MarkBajorek

　　马克.巴杰瑞克

　　Nightsweatsaredrenchingsweatsthatrequireachangeofbedding.

　　盗汗为淋透性出汗，需换床单。

　　I.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汗。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。

　　II.History.Nightsweatscanbecharacterizedbydeterminingonset,frequency,exacerbations,andremissionsofsymptoms.Questionpatientsaboutthecurrentstateofknowndisorders.Excessivesweatingisassociatedwithpoornocturnalglycemiccontrol.Flaresofrheumatologicdisorders（rheumatoidarthritis,lupus,juvenilerheumatoidarthritis,andtemporalarteritis）causesweatingtoo.Pregnancytemporarilychangestheintrinsicthermostatinmanywomenwhoperspireexcessively.Patientswhoareimmuno-compromisedareatincreasedriskforinfections,especiallywithatypicalagents.Patientswithahistoryofsubstanceabuseneedtobeaskedaboutneedleuseandcontaminants.

　　II．病史。盗汗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。

　　A.Reviewofsystems.Othersymptomsthatcanaccompanynightsweatsincludeflushing（carcinoidsyndrome,pheochromocytoma）,jointpain,sleepapnea,menstrualirregularities,reflux,cough,headache,dysuria,dyspnea,rashes,fatigue,palpitations,andweightandbowelhabitchanges.

　　A.系统检查。伴随盗汗的其他症状包括潮红（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。

　　B.Exposurefactors.Inquireaboutrecentimmunizationsornewmedicinessuchasantidepressants,cholinergics,meperidine,estrogeninhibitors,gonadotropininhibitors,niacin,steroids,stimulants,over-the-counterpreparations,antipyretics,andnaturopathictherapies.Questionpatientsaboutexposuretosexuallytransmitteddiseases（STDs）,humanimmuno-deficiencyvirus（HIV）,hepatitis,tuberculosis,oroccupationalandtravel-relatedexposures.Alsoaskaboutincreasesingeneralchangesintheambientnighttemperature.

　　B.暴露因素。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。

　　C.Psychologicalfactors.Anxiety,nightmares,andpsychoactivepreparationscanprecipitatenightsweatsinhealthyindividuals.

　　C.精神因素。焦虑、噩梦及兴奋剂可导致健康个体盗汗。

　　D.Familyhistory.Patientswhoreportafamilyhistoryofhereditarydisordersandpossiblemalignanciesshouldhaveappropriatescreening.

　　D.家庭史。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。

　　III.Physicalexamination.Thephysicalexaminationshouldaddressthepertinentpositivesnotedinthepatient'smedicalhistory.Notethepatient'sweightandtemperature.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。

　　IV.Testing

　　IV．检验。

　　A.Clinicallaboratorytesting.Forpatientswithaknowncondition,testingforexacerbationsisappropriate erythrocytesedimentationrate（infection,osteomyelitis,andtemporalarteritis）,C-reactiveprotein（rheumatologicdisorders）,andhemoglobinAiC（diabetesmellitus）.Dependingonthepatient'ssymptomsorexposures,otherappropriatetestscanincludepurifiedproteinderivativeskintestfortuberculosis,freeT4leveltoruleoutthyrotoxicosis,completebloodcountwithdifferential（infection）,andfollicle-stimulatinghormonetoinvestigatethepossibilityofmenopause.Specialtestsmayberequiredofpatientswithtravel-relatedorSTDexposures.

　　A.临床实验室检查。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。

　　B.Imaging.Chestx-raystudiesareusefulintheevaluationofnightsweatsinpatientswithasmokinghistory,industrialexposure,oracough.Thesepatientsneedtobescreenedforoccultmalignancy.Computedtomographyscansaregenerallynotappropriateunlessothersignsorsymptomsdictatefurtherevaluation.formwww.med66.com

　　B.影像检查。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扫描通常并不合适，除非其他症状或体征提示要作进一步检查。

　　V.Diagnosticassessment.Nightsweatingasasingleentityisnotworrisome.

　　V．诊断评估。盗汗作为单一征状并不令人担心。

　　Explorethelikelihoodofexacerbationofknownconditionsortheonsetofanewdiseaseprocess.Thehistoryisthemosthelpfulpartofthepatientencounter.Anewmedication,withperspirationasasideeffect,istheculprit.Patientsmayneedcessationofthemedicationaswellasawashoutperiod.Nightsweatsmightbeanearlysymptomofadevelopingillnesssowatchfulwaitingisuseful.Patientsneedtobeinstructedtowatchforweightchanges,fevers,andsleepandmoodchanges.Patientscancompleteasymptomdiary,whichisveryhelpfultotheclinicianindeterminingtheneedforadditionalevaluation.Considerillnessesthattendtobepresentinthepatient'sagegroup.Screeningforcommonmalignanciesthroughmammograms,papsmears,andfecaloccultbloodtestingisappropriatehealthmaintenanceaswellasoftenbeingapartoftheevaluationofthepresentingcomplaintofnightsweats.

　　检查已知疾病加剧可能性或所得疾病过程的发作情况。病史在病人疾病中最有帮助。有出汗副作用的新药常常是盗汗的魁首。病人可能需要停药及给予一段药物清除时间。盗汗也可能是某种疾病发展的早期症状，因此观察等待是有用的。应指导病人留意体重变化、发烧及睡眠和情绪变化。病人可填写一份症状日I，它对临床医师确定是否作进一步检查很有帮助。考虑该病人年龄组常见的疾病。通过乳房X线、巴氏涂片及粪便潜血试验筛检常见恶性肿瘤，既适于健康维持，也是当前盗汗主诉检查的内容之一。