急腹症地鉴别诊断与处理.pptVIP

* * * * * * * * * * * * General appearance “Sick versus not sick” Mobile versus still Obvious pain or discomfort “Doorway” impression Vital signs “That’s why they’re called vital” General exam: Is the patient distressed or in pain? Signs of shock Jaundice Anaemia Weight loss Objective measures: Temp; pulse; BP; resp rate. 病人烦躁不安、面色苍白、出汗，或仰卧 屈膝、侧卧不动，明显脱水，黏膜干燥，眼窝凹陷，呼吸浅快等提示病情很重。 * 心率快伴低血压，说明容量不足。 * 皮肤黏膜黄染提示胆道梗阻或感染。 * 高热提示有感染发生。 * Inspection Distention, scars, bruises Auscultation Present, hyper, or absent Actually not that helpful! Palpation Often the most helpful part of exam Tenderness versus pain Start away from painful area first Guarding, rebound, masses Inspection: external herniae; scars of previous surgery; movement of abdominal wall with respiration. Palpation: Peritonitis (absent/present). Percussion: as above. Auscultation: bowel sounds normal; absent or increased. PR. 望：腹式呼吸，腹型，皮疹，肠形，限局性隆起，静脉曲张 触：自非疼痛区开始，最后到病变部位。 着重检查腹部压痛、肌紧张、反跳痛的部位、范围和程度、有无包块。 压痛最显著部位通常即病变所在之处。如阑尾炎、胃穿孔等。 肌紧张为壁层腹膜受刺激后反射性腹肌痉挛，不受意识的支配，为腹膜炎的重要客观体征。但结核性腹膜炎触诊如柔面感。 老年人、衰弱者、小儿、经产妇、肥胖及休克病人，腹膜刺激征较实际为轻。 叩：先从无痛区开始，用力均匀。着重检查叩痛部位，肝浊音界，移动性浊音。 听：有无肠鸣音，频率，音调，振水音。 肠鸣音活跃、音调高、音响较强或气过水声—机械性肠梗阻。 肠鸣音消失是肠麻痹的表现，见于腹膜炎、小肠缺血、绞窄性肠梗阻。低血钾时肠鸣音也可减弱或消失。 振水声是急性胃潴留、胃扩张的表现。 * Signs Iliopsoas Obturator Rovsing’s Murphy’s Extra-abdominal exam Pelvic or scrotal exams Lungs, heart Remember it’s a patient, not a part Rectal Adds very little (despite the angst) beyond gross blood or melena * * Extra-abdominal exam Pelvic or scrotal exams Lungs, heart Remember it’s a patient, not a part Rectal Adds very little (despite the angst) beyond gross blood or melena 3 直肠指诊和妇科检查 对于诊断不明确的下腹痛病人，直肠指检是很必要的，应了解有无肿物，触痛，血便，并注意有无盆腔脓肿或积液。对疑有妇科问题的女性患者，应进一步妇科检查。 * * * Non-standard but useful Urine pregnancy test. Ultrasound scan. Enzymatic liver function tests. Radiological contrast studies. Computed tomography. * * * * * * * Acute abdominal pain is not uncommon. Approximately 5 admissions to the MRI/day with