问题 问答题 案例分析题

患者,男,58岁,教师。

主诉:舌右侧缘溃疡6年,快速增大、疼痛2个月。

现病史:约6年前,患者舌右侧缘与下颌牙齿残根对应部位出现约0.5cm直径的溃烂面,无明显的不适,仅进食吞咽时有轻微的疼痛,未重视。于校医院就诊,考虑口腔溃疡,建议拔除右侧下颌残根,同时给予西瓜霜等药,拔牙创愈合良好但溃疡面仍未愈合。2个月前,溃疡面迅速扩大,同时出现明显的自发性疼痛症状,进行抗生素静脉点滴(具体药品迹剂量不详)无明显疗效,经介绍前来我院就诊。

既往史:否认各种系统性疾病史。

检查:舌右侧缘溃疡,大小约2.5cm×3.0cm,未越过舌中线。溃疡中心凹陷,边缘隆起外翻,似火山口状,表面污秽,可见明显的坏死组织,轻微异味。触诊溃疡基底浸润明显,质地硬,触痛明显。伸舌无偏斜。右侧下颌下区可触及一枚肿大淋巴结,质地韧,动度尚可,压痛不明显(图4-26-5)。

全口牙龈色泽基本正常,牙龈及龈 * * 退缩2~4mm,外展隙大,机械刺激牙颈部敏感,冷诊(-),牙无松动。

病例分析

1.主诉疾病的诊断和诊断依据。

2.非主诉疾病的诊断和诊断依据。

3.主诉疾病的治疗原则。

4.全口其他疾病的治疗设计。(病例题)

答案

参考答案:

1.诊断

(1)主诉诊断:舌右侧缘恶性肿瘤(鳞状细胞癌)。

(2)非主诉疾病的诊断:牙龈退缩并发牙本质过敏症。

2.主诉疾病的诊断依据

(1)病史:舌右侧缘溃疡6年,快速增大疼痛2个月。抗感染治疗无效。

(2)检查:舌右侧缘溃疡,大小约2.5cm×3.0cm,未越过舌中线。溃疡中心凹陷,边缘隆起外翻,似火山口状,表面污秽,可见明显的坏死组织,轻微异味。触诊溃疡基底浸润明显,质地硬,触痛明显。

3.非主诉疾病的诊断依据牙龈及龈 * * 退缩2~4mm,外展隙大,机械刺激牙颈部敏感,冷诊(-),牙无松动。

4.主诉疾病的鉴别诊断创伤性溃疡:①去除刺激很快愈合;②溃疡边缘无隆起外翻,无组织坏死,无疼痛;③质地软。

5.主诉疾病的治疗计划(1)溃疡局部病理刮片活检证实诊断。(2)舌右侧缘恶性肿瘤局灶扩大切除术+右侧颈淋巴清扫术。

6.全口其他疾病的治疗设计口腔卫生维护,脱敏治疗。

【病例得分与失分要点】

1.主诉疾病

(1)关于诊断的失分要点:①诊断不准确:如答舌包块待查,溃疡待查均不是十分准确,一定要将病变部位,疾病性质明确。②诊断错误:如答舌创伤性溃疡,良性溃疡等。

(2)关于诊断依据失分要点:主要在病史和检查方面叙述不完整,如:①病史:舌右侧缘溃疡6年,快速增大,疼痛2个月,抗感染治疗无效;②检查:溃疡中心凹陷,边缘隆起外翻,似火山口状,表面污秽,可见明显的坏死组织,轻微异味。触诊溃疡基底浸润明显,质地硬,触痛明显。伸舌无偏斜。

(3)关于鉴别诊断失分要点:①病史:经久不愈的组织溃疡,抗感染治疗无效,快速的生长病史,疼痛等功能障碍;去除局部不良的刺激后溃疡无愈合表现,反而出现快速生长,因此不考虑创伤性溃疡。②检查结果:溃疡基底浸润,呈典型的火山口状,因此排除各种良性溃疡的可能。

(4)有的只考虑手术治疗,遗忘了化疗和放疗。

2.非主诉疾病大多没有对非主诉疾病进行诊断。

阅读理解

Killer bees started in Brazil in 1957. A scientist in Sao Paulo wanted bees to make more honey. So he put forty-six African bees with some Brazilian bees. The bees bred and made a new kind of bee. But the new bees were a mistake. They did not want to make more honey. They wanted to attack. Then, by accident, twenty-six African bees escaped and bred with the Brazilian bees outside.

Scientists could not control the problem. The bees spread. They went from Brazil to Venezuela. Then they went to Central America. Now they are in North America. They travel about 390 miles a year. Each group of bees, or colony (群体), grows four times a year. This means one million new colonies every five years.

Why are people afraid of killer bees? People are afraid for two reasons. First, the bees sting (刺痛、蜇) many more times than a normal bee. Killer bees can sting sixty times a minute non-stop for two hours. Second, killer bees attack in groups. Four hundred bee stings can kill a person.

Already several hundred people are dead. Now killer bees are in Texas. In a few years they will spread all over the United States. People can do nothing but wait.

小题1:A scientist in Brazil wanted bees ________.

A.to go to Central America

B.to grow four times a year

C.to make more honey

D.to breed with Brazilian bees outside小题2:The bees bred and made a new kind of bee. Here “bred” means ________.

A.attack

B.run away

C.died

D.produce young小题3:Killer bees can sting ________.

A.once two hours

B.400 times two hours

C.3600 times two hours

D.7200 times two hours小题4:Why are people afraid of killer bees?

A.Because they sting Brazilian bees.

B.Because they sting more and attack in groups.

C.Because they won’t make any honey.

D.Because each group of bees grows four times a year.小题5: What will the people do with the killer bees?

A.People can do nothing but wait.

B.People will make another kind of bees.

C.Scientists could control the problem.

D.They will spread all over the world.

单项选择题