醫學知識雙語閱讀
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醫學知識雙語閱讀：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.在許多系統性疾病中,口腔表現是獨特的,有時是病徵性的,可以是疾病的首先徵兆.口腔癌的早期發現是可能的.
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. 首先採集口腔科病史,可提示一個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,或顳頜關節及咀嚼肌羣功能紊亂.刷牙後輕度出血,提示輕度牙齦炎;經常的,自發的,大量出血,表示血液病.反覆出現的口腔感染,可能存在糖尿病(此爲最常見原因),粒細胞缺乏症,中性粒細胞減少症,白血病,免疫球蛋白缺乏病或白細胞功能紊亂.免疫抑制者可經歷口腔單純皰疹的疼痛反應,並伴有口腔潰瘍而導致妨礙攝食.
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.口鏡或咽喉鏡有助於口腔檢查.
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,如當說話時運動受限常出現於硬皮病或肢端肥大症.許多先天性綜合徵均產生特殊的面貌.例如,很薄的上脣提示胎兒酒精綜合徵或Prader-Willi綜合徵,青少年時期的創傷,特別是頰部的鈍傷,能傷及髁狀突的生長中心和導致下頜骨單側或雙側生長髮育受損.下頜一側或雙側自發性肥大,或面部其他部分自發性肥大,如肢端肥大症或涎腺腫瘤或頜骨腫瘤均可破壞面部外貌.如果後牙或義齒缺失,頰部會凹陷而形成早老的或惡病質樣的面貌.由於頜骨增大症,腮腺炎,SjÖgren綜合徵,腫瘤,過厚的義齒突緣,或牙槽膿腫引致的蜂窩織炎,均可使一側或雙側頰部腫起.面部多發性基底細胞肉瘤可表現痣樣基底細胞肉瘤綜合徵,這可使檢查者留心地在X線片上尋找多發性牙源性角化囊腫.
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. 對脣部作捫診,同時令患者張口,用舌板檢查頰粘膜和口腔前庭;然後巡檢硬軟齶,懸雍垂和口咽部.請患者儘快地伸出舌,暴露舌背,並且儘快地向每側移動舌,這樣就可看到舌的後側表面.如果患者不能將舌伸出足夠以使輪狀乳頭能被看見時,檢查者可用紗布墊拉住舌尖,使其伸出到所需的體位.然後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行捫診並用一個指頭捫所有牙齒的根部,用兩個指頭覈對.主檢手的示指放入口內,另個手的幾個手指置於口外相當部位,輕柔地觸捫口底.爲了使捫診更舒適些,可請患者將口腔放鬆,維持一定的開口度以使手指能進入口腔.對頸部淋巴結也應作捫診.
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. 顳下頜關節(TMJ)的檢查爲當開口時在耳前方捫診髁狀突的頭,檢視頜骨的偏向.然後檢查者將小指深入置於外耳道內,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三個手指.不能張口的牙關緊閉提示可能爲硬皮病,關節炎,顳下頜關節強直,顳下頜關節盤脫位,破傷風或扁桃體膿腫.異常的大開口提示關節盤半脫位或Ehlers-Danlos綜合徵的Ⅲ型(先天性遺傳性綜合徵,特徵爲關節過度伸長,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.口臭起源於口腔.最多的原因是來自於細菌代謝產生的易揮發的硫化物,尤其是口腔衛生不良或口乾症時.口臭也可隨胃腸道的噯氣而來或由系統性代謝性疾病引起,也即丙酮味與糖尿病有關,鼠臭味與肝功能衰竭有關,尿味與腎功能衰竭有關.口臭也可起源於鼻部,上頜竇,鼻咽部和肺,尤其當這些部位有感染或壞死性腫瘤時.經常散發着漱口液氣息的患者常感覺有潛在的口臭或可能是個嗅覺倒錯者(嗅覺反常,常自己感到不適的臭味,而事實上此味是不存在的).
醫學知識雙語閱讀：盜汗
Night sweats are drenching sweats that require a change of bedding. 盜汗爲淋透性出汗，需換牀單。
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。首先要排除發燒引起的出汗。發燒性出汗應另行診斷。20世紀前，盜汗通常提示有結核菌感染。現在，其他很多不適都與此症狀相關。盜汗通常是某已知病症的標誌，如糖尿病(特別是伴夜間低血糖者)、癌症、頭外傷和各種風溼病。盜汗也可能是新的疾病的一種症狀，在給盜汗報告病人進行檢查時，需檢查既往病史及新的症狀。
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。盜汗可通過確認發作時間、次數、加劇及症狀消退加以確定。詢問病人已知疾病。多汗也與夜間血糖控制不良有關。風溼性疾病(如類風溼關節炎、狼瘡、幼兒性類風溼性關節炎、顳關節炎等)也導致出汗，婦娠也會暫時的改變很多婦女的體溫狀況，導致出汗過多。免疫代償病人感染風險增加，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. 系統檢查。伴隨盜汗的其他症狀包括潮紅(類癌綜合症、嗜鉻細胞瘤)、關節痛、睡眠性呼吸暫停、月經不調、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，如抗抑鬱劑、膽鹼能藥、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、非處方製劑、解熱劑和自然療法。詢問病人有無接觸性傳染病(STD)、HIV、肝炎、結核病，有否職業性及旅遊相關性接觸。也應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、噩夢及興奮劑可導致健康個體盜汗。
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進行適當的篩檢。
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。身體檢查應針對病人醫療史中的相關陽性記錄。注意病人體重體溫。頭、眼、耳、鼻及喉檢查的重點是普通類型的感染：鼻竇炎、喉炎和耳炎。淋巴結徹底檢查有助於確認感染及淋巴病變。心肺檢查也可提示感染、辨膜疾病及興奮劑使用情況。應檢查病人是否有膿腫、皮膚潰瘍、關節膿腫、靜膜炎和骨髓炎。
IV. Testing
IV. 檢驗。
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. 臨牀實驗室檢查。對有已知病症病人，應檢測病症是否加劇：血沉(感染、骨髓炎和顳關節炎)、C反應蛋白(風溼性疾病)和血紅蛋白AIC(糖尿病)。根據病人症狀及暴露情況決定是否進行其他檢查，包括結合病純蛋白衍生物皮膚測試、排除甲狀腺機能亢進的遊離T4水平檢驗、全血計數及分類(感染)、促卵泡激素檢查停經可能性。有旅遊相關及STD接觸病人可能需要進行特種檢驗。
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：吸菸史、工業性接觸或咳嗽。這些病人需要進行潛在惡性腫瘤篩檢。CT掃描通常並不合適，除非其他症狀或體徵提示要作進一步檢查。
V. Diagnostic assessment. Night sweating as a single entity is not worrisome. V. 診斷評估。盜汗作爲單一徵狀並不令人擔心。
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間。盜汗也可能是某種疾病發展的早期症狀，因此觀察等待是有用的。應指導病人留意體重變化、發燒及睡眠和情緒變化。病人可填寫一份症狀日誌，它對臨牀醫師確定是否作進一步檢查很有幫助。考慮該病人年齡組常見的疾病。通過乳房X線、巴氏塗片及糞便潛血試驗篩檢常見惡性腫瘤，既適於健康維持，也是當前盜汗主訴檢查的內容之一。
