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该病例为藏毛窦（pilonidal sinus）。经典情况下，次级窦位于中线一侧，如本图所示，原发窦位于中线。原发窦存在但不易见。窦下方存在一个可延伸至骶骨的腔。该腔常向中线外延伸，并有其他窦道通向皮肤表面。这些次级外置窦道源于感染性腔内脓肿和肉芽肿破裂。该腔常充满毛发。窦道因存在这些异物而持续存在，一旦感染发生，抗生素治疗价值有限。次级外置窦道具有外置异物窦道的典型表现，即肉芽组织突出；相比之下，原发中线窦道（原发窦）中毛发进入的情况很少，肉芽组织证据少，因此不易见。将毛发钻入中线原发窦道会因臀部行走时产生的吸吮力而受到鼓励。毛发的起源可能来自局部区域，或有时是源自头皮的长毛发。若存在急性脓肿（通常向侧方突出），则需要切开引流，但本病例中窦道呈慢性排脓状态，最合适的治疗是切除该区域，包括次级和原发窦道及皮下腔和毛发（E正确）。Karydakis描述的推进皮瓣术式被广泛使用。另外两个藏毛窦的示例如下图所示。 (缺图)

该皮疹具有固定性药物疹（fixed drug eruption）的典型特征（D正确）。它非常对称且分布独特，累及足背、足底和踝关节，但保留足趾。这几乎肯定是三硝基甲苯的反应。固定性药物疹描述了一种皮肤药物反应，其特征是每次给予责任药物时，皮肤病变在同一部位反复出现。多种药物可能引起该反应，如复方新诺明和三硝基甲苯。 (缺图)

短暂性单眼黑矇（amaurosis fugax，即短暂性单眼视觉丧失）提示眼动脉血小板栓塞，来源于同侧颈内动脉斑块。右侧大脑皮层受累，伴有右侧上肢运动区栓塞，会导致右侧大脑上运动神经元病变。下行上运动神经元在锥体交叉至对侧，支配对侧下运动神经元手部肌肉，导致对侧左手短暂性无力。右侧颈内动脉近起源处的收缩性溃疡斑块，最可能引起右侧颈动脉分叉处的收缩期杂音（B正确）。左侧颈动脉分叉处的杂音会导致相反的效果——短暂性左眼视觉丧失和右侧手部无力。心房纤颤导致不规则脉率，可伴有左心房血栓引起外周栓塞，其中栓塞性血管卒中是最严重的。然而，本病例中颈内动脉的短暂性缺血发作，不如心房纤颤常见，更可能由颈动脉斑块引起。全收缩期心前区杂音可能由二尖瓣反流或左向右分流引起，均与栓塞无关。中-舒张期心前区杂音与二尖瓣狭窄相关，通常不与栓塞相关，而是与心力衰竭相关。

该核素扫描显示右甲状腺叶大部分下极区域摄取减少，其余甲状腺组织摄取正常且均匀。这与甲状腺内孤立性“冷”结节一致，即在一个正常甲状腺内存在孤立性结节，且该结节大小足以在临床上表现为颈部肿块（B正确）。该病变未摄取核素，因此生理上无活性，与正常甲状腺相比；它似乎是一个真正的孤立性结节，存在于一个正常甲状腺内——单结节性甲状腺肿。可能的诊断包括孤立性出血性囊肿或胶质囊肿、良性腺瘤，或甲状腺恶性肿瘤——这些可能是乳头状癌（年轻成人中最常见）、滤泡性癌（较少见且难以与良性腺瘤区分），或髓样癌（最少见，通常是多发性内分泌肿瘤综合征的一部分）。诊断可通过超声引导下的细针穿刺细胞学或核心活检获得。乳头状癌很少扩散至头颈部以外；滤泡性癌可发生血行转移，有时转移至骨骼，并可能以病理性骨折为首发表现。体重减轻和震颤发生于甲状腺功能亢进（Graves病）的年轻患者；甲状腺可能未肿大，但通常弥漫性摄取核素，这与扫描结果不符。疼痛可作为初始症状，表现为结节内急性出血，但更常见的表现是无痛性肿块。干燥粗糙的皮肤见于甲状腺功能减退，表现为核素摄取减少——这是年轻成人中罕见的表现，且与单结节性甲状腺肿无关，而本病例的诊断或排除甲状腺癌是主要关注点。

