沙多多的奇思妙想

云端部署FaceFusion-AI换脸

<img src="https://fallen.wang/p/facefusion/cover.png" alt="Featured image of post 云端部署FaceFusion-AI换脸" /><p>写在最前面：<strong>有些步骤可能需要魔法</strong></p> <p>号称***“Next generation face swapper and enhancer ”***的Facefusion 上周发布了<code>2.2.1</code> 版本。虽然对显卡要求没有以前的roop 和deepfake 那么夸张，但是GTX1650 跑起来还是比较吃力，所以决定云端部署。</p> <p>这次依然是选择了老朋友恒源云，如果有动手能力也可以尝试白嫖Colab。</p> <p>项目地址：https://github.com/facefusion/facefusion</p> <p>官方文档：https://docs.facefusion.io/</p> <p>这次创建镜像的时候选择的是<code>PyTorch</code> &gt;<code>2.0.0</code> &gt;<code>Cuda11.8.0</code> 刚好符合项目需求。</p> <h1 id="一文件下载">一、文件下载</h1> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#安装cli</span> </span></span><span class="line"><span class="cl">curl -L https://download.gpushare.com/download/gpushare-cli-linux -o /usr/local/bin/gpushare-cli </span></span><span class="line"><span class="cl">chmod u+x /usr/local/bin/gpushare-cli </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="c1">#验证是否安装成功</span> </span></span><span class="line"><span class="cl">gpushare-cli version </span></span></code></pre></td></tr></table> </div> </div><p>这一步是为了后续的文件传输，具体可以参考我之前的博客：https://fallen.wang/p/sovits/</p> <p>然后下载模型文件：<em><strong>此链接由Bilibili用户 @AI百晓生 提供</strong></em></p> <p><a class="link" href="https://pan.baidu.com/s/1U_vsRu9ILHn9FQ_5iph-YQ?pwd=f86f" target="_blank" rel="noopener" >https://pan.baidu.com/s/1U_vsRu9ILHn9FQ_5iph-YQ?pwd=f86f</a></p> <p>*这是为Windows 系统准备的，Linux 只需要下载其中的<code>models.7z</code>即可*</p> <p>将项目clone 到本地：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">git clone https://github.com/facefusion/facefusion </span></span></code></pre></td></tr></table> </div> </div><p>如果因为<em><strong>众所周知的原因</strong></em>导致clone 失败，请使用<em><strong>魔法</strong></em>，或者自行搭建<em><strong>异次元通道</strong></em>，当然也可以下载压缩包到本地手动上传：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt"> 1 </span><span class="lnt"> 2 </span><span class="lnt"> 3 </span><span class="lnt"> 4 </span><span class="lnt"> 5 </span><span class="lnt"> 6 </span><span class="lnt"> 7 </span><span class="lnt"> 8 </span><span class="lnt"> 9 </span><span class="lnt">10 </span><span class="lnt">11 </span><span class="lnt">12 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="nb">cd</span> /hy-tmp </span></span><span class="line"><span class="cl"><span class="c1">#上传项目压缩包然后解压</span> </span></span><span class="line"><span class="cl">unzip facefusion-master.zip </span></span><span class="line"><span class="cl"><span class="c1">#创建模型目录，注意以.开头的文件夹是隐藏的</span> </span></span><span class="line"><span class="cl"><span class="nb">cd</span> facefusion-master </span></span><span class="line"><span class="cl">mkdir .assets </span></span><span class="line"><span class="cl"><span class="c1">#下载模型文件</span> </span></span><span class="line"><span class="cl">gpushare-cli baidu down models.7z </span></span><span class="line"><span class="cl"><span class="c1">#解压，注意文件约6G需要使用7za命令解压</span> </span></span><span class="line"><span class="cl">7za x /usr/local/bin/models.7z </span></span><span class="line"><span class="cl"><span class="c1">#将解压后的models文件夹移动至/.assets内</span> </span></span><span class="line"><span class="cl">mv /models /hy-tmp/facefusion-master/.assets </span></span></code></pre></td></tr></table> </div> </div><h1 id="二环境部署">二、环境部署</h1> <h2 id="python">Python</h2> <p>该项目使用的是<code>Python3.10</code> ，而恒源云的Ubuntu 自带的是<code>Python3.8</code> ，因此需要升级：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt"> 1 </span><span class="lnt"> 2 </span><span class="lnt"> 3 </span><span class="lnt"> 4 </span><span class="lnt"> 5 </span><span class="lnt"> 6 </span><span class="lnt"> 7 </span><span class="lnt"> 8 </span><span class="lnt"> 9 </span><span class="lnt">10 </span><span class="lnt">11 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#更新包列表</span> </span></span><span class="line"><span class="cl">sudo apt update </span></span><span class="line"><span class="cl"><span class="c1">#安装依赖项</span> </span></span><span class="line"><span class="cl">sudo apt install -y software-properties-common </span></span><span class="line"><span class="cl"><span class="c1">#添加Python3.10 的PPA 到源列表中</span> </span></span><span class="line"><span class="cl">sudo add-apt-repository ppa:deadsnakes/ppa </span></span><span class="line"><span class="cl"><span class="c1">#若提示‘Press [ENTER] to continue or Ctrl-c to cancel adding it’则按回车</span> </span></span><span class="line"><span class="cl"><span class="c1">#安装Python3.10</span> </span></span><span class="line"><span class="cl">sudo apt install -y python3.10 </span></span><span class="line"><span class="cl"><span class="c1">#验证</span> </span></span><span class="line"><span class="cl">Python3.10 --version </span></span></code></pre></td></tr></table> </div> </div><h2 id="ffmpeg">FFmpeg</h2> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">apt install ffmpeg </span></span></code></pre></td></tr></table> </div> </div><p>若询问是否继续输入<code>y</code></p> <h2 id="curl">cURL</h2> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">apt install curl </span></span></code></pre></td></tr></table> </div> </div><p>若询问是否继续输入<code>y</code></p> <h2 id="虚拟环境">虚拟环境</h2> <p>接着创建虚拟环境：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="nb">cd</span> /hy-tmp/facefusion-master </span></span><span class="line"><span class="cl">python3.10 -m venv venv </span></span></code></pre></td></tr></table> </div> </div><p>此时却出现了这样一条报错：</p> <p><font color=#ff3030>Error: Command &lsquo;[&rsquo;/hy-tmp/venv/bin/python3.10&rsquo;, &lsquo;-m&rsquo;, &rsquo;ensurepip&rsquo;, &lsquo;&ndash;upgrade&rsquo;, &lsquo;&ndash;default-pip&rsquo;]&rsquo; returned non-zero exit status 1.</font></p> <p>此时已经创建了venv ，报错是因为缺少<code>ensurepip</code> 模块，具体原因尚不清楚。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#先把刚刚的venv删掉</span> </span></span><span class="line"><span class="cl">rm -rf venv </span></span><span class="line"><span class="cl"><span class="c1">#重新创建不带pip的venv</span> </span></span><span class="line"><span class="cl">python3.10 -m venv --without-pip venv </span></span><span class="line"><span class="cl"><span class="c1">#激活虚拟环境</span> </span></span><span class="line"><span class="cl"><span class="nb">source</span> venv/bin/activate </span></span></code></pre></td></tr></table> </div> </div><h1 id="三安装项目">三、安装项目</h1> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">python install.py </span></span></code></pre></td></tr></table> </div> </div><p>报错：<font color=#ff3030>ModuleNotFoundError: No module named &lsquo;inquirer&rsquo;</font> 尝试<code>pip</code> 却依然报错。</p> <p>查阅了官方discord后发现也有人遇到过类似问题，版主给出的解决方法是：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">python -m pip install --upgrade pip </span></span></code></pre></td></tr></table> </div> </div><p>这时却提示缺少<code>pip</code> ，因为刚刚创建虚拟环境的时候留了一个伏笔<code>--without-pip venv</code>。手动装一个：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">curl https://bootstrap.pypa.io/get-pip.py -o get-pip.py </span></span><span class="line"><span class="cl">python get-pip.py </span></span></code></pre></td></tr></table> </div> </div><p>安装了最新版<code>pip</code> 之后就可以运行 <code>install.py</code>了。</p> <p>因为显卡是N卡，所以按方向键选择<code>cuda</code>,选择两次。<img src="https://fallen.wang/p/facefusion/cuda.png" width="487" height="337" srcset="https://fallen.wang/p/facefusion/cuda_hue6db1a205efefcb37953a136283cd962_10389_480x0_resize_box_3.png 480w, https://fallen.wang/p/facefusion/cuda_hue6db1a205efefcb37953a136283cd962_10389_1024x0_resize_box_3.png 1024w" loading="lazy" alt="cuda" class="gallery-image" data-flex-grow="144" data-flex-basis="346px" > 耐心等待脚本执行完毕。 大致看一眼没有报错便可进入下一步。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">python run.py </span></span></code></pre></td></tr></table> </div> </div><p>当出现<code>Running on local URL: http://127.0.0.1:7860</code>时即为成功启动了。此时服务器端访问<code>127.0.0.1：7860</code>即可，但是毕竟服务器端没有图形化界面，所以可以在<code>launch()</code>函数里设置<code>share=True</code>以获得可供外网访问的链接：不过我个人更喜欢配置一个端口转发。</p> <p>以xshell为例，连接至实例时需要提供主机、端口、用户和密码，这些都可以在控制台界面找到。 <img src="https://fallen.wang/p/facefusion/user.png" width="521" height="342" srcset="https://fallen.wang/p/facefusion/user_hu037a3405aabe8ad6fe3c30f8a6b6be05_15660_480x0_resize_box_3.png 480w, https://fallen.wang/p/facefusion/user_hu037a3405aabe8ad6fe3c30f8a6b6be05_15660_1024x0_resize_box_3.png 1024w" loading="lazy" alt="user" class="gallery-image" data-flex-grow="152" data-flex-basis="365px" > 点击<code>登录指令</code>的<code>复制</code>按钮，得到如下信息： <code>ssh -p 41624 root@i-2.gpushare.com</code> 其中<code>41624</code> 为端口，<code>root</code> 为用户，<code>i-2.gpushare.com</code> 为主机，密码则单独列出。 新建会话，填写主机和端口，然后在侧边选项卡里找到<code>SSH</code> &gt; <code>隧道</code>&gt; <code>添加</code>，如图示填写： <img src="https://fallen.wang/p/facefusion/port.png" width="636" height="487" srcset="https://fallen.wang/p/facefusion/port_hu847fe2baf5811a4c09f5e63490096edc_28811_480x0_resize_box_3.png 480w, https://fallen.wang/p/facefusion/port_hu847fe2baf5811a4c09f5e63490096edc_28811_1024x0_resize_box_3.png 1024w" loading="lazy" alt="port" class="gallery-image" data-flex-grow="130" data-flex-basis="313px" > 其中<code>侦听端口</code>可随意填写。 以<code>ROOT</code> 身份登录，输入密码，成功建立会话后在本地浏览器中输入<code>127.0.0.1:8888</code>即可访问web-ui。 <img src="https://fallen.wang/p/facefusion/webui.png" width="1920" height="1080" srcset="https://fallen.wang/p/facefusion/webui_hu4148f1445820120991c9481ae02315cd_195773_480x0_resize_box_3.png 480w, https://fallen.wang/p/facefusion/webui_hu4148f1445820120991c9481ae02315cd_195773_1024x0_resize_box_3.png 1024w" loading="lazy" alt="webui" class="gallery-image" data-flex-grow="177" data-flex-basis="426px" ></p> <p>BTW，该项目引用了开源的NSFW 检测，具体代码位于<code>/facefusion/content_analyser.py</code>，可以尝试调整<code>probability</code>值。</p>

永久禁用Windows自动更新

<img src="https://fallen.wang/p/fuck-windows-update/19.png" alt="Featured image of post 永久禁用Windows自动更新" /><h1 id="font-colorff3030fuck-windows-updatefont"><font color=#ff3030><strong>fuck Windows update</strong></font></h1> <p><del><em><strong>微软的阿三程序员什么时候暴毙啊</strong></em></del></p> <p>每次一开电脑看到这正在更新就烦，而且我是双系统，默认引导的是Linux，更新重启跟难产似的。</p> <p>百度搜了搜，无外乎那几种互相抄袭的早被微软修复的解决办法，尝试了几个全然无效。<del>很符合我对简中互联网粪坑的刻板印象</del></p> <p>偶然在红迪看到这个方法，<a class="link" href="https://www.reddit.com/user/ikashanrat/comments/stsuwr/solved_how_to_disable_shitty_windows_updates/" target="_blank" rel="noopener" >SOLVED How to disable shitty Windows Updates permanently in Windows 10 guaranteed 100% !!</a>（<font color=#eeee00><strong>此链接需要魔法</strong></font>）标题写的Win 10，经我测试（2023年8月11日）Win 11依然有效</p> <h2 id="免责声明">免责声明</h2> <blockquote> <p>禁用Windows自动更新<font color=#ff3030><strong>可能会让您容易受到安全威胁</strong></font>,如果您不知道自己在做什么，<font color=#ff3030><strong>修改注册表可能会导致严重的系统问题</strong></font></p> <p>如果电源中显示<font color=#ff3030><strong>“更新并关闭”或“更新并重新启动”选项而不是“关闭”和“重新启动”</strong></font>，请勿尝试此方法。如果是这种情况，请停止“Update Orchestrator Service”、“Windows Update”、“Windows Update Medic Service”这3个服务，然后确认“关机”和“重启”是否恢复。(或者先更新完毕再食用本教程)</p> <p>该解决方法是<font color=#ff3030><strong>完全可逆</strong></font>的，因此如果您决定稍后启用更新，则可以这样做。</p> <p><font color=#ff3030><strong>自带的应用商店Microsoft Store 将不再能够连接到互联网（已安装的程序不会受到影响</strong></font> ，一旦过程逆转，将再次正常</p> </blockquote> <h1 id="操作步骤">操作步骤</h1> <h2 id="禁用usosvcwaasmedicsvcwuauserv的读写权限">禁用<strong>UsoSvc</strong>、<strong>WaaSMedicSvc</strong>、<strong>wuauserv</strong>的读写权限</h2> <p><code>Win</code>+<code>R</code>呼出运行窗口，输入<code>regedit</code>回车运行，在注册表编辑器内找到如下路径：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">计算机\HKEY_LOCAL_MACHINE\SYSTEM\CurrentControlSet\Services\ </span></span></code></pre></td></tr></table> </div> </div><p>向下滚动找到<code>UsoSvc</code>。右键<code>UsoSvc</code>，选择<code>权限</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/1.png" width="328" height="324" srcset="https://fallen.wang/p/fuck-windows-update/1_hu3a4cc43c8e6edd9dc8adcf5d74dbabb9_20422_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/1_hu3a4cc43c8e6edd9dc8adcf5d74dbabb9_20422_1024x0_resize_box_3.png 1024w" loading="lazy" alt="右键菜单中选择权限" class="gallery-image" data-flex-grow="101" data-flex-basis="242px" ></p> <p>选择<code>高级</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/2.png" width="531" height="639" srcset="https://fallen.wang/p/fuck-windows-update/2_hua31ce9882dd6c6ea5f32fecfc62e8dcb_32424_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/2_hua31ce9882dd6c6ea5f32fecfc62e8dcb_32424_1024x0_resize_box_3.png 1024w" loading="lazy" alt="高级选项" class="gallery-image" data-flex-grow="83" data-flex-basis="199px" ></p> <p>选择<code>更改</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/3.png" width="1147" height="733" srcset="https://fallen.wang/p/fuck-windows-update/3_hu4f459d75286e44ffd98d3b2bd72b578f_61910_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/3_hu4f459d75286e44ffd98d3b2bd72b578f_61910_1024x0_resize_box_3.png 1024w" loading="lazy" alt="更改所有者" class="gallery-image" data-flex-grow="156" data-flex-basis="375px" ></p> <p>选择<code>高级</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/4.png" width="684" height="404" srcset="https://fallen.wang/p/fuck-windows-update/4_hu0b64b29ac750e9a03966a281a695cc03_20496_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/4_hu0b64b29ac750e9a03966a281a695cc03_20496_1024x0_resize_box_3.png 1024w" loading="lazy" alt="高级" class="gallery-image" data-flex-grow="169" data-flex-basis="406px" ></p> <p>选择<code>立即查找</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/5.png" width="770" height="893" srcset="https://fallen.wang/p/fuck-windows-update/5_huf95b465f614aee3b5bbcdea7b94b93aa_36010_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/5_huf95b465f614aee3b5bbcdea7b94b93aa_36010_1024x0_resize_box_3.png 1024w" loading="lazy" alt="立即查找" class="gallery-image" data-flex-grow="86" data-flex-basis="206px" ></p> <p>在下方选择<code>Administrator</code>并点击<code>确定</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/6.png" width="745" height="386" srcset="https://fallen.wang/p/fuck-windows-update/6_hu2020bf935575e392c4619d8aed1a298f_27511_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/6_hu2020bf935575e392c4619d8aed1a298f_27511_1024x0_resize_box_3.png 1024w" loading="lazy" alt="Administrator" class="gallery-image" data-flex-grow="193" data-flex-basis="463px" ></p> <p>选择<code>确定</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/7.png" width="684" height="404" srcset="https://fallen.wang/p/fuck-windows-update/7_hucf335de760c8c11766e53500c1b6b4a0_21418_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/7_hucf335de760c8c11766e53500c1b6b4a0_21418_1024x0_resize_box_3.png 1024w" loading="lazy" alt="确定" class="gallery-image" data-flex-grow="169" data-flex-basis="406px" ></p> <p>选择下方<code>禁用继承</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/8.png" width="518" height="232" srcset="https://fallen.wang/p/fuck-windows-update/8_hucb0dd5cb07899a246a2ff540b430b550_9820_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/8_hucb0dd5cb07899a246a2ff540b430b550_9820_1024x0_resize_box_3.png 1024w" loading="lazy" alt="禁用继承" class="gallery-image" data-flex-grow="223" data-flex-basis="535px" ></p> <p>在弹出的对话框选择第二项<code>从此对象中删除所有已继承的权限</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/9.png" width="454" height="375" srcset="https://fallen.wang/p/fuck-windows-update/9_hua36c2b75427a89bbddb7ecf0aa034e59_28472_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/9_hua36c2b75427a89bbddb7ecf0aa034e59_28472_1024x0_resize_box_3.png 1024w" loading="lazy" alt="删除所有已继承的权限" class="gallery-image" data-flex-grow="121" data-flex-basis="290px" ></p> <p>勾选<code>使用可从此对象继承的权限项目替换所有子对象的权限项目</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/10.png" width="551" height="180" srcset="https://fallen.wang/p/fuck-windows-update/10_hu635bad4934e162bb63bbf971f0d224df_11375_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/10_hu635bad4934e162bb63bbf971f0d224df_11375_1024x0_resize_box_3.png 1024w" loading="lazy" alt="替换所有子对象的权限项目" class="gallery-image" data-flex-grow="306" data-flex-basis="734px" ></p> <p>选择<code>应用</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/11.png" width="420" height="274" srcset="https://fallen.wang/p/fuck-windows-update/11_hu6640fb1fc0a63312a65ebd1cc84cb5ac_6820_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/11_hu6640fb1fc0a63312a65ebd1cc84cb5ac_6820_1024x0_resize_box_3.png 1024w" loading="lazy" alt="应用" class="gallery-image" data-flex-grow="153" data-flex-basis="367px" ></p> <p>弹出第一个警告对话框，选择<code>是</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/12.png" width="554" height="260" srcset="https://fallen.wang/p/fuck-windows-update/12_hu4d0cc5a0ab6a01d903698d1527e41db9_14643_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/12_hu4d0cc5a0ab6a01d903698d1527e41db9_14643_1024x0_resize_box_3.png 1024w" loading="lazy" alt="是" class="gallery-image" data-flex-grow="213" data-flex-basis="511px" ></p> <p>第二个警告对话框依旧选择<code>是</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/13.png" width="558" height="260" srcset="https://fallen.wang/p/fuck-windows-update/13_huefe1fc9f6f5c031b2cd2701a610be680_13801_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/13_huefe1fc9f6f5c031b2cd2701a610be680_13801_1024x0_resize_box_3.png 1024w" loading="lazy" alt="是" class="gallery-image" data-flex-grow="214" data-flex-basis="515px" ></p> <p>选择下方<code>确定</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/14.png" width="429" height="202" srcset="https://fallen.wang/p/fuck-windows-update/14_hu8a3f836971883be2d244c9b392aa0262_5051_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/14_hu8a3f836971883be2d244c9b392aa0262_5051_1024x0_resize_box_3.png 1024w" loading="lazy" alt="确定" class="gallery-image" data-flex-grow="212" data-flex-basis="509px" ></p> <p>此时所有组或用户均无权访问，选择<code>确定</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/15.png" width="551" height="681" srcset="https://fallen.wang/p/fuck-windows-update/15_hubaba3a91af080fb91a907b87e1a89044_29567_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/15_hubaba3a91af080fb91a907b87e1a89044_29567_1024x0_resize_box_3.png 1024w" loading="lazy" alt="确定" class="gallery-image" data-flex-grow="80" data-flex-basis="194px" ></p> <p>因为无权访问，此时应会报错，选择<code>确定</code>即可。</p> <p><img src="https://fallen.wang/p/fuck-windows-update/16.png" width="454" height="214" srcset="https://fallen.wang/p/fuck-windows-update/16_hu88f7663c55ceb8849a355085ad4c17cf_12290_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/16_hu88f7663c55ceb8849a355085ad4c17cf_12290_1024x0_resize_box_3.png 1024w" loading="lazy" alt="确定" class="gallery-image" data-flex-grow="212" data-flex-basis="509px" ></p> <p>对于同路径下的<code>WaaSMedicSvc</code>和<code>wuauserv</code>也执行上述操作。</p> <h2 id="验证">验证</h2> <p><code>win</code>+<code>R</code>呼出运行，输入<code>services.msc</code>打开服务窗口。在<code>操作</code>菜单内选择<code>刷新</code></p> <p><img src="https://fallen.wang/p/fuck-windows-update/17.png" width="1008" height="743" srcset="https://fallen.wang/p/fuck-windows-update/17_hu33725d1aaf8a8c272bdd31e716eca48f_316770_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/17_hu33725d1aaf8a8c272bdd31e716eca48f_316770_1024x0_resize_box_3.png 1024w" loading="lazy" alt="刷新" class="gallery-image" data-flex-grow="135" data-flex-basis="325px" ></p> <p>此时，<code>Windows更新</code>、<code>更新Orchestrator服务</code>和<code>WaaSMedicSvc</code>均会在描述中包含错误信息：</p> <p><img src="https://fallen.wang/p/fuck-windows-update/18.png" width="1007" height="741" srcset="https://fallen.wang/p/fuck-windows-update/18_hu46f3d8bc878c8b7dd34ef026280e3ab5_313634_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/18_hu46f3d8bc878c8b7dd34ef026280e3ab5_313634_1024x0_resize_box_3.png 1024w" loading="lazy" alt="错误代码：5" class="gallery-image" data-flex-grow="135" data-flex-basis="326px" ></p> <p>重启后再打开服务窗口这三项将不再出现。若在<code>设置</code>中打开<code>Windows更新</code>窗口，将会显示“出现错误”</p> <p><img src="https://fallen.wang/p/fuck-windows-update/19.png" width="1361" height="442" srcset="https://fallen.wang/p/fuck-windows-update/19_hu05684357445af7c0f31215cefd7bd22f_23914_480x0_resize_box_3.png 480w, https://fallen.wang/p/fuck-windows-update/19_hu05684357445af7c0f31215cefd7bd22f_23914_1024x0_resize_box_3.png 1024w" loading="lazy" alt="出错" class="gallery-image" data-flex-grow="307" data-flex-basis="739px" ></p> <p>至此Windows自动更新已被彻底关闭。如果想恢复自动更新，请参阅上方原贴链接。</p>

