2021年医学知识双语阅读

口腔检查Examinationoftheoralcavityispartofeverygeneralphysicalexamination.Oralfindingsinmanysystemicdiseasesareunique,aresometimespathognomonic,andmaybethefirstsignofthedisease.Earlydetectionoforalcancermaybepossible.口腔检查是全身检查的一部分.在许多系统性疾病中,口腔表现是独特的,有时是病征性的,可以是疾病的首先征兆.口腔癌的早期发现是可能的.Adentalhistoryisobtainedfirst.Itmayindicateaparticulardentalproblemorneglectofdentalcare.Acomplaintofdifficultyinchewingfoodsuggestsinsufficientteethforpropermastication,looseorpainfulteeth,poorlyfittingdentalappliances,ordisordersofthetemporomandibularjointorthemasticatorymuscles.Slightbleedingafterbrushingsuggestsmildgingivitis;frequent,spontaneous,orprofusebleedingmayindicateablooddyscrasia.Recurringoralinfectionsmayindicatediabetesmellitus(themostcommoncause),agranulocytosis,neutropenia,leukemia,immunoglobulindefects,ordisordersofleukocytefunction.Immunosuppressedpersonsmayexperiencepainfulreactivationoforalherpessimplexorotherinfections,withpain,oralulcerations,andconsequentinterferencewithfoodintake.首先采集口腔科病史,可提示一个特别的口腔问题或被忽略的口腔保健.主诉咀嚼食物困难提示能行使咀嚼功能的牙齿缺失或疼痛,或颞颌关节及咀嚼肌群功能紊乱.刷牙后轻度出血,提示轻度牙龈炎;经常的,自发的,大量出血,表示血液病.反复出现的口腔感染,可能存在糖尿病(此为最常见原因),粒细胞缺乏症,中性粒细胞减少症,白血病,免疫球蛋白缺乏病或白细胞功能紊乱.免疫抑制者可经历口腔单纯疱疹的疼痛反应,并伴有口腔溃疡而导致妨碍摄食.Athoroughevaluationrequiresgoodillumination,atongueblade,gloves,andagauzepad.Adentalorlaryngealmirror,ifavailable,ishelpful.全面的评估需要良好的照明,压舌板,手套和纱布垫.口镜或咽喉镜有助于口腔检查.Theexaminerinitiallylooksatthefaceforappreciableasymmetry,skinlesions,andotherabnormalities,suchasrestrictedmovementduringspeech,asoccursinsclerodermaoracromegaly.Numerouscongenitalsyndromesproducecharacteristicfacies.Forexample,averythinupperlipsuggeststhefetalalcoholsyndromeorPrader-Willisyndrome.Traumainyouth,particularlyblunttraumatothepointofthechin,candamagegrowthcentersinthecondylesandleadtounilateralorbilateralimpairmentofmandibulargrowth.Idiopathichypertrophyofoneorbothsidesofthemandibleorotherpartsofthefacemaydistorttheface,asmayacromegalyorasalivaryglandorjawtumor.Iftheposteriorteethordentalprosthesesaremissing,thecheeksmaybesunken,producingaprematurelyagedorcachecticappearance.Oneorbothcheeksmayappearswollenduetocherubism,parotitis,Sjgrenssyndrome,tumor,anexcessivelythickdentureflange,orcellulitisfromanabscessedtooth.Multiplebasalcellcarcinomasonthefacemayindicatethenevoidbasalcellcarcinomasyndrome,whichalertstheexaminertolookformultipleodontogenickeratocystsonx-rays.检查者首先观察面部有无明显的不对称,皮肤病损和其他的不正常,如当说话时运动受限常出现于硬皮病或肢端肥大症.许多先天性综合征均产生特殊的面貌.例如,很薄的上唇提示胎儿酒精综合征或Prader-Willi综合征,青少年时期的创伤,特别是颊部的钝伤,能伤及髁状突的生长中心和导致下颌骨单侧或双侧生长发育受损.