该MRI显示C6-C7椎间盘向椎管内突出，压迫脊髓，但未造成脊髓移位。该水平的椎间盘脱出可能压迫第7颈神经根，导致C7神经根病，这与患者的临床表现一致：C7皮节的感觉异常，以及C7神经根受累导致肱三头肌腱反射减弱、腕关节和手指长屈肌力量减弱（B正确）。创伤性脊髓空洞症与本病例不符。颈脊髓空洞症可导致局部感觉丧失、疼痛，以及上运动神经元和下运动神经元体征，与本病例的影像学表现不符。脊髓半切综合征（Brown-Séquard syndrome）的影像学或临床表现不会显示该表现，该综合征表现为病变同侧下运动神经元损伤、病变下方同侧位置觉丧失、对侧疼痛和温度觉丧失，以及病变同侧上运动神经元体征。 “泥瓦匠损伤”（Clay shovellers' injury）是C7/T1棘突的牵拉性损伤，与本病例的临床表现和影像学表现不符。 (缺图)

面部或颧骨受到撞击后，出现双眼复视，高度提示颧骨/颧弓凹陷性骨折（E正确）。检查时可触及眶缘畸形，眶缘处可能有压痛，眶下神经分布区域可能出现感觉异常。通常需要手术复位。眼球破裂会导致视力严重丧失，而非复视。前房积血（hyphaema）会导致单眼视力模糊，检查时可发现前房积血，常伴有液平面。下颌骨升支骨折会导致张口困难，而非复视。上颌窦破裂通常是上颌骨粉碎性骨折或眶壁爆裂性骨折的继发损伤，通常由直接撞击眼球引起，而非撞击面部侧面。

The MRI demonstrates intervertebral disc protrusion between cervical vertebrae 6 and 7 extending to, but not displacing, the spinal cord. A prolapse at this level is likely to impinge upon the issuing 7th cervical nerve root, causing impingement C7 radiculopathy, which is consistent with his clinical features: sensory symptoms of paraesthesia in the C7 dermatome, and motor involvement of C7 causing diminution of triceps jerk and power of wrist and finger long flexors (B is correct). Traumatic syringomyelia is unlikely with this scenario. Cervical syringomyelia can cause local sensory loss to pain, upper limb lower motor neurone features, and lower limb long tract signs. The imaging does not suggest compression of the spinal cord; and an epidural haematoma would give a different imaging picture. Spinal cord hemisection (Brown-Séquard syndrome) is not suggested by the imaging or by the clinical features, which would be expected to include an ipsilateral lower motor neurone lesion, crossed sensory loss below the lesion with ipsilateral loss of position sense, contralateral pain and temperature sensory loss, and ipsilateral upper motor neurone signs below the lesion. 'Clay shovellers' injury is an occupational avulsion injury of the prominent spinous processes of C7/T1 and is not suggested by the clinical features or the imaging. (缺图)

After a blow to the cheek or side of the face, double vision of binocular type is very suggestive of a depressed fracture of the zyoma/zygomatic arch (E is correct). Inspection and palpation of the orbital margins may reveal a step deformity of the orbital margin or a depressed contour of the cheek, and there may also be anaesthesia in the distribution of the infraorbital nerve. Operative elevation is usually required. Rupture of the globe will cause gross loss of vision rather than diplopia. Hyphaema (bleeding into the anterior chamber) will cause monocular visual blurring, and is diagnosed by inspection revealing evidence of blood in the anterior chamber, often with a fluid level. Fracture of the mandibular ramus can cause difficulty opening the mouth, but not diplopia. Maxillary antrum rupture would be secondary to a comminuted maxillary fracture, or blowout fracture of the orbit, and usually follows a direct blow to the eye rather than to the lateral face or cheek.