消化系统病理

<img src="https://fallen.wang/p/digestive/cover.jpg" alt="Featured image of post 消化系统病理" /><script type="text/javascript">alert("病理还得看贺银成。贺门！");</script> <iframe frameborder="no" border="0" marginwidth="0" marginheight="0" width=330 height=86 src="//music.163.com/outchain/player?type=2&id=434902428&auto=0&height=66"></iframe> <h1 id="font-colorff3030考纲font"><font color=#ff3030><strong>考纲</strong></font></h1> <blockquote> <p><em><strong>1.慢性胃炎的类型及其病理特点。 2.溃疡病的病因、发病机制、病理特点及其并发症。 3.阑尾炎的病因、发病机制、病理变化及其并发症。 4.病毒性肝炎的病因、发病机制及基本病理变化，肝炎的临床病理类型及其病理学特点。 5.肝硬化的类型及其病因、发病机制、病理特点和临床病理联系。 6.早期食管癌的概念及各型的形态特点，中晚期食管癌各型的形态特点、临床表现及扩散途径。 7.早期胃癌的概念及各型的形态特点，中晚期胃癌的肉眼类型和组织学类型、临床表现及扩散途径。 8.大肠癌的病因、发病机制、癌前病变、肉眼类型及组织学类型，分期与预后的关系，临床表现及扩散途径。 9.原发性肝癌的肉眼类型、组织学类型、临床表现及扩散途径。 10.胰腺炎症及肿瘤性疾病的病因、发病机制及病理特点。</strong></em></p> </blockquote> <hr> <p><img src="https://fallen.wang/p/digestive/hepatic-portal-vein.png" width="775" height="573" srcset="https://fallen.wang/p/digestive/hepatic-portal-vein_hu6c5044afbbf591da4fe6b7f38e460dd6_330340_480x0_resize_box_3.png 480w, https://fallen.wang/p/digestive/hepatic-portal-vein_hu6c5044afbbf591da4fe6b7f38e460dd6_330340_1024x0_resize_box_3.png 1024w" loading="lazy" alt="图源9版局部解剖学P131" class="gallery-image" data-flex-grow="135" data-flex-basis="324px" ></p> <hr> <h1 id="font-colorff3030慢性胃炎font"><font color=#ff3030><strong>慢性胃炎</strong></font></h1> <h2 id="定义及分类">定义及分类</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">胃黏膜的慢性非特异性炎症，发病率高</td> </tr> <tr> <td style="text-align:center"><strong>分类</strong></td> <td style="text-align:center">非萎缩性胃炎：又称浅表性、单纯性胃炎，好发于胃窦；萎缩性胃炎：分A、B两型</td> </tr> </tbody> </table> <h2 id="非萎缩性胃炎">非萎缩性胃炎</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发</strong></td> <td style="text-align:center"><font color=#eeee00><strong>胃窦</strong></font>，病变呈多灶性或弥漫性</td> </tr> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">胃黏膜充血性水肿，呈淡红色，可伴点状出血糜烂，表面可有灰黄色或灰白色黏液性渗出物覆盖</td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">胃黏膜充血水肿，浅表上皮坏死脱落；固有层有<font color=#eeee00><strong>淋巴细胞、浆细胞</strong></font>等慢性炎症细胞浸润；腺体保持完整无萎缩性改变</td> </tr> </tbody> </table> <h2 id="慢性萎缩性胃炎">慢性萎缩性胃炎</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>特点</strong></td> <td style="text-align:center">胃黏膜萎缩变薄，腺体减少，固有层多量慢性炎细胞浸润</td> </tr> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">黏膜变薄，皱襞变浅甚至消失，<font color=#eeee00><strong>黏膜下血管清晰可见</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">胃黏膜变薄，腺体减少；固有层有多量<font color=#eeee00><strong>淋巴细胞、浆细胞浸润</strong></font>，可出现腺上皮化生，其中<font color=#eeee00><strong>肠上皮化生</strong></font>比<font color=#eeee00><strong>假幽门腺化生</strong></font>更常见；肠上皮化生可见<font color=#eeee00><strong>细胞不典型增生</strong></font></td> </tr> </tbody> </table> <p><code>2015N167X慢性萎缩性胃炎的病变包括</code> ABD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胃黏膜慢性炎细胞浸润 </span></span><span class="line"><span class="cl">B.肠上皮化生 </span></span><span class="line"><span class="cl">C.鳞状上皮化生 </span></span><span class="line"><span class="cl">D.幽门螺杆菌阳性 </span></span></code></pre></td></tr></table> </div> </div><p><code>2014N133B慢性萎缩性胃炎的主要病变是</code> D</p> <p><code>2014N134B迷离瘤的病变是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胃小凹上皮增生 </span></span><span class="line"><span class="cl">B.胃黏膜内出现胰腺组织 </span></span><span class="line"><span class="cl">C.胃黏膜浅层糜烂出血 </span></span><span class="line"><span class="cl">D.胃黏膜腺体变小减少 </span></span></code></pre></td></tr></table> </div> </div><p><code>2008N135B慢性萎缩性胃炎的病变特点</code> C</p> <p><code>2009N136B慢性浅表性胃炎的病变特点</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胃黏膜内多量中性粒细胞浸润 </span></span><span class="line"><span class="cl">B.胃黏膜内多量淋巴细胞浸润 </span></span><span class="line"><span class="cl">C.胃黏膜腺体减少伴肠上皮化生 </span></span><span class="line"><span class="cl">D.被覆上皮增生导致胃黏膜增厚 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030慢性萎缩性胃炎a型和b型的鉴别font"><font color=#ff3030><strong>慢性萎缩性胃炎A型和B型的鉴别</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">A型胃炎</th> <th style="text-align:center">B型胃炎</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>别称</strong></td> <td style="text-align:center">慢性胃体炎</td> <td style="text-align:center">慢性胃窦炎</td> </tr> <tr> <td style="text-align:center"><strong>累及部位</strong></td> <td style="text-align:center">胃体、胃底</td> <td style="text-align:center">胃窦</td> </tr> <tr> <td style="text-align:center"><strong>基本病变</strong></td> <td style="text-align:center">胃黏膜萎缩变薄、腺体减少</td> <td style="text-align:center">胃黏膜萎缩变薄、腺体减少</td> </tr> <tr> <td style="text-align:center"><strong>发病率</strong></td> <td style="text-align:center">少见</td> <td style="text-align:center">常见</td> </tr> <tr> <td style="text-align:center"><strong>病因</strong></td> <td style="text-align:center">自身免疫</td> <td style="text-align:center">幽门螺杆菌感染（60%~70%）</td> </tr> <tr> <td style="text-align:center"><strong>恶性贫血</strong></td> <td style="text-align:center">常有</td> <td style="text-align:center">无</td> </tr> <tr> <td style="text-align:center">**血清VitB₁₂水平</td> <td style="text-align:center">降低</td> <td style="text-align:center">正常</td> </tr> <tr> <td style="text-align:center"><strong>IFA（抗内因子抗体）</strong></td> <td style="text-align:center">阳性（75%）</td> <td style="text-align:center">阴性</td> </tr> <tr> <td style="text-align:center"><strong>PCA（抗胃壁细胞抗体）</strong></td> <td style="text-align:center">阳性（90%）</td> <td style="text-align:center">阴性</td> </tr> <tr> <td style="text-align:center"><strong>胃酸</strong></td> <td style="text-align:center">明显降低</td> <td style="text-align:center">中度降低或正常</td> </tr> <tr> <td style="text-align:center"><strong>血清胃泌素水平</strong></td> <td style="text-align:center">高</td> <td style="text-align:center">低</td> </tr> </tbody> </table> <p><code>2007N178A伴有恶性贫血的慢性胃炎是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.巨大肥厚性胃炎 </span></span><span class="line"><span class="cl">B.慢性浅表性胃炎 </span></span><span class="line"><span class="cl">C.疣状胃炎 </span></span><span class="line"><span class="cl">D.A型慢性萎缩性胃炎 </span></span></code></pre></td></tr></table> </div> </div><p><code>2007N121B自身免疫性胃炎的胃酸分泌</code> A</p> <p><code>2007N122B多灶萎缩性胃炎的胃酸分泌</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.缺乏 </span></span><span class="line"><span class="cl">B.正常或减少 </span></span><span class="line"><span class="cl">C.少量增加 </span></span><span class="line"><span class="cl">D.明显增加 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="消化性溃疡">消化性溃疡</h1> <h2 id="病因和发病机制">病因和发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>幽门螺杆菌感染</strong></td> <td style="text-align:center">在消化性溃疡的发病中具有重要作用</td> </tr> <tr> <td style="text-align:center"><strong>黏膜抗消化能力下降</strong></td> <td style="text-align:center">黏膜组织被<font color=#eeee00><strong>胃酸、胃蛋白酶消化</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>胃液的消化作用</strong></td> <td style="text-align:center">胃液对胃壁组织的<font color=#eeee00><strong>自我消化</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>功能失调</strong></td> <td style="text-align:center">神经内分泌功能失调致精神紧张、胃液分泌障碍</td> </tr> <tr> <td style="text-align:center"><strong>遗传因素</strong></td> <td style="text-align:center">家族聚集性发病</td> </tr> </tbody> </table> <h2 id="病理变化">病理变化</h2> <h3 id="胃溃疡">胃溃疡</h3> <h4 id="肉眼观">肉眼观</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>部位</strong></td> <td style="text-align:center">好发于<font color=#eeee00><strong>胃小弯侧</strong></font>，以<font color=#eeee00><strong>胃窦部</strong></font>多见</td> </tr> <tr> <td style="text-align:center"><strong>病理改变</strong></td> <td style="text-align:center">溃疡常为一个，圆形或椭圆形，直径多小于2cm；边缘整齐底部平坦，可穿越黏膜下层深达肌层甚至浆膜层；周围黏膜皱襞因瘢痕组织牵拉呈放射状向溃疡集中</td> </tr> </tbody> </table> <h4 id="镜下观">镜下观</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>炎症层</strong></td> <td style="text-align:center">为最表层，以<font color=#eeee00><strong>嗜中性粒细胞</strong></font>为主的炎症细胞浸润</td> </tr> <tr> <td style="text-align:center"><strong>坏死组织层</strong></td> <td style="text-align:center">由一薄层纤维素性渗出物、坏死的细胞碎片覆盖</td> </tr> <tr> <td style="text-align:center"><strong>肉芽组织层</strong></td> <td style="text-align:center">新鲜的肉芽组织</td> </tr> <tr> <td style="text-align:center"><strong>瘢痕组织层</strong></td> <td style="text-align:center">肉芽组织形成陈旧的<font color=#eeee00><strong>瘢痕组织</strong></font>，底部有<font color=#eeee00><strong>增殖性动脉内膜炎</strong></font>，小动脉管壁增厚、管腔狭窄或有<font color=#eeee00><strong>血栓形成</strong></font>，造成局部供血不足，妨碍再生，溃疡不易愈合</td> </tr> </tbody> </table> <h3 id="十二指肠溃疡">十二指肠溃疡</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>部位</strong></td> <td style="text-align:center">好发于球部前壁或后壁</td> </tr> <tr> <td style="text-align:center"><strong>特点</strong></td> <td style="text-align:center">溃疡一般较小，直径多小于1cm，溃疡较浅且易愈合</td> </tr> </tbody> </table> <p><code>2013N166X胃溃疡的镜下病理特征</code> ACD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.纤维蛋白和中性粒细胞渗出 </span></span><span class="line"><span class="cl">B.肉芽肿形成 </span></span><span class="line"><span class="cl">C.纤维瘢痕形成 </span></span><span class="line"><span class="cl">D.闭塞性动脉内膜炎 </span></span></code></pre></td></tr></table> </div> </div><p><code>2007N45A下列关于消化性溃疡形态特征的叙述错误的是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.表层以伊红色坏死组织和炎性渗出为主 </span></span><span class="line"><span class="cl">B.坏死组织下是大量新生毛细血管和成纤维细胞 </span></span><span class="line"><span class="cl">C.底层瘢痕内可见闭塞性动脉内膜炎 </span></span><span class="line"><span class="cl">D.溃疡周围见大量异型细胞增生 </span></span></code></pre></td></tr></table> </div> </div><p><code>2019N151X消化性溃疡好发部位</code> AC</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.十二指肠球部 </span></span><span class="line"><span class="cl">B.十二指肠升部 </span></span><span class="line"><span class="cl">C.胃窦部小弯侧 </span></span><span class="line"><span class="cl">D.胃窦部大弯侧 </span></span></code></pre></td></tr></table> </div> </div><h3 id="结局和并发症">结局和并发症</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">发生率</th> <th style="text-align:center">原因</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>出血</strong></td> <td style="text-align:center"><font color=#eeee00><strong>10%~35%</strong></font></td> <td style="text-align:center">溃疡底部毛细血管或大血管破裂</td> </tr> <tr> <td style="text-align:center"><strong>穿孔</strong></td> <td style="text-align:center">5%</td> <td style="text-align:center">十二指肠溃疡因肠壁较薄更易穿孔</td> </tr> <tr> <td style="text-align:center"><strong>幽门狭窄</strong></td> <td style="text-align:center">3%</td> <td style="text-align:center">由于瘢痕收缩可引起幽门狭窄</td> </tr> <tr> <td style="text-align:center"><strong>恶变</strong></td> <td style="text-align:center"><font color=#eeee00><strong>&lt;1%</strong></font></td> <td style="text-align:center">十二指肠溃疡几乎不发生癌变</td> </tr> </tbody> </table> <p><code>2015N143B消化性溃疡最常见并发症</code> B</p> <p><code>2015N144B十二指肠溃疡不易发生的并发症</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.穿孔 </span></span><span class="line"><span class="cl">B.出血 </span></span><span class="line"><span class="cl">C.幽门梗阻 </span></span><span class="line"><span class="cl">D.癌变 </span></span></code></pre></td></tr></table> </div> </div><p><code>2022N150X消化性溃疡发生游离性穿孔的常见部位</code> AB</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胃小弯 </span></span><span class="line"><span class="cl">B.十二指肠球部前壁 </span></span><span class="line"><span class="cl">C.胃大弯 </span></span><span class="line"><span class="cl">D.十二指肠球部后壁 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="阑尾炎">阑尾炎</h1> <h2 id="病因和发病机制-1">病因和发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>阑尾腔阻塞</strong></td> <td style="text-align:center">有50%~80%的阑尾炎病例伴阑尾腔的阻塞，病理学常见阻塞物为粪石；外科学最常见原因为淋巴滤泡增生</td> </tr> <tr> <td style="text-align:center"><strong>细菌入侵</strong></td> <td style="text-align:center">大肠杆菌、肠球菌、链球菌非特异性感染</td> </tr> </tbody> </table> <h2 id="病理变化-1">病理变化</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>急性阑尾炎</strong></td> <td style="text-align:center">早期：单纯性阑尾炎；中期：蜂窝织炎性阑尾炎；晚期：坏疽性阑尾炎</td> </tr> <tr> <td style="text-align:center"><strong>慢性阑尾炎</strong></td> <td style="text-align:center">多由急性阑尾炎转变而来，表现为阑尾壁的不同程度纤维化、慢性炎细胞浸润</td> </tr> <tr> <td style="text-align:center"><strong>急性阑尾炎并发症</strong></td> <td style="text-align:center">急性弥漫性腹膜炎、阑尾周围脓肿、阑尾系膜静脉炎、肝脓肿</td> </tr> </tbody> </table> <hr> <h1 id="font-colorff3030病毒性肝炎font"><font color=#ff3030><strong>病毒性肝炎</strong></font></h1> <h2 id="font-colorff3030病因和发病机制font"><font color=#ff3030><strong>病因和发病机制</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">病毒</th> <th style="text-align:center">病毒性质</th> <th style="text-align:center">传染途径</th> <th style="text-align:center">转为慢性肝炎概率</th> <th style="text-align:center">爆发性肝炎概率</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>甲肝</strong></td> <td style="text-align:center">HAV</td> <td style="text-align:center">单链RNA</td> <td style="text-align:center">肠道</td> <td style="text-align:center"><font color=eeee00><strong>无</strong></font></td> <td style="text-align:center">0.1%~0.4%</td> </tr> <tr> <td style="text-align:center"><strong>乙肝</strong></td> <td style="text-align:center">HBV</td> <td style="text-align:center"><font color=eeee00><strong>DNA</strong></font></td> <td style="text-align:center">密接；血液</td> <td style="text-align:center">5%~10%</td> <td style="text-align:center">&lt;1%</td> </tr> <tr> <td style="text-align:center"><strong>丙肝</strong></td> <td style="text-align:center">HCV</td> <td style="text-align:center">单链RNA</td> <td style="text-align:center">同乙肝</td> <td style="text-align:center">&gt;70%</td> <td style="text-align:center">极少</td> </tr> <tr> <td style="text-align:center"><strong>丁肝</strong></td> <td style="text-align:center">HDV</td> <td style="text-align:center"><font color=eeee00><strong>缺陷性RNA</strong></font></td> <td style="text-align:center">同乙肝</td> <td style="text-align:center">共同感染&lt;5%；重叠感染&gt;80%</td> <td style="text-align:center">共同感染3%~4%</td> </tr> <tr> <td style="text-align:center"><strong>戊肝</strong></td> <td style="text-align:center">HEV</td> <td style="text-align:center">单链RNA</td> <td style="text-align:center">肠道</td> <td style="text-align:center"><font color=eeee00><strong>无</strong></font></td> <td style="text-align:center">合并妊娠者20%</td> </tr> <tr> <td style="text-align:center"><strong>庚肝</strong></td> <td style="text-align:center">HGV</td> <td style="text-align:center">单链RNA</td> <td style="text-align:center">血液</td> <td style="text-align:center"><font color=eeee00><strong>无</strong></font></td> <td style="text-align:center">不详</td> </tr> </tbody> </table> <h2 id="font-colorff3030病理变化font"><font color=#ff3030><strong>病理变化</strong></font></h2> <h3 id="基本病变">基本病变</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>变质</strong></td> <td style="text-align:center">各型病毒性肝炎病变基本相同，以肝细胞<font color=eeee00><strong>变性坏死</strong></font>为主；<font color=eeee00><strong>水样变性</strong></font>（细胞肿胀）→气球样变→<font color=eeee00><strong>溶解坏死</strong></font>（即液化性坏死，最常见）；<font color=eeee00><strong>嗜酸性变</strong></font>→嗜酸性坏死（<font color=eeee00><strong>凋亡</strong></font>）；<font color=eeee00><strong>脂肪变性</strong></font>→无脂肪坏死（仅丙肝可脂肪样变<font color=#1e90ff><strong>¹</strong></font>）</td> </tr> <tr> <td style="text-align:center"><strong>渗出</strong></td> <td style="text-align:center">以淋巴细胞、单核细胞浸润多见</td> </tr> <tr> <td style="text-align:center"><strong>增生</strong></td> <td style="text-align:center">肝细胞增生；间质增生性反应：Kupffer细胞（即肝巨噬细胞）、间叶细胞、成纤维细胞增生；小胆管增生；纤维化</td> </tr> </tbody> </table> <blockquote> <p><font color=#1e90ff><strong>¹仅丙肝可见</strong></font>：9版病理学P219指出，<font color=#ff3030><strong>丁肝</strong></font>亦可见。</p> </blockquote> <p><img src="https://fallen.wang/p/digestive/HDV.png" width="1170" height="216" srcset="https://fallen.wang/p/digestive/HDV_huaf6d5fd8734fd8adfb2431a9ace6da5e_110411_480x0_resize_box_3.png 480w, https://fallen.wang/p/digestive/HDV_huaf6d5fd8734fd8adfb2431a9ace6da5e_110411_1024x0_resize_box_3.png 1024w" loading="lazy" alt="9版病理学P219" class="gallery-image" data-flex-grow="541" data-flex-basis="1300px" ></p> <h3 id="肝细胞变性">肝细胞变性</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>细胞水肿（最常见）</strong></td> <td style="text-align:center">光镜：肝细胞明显肿大，胞质疏松半透明，<font color=eeee00><strong>气球样变</strong></font>；电镜：<font color=eeee00><strong>线粒体</strong></font>明显肿胀，<font color=eeee00><strong>内质网</strong></font>扩张，溶酶体增多</td> </tr> <tr> <td style="text-align:center"><strong>嗜酸性变</strong></td> <td style="text-align:center">一般仅累及单个或数个肝细胞，散在于肝小叶内，镜下见肝细胞脱水，体积变小，胞质嗜酸性增强（红染）；核染色深</td> </tr> <tr> <td style="text-align:center"><strong>脂肪变性</strong></td> <td style="text-align:center">肝细胞胞质内出现大小不等的球型脂滴</td> </tr> </tbody> </table> <h3 id="肝细胞坏死凋亡">肝细胞坏死凋亡</h3> <h4 id="font-colorff3030溶解坏死font"><font color=#ff3030><strong>溶解坏死</strong></font></h4> <table> <thead> <tr> <th style="text-align:center">类型</th> <th style="text-align:center">定义</th> <th style="text-align:center">见于</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>点状坏死</strong></td> <td style="text-align:center">散在分布的单个或数个肝细胞坏死</td> <td style="text-align:center">急性普通型肝炎</td> </tr> <tr> <td style="text-align:center"><strong>碎片状坏死</strong></td> <td style="text-align:center">肝小叶周边部<font color=eeee00><strong>界板</strong></font>肝细胞的灶性坏死崩解，是慢性肝炎的<font color=eeee00><strong>特征性病变</strong></font></td> <td style="text-align:center">慢性肝炎</td> </tr> <tr> <td style="text-align:center"><strong>桥接坏死</strong></td> <td style="text-align:center"><font color=eeee00><strong>中央静脉与门管区之间</strong></font>、两个门管区之间或两个中央静脉间出现的相互连接的坏死带</td> <td style="text-align:center">较重慢性肝炎</td> </tr> <tr> <td style="text-align:center"><strong>亚大块坏死</strong></td> <td style="text-align:center">肝细胞坏死占<font color=eeee00><strong>肝小叶</strong></font>大部分</td> <td style="text-align:center">重型肝炎</td> </tr> <tr> <td style="text-align:center"><strong>大块坏死</strong></td> <td style="text-align:center">肝细胞坏死几乎占据整个肝小叶</td> <td style="text-align:center">重型肝炎</td> </tr> </tbody> </table> <h4 id="凋亡嗜酸性坏死">凋亡（嗜酸性坏死）</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">由嗜酸性变发展而来，胞质浓缩，核浓缩消失，形成深红色浓染的圆形小体，称<font color=eeee00><strong>嗜酸性小体（凋亡小体）</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">细胞皱缩，嗜酸性，核固缩</td> </tr> <tr> <td style="text-align:center"><strong>意义</strong></td> <td style="text-align:center">凋亡是单个肝细胞生理性死亡，见于普通型肝炎</td> </tr> </tbody> </table> <h4 id="其它改变">其它改变</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>炎症细胞浸润</strong></td> <td style="text-align:center">淋巴、单核细胞浸润于肝细胞坏死区或门管区</td> </tr> <tr> <td style="text-align:center"><strong>肝细胞再生</strong></td> <td style="text-align:center">坏死的肝细胞由周围肝细胞再生修复</td> </tr> <tr> <td style="text-align:center"><strong>间质反应性增生</strong></td> <td style="text-align:center">Kupffer细胞、间叶细胞、成纤维细胞增生</td> </tr> <tr> <td style="text-align:center"><strong>小胆管增生</strong></td> <td style="text-align:center">慢性且坏死较重的病例，可见小胆管增生</td> </tr> <tr> <td style="text-align:center"><strong>纤维化</strong></td> <td style="text-align:center">可致肝硬化</td> </tr> </tbody> </table> <p><code>2005N46A肝细胞点状坏死的特点</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肝细胞核碎裂为小点状的坏死 </span></span><span class="line"><span class="cl">B.破坏界板的坏死 </span></span><span class="line"><span class="cl">C.形成嗜酸性坏死 </span></span><span class="line"><span class="cl">D.坏死灶仅累及几个细胞 </span></span><span class="line"><span class="cl">E.伴有严重脂肪变性的坏死 </span></span></code></pre></td></tr></table> </div> </div><p><code>2018N36A肝细胞碎片样坏死的形态学改变</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.坏死细胞核碎裂 </span></span><span class="line"><span class="cl">B.肝小叶内肝细胞广泛点状坏死 </span></span><span class="line"><span class="cl">C.坏死突破界板向肝小叶内扩散 </span></span><span class="line"><span class="cl">D.肝细胞坏死超过1/3造成肝小叶结构不完整 </span></span></code></pre></td></tr></table> </div> </div><p><code>2014N44A下列肝细胞坏死中属于凋亡的</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.碎片状坏死 </span></span><span class="line"><span class="cl">B.点状坏死 </span></span><span class="line"><span class="cl">C.桥接坏死 </span></span><span class="line"><span class="cl">D.嗜酸性坏死 </span></span></code></pre></td></tr></table> </div> </div><p><code>2011N55A下列肝细胞坏死中可以完全经过再生修复的</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大块坏死 </span></span><span class="line"><span class="cl">B.点状坏死 </span></span><span class="line"><span class="cl">C.桥接坏死 </span></span><span class="line"><span class="cl">D.碎片坏死 </span></span></code></pre></td></tr></table> </div> </div><p><code>1997N149X病毒性肝炎中常见的肝细胞病变</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胞浆疏松化 </span></span><span class="line"><span class="cl">B.气球样变 </span></span><span class="line"><span class="cl">C.嗜酸性坏死 </span></span><span class="line"><span class="cl">D.溶解坏死 </span></span></code></pre></td></tr></table> </div> </div><h3 id="font-colorff3030各型病毒性肝炎的病变特点font"><font color=#ff3030><strong>各型病毒性肝炎的病变特点</strong></font></h3> <h4 id="甲肝">甲肝</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>变性坏死</strong></td> <td style="text-align:center">肝细胞<font color=eeee00><strong>气球样变</strong></font>（最常见）、<font color=eeee00><strong>嗜酸性变</strong></font>、嗜酸性小体形成；肝小叶中央静脉周围肝细胞<font color=eeee00><strong>溶解性坏死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>炎细胞浸润</strong></td> <td style="text-align:center">门管区单核、淋巴细胞浸润</td> </tr> <tr> <td style="text-align:center"><strong>间质增生</strong></td> <td style="text-align:center">Kupffer细胞增生</td> </tr> </tbody> </table> <h4 id="乙肝">乙肝</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center"><font color=eeee00><strong>毛玻璃样细胞</strong></font>，肝细胞胞质含<font color=eeee00><strong><ruby>HBsAg<rp>(</rp><rt>乙肝表面抗原</rt><rp>)</rp></ruby></strong></font></td> </tr> <tr> <td style="text-align:center"><strong>光镜</strong></td> <td style="text-align:center">HBsAg携带者及慢性肝炎患者肝细胞体积较大，胞质内充满嗜酸性细颗粒物质，胞质不透明似毛玻璃样</td> </tr> <tr> <td style="text-align:center"><strong>电镜</strong></td> <td style="text-align:center"><font color=eeee00><strong>光面内质网</strong></font>增生，其内有较多HBsAg颗粒</td> </tr> <tr> <td style="text-align:center"><strong>砂粒</strong></td> <td style="text-align:center">核内大量<font color=eeee00><strong><ruby>HBcAg<rp>(</rp><rt>乙肝核心抗原</rt><rp>)</rp></ruby></strong></font>形成<font color=#eeee00><strong>砂粒样细胞核</strong></font>，表示HBV复制活跃</td> </tr> </tbody> </table> <p><code>2017N35A引起肝细胞毛玻璃样变的病原体是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.HAV </span></span><span class="line"><span class="cl">B.HBV </span></span><span class="line"><span class="cl">C.HCV </span></span><span class="line"><span class="cl">D.HEV </span></span></code></pre></td></tr></table> </div> </div><p><code>2017N149X毛玻璃样肝细胞的特点</code> BCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胞浆内含淀粉样物质 </span></span><span class="line"><span class="cl">B.胞浆内含HBsAg阳性物质 </span></span><span class="line"><span class="cl">C.胞浆不透明似毛玻璃样 </span></span><span class="line"><span class="cl">D.胞浆内充满嗜酸性细颗粒物质 </span></span></code></pre></td></tr></table> </div> </div><h4 id="丙肝">丙肝</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>脂肪变性</strong></td> <td style="text-align:center">肝细胞<font color=#eeee00><strong>脂肪变性</strong></font>明显，但不引起脂肪坏死</td> </tr> <tr> <td style="text-align:center"><strong>淋巴滤泡</strong></td> <td style="text-align:center">门管区淋巴细胞浸润，可见<font color=#eeee00><strong>淋巴滤泡</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>胆管损伤</strong></td> <td style="text-align:center">可能与病毒直接感染胆管上皮细胞有关</td> </tr> </tbody> </table> <p><code>2013N167X丙肝除了一般病毒性肝炎的特点外相对特异的镜下特点</code> CD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.碎屑样坏死 </span></span><span class="line"><span class="cl">B.凋亡小体 </span></span><span class="line"><span class="cl">C.汇管区淋巴滤泡形成 </span></span><span class="line"><span class="cl">D.肝细胞脂肪变性明显 </span></span></code></pre></td></tr></table> </div> </div><h4 id="其他病毒性肝炎">其他病毒性肝炎</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>丁肝</strong></td> <td style="text-align:center">肝细胞嗜酸性变、脂肪变性（偶见）；炎细胞浸润门管区；慢性<font color=eeee00><strong>HBV</strong></font>感染者<font color=eeee00><strong>重叠感染</strong></font>HDV后加重肝组织病变</td> </tr> <tr> <td style="text-align:center"><strong>戊肝</strong></td> <td style="text-align:center">门脉区炎症：大量Kupffer细胞、多形核白细胞，淋巴细胞少见；胆汁淤积：肝细胞、毛细胆管胆汁淤积；肝细胞坏死：灶状、小片状、亚大块、大块坏死</td> </tr> <tr> <td style="text-align:center"><strong>庚肝</strong></td> <td style="text-align:center">急性肝炎：肝细胞肿胀、门管区炎症为主；慢性肝炎：肝细胞肿胀、点状坏死、门管区炎、纤维组织增生</td> </tr> </tbody> </table> <h3 id="font-colorff3030临床病理特点font"><font color=FF3030><strong>临床病理特点</strong></font></h3> <h4 id="分类">分类</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">急性普通型</th> <th style="text-align:center">慢性普通型</th> <th style="text-align:center">急性重型</th> <th style="text-align:center">亚急性重型</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>坏死类型</strong></td> <td style="text-align:center"><font color=eeee00><strong>点状坏死</strong></font></td> <td style="text-align:center"><font color=eeee00><strong>点状、碎片状、桥接坏死</strong></font></td> <td style="text-align:center"><font color=eeee00><strong>大块坏死</strong></font></td> <td style="text-align:center"><font color=eeee00><strong>亚大块坏死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>再生</strong></td> <td style="text-align:center">完全再生</td> <td style="text-align:center">少量再生</td> <td style="text-align:center">不明显</td> <td style="text-align:center">结节状再生</td> </tr> <tr> <td style="text-align:center"><strong>炎性浸润</strong></td> <td style="text-align:center">轻度</td> <td style="text-align:center">慢性炎细胞浸润</td> <td style="text-align:center">大量</td> <td style="text-align:center">明显</td> </tr> <tr> <td style="text-align:center"><strong>肝脏变化</strong></td> <td style="text-align:center">肿胀质软</td> <td style="text-align:center">无变化或略增大</td> <td style="text-align:center">明显缩小</td> <td style="text-align:center">缩小</td> </tr> <tr> <td style="text-align:center"><strong>肝脏被膜</strong></td> <td style="text-align:center">紧张</td> <td style="text-align:center">稍紧张</td> <td style="text-align:center">皱缩</td> <td style="text-align:center">皱缩</td> </tr> </tbody> </table> <p><code>2001N101B急性重型肝炎的病理学特点</code> E</p> <p><code>2001N102B急性普通型肝炎的病理学特点</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肝细胞点状坏死 </span></span><span class="line"><span class="cl">B.肝细胞碎片状坏死 </span></span><span class="line"><span class="cl">C.肝细胞桥接坏死 </span></span><span class="line"><span class="cl">D.肝细胞亚大片坏死 </span></span><span class="line"><span class="cl">E.肝细胞大片坏死 </span></span></code></pre></td></tr></table> </div> </div><p><code>2016N48A下列病理变化中属于急性普通型肝炎的是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.汇管区炎症并突破界板 </span></span><span class="line"><span class="cl">B.桥接坏死伴小叶结构破坏 </span></span><span class="line"><span class="cl">C.肝细胞广泛脂肪变性伴嗜酸性粒细胞浸润 </span></span><span class="line"><span class="cl">D.肝细胞广泛水肿斑点状坏死 </span></span></code></pre></td></tr></table> </div> </div><p><code>1999N147X急性重型肝炎的病理特点是</code> BCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肝细胞点状坏死 </span></span><span class="line"><span class="cl">B.肝体积明显缩小 </span></span><span class="line"><span class="cl">C.肝质地柔软呈黄色或红褐色 </span></span><span class="line"><span class="cl">D.肝细胞再生不明显 </span></span></code></pre></td></tr></table> </div> </div><p><code>2021N32A急性重型肝炎残留少量肝细胞，多见的部位是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.中央静脉周围 </span></span><span class="line"><span class="cl">B.肝小叶周边 </span></span><span class="line"><span class="cl">C.全小叶随机分布 </span></span><span class="line"><span class="cl">D.残留的网状支架旁 </span></span></code></pre></td></tr></table> </div> </div><p><code>2020N151X亚急性重型肝炎的病理特点</code> ABD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肝细胞亚大块坏死 </span></span><span class="line"><span class="cl">B.肝细胞再生结节形成 </span></span><span class="line"><span class="cl">C.残存肝细胞出现明显异型 </span></span><span class="line"><span class="cl">D.网状纤维支架塌陷 </span></span></code></pre></td></tr></table> </div> </div><h5 id="慢性普通型肝炎的分型">慢性普通型肝炎的分型</h5> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">轻度</th> <th style="text-align:center">中度</th> <th style="text-align:center">重度</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>变性坏死</strong></td> <td style="text-align:center">轻</td> <td style="text-align:center">明显</td> <td style="text-align:center">严重</td> </tr> <tr> <td style="text-align:center"><strong>坏死类型</strong></td> <td style="text-align:center">多为<font color=eeee00><strong>点状坏死</strong></font>、轻度<font color=eeee00><strong>碎片状坏死</strong></font></td> <td style="text-align:center">中度<font color=eeee00><strong>碎片状坏死</strong></font>、特征性<font color=eeee00><strong>桥接坏死</strong></font></td> <td style="text-align:center">重度<font color=eeee00><strong>碎片状坏死</strong></font>、大范围<font color=eeee00><strong>桥接坏死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>肝小叶</strong></td> <td style="text-align:center">结构清晰，界板无坏死</td> <td style="text-align:center">小叶结构大都保存，内有纤维间隔形成</td> <td style="text-align:center">小叶结构不规则，纤维间隔分割肝小叶</td> </tr> <tr> <td style="text-align:center"><strong>再生</strong></td> <td style="text-align:center">完全再生</td> <td style="text-align:center">较明显再生</td> <td style="text-align:center">坏死区不规则再生</td> </tr> </tbody> </table> <p><code>2006N115B急性重型肝炎的特征性病变</code> E</p> <p><code>2006N116B中度慢性肝炎的特征性病变</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.点状坏死 </span></span><span class="line"><span class="cl">B.桥接坏死 </span></span><span class="line"><span class="cl">C.碎片状坏死伴桥接坏死 </span></span><span class="line"><span class="cl">D.亚大片坏死 </span></span><span class="line"><span class="cl">E.大片坏死 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="肝硬化">肝硬化</h1> <h2 id="类型">类型</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病因分型</strong></td> <td style="text-align:center">肝炎、酒精性、胆汁性、淤血性</td> </tr> <tr> <td style="text-align:center"><strong>曾用分型</strong></td> <td style="text-align:center">门脉性、坏死后性、胆汁性</td> </tr> <tr> <td style="text-align:center"><strong>国际分型</strong></td> <td style="text-align:center">小结节性：结节大小相仿，直径&lt;3mm，纤维间隔较细；大结节性：结节粗大，大小不均，直径&gt;3mm，纤维间隔较宽；混合结节性：各占一半</td> </tr> </tbody> </table> <h2 id="病因">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病毒性肝炎</strong></td> <td style="text-align:center">由<font color=#eeee00><strong>乙肝、丙肝</strong></font>引起，占77%，我国以乙肝最常见</td> </tr> <tr> <td style="text-align:center"><strong>酒精性</strong></td> <td style="text-align:center">欧美占50%~90%，酒精性肝硬化可见<font color=#eeee00><strong>Mallory小体</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>胆汁淤积</strong></td> <td style="text-align:center">肝内、外胆道阻塞，持续胆汁淤积，可致胆汁性肝硬化</td> </tr> <tr> <td style="text-align:center"><strong>药物毒物</strong></td> <td style="text-align:center">长期服用损肝药物、接触有毒物质（<font color=#eeee00><strong>四氯化碳</strong></font>、磷）</td> </tr> <tr> <td style="text-align:center"><strong>代谢障碍</strong></td> <td style="text-align:center">铜代谢紊乱可致肝豆状核变性以至肝硬化</td> </tr> <tr> <td style="text-align:center"><strong>营养障碍</strong></td> <td style="text-align:center">长期营养不良、肥胖、糖尿病致脂肪肝，发展为肝硬化</td> </tr> <tr> <td style="text-align:center"><strong>其他</strong></td> <td style="text-align:center">血吸虫性肝硬化、Budd-Chiari综合征、淤血性肝硬化</td> </tr> <tr> <td style="text-align:center"><strong>原因不明</strong></td> <td style="text-align:center">隐源性肝硬化</td> </tr> </tbody> </table> <p><code>1998N44A最常导致肝硬化的DNA病毒是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.HAV </span></span><span class="line"><span class="cl">B.HBV </span></span><span class="line"><span class="cl">C.HCV </span></span><span class="line"><span class="cl">D.HDV </span></span><span class="line"><span class="cl">E.HEV </span></span></code></pre></td></tr></table> </div> </div><p><code>2014N55A下列肝细胞病变中与肝硬化形成最相关的是</code> B<font color=#1e90ff>^{<strong>2</strong>}</font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大块坏死 </span></span><span class="line"><span class="cl">B.桥接坏死 </span></span><span class="line"><span class="cl">C.灶状坏死 </span></span><span class="line"><span class="cl">D.碎片样坏死 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>²9版教材无此表述</strong></font>：<font color=#ff3030><strong>桥接坏死</strong></font>与<font color=#ff3030><strong>肝硬化</strong></font>关系最密切见于2版8年制病理学P274</p> </blockquote> <h2 id="发病机制">发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>胶原纤维增生</strong></td> <td style="text-align:center">长期反复弥漫性肝损伤可致肝内广泛胶原纤维增生</td> </tr> <tr> <td style="text-align:center"><strong>肝细胞再生</strong></td> <td style="text-align:center">肝细胞坏死可启动肝细胞再生</td> </tr> <tr> <td style="text-align:center"><strong>假小叶形成</strong></td> <td style="text-align:center">再生的肝细胞不能沿原有支架排列，形成不规则结节；增生的胶原纤维伸展分隔肝小叶形成假小叶，是<font color=eeee00><strong>特征性病变</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>肝硬化形成</strong></td> <td style="text-align:center">肝细胞反复坏死再生最终形成弥漫全肝的假小叶，导致肝内血液循环改建、肝功能障碍而形成肝硬化</td> </tr> </tbody> </table> <h2 id="病理变化-2">病理变化</h2> <h3 id="肉眼观-1">肉眼观</h3> <table border=“0”> <tr> <th></th> <th align="center">小结节性肝硬化</th> <th align="center">大结节性肝硬化</th> </tr> <tr> <th align="center"><b>特点</b></th> <th align="center">肝细胞坏死范围小，分布均匀；肝细胞再生结节小且均匀；纤维间隔较细</th> <th align="center">肝细胞坏死范围大，分布不均；肝细胞再生结节较大且大小不均；纤维间隔较宽，宽窄不一</th> </tr> <tr> <th align="center"><b>病因</b></th> <th align="center">轻型肝炎、慢性酒精中毒</th> <th align="center">重型肝炎、中毒性肝炎</th> </tr> <tr> <th align="center"><b>早期</b></th> <th colspan="2" align="center">肝体积正常或稍增大，质地正常或稍硬</th> </tr> <tr> <th align="center"><b>晚期</b></th> <th colspan="2" align="center">肝体积缩小，质硬，表面结节状</th> </tr> </table> <h3 id="镜下观-1">镜下观</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center">广泛增生的纤维组织包裹肝细胞结节，称为<font color=eeee00><strong>假小叶</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>病变</strong></td> <td style="text-align:center">正常肝小叶结构破坏，被假小叶取代；假小叶内肝细胞排列紊乱，再生肝细胞体积大，核大深染；中央静脉缺如、偏位或有两个以上；纤维间隔内可有炎细胞浸润；纤维间隔内小胆管增生</td> </tr> </tbody> </table> <p><code>2009N56A下列关于肝硬化的病变中符合假小叶的是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肉眼下见肝内大小不等的结节 </span></span><span class="line"><span class="cl">B.