下颌一侧或双侧自发性肥大,或面部其他部分自发性肥大,如肢端肥大症或涎腺肿瘤或颌骨肿瘤均可破坏面部外貌.如果后牙或义齿缺失,颊部会凹陷而形成早老的或恶病质样的面貌.由于颌骨增大症，腮腺炎,Sjgren综合征，月中瘤，过厚的义齿突缘,或牙槽脓肿引致的蜂窝织炎,均可使一侧或双侧颊部肿起.面部多发性基底细胞肉瘤可表现痣样基底细胞肉瘤综合征,这可使检查者留心地在X线片上寻找多发性牙源性角化囊肿.Thelipsarepalpated.Withthepatientsmouthopen,thebuccalmucosaandvestibulesareexaminedusingatongueblade;thenthehardandsoftpalates,uvula,andoropharynxareviewed.Thepatientisaskedtoextendthetongueasfaraspossible,exposingthedorsum,andtomovetheextendedtongueasfaraspossibletoeachside,sothatitsposterolateralsurfacescanbeseen.Ifapatientdoesnotextendthetonguefarenoughforthecircumvallatepapillaetobeseen,theexaminerusesagauzepadtograspthetipofthetongueandextendittothedesiredposition.Thetongueisthenraisedtoviewtheventralsurfaceandthefloorofthemouth.Theteethandgingivaeshouldbeviewed.对唇部作扪诊,同时令患者张口,用舌板检查颊粘膜和口腔前庭;然后巡检硬软腭,悬雍垂和口咽部.请患者尽快地伸出舌,暴露舌背,并且尽快地向每侧移动舌,这样就可看到舌的后侧表面.如果患者不能将舌伸出足够以使轮状乳头能被看见时,检查者可用纱布垫拉住舌尖,使其伸出到所需的体位.然后巡检舌腹部表面和口底,再检视牙齿和牙龈.Withglovedhand,theexaminerpalpatesthevestibulesandtheareaovertherootsoftheteethwithonefingerandthecheekwithtwofingers.Theindexfingerofthedominanthandisinsertedinsidethemouth,andthecontentsofthefloorofthemoutharecompressedgentlybetweenitandthefingersoftheotherhand.Tomakepalpitationmorecomfortable,theexaminerasksthepatienttorelaxthemouth,keepingitopenjustwideenoughtoallowaccess.Thecervicallymphnodesshouldalsobepalpated.检查者用戴手套的手指对口腔前庭进行扪诊并用一个指头扪所有牙齿的根部,用两个指头核对.主检手的示指放入口内,另个手的几个手指置于口外相当部位,轻柔地触扪口底.为了使扪诊更舒适些,可请患者将口腔放松,维持一定的开口度以使手指能进入口腔.对颈部淋巴结也应作扪诊.Thetemporomandibularjoint(TMJ)isassessedbylookingforjawdeviationduringopeningandbypalpatingtheheadofthecondyle,anteriortotheear.Theexaminerthenplaceshislittlefingersintrameatallywhilethepatientopenswidelyandclosesthreetimes.Thepatientshouldbeabletocomfortablyopenwideenoughtofitthreefingersbetweentheincisors.Trismus,theinabilitytoopenthemouth,mayindicatescleroderma,arthritis,ankylosisoftheTMJ,dislocationofthetemporomandibulardisk,tetanus,ortonsillarabscess.UnusuallywideopeningsuggestssubluxationortypeIIIEhlers-Danlossyndrome.颞下颌关节(TMJ)的检查为当开口时在耳前方扪诊髁状突的头,检视颌骨的偏向.然后检查者将小指深入置于外耳道内,请患者张大口和闭口3次.患者能舒适地张大口,足以使上下切牙之间能放进三个手指.不能张口的牙关紧闭提示可能为硬皮病,关节炎,颞下颌关节强直,颞下颌关节盘脱位,破伤风或扁桃体脓肿.异常的大开口提示关节盘半脱位或Ehlers-Danlos综合征的ID型(先天性遗传性综合征，特征为关节过度伸长，皮肤弹性脆弱等---译者注).Malodorofexhaledbreathmayhavemanycauses.Fetororisoriginatesinthemouth.Mostcommonly,itiscausedbyvolatilesulfurcompoundsresultingfrombacterialmetabolism,particularlywhenoralhygieneispoororxerostomiaispresent.HalitosismayfolloweructationfromtheGItractormaybecausedbysystemicmetabolicconditions--eg,anacetoneodorwithdiabetesmellitus,amousyodorwithliverfailure,andaurinousodorwithkidneyfailure.Halitosismayalsooriginatefromthenose,sinuses,nasopharynx,andlungs,particularlywheninfectionsornecroticneoplasmsarepresent.Apatientwhosebreathfrequentlysmellsofmouthwashmaybemaskinghalitosisormayhaveparosmia(aperversionofthesenseofsmell,usuallyinvolvingsmellingunpleasantodorsthatdonotexist).