Previously thought possibly to represent thyroid metaplasia in lymphoid tissue, and labelled 'lateral aberrant thyroid', it is now recognised that findings of differentiated thyroid tissue in a lymph node invariably indicate lymph node metastasis from a primary carcinoma of the thyroid, which is often small and occult (C is correct). The usual type of thyroid cancer to give lymph node metastases is the papillary carcinoma, which has no familial tendency. Papillary thyroid cancer affects young adults of either sex and is a slow-growing neoplasm. Spread is predominantly via lymphatic drainage to midline pretracheal and prelaryngeal nodes in front of the thyrohyoid membrane (the latter called 'Delphic' or 'oracular' node because it is a predictor of an underlying, but inapparent cancer). Spread also occurs to the deep cervical chain of nodes following superior and middle thyroid veins, and to nodes around the recurrent (inferior) laryngeal nerve and anterior mediastinum following inferior thyroid veins. The natural history of the condition is generally favourable and usually extends over many years. The lesion only rarely spreads beyond head and neck: repeated operations for recurrent tumour can often contain the disease for years. Spread via the blood stream is unusual, in contrast to the follicular and medullary types of thyroid cancer, so repeated local surgery for recurrences after primary surgery is worthwhile. Subacute (de Quervain) thyroiditis, thyroglossal duct cyst and lymphadenoid (Hashimoto) thyroiditis have entirely different clinical features, and benign thyroid adenomas are confined to the thyroid gland itself. (缺图)

The findings are classical of a right third (oculomotor) nerve palsy. Paralysis of the autonomic motor parasympathetic fibres coming from the Edinger-Westphal nucleus, results in sympathetic pupillary dilatation and failure of the direct and consensual responses to light (subserved by afferent impulses along the right and left optic nerves and efferent autonomic innervation of the right sphincter pupillae). These autonomic motor fibres are situated in the superior part of the third nerve and are involved early by focal compression secondary to an epidural haematoma (B is correct). The corneal reflex is subserved by the sensory fifth nerve afferents, but the efferent motor side of the reflex arc is via the seventh nerve. The fourth and sixth nerves do not subserve pupillary reflexes but give isolated ocular muscle palsies causing vertical diplopia on downward gaze (fourth nerve - superior oblique palsy), or lateral diplopia on outward gaze (sixth nerve - external rectus palsy). A second nerve palsy causes unilateral blindness with failure of the direct but not the consensual responses to light, and without change in pupillary size. Ptosis is commonly associated with a third nerve palsy, as the third nerve supplies the levator of the upper lid (levator palpebrae superioris) as well as the muscles responsible for ocular movements apart from the two mentioned above. In a complete third nerve lesion the eye is displaced downwards and outwards due to unopposed actions of external rectus and superior oblique - the 'down-and-out' eye. In a partial third nerve paralysis, ptosis may be the most prominent feature as illustrated below. The other illustration shows a left sixth nerve palsy identified on left lateral gaze. (缺图)

Metastatic carcinoma with an occult primary can be found with each of the options mentioned and also the skin. Thyroid cancer would not be expected to be of squamous cell type, but the others would. Piriform fossa laryngeal neoplasms would be expected to drain to anterior triangle deep cervical nodes, as would cancers of buccal cavity or tonsil. Drainage to posterior triangle nodes occurs from nasopharynx (which is the most likely primary site) and full otolaryngologic review and endoscopy will be required to confirm this (D is correct).

The photograph shows evidence of a right-sided glossal atrophy with atrophic glossitis consistent with a 12th (hypoglossal) nerve palsy (E is correct). The nerve is at risk during operations around the carotid bifurcation, near which the 12th nerve crosses the external and internal carotid arteries on its course from the base of the skull to the side of the tongue. Soft tissue tumours of the striated muscle of the tongue (rhabdomyosarcoma) are rare tumours, giving massive enlargement of the tongue. Squamous cell carcinoma, presenting as an ulcerated exophytic or indurated lesion, should always be suspected when any glossal ulcer fails to heal. Squamous carcinomas are often secondary to the four S's - Smoking, Spirits, Spices (betel nut, pan), and Syphilis. 'Geographic' tongue has a characteristic appearance and is not associated with other diseases. The trigeminal nerve supplies sensation to the tongue via the lingual nerve. (缺图)

Each of the measures described may be required, but the most appropriate immediate first aid treatment of a chemical burn eye injury is copious water irrigation to dilute and wash away the injurious chemical agent, which otherwise will continue to act and produce progressively deeper injury (D is correct). When an ocular chemical burn injury presents to an Emergency Department, local anaesthetic eye drops should be instilled in the eye, followed by irrigation for a minimum of 20 minutes with isotonic 0.9% (normal) saline.