再生的肝细胞形成的结节 </span></span><span class="line"><span class="cl">C.广泛增生的纤维组织包绕的肝细胞结节 </span></span><span class="line"><span class="cl">D.异型增生肝细胞形成的结节 </span></span></code></pre></td></tr></table> </div> </div><p><code>1996N150X肝硬化的病理组织学变化有</code> ABD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.假小叶形成 </span></span><span class="line"><span class="cl">B.纤维组织增生 </span></span><span class="line"><span class="cl">C.肝细胞弥漫大片坏死 </span></span><span class="line"><span class="cl">D.淋巴细胞浸润 </span></span></code></pre></td></tr></table> </div> </div><h2 id="临床病理联系">临床病理联系</h2> <h3 id="门脉高压症的病因">门脉高压症的病因</h3> <p>||| |<strong>窦性阻塞</strong>|肝内广泛结缔组织增生，肝血窦闭塞、门静脉循环受阻| |<strong>窦后性阻塞</strong>|假小叶压迫小叶下静脉，使肝窦内血液流出受阻，影响门静脉血流入肝血窦| |<strong>窦前性阻塞</strong>|肝内肝动脉与门静脉小分支在汇入肝血窦前形成异常吻合，使高压力的动脉血流入门静脉内|</p> <h3 id="门脉高压症的症状和体征">门脉高压症的症状和体征</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>淤血性脾大</strong></td> <td style="text-align:center">70%~85%出现脾大，镜下见脾窦扩张，窦内皮细胞增生</td> </tr> <tr> <td style="text-align:center"><strong>腹水</strong></td> <td style="text-align:center">①门静脉高压使门静脉系统小静脉和毛细血管流体静压上升，通透性增加，水、电解质和血浆蛋白<font color=#eeee00><strong>漏入</strong></font>腹腔；②门静脉高压使肝血窦压力增加，淋巴液从淋巴管漏入腹腔；③肝脏受损后肝细胞合成白蛋白减少，腹水形成；④肝功能障碍导致醛固酮和<ruby>ADH<rp>(</rp><rt>抗利尿激素</rt><rp>)</rp></ruby>灭活减少，致继发性水钠潴留</td> </tr> <tr> <td style="text-align:center"><strong>侧支循环</strong></td> <td style="text-align:center">门腔静脉之间有4个交通支，以食管下段交通支最重要</td> </tr> <tr> <td style="text-align:center"><strong>胃肠淤血</strong></td> <td style="text-align:center">腹胀、食欲减退</td> </tr> </tbody> </table> <p><img src="https://fallen.wang/p/digestive/portacaval.png" width="356" height="589" srcset="https://fallen.wang/p/digestive/portacaval_hu6671c47f8e22f9e6083cbbe37c29a9cd_137324_480x0_resize_box_3.png 480w, https://fallen.wang/p/digestive/portacaval_hu6671c47f8e22f9e6083cbbe37c29a9cd_137324_1024x0_resize_box_3.png 1024w" loading="lazy" alt="图源9版外科学P423" class="gallery-image" data-flex-grow="60" data-flex-basis="145px" ></p> <h3 id="肝功能障碍">肝功能障碍</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>蛋白质合成障碍</strong></td> <td style="text-align:center">肝合成白蛋白减少，血浆白蛋白减少，白/球蛋白减少</td> </tr> <tr> <td style="text-align:center"><strong>出血倾向</strong></td> <td style="text-align:center">肝合成凝血因子减少，致皮肤黏膜和皮下出血</td> </tr> <tr> <td style="text-align:center"><strong>胆色素代谢障碍</strong></td> <td style="text-align:center">毛细胆管淤胆，<font color=eeee00><strong>肝细胞性黄疸</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>灭活作用减弱</strong></td> <td style="text-align:center">雌激素灭活减少，睾丸萎缩、男乳发育、<font color=eeee00><strong>蜘蛛痣</strong></font>、<font color=eeee00><strong>肝掌</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>肝性脑病</strong></td> <td style="text-align:center">肝功能极度衰竭的表现，为毒性物质未经肝细胞代谢解毒进入体循环所致</td> </tr> </tbody> </table> <p><code>2018N148X下列选项中与肝硬化腹水生成机制相关的有</code> AD<font color=#1e90ff>^{<strong>3</strong>}</font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.门静脉高压 </span></span><span class="line"><span class="cl">B.肝脏处理胆红素功能下降 </span></span><span class="line"><span class="cl">C.肝内纤维组织增生压迫肝静脉主干 </span></span><span class="line"><span class="cl">D.淋巴液从肝包膜中外渗 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>³C选项错误</strong></font>：1版病理学教材P246表述为：<font color=#40e0d0><strong>肝内纤维组织</strong></font>增生，压迫<font color=40e0d0><strong>小叶下静脉</strong></font>可致<font color=#ff3030><strong>肝窦压力增高</strong></font>，液体漏出，经<font color=#40e0d0><strong>肝包膜</strong></font>漏入腹腔，形成腹水。</p> </blockquote> <p><code>2021N152X有门脉高压症导致的病理表现包括</code> ABD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.淤血性脾大 </span></span><span class="line"><span class="cl">B.胃底食管静脉曲张 </span></span><span class="line"><span class="cl">C.蜘蛛状血管痣 </span></span><span class="line"><span class="cl">D.胃肠淤血、水肿 </span></span></code></pre></td></tr></table> </div> </div><h1 id="食管癌">食管癌</h1> <h2 id="早期食管癌和中晚期食管癌的比较">早期食管癌和中晚期食管癌的比较</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">早期食管癌</th> <th style="text-align:center">中晚期食管癌</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发</strong></td> <td style="text-align:center"><font color=eeee00><strong>中段</strong></font>&gt;下段&gt;上段<font color=#1e90ff>^{<strong>4</strong>}</font></td> <td style="text-align:center">同左</td> </tr> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">侵犯黏膜或黏膜下层的癌，未侵犯肌层，<font color=eeee00><strong>无论是否有淋巴结转移</strong></font></td> <td style="text-align:center">穿破黏膜下层，侵犯肌层</td> </tr> <tr> <td style="text-align:center"><strong>临床表现</strong></td> <td style="text-align:center">无明显症状</td> <td style="text-align:center">进行性吞咽困难</td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">黏膜轻度糜烂，表面呈颗粒状、微小乳头状</td> <td style="text-align:center">髓质型（<font color=eeee00><strong>最多见</strong></font>)、蕈伞形、溃疡型、缩窄型</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">绝大多数为<font color=eeee00><strong>鳞癌</strong></font></td> <td style="text-align:center"><font color=eeee00><strong>鳞癌</strong></font>（90%）、腺癌、燕麦小细胞癌、腺棘皮癌</td> </tr> </tbody> </table> <p><code>2007N155A食管癌最多见的发病部位是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.颈段 </span></span><span class="line"><span class="cl">B.胸部上段 </span></span><span class="line"><span class="cl">C.胸部中段 </span></span><span class="line"><span class="cl">D.胸部下段 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁴发生部位</strong></font>：<font color=#ff3030><strong>普通食管癌</strong></font>好发于<font color=#40e0d0><strong>食管中段</strong></font>，以<font color=#ff3030><strong>鳞状细胞癌</strong></font>多见；<font color=#ff3030><strong>Barrett食管癌</strong></font>好发于<font color=#40e0d0><strong>食管下段</strong></font>，以<font color=#ff3030><strong>腺癌</strong></font>最多见。</p> </blockquote> <p><code>1997N41A下列哪一项有关早期食管癌的描述是错误的</code> E</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.常无明显症状 </span></span><span class="line"><span class="cl">B可以是黏膜内癌 </span></span><span class="line"><span class="cl">C.可以是黏膜下癌 </span></span><span class="line"><span class="cl">D.可以是原位癌 </span></span><span class="line"><span class="cl">E.可以侵及浅肌层 </span></span></code></pre></td></tr></table> </div> </div><p><code>2014N165X中晚期食管癌的肉眼类型有</code> BCD<font color=#1e90ff><strong>⁵</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胶样型 </span></span><span class="line"><span class="cl">B.髓质型 </span></span><span class="line"><span class="cl">C.溃疡型 </span></span><span class="line"><span class="cl">D.隆起型 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁵隆起型</strong></font>：<font color=#bdfcc9><strong>隆起型</strong></font>即<font color=#bdfcc9><strong>蕈伞型</strong></font>，出处未知，9版病理学教材无此表述。</p> </blockquote> <h2 id="扩散途径">扩散途径</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>直接蔓延</strong></td> <td style="text-align:center">癌组织穿透食管壁向周围组织、器官浸润</td> </tr> <tr> <td style="text-align:center"><strong>淋巴转移</strong></td> <td style="text-align:center">与食管淋巴引流途径一致：上段癌转移至颈淋巴结、上纵膈淋巴结；中段癌转移至食管旁、肺门淋巴结；下段癌转移至食管旁、贲门旁、腹腔上部淋巴结</td> </tr> <tr> <td style="text-align:center"><strong>血道转移</strong></td> <td style="text-align:center">常转移至肝、肺</td> </tr> </tbody> </table> <h1 id="font-colorff3030胃癌font"><font color=#ff3030><strong>胃癌</strong></font></h1> <h2 id="定义和癌前病变">定义和癌前病变</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">胃癌是由胃黏膜上皮、腺上皮发生的恶性肿瘤</td> </tr> <tr> <td style="text-align:center"><strong>好发年龄</strong></td> <td style="text-align:center">40~60岁，男多于女</td> </tr> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center"><font color=eeee00><strong>胃窦</strong></font>小弯侧，胃体部少见</td> </tr> <tr> <td style="text-align:center"><strong>癌前病变</strong></td> <td style="text-align:center">慢性萎缩性胃炎，胃息肉，胃溃疡，胃黏膜肠化</td> </tr> </tbody> </table> <p><code>2021N34A胃癌的好发部位是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胃前壁 </span></span><span class="line"><span class="cl">B.胃后壁 </span></span><span class="line"><span class="cl">C.胃窦 </span></span><span class="line"><span class="cl">D.胃底 </span></span></code></pre></td></tr></table> </div> </div><p><code>2005N139X与胃癌发生有关的疾病或病变有</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.萎缩性胃炎 </span></span><span class="line"><span class="cl">B.胃溃疡 </span></span><span class="line"><span class="cl">C.黏膜上皮非典型性增生 </span></span><span class="line"><span class="cl">D.黏膜肠上皮化生 </span></span></code></pre></td></tr></table> </div> </div><h2 id="早期胃癌">早期胃癌</h2> <h3 id="概念">概念</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>早期胃癌</strong></td> <td style="text-align:center">癌组织浸润局限于黏膜或黏膜下层，无论有无淋巴结转移</td> </tr> <tr> <td style="text-align:center"><strong>微小癌</strong></td> <td style="text-align:center">直径<font color=eeee00><strong>&lt;0.5cm</strong></font>者</td> </tr> <tr> <td style="text-align:center"><strong>小胃癌</strong></td> <td style="text-align:center">直径<font color=eeee00><strong>0.6~1.0cm</strong></font>者</td> </tr> <tr> <td style="text-align:center"><strong>一点癌</strong></td> <td style="text-align:center">内镜检查是活检为癌，手术切片未发现癌</td> </tr> </tbody> </table> <h3 id="早期胃癌的病理变化">早期胃癌的病理变化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>大体分型</strong></td> <td style="text-align:center">隆起型：肿瘤从黏膜面明显隆起呈息肉状，此型较少见；表浅型：肿瘤呈扁平状，或稍隆起于黏膜表面；凹陷型：溃疡周边癌性糜烂，此型<font color=eeee00><strong>最多见</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>镜下特点</strong></td> <td style="text-align:center">以管状腺癌多见，其次是乳头状腺癌，未分化癌最少见</td> </tr> </tbody> </table> <p><code>2019N33A关于早期胃癌的描述，不正确的是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.癌细胞不能侵犯黏膜下层 </span></span><span class="line"><span class="cl">B.可有胃周淋巴结转移 </span></span><span class="line"><span class="cl">C.无远处转移 </span></span><span class="line"><span class="cl">D.大多数属于腺癌 </span></span></code></pre></td></tr></table> </div> </div><p><code>2021N162X早期胃癌概念包含的内容有</code> ABD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.病变局限于胃黏膜内或黏膜下层，有淋巴结转移 </span></span><span class="line"><span class="cl">B.病变局限于胃黏膜内或黏膜下层，无淋巴结转移 </span></span><span class="line"><span class="cl">C.病变浸润达浆膜层，无淋巴结转移 </span></span><span class="line"><span class="cl">D.微小胃癌及小胃癌是早期胃癌的特殊类型 </span></span></code></pre></td></tr></table> </div> </div><h2 id="中晚期胃癌进展期胃癌">中晚期胃癌（进展期胃癌）</h2> <h3 id="概念及肉眼类型">概念及肉眼类型</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>概念</strong></td> <td style="text-align:center">指癌组织浸润超过黏膜下层的胃癌</td> </tr> <tr> <td style="text-align:center"><strong>息肉型</strong></td> <td style="text-align:center">即蕈伞型，癌组织向黏膜表面生长，息肉状或蕈伞状，突入胃腔</td> </tr> <tr> <td style="text-align:center"><strong>溃疡型</strong></td> <td style="text-align:center">癌组织坏死脱落形成溃疡，边界不清，火山口状，凹凸不平</td> </tr> <tr> <td style="text-align:center"><strong>浸润型</strong></td> <td style="text-align:center">癌组织向胃壁局限性或弥漫性浸润，与周围正常组织分界不清；弥漫性浸润可致胃壁增厚、变硬，胃腔变小，状如皮革<font color=eeee00><strong>革囊胃</strong></font>（预后最差，存活时间短）</td> </tr> <tr> <td style="text-align:center"><strong>胶样癌</strong></td> <td style="text-align:center">当癌细胞分泌大量黏液时，癌组织肉眼呈半透明的胶冻状</td> </tr> </tbody> </table> <h3 id="组织学类型">组织学类型</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>常见类型</strong></td> <td style="text-align:center">腺癌（<font color=eeee00><strong>最常见</strong></font>），有管状腺癌、乳头状腺癌、黏液腺癌、低黏附性癌（包括印戒细胞癌）、混合性癌</td> </tr> <tr> <td style="text-align:center"><strong>少见类型</strong></td> <td style="text-align:center">腺鳞癌、鳞状细胞癌、未分化癌</td> </tr> </tbody> </table> <p><code>2015N165X胃癌的肉眼类型有</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.蕈伞型 </span></span><span class="line"><span class="cl">B.溃疡型 </span></span><span class="line"><span class="cl">C.浸润型 </span></span><span class="line"><span class="cl">D.胶样型 </span></span></code></pre></td></tr></table> </div> </div><p><code>2020N152X下列病变中属于胃癌晚期的有</code> CD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.癌细胞浸润至黏膜下层 </span></span><span class="line"><span class="cl">B.癌细胞转移到局部淋巴结 </span></span><span class="line"><span class="cl">C.癌细胞转移到双侧卵巢 </span></span><span class="line"><span class="cl">D.癌细胞转移到左锁骨上淋巴结 </span></span></code></pre></td></tr></table> </div> </div><p><code>2016N147B属于早期胃癌的是</code> A</p> <p><code>2016N148B预后最差的是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.癌组织侵入黏膜下层并有淋巴结转移 </span></span><span class="line"><span class="cl">B.癌组织侵入胃壁肌层有淋巴结转移 </span></span><span class="line"><span class="cl">C.癌组织侵出浆膜无淋巴结转移 </span></span><span class="line"><span class="cl">D.皮革胃 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030早期胃癌与中晚期胃癌的比较font"><font color=ff3030><strong>早期胃癌与中晚期胃癌的比较</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">早期胃癌</th> <th style="text-align:center">中晚期胃癌</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">癌浸润局限于黏膜或黏膜下层，无论是否有淋巴结转移</td> <td style="text-align:center">癌组织浸润超过黏膜下层或浸润胃壁全层</td> </tr> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">隆起型、表浅型、凹陷型（<font color=eeee00><strong>最常见</strong></font>）</td> <td style="text-align:center">息肉型或蕈伞型、浸润型、溃疡型（<font color=eeee00><strong>最常见</strong></font>）</td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">管状腺癌、乳头状腺癌、未分化癌</td> <td style="text-align:center">腺癌、腺棘皮癌、鳞癌</td> </tr> </tbody> </table> <h2 id="扩散途径-1">扩散途径</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>直接蔓延</strong></td> <td style="text-align:center">癌组织向胃壁各层浸润，也可向周围、邻近器官蔓延</td> </tr> <tr> <td style="text-align:center"><strong>淋巴道转移</strong></td> <td style="text-align:center"><font color=eeee00><strong>主要途径</strong></font>，晚期可转移到左锁骨上<font color=eeee00><strong>Virchow</strong></font>淋巴结</td> </tr> <tr> <td style="text-align:center"><strong>血道转移</strong></td> <td style="text-align:center">经血道转移至肝（<font color=eeee00><strong>最常见</strong></font>）、肺、脑、肾</td> </tr> <tr> <td style="text-align:center"><strong>种植性转移</strong></td> <td style="text-align:center">转移到双侧卵巢形成转移性黏液癌，称<font color=eeee00><strong>Krukenberg瘤</strong></font></td> </tr> </tbody> </table> <p><code>2022N39AVirchow淋巴结穿刺标本中发现癌细胞，最可能的原发灶是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大肠 </span></span><span class="line"><span class="cl">B.胃 </span></span><span class="line"><span class="cl">C.肝 </span></span><span class="line"><span class="cl">D.肺 </span></span></code></pre></td></tr></table> </div> </div><p><code>2009N84A胃癌晚期血行转移最多见的部位</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.胃 </span></span><span class="line"><span class="cl">B.胰 </span></span><span class="line"><span class="cl">C.肺 </span></span><span class="line"><span class="cl">D.肝 </span></span></code></pre></td></tr></table> </div> </div><p><code>2015N47A双侧卵巢肿大，活检发现癌细胞，首先考虑癌细胞来源于</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.子宫 </span></span><span class="line"><span class="cl">B.肠 </span></span><span class="line"><span class="cl">C.胃 </span></span><span class="line"><span class="cl">D.卵巢 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030良恶性溃疡的鉴别font"><font color=ff3030><strong>良恶性溃疡的鉴别</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">良性溃疡（溃疡病）</th> <th style="text-align:center">恶性溃疡（溃疡型胃癌）</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>外形</strong></td> <td style="text-align:center">圆形或椭圆形</td> <td style="text-align:center">不整形、皿状、火山口状</td> </tr> <tr> <td style="text-align:center"><strong>大小</strong></td> <td style="text-align:center">溃疡直径一般&lt;2cm</td> <td style="text-align:center">溃疡直径常&gt;2cm</td> </tr> <tr> <td style="text-align:center"><strong>边缘</strong></td> <td style="text-align:center">整齐、不隆起</td> <td style="text-align:center">不整齐、隆起</td> </tr> <tr> <td style="text-align:center"><strong>底部</strong></td> <td style="text-align:center">较平坦</td> <td style="text-align:center">凹凸不平，有坏死出血</td> </tr> <tr> <td style="text-align:center"><strong>周围黏膜</strong></td> <td style="text-align:center">皱襞向溃疡集中</td> <td style="text-align:center">皱襞中断，呈结节状肥厚</td> </tr> </tbody> </table> <h1 id="大肠癌">大肠癌</h1> <h2 id="病因-1">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>饮食习惯</strong></td> <td style="text-align:center">高营养少纤维饮食与本病发生有关</td> </tr> <tr> <td style="text-align:center"><strong>遗传因素</strong></td> <td style="text-align:center">家族性腺瘤性息肉病癌变：APC突变；遗传性非息肉病性大肠癌：错配修复基因突变</td> </tr> <tr> <td style="text-align:center"><strong>癌前病变</strong></td> <td style="text-align:center">肠息肉状腺瘤、绒毛状腺瘤、增生性息肉病、幼年性息肉病、慢性吸血虫病、慢性溃疡性结肠炎</td> </tr> <tr> <td style="text-align:center"><strong>基因突变</strong></td> <td style="text-align:center">多基因突变所致，如APC、<font color=eeee00><strong>c-myc</strong></font>、ras、<font color=eeee00><strong>p53</strong></font>、p16、DCC、MCC、DPC4、BRAF或错配修复基因突变</td> </tr> </tbody> </table> <p><code>2000N149X大肠癌的癌前病变有</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.腺瘤样息肉 </span></span><span class="line"><span class="cl">B.家族息肉病 </span></span><span class="line"><span class="cl">C.溃疡性结肠炎 </span></span><span class="line"><span class="cl">D.绒毛状腺瘤 </span></span></code></pre></td></tr></table> </div> </div><p><code>2011N167X下列大肠息肉病变中，属于癌前病变的有</code> BD<font color=#1e90ff><strong>⁶</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.幼年性息肉 </span></span><span class="line"><span class="cl">B.家族性腺瘤性息肉病 </span></span><span class="line"><span class="cl">C.炎症性息肉 </span></span><span class="line"><span class="cl">D.腺瘤性息肉 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁶注意审题</strong></font>：<font color=ff3030><strong>增生性息肉</strong></font>、<font color=ff3030><strong>幼年性息肉</strong></font>、<font color=ff3030><strong>炎性息肉</strong></font>都不是癌前病变；<font color=ff3030><strong>增生性息肉病</strong></font>、<font color=ff3030><strong>幼年息肉病</strong></font>是癌前病变，一字之差。</p> </blockquote> <h2 id="发病机制-1">发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>经腺瘤癌变</strong></td> <td style="text-align:center">家族性腺瘤性息肉病、遗传性非息肉病性大肠癌</td> </tr> <tr> <td style="text-align:center"><strong>锯齿状病变通路</strong></td> <td style="text-align:center">增生性息肉病、锯齿状腺瘤的恶变是由于错配修复基因突变所致</td> </tr> <tr> <td style="text-align:center"><strong>溃疡性结肠炎</strong></td> <td style="text-align:center">溃疡性结肠炎相关的大肠癌通路是p53异常所致</td> </tr> <tr> <td style="text-align:center"><strong>幼年性息肉病-癌途径</strong></td> <td style="text-align:center">是由于Smad4基因突变所致</td> </tr> </tbody> </table> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">正常黏膜→→→增生→→→早期腺瘤→→→中期腺瘤→→→晚期腺瘤→→→癌→→→转移癌 </span></span><span class="line"><span class="cl"> ↑ ↑ ↑ ↑ ↑ ↑ </span></span><span class="line"><span class="cl"> APC突变 DNA甲基化异常 Ras突变 DCC丢失 p53突变 其他突变 </span></span></code></pre></td></tr></table> </div> </div><h2 id="病理变化-3">病理变化</h2> <h3 id="好发部位">好发部位</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>大肠癌好发于</strong></td> <td style="text-align:center">直肠（50%），其余依次为乙状结肠（20%）、盲肠及升结肠（16%）、横结肠、降结肠</td> </tr> <tr> <td style="text-align:center"><strong>直肠癌好发于</strong></td> <td style="text-align:center">直肠壶腹部</td> </tr> </tbody> </table> <p><code>2012N78A大肠癌的好发部位</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.横结肠 </span></span><span class="line"><span class="cl">B.升结肠及结肠肝曲 </span></span><span class="line"><span class="cl">C.降结肠及乙状结肠 </span></span><span class="line"><span class="cl">D.直肠及乙状结肠 </span></span></code></pre></td></tr></table> </div> </div><h3 id="肉眼观-2">肉眼观</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">病理特点</th> <th style="text-align:center">备注</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>隆起型</strong></td> <td style="text-align:center">肿瘤呈息肉状、盘状向肠腔突出</td> <td style="text-align:center">多为高分化腺癌</td> </tr> <tr> <td style="text-align:center"><strong>溃疡型</strong></td> <td style="text-align:center">肿瘤表面形成较深溃疡，或呈火山口状</td> <td style="text-align:center"><font color=eeee00><strong>较常见</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>浸润型</strong></td> <td style="text-align:center">癌组织向肠壁深层弥漫浸润，常累及肠管全周，使局部肠管周径明显缩小</td> <td style="text-align:center">易形成<font color=eeee00><strong>环状狭窄</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>胶样型</strong></td> <td style="text-align:center">癌细胞分泌大量黏液，肿瘤表面及切面均呈半透明、胶冻状，属于特殊<font color=eeee00><strong>黏液瘤</strong></font></td> <td style="text-align:center">预后较差</td> </tr> </tbody> </table> <p><code>2011N165X大肠癌的肉眼类型有</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.隆起型 </span></span><span class="line"><span class="cl">B.溃疡型 </span></span><span class="line"><span class="cl">C.浸润型 </span></span><span class="line"><span class="cl">D.胶样型 </span></span></code></pre></td></tr></table> </div> </div><p><code>2015N133B组织学上表现为黏液癌的大肠癌类型是</code> B</p> <p><code>2015N134B较易引起肠梗阻的大肠癌类型是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.溃疡型 </span></span><span class="line"><span class="cl">B.胶样型 </span></span><span class="line"><span class="cl">C.浸润型 </span></span><span class="line"><span class="cl">D.隆起型 </span></span></code></pre></td></tr></table> </div> </div><h3 id="组织学类型-1">组织学类型</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>腺癌</strong></td> <td style="text-align:center">管状腺癌（<font color=eeee00><strong>最常见</strong></font>）、乳头状腺癌、黏液腺癌、印戒细胞癌</td> </tr> <tr> <td style="text-align:center"><strong>其他</strong></td> <td style="text-align:center">未分化癌、腺鳞癌、鳞状细胞癌</td> </tr> </tbody> </table> <h3 id="大肠癌的dukes分期">大肠癌的Dukes分期</h3> <table> <thead> <tr> <th style="text-align:center">分期</th> <th style="text-align:center">肿瘤生长范围</th> <th style="text-align:center">5年存活率</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>A</strong></td> <td style="text-align:center">肿瘤局限于黏膜层（重度上皮内瘤变）</td> <td style="text-align:center">100%</td> </tr> <tr> <td style="text-align:center"><strong>B₁</strong></td> <td style="text-align:center">肿瘤侵及肌层但未穿透，<font color=eeee00><strong>无</strong></font>淋巴结转移</td> <td style="text-align:center">67%</td> </tr> <tr> <td style="text-align:center"><strong>B₂</strong></td> <td style="text-align:center">肿瘤穿透肌层，<font color=eeee00><strong>无</strong></font>淋巴结转移</td> <td style="text-align:center">54%</td> </tr> <tr> <td style="text-align:center"><strong>C₁</strong></td> <td style="text-align:center">肿瘤未穿透肌层，但<font color=eeee00><strong>有</strong></font>淋巴结转移</td> <td style="text-align:center">43%</td> </tr> <tr> <td style="text-align:center"><strong>C₂</strong></td> <td style="text-align:center">肿瘤穿透肠壁，<font color=eeee00><strong>有</strong></font>淋巴结转移</td> <td style="text-align:center">22%</td> </tr> <tr> <td style="text-align:center"><strong>D</strong></td> <td style="text-align:center">有远隔脏器转移</td> <td style="text-align:center">极低</td> </tr> </tbody> </table> <p><code>2000N87A结肠癌Dukes分期中B期是指</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.癌达黏膜下层 </span></span><span class="line"><span class="cl">B.癌累及肠壁肌层 </span></span><span class="line"><span class="cl">C.癌穿透肠壁 </span></span><span class="line"><span class="cl">D.有淋巴结转移，仅局限于结肠旁淋巴结 </span></span><span class="line"><span class="cl">E.有淋巴结转移至系膜和系膜根部淋巴结 </span></span></code></pre></td></tr></table> </div> </div><p><code>1999N34A关于大肠癌的描述，下列哪项是正确的</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.盲肠癌最多见 </span></span><span class="line"><span class="cl">B.类癌由腺瘤癌变而来 </span></span><span class="line"><span class="cl">C.少数癌瘤产生CEA </span></span><span class="line"><span class="cl">D.Dukes D期有远隔器官转移 </span></span><span class="line"><span class="cl">E.未分化癌多见 </span></span></code></pre></td></tr></table> </div> </div><h2 id="扩散途径-2">扩散途径</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>直接蔓延</strong></td> <td style="text-align:center">至周围邻近器官，如前列腺癌、膀胱、腹膜等处</td> </tr> <tr> <td style="text-align:center"><strong>淋巴转移</strong></td> <td style="text-align:center">癌组织未穿透肠壁肌层时较少发生淋巴道转移；一旦穿透肌层则转移率明显增加</td> </tr> <tr> <td style="text-align:center"><strong>血道转移</strong></td> <td style="text-align:center">常见为肝，其次为肺、脑</td> </tr> <tr> <td style="text-align:center"><strong>种植转移</strong></td> <td style="text-align:center">癌细胞穿破浆膜后脱落，播散到腹腔内形成种植转移</td> </tr> </tbody> </table> <h1 id="原发性肝癌">原发性肝癌</h1> <h2 id="定义">定义</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">原发性肝癌是指肝细胞、肝内胆管上皮细胞发生的恶性肿瘤</td> </tr> <tr> <td style="text-align:center"><strong>分型</strong></td> <td style="text-align:center">肝细胞癌约占90%，起源于肝细胞；胆管细胞癌占10%以下；起源于肝内胆管上皮细胞；混合性肝癌占1%以下，两者均有</td> </tr> </tbody> </table> <p><code>2004N139X原发性肝癌的组织学类型有</code> BCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.鳞癌 </span></span><span class="line"><span class="cl">B.胆管细胞癌 </span></span><span class="line"><span class="cl">C.混合性肝癌 </span></span><span class="line"><span class="cl">D.肝细胞癌 </span></span></code></pre></td></tr></table> </div> </div><h2 id="肝细胞癌">肝细胞癌</h2> <h3 id="病因-2">病因</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肝炎病毒</strong></td> <td style="text-align:center"><font color=eeee00><strong>HBV</strong></font>、<font color=eeee00><strong>HEV</strong></font>与肝癌关系密切</td> </tr> <tr> <td style="text-align:center"><strong>肝硬化</strong></td> <td style="text-align:center"><font color=eeee00><strong>HBV</strong></font>引起的肝硬化，约7年肝硬化可发展为肝癌</td> </tr> <tr> <td style="text-align:center"><strong>酒精</strong></td> <td style="text-align:center">间接经肝硬化而后修补过程产生肝癌</td> </tr> <tr> <td style="text-align:center"><strong>真菌及毒素</strong></td> <td style="text-align:center">黄曲霉菌可致实验性肝癌，<font color=eeee00><strong>黄曲霉素B₁</strong></font>与肝癌密切相关</td> </tr> </tbody> </table> <p><code>2022N153X与肝细胞癌发生有关的肝炎病毒有</code> BC</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.HAV </span></span><span class="line"><span class="cl">B.HBV </span></span><span class="line"><span class="cl">C.HCV </span></span><span class="line"><span class="cl">D.HDV </span></span><span class="line"><span class="cl">E.HEV </span></span></code></pre></td></tr></table> </div> </div><p><code>1994N54A原发性肝癌的发生与下列哪种因素最有关</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肠道戊型肝炎病毒感染 </span></span><span class="line"><span class="cl">B.肠道寄生虫感染 </span></span><span class="line"><span class="cl">C.肠道细菌感染 </span></span><span class="line"><span class="cl">D.黄曲霉素污染 </span></span><span class="line"><span class="cl">E.酒精中毒 </span></span></code></pre></td></tr></table> </div> </div><h3 id="病理变化-4">病理变化</h3> <h4 id="肉眼观-3">肉眼观</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>小肝癌型</strong></td> <td style="text-align:center">单个癌结节最大直径<font color=eeee00><strong>&lt;3cm</strong></font>或两个合计最大直径&lt;3cm；球形，边界清楚，切面均匀一致，出血及坏死少见</td> <td style="text-align:center">多为早期肝癌</td> </tr> <tr> <td style="text-align:center"><strong>多结节型</strong></td> <td style="text-align:center">常合并<font color=eeee00><strong>肝硬化</strong></font>，可为单个或多个，圆形，大小不等</td> <td style="text-align:center"><font color=eeee00><strong>最常见</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>弥漫型</strong></td> <td style="text-align:center">癌组织弥散于肝内，结节不明显，常发生于肝硬化</td> <td style="text-align:center">较少见</td> </tr> <tr> <td style="text-align:center"><strong>巨块型</strong></td> <td style="text-align:center">直径&gt;10cm，圆形，右叶多见，切面常有出血坏死，瘤体周围常有卫星状癌结节，不合并或仅合并轻度肝硬化</td> <td style="text-align:center">次常见</td> </tr> </tbody> </table> <h4 id="镜下观-2">镜下观</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">高分化</th> <th style="text-align:center">低分化</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>癌细胞</strong></td> <td style="text-align:center">类似于肝细胞</td> <td style="text-align:center">异型性明显，大小不一，形态各异</td> </tr> <tr> <td style="text-align:center"><strong>排列</strong></td> <td style="text-align:center">细小梁状，假腺体结构</td> <td style="text-align:center">呈实性生长</td> </tr> <tr> <td style="text-align:center"><strong>分泌</strong></td> <td style="text-align:center">可分泌胆汁</td> <td style="text-align:center">不能分泌胆汁</td> </tr> <tr> <td style="text-align:center"><strong>血管</strong></td> <td style="text-align:center">多</td> <td style="text-align:center">少</td> </tr> <tr> <td style="text-align:center"><strong>间质</strong></td> <td style="text-align:center">少</td> <td style="text-align:center">多</td> </tr> </tbody> </table> <h3 id="扩散途径-3">扩散途径</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肝内直接蔓延</strong></td> <td style="text-align:center">首先沿<font color=eeee00><strong>门静脉分支</strong></font>在肝内蔓延</td> </tr> <tr> <td style="text-align:center"><strong>肝外转移</strong></td> <td style="text-align:center">多经淋巴道转移至<font color=eeee00><strong>肝门淋巴结</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>血行转移</strong></td> <td style="text-align:center">通过肝静脉转移至肺、肾上腺、脑、肾</td> </tr> <tr> <td style="text-align:center"><strong>种植转移</strong></td> <td style="text-align:center">侵入肝表面的癌细胞脱落后可形成种植性转移</td> </tr> </tbody> </table> <p><code>2012N53A肝细胞性肝癌最常见的转移部位</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肝 </span></span><span class="line"><span class="cl">B.肺 </span></span><span class="line"><span class="cl">C.骨 </span></span><span class="line"><span class="cl">D.肝门区淋巴结 </span></span></code></pre></td></tr></table> </div> </div><h2 id="胆管细胞癌">胆管细胞癌</h2> <h3 id="概念与病因">概念与病因</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>概念</strong></td> <td style="text-align:center">胆管细胞癌是发生于肝内胆管上皮的恶性肿瘤</td> </tr> <tr> <td style="text-align:center"><strong>病因</strong></td> <td style="text-align:center">尚未明确，但与HBV、HCV感染<font color=eeee00><strong>无关</strong></font>；可能与胆管内寄生虫、接触胆道造影剂有关</td> </tr> </tbody> </table> <h3 id="病理变化与转移途径">病理变化与转移途径</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">多为单个肿块，含丰富纤维结缔组织，色苍白</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">癌细胞呈<font color=eeee00><strong>腺管状排列</strong></font>，可分泌<font color=eeee00><strong>黏液</strong></font>，癌组织间质较多</td> </tr> <tr> <td style="text-align:center"><strong>转移</strong></td> <td style="text-align:center">易发生<font color=eeee00><strong>肝外转移</strong></font>，常见部位是肺、骨、脑等</td> </tr> </tbody> </table> <h1 id="胰腺炎症与肿瘤性疾病">胰腺炎症与肿瘤性疾病</h1> <h2 id="急性胰腺炎">急性胰腺炎</h2> <h3 id="病因-3">病因</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>胆道疾病</strong></td> <td style="text-align:center">是我国<font color=eeee00><strong>最常见</strong></font>的病因，尤其是胆道结石</td> </tr> <tr> <td style="text-align:center"><strong>酗酒</strong></td> <td style="text-align:center">是国外最常见的病因</td> </tr> <tr> <td style="text-align:center"><strong>其他因素</strong></td> <td style="text-align:center">妊娠、高脂血症、药物、胰管阻塞、内分泌及免疫异常</td> </tr> <tr> <td style="text-align:center"><strong>特发性</strong></td> <td style="text-align:center">特发性急性胰腺炎病因不明</td> </tr> </tbody> </table> <h3 id="发病机制-2">发病机制</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>常见病因</strong></td> <td style="text-align:center">胆总管结石造成胆道梗阻，致胆源性胰腺炎</td> </tr> <tr> <td style="text-align:center"><strong>自家消化</strong></td> <td style="text-align:center">胆道梗阻→胰管内高压→腺泡破裂→胰液外溢→胰酶激活</td> </tr> </tbody> </table> <h3 id="病理特点">病理特点</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>急性水肿型胰腺炎</strong></td> <td style="text-align:center">表现为胰腺肿大变硬，间质<font color=eeee00><strong>充血水肿</strong></font>，中性粒细胞、单核细胞浸润；可见局限性脂肪坏死；腹腔内可有少量渗出液</td> </tr> <tr> <td style="text-align:center"><strong>急性出血性胰腺炎</strong></td> <td style="text-align:center">以广泛出血坏死为特征，肉眼：胰腺肿大质软，暗红色，可见<font color=eeee00><strong>钙皂、坏死灶</strong></font>；镜下：大片<font color=eeee00><strong>凝固性坏死</strong></font>，间质小血管壁坏死，故有大量出血，坏死灶周围可见轻度炎细胞浸润</td> </tr> </tbody> </table> <h2 id="胰腺癌">胰腺癌</h2> <h3 id="病因和发病机制-2">病因和发病机制</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>吸烟</strong></td> <td style="text-align:center">发病的主要环境因素是吸烟，可使发病风险翻倍</td> </tr> <tr> <td style="text-align:center"><strong>慢性胰腺炎</strong></td> <td style="text-align:center">遗传性胰腺炎是高危因素</td> </tr> <tr> <td style="text-align:center"><strong>化学毒物</strong></td> <td style="text-align:center">联苯胺是高危因素</td> </tr> <tr> <td style="text-align:center"><strong>基因突变</strong></td> <td style="text-align:center">90%有K-ras点突变，50%有TP53突变和DPC4缺失</td> </tr> </tbody> </table> <h3 id="病理变化-5">病理变化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>分布</strong></td> <td style="text-align:center">胰腺头部（60%）、体部（15%）、尾部（5%）、整个胰腺</td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">肿块大小形态不一，肿瘤呈硬性结节可突出于胰腺表面，也可埋藏于胰腺内，不深部取材难以确诊</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">常见类型：<font color=eeee00><strong>导管腺癌</strong></font>（85%）、囊腺癌、黏液癌、实性癌；少见类型：未分化癌、多形性癌、鳞状细胞癌、腺鳞癌</td> </tr> </tbody> </table> <hr> <p>贺门！</p> <hr>