呼吸气味的恶臭可由许多原因引起.口臭起源于口腔.最多的原因是来自于细菌代谢产生的易挥发的硫化物,尤其是口腔卫生不良或口干症时.口臭也可随胃肠道的嗳气而来或由系统性代谢性疾病引起,也即丙酮味与糖尿病有关,鼠臭味与肝功能衰竭有关,尿味与肾功能衰竭有关.口臭也可起源于鼻部,上颌窦,鼻咽部和肺,尤其当这些部位有感染或坏死性肿瘤时.经常散发着漱口液气息的患者常感觉有潜在的口臭或可能是个嗅觉倒错者(嗅觉反常,常自己感到不适的臭味,而事实上此味是不存在的).盗汗Nightsweatsaredrenchingsweatsthatrequireachangeofbeddi添汗为淋透性出汗，需换床单。Approach.Thefirstpriorityistoexcludenightsweatscausedbyfever.Sweatingassociatedwithfeverisaseparateevaluation.Beforethe20thcentury,nightsweatsimpliedinfectionwithtuberculosis.Now,manyotherailmentsareassociatedwiththissymptom.Nightsweatsareoftenthemarkofaknownconditionsuchasdiabetes(especiallywithnocturnalhypoglycemia),cancer,headtrauma,andrheumatologicdisorders.Nightsweatscanalsobeasymptomofanewdisorder.Theinvestigationofapatientreportingnightsweatsrequiresareviewofpastillnessesandnewsymptoms.I.诊断。首先要排除发烧引起的出作。发烧性出汗应另行诊断。20世纪前，盗汗通常提示有结核菌感染。现在，其他很多不适都与此症状相关。盗汗通常是某已知病症的标志，如糖尿病(特别是伴夜间低血糖者)、癌症、头外伤和各种风湿病。盗汗也可能是新的疾病的一种症状，在给盗汗报告病人进行检查时，需检查既往病史及新的症状。History.Nightsweatscanbecharacterizedbydeterminingonset,frequency,exacerbations,andremissionsofsymptoms.Questionpatientsaboutthecurrentstateofknowndisorders.Excessivesweatingisassociatedwithpoornocturnalglycemiccontrol.Flaresofrheumatologicdisorders(rheumatoidarthritis,lupus,juvenilerheumatoidarthritis,andtemporalarteritis)causesweatingtoo.Pregnancytemporarilychangestheintrinsicthermostatinmanywomenwhoperspireexcessively.Patientswhoareimmuno-compromisedareatincreasedriskforinfections,especiallywithatypicalagents.Patientswithahistoryofsubstanceabuseneedtobeaskedaboutneedleuseandcontaminants.II病史。盗汴可通过确认发作时间、次数、加剧及症状消退加以确定。询问病人已知疾病。多汗也与夜间血糖控制不良有关。风湿性疾病(如类风湿关节炎、狼疮、幼儿性类风湿性关节炎、颞关节炎等)也导致出汗，妇娠也会暂时的改变很多妇女的体温状况，导致出汗过多。免疫代偿病人感染风险增加，特别是非典型性病原体感染。有药物滥用史病人需询问其针头使用及其他接触状况。Reviewofsystems.Othersymptomsthatcanaccompanynightsweatsincludeflushing(carcinoidsyndrome,pheochromocytoma),jointpain,sleepapnea,menstrualirregularities,reflux,cough,headache,dysuria,dyspnea,rashes,fatigue,palpitations,andweightandbowelhabitchanges.A索统检查。"随盗汗的其他症状包括疝红(类癌综合症、嗜铬细胞瘤)、关节痛、睡眠性呼吸暂停、月经不调、反流、咳嗽、头痛、排尿困难、睡眠困难、皮疹、疲乏、心悸及体重与排便习惯改变。