Because of the patient's increased metabolic state and vascular hyperactivity, pulmonary embolism is extremely uncommon after thyroidectomy for thyrotoxicosis, especially given the onset of symptoms soon after surgery. Pulmonary atelectasis is the most common cause of early postoperative fever and tachycardia after all classes of surgery (A is correct). Wound infection and septicaemia are both uncommon after the elective clean surgical procedure of thyroidectomy, unless a gross breach of aseptic technique has occurred in conjunction with a wound haematoma; and the onset is again earlier than one would expect. Inspection of the wound area to check that no upper airway obstruction from a deep wound haematoma is present is, however, mandatory. A thyroid crisis is an important differential diagnosis. This complication is now very uncommon after adequate preoperative patient preparation; and all thyrotoxic patients proceeding to surgery require adequate medical treatment with antithyroid medication, if necessary supplemented by addition of a beta-blocker. Such treatment is usually required for one or two weeks, so that the patient is clinically and biochemically euthyroid at the time of surgery, and the risk of exacerbation of thyrotoxicosis after surgery (thyroid crisis) is thereby minimised or eliminated. An ECG would be appropriate to exclude with certainty a dysrhythmia - but atrial fibrillation is unlikely with a regular pulse and atrial flutter also less likely than sinus tachycardia with a pulse rate of 110/min. In patients with florid postoperative thyroid crisis, in times past, the clinical picture was usually distinctive and alarming with more rapid pulse, higher fever and marked systemic signs.

Episodes of fleeting transient monocular loss or blurring of vision (amaurosis fugax) are characteristic of an ipsilateral carotid artery lesion, often a stenotic lesion or an ulcerating atherosclerotic plaque, causing transient reversible ophthalmic artery ischaemia from minute emboli. The central retinal artery divides into upper and lower branches at the optic nerve head (B is correct). • When an embolus blocks the upper branch, the experience is described as a shadow moving up from the inferior periphery and stopping in the middle of the field at the horizontal line. • When the embolus blocks the lower branch, the resulting obscuration is described as descending from above, and again stops at a central horizontal line. • When the main trunk of the retinal artery is blocked in the optic nerve head, there is a gradual constriction of the visual field until only a central bright spot remains, which then extinguishes. In all cases, the obstruction usually lasts less than a minute and, as the embolus breaks up, it moves to the periphery. The retinal circulation is re-established and the visual obscuration reverses. The sight returns as the obscuration moves either up or down, in the case of a branch occlusion, or expands from a central point, expanding to the periphery when the main trunk of the central retinal artery is involved. Giant cell (temporal) arteritis classically causes premonitory severe constant focal headache preceding visual loss, which, when it occurs, is usually permanent. The headache is often associated with aching jaw claudication on chewing. Acute glaucoma classically presents with acute pain associated with a painful red eye, with dilated ciliary vessels and corneal oedema with a hazy cornea, an irregular light reflex and a nonreactive pupil, and a high intraocular pressure. In chronic glaucoma there is chronic gradual loss of sight that is non-symptomatic. Raised intracranial pressure is characterised by worsening headache, often associated with vomiting, progressing to drowsiness and papilloedema. Bradycardia and hypertension are late symptoms associated with tentorial herniation. Transient visual obscurations frequently accompany raised intracranial pressure due to transient interference with optic nerve transmission in the presence of papilloedema. Systemic hypertension is another important cause of headache, rather than transient loss of vision as is the case in this scenario.

The site of any ulcer on the lower limb is of great importance in the determination of the underlying cause. The important causes include venous stasis, arterial insufficiency, infection and trauma. Venous insufficiency ulcers are most often situated around the ankle and, characteristically, over the medial malleolus. Venous pressure tends to be highest at this site, where there are many perforating veins. Arterial ulcers from large vessel atherosclerosis usually occur at the extremities, typically on the toes and dorsum of the foot. Infectious ulcers may occur at any site, as with the ulcer due to the presence of a foreign body. Ulcers associated with

患者出现一过性单眼视力丧失或模糊（amaurosis fugax），该症状最可能的原因是？

下肢溃疡的溃疡部位对判断病因至关重要，该溃疡最可能的病因是？

患者双耳听力检查显示骨传导优于气传导，Rinne试验异常，Weber试验偏向右耳，该患者最可能的听力障碍类型是？

患者出现双眼睁开时垂直性复视，闭眼时复视消失，最可能的诊断是？