生化循环汇总

<img src="https://fallen.wang/p/biochemistry-cycles/cover.png" alt="Featured image of post 生化循环汇总" /><hr> <h1 id="参考人卫9-版生物化学与分子生物学维基百科">参考：人卫9 版生物化学与分子生物学，维基百科</h1> <hr> <h1 id="三羧酸循环">三羧酸循环</h1> <p><img src="https://fallen.wang/p/biochemistry-cycles/TCA-cycle.png" width="905" height="695" srcset="https://fallen.wang/p/biochemistry-cycles/TCA-cycle_hu1b4185c4eac7f92206fa3d8b6d9a5af9_282376_480x0_resize_box_3.png 480w, https://fallen.wang/p/biochemistry-cycles/TCA-cycle_hu1b4185c4eac7f92206fa3d8b6d9a5af9_282376_1024x0_resize_box_3.png 1024w" loading="lazy" alt="图源9 版生化教材P 100" class="gallery-image" data-flex-grow="130" data-flex-basis="312px" ></p> <p>三羧酸循环是生物体内最重要的循环之一，是三大营养物质的代谢枢纽，通过脱氢提供还原当量从而进行电子传递和氧化磷酸化生成ATP 。</p> <h2 id="过程">过程</h2> <p>①来自丙酮酸脱氢生成的<font color=#40e0d0><strong>乙酰CoA</strong></font> 和<font color=#40e0d0><strong>草酰乙酸</strong></font>在<font color=#eeee00><strong>柠檬酸合酶</strong></font>作用下生成<font color=#40e0d0><strong>柠檬酸</strong></font>，此为<strong>第一个</strong><font color=#eeee00><strong>限速步骤</strong></font>；②<font color=#40e0d0><strong>柠檬酸</strong></font>经<font color=#40e0d0><strong>顺乌头酸</strong></font>转化为<font color=#40e0d0><strong>异柠檬酸</strong></font>；③<font color=#40e0d0><strong>异柠檬酸</strong></font>在<font color=#eeee00><strong>异柠檬酸脱氢酶</strong></font>作用下氧化脱羧转变为<font color=#40e0d0><strong>α -酮戊二酸</strong></font>，脱下的氢由<font color=#40e0d0><strong>NAD⁺</strong></font> 接受生成<font color=#40e0d0><strong>NADH +H⁺</strong></font> ，此为<strong>第一次</strong><font color=#eeee00><strong>氧化脱羧</strong></font>，也是<strong>第二个</strong><font color=#eeee00><strong>限速步骤</strong></font>；④<font color=#40e0d0><strong>α -酮戊二酸</strong></font>在<font color=#eeee00><strong>α -酮戊二酸脱氢酶复合体</strong></font>作用下氧化脱羧生成<font color=#40e0d0><strong>琥珀酰CoA</strong></font> ，脱下的氢由<font color=#40e0d0><strong>NAD⁺</strong></font> 接受生成<font color=#40e0d0><strong>NADH +H⁺</strong></font> ，此为<strong>第二次</strong>氧化脱羧，也是<strong>第三个</strong><font color=#eeee00><strong>限速步骤</strong></font>；⑤<font color=#40e0d0><strong>琥珀酰CoA</strong></font> 在<font color=#40e0d0><strong>琥珀酰CoA 合成酶</strong></font>作用下水解生成<font color=#40e0d0><strong>琥珀酸</strong></font>，同时与<font color=#40e0d0><strong>核苷二磷酸</strong></font>偶联，是<strong>唯一</strong>一次<font color=#eeee00><strong>底物水平磷酸化</strong></font>；⑥<font color=#40e0d0><strong>琥珀酸</strong></font>在<font color=#40e0d0><strong>琥珀酸脱氢酶</strong></font>作用下脱氢生成<font color=#40e0d0><strong>延胡索酸</strong></font>，脱下的氢由<font color=#40e0d0><strong>FAD</strong></font> 接受生成<font color=#40e0d0><strong>FADH₂</strong></font> ；⑦<font color=#40e0d0><strong>延胡索酸</strong></font>在<font color=#40e0d0><strong>延胡索酸酶</strong></font>作用下生成<font color=#40e0d0><strong>苹果酸</strong></font>；⑧<font color=#40e0d0><strong>苹果酸</strong></font>在<font color=#40e0d0><strong>苹果酸脱氢酶</strong></font>作用下脱氢生成<font color=#40e0d0><strong>草酰乙酸</strong></font>，脱下的氢由<font color=#40e0d0><strong>NAD⁺</strong></font> 接受生成<font color=#40e0d0><strong>NADH⁺</strong></font> 。</p> <p>记忆口诀：<code>草酰乙酰成柠檬，异柠檬又成α 酮，琥酰琥珀延胡索，苹果落在草丛中。</code>（来自天天师兄）</p> <h2 id="特点">特点</h2> <p>记住“1 ,2 ,3 ,4 ,5 ”</p> <p>1 ：一次<font color=#eeee00><strong>底物水平磷酸化</strong></font>，第五步<font color=#40e0d0><strong>琥珀酰CoA</strong></font> 水解为<font color=#40e0d0><strong>琥珀酸</strong></font>时底物水平磷酸化，产生<code>1 </code>分子ATP 。</p> <p>2 ：两次脱羧，分别在第三步和第四步。</p> <p>3 ：三个限速酶，依次分别是<font color=#eeee00><strong>柠檬酸合酶</strong></font>、<font color=#eeee00><strong>异柠檬酸脱氢酶</strong></font>、<font color=#eeee00><strong>α -酮戊二酸脱氢酶</strong></font>。</p> <p>4 ：四次脱氢，第三步、第四步、第六步和第八步，其中第六步由<font color=#40e0d0><strong>FAD</strong></font> 受氢，其余三步均为<font color=#40e0d0><strong>NAD⁺</strong></font> 。</p> <p>5 ：循环过程中，共有五步产能：第三步产生<code>2.5 </code> 分子ATP ，第四步产生<code>2.5 </code>分子ATP ，第五步产生<code>1</code> 分子ATP ，第六步产生<code>1.5</code> 分子ATP ，第八步产生<code>2.5</code> 分子ATP ，故一分子<font color=#40e0d0><strong>乙酰CoA</strong></font> 参与三羧酸循环产生<code>2.5 +2.5 +1 +1.5 +2.5 = 10</code> 分子ATP 。由于一分子<font color=#40e0d0><strong>葡萄糖</strong></font>进入糖酵解产生<code>2</code> 分子<font color=#40e0d0><strong>3 -磷酸甘油醛</strong></font>，其后所有能量计算都要*2 ，故一分子<font color=#40e0d0><strong>葡萄糖</strong></font>经过三羧酸循环产生<code>20</code> 分子ATP 。</p> <h2 id="意义">意义</h2> <p>1 ：TCA 是三大营养物质分解产能的共同通路。三大营养物质分解代谢最终都产生<font color=#40e0d0><strong>乙酰CoA</strong></font> 进入TCA 而彻底氧化。TCA 并不直接产能，但是能提供足够的还原当量进入呼吸链，经氧化磷酸化产生大量ATP 。</p> <p>2 ：TCA 是<font color=#40e0d0><strong>糖</strong></font>、<font color=#40e0d0><strong>脂肪</strong></font>、<font color=#40e0d0><strong>氨基酸</strong></font>代谢的联系枢纽，三大营养物质通过TCA 一定程度上相互转变。</p> <h2 id="调节">调节</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">调节机制</th> <th style="text-align:center">抑制剂</th> <th style="text-align:center">激活剂</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>柠檬酸合酶</strong></td> <td style="text-align:center">反馈抑制</td> <td style="text-align:center">NADH 、琥珀酰CoA 、ATP 、柠檬酸</td> <td style="text-align:center">ADP</td> </tr> <tr> <td style="text-align:center"><strong>异柠檬酸脱氢酶</strong></td> <td style="text-align:center">反馈抑制</td> <td style="text-align:center">ATP</td> <td style="text-align:center">ADP 、Ca²⁺</td> </tr> <tr> <td style="text-align:center"><strong>α -酮戊二酸脱氢酶</strong></td> <td style="text-align:center">反馈抑制</td> <td style="text-align:center">ATP 、NADH 、琥珀酰CoA</td> <td style="text-align:center">Ca²⁺</td> </tr> </tbody> </table> <hr> <h1 id="丙氨酸-葡萄糖循环">丙氨酸-葡萄糖循环</h1> <p><img src="https://fallen.wang/p/biochemistry-cycles/glu-ala-cycle.png" width="968" height="461" srcset="https://fallen.wang/p/biochemistry-cycles/glu-ala-cycle_hueb1ca8e54f82dfffdef58fc7f2cb548b_151981_480x0_resize_box_3.png 480w, https://fallen.wang/p/biochemistry-cycles/glu-ala-cycle_hueb1ca8e54f82dfffdef58fc7f2cb548b_151981_1024x0_resize_box_3.png 1024w" loading="lazy" alt="图源9 版生化教材P 182" class="gallery-image" data-flex-grow="209" data-flex-basis="503px" ></p> <p><font color=#40e0d0><strong>氨</strong></font>在人体内有毒，在血液中以<font color=#40e0d0><strong>丙氨酸</strong></font>或<font color=#40e0d0><strong>谷氨酰胺</strong></font>两种形式运输。</p> <h2 id="过程-1">过程</h2> <p>骨骼肌通过转氨基作用将<font color=#40e0d0><strong>丙酮酸</strong></font>转化为<font color=#40e0d0><strong>丙氨酸</strong></font>，经血液到达肝脏后通过联合脱氨基作用生成<font color=#40e0d0><strong>丙酮酸</strong></font>并释放<font color=#40e0d0><strong>氨</strong></font>，<font color=#40e0d0><strong>丙酮酸</strong></font>经糖异生合成<font color=#40e0d0><strong>葡萄糖</strong></font>，<font color=#40e0d0><strong>氨</strong></font>用于合成<font color=#40e0d0><strong>尿素</strong></font>。<font color=#40e0d0><strong>葡萄糖</strong></font>经血到肌肉，糖酵解成为<font color=#40e0d0><strong>丙酮酸</strong></font>。</p> <h2 id="意义-1">意义</h2> <p>使肌肉中的<font color=#40e0d0><strong>氨</strong></font>以无毒的<font color=#40e0d0><strong>丙氨酸</strong></font>形式运送至肝，同时肝又提供了生成<font color=#40e0d0><strong>丙酮酸</strong></font>的<font color=#40e0d0><strong>葡萄糖</strong></font>。</p> <hr> <h1 id="柠檬酸-丙酮酸循环">柠檬酸-丙酮酸循环</h1> <h1 id="鸟氨酸循环">鸟氨酸循环</h1> <h1 id="乳酸循环">乳酸循环</h1> <p><img src="https://fallen.wang/p/biochemistry-cycles/cori-cycle.jpg" width="342" height="307" srcset="https://fallen.wang/p/biochemistry-cycles/cori-cycle_huca9f532f4e7a39db934bd28256dc8ebc_12836_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/biochemistry-cycles/cori-cycle_huca9f532f4e7a39db934bd28256dc8ebc_12836_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="图源9 版生化教材P 115" class="gallery-image" data-flex-grow="111" data-flex-basis="267px" > 运动时肌细胞无氧呼吸导致<font color=#40e0d0><strong>乳酸</strong></font>大量堆积，而肌肉组织中无<font color=#eeee00><strong>葡糖-6 -磷酸酶</strong></font>，无法由<font color=#40e0d0><strong>乳酸</strong></font>糖异生，须经血液转运至肝脏。该循环涉及的糖代谢途径有糖酵解和糖异生。</p> <p><code>2</code> 分子<font color=#40e0d0><strong>乳酸</strong></font>进入肝脏异生为<font color=#40e0d0><strong>葡萄糖</strong></font>需消耗<code>6</code> 分子ATP 。</p> <h2 id="生理意义">生理意义</h2> <p>既能回收<font color=#40e0d0><strong>乳酸</strong></font>中的能量，又能避免<font color=#40e0d0><strong>乳酸</strong></font>堆积引起酸中毒。</p> <h1 id="甲硫氨酸循环">甲硫氨酸循环</h1>

