprue present with a wide ( )of clinical manifestations.Methods for the diagnosis of celiac sprue include serologic tests and biopsy of the small intestine taken as diagnostic( )standard.A gluten free diet will not be recommended to the patients until a definite ( )is made.Choose the correct heading for Paragraph 7 ( )
A.Pathogenesis of celiac sprue
B.Clinical presentations of celiac sprue in adults
C.Treatment of celiac sprue with a gluten-free diet
D.Causes and diagnosis history of celiac sprue
E.Treatment of celiac sprue with multivitamin intake
F.Diagnosis of celiac sprue with serologic tests
G.Clinical manifestations in children with celiac sprue
H.Diagnosis of celiac sprue with biopsy of the small intestine
I.Epidemiological features of celiac sprue
J.Refractory sprue and enteropathy-associated T-cell lymphoma

正確答案：H

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