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　　醫(yī)學(xué)知識雙語閱讀：口腔檢查

　　Examination of the oral cavity is part of every general physical examination. Oral findings in many systemic diseases are unique, are sometimes pathognomonic, and may be the first sign of the disease. Early detection of oral cancer may be possible.　 口腔檢查是全身檢查的一部分.在許多系統(tǒng)性疾病中,口腔表現(xiàn)是獨(dú)特的,有時(shí)是病征性的,可以是疾病的首先征兆.口腔癌的早期發(fā)現(xiàn)是可能的.

　　A dental history is obtained first. It may indicate a particular dental problem or neglect of dental care. A complaint of difficulty in chewing food suggests insufficient teeth for proper mastication, loose or painful teeth, poorly fitting dental appliances, or disorders of the temporomandibular joint or the masticatory muscles. Slight bleeding after brushing suggests mild gingivitis; frequent, spontaneous, or profuse bleeding may indicate a blood dyscrasia. Recurring oral infections may indicate diabetes mellitus (the most common cause), agranulocytosis, neutropenia, leukemia, immunoglobulin defects, or disorders of leukocyte function. Immunosuppressed persons may experience painful reactivation of oral herpes simplex or other infections, with pain, oral ulcerations, and consequent interference with food intake.　 首先采集口腔科病史,可提示一個(gè)特別的口腔問題或被忽略的口腔保健.主訴咀嚼食物困難提示能行使咀嚼功能的牙齒缺失或疼痛,或顳頜關(guān)節(jié)及咀嚼肌群功能紊亂.刷牙后輕度出血,提示輕度牙齦炎;經(jīng)常的,自發(fā)的,大量出血,表示血液病.反復(fù)出現(xiàn)的口腔感染,可能存在糖尿病(此為最常見原因),粒細(xì)胞缺乏癥,中性粒細(xì)胞減少癥,白血病,免疫球蛋白缺乏病或白細(xì)胞功能紊亂.免疫抑制者可經(jīng)歷口腔單純皰疹的疼痛反應(yīng),并伴有口腔潰瘍而導(dǎo)致妨礙攝食.

　　A thorough evaluation requires good illumination, a tongue blade, gloves, and a gauze pad. A dental or laryngeal mirror, if available, is helpful.　 　　全面的評估需要良好的照明,壓舌板,手套和紗布墊.口鏡或咽喉鏡有助于口腔檢查.

　　The examiner initially looks at the face for appreciable asymmetry, skin lesions, and other abnormalities, such as restricted movement during speech, as occurs in scleroderma or acromegaly. Numerous congenital syndromes produce characteristic facies. For example, a very thin upper lip suggests the fetal alcohol syndrome or Prader-Willi syndrome. Trauma in youth, particularly blunt trauma to the point of the chin, can damage growth centers in the condyles and lead to unilateral or bilateral impairment of mandibular growth. Idiopathic hypertrophy of one or both sides of the mandible or other parts of the face may distort the face, as may acromegaly or a salivary gland or jaw tumor. If the posterior teeth or dental prostheses are missing, the cheeks may be sunken, producing a prematurely aged or cachectic appearance. One or both cheeks may appear swollen due to cherubism, parotitis, Sjögren's syndrome, tumor, an excessively thick denture flange, or cellulitis from an abscessed tooth. Multiple basal cell carcinomas on the face may indicate the nevoid basal cell carcinoma syndrome, which alerts the examiner to look for multiple odontogenic keratocysts on x-rays.　 檢查者首先觀察面部有無明顯的不對稱,皮膚病損和其他的不正常,如當(dāng)說話時(shí)運(yùn)動受限常出現(xiàn)于硬皮病或肢端肥大癥.許多先天性綜合征均產(chǎn)生特殊的面貌.例如,很薄的上唇提示胎兒酒精綜合征或Prader-Willi綜合征,青少年時(shí)期的創(chuàng)傷,特別是頰部的鈍傷,能傷及髁狀突的生長中心和導(dǎo)致下頜骨單側(cè)或雙側(cè)生長發(fā)育受損.下頜一側(cè)或雙側(cè)自發(fā)性肥大,或面部其他部分自發(fā)性肥大,如肢端肥大癥或涎腺腫瘤或頜骨腫瘤均可破壞面部外貌.如果后牙或義齒缺失,頰部會凹陷而形成早老的或惡病質(zhì)樣的面貌.由于頜骨增大癥,腮腺炎,SjÖgren綜合征,腫瘤,過厚的義齒突緣,或牙槽膿腫引致的蜂窩織炎,均可使一側(cè)或雙側(cè)頰部腫起.面部多發(fā)性基底細(xì)胞肉瘤可表現(xiàn)痣樣基底細(xì)胞肉瘤綜合征,這可使檢查者留心地在X線片上尋找多發(fā)性牙源性角化囊腫.