心血管系统病理

<img src="https://fallen.wang/p/cardiovascular/cover.png" alt="Featured image of post 心血管系统病理" /><script type="text/javascript">alert("病理还得看贺银成。贺门！");</script> <iframe frameborder="no" border="0" marginwidth="0" marginheight="0" width=330 height=86 src="//music.163.com/outchain/player?type=2&id=857881&auto=0&height=66"></iframe> <h1 id="font-colorff3030-考纲font"><font color=#ff3030 ><strong>考纲</strong></font></h1> <blockquote> <p><em><strong>1.风湿病的病因、发病机制、基本病理改变及各器官的病理变化。 2.心内膜炎的分类及其病因、发病机制、病理改变、合并症和结局。 3.心瓣膜病的类型、病理改变、血流动力学改变和临床病理联系。 4.高血压病的概念、发病机制，良性高血压的分期及其病理变化，恶性高血压的病理特点。 5.动脉粥样硬化的病因、发病机制及基本病理变化，各器官的动脉粥样硬化所引起的各脏器的病理改变和后果。 6.心肌病的概念，克山病、充血性心肌病、肥厚阻塞性心肌病及闭塞性心肌病的病理学特点。 7.心肌炎的概念、病理学类型及其病理特点。</strong></em></p> </blockquote> <hr> <h1 id="font-colorff3030-风湿病font"><font color=#ff3030 ><strong>风湿病</strong></font></h1> <h2 id="病因">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>发病原因</strong></td> <td style="text-align:center">与A组乙型溶血性链球菌感染有关</td> </tr> <tr> <td style="text-align:center"><strong>临床表现</strong></td> <td style="text-align:center">发热、心脏和关节损害、环形红斑、皮下小结和舞蹈病，可累及全身结缔组织及血管，<font color=#eeee00><strong>最常</strong></font>侵犯心（<font color=#eeee00><strong>最严重</strong></font>）、关节和血管</td> </tr> <tr> <td style="text-align:center"><strong>病理特征</strong></td> <td style="text-align:center">特征病变是<font color=#eeee00><strong>风湿肉芽肿</strong></font>，即<font color=#eeee00><strong>Aschoff小体</strong></font></td> </tr> </tbody> </table> <p><code>2013N133B对风湿病最有诊断意义的病变是</code> C</p> <p><code>2013N134B对风湿病人造成最严重危害的病变是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.关节病变 </span></span><span class="line"><span class="cl">B.心包内纤维蛋白性炎症 </span></span><span class="line"><span class="cl">C.心肌内Aschoff小体 </span></span><span class="line"><span class="cl">D.心内膜炎 </span></span></code></pre></td></tr></table> </div> </div><h2 id="发病机制">发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>A组溶血性链球菌</strong></td> <td style="text-align:center"><font color=#eeee00><strong>M蛋白抗原</strong></font>可以起交叉免疫，是“<font color=#eeee00><strong>致风湿源性</strong></font>”</td> </tr> <tr> <td style="text-align:center"><strong>自身免疫反应</strong></td> <td style="text-align:center">见<strong>七版免疫学</strong>22页“交叉抗原”</td> </tr> <tr> <td style="text-align:center"><strong>遗传易感性</strong></td> <td style="text-align:center">风湿热患者亲属患病率更高</td> </tr> <tr> <td style="text-align:center"><strong>链球菌毒素</strong></td> <td style="text-align:center">链球菌分泌的细胞外毒素和酶可破坏机体组织器官</td> </tr> </tbody> </table> <h2 id="font-colorff3030基本病理变化font"><font color=#ff3030><strong>基本病理变化</strong></font></h2> <h3 id="时期">时期</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">变质渗出期（早期）</th> <th style="text-align:center">增生期（肉芽肿期）</th> <th style="text-align:center">纤维化期（硬化期）</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病程</strong></td> <td style="text-align:center">持续1月</td> <td style="text-align:center">持续2~3月</td> <td style="text-align:center">持续2~3月</td> </tr> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center"><font color=#eeee00><strong>胶原的纤维素样坏死</strong></font></td> <td style="text-align:center"><font color=#eeee00><strong>Aschoff小体形成</strong></font></td> <td style="text-align:center"><font color=#eeee00><strong>梭形瘢痕形成</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>其他病变</strong></td> <td style="text-align:center">结缔组织基质黏液样变性，胶原纤维素样坏死，少量淋巴、单核、浆细胞浸润</td> <td style="text-align:center">同渗出期</td> <td style="text-align:center">Aschoff小体内坏死细胞被吸收</td> </tr> </tbody> </table> <p><code>2011N48A风湿性病变质渗出期的主要病变是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.纤维素样坏死形成 </span></span><span class="line"><span class="cl">B.阿绍夫小体形成 </span></span><span class="line"><span class="cl">C.梭形瘢痕形成 </span></span><span class="line"><span class="cl">D.小化脓灶形成 </span></span></code></pre></td></tr></table> </div> </div><h3 id="font-colorff3030aschoff小体font"><font color=#ff3030><strong>Aschoff小体</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>特点</strong></td> <td style="text-align:center">肉芽肿性病变，是风湿病增生期的<font color=#eeee00><strong>特征性病变</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>组成</strong></td> <td style="text-align:center">Aschoff细胞、浆细胞、Aschoff巨细胞、少量T细胞</td> </tr> <tr> <td style="text-align:center"><strong>部位</strong></td> <td style="text-align:center">多位于纤维素样坏死灶内；在<font color=#eeee00><strong>心肌间质</strong></font>内多位于<font color=#eeee00><strong>小血管</strong></font>旁</td> </tr> <tr> <td style="text-align:center"><strong>来源</strong></td> <td style="text-align:center">巨噬细胞吞噬纤维素样坏死物质后形成</td> </tr> </tbody> </table> <p><code>2015N48A风湿小结内的阿绍夫细胞来源于</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.T淋巴细胞 </span></span><span class="line"><span class="cl">B.B淋巴细胞 </span></span><span class="line"><span class="cl">C.巨噬细胞 </span></span><span class="line"><span class="cl">D.成纤维细胞 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030风湿的各器官病理变化font"><font color=#ff3030><strong>风湿的各器官病理变化</strong></font></h2> <h3 id="font-colorff3030-风湿性心脏病font"><font color=#ff3030 ><strong>风湿性心脏病</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">风湿性心内膜炎</th> <th style="text-align:center">风湿性心肌炎</th> <th style="text-align:center">风湿性心外膜炎</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>部位</strong></td> <td style="text-align:center">二尖瓣最常见</td> <td style="text-align:center"><font color=#eeee00><strong>心肌间质</strong></font>结缔组织</td> <td style="text-align:center">心外膜脏层（心包）</td> </tr> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center">瓣膜<font color=#eeee00><strong>疣状赘生物</strong></font></td> <td style="text-align:center">间质血管附近<font color=#eeee00><strong>Aschoff小体</strong></font></td> <td style="text-align:center">浆液或纤维素样渗出</td> </tr> <tr> <td style="text-align:center"><strong>其他病变</strong></td> <td style="text-align:center">瓣膜（主要是二尖瓣或二尖瓣主动脉瓣同时受累）肿胀变性，赘生物纤维素样坏死，<font color=#eeee00><strong>左心房后壁增厚，称McCallum斑</strong></font></td> <td style="text-align:center">少量淋巴细胞浸润</td> <td style="text-align:center">心外膜脏层浆液性炎或纤维素性炎；前者可致心包积液，后者致绒毛心、缩窄性心外膜炎</td> </tr> </tbody> </table> <p><code>1992N32A关于风湿病的描述，哪一项是错误的</code> C<font color=#1e90ff><strong>¹</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.风湿性心内膜炎最常累及二尖瓣和主动脉瓣 </span></span><span class="line"><span class="cl">B.心内膜炎疣状赘生物不易脱落 </span></span><span class="line"><span class="cl">C.风湿性心肌炎可导致心肌广泛纤维化 </span></span><span class="line"><span class="cl">D.风湿性心外膜炎可导致心包粘连 </span></span><span class="line"><span class="cl">E.风湿性关节炎不会导致关节畸形 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>¹答案有争议</strong></font>：<font color=#ff3030><strong>风湿性心肌炎</strong></font>反复发作时，<font color=#40e0d0><strong>心肌间质</strong></font>中的<font color=#40e0d0><strong>Aschoff小体</strong></font>纤维化形成梭形瘢痕，可导致<font color=#ff3030><strong>心肌纤维化</strong></font>，故C项正确。 对此老贺的解释是：<font color=#ff3030><strong>风湿性心肌炎</strong></font>导致的是<font color=#ff3030><strong>心肌间质纤维化</strong></font>而非<font color=#ff3030><strong>心肌纤维化</strong></font>。 区别在于：<font color=#ff3030><strong>心肌纤维化</strong></font>强调的是<font color=#40e0d0><strong>间质结缔组织</strong></font>纤维化，作为<font color=#40e0d0><strong>心肌实质</strong></font>的心肌细胞不受累；而<font color=#ff3030><strong>心肌纤维化</strong></font>强调的是<font color=#40e0d0><strong>心肌实质</strong></font>细胞坏死并发<font color=#40e0d0><strong>间质结缔组织</strong></font>增生纤维化，例如<font color=#ff3030><strong>心梗</strong></font>。 贺门！</p> </blockquote> <h3 id="风湿性关节炎">风湿性关节炎</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">风湿性关节炎</th> <th style="text-align:center">类风湿性关节炎</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>起病</strong></td> <td style="text-align:center">亚急性</td> <td style="text-align:center">缓慢</td> </tr> <tr> <td style="text-align:center"><strong>累及</strong></td> <td style="text-align:center">膝、肩、腕、肘关节</td> <td style="text-align:center">腕、掌指关节、近端指间关节</td> </tr> <tr> <td style="text-align:center"><strong>病变</strong></td> <td style="text-align:center">滑膜充血、肿胀</td> <td style="text-align:center">滑膜炎性渗出、滑膜下血管扩张</td> </tr> <tr> <td style="text-align:center"><strong>渗出</strong></td> <td style="text-align:center"><font color=#eeee00><strong>浆液和纤维素</strong></font>渗出、易吸收</td> <td style="text-align:center"><font color=#eeee00><strong>纤维素</strong></font>渗出、不易吸收</td> </tr> <tr> <td style="text-align:center"><strong>畸形</strong></td> <td style="text-align:center"><font color=#eeee00><strong>不留关节畸形</strong></font></td> <td style="text-align:center"><font color=#eeee00><strong>遗留关节畸形</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center">游走性疼痛，反复发作</td> <td style="text-align:center">对称性持续关节痛，时轻时重</td> </tr> </tbody> </table> <p><code>2017N126B急性蜂窝织炎性阑尾炎的病理特点</code> A</p> <p><code>2017N127B风湿性关节炎的病理特点</code> C<font color=#1e90ff><strong>²</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.化脓性炎 </span></span><span class="line"><span class="cl">B.纤维素性炎 </span></span><span class="line"><span class="cl">C.浆液性炎 </span></span><span class="line"><span class="cl">D.变质性炎 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>²答案有争议</strong></font>:在5版病理学教材中明确指出<font color=ff3030><strong>风湿性关节炎</strong></font>是<font color=#bdfcc9><strong>浆液性炎</strong></font>，而在9版教材中则定性为<font color=#bdfcc9><strong>浆液及纤维素渗出</strong></font>，故此题无解。</p> </blockquote> <p><img src="https://fallen.wang/p/cardiovascular/arthritis.png" width="807" height="176" srcset="https://fallen.wang/p/cardiovascular/arthritis_huad691159818adbb792edcd544e9a0ee4_121181_480x0_resize_box_3.png 480w, https://fallen.wang/p/cardiovascular/arthritis_huad691159818adbb792edcd544e9a0ee4_121181_1024x0_resize_box_3.png 1024w" loading="lazy" alt="9版病理P169" class="gallery-image" data-flex-grow="458" data-flex-basis="1100px" > <code>1998N41A下列有关风湿病的描述，哪项是错误的</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.可引起缩窄性心包炎 </span></span><span class="line"><span class="cl">B.风湿性关节炎是纤维素性炎 </span></span><span class="line"><span class="cl">C.风湿性肉芽肿具有诊断意义 </span></span><span class="line"><span class="cl">D.Aschoff细胞可能为巨噬细胞源性 </span></span><span class="line"><span class="cl">E.Aschoff小体内淋巴细胞主要是T细胞 </span></span></code></pre></td></tr></table> </div> </div><p><code>2018N34A下列对风湿热的描述，错误的是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.属于变态反应性疾病 </span></span><span class="line"><span class="cl">B.发病与溶血性链球菌感染有关 </span></span><span class="line"><span class="cl">C.常可导致关节畸形 </span></span><span class="line"><span class="cl">D.心脏病变对人体危害最大 </span></span></code></pre></td></tr></table> </div> </div><h4 id="皮肤病变具有诊断意义">皮肤病变（具有诊断意义</h4> <table> <thead> <tr> <th></th> <th style="text-align:center">临床特点</th> <th>性质</th> </tr> </thead> <tbody> <tr> <td><strong>环形红斑</strong></td> <td style="text-align:center">多见于躯干和四肢皮肤，好发于儿童，1~2天消退</td> <td>渗出性病变</td> </tr> <tr> <td><strong>皮下结节</strong></td> <td style="text-align:center">多见于关节伸侧面皮下结缔组织，镜下见结节中心为大片<font color=#eeee00><strong>纤维素样坏死物</strong></font>，Aschoff细胞放射状排列，淋巴细胞浸润</td> <td>增生性病变</td> </tr> </tbody> </table> <p><code>2016N168X在风湿热病变中，可以出现Aschoff小体的有</code> ABC<font color=#1e90ff><strong>³</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.风湿性心肌炎 </span></span><span class="line"><span class="cl">B.风湿性动脉炎 </span></span><span class="line"><span class="cl">C.皮下结节 </span></span><span class="line"><span class="cl">D.环形红斑 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>³9版教材无相关表述</strong></font>：在5版病理学教材中，<font color=#ff3030><strong>环形红斑</strong></font>具有诊断意义，镜下为<font color=#bdfcc9><strong>非特异炎</strong></font>，无<font color=#40e0d0><strong>Aschoff小体</strong></font>形成。</p> </blockquote> <h3 id="风湿性脑病">风湿性脑病</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center"></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发于</strong></td> <td style="text-align:center">5~12岁儿童，女孩多见</td> </tr> <tr> <td style="text-align:center"><strong>主要病变</strong></td> <td style="text-align:center">脑的风湿性动脉炎、皮质下脑炎</td> </tr> <tr> <td style="text-align:center"><strong>小舞蹈症</strong></td> <td style="text-align:center">锥体外系受累时，出现肢体不自主运动</td> </tr> </tbody> </table> <p><code>1997N74A哪项急性风湿病伴发心脏炎的几率最低</code> C<font color=#1e90ff><strong>⁴</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.关节炎 </span></span><span class="line"><span class="cl">B.皮下结节 </span></span><span class="line"><span class="cl">C.舞蹈病 </span></span><span class="line"><span class="cl">D.环形红斑 </span></span><span class="line"><span class="cl">E.血管炎 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁴9版教材无相关表述</strong></font>：1~9版教材均无相关表述。</p> </blockquote> <hr> <h1 id="font-colorff3030-感染性心内膜炎font"><font color=#ff3030 ><strong>感染性心内膜炎</strong></font></h1> <h2 id="分类">分类</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td>感染性心内膜炎是病原微生物经血直接侵袭心内膜特别是<font color=#eeee00 ><strong>心瓣膜</strong></font>而引起的炎症性疾病，常伴<font color=#eeee00 ><strong>赘生物</strong></font>形成</td> </tr> <tr> <td style="text-align:center"><strong>根据病情分类</strong></td> <td>急性感染性心内膜炎、亚急性感染性心内膜炎</td> </tr> <tr> <td style="text-align:center"><strong>根据瓣膜类型分类</strong></td> <td>自体瓣膜心内膜炎、人工瓣膜心内膜炎</td> </tr> </tbody> </table> <h2 id="病因-1">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center"></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>自体瓣膜型</strong></td> <td style="text-align:center">急性：<font color=#eeee00 ><strong>金葡菌</strong></font>最多见，亦有肺炎球菌、流感杆菌、淋球菌；亚急性：<font color=#eeee00 ><strong>草绿色葡萄球菌</strong></font>最多见，亦有肠球菌</td> </tr> <tr> <td style="text-align:center"><strong>人工瓣膜型</strong></td> <td style="text-align:center">早期：手术感染，多为表皮葡萄球菌、金葡菌；晚期：一过性菌血症所致，多为金葡菌（50%）</td> </tr> </tbody> </table> <h2 id="发病机制-1">发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center"></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>赘生物形成</strong></td> <td style="text-align:center">血流形成涡流，病原菌沉积生长，受血流冲击处内膜损伤，形成赘生物</td> </tr> <tr> <td style="text-align:center"><strong>赘生物导致的并发症</strong></td> <td style="text-align:center">病原体在赘生物中繁殖引起菌血症；赘生物脱离，可致外周血管阻塞，形成转移性脓肿；赘生物可致瓣膜穿孔破裂、心肌脓肿</td> </tr> <tr> <td style="text-align:center"><strong>反复感染</strong></td> <td style="text-align:center">激活免疫系统引起变态反应炎症</td> </tr> </tbody> </table> <h2 id="font-colorff3030病理变化font"><font color=#ff3030><strong>病理变化</strong></font></h2> <h3 id="font-colorff3030急性感染性心内膜炎font"><font color=#ff3030><strong>急性感染性心内膜炎</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>脓毒血症</strong></td> <td style="text-align:center">病原体感染，若抵抗力降低，细菌入血引起脓毒血症</td> </tr> <tr> <td style="text-align:center"><strong>赘生物</strong></td> <td style="text-align:center">由脓性渗出物、血栓、坏死组织等组成，侵犯<font color=#eeee00 ><strong>二尖瓣、主动脉瓣</strong></font><font color=#1e90ff><strong>⁵</strong></font>，引起<font color=#eeee00 ><strong>急性化脓性心瓣膜炎</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>并发症</strong></td> <td style="text-align:center">赘生物脱落可引起心脑肾脾感染性梗死和脓肿</td> </tr> </tbody> </table> <blockquote> <p><font color=#1e90ff><strong>⁵教材相互矛盾</strong></font>：按病理学教材观点，应为<font color=#40e0d0><strong>二尖瓣</strong></font>；按内科学教材观点，应为<font color=#40e0d0><strong>主动脉瓣</strong></font>。699不考内科，若遇到A型题则选<font color=#40e0d0><strong>二尖瓣</strong></font>，遇到X型题则两个都选。</p> </blockquote> <h3 id="font-colorff3030亚急性感染性心内膜炎font"><font color=#ff3030><strong>亚急性感染性心内膜炎</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>心脏</strong></td> <td style="text-align:center">常侵犯<font color=#eeee00 ><strong>二尖瓣、主动脉瓣</strong></font>，瓣膜上形成赘生物，可致狭窄、关闭不全等</td> </tr> <tr> <td style="text-align:center"><strong>血管</strong></td> <td style="text-align:center">赘生物脱落可致动脉性栓塞，<font color=#eeee00><strong>脑栓塞</strong></font>多见；由于栓子含菌极少，常为<font color=#eeee00><strong>无菌性梗死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>变态反应</strong></td> <td style="text-align:center">微栓塞可致局灶性或弥漫性肾炎，皮肤出现<font color=#eeee00><strong>Osler小结</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>败血症</strong></td> <td style="text-align:center">脱落赘生物中的细菌侵入血流并在其中繁殖</td> </tr> </tbody> </table> <p><code>2004N137X亚急性感染性心内膜炎可引起</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.心瓣膜变形 </span></span><span class="line"><span class="cl">B.局灶性肾小球肾炎 </span></span><span class="line"><span class="cl">C.无菌性坏死 </span></span><span class="line"><span class="cl">D.Osler小结 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030三种心内膜炎的比较font"><font color=#ff3030><strong>三种心内膜炎的比较</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">风湿性心内膜炎</th> <th style="text-align:center">急性感染性心内膜炎</th> <th style="text-align:center">亚急性感染性心内膜炎</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>别名</strong></td> <td style="text-align:center">疣状心内膜炎</td> <td style="text-align:center">急性细菌性心内膜炎</td> <td style="text-align:center">亚急性细菌性心内膜炎</td> </tr> <tr> <td style="text-align:center"><strong>致病菌</strong></td> <td style="text-align:center"><font color=#eeee00 ><strong>A组溶血链球菌</strong></font></td> <td style="text-align:center"><font color=#eeee00 ><strong>金葡菌</strong></font></td> <td style="text-align:center"><font color=#eeee00 ><strong>草绿色链球菌</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>受累部位</strong></td> <td style="text-align:center">二尖瓣&gt;二尖瓣+主动脉瓣</td> <td style="text-align:center">二尖瓣+主动脉瓣</td> <td style="text-align:center">二尖瓣+主动脉瓣</td> </tr> <tr> <td style="text-align:center"><strong>赘生物</strong></td> <td style="text-align:center">位于瓣膜闭锁缘上，细小灰白色，主要成分为血小板和纤维素，<font color=#eeee00 ><strong>不易脱落</strong></font>，不含细菌</td> <td style="text-align:center">位于瓣膜表面，体积庞大灰黄或浅绿色，主要成分为脓性渗出物、血栓、坏死组织和菌落，<font color=#eeee00 ><strong>最易脱落</strong></font>形成菌栓，含菌</td> <td style="text-align:center">位于瓣膜上，息肉状或菜花状，主要成分为血小板、纤维素、中性粒细胞和坏死组织，<font color=#eeee00 ><strong>较易破碎脱落</strong></font>，不含或含极少细菌</td> </tr> </tbody> </table> <p><code>2006N117B风湿性心内膜炎的发生</code> C</p> <p><code>2006N118B亚急性细菌性心内膜炎的发生</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.由致病力强的化脓菌引起 </span></span><span class="line"><span class="cl">B.由致病力弱的草绿色链球菌引起 </span></span><span class="line"><span class="cl">C.与A组乙型溶血链球菌有关 </span></span><span class="line"><span class="cl">D.与系统性红斑狼疮有关 </span></span><span class="line"><span class="cl">E.与慢性消耗性疾病有关 </span></span></code></pre></td></tr></table> </div> </div><p><code>2009N55A风湿病时，心内膜疣状赘生物属于</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.白色血栓 </span></span><span class="line"><span class="cl">B.红色血栓 </span></span><span class="line"><span class="cl">C.混合血栓 </span></span><span class="line"><span class="cl">D.透明血栓 </span></span></code></pre></td></tr></table> </div> </div><p><img src="https://fallen.wang/p/cardiovascular/thrombus.png" width="769" height="355" srcset="https://fallen.wang/p/cardiovascular/thrombus_hu5ca7de6918414d888e31a80496668ba9_211103_480x0_resize_box_3.png 480w, https://fallen.wang/p/cardiovascular/thrombus_hu5ca7de6918414d888e31a80496668ba9_211103_1024x0_resize_box_3.png 1024w" loading="lazy" alt="血栓" class="gallery-image" data-flex-grow="216" data-flex-basis="519px" ></p> <p><code>2010N47A风湿性心内膜炎时，心瓣膜疣状赘生物的主要成分是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.细菌菌落和炎症细胞 </span></span><span class="line"><span class="cl">B.血小板和纤维素 </span></span><span class="line"><span class="cl">C.肉芽组织和瘢痕 </span></span><span class="line"><span class="cl">D.小血管和风湿肉芽肿 </span></span></code></pre></td></tr></table> </div> </div><p><code>2016N135B急性风湿性心内膜炎二尖瓣上的血栓主要成分是</code> A<font color=#1e90ff><strong>⁶</strong></font></p> <p><code>2016N136B弥漫性毛细血管内凝血时血栓的主要成分是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.血小板凝块 </span></span><span class="line"><span class="cl">B.红细胞凝块 </span></span><span class="line"><span class="cl">C.纤维蛋白凝块 </span></span><span class="line"><span class="cl">D.血小板和纤维蛋白相间的凝块 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁶注意题干</strong></font>：若没有<strong>主要</strong>二字，则选D。</p> </blockquote> <hr> <h1 id="心瓣膜病">心瓣膜病</h1> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">病因</th> <th style="text-align:center">血流动力学</th> <th style="text-align:center">临床表现</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>二狭</strong></td> <td style="text-align:center">风湿性心内膜炎，感染性心内膜炎</td> <td style="text-align:center">左房大→左房衰竭→右室大→右心衰</td> <td style="text-align:center">体循环淤血、<font color=#eeee00 ><strong>梨形心</strong></font><font color=#1e90ff><strong>⁷</strong></font>，心尖舒张期隆隆样杂音</td> </tr> <tr> <td style="text-align:center"><strong>二闭</strong></td> <td style="text-align:center">风湿性心内膜炎，亚急性心内膜炎</td> <td style="text-align:center">左心房大→左房衰竭→左室大</td> <td style="text-align:center"><font color=#eeee00 ><strong>球形心</strong></font>，心尖收缩期吹风样杂音</td> </tr> <tr> <td style="text-align:center"><strong>主狭</strong></td> <td style="text-align:center">风湿性主动脉炎，AS所致瓣膜钙化</td> <td style="text-align:center">左室大→左室衰竭→右心衰竭</td> <td style="text-align:center">肺淤血→体循环淤血，<font color=#eeee00 ><strong>靴型心</strong></font>，主动脉瓣区SM</td> </tr> <tr> <td style="text-align:center"><strong>主闭</strong></td> <td style="text-align:center">风湿性主动脉炎，感染性心内膜炎，AS</td> <td style="text-align:center">左室衰竭→肺动脉高压→右心衰竭</td> <td style="text-align:center">主动脉瓣舒张期杂音，周围血管征</td> </tr> </tbody> </table> <blockquote> <p><font color=#1e90ff><strong>⁷梨形心</strong></font>：<font color=#ff3030><strong>左心房肥大</strong></font>，晚期<font color=#ff3030><strong>左心室废用性萎缩</strong></font>，但是一般不致坏死。见<code>1998N42A下列哪种疾病一般不致左室壁肌坏死</code>正确答案为<code>二尖瓣狭窄</code>。</p> </blockquote> <p><code>2003N44A引起水冲脉的是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.二尖瓣关闭不全 </span></span><span class="line"><span class="cl">B.三尖瓣关闭不全 </span></span><span class="line"><span class="cl">C.主动脉瓣关闭不全 </span></span><span class="line"><span class="cl">D.二尖瓣狭窄 </span></span><span class="line"><span class="cl">E.主动脉瓣狭窄 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="font-colorff3030高血压病font"><font color=#ff3030><strong>高血压病</strong></font></h1> <h2 id="发病机制-2">发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>遗传</strong></td> <td style="text-align:center">分单基因和多基因遗传两种</td> </tr> <tr> <td style="text-align:center"><strong>RAAS</strong></td> <td style="text-align:center">Ang II是高血压发病<font color=#eeee00 ><strong>中心环节</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>交感神经系统</strong></td> <td style="text-align:center">NA激动β₁受体，致心率上升，心肌收缩力增加，心输出量增加，血压升高</td> </tr> <tr> <td style="text-align:center"><strong>血管内皮功能紊乱</strong></td> <td style="text-align:center">表现为内皮NO水平下降；局部RAAS过度激活；类花生四烯酸物质代谢异常</td> </tr> <tr> <td style="text-align:center"><strong>胰岛素抵抗</strong></td> <td style="text-align:center">高胰岛素可致钠水潴留，血容量增加；内皮素与NO失衡；增加交感活性，提高RAAS兴奋性；NA⁺-K⁺-ATP酶和Ca²⁺-ATP酶活性降低，促进SMC增生迁移</td> </tr> <tr> <td style="text-align:center"><strong>血管重构</strong></td> <td style="text-align:center">壁腔比值变化和微血管减少</td> </tr> </tbody> </table> <h2 id="良性高血压">良性高血压</h2> <h3 id="功能紊乱期">功能紊乱期</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center"></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病理改变</strong></td> <td style="text-align:center">全身细小动脉间歇性痉挛收缩，无器质性病变</td> </tr> <tr> <td style="text-align:center"><strong>临床表现</strong></td> <td style="text-align:center">无明显症状，波动性血压升高经休息治疗可恢复正常</td> </tr> </tbody> </table> <h3 id="动脉病变期">动脉病变期</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>细动脉硬化</strong></td> <td style="text-align:center">是<font color=#eeee00 ><strong>主要病变特征</strong></font>，表现为<font color=#eeee00 ><strong>细小动脉玻璃样变</strong></font>，主要累及肾入球小动脉等</td> </tr> <tr> <td style="text-align:center"><strong>小动脉硬化</strong></td> <td style="text-align:center">主要累及肌型小动脉如肾小叶间动脉、弓状动脉、脑部小动脉等</td> </tr> <tr> <td style="text-align:center"><strong>大动脉硬化</strong></td> <td style="text-align:center">弹力肌型或弹力型大动脉无明显改变，或并发AS</td> </tr> </tbody> </table> <h3 id="内脏病变期">内脏病变期</h3> <h4 id="心脏病变">心脏病变</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病变</strong></td> <td style="text-align:center">左室代偿性肺大，心室壁增厚</td> </tr> <tr> <td style="text-align:center"><strong>早期</strong></td> <td style="text-align:center">向心性肥大，室壁增厚，心腔缩小</td> </tr> <tr> <td style="text-align:center"><strong>晚期</strong></td> <td style="text-align:center">离心性肥大，室壁增厚，心腔扩大</td> </tr> </tbody> </table> <h4 id="脑病变">脑病变</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">脑水肿或高血压脑病</th> <th style="text-align:center">脑软化</th> <th style="text-align:center">脑出血（最严重并发症）</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病因</strong></td> <td style="text-align:center">脑小动脉硬化和痉挛</td> <td style="text-align:center">细小动脉病变致供血区脑组织缺血</td> <td style="text-align:center">细小动脉硬化致血管壁变脆</td> </tr> <tr> <td style="text-align:center"><strong>病理</strong></td> <td style="text-align:center">局部缺血、毛细血管通透性增高，致脑水肿，可发生高血压危象</td> <td style="text-align:center">缺血致微梗死灶</td> <td style="text-align:center">颅内高压，脑疝</td> </tr> <tr> <td style="text-align:center"><strong>部位</strong></td> <td style="text-align:center">不定</td> <td style="text-align:center">脑皮质、白质、丘脑</td> <td style="text-align:center">基底节、内囊最常见</td> </tr> <tr> <td style="text-align:center"><strong>临床表现</strong></td> <td style="text-align:center">颅内压升高三主征</td> <td style="text-align:center">依软化灶大小而定</td> <td style="text-align:center">颅内压升高三主征、偏瘫</td> </tr> </tbody> </table> <p><code>1996N41A下述有关脑血压病不正确的是</code> E</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.脑内可有小软化灶形成 </span></span><span class="line"><span class="cl">B.脑内可有微小动脉瘤形成 </span></span><span class="line"><span class="cl">C.脑出血是常见死因 </span></span><span class="line"><span class="cl">D.基底节、内囊是出血的常见部位 </span></span><span class="line"><span class="cl">E.脑动脉栓塞常见 </span></span></code></pre></td></tr></table> </div> </div><h4 id="肾病变">肾病变</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center">入球动脉玻璃样变、肌型小动脉硬化使得肾小球纤维化，肾小管缺血萎缩，周围肾小球肾小管代偿性肥大，称<font color=#eeee00><strong>原发性颗粒性固缩肾</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">双侧肾脏对称性缩小，质硬，表面凹凸不平</td> </tr> </tbody> </table> <p><code>2006N43A引起原发性颗粒性固缩肾的主要病变是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.部分肾小球纤维化 </span></span><span class="line"><span class="cl">B.肾间质纤维组织增生 </span></span><span class="line"><span class="cl">C.肾间质淋巴细胞浸润 </span></span><span class="line"><span class="cl">D.入球小动脉玻璃样变性 </span></span><span class="line"><span class="cl">E.部分肾小球代偿性肥大 </span></span></code></pre></td></tr></table> </div> </div><p><code>1997N37A下列描述哪一项不符合高血压病理变化</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.细小动脉硬化 </span></span><span class="line"><span class="cl">B.左心室肥大 </span></span><span class="line"><span class="cl">C.肾脏大瘢痕性萎缩 </span></span><span class="line"><span class="cl">D.脑出血 </span></span><span class="line"><span class="cl">E.视乳头水肿出血 </span></span></code></pre></td></tr></table> </div> </div><h2 id="恶性高血压">恶性高血压</h2> <h3 id="特征病变">特征病变</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>增生细小动脉硬化</strong></td> <td style="text-align:center">表现为动脉内膜显著增厚，SMC增生，管腔狭窄</td> </tr> <tr> <td style="text-align:center"><strong>坏死性细动脉炎</strong></td> <td style="text-align:center">常累及动脉内膜和中膜，发生<font color=#eeee00><strong>纤维素样坏死</strong></font>，周围有单核、中性粒细胞浸润</td> </tr> </tbody> </table> <h3 id="小动脉病变">小动脉病变</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肾</strong></td> <td style="text-align:center">最常累及<font color=#eeee00><strong>入球小动脉</strong></font>，使肾小球毛细血管发生节段性坏死</td> </tr> <tr> <td style="text-align:center"><strong>大脑</strong></td> <td style="text-align:center">常引起局部脑组织缺血、微梗死形成、脑出血</td> </tr> </tbody> </table> <h3 id="font-colorff3030良性高血压和恶性高血压对比font"><font color=#ff3030><strong>良性高血压和恶性高血压对比</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">良性高血压</th> <th style="text-align:center">恶性高血压</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>别称</strong></td> <td style="text-align:center">缓进型高血压</td> <td style="text-align:center">急进型高血压</td> </tr> <tr> <td style="text-align:center"><strong>发病年龄</strong></td> <td style="text-align:center">30~40以上中老年</td> <td style="text-align:center">青少年</td> </tr> <tr> <td style="text-align:center"><strong>特征病变</strong></td> <td style="text-align:center"><font color=#eeee00><strong>细小动脉玻璃样变</strong></font></td> <td style="text-align:center"><font color=#eeee00><strong>细动脉纤维素样坏死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>累及</strong></td> <td style="text-align:center">全身细小动脉</td> <td style="text-align:center">肾细小动脉</td> </tr> <tr> <td style="text-align:center"><strong>肾衰发生</strong></td> <td style="text-align:center">晚</td> <td style="text-align:center">早</td> </tr> <tr> <td style="text-align:center"><strong>主要死因</strong></td> <td style="text-align:center">脑血管意外</td> <td style="text-align:center">急性肾衰竭</td> </tr> </tbody> </table> <p><code>2009N135B良性高血压的基本病变是</code> A</p> <p><code>2009N136B恶性高血压的基本病变是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.细动脉玻璃样变性 </span></span><span class="line"><span class="cl">B.细动脉纤维化 </span></span><span class="line"><span class="cl">C.细动脉淀粉样变性 </span></span><span class="line"><span class="cl">D.细动脉纤维素样坏死 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="font-colorff3030动脉粥样硬化font"><font color=#ff3030><strong>动脉粥样硬化</strong></font></h1> <h2 id="定义">定义</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>动脉粥样硬化</strong></td> <td style="text-align:center">以血管内膜形成<font color=#eeee00><strong>粥瘤</strong></font>或<font color=#eeee00><strong>纤维斑块</strong></font>为特征，主要累及大中动脉，致管壁变硬管腔狭窄及器官缺血性病变</td> </tr> <tr> <td style="text-align:center"><strong>大动脉</strong></td> <td style="text-align:center">弹力性动脉，指主动脉及其一级分支</td> </tr> <tr> <td style="text-align:center"><strong>中动脉</strong></td> <td style="text-align:center">弹力肌型动脉，如冠状动脉、脑动脉</td> </tr> </tbody> </table> <p><code>2016N49A动脉粥样硬化对人体伤害最大的动脉类型是</code> B<font color=#1e90ff><strong>⁸</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大动脉 </span></span><span class="line"><span class="cl">B.中动脉 </span></span><span class="line"><span class="cl">C.小动脉 </span></span><span class="line"><span class="cl">D.细动脉 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁸动脉类型</strong></font>：大动脉（如主动脉等）<font color=#ff3030><strong>粥样硬化</strong></font>一般症状不明显。</p> </blockquote> <h2 id="病因-2">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>高脂血症</strong></td> <td style="text-align:center">氧化低密度脂蛋白<font color=#eeee00><strong>ox-LDL</strong></font>是最重要的致粥样硬化因子，也是致内皮细胞和SMC损伤的主要因子</td> </tr> <tr> <td style="text-align:center"><strong>高血压</strong></td> <td style="text-align:center">致血管内皮损伤，脂质通透性增加单核细胞和血小板黏附迁入内膜，中膜SMC迁入内膜</td> </tr> <tr> <td style="text-align:center"><strong>吸烟</strong></td> <td style="text-align:center">CO致血管内皮细胞缺氧损伤，促LDL氧化</td> </tr> <tr> <td style="text-align:center"><strong>致继发性高血脂症的疾病</strong></td> <td style="text-align:center">糖尿病高血糖促LDL氧化；高胰岛素血症促SMC增生；甲减和肾综可致高胆固醇血症，LDL水平升高</td> </tr> <tr> <td style="text-align:center"><strong>遗传</strong></td> <td style="text-align:center">家族聚集现象</td> </tr> <tr> <td style="text-align:center"><strong>性别和年龄</strong></td> <td style="text-align:center">雌激素可改善血管内皮功能</td> </tr> <tr> <td style="text-align:center"><strong>代谢综合征</strong></td> <td style="text-align:center">导致严重心血管事件</td> </tr> </tbody> </table> <p><code>1996N42A下列哪项不属于动脉粥样硬化的危险因素</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.高胆固醇血症 </span></span><span class="line"><span class="cl">B.甲亢 </span></span><span class="line"><span class="cl">C.糖尿病 </span></span><span class="line"><span class="cl">D.吸烟 </span></span><span class="line"><span class="cl">E.高血压 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030发病机制font"><font color=#ff3030><strong>发病机制</strong></font></h2> <h3 id="脂质渗入学说">脂质渗入学说</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>学说</strong></td> <td style="text-align:center"><font color=#eeee00><strong>胆固醇、胆固醇酯</strong></font>沉积于内膜，引起结缔组织增生，使动脉壁增厚变硬，结缔组织坏死形成粥样硬化</td> </tr> <tr> <td style="text-align:center"><strong>LDL</strong></td> <td style="text-align:center">LDL易穿透动脉内膜，具有很强的致粥样硬化作用；LDL抗氧化作用弱，进入粥斑后致粥样硬化作用更明显</td> </tr> </tbody> </table> <h3 id="font-colorff3030内皮损伤学说font"><Font color=#ff3030><strong>内皮损伤学说</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>内皮损伤</strong></td> <td style="text-align:center">机械损伤、<font color=#eeee00><strong>ox-LDL</strong></font>等使内皮损伤通透性增加</td> </tr> <tr> <td style="text-align:center"><strong>单核细胞</strong></td> <td style="text-align:center">受损内皮细胞分泌细胞因子吸引单核细胞聚集并摄取ox-LDL生成单核细胞源性泡沫细胞</td> </tr> <tr> <td style="text-align:center"><strong>SMC</strong></td> <td style="text-align:center">受损内皮细胞分泌细胞因子促进SMC向内膜迁移，吞噬ox-LDL成为SMC源性泡沫细胞</td> </tr> </tbody> </table> <p><code>2007N43A在动脉粥样硬化的发病机制中，粥斑形成的首要条件是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.慢性、反复的血管内皮细胞损伤 </span></span><span class="line"><span class="cl">B.血脂的沉积及其氧化作用 </span></span><span class="line"><span class="cl">C.炎症细胞的渗出 </span></span><span class="line"><span class="cl">D.平滑肌细胞反应 </span></span></code></pre></td></tr></table> </div> </div><p><code>2015N50A早期动脉粥样硬化的主要病变细胞是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.平滑肌细胞 </span></span><span class="line"><span class="cl">B.泡沫细胞 </span></span><span class="line"><span class="cl">C.成纤维细胞 </span></span><span class="line"><span class="cl">D.内皮细胞 </span></span></code></pre></td></tr></table> </div> </div><p><code>2012N166X在动脉粥样硬化早期病变中泡沫细胞的来源</code> BC</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.内皮细胞 </span></span><span class="line"><span class="cl">B.平滑肌细胞 </span></span><span class="line"><span class="cl">C.巨噬细胞 </span></span><span class="line"><span class="cl">D.成纤维细胞 </span></span></code></pre></td></tr></table> </div> </div><h3 id="font-colorff3030动脉平滑肌细胞的作用font"><font color=#ff3030><strong>动脉平滑肌细胞的作用</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>SMC</strong></td> <td style="text-align:center">动脉中膜SMC迁入内膜增生是AS进展期重要环节，SMC可摄取ox-LDL成为<font color=#eeee00><strong>肌源性泡沫细胞</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>病变进展</strong></td> <td style="text-align:center">增生的SMC可合成细胞外基质使内膜增厚，促进粥斑形成</td> </tr> </tbody> </table> <h3 id="慢性炎症学说">慢性炎症学说</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>慢性炎症</strong></td> <td style="text-align:center">致内皮细胞损伤，促进泡沫细胞生成</td> </tr> <tr> <td style="text-align:center"><strong>CRP</strong></td> <td style="text-align:center">高敏C反应蛋白可抑制内皮细胞产生NO，促进巨噬细胞吞噬ox-LDL，促进SMC增生</td> </tr> </tbody> </table> <p><code>1997N103B动脉粥样硬化可见</code> D</p> <p><code>1997N104B乙型脑炎可见</code> E</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.阿绍夫细胞 </span></span><span class="line"><span class="cl">B.陷窝细胞 </span></span><span class="line"><span class="cl">C.类上皮细胞 </span></span><span class="line"><span class="cl">D.泡沫细胞 </span></span><span class="line"><span class="cl">E.噬神经细胞现象 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030基本病理变化font-1"><font color=ff3030><strong>基本病理变化</strong></font></h2> <h3 id="font-colorff3030脂纹纤维斑块和粥斑font"><font color=ff3030><strong>脂纹、纤维斑块和粥斑</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>脂纹</strong></td> <td style="text-align:center"><font color=eeee00><strong>最早</strong></font>肉眼病变，位于主动脉<font color=#eeee00><strong>后壁</strong></font>及分支开口处，镜下见大量泡沫细胞</td> </tr> <tr> <td style="text-align:center"><strong>纤维斑块</strong></td> <td style="text-align:center">由脂纹发展而来，镜下见大量胶原纤维玻璃样变，SMC增生并分泌细胞外基质形成<font color=#eeee00><strong>纤维帽</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>粥斑</strong></td> <td style="text-align:center">也叫粥瘤，有纤维斑块深层细胞坏死发展而来，是AS<font color=#eeee00><strong>典型病变</strong></font></td> </tr> </tbody> </table> <h3 id="继发性病变">继发性病变</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">形成原因</th> <th style="text-align:center">后果</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>斑块内出血</strong></td> <td style="text-align:center">斑块内新生血管破裂形成血肿</td> <td style="text-align:center">管腔狭窄</td> </tr> <tr> <td style="text-align:center"><strong>斑块破裂</strong></td> <td style="text-align:center">纤维帽破裂粥样物质自裂口逸入血流</td> <td style="text-align:center">形成胆固醇栓子</td> </tr> <tr> <td style="text-align:center"><strong>血栓形成</strong></td> <td style="text-align:center">斑块破裂形成溃疡，胶原暴露</td> <td style="text-align:center">动脉栓塞或器官梗死</td> </tr> <tr> <td style="text-align:center"><strong>钙化</strong></td> <td style="text-align:center">纤维帽、粥瘤病灶内钙盐沉积</td> <td style="text-align:center">管壁变硬变脆</td> </tr> <tr> <td style="text-align:center"><strong>动脉瘤形成</strong></td> <td style="text-align:center">中膜平滑肌萎缩</td> <td style="text-align:center">动脉壁局限性扩张</td> </tr> <tr> <td style="text-align:center"><strong>血管腔狭窄</strong></td> <td style="text-align:center">弹力肌层粥斑</td> <td style="text-align:center">相应器官缺血</td> </tr> </tbody> </table> <p><code>2000N41A关于动脉粥样硬化的描述正确的是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.主动脉脂纹仅见于老年 </span></span><span class="line"><span class="cl">B.粥瘤内泡沫细胞均来自单核细胞 </span></span><span class="line"><span class="cl">C.脂纹以主动脉前壁多见 </span></span><span class="line"><span class="cl">D.氧化低密度脂蛋白具有细胞毒性 </span></span><span class="line"><span class="cl">E.粥瘤内胶原由纤维母细胞产生 </span></span></code></pre></td></tr></table> </div> </div><p><code>2004N38A造成动脉粥样硬化纤维增生的主要细胞是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.内皮细胞 </span></span><span class="line"><span class="cl">B.泡沫细胞 </span></span><span class="line"><span class="cl">C.平滑肌细胞 </span></span><span class="line"><span class="cl">D.纤维母细胞 </span></span><span class="line"><span class="cl">E.淋巴细胞 </span></span></code></pre></td></tr></table> </div> </div><p><code>2014N50A与粥斑表面纤维帽形成关系密切的细胞是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.平滑肌细胞 </span></span><span class="line"><span class="cl">B.内皮细胞 </span></span><span class="line"><span class="cl">C.成纤维细胞 </span></span><span class="line"><span class="cl">D.单核细胞 </span></span></code></pre></td></tr></table> </div> </div><p><code>1996N149X动脉粥样硬化斑块可发生</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.出血 </span></span><span class="line"><span class="cl">B.溃疡 </span></span><span class="line"><span class="cl">C.血栓形成 </span></span><span class="line"><span class="cl">D.动脉瘤 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030主要动脉的病理改变及后果font"><font color=#ff3030><strong>主要动脉的病理改变及后果</strong></font></h2> <h3 id="主动脉粥样硬化">主动脉粥样硬化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">主动脉<font color=#eeee00><strong>后壁</strong></font>及分支开口处，以腹主动脉病变最严重</td> </tr> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center">主动脉内膜出现各种AS病变</td> </tr> <tr> <td style="text-align:center"><strong>后果</strong></td> <td style="text-align:center">严重者可出现动脉瘤，可致致命性大出血</td> </tr> </tbody> </table> <h3 id="font-colorff3030冠状动脉粥样硬化font"><font color=#ff3030><strong>冠状动脉粥样硬化</strong></font></h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>冠脉粥样硬化</strong></td> <td style="text-align:center"><font color=#eeee00><strong>左前降支</strong></font>最多，其次是右主干，左主干，左旋支，后降支</td> </tr> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center">冠脉内发生各种AS病变</td> </tr> <tr> <td style="text-align:center"><strong>冠心病</strong></td> <td style="text-align:center">心绞痛；心肌梗死</td> </tr> </tbody> </table> <p><code>2005N44A冠脉粥样硬化发生率最高的部位是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.左主干 </span></span><span class="line"><span class="cl">B.左旋支 </span></span><span class="line"><span class="cl">C.左前降支 </span></span><span class="line"><span class="cl">D.右冠脉 </span></span><span class="line"><span class="cl">E.后降支 </span></span></code></pre></td></tr></table> </div> </div><p><code>2017N124B高血压常见的血管病变是</code> A</p> <p><code>2017N125B心肌梗死常见的冠状动脉病变是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.动脉玻璃样变 </span></span><span class="line"><span class="cl">B.动脉壁纤维素样变性 </span></span><span class="line"><span class="cl">C.动脉粥样硬化 </span></span><span class="line"><span class="cl">D.动脉中层钙化 </span></span></code></pre></td></tr></table> </div> </div><h4 id="心绞痛">心绞痛</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>稳定性心绞痛</strong></td> <td style="text-align:center">冠脉横切面见斑块阻塞管腔&gt;75%</td> </tr> <tr> <td style="text-align:center"><strong>不稳定性心绞痛</strong></td> <td style="text-align:center">多因粥斑破裂血栓形成所致</td> </tr> <tr> <td style="text-align:center"><strong>变异性心绞痛</strong></td> <td style="text-align:center">冠脉明显狭窄或发作性痉挛所致</td> </tr> </tbody> </table> <h4 id="心肌梗死">心肌梗死</h4> <h5 id="分类-1">分类</h5> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">心内膜下心肌梗死</th> <th style="text-align:center">透壁性心肌梗死</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">心室壁内层1/3心肌，可波及肉柱、乳头肌</td> <td style="text-align:center">左前降支供血区，左室前壁、心尖、室间隔前2/3</td> </tr> <tr> <td style="text-align:center"><strong>累及</strong></td> <td style="text-align:center">心内膜下，多发小灶坏死</td> <td style="text-align:center">心室壁2/3至全层，病灶较大</td> </tr> </tbody> </table> <h5 id="病理变化">病理变化</h5> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>梗死类型</strong></td> <td style="text-align:center"><font color=#eeee00><strong>贫血性梗死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">梗死6小时后才能辨认，梗死灶苍白色，8~9小时土黄色</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">早起心肌纤维<font color=#eeee00><strong>凝固性坏死</strong></font>，间质水肿，中性粒细胞浸润；4天后出现充血出血带；1~2周边缘出现<font color=#eeee00><strong>肉芽组织</strong></font>；3周后开始机化，逐渐形成瘢痕组织</td> </tr> </tbody> </table> <p><code>2019N124B心肌梗死的病理变化是</code> C</p> <p><code>2019N125B阿米巴肝脓肿的病理变化是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.坏疽 </span></span><span class="line"><span class="cl">B.液化性坏死 </span></span><span class="line"><span class="cl">C.凝固性坏死 </span></span><span class="line"><span class="cl">D.脂肪坏死 </span></span></code></pre></td></tr></table> </div> </div><p><code>2020N34A急性透壁性心肌梗死患者3周后死亡，解剖时梗死灶内的主要发现是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.心肌细胞出现核固缩 </span></span><span class="line"><span class="cl">B.心肌细胞出现核碎裂 </span></span><span class="line"><span class="cl">C.梗死灶周围肉芽组织形成 </span></span><span class="line"><span class="cl">D.大片纤维瘢痕 </span></span></code></pre></td></tr></table> </div> </div><h3 id="颈动脉粥样硬化">颈动脉粥样硬化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">颈动脉起始部</td> </tr> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center">纤维斑块、粥斑导致管腔狭窄甚至闭塞</td> </tr> </tbody> </table> <h3 id="脑动脉粥样硬化">脑动脉粥样硬化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">基底动脉、大脑中动脉、Willis环</td> </tr> <tr> <td style="text-align:center"><strong>脑萎缩</strong></td> <td style="text-align:center">AS是引起脑萎缩<font color=#eeee00><strong>最常见</strong></font>的原因，表现为皮质变薄，脑回变窄</td> </tr> <tr> <td style="text-align:center"><strong>脑梗死</strong></td> <td style="text-align:center">即<font color=#eeee00><strong>脑软化</strong></font>，主要发生在颞叶、内囊、豆状核和丘脑</td> </tr> <tr> <td style="text-align:center"><strong>脑出血</strong></td> <td style="text-align:center">AS致小动脉瘤，多见于Willis环起始部，血压突然升高可致小动脉瘤破裂出血</td> </tr> </tbody> </table> <p><code>1996N149X脑动脉粥样硬化时，脑组织可发生</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.萎缩 </span></span><span class="line"><span class="cl">B.软化 </span></span><span class="line"><span class="cl">C.梗死 </span></span><span class="line"><span class="cl">D.出血 </span></span></code></pre></td></tr></table> </div> </div><p><code>2019N37A脑动脉粥样硬化最常累及部位</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.小脑 </span></span><span class="line"><span class="cl">B.大脑基底核 </span></span><span class="line"><span class="cl">C.脑桥 </span></span><span class="line"><span class="cl">D.丘脑 </span></span></code></pre></td></tr></table> </div> </div><h3 id="肾动脉粥样硬化">肾动脉粥样硬化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">肾动脉开口处、主动脉近侧端</td> </tr> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center">斑块致肾动脉狭窄、肾缺血、实质萎缩间质纤维化、斑块合并血栓形成，<font color=#eeee00><strong>肾贫血性梗死</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>AS性固缩肾</strong></td> <td style="text-align:center">梗死灶机化后遗留较大凹陷瘢痕，多瘢痕可致肾缩小，称为AS性固缩肾</td> </tr> </tbody> </table> <hr> <h1 id="心肌病">心肌病</h1> <h2 id="概念及分类">概念及分类</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>概念</strong></td> <td style="text-align:center">除冠心病、高心病、心瓣膜病、先心病、肺心病以外，以心肌结构、功能异常为主要表现的一组疾病</td> </tr> <tr> <td style="text-align:center"><strong>分类</strong></td> <td style="text-align:center">扩张性心肌病；肥厚性心肌病；限制性心肌病；<font color=#eeee00><strong>克山病</strong></font>属于特异性心肌病</td> </tr> </tbody> </table> <p><code>2000N42A下列哪项符合原发性心肌病</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.炎症性心肌改变 </span></span><span class="line"><span class="cl">B.冠状动脉粥样硬化引起的心肌病变 </span></span><span class="line"><span class="cl">C.原因不明的代谢性心肌改变 </span></span><span class="line"><span class="cl">D.高血压引起的心肌病变 </span></span><span class="line"><span class="cl">E.甲亢引起的心肌病变 </span></span></code></pre></td></tr></table> </div> </div><h2 id="病理变化-1">病理变化</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">扩张性心肌病</th> <th style="text-align:center">肥厚性心肌病</th> <th style="text-align:center">限制性心肌病</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center"><font color=#eeee00><strong>心脏扩大为主</strong></font>，一定程度的心肌肥厚，可致<font color=#eeee00><strong>充血性心衰</strong></font></td> <td style="text-align:center"><font color=#eeee00><strong>非对称性室间隔肥厚</strong></font>，<font color=#eeee00><strong>左心室显著肥厚</strong></font>，左心室流出道受阻</td> <td style="text-align:center">单/双侧心室充盈受限，舒张期容量减少，心室<font color=#eeee00><strong>内膜下心肌纤维化</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>病因</strong></td> <td style="text-align:center">特发性、遗传性、获得性、继发性</td> <td style="text-align:center">50%家族史常染色体显性遗传</td> <td style="text-align:center">特发性，病因不明</td> </tr> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">心脏重量增加，两侧心腔扩张，心室壁略厚或正常（离心性肥大）心尖部室壁钝圆形</td> <td style="text-align:center">心脏重量增加，<font color=#eeee00><strong>两侧心室壁肥厚（室间隔肥厚突出）</strong></font>二尖瓣、主动脉瓣下内膜增厚</td> <td style="text-align:center">心腔狭窄，心内膜、内膜下纤维性增厚，可致<strong>三闭</strong>或<strong>二闭</strong></td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">心肌细胞<font color=#eeee00><strong>不均匀肥大</strong></font>，核大、浓染，间质纤维化、瘢痕灶</td> <td style="text-align:center">心肌细胞<font color=#eeee00><strong>弥漫性肥大</strong></font>，核大、深染，心肌纤维走行紊乱</td> <td style="text-align:center"><font color=#eeee00><strong>心内膜纤维化</strong></font>，内膜下心肌萎缩变性，附壁血栓形成</td> </tr> <tr> <td style="text-align:center"><strong>临表</strong></td> <td style="text-align:center"><font color=#eeee00><strong>充血性心衰</strong></font></td> <td style="text-align:center">心输出量下降</td> <td style="text-align:center">酷似<font color=#eeee00><strong>缩窄性心包炎</strong></font></td> </tr> </tbody> </table> <p><code>2007N177A特发性心肌病中，最常见的类型是</code> C<font color=#1e90ff><strong>⁹</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.克山病 </span></span><span class="line"><span class="cl">B.限制性心肌病 </span></span><span class="line"><span class="cl">C.扩张性心肌病 </span></span><span class="line"><span class="cl">D.肥厚性心肌病 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>⁹答案有争议</strong></font>：按6版病理教材，<font color=#ff3030><strong>扩张性心肌病</strong></font>占90%，最常见；按9版教材，<font color=#ff3030><strong>扩张性心肌病</strong></font>发病率19/100K，<font color=#ff3030><strong>肥厚性心肌病</strong></font>发病率180/100K，则此题应选D。</p> </blockquote> <p><img src="https://fallen.wang/p/cardiovascular/rate.png" width="766" height="272" srcset="https://fallen.wang/p/cardiovascular/rate_hue3a885a63accd741e0120ca9b3b9351c_124812_480x0_resize_box_3.png 480w, https://fallen.wang/p/cardiovascular/rate_hue3a885a63accd741e0120ca9b3b9351c_124812_1024x0_resize_box_3.png 1024w" loading="lazy" alt="9版病理P173，P174" class="gallery-image" data-flex-grow="281" data-flex-basis="675px" ></p> <p><code>2014N48A扩张性心肌病肉眼检查不包括的主要病理变化是</code> D<font color=#1e90ff><strong>¹⁰</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.心脏重量增加达500~800克 </span></span><span class="line"><span class="cl">B.两侧心腔扩张 </span></span><span class="line"><span class="cl">C.二尖瓣、三尖瓣关闭不全 </span></span><span class="line"><span class="cl">D.心内膜增厚 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>¹⁰答案有争议</strong>：</font>按9版教材P173所述主要病理变化，四个选项全对，此题无解。</p> </blockquote> <p><img src="https://fallen.wang/p/cardiovascular/DCM.png" width="850" height="422" srcset="https://fallen.wang/p/cardiovascular/DCM_hub43a61fac7f9809e0fa8e421f9c38093_382297_480x0_resize_box_3.png 480w, https://fallen.wang/p/cardiovascular/DCM_hub43a61fac7f9809e0fa8e421f9c38093_382297_1024x0_resize_box_3.png 1024w" loading="lazy" alt="9版病理P173" class="gallery-image" data-flex-grow="201" data-flex-basis="483px" ></p> <p><code>2015N163X肥厚性心肌病的肉眼病理变化有</code> AB<font color=#1e90ff><strong>¹¹</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.左心室壁肥厚 </span></span><span class="line"><span class="cl">B.室间隔不均肥厚 </span></span><span class="line"><span class="cl">C.二尖瓣肥厚 </span></span><span class="line"><span class="cl">D.左心房壁肥厚 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>¹¹答案有争议</strong></font>：按9版教材P174，由于收缩期<font color=#40e0d0><strong>二尖瓣</strong></font>向前移动与<font color=#40e0d0><strong>室间隔左侧心内膜</strong></font>接触，可引起<font color=#ff3030><strong>二尖瓣</strong></font>增厚。</p> </blockquote> <p><img src="https://fallen.wang/p/cardiovascular/HCM.png" width="775" height="391" srcset="https://fallen.wang/p/cardiovascular/HCM_huf9d1aa4114bde1d8efb589d2c9db441a_386888_480x0_resize_box_3.png 480w, https://fallen.wang/p/cardiovascular/HCM_huf9d1aa4114bde1d8efb589d2c9db441a_386888_1024x0_resize_box_3.png 1024w" loading="lazy" alt="9版病理P174" class="gallery-image" data-flex-grow="198" data-flex-basis="475px" ></p> <p><code>1999N44A下述哪项符合限制性心肌病</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.心内膜及心内膜下心肌纤维化 </span></span><span class="line"><span class="cl">B.心肌间质纤维化 </span></span><span class="line"><span class="cl">C.心肌细胞呈旋涡状排列 </span></span><span class="line"><span class="cl">D.心肌细胞变性坏死 </span></span><span class="line"><span class="cl">E.心肌间质内淋巴细胞浸润 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="心肌炎">心肌炎</h1> <h2 id="font-colorff3030病毒性心肌炎font"><font color=#ff3030><strong>病毒性心肌炎</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病因</strong><font color=#1e90ff><strong>¹²</strong></font></td> <td style="text-align:center">柯萨奇病毒（<font color=#eeee00><strong>最常见</strong></font>）、ECHO病毒、腺病毒、流感病毒、风疹病毒、巨细胞病毒、肝炎病毒</td> </tr> <tr> <td style="text-align:center"><strong>机制</strong></td> <td style="text-align:center">病毒可直接导致心肌细胞损伤，也可通过T细胞介导的免疫反应间接损伤心肌细胞</td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">心脏略增大或无明显变化</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">心肌细胞间质水肿，大量淋巴、单核细胞浸润；心肌被分割呈条纹状，可有心肌断裂，伴心肌间质纤维化</td> </tr> </tbody> </table> <p><code>2005N137X病毒性心肌炎的常见病原菌是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.柯萨奇病毒 </span></span><span class="line"><span class="cl">B.ECHO病毒 </span></span><span class="line"><span class="cl">C.流感病毒 </span></span><span class="line"><span class="cl">D.EB病毒 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>¹²记忆口诀</strong></font>：“可爱先锋刘柑橘”（柯萨奇，埃可，腺，风，流，肝，巨）</p> </blockquote> <h2 id="细菌性心肌炎">细菌性心肌炎</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病因</strong></td> <td style="text-align:center">白喉B、沙门菌、链球菌、结核菌等</td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">心脏表面及切面可见多发黄色小脓肿，周围有充血带</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">心肌及间质<font color=#eeee00><strong>多发性小脓肿灶</strong></font>，间质以<font color=#eeee00><strong>中性粒细胞</strong></font>浸润为主，不同程度的心肌细胞变性坏死</td> </tr> </tbody> </table> <h2 id="孤立性心肌炎">孤立性心肌炎</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>别称</strong></td> <td style="text-align:center">特发性心肌炎</td> </tr> <tr> <td style="text-align:center"><strong>弥漫性间质性心肌炎</strong></td> <td style="text-align:center">心肌间质较多<font color=#eeee00><strong>淋巴细胞、单核细胞、巨噬细胞浸润</strong></font>，早期心肌细胞较少发生变性坏死，病程较长者可发生心肌间质纤维化/心肌细胞肥大</td> </tr> <tr> <td style="text-align:center"><strong>特发性巨细胞性心肌炎</strong></td> <td style="text-align:center">心肌灶状坏死/<font color=#eeee00><strong>肉芽肿形成</strong>，中心红染、无结构坏死物，周围有淋巴、单核、浆细胞和嗜酸性粒细胞浸润，混有大量多核巨细胞</font></td> </tr> </tbody> </table> <p><code>2008N54A形成肉芽肿的心肌炎是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.特发性巨细胞性心肌炎 </span></span><span class="line"><span class="cl">B.柯萨奇B病毒性心肌炎 </span></span><span class="line"><span class="cl">C.埃可病毒性心肌炎 </span></span><span class="line"><span class="cl">D.葡萄球菌性心肌炎 </span></span><span class="line"><span class="cl">E.白喉性心肌炎 </span></span></code></pre></td></tr></table> </div> </div><hr> <p>贺门！</p> <hr>

