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ҽѧ֪ʶ˫Ķ

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ҽѧ֪ʶ˫Ķǻ

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. ǻȫһ.ϵͳԼ,ǻǶص,ʱDzԵ,Ǽ.ǻڷǿܵ.

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. ȲɼǻƲʷ,ʾһرĿǻ򱻺ԵĿǻ.߾׽ʳʾʹ׽ܵȱʧʹ,ؽڼ׽Ⱥ.ˢȳѪ,ʾ;,Է,Ѫ,ʾѪҺ.ֵĿǻȾ,ܴ(Ϊԭ),ϸȱ֢,ϸ֢,Ѫ,򵰰ȱϸ.߿ɾǻʹӦ,пǻ·ʳ.

A thorough evaluation requires good illumination, a tongue blade, gloves, and a gauze pad. A dental or laryngeal mirror, if available, is helpful. ȫҪõ,ѹ,׺ɴ.ھʺڿǻ.

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. ȹ۲沿ԵIJԳ,ƤIJ,統˵ʱ˶޳ӲƤ֫˷ʴ֢.ۺò.,ܱϴʾ̥ƾۺPrader-Williۺ,ʱڵĴ,رǼղĶ,˼״ͻĺ͵ǵ˫.һ˫ԷԷʴ,沿ԷԷʴ,֫˷ʴ֢ƻ沿ò.ȱʧ,ղ᰼ݶγϵĻò.֢,,SjÖgrenۺ,,ͻԵ,ŧµķ֯,ʹһ˫ղ.沿෢Իϸɱϸۺ,ʹĵXƬѰҶ෢ԴԽǻ.

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. Դ,ͬʱſ,ճĤͿǻǰͥ;ȻѲӲ,ӺͿʲ.뻼߾,¶౳,Ҿÿƶ,Ϳɿĺ.߲ܽ㹻ʹ״ͷܱʱ,߿ɴס,ʹλ.ȻѲูͿڵ,ټݺ.

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. ô׵ָԿǻǰͥﲢһָͷݵĸ,ָͷ˶.ֵʾָ,ֵļָڿ൱λ,شѿڵ.ΪʹЩ,뻼߽ǻ,άһĿڶʹָܽǻ.ԾܰͽҲӦ.

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. ؽ(TMJ)ļΪʱڶǰ״ͻͷ,ǵƫ.Ȼ߽Сָ,뻼Ŵںͱտ3.ʵŴ,ʹܷ֮Žָ.ſڵؽʾΪӲƤ,ؽ,ؽǿֱ,ؽλ,˷ŧ.쳣Ĵ󿪿ʾؽ̰λEhlers-DanlosۺĢ(Ŵۺ,Ϊؽڹ쳤,ƤԴ---ע).

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). ζĶԭ.ڳԴڿǻ.ԭϸл׻ӷ,ǿǻڸ֢ʱ.ڳҲθϵͳԴлԼ,Ҳͪζй,ζι˥й,ζ˥й.ڳҲԴڱDz,,ʲͷ,䵱ЩλиȾʱ.ɢҺϢĻ߳оDZڵĿڳǸ(,Լеʵijζ,ʵϴζDzڵ).

ҽѧ֪ʶ˫Ķ

Night sweats are drenching sweats that require a change of bedding. Ϊ͸Գ軻

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. ϡҪųijԳӦϡ20ǰͨʾн˾Ⱦڣܶ಻ʶ֢״ءͨij֪֢ı־(رǰҹѪ)֢ͷ˺͸ַʪҲµļһ֢״ڸ没˽мʱʷµ֢״

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. ʷͨȷϷʱ䡢Ӿ缰֢״˼ȷѯʲູ֪ҲҹѪǿƲйءʪԼ(ʪؽסǴ׶ʪԹؽסؽ׵)Ҳ³Ҳʱĸıܶ฾Ů״³ࡣߴ˸ȾӣرǷǵԲԭȾҩʷѯͷʹüӴ״

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. ϵͳ顣֢״(఩ۺ֢ȸϸ)ؽʹ˯Ժͣ¾ԡͷʹѡ˯ѡƤƣļ¼űϰ߸ı䡣

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. ¶ءѯ߼ҩʹ翹ҩ涨ƼƼټƼᡢ̴˷ܼǴƼȼȻƷѯʲ޽ӴԴȾ(STD)HIVס˲зְҵԼԽӴҲӦѯΧҹ仯

C. Psychological factors. Anxiety, nightmares, and psychoactive preparations can precipitate night sweats in healthy individuals. C. ءǡجμ˷ܼɵ½

D. Family history. Patients who report a family history of hereditary disorders and possible malignancies should have appropriate screening. D. ͥʷŴܵĶͥʷӦʵɸ졣

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. 顣ӦԲҽʷеԼ¼עⲡ¡ͷۡǼصͨ͵ĸȾס׺Ͷסܰͽ᳹׼ȷϸȾܰͲ䡣ķμҲʾȾĤ˷ܼʹӦ鲡ǷŧסƤ񡢹ؽŧסĤ׺͹ס

IV. Testing

IV. 顣

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. ٴʵҼ顣֪֢ˣӦⲡ֢ǷӾ磺Ѫ(Ⱦ׺ؽ)CӦ(ʪԼ)Ѫ쵰AIC()ݲ֢״¶Ƿ飬ϲƤԡų״ٻܿT4ˮƽ顢ȫѪ(Ⱦ)ݼؼͣԡؼSTDӴ˿Ҫּ顣

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. Ӱ顣زX߼˵ĵãʷҵԽӴԡЩҪDZڶɸ졣CTɨͨʣ֢״ʾҪһ顣

V. Diagnostic assessment. Night sweating as a single entity is not worrisome. V. Ϊһ״˵ġ

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. ֪ӾԻü̵ķʷڲ˼агõҩǵĿס˿Ҫͣҩһҩʱ䡣Ҳijּչ֢״˹۲ȴõġӦָر仯ռ˯ߺ仯˿дһ֢״IٴҽʦȷǷһаǸò鳣ļͨ鷿XߡͿƬDZѪɸ쳣ڽά֣Ҳǵǰ߼֮һ

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