　　The lips are palpated. With the patient's mouth open, the buccal mucosa and vestibules are examined using a tongue blade; then the hard and soft palates, uvula, and oropharynx are viewed. The patient is asked to extend the tongue as far as possible, exposing the dorsum, and to move the extended tongue as far as possible to each side, so that its posterolateral surfaces can be seen. If a patient does not extend the tongue far enough for the circumvallate papillae to be seen, the examiner uses a gauze pad to grasp the tip of the tongue and extend it to the desired position. The tongue is then raised to view the ventral surface and the floor of the mouth. The teeth and gingivae should be viewed.　 對唇部作捫診,同時(shí)令患者張口,用舌板檢查頰粘膜和口腔前庭;然后巡檢硬軟腭,懸雍垂和口咽部.請患者盡快地伸出舌,暴露舌背,并且盡快地向每側(cè)移動舌,這樣就可看到舌的后側(cè)表面.如果患者不能將舌伸出足夠以使輪狀乳頭能被看見時(shí),檢查者可用紗布墊拉住舌尖,使其伸出到所需的體位.然后巡檢舌腹部表面和口底,再檢視牙齒和牙齦.

　　With gloved hand, the examiner palpates the vestibules and the area over the roots of the teeth with one finger and the cheek with two fingers. The index finger of the dominant hand is inserted inside the mouth, and the contents of the floor of the mouth are compressed gently between it and the fingers of the other hand. To make palpitation more comfortable, the examiner asks the patient to relax the mouth, keeping it open just wide enough to allow access. The cervical lymph nodes should also be palpated.　 檢查者用戴手套的手指對口腔前庭進(jìn)行捫診并用一個(gè)指頭捫所有牙齒的根部,用兩個(gè)指頭核對.主檢手的示指放入口內(nèi),另個(gè)手的幾個(gè)手指置于口外相當(dāng)部位,輕柔地觸捫口底.為了使捫診更舒適些,可請患者將口腔放松,維持一定的開口度以使手指能進(jìn)入口腔.對頸部淋巴結(jié)也應(yīng)作捫診.

　　The temporomandibular joint (TMJ) is assessed by looking for jaw deviation during opening and by palpating the head of the condyle, anterior to the ear. The examiner then places his little fingers intrameatally while the patient opens widely and closes three times. The patient should be able to comfortably open wide enough to fit three fingers between the incisors. Trismus, the inability to open the mouth, may indicate scleroderma, arthritis, ankylosis of the TMJ, dislocation of the temporomandibular disk, tetanus, or tonsillar abscess. Unusually wide opening suggests subluxation or type III Ehlers-Danlos syndrome.　 顳下頜關(guān)節(jié)(TMJ)的檢查為當(dāng)開口時(shí)在耳前方捫診髁狀突的頭,檢視頜骨的偏向.然后檢查者將小指深入置于外耳道內(nèi),請患者張大口和閉口3次.患者能舒適地張大口,足以使上下切牙之間能放進(jìn)三個(gè)手指.不能張口的牙關(guān)緊閉提示可能為硬皮病,關(guān)節(jié)炎,顳下頜關(guān)節(jié)強(qiáng)直,顳下頜關(guān)節(jié)盤脫位,破傷風(fēng)或扁桃體膿腫.異常的大開口提示關(guān)節(jié)盤半脫位或Ehlers-Danlos綜合征的Ⅲ型(先天性遺傳性綜合征,特征為關(guān)節(jié)過度伸長,皮膚彈性脆弱等---譯者注).