呼吸系统病理

<img src="https://fallen.wang/p/respiratory/cover.jpg" alt="Featured image of post 呼吸系统病理" /><script type="text/javascript">alert("病理还得看贺银成。贺门！");</script> <iframe frameborder="no" border="0" marginwidth="0" marginheight="0" width=330 height=86 src="//music.163.com/outchain/player?type=2&id=857896&auto=1&height=66"></iframe> <h1 id="font-colorff3030-考纲font"><font color=#ff3030 ><strong>考纲</strong></font></h1> <blockquote> <p><em><strong>1.慢性支气管炎的病因、发病机制和病理变化。 2.肺气肿的概念、分类。慢性阻塞性肺气肿的发病机制、病理变化和临床病理联系。 3.慢性肺源性心脏病的病因、发病机制、病理变化及临床病理联系。 4.各种细菌性肺炎的病因、发病机制、病理变化和并发症。 5.支原体肺炎的病因、发病机制、病理变化和并发症。 6.病毒性肺炎的病因、发病机制和病理特点。 7.支气管扩张的概念、病因、发病机制、病理变化和并发症。 8.硅沉着病的病因、常见类型、各期病变特点及并发症。 9.肺泡性损伤及肺间质性疾病的概念、病因、发病机制和病理变化。 10.鼻咽癌和肺癌的病因和常见的肉眼类型、组织学类型及它们的特点、转移途径及合并症。</strong></em></p> </blockquote> <hr> <h1 id="慢性支气管炎">慢性支气管炎</h1> <h2 id="病因和发病机制">病因和发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">慢支是支气管黏膜及周围组织慢性非特异性炎性疾病</td> </tr> <tr> <td style="text-align:center"><strong>感染</strong></td> <td style="text-align:center">慢支的发病与上呼吸道<font color=#EEEE00><strong>病毒或细菌感染</strong></font>密切相关</td> </tr> <tr> <td style="text-align:center"><strong>吸烟</strong></td> <td style="text-align:center">患病率与吸烟量成正比</td> </tr> <tr> <td style="text-align:center"><strong>空气污染</strong></td> <td style="text-align:center">空气污染与慢支有明显因果关系</td> </tr> <tr> <td style="text-align:center"><strong>内在因素</strong></td> <td style="text-align:center">机体抵抗力降低、呼吸系统防御功能受损、内分泌失调等</td> </tr> </tbody> </table> <h2 id="病理变化">病理变化</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>黏液-纤毛排送系统受损</strong></td> <td style="text-align:center">纤毛柱状上皮变性坏死，再生的上皮杯状细胞增多，并发鳞状上皮化生</td> </tr> <tr> <td style="text-align:center"><strong>黏膜下腺体增生</strong></td> <td style="text-align:center">浆液性上皮发生黏液腺化生，导致黏液分泌增多</td> </tr> <tr> <td style="text-align:center"><strong>管壁</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>管壁充血水肿</strong></font>，<font color=#EEEE00><strong>淋巴细胞和浆细胞浸润</strong></font>；管壁平滑肌断裂萎缩；软骨变性萎缩骨化</td> </tr> <tr> <td style="text-align:center"><strong>细支气管炎和细支气管周围炎</strong></td> <td style="text-align:center">为慢支反复发作的结果，是引起肺气肿的病变基础</td> </tr> </tbody> </table> <p><code>2020N150X在慢性支气管炎中常见的病变有</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.柱状上皮细胞脱落 </span></span><span class="line"><span class="cl">B.支气管上皮鳞状化生 </span></span><span class="line"><span class="cl">C.支气管管壁软骨变性萎缩 </span></span><span class="line"><span class="cl">D.支气管腺体黏液腺化生 </span></span></code></pre></td></tr></table> </div> </div><p><code>2007N138X慢性支气管炎的病理变化可有</code> ABC</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.柱状上皮的纤毛倒伏甚至完全脱失 </span></span><span class="line"><span class="cl">B.支气管腺体增生和黏液腺化生 </span></span><span class="line"><span class="cl">C.支气管管壁中出现大量淋巴细胞 </span></span><span class="line"><span class="cl">D.支气管管壁软骨出现不典型增生 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="肺气肿">肺气肿</h1> <h2 id="病因和发病机制-1">病因和发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">是<font color=#EEEE00><strong>末梢肺组织</strong></font>因含气量过多、肺泡间隔破坏、肺组织弹性减弱，导致非体积膨大、通气功能降低的状态</td> </tr> <tr> <td style="text-align:center"><strong>通气障碍</strong></td> <td style="text-align:center">慢支时呈现典型的阻塞性通气障碍</td> </tr> <tr> <td style="text-align:center"><strong>弹性降低</strong></td> <td style="text-align:center">长期支气管炎可导致呼吸性细支气管和肺泡壁弹性降低</td> </tr> <tr> <td style="text-align:center"><strong>α₁-AT缺乏</strong></td> <td style="text-align:center">遗传性α₁-抗胰蛋白酶缺乏可导致全腺泡型肺气肿</td> </tr> </tbody> </table> <p><code>2000N147X慢性阻塞性肺气肿的发生与下列哪些因素有关</code> ABC<font color=#1e90ff><strong>¹</strong></font></p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.小气道的阻塞性通气障碍 </span></span><span class="line"><span class="cl">B.内源性弹性蛋白酶增多 </span></span><span class="line"><span class="cl">C.吸烟 </span></span><span class="line"><span class="cl">D.遗传性α₁ -抗胰蛋白酶缺乏 </span></span></code></pre></td></tr></table> </div> </div><blockquote> <p><font color=#1e90ff><strong>¹答案有争议</strong></font>：按9版病理学P194遗传性α₁-AT缺乏是<font color=#ff3030><strong>全腺泡型肺气肿</strong></font>的病因，但当年医学考试中心给出的参考答案没有D选项。<del>可能是因为与内科教材相互矛盾。</del> <img src="https://fallen.wang/p/respiratory/panacinar-emphysema.png" width="1175" height="662" srcset="https://fallen.wang/p/respiratory/panacinar-emphysema_hu9d0dd8f7ca65f4f9ddf0b4a5c026cb67_298947_480x0_resize_box_3.png 480w, https://fallen.wang/p/respiratory/panacinar-emphysema_hu9d0dd8f7ca65f4f9ddf0b4a5c026cb67_298947_1024x0_resize_box_3.png 1024w" loading="lazy" alt="全腺泡型肺气肿" class="gallery-image" data-flex-grow="177" data-flex-basis="425px" ></p> </blockquote> <p><code>1997N45A遗传性α₁ -抗胰蛋白酶缺乏与下列哪种肺气肿的发生关系密切</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.小叶中央型肺气肿 </span></span><span class="line"><span class="cl">B.间质性肺气肿 </span></span><span class="line"><span class="cl">C.全腺泡型肺气肿 </span></span><span class="line"><span class="cl">D.肺大疱 </span></span><span class="line"><span class="cl">E.瘢痕旁肺气肿 </span></span></code></pre></td></tr></table> </div> </div><h2 id="肺气肿的类型">肺气肿的类型</h2> <h3 id="肺泡性肺气肿">肺泡性肺气肿</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>腺泡中央型</strong></td> <td style="text-align:center">呼吸性细小支气管扩张；肺泡管、肺泡囊扩张不明显</td> </tr> <tr> <td style="text-align:center"><strong>腺泡周围型</strong></td> <td style="text-align:center">呼吸性细小支气管正常；<font color=#eeee00><strong>肺泡管、肺泡囊扩张</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>全腺泡型</strong></td> <td style="text-align:center">呼吸性细小支气管、肺泡管、肺泡囊均扩张</td> </tr> </tbody> </table> <p><code>2011N52A中央型肺气肿是指</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.三、四级支气管和周围肺泡囊扩张 </span></span><span class="line"><span class="cl">B.呼吸性支气管扩张，周围肺泡扩张不明显 </span></span><span class="line"><span class="cl">C.肺门周围的肺组织扩张，近胸膜处肺组织扩张不明显 </span></span><span class="line"><span class="cl">D.呼吸性细支气管扩张不明显，周围肺泡管和肺泡囊扩张 </span></span></code></pre></td></tr></table> </div> </div><p><code>2015N52A腺泡周围型肺气肿的病理表现</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.呼吸性细支气管不扩张，周围肺泡扩张 </span></span><span class="line"><span class="cl">B.呼吸性细支气管扩张，周围肺泡扩张不明显 </span></span><span class="line"><span class="cl">C.肺泡间隔内出现成串小气泡 </span></span><span class="line"><span class="cl">D.呼吸性细支气管、肺泡管和肺泡囊均扩张 </span></span></code></pre></td></tr></table> </div> </div><h3 id="其他类型肺气肿">其他类型肺气肿</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>间质性肺气肿</strong></td> <td style="text-align:center">肋骨骨折、胸壁穿透等致肺内压急剧增高，肺泡间隔破裂，空气进入肺间质</td> </tr> <tr> <td style="text-align:center"><strong>瘢痕旁肺气肿</strong></td> <td style="text-align:center"><font color=#eeee00><strong>肺组织瘢痕灶</strong></font>周围肺泡破裂融合形成的局限性肺气肿；若囊腔过大破坏肺小叶间隔，称<font color=#eeee00><strong>肺大疱</strong></font>，肺大疱破裂可致气胸</td> </tr> <tr> <td style="text-align:center"><strong>代偿性肺气肿</strong></td> <td style="text-align:center">肺萎缩、肺叶切除后残余组织或肺炎性实变病灶周围肺组织的肺泡代偿性过度充气</td> </tr> <tr> <td style="text-align:center"><strong>老年性肺气肿</strong></td> <td style="text-align:center">老年人肺组织弹力减弱，肺残气量增多</td> </tr> </tbody> </table> <h2 id="肺气肿的病理变化">肺气肿的病理变化</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">肺体积显著增大，灰白色，质柔软而缺乏弹性，按压痕不易消失</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">肺泡扩张，肺泡间隔变窄断裂，相邻肺泡融合，间隔内毛细血管床数量减少，间质内肺小动脉内膜纤维性增厚，细小支气管借鉴慢性炎症改变</td> </tr> </tbody> </table> <hr> <h1 id="肺源性心脏病">肺源性心脏病</h1> <h2 id="病因和发病机制-2">病因和发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">各种原因所致的<font color=#EEEE00><strong>肺动脉高压</strong></font>→肺循环障碍→右室肥大</td> </tr> <tr> <td style="text-align:center"><strong>肺疾病</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>COPD（80%~90%）</strong></font>、支喘、支扩、肺尘埃沉着症、慢性纤维空洞型肺结核、弥漫性间质性肺纤维化</td> </tr> <tr> <td style="text-align:center"><strong>胸廓疾病</strong></td> <td style="text-align:center">胸廓畸形、类风湿关节炎、胸膜广泛粘连</td> </tr> <tr> <td style="text-align:center"><strong>肺血管疾病</strong></td> <td style="text-align:center">原发性肺动脉高压症、反复发生非小动脉栓塞</td> </tr> </tbody> </table> <p><code>2003N33A慢性肺源性心脏病发生的关键环节是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肺间质纤维化 </span></span><span class="line"><span class="cl">B.肺气肿 </span></span><span class="line"><span class="cl">C.肺动脉高压 </span></span><span class="line"><span class="cl">D.肺动脉分支血栓栓塞 </span></span><span class="line"><span class="cl">E.肺阻塞性通气障碍 </span></span></code></pre></td></tr></table> </div> </div><p><code>1998N147X下述哪些疾病可以导致慢性肺源性心脏病</code> ABCD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.慢性阻塞性肺气肿 </span></span><span class="line"><span class="cl">B.三期矽肺 </span></span><span class="line"><span class="cl">C.慢性空洞性肺结核 </span></span><span class="line"><span class="cl">D.肺动脉反复血栓栓塞 </span></span></code></pre></td></tr></table> </div> </div><h2 id="病理变化-1">病理变化</h2> <table> <thead> <tr> <th style="text-align:center">部位</th> <th style="text-align:center">病变</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺部</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>无肌型细动脉</strong></font>肌化；<font color=#EEEE00><strong>肌型小动脉</strong></font>中膜增生肥厚、内膜下出现纵行肌束；肺<font color=#EEEE00><strong>小动脉炎</strong></font>，肺<font color=#EEEE00><strong>小动脉</strong></font>弹力纤维、胶原纤维增生；肺泡间隔毛细血管数量显著减少</td> </tr> <tr> <td style="text-align:center"><strong>心脏</strong></td> <td style="text-align:center">右室肥厚、心室腔扩大；肺动脉瓣下2cm处右室前壁肌层厚度&gt;<font color=#EEEE00><strong>0.5cm</strong></font>是肺心病的病理诊断标准；右心室壁心肌细胞肥大；心肌间质水肿、胶原纤维增生</td> </tr> </tbody> </table> <p><code>2004N138X下列属于慢性肺源性心脏病肺内血管病变的有</code> ACD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.毛细血管数量减少 </span></span><span class="line"><span class="cl">B.中型动脉纤维素样坏死 </span></span><span class="line"><span class="cl">C.无肌型细动脉肌化 </span></span><span class="line"><span class="cl">D.肌型小动脉中膜增厚 </span></span></code></pre></td></tr></table> </div> </div><p><code>2014N52A慢性肺源性心脏病的主要指标是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肺动脉瓣下2cm处右心室壁厚度超过0.5cm </span></span><span class="line"><span class="cl">B.左心室肥厚 </span></span><span class="line"><span class="cl">C.心脏重量增加可达850克 </span></span><span class="line"><span class="cl">D.三尖瓣关闭不全 </span></span></code></pre></td></tr></table> </div> </div><h2 id="临床病理联系">临床病理联系</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>临床表现</strong></td> <td style="text-align:center">原有肺疾病的临床症状和体征、呼吸功能不全、右心衰竭</td> </tr> <tr> <td style="text-align:center"><strong>病情严重</strong></td> <td style="text-align:center">可合并呼吸性酸中毒、脑水肿甚至肺性脑病</td> </tr> </tbody> </table> <hr> <h1 id="font-colorff3030细菌性肺炎font"><font color=#ff3030><strong>细菌性肺炎</strong></font></h1> <h2 id="font-colorff3030-大叶性肺炎font"><font color=#ff3030 ><strong>大叶性肺炎</strong></font></h2> <h3 id="病因和发病机制-3">病因和发病机制</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center"></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺炎链球菌</strong></td> <td style="text-align:center">占<font color=#EEEE00><strong>90%</strong></font>，以1、2、3、7型多见，3型毒力最强</td> </tr> <tr> <td style="text-align:center"><strong>其他病原菌</strong></td> <td style="text-align:center">肺炎杆菌、金葡菌、流感嗜血杆菌、溶血性链球菌</td> </tr> <tr> <td style="text-align:center"><strong>诱因</strong></td> <td style="text-align:center">受寒、醉酒、疲劳、麻醉等机体抵抗力降低时</td> </tr> <tr> <td style="text-align:center"><strong>发病机制</strong></td> <td style="text-align:center">由肺炎链球菌引起的以肺泡内弥漫性<font color=#EEEE00 ><strong>纤维素渗出为主</strong></font></td> </tr> </tbody> </table> <p><code>2016NO137肺炎链球菌感染常引起的病变是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.纤维素性炎症 </span></span><span class="line"><span class="cl">B.化脓性炎症 </span></span><span class="line"><span class="cl">C.增生性炎症 </span></span><span class="line"><span class="cl">D.浆液性炎症 </span></span></code></pre></td></tr></table> </div> </div><h3 id="病理变化-2">病理变化</h3> <h4 id="肉眼观">肉眼观</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">充血水肿期</th> <th style="text-align:center">红色肝样变期</th> <th style="text-align:center">灰色肝样变期</th> <th style="text-align:center">溶解消散期</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病程</strong></td> <td style="text-align:center">发病后1-2天</td> <td style="text-align:center">发病后3-4天</td> <td style="text-align:center">发病5-6天</td> <td style="text-align:center">发病后7天</td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">肺叶肿胀、充血呈暗红色，挤压切面见淡红色浆液溢出</td> <td style="text-align:center">肺叶肿大加重，质地变硬，切面灰红色，粗糙外观似肝脏</td> <td style="text-align:center">肺叶肿大，实质如肝，灰白色，干燥粗糙</td> <td style="text-align:center">肺开始缩小，质地变软，病灶消失，切面少量浑浊液</td> </tr> </tbody> </table> <h4 id="镜下观">镜下观</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">充血水肿期</th> <th style="text-align:center">红色肝样变期</th> <th style="text-align:center">灰色肝样变期</th> <th style="text-align:center">溶解消散期</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺泡壁CAP</strong></td> <td style="text-align:center">扩张</td> <td style="text-align:center">扩张</td> <td style="text-align:center">受压贫血</td> <td style="text-align:center">逐渐恢复</td> </tr> <tr> <td style="text-align:center"><strong>肺泡渗出</strong></td> <td style="text-align:center">浆液性渗出</td> <td style="text-align:center">中量纤维素渗出</td> <td style="text-align:center">大量纤维素渗出</td> <td style="text-align:center">纤维素逐渐溶解</td> </tr> <tr> <td style="text-align:center"><strong>红细胞</strong></td> <td style="text-align:center">少量</td> <td style="text-align:center">多量</td> <td style="text-align:center">大量溶解</td> <td style="text-align:center">极少</td> </tr> <tr> <td style="text-align:center"><strong>中性粒细胞</strong></td> <td style="text-align:center">少量</td> <td style="text-align:center">少量</td> <td style="text-align:center">多量</td> <td style="text-align:center">死亡</td> </tr> <tr> <td style="text-align:center"><strong>巨噬细胞</strong></td> <td style="text-align:center">少量</td> <td style="text-align:center">少量</td> <td style="text-align:center">中量</td> <td style="text-align:center">大量</td> </tr> </tbody> </table> <h4 id="并发症">并发症</h4> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺肉质变（机化性肺炎）</strong></td> <td style="text-align:center"><font color=#eeee00><strong>中性粒细胞过少</strong></font>，释放的蛋白酶不足以溶解渗出的纤维素，被肉芽组织取代，病变肺组织呈褐色肉样外观<font color=#1e90ff>^{<strong>2</strong>}</font></td> </tr> <tr> <td style="text-align:center"><strong>胸膜肥厚粘连</strong></td> <td style="text-align:center">纤维素性胸膜炎不能完全溶解发生机化</td> </tr> <tr> <td style="text-align:center"><strong>肺脓肿、脓胸</strong></td> <td style="text-align:center">病原菌毒力大、机体抵抗力下降时发生</td> </tr> <tr> <td style="text-align:center"><strong>败血症、脓毒败血症及感染性休克</strong></td> <td style="text-align:center">见于重症病例</td> </tr> </tbody> </table> <blockquote> <p><font color=#1e90ff><strong>²褐色肉样外观</strong></font>：区别于<font color=#ff3030><strong>肺褐色硬化</strong></font>，<font color=#ff3030><strong>肺褐色硬化</strong></font>见于<font color=#ff3030><strong>慢性肺淤血</strong></font>，是局部血液循环障碍。</p> </blockquote> <p><code>2009NO48A中性粒细胞渗出过少的大叶性肺炎易发生的并发症是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肺肉质变 </span></span><span class="line"><span class="cl">B.肺脓肿 </span></span><span class="line"><span class="cl">C.脓胸 </span></span><span class="line"><span class="cl">D.败血症 </span></span></code></pre></td></tr></table> </div> </div><p><code>2022NO31A下列易并发肺肉质变的肺部疾病是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.由化脓菌引起的小叶性肺炎 </span></span><span class="line"><span class="cl">B.由病毒引起的间质性肺炎 </span></span><span class="line"><span class="cl">C.由肺炎链球菌引起的大叶性肺炎 </span></span><span class="line"><span class="cl">D.由肺炎支原体引起的间质性肺炎 </span></span></code></pre></td></tr></table> </div> </div><p><code>2007NO39A肺褐色硬化是下列哪种疾病的形态改变</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.特发性肺纤维化 </span></span><span class="line"><span class="cl">B.机化性肺炎 </span></span><span class="line"><span class="cl">C.慢性肺淤血 </span></span><span class="line"><span class="cl">D.大叶性肺炎 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030-小叶性肺炎支气管肺炎font"><font color=#ff3030 ><strong>小叶性肺炎（支气管肺炎）</strong></font></h2> <h3 id="病因和发病机制-4">病因和发病机制</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺炎链球菌</strong></td> <td style="text-align:center">致病力较弱的4、6、10型肺炎链球菌是最常见的致病菌</td> </tr> <tr> <td style="text-align:center"><strong>其他病原菌</strong></td> <td style="text-align:center">葡萄球菌、流感嗜血杆菌、肺炎克雷伯杆菌、铜绿假单胞菌、大肠埃希菌</td> </tr> <tr> <td style="text-align:center"><strong>诱因</strong></td> <td style="text-align:center">机体抵抗力降低；某些疾病的并发症：<font color=#EEEE00 ><strong>吸入性肺炎</strong></font>、<font color=#EEEE00 ><strong>坠积性肺炎</strong></font>、麻疹后肺炎、手术后肺炎</td> </tr> <tr> <td style="text-align:center"><strong>发病机制</strong></td> <td style="text-align:center">由化脓性细菌引起的以肺小叶为病变单位的<font color=#eeee00><strong>急性化脓性</strong></font>炎症</td> </tr> </tbody> </table> <p><code>2010NO48A吸入性肺炎的病理学类型是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.支气管肺炎 </span></span><span class="line"><span class="cl">B.大叶性肺炎 </span></span><span class="line"><span class="cl">C.间质性肺炎 </span></span><span class="line"><span class="cl">D.弥漫性肺泡损伤 </span></span></code></pre></td></tr></table> </div> </div><h3 id="病理变化和并发症">病理变化和并发症</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">表面和切面散在分布灰黄质实病灶，以<font color=#EEEE00 ><strong>下叶和背侧</strong></font>多见，病灶大小不一，形状不规则，<font color=#EEEE00 ><strong>一般不累及胸膜</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">细支气管黏膜充血水肿；肺泡腔较多<font color=#EEEE00 ><strong>中性粒细胞</strong></font>浸润</td> </tr> <tr> <td style="text-align:center"><strong>并发症</strong></td> <td style="text-align:center">呼吸功能不全、心力衰竭、脓毒血症、肺脓肿、脓胸</td> </tr> </tbody> </table> <h2 id="font-colorff3030-大叶性肺炎和小叶性肺炎的鉴别font"><font color=#ff3030 ><strong>大叶性肺炎和小叶性肺炎的鉴别</strong></font></h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">大叶性肺炎</th> <th style="text-align:center">小叶性肺炎</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病原菌</strong></td> <td style="text-align:center"><font color=#EEEE00 ><strong>肺炎球菌（90%）</strong></font></td> <td style="text-align:center">葡萄球菌、肺炎球菌等</td> </tr> <tr> <td style="text-align:center"><strong>典型病变</strong></td> <td style="text-align:center">肺泡到肺段、肺叶</td> <td style="text-align:center">以肺小叶为单位灶性散布</td> </tr> <tr> <td style="text-align:center"><strong>特点</strong></td> <td style="text-align:center"><font color=#EEEE00 ><strong>支气管不受累</strong></font></td> <td style="text-align:center"><font color=#EEEE00 ><strong>胸膜不受累</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>好发人群</strong></td> <td style="text-align:center">青壮年</td> <td style="text-align:center">小儿、年老体弱者</td> </tr> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">左肺、右肺下叶</td> <td style="text-align:center">双肺下叶、背侧</td> </tr> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center"><font color=#EEEE00 ><strong>纤维素性炎</strong></font></td> <td style="text-align:center"><font color=#EEEE00 ><strong>化脓性炎</strong></font></td> </tr> </tbody> </table> <p><code>2021NO124B属于纤维素性炎的是</code> A</p> <p><code>2021NO125B属于化脓性炎的是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大叶性肺炎 </span></span><span class="line"><span class="cl">B.小叶性肺炎 </span></span><span class="line"><span class="cl">C.支原体肺炎 </span></span><span class="line"><span class="cl">D.病毒性肺炎 </span></span></code></pre></td></tr></table> </div> </div><p><code>1994NO148X大叶性肺炎的病理特点</code> ACD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肺泡的纤维素性炎 </span></span><span class="line"><span class="cl">B.支气管常受累 </span></span><span class="line"><span class="cl">C.可合并中毒性休克 </span></span><span class="line"><span class="cl">D.可合并肺脓肿 </span></span></code></pre></td></tr></table> </div> </div><hr> <h2 id="军团菌肺炎">军团菌肺炎</h2> <h3 id="病因和发病机制-5">病因和发病机制</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病因</strong></td> <td style="text-align:center">军团菌是需氧G^-杆菌，主要通过空气传播</td> </tr> <tr> <td style="text-align:center"><strong>发病机制</strong></td> <td style="text-align:center">从呼吸道侵犯肺泡和细支气管，进入胞质繁殖致细胞破裂释放酶类和细胞毒因子，损伤肺组织</td> </tr> </tbody> </table> <h3 id="病理变化-3">病理变化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">肺体积增大，质硬，表面粗糙，有<font color=#EEEE00 ><strong>纤维素附着</strong></font>，病灶切面呈暗灰色片状，晚期可波及多肺叶，严重病例可见<font color=#EEEE00 ><strong>肺脓肿</strong></font>形成</td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">早期以大量<font color=#EEEE00 ><strong>纤维素、中性粒细胞</strong></font>渗出为主，常伴坏死；晚期坏死组织机化，间质纤维化</td> </tr> </tbody> </table> <h2 id="font-colorff3030-病毒性肺炎font和font-colorff3030-支原体肺炎font"><font color=#ff3030 ><strong>病毒性肺炎</strong></font>和<font color=#ff3030 ><strong>支原体肺炎</strong></font></h2> <h3 id="病因及病理变化">病因及病理变化</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病原体</strong></td> <td style="text-align:center">常见于<font color=#EEEE00 ><strong>流感病毒</strong></font>、呼吸道合胞病毒、腺病毒、麻疹病毒</td> </tr> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">病变常不明显，肺组织可因充血水肿轻度肿大</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">主要表现为<font color=#EEEE00 ><strong>间质性肺炎</strong></font>，肺泡腔内无渗出或少量渗出；肺泡间隔明显变宽，其内血管扩张充血；间质水肿，大量淋巴细胞、单核细胞浸润</td> </tr> <tr> <td style="text-align:center"><strong>特征</strong></td> <td style="text-align:center"><font color=#EEEE00 ><strong>病毒包涵体</strong></font>是诊断病毒性肺炎的重要依据，多见于支气管上皮细胞、肺泡上皮细胞、多核巨细胞</td> </tr> </tbody> </table> <p><code>2017NO34A下列病理改变符合病毒性肺炎的是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.常有肺泡结构破坏 </span></span><span class="line"><span class="cl">B.肺泡间隔水肿，炎细胞浸润 </span></span><span class="line"><span class="cl">C.肺泡内常有大量纤维素渗出 </span></span><span class="line"><span class="cl">D.局部区域中性粒细胞浸润 </span></span></code></pre></td></tr></table> </div> </div><h3 id="font-colorff3030病毒包涵体font"><font color=#ff3030><strong>病毒包涵体</strong></font></h3> <table> <thead> <tr> <th style="text-align:center">位置</th> <th style="text-align:center">病原体</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>胞核</strong></td> <td style="text-align:center">腺病毒、单纯疱疹病毒、巨细胞病毒（嗜碱性）</td> </tr> <tr> <td style="text-align:center"><strong>胞质</strong></td> <td style="text-align:center">呼吸道合胞病毒（嗜酸性）</td> </tr> <tr> <td style="text-align:center"><strong>胞核和胞质</strong></td> <td style="text-align:center">麻疹病毒</td> </tr> </tbody> </table> <p><code>1992NO35A病毒性肺炎的主要诊断依据是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.间质性肺炎 </span></span><span class="line"><span class="cl">B.淋巴细胞、单核细胞为主的炎细胞浸润 </span></span><span class="line"><span class="cl">C.上皮细胞内病毒包涵体 </span></span><span class="line"><span class="cl">D.肺泡上皮细胞增生 </span></span><span class="line"><span class="cl">E.肺泡内透明膜形成 </span></span></code></pre></td></tr></table> </div> </div><p><code>1994NO125C麻疹病毒</code> C</p> <p><code>1994NO126C腺病毒</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.核内病毒包涵体 </span></span><span class="line"><span class="cl">B.胞质内病毒包涵体 </span></span><span class="line"><span class="cl">C.两者皆有 </span></span><span class="line"><span class="cl">D.两者皆无 </span></span></code></pre></td></tr></table> </div> </div><h3 id="支原体肺炎">支原体肺炎</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">病毒性肺炎</th> <th style="text-align:center">支原体肺炎</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病原体</strong></td> <td style="text-align:center">流感病毒（<font color=#eeee00 ><strong>最常见</strong></font>）、呼吸道合胞病毒、腺病毒、麻疹病毒、巨细胞病毒</td> <td style="text-align:center">支原体</td> </tr> <tr> <td style="text-align:center"><strong>病理变化</strong></td> <td style="text-align:center"><font color=#eeee00 ><strong>间质性肺炎</strong></font>间质水肿、大量淋巴单核细胞浸润；肺泡腔变小、无或少量浆液渗出<font color=#1e90ff >^{<strong>2</strong>}</font></td> <td style="text-align:center">同左</td> </tr> <tr> <td style="text-align:center"><strong>包涵体</strong></td> <td style="text-align:center">有</td> <td style="text-align:center">无</td> </tr> </tbody> </table> <blockquote> <p><font color=#1e90ff ><strong>²根据肺泡腔内有无渗出判断肺炎类型</strong></font>： 若渗出物为<font color=#40e0d0 ><strong>纤维素</strong></font>，则为<font color=#ff3030 ><strong>大叶性肺炎</strong></font>；渗出物为<font color=#40e0d0 ><strong>中性粒细胞</strong></font>，为<font color=#ff3030 ><strong>小叶性肺炎</strong></font>；两者均有，为<font color=#ff3030 ><strong>军团菌肺炎</strong></font>；无渗出或少量浆液性渗出为<font color=#ff3030 ><strong>病毒性肺炎</strong></font>或<font color=#ff3030 ><strong>支原体肺炎</strong></font>。</p> </blockquote> <p><code>2013NO135支原体肺炎的病理类型通常是</code> C</p> <p><code>2013NO136病毒性肺炎的病理类型通常是</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大叶性肺炎 </span></span><span class="line"><span class="cl">B.小叶性肺炎 </span></span><span class="line"><span class="cl">C.间质性肺炎 </span></span><span class="line"><span class="cl">D.有肉芽肿形成的肺炎 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="支气管扩张症">支气管扩张症</h1> <h2 id="病因和发病机制-6">病因和发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">支气管扩张症是以肺内<font color=#EEEE00><strong>小支气管管腔</strong></font>持久性扩张伴<font color=#EEEE00><strong>管壁</strong></font>纤维性增厚为特征的慢性呼吸道疾病</td> </tr> <tr> <td style="text-align:center"><strong>基础病变</strong></td> <td style="text-align:center">继发于慢支、麻疹、百日咳后的支气管肺炎、肺结核</td> </tr> <tr> <td style="text-align:center"><strong>先天性疾病</strong></td> <td style="text-align:center">先天性支气管发育不全，巨大气管支气管扩张症</td> </tr> </tbody> </table> <h2 id="病理变化和并发症-1">病理变化和并发症</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肉眼观</strong></td> <td style="text-align:center">支气管囊状扩张，可累及肺段肺叶和双肺；扩张的支气管数目不等，多者肺切面可呈<font color=#EEEE00><strong>蜂窝状</strong></font>；扩张的支气管腔内可见黏液脓性、血性渗出物</td> </tr> <tr> <td style="text-align:center"><strong>镜下观</strong></td> <td style="text-align:center">支气管壁明显增厚，黏膜上皮增生伴鳞状化生；黏膜下血管扩张充血，淋巴细胞、浆细胞和中性粒细胞浸润；管壁腺体、平滑肌、弹力纤维、软骨不同程度遭受破坏</td> </tr> <tr> <td style="text-align:center"><strong>并发症</strong></td> <td style="text-align:center">肺脓肿、脓胸、脓气胸、肺功能障碍、慢性肺心病</td> </tr> </tbody> </table> <p><code>2021N37A导致支气管扩张症的主要病变基础</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.支气管纤毛柱状上皮鳞状化生 </span></span><span class="line"><span class="cl">B.支气管壁的黏液腺大量增生 </span></span><span class="line"><span class="cl">C.支气管壁结构破坏 </span></span><span class="line"><span class="cl">D.肺组织纤维化 </span></span></code></pre></td></tr></table> </div> </div><h1 id="font-colorff3030肺硅沉着病font"><font color=#ff3030><strong>肺硅沉着病</strong></font></h1> <h2 id="定义">定义</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>定义</strong></td> <td style="text-align:center">肺硅沉着病简称硅肺或矽肺，是长期吸入二氧化硅粉尘沉着于肺组织引起的常见职业病。</td> </tr> <tr> <td style="text-align:center"><strong>好发</strong></td> <td style="text-align:center">长期从事矿石业、玻璃厂工人</td> </tr> <tr> <td style="text-align:center"><strong>发病</strong></td> <td style="text-align:center">多在接触硅尘<font color=#EEEE00><strong>10~15年</strong></font>发病，进展缓慢，即使脱离环境病变仍继续发展</td> </tr> </tbody> </table> <h2 id="病因">病因</h2> <table> <thead> <tr> <th style="text-align:left"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:left"><strong>主要病因</strong></td> <td style="text-align:center">吸入游离二氧化硅粉尘</td> </tr> <tr> <td style="text-align:left"><strong>硅尘形状</strong></td> <td style="text-align:center">不同形状均可致病，以四面体石英结晶作用最强</td> </tr> <tr> <td style="text-align:left"><strong>硅尘大小</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>直径&gt;5μm</strong></font>不易致病；<font color=#EEEE00><strong>直径&lt;5μm</strong></font>易沉积在肺泡管被巨噬细胞吞噬而发病；其中<font color=#EEEE00><strong>直径1~2μm</strong></font>致病性最强</td> </tr> </tbody> </table> <h2 id="发病机制">发病机制</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>巨噬细胞</strong></td> <td style="text-align:center">二氧化硅被巨噬细胞吞噬后与水聚合形成硅酸致溶酶体破裂，酶逸出致巨噬细胞自溶；硅尘释放后可被其他巨噬细胞再吞噬</td> </tr> <tr> <td style="text-align:center"><strong>免疫因素</strong></td> <td style="text-align:center">玻璃样变的<font color=#EEEE00><strong>硅结节</strong></font>含较多免疫球蛋白，血清中见IgG、IgM抗体</td> </tr> </tbody> </table> <h2 id="病理变化-4">病理变化</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>基本病变</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>硅结节</strong></font>形成、肺组织弥漫性纤维化</td> </tr> <tr> <td style="text-align:center"><strong>硅结节</strong></td> <td style="text-align:center">早期吞噬硅尘的巨噬细胞聚集形成<font color=#EEEE00><strong>细胞性硅结节</strong></font>；中期成纤维细胞增生玻璃样变形成<font color=#EEEE00><strong>纤维性硅结节</strong></font>；晚期结节中央缺血坏死液化形成<font color=#EEEE00><strong>硅肺性空洞</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>肺组织纤维化</strong></td> <td style="text-align:center">肺组织弥漫性纤维化，镜下见玻璃样变的胶原纤维</td> </tr> <tr> <td style="text-align:center"><strong>胸膜纤维化</strong></td> <td style="text-align:center">胸膜纤维化增厚</td> </tr> </tbody> </table> <p><code>2001N41A关于硅肺的描述，正确的是</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.大于5μm的硅尘致病性强 </span></span><span class="line"><span class="cl">B.硅酸导致巨噬细胞自溶 </span></span><span class="line"><span class="cl">C.硅结节内无免疫球蛋白 </span></span><span class="line"><span class="cl">D.纤维性结节是硅肺的早期病变 </span></span><span class="line"><span class="cl">E.胸膜常无病变 </span></span></code></pre></td></tr></table> </div> </div><p><code>2011N51A形成早期细胞性硅结节的细胞主要是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.巨噬细胞 </span></span><span class="line"><span class="cl">B.淋巴细胞 </span></span><span class="line"><span class="cl">C.成纤维细胞 </span></span><span class="line"><span class="cl">D.中性粒细胞 </span></span></code></pre></td></tr></table> </div> </div><h2 id="分期和病变特点">分期和病变特点</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">I期硅肺</th> <th style="text-align:center">II期硅肺</th> <th style="text-align:center">III期硅肺</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>病变</strong></td> <td style="text-align:center">硅结节浸润肺门淋巴结及肺组织、胸膜</td> <td style="text-align:center">硅结节扩展到淋巴结外肺组织</td> <td style="text-align:center">硅结节密集与肺纤维化融合成块</td> </tr> <tr> <td style="text-align:center"><strong>胸膜</strong></td> <td style="text-align:center">有硅结节，增厚不明显</td> <td style="text-align:center">胸膜增厚</td> <td style="text-align:center">胸膜明显增厚</td> </tr> <tr> <td style="text-align:center"><strong>硅结节</strong></td> <td style="text-align:center">数量少，米粒至绿豆大</td> <td style="text-align:center">数量多，黄豆大</td> <td style="text-align:center">弥散全肺融合成团</td> </tr> <tr> <td style="text-align:center"><strong>部位</strong></td> <td style="text-align:center">中下叶近肺门处<font color=#EEEE00><strong>肺门淋巴结</strong></font>最先形成硅结节</td> <td style="text-align:center">散布双肺，中下肺叶近肺门处多见</td> <td style="text-align:center">弥散全肺，病灶周围合并肺气肿</td> </tr> <tr> <td style="text-align:center"><strong>肺</strong></td> <td style="text-align:center">重量、体积、硬度不变</td> <td style="text-align:center">重量、体积、硬度增加</td> <td style="text-align:center">重量、体积、硬度明显增加</td> </tr> <tr> <td style="text-align:center"><strong>胸片</strong></td> <td style="text-align:center">肺门阴影增大，密度增加，肺野可见少量类圆形或不规则小阴影</td> <td style="text-align:center">直径小于1cm阴影分布范围较广</td> <td style="text-align:center">直径大于2cm大阴影，肺门淋巴结肿大，可有硅肺空洞</td> </tr> </tbody> </table> <p><code>2018N35A硅沉着病最早期病变出现的部位是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.两肺上叶 </span></span><span class="line"><span class="cl">B.两肺下叶 </span></span><span class="line"><span class="cl">C.上、下肺叶交界的胸膜处 </span></span><span class="line"><span class="cl">D.肺门淋巴结 </span></span></code></pre></td></tr></table> </div> </div><p><code>2022N40AI期硅肺沉着病的病变特点</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.病变主要在肺门淋巴结 </span></span><span class="line"><span class="cl">B.胸膜明显增厚 </span></span><span class="line"><span class="cl">C.结节性病变散布于双肺 </span></span><span class="line"><span class="cl">D.肺重量增加 </span></span></code></pre></td></tr></table> </div> </div><h2 id="并发症-1">并发症</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺结核</strong></td> <td style="text-align:center">III期硅肺的肺结核发生率70%以上</td> </tr> <tr> <td style="text-align:center"><strong>慢性肺心病</strong></td> <td style="text-align:center">约60%~75%的晚期硅肺并发慢性肺心病</td> </tr> <tr> <td style="text-align:center"><strong>肺部感染</strong></td> <td style="text-align:center">易并发严重的感染导致死亡</td> </tr> <tr> <td style="text-align:center"><strong>阻塞性肺气肿</strong></td> <td style="text-align:center">常合并肺气肿导致自发性气胸</td> </tr> </tbody> </table> <p><code>1991N34A下列哪项不符合硅肺的病理变化</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.易并发肺结核 </span></span><span class="line"><span class="cl">B.可引起肺间质纤维化 </span></span><span class="line"><span class="cl">C.早起硅结节在肺实质内 </span></span><span class="line"><span class="cl">D.硅结节中央可发生坏死 </span></span><span class="line"><span class="cl">E.硅结节由呈同心环状胶原纤维组成 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="font-colorff3030肺癌font"><font color=#ff3030><strong>肺癌</strong></font></h1> <h2 id="病因-1">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>吸烟</strong></td> <td style="text-align:center">吸烟者肺癌发病率是普通人的20倍</td> </tr> <tr> <td style="text-align:center"><strong>空气污染</strong></td> <td style="text-align:center">肺癌发病率与空气污染浓度呈正相关</td> </tr> <tr> <td style="text-align:center"><strong>职业因素</strong></td> <td style="text-align:center">长期接触放射性物质或吸入粉尘</td> </tr> <tr> <td style="text-align:center"><strong>基因改变</strong></td> <td style="text-align:center">KRAS基因突变；c-MYC基因过度表达；p53基因突变</td> </tr> </tbody> </table> <h2 id="font-colorff3030病理变化font"><font color=#ff3030><strong>病理变化</strong></font></h2> <h3 id="大体类型">大体类型</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">中央型肺癌</th> <th style="text-align:center">周围型肺癌</th> <th style="text-align:center">弥漫型肺癌</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>肺癌占比</strong></td> <td style="text-align:center">60%~70%</td> <td style="text-align:center">30%~40%</td> <td style="text-align:center">2%~5%</td> </tr> <tr> <td style="text-align:center"><strong>病变部位</strong></td> <td style="text-align:center">主气管或叶支气管</td> <td style="text-align:center"><font color=#EEEE00><strong>肺段</strong></font>或远端支气管</td> <td style="text-align:center">末梢肺组织</td> </tr> <tr> <td style="text-align:center"><strong>肿块形状</strong></td> <td style="text-align:center">巨大肿块</td> <td style="text-align:center">结节状，2~8cm</td> <td style="text-align:center">粟粒，多发结节</td> </tr> <tr> <td style="text-align:center"><strong>肺门转移</strong></td> <td style="text-align:center">发生早</td> <td style="text-align:center">发生晚，侵犯胸膜</td> <td style="text-align:center">少见</td> </tr> <tr> <td style="text-align:center"><strong>病理类型</strong></td> <td style="text-align:center">鳞癌最多</td> <td style="text-align:center">腺癌最多</td> <td style="text-align:center">肺泡细胞癌最多</td> </tr> </tbody> </table> <h3 id="组织学类型">组织学类型</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th style="text-align:center">肺腺癌</th> <th style="text-align:center">肺鳞状细胞癌</th> <th style="text-align:center">肺小细胞癌</th> <th style="text-align:center">肺大细胞癌</th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>占比</strong></td> <td style="text-align:center">30%~35%</td> <td style="text-align:center">30%~50%</td> <td style="text-align:center">15%~20%</td> <td style="text-align:center">15%~20%</td> </tr> <tr> <td style="text-align:center"><strong>类型</strong></td> <td style="text-align:center">65%为<font color=#EEEE00><strong>周围型</strong></font></td> <td style="text-align:center">80%为<font color=#EEEE00><strong>中央型</strong></font></td> <td style="text-align:center">多为<font color=#EEEE00><strong>中央型</strong></font></td> <td style="text-align:center">多为<font color=#EEEE00><strong>中央型</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>特点</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>女性</strong></font>最常见，多为非吸烟者，常累及胸膜纤维化和瘢痕</td> <td style="text-align:center">中老年<font color=#EEEE00><strong>男性</strong></font>多见，多有吸烟史，易被镜检发现，特征为<font color=#EEEE00><strong>角化珠</strong></font></td> <td style="text-align:center">有<font color=#EEEE00><strong>内分泌功能</strong></font>，生长迅速，转移早，手术效果差，对放化疗敏感</td> <td style="text-align:center">好发大支气管，肿块较大，恶性程度高，生长迅速，转移早而广泛</td> </tr> </tbody> </table> <p><code>2009N49A肺癌中恶性程度最高的是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.鳞癌 </span></span><span class="line"><span class="cl">B.腺癌 </span></span><span class="line"><span class="cl">C.细支气管肺泡细胞癌 </span></span><span class="line"><span class="cl">D.小细胞癌 </span></span></code></pre></td></tr></table> </div> </div><p><code>2005N45A肺癌的恶性程度最低的类型是</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.类癌 </span></span><span class="line"><span class="cl">B.腺癌 </span></span><span class="line"><span class="cl">C.鳞癌 </span></span><span class="line"><span class="cl">D.大细胞癌 </span></span><span class="line"><span class="cl">E.小细胞癌 </span></span></code></pre></td></tr></table> </div> </div><p><code>1997N101B肺腺癌</code> B <code>1997N102B肺鳞癌</code> A</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.中央型多见 </span></span><span class="line"><span class="cl">B.周围型多见 </span></span><span class="line"><span class="cl">C.弥漫型多见 </span></span><span class="line"><span class="cl">D.常具有内分泌功能 </span></span><span class="line"><span class="cl">E.肿瘤呈胶冻状 </span></span></code></pre></td></tr></table> </div> </div><p><code>2015N51A在下列肿瘤类型中，细支气管肺泡癌</code> C</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.小细胞癌 </span></span><span class="line"><span class="cl">B.鳞状细胞癌 </span></span><span class="line"><span class="cl">C.腺癌 </span></span><span class="line"><span class="cl">D.大细胞癌 </span></span></code></pre></td></tr></table> </div> </div><h2 id="扩散途径">扩散途径</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>直接蔓延</strong></td> <td style="text-align:center">中央型肺癌常直接侵犯纵膈、心包和周围血管；周围型肺癌可侵犯胸膜并侵入胸壁</td> </tr> <tr> <td style="text-align:center"><strong>淋巴道转移</strong></td> <td style="text-align:center">发生较早，扩散速度快</td> </tr> <tr> <td style="text-align:center"><strong>血道转移</strong></td> <td style="text-align:center">常见于<font color=#EEEE00><strong>脑、肾上腺、骨</strong></font>等器官组织</td> </tr> </tbody> </table> <h2 id="临床病理联系-1">临床病理联系</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>早期</strong></td> <td style="text-align:center">无明显症状</td> </tr> <tr> <td style="text-align:center"><strong>中晚期</strong></td> <td style="text-align:center">咳嗽，痰中带血，咯血，胸痛</td> </tr> <tr> <td style="text-align:center"><strong>压迫症状</strong></td> <td style="text-align:center">支气管、上腔静脉、交感神经、臂丛</td> </tr> <tr> <td style="text-align:center"><strong>副肿瘤综合征</strong></td> <td style="text-align:center">神经内分泌型肺癌如小细胞肺癌、支气管类癌</td> </tr> </tbody> </table> <p><code>2015N168X呼吸系统肿瘤中，由神经内分泌细胞发生的包括</code> AD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.支气管 </span></span><span class="line"><span class="cl">B.腺癌 </span></span><span class="line"><span class="cl">C.鳞癌 </span></span><span class="line"><span class="cl">D.小细胞癌 </span></span></code></pre></td></tr></table> </div> </div><h2 id="font-colorff3030基本概念font"><font color=#ff3030><strong>基本概念</strong></font></h2> <h3 id="小细胞肺癌燕麦细胞癌">小细胞肺癌（燕麦细胞癌）</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发</strong></td> <td style="text-align:center">中老年吸烟男性</td> </tr> <tr> <td style="text-align:center"><strong>起源</strong></td> <td style="text-align:center">支气管黏膜上皮的APUD细胞，能分泌5-HT致支气管痉挛、阵发性窦速、水样腹泻、皮肤潮红</td> </tr> <tr> <td style="text-align:center"><strong>肉眼</strong></td> <td style="text-align:center">多为中央型，常发生于大支气管，向肺实质浸润生长形成巨块</td> </tr> <tr> <td style="text-align:center"><strong>镜下</strong></td> <td style="text-align:center">癌细胞小，圆形，似淋巴细胞，可围绕小血管形成<font color=#EEEE00><strong>假菊形团</strong></font>结构，燕麦形，胞质少，似裸核，弥漫分布、条索状排列-燕麦细胞癌</td> </tr> <tr> <td style="text-align:center"><strong>病理</strong></td> <td style="text-align:center">三最：恶性程度最高；转移最早；对放化疗效果最好</td> </tr> </tbody> </table> <h3 id="其他">其他</h3> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>瘢痕癌</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>腺癌</strong></font>伴纤维化、瘢痕形成：对肿瘤出现的间质胶原纤维反应</td> </tr> <tr> <td style="text-align:center"><strong>隐性肺癌</strong></td> <td style="text-align:center">痰细胞学检查阳性；临床及X线检查阴性；<font color=#EEEE00><strong>无淋巴结转移</strong></font>；手术标本经病检证实为支气管黏膜原位癌、早期浸润癌</td> </tr> <tr> <td style="text-align:center"><strong>早期肺癌</strong></td> <td style="text-align:center"><font color=#EEEE00><strong>中央型</strong></font>：发于段以上支气管，不突破外模，未侵及肺实质，<font color=#EEEE00><strong>无局部淋巴结转移</strong></font>；<font color=#EEEE00><strong>周围型</strong></font>：发于小支气管，在肺内呈结节状，直径小于2cm，<font color=#EEEE00><strong>无局部淋巴结转移</strong></font></td> </tr> </tbody> </table> <p><code>2000N43A下列哪项符合肺小细胞癌</code> B</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.与吸烟关系不密切 </span></span><span class="line"><span class="cl">B.可伴有异位激素分泌 </span></span><span class="line"><span class="cl">C.起源于化生的上皮细胞 </span></span><span class="line"><span class="cl">D.5年存活率高 </span></span><span class="line"><span class="cl">E.发病率在肺癌中居首位 </span></span></code></pre></td></tr></table> </div> </div><p><code>2007N44A下列癌中属于肺腺癌特殊类型的是</code> D</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.小细胞肺癌 </span></span><span class="line"><span class="cl">B.大细胞肺癌 </span></span><span class="line"><span class="cl">C.肺类癌 </span></span><span class="line"><span class="cl">D.肺瘢痕癌 </span></span></code></pre></td></tr></table> </div> </div><hr> <h1 id="鼻咽癌">鼻咽癌</h1> <h2 id="病因-2">病因</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>EB病毒</strong></td> <td style="text-align:center">EB病毒与鼻咽癌关系密切，血清中有<font color=#EEEE00><strong>EBV壳抗原IgA抗体</strong></font></td> </tr> <tr> <td style="text-align:center"><strong>遗传因素</strong></td> <td style="text-align:center">部分病理有明显的家族性</td> </tr> <tr> <td style="text-align:center"><strong>化学致癌物</strong></td> <td style="text-align:center">亚硝酸盐类、多环芳烃类镍</td> </tr> </tbody> </table> <p><code>2017N148X下列肿瘤的发生与EBV相关的有</code> CD</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">A.肝癌 </span></span><span class="line"><span class="cl">B.肺癌 </span></span><span class="line"><span class="cl">C.鼻咽癌 </span></span><span class="line"><span class="cl">D.淋巴瘤 </span></span></code></pre></td></tr></table> </div> </div><h2 id="病理变化-5">病理变化</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>好发部位</strong></td> <td style="text-align:center">鼻咽顶部（<font color=#EEEE00><strong>最常见</strong></font>）、外侧壁和咽隐窝、前壁</td> </tr> <tr> <td style="text-align:center"><strong>鳞状细胞癌</strong></td> <td style="text-align:center">高分化（角化型）、低分化（非角化型）、未分化性鳞癌</td> </tr> <tr> <td style="text-align:center"><strong>腺癌</strong></td> <td style="text-align:center">少见</td> </tr> <tr> <td style="text-align:center"><strong>扩散途径</strong></td> <td style="text-align:center">直接蔓延、淋巴道转移、血道转移</td> </tr> </tbody> </table> <h2 id="临床病理联系-2">临床病理联系</h2> <table> <thead> <tr> <th style="text-align:center"></th> <th></th> </tr> </thead> <tbody> <tr> <td style="text-align:center"><strong>早期</strong></td> <td style="text-align:center">症状不明显</td> </tr> <tr> <td style="text-align:center"><strong>中期</strong></td> <td style="text-align:center">闭塞、鼻出血、头痛耳鸣</td> </tr> <tr> <td style="text-align:center"><strong>压迫</strong></td> <td style="text-align:center">颅神经：视物模糊、面目麻木、眼睑下垂；经交感神经：麻痹综合征</td> </tr> <tr> <td style="text-align:center"><strong>症状</strong></td> <td style="text-align:center">常见首发症状为颈部肿块</td> </tr> </tbody> </table> <hr> <p>贺门！</p> <hr> <p>最后贴一张6月的安排表 倒也不是为了丢人现眼</p> <blockquote> <p><del>本来这勾八博客也就那三四个人看 主要还是想卷死我那几个卷王室友</del></p> </blockquote> <p>算是督促自己 贴出来就不能反悔了QAQ</p> <p><img src="https://fallen.wang/p/respiratory/timetable.png" width="1473" height="773" srcset="https://fallen.wang/p/respiratory/timetable_hu8cf5437c6864321a9be109b86b506853_139303_480x0_resize_box_3.png 480w, https://fallen.wang/p/respiratory/timetable_hu8cf5437c6864321a9be109b86b506853_139303_1024x0_resize_box_3.png 1024w" loading="lazy" alt="timetable" class="gallery-image" data-flex-grow="190" data-flex-basis="457px" ></p> <blockquote> <p><del>妈的六点要到教室五点半就得起 早饭得提前一天买</del></p> </blockquote> <blockquote> <p><del>一点睡五点起，阎王夸我好身体</del></p> </blockquote> <blockquote> <p>哈哈没想到吧爷睡在教室了 一周通宵四天 俺は、人間をやめるぞ！</p> </blockquote>