Exposurefactors.Inquireaboutrecentimmunizationsornewmedicinessuchasantidepressants,cholinergics,meperidine,estrogeninhibitors,gonadotropininhibitors,niacin,steroids,stimulants,over-the-counterpreparations,antipyretics,andnaturopathictherapies.Questionpatientsaboutexposuretosexuallytransmitteddiseases(STDs),humanimmuno-deficiencyvirus(HIV),hepatitis,tuberculosis,oroccupationalandtravel-relatedexposures.Alsoaskaboutincreasesingeneralchangesintheambientnighttemperature.眯露因素。询问最近免疫及新药使用情况，如抗抑郁剂、胆碱能药、哌替定、雌激素抑制剂、促性腺激素抑制剂、烟酸、类固醇、兴奋剂、非处方制剂、解热剂和自然疗法。询问病人有无接触性传染病(STD)、HIV、肝炎、结核病，有否职业性及旅游相关性接触。也应询问周围夜间体温总体变化增多情况。Psychologicalfactors.Anxiety,nightmares,andpsychoactivepreparationscanprecipitatenightsweatsinhealthyindividuals.C精神向素。焦虑、噩梦及兴奋剂可导致健康个体盗汗。Familyhistory.Patientswhoreportafamilyhistoryofhereditarydisordersandpossiblemalignanciesshouldhaveappropriatescreening.窿庭史。有遗传疾病及可能的恶性肿瘤家庭史病人应进行适当的筛检。Physicalexamination.Thephysicalexaminationshouldaddressthepertinentpositivesnotedinthepatientsmedicalhistory.Notethepatientsweightandtemperature.Examinationofthehead,eyes,ears,nose,andthroat(HEENT)shouldfocusoncommontypesofinfection:sinusitis,pharyngitis,andotitis.Athoroughexaminationoflymphnodesishelpfultoidentifyinfectionorlymphaticabnormalities.Thecardiopulmonaryexaminationcanalsosignalinfection,valvulardisease,andstimulantuse.Patientsshouldbeexaminedforabscesses,skinulcers,septicjoints,phlebitis,andosteomyelitis.III.身体检查。身体检查应针对病人医疗史中的相关阳性记录。注意病人体重体温。头、眼、耳、鼻及喉检查的重点是普通类型的感染鼻窦炎、喉炎和耳炎。淋巴结彻底检查有助于确认感染及淋巴病变。心肺检查也可提示感染、辨膜疾病及兴奋剂使用情况。应检查病人是否有脓肿、皮肤溃疡、关节脓肿、静膜炎和骨髓炎。Testing.检验。Clinicallaboratorytesting.Forpatientswithaknowncondition,testingforexacerbationsisappropriate:erythrocytesedimentationrate(infection,osteomyelitis,andtemporalarteritis),C-reactiveprotein(rheumatologicdisorders),andhemoglobinAiC(diabetesmellitus).Dependingonthepatientssymptomsorexposures,otherappropriatetestscanincludepurifiedproteinderivativeskintestfortuberculosis,freeT4leveltoruleoutthyrotoxicosis,completebloodcountwithdifferential(infection),andfollicle-stimulatinghormonetoinvestigatethepossibilityofmenopause.Specialtestsmayberequiredofpatientswithtravel-relatedorSTDexposures.Al缶床实验室检查。对有已知病症病人，应检测病症是否加剧血沉(感染、骨髓炎和颞关节炎)、C反应蛋白(风湿性疾病)和血红蛋白AIC(糖尿病)。根据病人症状及暴露情况决定是否进行其他检查，包括结合病纯蛋白衍生物皮肤测试、排除甲状腺机能亢进的游离T4水平检验、全血计数及分类(感染)、促卵泡激素检查停经可能性。有旅游相关及STD接触病人可能需要进行特种检验。Imaging.Chestx-raystudiesareusefulintheevaluationofnightsweatsinpatientswithasmokinghistory,industrialexposure,oracough.Thesepatientsneedtobescreenedforoccultmalignancy.Computedtomographyscansaregenerallynotappropriateunlessothersignsorsymptomsdictatefurtherevaluation.展像检查。胸部X线检查对评估有下列情况病人的盗汗很有用吸烟史、工业性接触或咳嗽。这些病人需要进行潜在恶性肿瘤筛检。CT扫描