　　Malodor of exhaled breath may have many causes. Fetor oris originates in the mouth. Most commonly, it is caused by volatile sulfur compounds resulting from bacterial metabolism, particularly when oral hygiene is poor or xerostomia is present. Halitosis may follow eructation from the GI tract or may be caused by systemic metabolic conditions--eg, an acetone odor with diabetes mellitus, a mousy odor with liver failure, and a urinous odor with kidney failure. Halitosis may also originate from the nose, sinuses, nasopharynx, and lungs, particularly when infections or necrotic neoplasms are present. A patient whose breath frequently smells of mouthwash may be masking halitosis or may have parosmia (a perversion of the sense of smell, usually involving smelling unpleasant odors that do not exist).　 呼吸氣味的惡臭可由許多原因引起.口臭起源于口腔.最多的原因是來自于細(xì)菌代謝產(chǎn)生的易揮發(fā)的硫化物,尤其是口腔衛(wèi)生不良或口干癥時(shí).口臭也可隨胃腸道的噯氣而來或由系統(tǒng)性代謝性疾病引起,也即丙酮味與糖尿病有關(guān),鼠臭味與肝功能衰竭有關(guān),尿味與腎功能衰竭有關(guān).口臭也可起源于鼻部,上頜竇,鼻咽部和肺,尤其當(dāng)這些部位有感染或壞死性腫瘤時(shí).經(jīng)常散發(fā)著漱口液氣息的患者常感覺有潛在的口臭或可能是個(gè)嗅覺倒錯(cuò)者(嗅覺反常,常自己感到不適的臭味,而事實(shí)上此味是不存在的).

　　醫(yī)學(xué)知識雙語閱讀：盜汗

　　Night sweats are drenching sweats that require a change of bedding. 盜汗為淋透性出汗，需換床單。

　　I. Approach. The first priority is to exclude night sweats caused by fever. Sweating associated with fever is a separate evaluation. Before the 20th century, night sweats implied infection with tuberculosis. Now, many other ailments are associated with this symptom. Night sweats are often the mark of a known condition such as diabetes (especially with nocturnal hypoglycemia), cancer, head trauma, and rheumatologic disorders. Night sweats can also be a symptom of a new disorder. The investigation of a patient reporting night sweats requires a review of past illnesses and new symptoms. I. 診斷。首先要排除發(fā)燒引起的出汗。發(fā)燒性出汗應(yīng)另行診斷。20世紀(jì)前，盜汗通常提示有結(jié)核菌感染。現(xiàn)在，其他很多不適都與此癥狀相關(guān)。盜汗通常是某已知病癥的標(biāo)志，如糖尿病(特別是伴夜間低血糖者)、癌癥、頭外傷和各種風(fēng)濕病。盜汗也可能是新的疾病的一種癥狀，在給盜汗報(bào)告病人進(jìn)行檢查時(shí)，需檢查既往病史及新的癥狀。