未来规划

<img src="https://fallen.wang/p/future-plan/cover.jpg" alt="Featured image of post 未来规划" /> <iframe style="width: 100%; height: 100%" src="https://music.163.com/outchain/player?type=2&id=65538&auto=1&height=66" frameborder="0"marginwidth="0" marginheight="0"></iframe> <p>前一个博客因为<strong>不可抗力</strong>挂了，到今天也快一年了，抽空搞了个新的。可惜好多文章没有备份，有点对不起曾经关注我支持我的朋友们。仅存的几篇2022年及之前的文章有些还涉及<em><strong>魔法</strong></em>之类的敏感技术，现在域名备案了不太方便再放出来 TAT~~（所谓不可抗力其实是vps服务商跑路了&hellip;&hellip;这个故事告诉我们<strong>一定要备份！一定要备份！一定要备份！</strong>）~~</p> <p>这个博客也基本建设好了，目前的想法是只保留技术性文章，随笔什么的将在不久后迁移到这里：<a class="link" href="" >inspire.fallen.wang</a></p> <p><img src="https://fallen.wang/p/future-plan/1.jpg" width="474" height="490" srcset="https://fallen.wang/p/future-plan/1_hu4f38cf8a13d3933bcdc15cb6faeb26fb_57974_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/future-plan/1_hu4f38cf8a13d3933bcdc15cb6faeb26fb_57974_1024x0_resize_q75_box.jpg 1024w" loading="lazy" class="gallery-image" data-flex-grow="96" data-flex-basis="232px" ></p> <p>接下来准备备考699（生理生化病理诊断外科总论 鲨了我吧😭）大概不能像大一大二时那样腹泻式更新了</p> <p>如果有空可能会更新这几个方面：</p> <blockquote> <p>神经网络</p> <p>基础乐理</p> <p>python相关</p> <p>基础医学的笔记</p> </blockquote> <p>牙膏要一点一点挤；显卡要一刀一刀切；提琴要一天一天锯，代码要一行一行写。再见咯</p> <blockquote> <p>_φ(❐_❐✧ 人丑就要多读书</p> <p>(为什么颜文字显示不全&hellip;)</p> </blockquote> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span><span class="lnt">7 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-python" data-lang="python"><span class="line"><span class="cl"><span class="n">lingling</span> <span class="o">=</span> <span class="s1">&#39;yes&#39;</span> </span></span><span class="line"><span class="cl"><span class="n">hrs</span> <span class="o">=</span> <span class="nb">input</span><span class="p">(</span><span class="s2">&#34;Did you practice 40hrs today? (yes/no):&#34;</span><span class="p">)</span> </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="k">if</span> <span class="n">hrs</span> <span class="o">==</span> <span class="n">lingling</span><span class="p">:</span> </span></span><span class="line"><span class="cl"> <span class="nb">print</span><span class="p">(</span><span class="s2">&#34;Bravo&#34;</span><span class="p">)</span> </span></span><span class="line"><span class="cl"><span class="k">else</span><span class="p">:</span> </span></span><span class="line"><span class="cl"> <span class="nb">print</span><span class="p">(</span><span class="s2">&#34;Go practice&#34;</span><span class="p">)</span> </span></span></code></pre></td></tr></table> </div> </div>

云端部署so-vits-svc流程

<img src="https://fallen.wang/p/sovits/cover.jpg" alt="Featured image of post 云端部署so-vits-svc流程" /><p>[TOC]</p> <h1 id="前言">前言：</h1> <p><font color=#1E90FF>Apr 23,2023更新：现在已经可以正常访问,项目已存档并停止维护</font>:https://github.com/svc-develop-team/so-vits-svc</p> <hr> <p><font color=#1E90FF>更新：目前无法正常访问Github原项目地址，据说因为有人用它跑政治敏感的东西所以作者删库跑路了=_=如果属实那么只能手动上传整合包到服务器</font>，</p> <hr> <p>体验了一把最近很火的so-vits-svc ，效果确实不错，但是训练模型对低配显卡很不友好，实测GTX 1650要跑一个效果还行的模型（36 epoch ,20K+ steps ）需要接近十个小时。于是考虑在云端部署，对比了几个知名GPU 租借平台，最终选了恒源云的英伟达V100 16G （恒源云打钱！）这配置用来跑sovits 是绰绰有余了，1.5元/小时的价格也比较亲民。如果选用GeForce系列的游戏卡应该能进一步压缩成本，而且效果并不会差太多。写这篇文章时已经换到了RTX 3060 12G ,0.54/小时太香了😀以下均以恒源云为例，其他平台大同小异，注意文件目录。</p> <blockquote> <p>为什么不使用免费的Colab ：首先，由于<em><strong>众所周知的原因</strong></em>，大陆无法正常访问谷歌。其次，Colab 目前更改了服务策略，一段时间不使用将会收回资源，这对于需要长时间训练模型的程序来说是不可接受的。</p> <p>如果你会<em><strong>魔法</strong></em>并且对于自己的<em><strong>网络施法工具</strong></em>有信心，可以试试在Colab 上部署： <a class="link" href="https://colab.research.google.com/github/svc-develop-team/so-vits-svc/blob/4.0/sovits4_for_colab.ipynb" target="_blank" rel="noopener" >https://colab.research.google.com/github/svc-develop-team/so-vits-svc/blob/4.0/sovits4_for_colab.ipynb</a></p> </blockquote> <p><font color=#7FFF00>关于该项目的<strong>本地化</strong>使用，睿站已经有很详细的保姆级教程了，参见 https://www.bilibili.com/video/BV1H24y187Ko 本文只是介绍云端部署时的主要流程、遇到的报错及解决办法。</font>（一定要看！）</p> <blockquote> <p>一般情况下GPU 服务器均为Linux 系统，需要Windows 图形界面的可以去腾讯和阿里这些平台看看。关于上述视频发布的整合包只适用于Windows 系统，要在Linux 上运行可以考虑使用<code>Wine </code> 。</p> </blockquote> <hr> <h1 id="准备工作">准备工作</h1> <p>租借一张显卡，创建一个实例，然后在公共网盘处授权，以便后续下载数据集。进入<code>JupyterLab</code> ,选择<code>terminal</code> 终端。依次执行下列命令下载cli 工具：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#安装cli</span> </span></span><span class="line"><span class="cl">curl -L https://download.gpushare.com/download/gpushare-cli-linux -o /usr/local/bin/gpushare-cli </span></span><span class="line"><span class="cl">chmod u+x /usr/local/bin/gpushare-cli </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="c1">#验证是否安装成功</span> </span></span><span class="line"><span class="cl">gpushare-cli version </span></span></code></pre></td></tr></table> </div> </div><p>如果服务器抽风下载很慢建议复制https 地址到浏览器手动下载然后上传到实例。或者直接释放，重开一台实例。</p> <p>依次执行下列命令安装解压工具：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">apt-get update </span></span><span class="line"><span class="cl">apt-get install p7zip-full -y </span></span></code></pre></td></tr></table> </div> </div><p>将处理好的数据集压缩并上传到网盘。</p> <h1 id="预处理">预处理</h1> <p>准备工作就绪，下面开始部署项目。注意切换到数据盘<code>cd hy-tmp</code> ,别把系统盘给干废了。先把项目扒到本地：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">git clone https://github.com/svc-develop-team/so-vits-svc.git </span></span></code></pre></td></tr></table> </div> </div><p>这时出现了第一个报错：</p> <p><img src="https://fallen.wang/p/sovits/e1.jpg" width="619" height="119" srcset="https://fallen.wang/p/sovits/e1_hu2e6e230a4dc37465aeed5f7d900a61b8_16122_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/sovits/e1_hu2e6e230a4dc37465aeed5f7d900a61b8_16122_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="error1" class="gallery-image" data-flex-grow="520" data-flex-basis="1248px" ></p> <p>clone 出错，不用想，肯定是GFW 在作妖。~~GFW 你坏事做尽！~~如果是本地，我会直接改hosts 或者使用DevSideCar ，或者干脆开<em><strong>魔法</strong></em>全局加速，然而在Linux 上这些操作都比较繁琐，所以我会使用<code>gitclone</code> 代理：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">git clone https://gitclone.com/github.com/svc-develop-team/so-vits-svc.git </span></span></code></pre></td></tr></table> </div> </div><p>这时应该很快就扒下来了。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#进入数据集目录</span> </span></span><span class="line"><span class="cl"><span class="nb">cd</span> /hy-tmp/so-vits-svc/dataset_raw </span></span><span class="line"><span class="cl"><span class="c1">#登陆网盘，注意用户名和密码是控制台的用户名密码</span> </span></span><span class="line"><span class="cl">gpushare-cli login -u 你的用户名 -p 你的密码 </span></span></code></pre></td></tr></table> </div> </div><p>以百度网盘为例</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">#展开网盘内容 </span></span><span class="line"><span class="cl">gpushare-cli baidu ls </span></span></code></pre></td></tr></table> </div> </div><p>找到已经处理好的数据集</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#下载数据集</span> </span></span><span class="line"><span class="cl">gpushare-cli baidu down /网盘中数据集的路径 /hy-tmp/so-vits-svc/dataset_raw </span></span></code></pre></td></tr></table> </div> </div><p>使用<code>7z</code>命令解压：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">7z x 数据集名称.zip -o/hy-tmp/so-vits-svc/dataset_raw </span></span></code></pre></td></tr></table> </div> </div><p><code>unzip</code> 命令也是可以的，但是遇到大文件容易报错。</p> <p>接下来安装运行库：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#回到上级目录</span> </span></span><span class="line"><span class="cl"><span class="nb">cd</span> /hy-tmp/so-vits-svc </span></span></code></pre></td></tr></table> </div> </div><div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#安装运行库，后续如果提示缺少某模块那就单独pip安装一次，例如pip install librosa</span> </span></span><span class="line"><span class="cl">pip install -r requirements.txt </span></span></code></pre></td></tr></table> </div> </div><p>待安装完成后依次运行下列命令开始预处理：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-python" data-lang="python"><span class="line"><span class="cl"><span class="c1">#重采样</span> </span></span><span class="line"><span class="cl"><span class="n">python</span> <span class="n">resample</span><span class="o">.</span><span class="n">py</span> </span></span><span class="line"><span class="cl"><span class="c1">#预处理配置</span> </span></span><span class="line"><span class="cl"><span class="n">python</span> <span class="n">preprocess_flist_config</span><span class="o">.</span><span class="n">py</span> </span></span><span class="line"><span class="cl"><span class="c1">#预处理hubert和f0</span> </span></span><span class="line"><span class="cl"><span class="n">python</span> <span class="n">preprocess_hubert_f0</span><span class="o">.</span><span class="n">py</span> </span></span></code></pre></td></tr></table> </div> </div><p>此时出现第二次报错：</p> <p><img src="https://fallen.wang/p/sovits/e2.jpg" width="643" height="242" srcset="https://fallen.wang/p/sovits/e2_hu7b5db90ff83acd2ba33992b51dddb2d2_40284_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/sovits/e2_hu7b5db90ff83acd2ba33992b51dddb2d2_40284_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="error2" class="gallery-image" data-flex-grow="265" data-flex-basis="637px" ></p> <p>缺少<strong>checkpoint_best_legacy_500.pt</strong> 文件。文档中说这是一个预训练模型，我们可以<code>wget</code> 下载：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">wget hubert/ http://obs.cstcloud.cn/share/obs/sankagenkeshi/checkpoint_best_legacy_500.pt -P /hy-tmp/so-vits-svc/hubert </span></span></code></pre></td></tr></table> </div> </div><p>下载完成后再次执行<code>python preprocess_hubert_f0.py</code> 。此时应该还有一次报错，但不影响运行，程序开始生成<code>hubert</code> 和<code>f0</code> 文件。</p> <h1 id="训练">训练</h1> <p>生成完毕后就可以开始训练了。由于训练需要很长时间，建议使用<code>tmux</code> ，这样即使关闭了ssh 程序还能继续运行。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">tmux new -s 会话名称 </span></span></code></pre></td></tr></table> </div> </div><p>在新建的会话窗口执行训练命令：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-python" data-lang="python"><span class="line"><span class="cl"><span class="n">python</span> <span class="n">train</span><span class="o">.</span><span class="n">py</span> <span class="o">-</span><span class="n">c</span> <span class="n">configs</span><span class="o">/</span><span class="n">config</span><span class="o">.</span><span class="n">json</span> <span class="o">-</span><span class="n">m</span> <span class="mi">44</span><span class="n">k</span> </span></span></code></pre></td></tr></table> </div> </div><p>出现train epoch 时表示开始训练了。<img src="https://fallen.wang/p/sovits/train.jpg" width="683" height="216" srcset="https://fallen.wang/p/sovits/train_hu98231c622709f99ee761a9b65f6d1d5d_36831_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/sovits/train_hu98231c622709f99ee761a9b65f6d1d5d_36831_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="train" class="gallery-image" data-flex-grow="316" data-flex-basis="758px" ></p> <h1 id="推理">推理</h1> <p>训练到合适的步数就可以开始推理，参考官方文档：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">python inference_main.py -m <span class="s2">&#34;logs/44k/G_30400.pth&#34;</span> -c <span class="s2">&#34;configs/config.json&#34;</span> -s <span class="s2">&#34;nen&#34;</span> -n <span class="s2">&#34;君の知らない物語-src.wav&#34;</span> -t <span class="m">0</span> </span></span></code></pre></td></tr></table> </div> </div><p>其中<code>-m</code> 是模型的路径，G 后面的数字代表训练步数；<code>-c</code> 是配置文件的路径；<code>-s</code> 是说话者的名字，也就是数据集文件夹的名称；</p> <p><code>-n</code> 是歌声片段，需手动上传至<code>/raw</code> 文件夹;<code>-t</code> 是移调，正负值均可，如<code>-12</code> 就是降低一个八度，<code>7</code> 就是升高一个纯五度。</p> <p>（QAQ乐理有什么难的？.jpg）其他可选参数见官方文档：https://github.com/svc-develop-team/so-vits-svc#-inference</p> <p>如果觉得推理这一步过于复杂可以参考前述视频的整合包，那个有图形界面，而且相比于推理，吃的配置稍微低一些，GTX 1650 可以跑个30 秒左右的音频。可以在云端训练然后把训练好的模型下载到本地进行推理。</p> <p>至此云端部署过程结束。这是直接<code>git clone</code> 的项目，所以报错较少。如果头铁一定要在Linux 下运行适用于Windows 的整合包那么报错会非常多。</p> <h1 id="qa">Q&amp;A</h1> <blockquote> <p>Q：需要的环境和框架？</p> <p>A：支持CUDA 的N 卡，Python 3.8 ，Pytorch 。</p> </blockquote> <blockquote> <p>Q：如何查看显驱对应的CUDA版本？</p> <p>A：Linux 使用<code>nvcc -v</code> ,Windows 使用<code>nvidia-smi.exe</code> ，注意CUDA版本大于等于11.7请下载11.7。</p> </blockquote> <blockquote> <p>Q：看不懂的和CUDA有关的报错？</p> <p>A：大概率爆显存了，改<code>Batch Size</code> （参考前述视频）</p> </blockquote> <blockquote> <p>Q：CUDA版本不对？</p> <p>A：安装这三个库（注意torch 、CUDA 以及系统版本，以CUDA11.7 、torch 1.13 、Windows 64 位为例）：①https://download.pytorch.org/whl/cu117/torch-1.13.0%2Bcu117-cp310-cp310-win_amd64.whl，②https://download.pytorch.org/whl/cu117/torchaudio-0.13.0%2Bcu117-cp310-cp310-win_amd64.whl ,③https://download.pytorch.org/whl/cu117/torchvision-0.14.0%2Bcu117-cp310-cp310-win_amd64.whl</p> <p>由于<strong>众所周知的原因</strong>这几个包下载会很慢，有能力请使用<strong>魔法</strong>。下载完之后别忘了安装：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl">pip install .<span class="se">\t</span>orch-1.13.0+cu117-cp310-cp310-win_amd64.whl </span></span><span class="line"><span class="cl">pip install .<span class="se">\t</span>orchaudio-0.13.0+cu117-cp310-cp310-win_amd64.whl </span></span><span class="line"><span class="cl">pip install .<span class="se">\t</span>orchvision-0.14.0+cu117-cp310-cp310-win_amd64.whl </span></span></code></pre></td></tr></table> </div> </div></blockquote> <blockquote> <p>Q：为什么运行不了整合包里的批处理？</p> <p>A：那个是为Windows 写的，而你使用的是Linux 服务器。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span><span class="lnt">7 </span><span class="lnt">8 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-bash" data-lang="bash"><span class="line"><span class="cl"><span class="c1">#安装Wine</span> </span></span><span class="line"><span class="cl">apt-get install wine </span></span><span class="line"><span class="cl"><span class="c1">#在Wine 中运行批处理</span> </span></span><span class="line"><span class="cl">Wine /hy-tmp/so-vits-svc/批处理名称.bat </span></span><span class="line"><span class="cl"><span class="c1">#如果上一条命令无效请在Wine 中运行命令行，在命令行中运行批处理</span> </span></span><span class="line"><span class="cl">Wine cmd </span></span><span class="line"><span class="cl"><span class="nb">cd</span> /hy-tmp/so-vits-svc </span></span><span class="line"><span class="cl">批处理名称.bat </span></span></code></pre></td></tr></table> </div> </div></blockquote> <blockquote> <p>Q:明明是N 卡，但是还是提示不支持CPU 训练是怎么回事？</p> <p>A:驱动或者CUDA 版本不对，无法识别。</p> </blockquote> <p>其他报错请移步前述视频评论区。</p>