　　II. History. Night sweats can be characterized by determining onset, frequency, exacerbations, and remissions of symptoms. Question patients about the current state of known disorders. Excessive sweating is associated with poor nocturnal glycemic control. Flares of rheumatologic disorders (rheumatoid arthritis, lupus, juvenile rheumatoid arthritis, and temporal arteritis) cause sweating too. Pregnancy temporarily changes the intrinsic thermostat in many women who perspire excessively. Patients who are immuno-compromised are at increased risk for infections, especially with atypical agents. Patients with a history of substance abuse need to be asked about needle use and contaminants. II. 病史。盜汗可通過確認(rèn)發(fā)作時(shí)間、次數(shù)、加劇及癥狀消退加以確定。詢問病人已知疾病。多汗也與夜間血糖控制不良有關(guān)。風(fēng)濕性疾病(如類風(fēng)濕關(guān)節(jié)炎、狼瘡、幼兒性類風(fēng)濕性關(guān)節(jié)炎、顳關(guān)節(jié)炎等)也導(dǎo)致出汗，婦娠也會暫時(shí)的改變很多婦女的體溫狀況，導(dǎo)致出汗過多。免疫代償病人感染風(fēng)險(xiǎn)增加，特別是非典型性病原體感染。有藥物濫用史病人需詢問其針頭使用及其他接觸狀況。

　　A. Review of systems. Other symptoms that can accompany night sweats include flushing (carcinoid syndrome, pheochromocytoma), joint pain, sleep apnea, menstrual irregularities, reflux, cough, headache, dysuria, dyspnea, rashes, fatigue, palpitations, and weight and bowel habit changes. A. 系統(tǒng)檢查。伴隨盜汗的其他癥狀包括潮紅(類癌綜合癥、嗜鉻細(xì)胞瘤)、關(guān)節(jié)痛、睡眠性呼吸暫停、月經(jīng)不調(diào)、反流、咳嗽、頭痛、排尿困難、睡眠困難、皮疹、疲乏、心悸及體重與排便習(xí)慣改變。

　　B. Exposure factors. Inquire about recent immunizations or new medicines such as antidepressants, cholinergics, meperidine, estrogen inhibitors, gonadotropin inhibitors, niacin, steroids, stimulants, over-the-counter preparations, antipyretics, and naturopathic therapies. Question patients about exposure to sexually transmitted diseases (STDs), human immuno-deficiency virus (HIV), hepatitis, tuberculosis, or occupational and travel-related exposures. Also ask about increases in general changes in the ambient night temperature. B. 暴露因素。詢問最近免疫及新藥使用情況，如抗抑郁劑、膽堿能藥、哌替定、雌激素抑制劑、促性腺激素抑制劑、煙酸、類固醇、興奮劑、非處方制劑、解熱劑和自然療法。詢問病人有無接觸性傳染病(STD)、HIV、肝炎、結(jié)核病，有否職業(yè)性及旅游相關(guān)性接觸。也應(yīng)詢問周圍夜間體溫總體變化增多情況。

　　C. Psychological factors. Anxiety, nightmares, and psychoactive preparations can precipitate night sweats in healthy individuals. C. 精神因素。焦慮、噩夢及興奮劑可導(dǎo)致健康個(gè)體盜汗。

　　D. Family history. Patients who report a family history of hereditary disorders and possible malignancies should have appropriate screening. D. 家庭史。有遺傳疾病及可能的惡性腫瘤家庭史病人應(yīng)進(jìn)行適當(dāng)?shù)暮Y檢。

　　III. Physical examination. The physical examination should address the pertinent positives noted in the patient's medical history. Note the patient's weight and temperature. Examination of the head, eyes, ears, nose, and throat (HEENT) should focus on common types of infection: sinusitis, pharyngitis, and otitis. A thorough examination of lymph nodes is helpful to identify infection or lymphatic abnormalities. The cardiopulmonary examination can also signal infection, valvular disease, and stimulant use. Patients should be examined for abscesses, skin ulcers, septic joints, phlebitis, and osteomyelitis. III. 身體檢查。身體檢查應(yīng)針對病人醫(yī)療史中的相關(guān)陽性記錄。注意病人體重體溫。頭、眼、耳、鼻及喉檢查的重點(diǎn)是普通類型的感染：鼻竇炎、喉炎和耳炎。淋巴結(jié)徹底檢查有助于確認(rèn)感染及淋巴病變。心肺檢查也可提示感染、辨膜疾病及興奮劑使用情況。應(yīng)檢查病人是否有膿腫、皮膚潰瘍、關(guān)節(jié)膿腫、靜膜炎和骨髓炎。

　　IV. Testing

　　IV. 檢驗(yàn)。

　　A. Clinical laboratory testing. For patients with a known condition, testing for exacerbations is appropriate: erythrocyte sedimentation rate (infection, osteomyelitis, and temporal arteritis), C-reactive protein (rheumatologic disorders), and hemoglobin AiC (diabetes mellitus). Depending on the patient's symptoms or exposures, other appropriate tests can include purified protein derivative skin test for tuberculosis, free T4 level to rule out thyrotoxicosis, complete blood count with differential (infection), and follicle-stimulating hormone to investigate the possibility of menopause. Special tests may be required of patients with travel-related or STD exposures. A. 臨床實(shí)驗(yàn)室檢查。對有已知病癥病人，應(yīng)檢測病癥是否加?。貉?感染、骨髓炎和顳關(guān)節(jié)炎)、C反應(yīng)蛋白(風(fēng)濕性疾病)和血紅蛋白AIC(糖尿病)。根據(jù)病人癥狀及暴露情況決定是否進(jìn)行其他檢查，包括結(jié)合病純蛋白衍生物皮膚測試、排除甲狀腺機(jī)能亢進(jìn)的游離T4水平檢驗(yàn)、全血計(jì)數(shù)及分類(感染)、促卵泡激素檢查停經(jīng)可能性。有旅游相關(guān)及STD接觸病人可能需要進(jìn)行特種檢驗(yàn)。

　　B. Imaging. Chest x-ray studies are useful in the evaluation of night sweats in patients with a smoking history, industrial exposure, or a cough. These patients need to be screened for occult malignancy. Computed tomography scans are generally not appropriate unless other signs or symptoms dictate further evaluation. B. 影像檢查。胸部X線檢查對評估有下列情況病人的盜汗很有用：吸煙史、工業(yè)性接觸或咳嗽。這些病人需要進(jìn)行潛在惡性腫瘤篩檢。CT掃描通常并不合適，除非其他癥狀或體征提示要作進(jìn)一步檢查。

　　V. Diagnostic assessment. Night sweating as a single entity is not worrisome. V. 診斷評估。盜汗作為單一征狀并不令人擔(dān)心。

　　Explore the likelihood of exacerbation of known conditions or the onset of a new disease process. The history is the most helpful part of the patient encounter. A new medication, with perspiration as a side effect, is the culprit. Patients may need cessation of the medication as well as a washout period. Night sweats might be an early symptom of a developing illness so watchful waiting is useful. Patients need to be instructed to watch for weight changes, fevers, and sleep and mood changes. Patients can complete a symptom diary, which is very helpful to the clinician in determining the need for additional evaluation. Consider illnesses that tend to be present in the patient's age group. Screening for common malignancies through mammograms, pap smears, and fecal occult blood testing is appropriate health maintenance as well as often being a part of the evaluation of the presenting complaint of night sweats. 檢查已知疾病加劇可能性或所得疾病過程的發(fā)作情況。病史在病人疾病中最有幫助。有出汗副作用的新藥常常是盜汗的魁首。病人可能需要停藥及給予一段藥物清除時(shí)間。盜汗也可能是某種疾病發(fā)展的早期癥狀，因此觀察等待是有用的。應(yīng)指導(dǎo)病人留意體重變化、發(fā)燒及睡眠和情緒變化。病人可填寫一份癥狀日誌，它對臨床醫(yī)師確定是否作進(jìn)一步檢查很有幫助?？紤]該病人年齡組常見的疾病。通過乳房X線、巴氏涂片及糞便潛血試驗(yàn)篩檢常見惡性腫瘤，既適于健康維持，也是當(dāng)前盜汗主訴檢查的內(nèi)容之一。