给博客换了个stack主题

<img src="https://fallen.wang/p/stack-build/cover.jpg" alt="Featured image of post 给博客换了个stack主题" /><p>写了两年的blog，因为一些不可抗力挂了。只有为数不多的几篇做了备份，遂转战GitHub托管静态博客。这近一年玩了玩Hexo、Jekyll和Hugo，感觉还是Hugo爽，渲染速度飞起。主题少，看这个Stack还挺好就试了试，结果踩了一堆坑，<strong>而且这货的官方文档就是一坨答辩</strong>，相对来说用户也少一些，踩坑了也搜不到解决办法。</p> <p>首先不推荐用他的快速模板，总是出bug。还是老实一点clone到本地，<code>git clone https://github.com/CaiJimmy/hugo-theme-stack/ themes/hugo-theme-stack</code>，对<code>config</code>进行修改后push到GitHub仓库。<strong>这里有一个大坑</strong>：</p> <p>GitHub默认push的是<code>main</code>分支：</p> <p><img src="https://fallen.wang/p/stack-build/main_branch.jpg" width="758" height="302" srcset="https://fallen.wang/p/stack-build/main_branch_hu9a6780d04969979093e01e32cd1a0af4_20074_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/stack-build/main_branch_hu9a6780d04969979093e01e32cd1a0af4_20074_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="main_branch" class="gallery-image" data-flex-grow="250" data-flex-basis="602px" ></p> <p>而Stack触发分支是<code>master</code>分支：</p> <p><img src="https://fallen.wang/p/stack-build/master_branch.jpg" width="644" height="377" srcset="https://fallen.wang/p/stack-build/master_branch_hu5f583876a681aa20d559c65aea8678f7_21228_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/stack-build/master_branch_hu5f583876a681aa20d559c65aea8678f7_21228_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="master_branch" class="gallery-image" data-flex-grow="170" data-flex-basis="409px" ></p> <p>若不将此处<code>master</code>改为<code>main</code>工作流是无法正常运行的。设置了<code>main</code>分支后工作流会自动创建一个<code>gh_page</code>分支，在设置里将GitHub Page设置为来自<code>gh_page</code>分支即可正常展示。</p> <p>接着是评论区，默认的是disqus，由于一些众所周知的原因在大陆是无法访问的。在<code>params.toml</code>中似乎可以配置 其他评论插件，还没有仔细研究。一定要用disqus的话也可以使用disqusjs，或者用国外的vps写一个很简单的反向代理即可。<del>不过相比之下Git talk更符合我的审美，况且本来就是部署在GitHub上的博客，何必再舍近求远呢</del> 更新：waline永远滴神( ･´ω`･ )</p> <p>还有侧边目录又是一个大坑。不仅要在<code>params.toml</code>中<code>[artical]</code>添加<code>toc = true</code>，还需要将<code>markup.toml</code>中<code>unsafe = false</code>改为<code>unsafe = true</code>，否则无法加载html元素。此外，还有<code>[tableOfContents]</code>中<code>startLevel</code>需要设置为<code>1</code>。TAT</p> <p>待续</p>

一次破解水卡的尝试

<img src="https://fallen.wang/p/mifare-crack/cover.jpg" alt="Featured image of post 一次破解水卡的尝试" /><body> <div id="dialog" style="display: none; position: fixed; top: 0; left: 0; width: 100%; height: 100%; background-color: rgba(0, 0, 0, 0.5); z-index: 9999;"> <div style="position: absolute; top: 50%; left: 50%; transform: translate(-50%, -50%); background-color: white; padding: 20px; border-radius: 5px;"> <p><font color=#FF0000>**本文仅为探讨M1 卡加密原理，文中所述卡片均已格式化并物理销毁，如有利用该算法恶意刷取金额，所造成的任何问题及由此产生的一切后果由您自行承担！**</font></p> <button onclick="closeDialog()" style="background-color: #4CAF50; color: white; border: none; padding: 10px 20px; text-align: center; text-decoration: none; display: inline-block; font-size: 16px; border-radius: 5px; cursor: pointer;">我已知晓并同意</button> </div> </div> <script> window.onload = function() { openDialog(); } function openDialog() { document.getElementById('dialog').style.display = 'block'; } function closeDialog() { document.getElementById('dialog').style.display = 'none'; } </script> </body> <p><strong><font color=#FF6100>仅供技术交流使用，请勿用于违法用途，否则后果自负！</font></strong></p> <p>[TOC]</p> <h1 id="前言">前言</h1> <p>本文只针对IC 卡下属的Mifare Classic 1k (简称M1 卡，目前国内大多数校园卡、公交卡、门禁卡等都在此列)，其包含了16 个扇区，每个扇区有0-3 共4 个块，每块16 字节，共1024 字节。</p> <p><strong>只对离线数据有效！</strong>（例如，充值后需要去激活器上刷卡激活的卡片。部分卡片同时存储了离线数据和在线数据，如即充即用的圈存数据，和充值后需要刷卡激活的水卡数据，则只能修改后者。在线数据存储在服务器中，即使修改了本地缓存也无效）</p> <p>如何确认自己的卡是否属于M1 卡？可以使用带NFC功能的安卓手机进行检测。（参考正文第一段<strong>准备</strong>中的Mifare Classic Tool 软件）将卡片紧贴手机，打开软件，选择工具&gt;显示标签信息&gt;若出现如下截图：<img src="https://fallen.wang/p/mifare-crack/mct.jpg" width="1080" height="2400" srcset="https://fallen.wang/p/mifare-crack/mct_hu168d064fece5b0f17bdc512d791cea9d_222913_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/mifare-crack/mct_hu168d064fece5b0f17bdc512d791cea9d_222913_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="注意Tag Type属性" class="gallery-image" data-flex-grow="45" data-flex-basis="108px" ></p> <p>标签类型为MIFARE Classic 的即为M1 卡，其中SAK 值为08 代表s50 型号，18 代表s70 型号</p> <h1 id="一准备">一.准备</h1> <p>·需要准备的硬件：</p> <blockquote> <p>一台有USB 接口的计算机</p> <p>一部有NFC 功能的安卓手机</p> <p>PN532 ，某宝上有集成板，约30 元</p> <p>若干张水卡</p> <p>一个健全的大脑</p> </blockquote> <p>·需要准备的软件：</p> <blockquote> <p>PC端：PN532 配套软件（链接：https://pan.baidu.com/s/1-FrJKKnw1JbR4lnyaRR22A?pwd=wa2v 提取码：wa2v 解压密码：pn532</p> <p>安卓端：Mifare Classic Tool（链接：https://pan.baidu.com/s/11x10vu_GMiNZoJp5igiaHg?pwd=zc0y 提取码：zc0y ）</p> </blockquote> <h1 id="二读取数据">二.读取数据</h1> <p>安装pn532 驱动后打开软件，准备若干张水卡。依次点击串口，连接设备，开始解卡，此时软件开始读取数据。</p> <p><img src="https://fallen.wang/p/mifare-crack/pn532start.png" width="430" height="291" srcset="https://fallen.wang/p/mifare-crack/pn532start_hu4989f62d343d09ed632bbecf1095d516_30589_480x0_resize_box_3.png 480w, https://fallen.wang/p/mifare-crack/pn532start_hu4989f62d343d09ed632bbecf1095d516_30589_1024x0_resize_box_3.png 1024w" loading="lazy" alt="主界面" class="gallery-image" data-flex-grow="147" data-flex-basis="354px" ></p> <p>成功破解后当前卡片的数据会在表A 中列出。可以看到每个扇区都有4 个块，其中0-2 块储存数据，3 块储存密钥及控制位。</p> <p><img src="https://fallen.wang/p/mifare-crack/dumpintro.png" width="404" height="193" srcset="https://fallen.wang/p/mifare-crack/dumpintro_hu65593e83ec2e65c126e7de0092cf0076_7973_480x0_resize_box_3.png 480w, https://fallen.wang/p/mifare-crack/dumpintro_hu65593e83ec2e65c126e7de0092cf0076_7973_1024x0_resize_box_3.png 1024w" loading="lazy" alt="扇区和块" class="gallery-image" data-flex-grow="209" data-flex-basis="502px" ></p> <h1 id="三分析数据">三.分析数据</h1> <p>将读取到的数据保存，然后去消费一定数量金额，再次解卡。将上一次保存的数据导入到表B 中，然后对比数据。可以发现，只有第10 扇区数据发生了变化，因此可以得出结论，金额数据存储在第10 扇区。</p> <p><img src="https://fallen.wang/p/mifare-crack/908906.png" width="851" height="180" srcset="https://fallen.wang/p/mifare-crack/908906_hu906b06ce2a056f8da89ae18215a9102a_16014_480x0_resize_box_3.png 480w, https://fallen.wang/p/mifare-crack/908906_hu906b06ce2a056f8da89ae18215a9102a_16014_1024x0_resize_box_3.png 1024w" loading="lazy" alt="数据对比" class="gallery-image" data-flex-grow="472" data-flex-basis="1134px" ></p> <p>观察表A和表B前两个块的数据发现，第三、四字节的数据分别为<code>038A</code> ，<code>038C</code> ，<code>038E</code> ，成等差数列。打开计算机自带的计算器，切换到程序员模式，选择十六进制（HEX ），输入<code>038A</code> ，得到对应的十进制数值（DEC ）为906 。而此时卡里的金额为9.06 元，前一次消费时金额9.08 也与<code>038C</code> 对应，基本可以确定前四个字节存储的是金额。由于消费金额较少（0.02 ），可能会出现如图两块数据只有一块数据改变的情况。金额一旦确定，剩下的便是校验位的问题。为防止篡改，卡片会有一个安全算法，对金额进行加密。由于中间部分没有发生变化，所以可以合理假设最后两个字节为校验位。</p> <p>一般来说校验位算法比较复杂，可能涉及异或、取反等多种运算，而我们现有的数据太少难以发现规律，因此首先可以考虑克隆。由于掌握了密钥，我们可以对卡里的数据进行复制和更改。消费掉一定金额后，将表A的数据再次刷入，然后观察读卡器，金额又变回了9.06 ，这一思路是可行的。但是多次以同一金额重复刷卡测试会导致卡片锁死（惨痛教训），除非本来卡内金额较多可以支撑长时间使用外，我们不得不考虑更改数据。</p> <p>然而要更改数据必然涉及到校验位算法。前前后后忙活了近一年，仍然没有取得实质性进展。然而某一天阅读维修文档时发现，有一类卡片报错是由于<u>CRC 校验错误</u>引起的。这给我带来了灵感，我并不需要知道具体的校验算法是什么，只要能得到校验后的数据就行。可以参考这个在线计算CRC 的网站：https://www.lammertbies.nl/comm/info/crc-calculation，选择HEX 模式，将第一块的数据复制进去，得到<code>0000038a00000000000000000000271f</code> 的CRC-16 校验值为<code>F0BE</code> ，而第二块数据<code>0000038c000000000000000000003997</code> 的CRC-16 校验值也是<code>F0BE</code> 。</p> <p><img src="https://fallen.wang/p/mifare-crack/f0be1.png" width="543" height="442" srcset="https://fallen.wang/p/mifare-crack/f0be1_hue85776b8aa6d63413d863c4bb78aab31_38865_480x0_resize_box_3.png 480w, https://fallen.wang/p/mifare-crack/f0be1_hue85776b8aa6d63413d863c4bb78aab31_38865_1024x0_resize_box_3.png 1024w" loading="lazy" alt="注意选择HEX模式,CRC-16校验" class="gallery-image" data-flex-grow="122" data-flex-basis="294px" ></p> <p><img src="https://fallen.wang/p/mifare-crack/f0be2.png" width="549" height="424" srcset="https://fallen.wang/p/mifare-crack/f0be2_hu16b5c51d1813bf758fce256ed57beac3_37997_480x0_resize_box_3.png 480w, https://fallen.wang/p/mifare-crack/f0be2_hu16b5c51d1813bf758fce256ed57beac3_37997_1024x0_resize_box_3.png 1024w" loading="lazy" alt="CRC-16校验值相同" class="gallery-image" data-flex-grow="129" data-flex-basis="310px" ></p> <p>同理,对表B的数据进行验证，校验值 依然是<code>F0BE</code> 。也就是说，无论这个神秘的校验算法是什么，最终整个块的CRC-16 校验值是不变的，因此我们有了这样一个逆向思路：</p> <blockquote> <p>输入我想要的金额→校验算法对金额加密并输出到最后两字节→整体CRC-16 校验值不变，为<code>F0BE</code> →穷举最后两字节16×16×16×16＝65536 种可能组合，与块中前14 个不变字节拼接并分别计算CRC-16 校验值→找到校验值同为<code>F0BE</code> 的组合→其末尾两个字节即为我们需要的校验算法得到的数据</p> </blockquote> <p>人工计算65536 个16 字节字符串显然不现实，这里使用Python 辅助。C 语言和Java 同理。</p> <h1 id="四破解">四.破解</h1> <p>(由于对CRC 并不熟悉，所以代码让ChatGPT 写了个模板，自己稍微改了改，这时候就觉得人工智能真牛逼QAQ)</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt"> 1 </span><span class="lnt"> 2 </span><span class="lnt"> 3 </span><span class="lnt"> 4 </span><span class="lnt"> 5 </span><span class="lnt"> 6 </span><span class="lnt"> 7 </span><span class="lnt"> 8 </span><span class="lnt"> 9 </span><span class="lnt">10 </span><span class="lnt">11 </span><span class="lnt">12 </span><span class="lnt">13 </span><span class="lnt">14 </span><span class="lnt">15 </span><span class="lnt">16 </span><span class="lnt">17 </span><span class="lnt">18 </span><span class="lnt">19 </span><span class="lnt">20 </span><span class="lnt">21 </span><span class="lnt">22 </span><span class="lnt">23 </span><span class="lnt">24 </span><span class="lnt">25 </span><span class="lnt">26 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-python" data-lang="python"><span class="line"><span class="cl"><span class="kn">import</span> <span class="nn">binascii</span> </span></span><span class="line"><span class="cl"><span class="kn">import</span> <span class="nn">crcmod</span> </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="c1"># 定义计算CRC16校验值的函数</span> </span></span><span class="line"><span class="cl"><span class="k">def</span> <span class="nf">crc16</span><span class="p">(</span><span class="n">data</span><span class="p">):</span> </span></span><span class="line"><span class="cl"> <span class="n">crc16_func</span> <span class="o">=</span> <span class="n">crcmod</span><span class="o">.</span><span class="n">predefined</span><span class="o">.</span><span class="n">Crc</span><span class="p">(</span><span class="s1">&#39;crc-16&#39;</span><span class="p">)</span> </span></span><span class="line"><span class="cl"> <span class="n">crc16_func</span><span class="o">.</span><span class="n">update</span><span class="p">(</span><span class="n">data</span><span class="p">)</span> </span></span><span class="line"><span class="cl"> <span class="k">return</span> <span class="n">crc16_func</span><span class="o">.</span><span class="n">hexdigest</span><span class="p">()</span> </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="c1"># 打开shuju.txt文件并穷举65536个字符串</span> </span></span><span class="line"><span class="cl"><span class="k">with</span> <span class="nb">open</span><span class="p">(</span><span class="s2">&#34;shuju.txt&#34;</span><span class="p">,</span> <span class="s2">&#34;w&#34;</span><span class="p">)</span> <span class="k">as</span> <span class="n">f</span><span class="p">:</span> </span></span><span class="line"><span class="cl"> <span class="n">hex_data</span> <span class="o">=</span> <span class="nb">input</span><span class="p">(</span><span class="s2">&#34;请输入16进制数据：&#34;</span><span class="p">)</span> </span></span><span class="line"><span class="cl"> <span class="k">for</span> <span class="n">i</span> <span class="ow">in</span> <span class="nb">range</span><span class="p">(</span><span class="mi">65536</span><span class="p">):</span> </span></span><span class="line"><span class="cl"> <span class="n">new_data</span> <span class="o">=</span> <span class="nb">hex</span><span class="p">(</span><span class="n">i</span><span class="p">)[</span><span class="mi">2</span><span class="p">:]</span><span class="o">.</span><span class="n">zfill</span><span class="p">(</span><span class="mi">4</span><span class="p">)</span><span class="o">.</span><span class="n">upper</span><span class="p">()</span> </span></span><span class="line"><span class="cl"> <span class="n">f</span><span class="o">.</span><span class="n">write</span><span class="p">(</span><span class="n">hex_data</span> <span class="o">+</span> <span class="n">new_data</span> <span class="o">+</span> <span class="s2">&#34;</span><span class="se">\n</span><span class="s2">&#34;</span><span class="p">)</span> </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="c1"># 打开shuju.txt文件并计算每个字符串的CRC16校验值</span> </span></span><span class="line"><span class="cl"><span class="k">with</span> <span class="nb">open</span><span class="p">(</span><span class="s1">&#39;shuju.txt&#39;</span><span class="p">,</span> <span class="s1">&#39;r&#39;</span><span class="p">)</span> <span class="k">as</span> <span class="n">f</span><span class="p">:</span> </span></span><span class="line"><span class="cl"> <span class="n">lines</span> <span class="o">=</span> <span class="n">f</span><span class="o">.</span><span class="n">readlines</span><span class="p">()</span> </span></span><span class="line"><span class="cl"> </span></span><span class="line"><span class="cl"><span class="c1"># 将字符串及其CRC16校验值输出到shuju_crc.txt中</span> </span></span><span class="line"><span class="cl"><span class="k">with</span> <span class="nb">open</span><span class="p">(</span><span class="s1">&#39;shuju_crc.txt&#39;</span><span class="p">,</span> <span class="s1">&#39;w&#39;</span><span class="p">)</span> <span class="k">as</span> <span class="n">f</span><span class="p">:</span> </span></span><span class="line"><span class="cl"> <span class="k">for</span> <span class="n">line</span> <span class="ow">in</span> <span class="n">lines</span><span class="p">:</span> </span></span><span class="line"><span class="cl"> <span class="n">data</span> <span class="o">=</span> <span class="n">binascii</span><span class="o">.</span><span class="n">unhexlify</span><span class="p">(</span><span class="n">line</span><span class="o">.</span><span class="n">strip</span><span class="p">())</span> </span></span><span class="line"><span class="cl"> <span class="n">crc</span> <span class="o">=</span> <span class="n">crc16</span><span class="p">(</span><span class="n">data</span><span class="p">)</span> </span></span><span class="line"><span class="cl"> <span class="n">f</span><span class="o">.</span><span class="n">write</span><span class="p">(</span><span class="s1">&#39;</span><span class="si">{}</span><span class="s1"> </span><span class="si">{}</span><span class="se">\n</span><span class="s1">&#39;</span><span class="o">.</span><span class="n">format</span><span class="p">(</span><span class="n">line</span><span class="o">.</span><span class="n">strip</span><span class="p">(),</span> <span class="n">crc</span><span class="p">))</span> </span></span></code></pre></td></tr></table> </div> </div><p>例如，将金额设置为100 元，在计算器中输入10000 ，可知对应的16 进制数值为<code>2710</code> ，运行上述代码，输入前14 个不变字节<code>0000271000000000000000000000</code> ，程序将会在末尾加上从<code>0000</code> 递增到 <code>FFFF</code> 的字符串，并将这65536 个新的字符串输出到<code>shuju.txt</code> 中。接着对这些数据分别计算CRC-16 校验值，并将原始数据和对应的校验值输出到<code>shuju_crc.txt</code> 中。</p> <p>由于CRC-16 涉及到多项式计算，65536 个数据可能对CPU 有一定要求，以我为例，穷举过程只用了不到0.5 秒，计算CRC则用了约15 秒。结束后得到如下数据：</p> <p><img src="https://fallen.wang/p/mifare-crack/8bb5.png" width="586" height="733" srcset="https://fallen.wang/p/mifare-crack/8bb5_hu9b5e445e627b6696f193371e15dd24f5_46873_480x0_resize_box_3.png 480w, https://fallen.wang/p/mifare-crack/8bb5_hu9b5e445e627b6696f193371e15dd24f5_46873_1024x0_resize_box_3.png 1024w" loading="lazy" alt="注意是shuju_crc.txt，不是shuju.txt" class="gallery-image" data-flex-grow="79" data-flex-basis="191px" ></p> <p>按<code>crtl</code>+<code>F</code> 呼出查找界面，查找<code>F0BE</code> 应该会有两个结果，一个是作为穷举数据出现在原字符串末尾的；另一个是作为CRC-16 计算结果，与原始字符串间隔了一个空格的，我们需要的是后者。如图，看到该字符串结尾是<code>8BB5</code> ，即<code>2710 </code>经过神秘校验算法得到的数值为<code>8BB5</code> 。同理，我们对99.98 对应的16 进制数据<code>270E</code> 进行如上操作，得到末尾两字节为<code>EB9D</code> 。此时我们将<code>00002710000000000000000000008BB5</code> 和<code>0000270E00000000000000000000EB9D</code> 刷入第10 扇区的前两个块，然后任意消费验证，金额变成了100 元。至此M1 卡破解完毕。</p> <hr> <h1 id="五后续">五.后续</h1> <p>仅仅是破解了CRC 校验并没有让我满足，毕竟至今我还未曾解开校验算法的神秘面纱。以及，每张卡的密钥是不同的，且似乎与卡号有着某种联系。遗憾的是对于异或、取余、取反等运算不够熟悉，且样本量太小，还没有头绪。先挖个坑吧，将来有机会一定补上。</p> <p><img src="https://fallen.wang/p/mifare-crack/caogao.jpg" width="4608" height="3131" srcset="https://fallen.wang/p/mifare-crack/caogao_hu7afe1bc5671a417c1f7b0e6df3eb7ff2_1103361_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/mifare-crack/caogao_hu7afe1bc5671a417c1f7b0e6df3eb7ff2_1103361_1024x0_resize_q75_box.jpg 1024w" loading="lazy" alt="草稿" class="gallery-image" data-flex-grow="147" data-flex-basis="353px" ></p> <p><strong><font color=#FF0000>本文仅为探讨M1 卡加密原理，文中所述卡片均已格式化并物理销毁，如有利用该算法恶意刷取金额，所造成的任何问题及由此产生的一切后果由您自行承担！</font></strong></p>

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gradlew构建apk时报错

<img src="https://fallen.wang/p/gradle/cover.jpg" alt="Featured image of post gradlew构建apk时报错" /><blockquote> <p>①**<font color=#ff0000>简</font><font color=#ffa3c7>中</font><font color=#b5a3a7>互</font><font color=#f00fff>联</font><font color=#3d9142>网</font><font color=#4169e1>社</font><font color=#7fff00>区</font><font color=#ffd700>就</font><font color=#802a2a>是</font><font color=#4169e1>一</font><font color=#40e0d0>个</font><font color=#fff500>粪</font><font color=#33a1c9>坑</font>**</p> <p>②<strong>Fuck CSDN</strong></p> <p>③<strong>Fuck Baidu</strong></p> </blockquote> <p><del>百度你就吃烂钱吧 迟早倒闭 还有csdn 呕 屏蔽csdn 人人有责</del></p> <p><del>许多问题去bing 上搜索效率能提高十倍 会魔法的直接去谷歌和Stack Overflow 这不比粪坑里淘金舒服？</del></p> <hr> <p>在GitHub 上看到一个比较有意思的开源项目，但是只有源码没有<code>release </code>，所以<code>clone </code>到本地尝试运行<code>gradlew.bat</code> 编译。命令行一闪而过，还没看清报错信息就没了。之前没有接触过gradle ,粪坑里搜了半天全是csdn 互相抄的不知所云的🐶💩，最后在某小众论坛看到有人提了一嘴，要在命令行中运行。</p> <p><code>cd </code> 到项目目录再运行，果不其然又报错了：<img src="https://fallen.wang/p/gradle/e1.jpg" width="1222" height="639" srcset="https://fallen.wang/p/gradle/e1_hu931b16557088f52b47a3c3cf16fd7cc2_53643_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/gradle/e1_hu931b16557088f52b47a3c3cf16fd7cc2_53643_1024x0_resize_q75_box.jpg 1024w" loading="lazy" class="gallery-image" data-flex-grow="191" data-flex-basis="458px" ></p> <p>瞄了一眼项目目录似乎没有<code>local.properties </code> ，那就新建一个。查了一下要在这个文件中声明SDK 的路径。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-java" data-lang="java"><span class="line"><span class="cl"><span class="n">sdk</span><span class="o">.</span><span class="na">dir</span><span class="o">=</span> <span class="n">C</span><span class="o">:</span><span class="err">\</span><span class="n">Users</span><span class="err">\用户名\</span><span class="n">AppData</span><span class="err">\</span><span class="n">Local</span><span class="err">\</span><span class="n">Android</span><span class="err">\</span><span class="n">Sdk</span> </span></span></code></pre></td></tr></table> </div> </div><p>再次运行，依然报错：<img src="https://fallen.wang/p/gradle/e2.jpg" width="1195" height="378" srcset="https://fallen.wang/p/gradle/e2_hue3e1d675f738744e71d3891fc4a69c8a_34929_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/gradle/e2_hue3e1d675f738744e71d3891fc4a69c8a_34929_1024x0_resize_q75_box.jpg 1024w" loading="lazy" class="gallery-image" data-flex-grow="316" data-flex-basis="758px" ></p> <p>这次的报错很明了：我们声明的SDK 的路径与报错中的路径不符，添加转义符即可。</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-java" data-lang="java"><span class="line"><span class="cl"><span class="n">sdk</span><span class="o">.</span><span class="na">dir</span><span class="o">=</span> <span class="n">C</span><span class="err">\</span><span class="o">:</span><span class="err">\\</span><span class="n">Users</span><span class="err">\\</span><span class="n">Joe</span><span class="err">\\</span><span class="n">AppData</span><span class="err">\\</span><span class="n">Local</span><span class="err">\\</span><span class="n">Android</span><span class="err">\\</span><span class="n">Sdk</span> </span></span></code></pre></td></tr></table> </div> </div><p>再次运行批处理即可。</p> <p>然而此时还未能构建出apk 安装包，</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-shell" data-lang="shell"><span class="line"><span class="cl"><span class="c1">#清理build文件夹</span> </span></span><span class="line"><span class="cl">gradlew clean </span></span><span class="line"><span class="cl"><span class="c1">#打包</span> </span></span><span class="line"><span class="cl">gradlew assembleRelease </span></span></code></pre></td></tr></table> </div> </div><p>报错：<code>Error:Unable to start the daemon process.</code></p> <p>这时需要修改<code>gradle.properties </code> 中<code>org.gradle.jvmargs=-Xmx1536m </code> 一项，参数设置为<code>1024</code> 。</p> <p><img src="https://fallen.wang/p/gradle/property.jpg" width="814" height="733" srcset="https://fallen.wang/p/gradle/property_hu64ff89970aad6509a495256135880e32_73047_480x0_resize_q75_box.jpg 480w, https://fallen.wang/p/gradle/property_hu64ff89970aad6509a495256135880e32_73047_1024x0_resize_q75_box.jpg 1024w" loading="lazy" class="gallery-image" data-flex-grow="111" data-flex-basis="266px" ></p> <p>继续运行，继续报错。<code>Could not find tools.jar</code></p> <p>第一想法是Java环境变量没配置好。添加系统变量<code>JAVA_HOME</code> ，值设定为Java根目录并编辑<code>PATH</code> 变量，依然报错。于是点进Java目录一看，好家伙根本没有<code>tools.jar</code> ，甚至没有<code>jdk</code> ，只有<code>jre</code> 。之前在其他电脑上安装Java 时改了一些安装设置，结果出现了各种莫名其妙的错误，所以这台电脑上我是以默认设置安装的，却还是出现了这种情况。关于错误原因粪坑里众说纷纭，忽然想到<code>jdk</code> 是开发环境而<code>jre</code> 是运行环境，或许Java官网有开发工具包什么的。果然，安装了<code>Java SE Development Kit 8u371</code> 后解决了这一问题。</p> <p>在另一个项目中还遇到了<code>javac错误：找不到或无法加载主类 com.sun.tools.javac.Main</code>错误，这也是由于<code>jdk</code> 安装出错造成的。正确安装并配置环境变量后，在命令行中</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-shell" data-lang="shell"><span class="line"><span class="cl">javac -version </span></span></code></pre></td></tr></table> </div> </div><p>出现了版本信息即为成功。</p> <p>此时再次构建即可在<code>app\build\outputs\apk\release</code>找到安装包。然而通过<code>gradlew assembleRelease</code> 得到的安装包是<code>app-release-unsigned.apk</code> 未签名的，无法直接安装，可以用Android Studio，或者手机上使用mt管理器进行签名并安装。也可以在构建时直接使用</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-shell" data-lang="shell"><span class="line"><span class="cl">gradle assembleDebug </span></span></code></pre></td></tr></table> </div> </div><p>这样生成的是debug调试包，已经签名可以直接安装。</p> <iframe src="heimu.html" scrolling="no" width="50" height="50" frameborder="0"></iframe>

<h1 id="血液循环">血液循环</h1> <hr> <h2 id="一心动周期">一、心动周期</h2> <p><img src="https://fallen.wang/p/cardiac-cycle.png" width="1751" height="2486" srcset="https://fallen.wang/p/cardiac-cycle_hu68cbb93bcb357a7d40fada0d2af75ffe_1337524_480x0_resize_box_3.png 480w, https://fallen.wang/p/cardiac-cycle_hu68cbb93bcb357a7d40fada0d2af75ffe_1337524_1024x0_resize_box_3.png 1024w" loading="lazy" alt="心动周期" class="gallery-image" data-flex-grow="70" data-flex-basis="169px" ></p> <h3 id="判断心动周期阶段">判断心动周期阶段</h3> <p>阶段划分：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">1993N3A心动周期中从房室瓣关闭到开放的时间相当于：E </span></span><span class="line"><span class="cl">A.心房收缩期+心室等容收缩期 </span></span><span class="line"><span class="cl">B.心房收缩期 </span></span><span class="line"><span class="cl">C.心室收缩期 </span></span><span class="line"><span class="cl">D.心室舒张期 </span></span><span class="line"><span class="cl">E.心室收缩期+等容舒张期 </span></span></code></pre></td></tr></table> </div> </div><p>各期特点，如动脉压、室内压、心室容积、瓣膜开放或关闭时间、心音的形成：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">1994N15A心动周期中在下列哪个时期主动脉压最低：A </span></span><span class="line"><span class="cl">A.等容收缩期末 </span></span><span class="line"><span class="cl">B.等容舒张期末 </span></span><span class="line"><span class="cl">C.心房收缩期末 </span></span><span class="line"><span class="cl">D.快速充盈期末 </span></span><span class="line"><span class="cl">E.减慢充盈期末 </span></span></code></pre></td></tr></table> </div> </div><table> <thead> <tr> <th style="text-align:center">特征</th> <th style="text-align:center">时期</th> </tr> </thead> <tbody> <tr> <td style="text-align:center">左心室压力MAX</td> <td style="text-align:center">快速射血期末</td> </tr> <tr> <td style="text-align:center">左心室容积MIN</td> <td style="text-align:center">等容舒张期末</td> </tr> <tr> <td style="text-align:center">左心室容积MAX</td> <td style="text-align:center">心房收缩期末</td> </tr> <tr> <td style="text-align:center">主动脉压MAX</td> <td style="text-align:center">快速射血期末</td> </tr> <tr> <td style="text-align:center">主动脉压MIN</td> <td style="text-align:center">等容收缩期末</td> </tr> <tr> <td style="text-align:center">主动脉血流量MAX</td> <td style="text-align:center">快速射血期</td> </tr> <tr> <td style="text-align:center">室内压升高最快</td> <td style="text-align:center">等容收缩期</td> </tr> <tr> <td style="text-align:center">第一心音产生</td> <td style="text-align:center">心房收缩期末（房室瓣关闭）</td> </tr> <tr> <td style="text-align:center">第二心音产生</td> <td style="text-align:center">减慢射血期末（主动脉瓣关闭）</td> </tr> </tbody> </table> <h3 id="评价心功能的指标">评价心功能的指标</h3> <p>射血分数、心输出量、每搏输出量、心指数、心脏做功量：</p> <div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-fallback" data-lang="fallback"><span class="line"><span class="cl">2005N6A高血压患者与正常人相比哪项指标明显升高：E </span></span><span class="line"><span class="cl">A.每搏输出量 </span></span><span class="line"><span class="cl">B.射血分数 </span></span><span class="line"><span class="cl">C.心输出量 </span></span><span class="line"><span class="cl">D.心指数 </span></span><span class="line"><span class="cl">E.心脏做功量 </span></span></code></pre></td></tr></table> </div> </div><p>搏出量即每搏输出量，约60~80ml。影响因素有前负荷、后负荷、心肌收缩能力和回心血量等。</p> <p>射血分数是搏出量除以心室舒张末期容积。扩心病患者心室舒张末期容积变大，射血分数降低。因此射血分数对早期心脏泵血功能异常具有重要意义。</p> <p><font color=#ffff30><strong>单侧</strong></font>心室每分钟输出的血液量称为心输出量。数值等于心率乘以搏出量。左右两侧心输出量基本相等。</p> <p>以单位面积计算的心输出量为心指数。静息心指数用于评价不同个体的心功能。</p>

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<div class="highlight"><div class="chroma"> <table class="lntable"><tr><td class="lntd"> <pre tabindex="0" class="chroma"><code><span class="lnt">1 </span><span class="lnt">2 </span><span class="lnt">3 </span><span class="lnt">4 </span><span class="lnt">5 </span><span class="lnt">6 </span></code></pre></td> <td class="lntd"> <pre tabindex="0" class="chroma"><code class="language-yaml" data-lang="yaml"><span class="line"><span class="cl"><span class="l">眼高手低第一人</span><span class="w"> </span></span></span><span class="line"><span class="cl"><span class="w"></span><span class="l">当代不著名空想家</span><span class="w"> </span></span></span><span class="line"><span class="cl"><span class="w"></span><span class="l">躺平摆烂大赛冠军</span><span class="w"> </span></span></span><span class="line"><span class="cl"><span class="w"></span><span class="l">国际吃小饼干比赛一等奖</span><span class="w"> </span></span></span><span class="line"><span class="cl"><span class="w"></span><span class="l">和蚂蚁打架金牌得主</span><span class="w"> </span></span></span><span class="line"><span class="cl"><span class="w"></span><span class="l">就读于某双一流野鸡大学的平凡锯木工</span><span class="w"> </span></span></span></code></pre></td></tr></table> </div> </div>

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