Chapter 45 Acute Abodomen -Decision to Operate
These difficulties notwithstanding, the surgeon must make a decision to operate or not. Certain indications for surgical treatment exist. (Notwithstanding 盡管 雖然 )
盡管有這些困難，外科醫(yī)生必須作出是否手術(shù)的選擇。有一些外科手術(shù)的指征。
For example, definite signs of peritonitis such as tenderness, guarding, and rebound tenderness support the decision to operate. ( Peritonitis 腹膜炎)
比如說，特定的腹膜炎體征如腹痛，肌衛(wèi)，反跳痛都支持手術(shù)的決定。
Likewise， severe or increasing localized abdominal tenderness should prompt an operation.
同樣的，嚴(yán)重的或者逐漸加重的局限性腹痛也應(yīng)馬上手術(shù)。
Patients with abdominal pain and signs of sepsis that cannot be explained by any other finding should undergo operation.
無法解釋的腹痛伴隨膿毒癥的病人應(yīng)該進(jìn)行手術(shù)。
Those patients suspected of having acute intestinal ischemia should be operated on after complete evalution.
對懷疑腸缺血的病人需進(jìn)行充分評估后手術(shù)。
Certain radiogragphic findings confidently predict the need for operation.
某些診斷學(xué)的發(fā)現(xiàn)比較確切地提示了手術(shù)指證。
These finding include pneumoperitoneum and radiologic evidence of gastrointestinal perforation
這些發(fā)現(xiàn)包括氣腹證或者胃腸穿孔的放射學(xué)證據(jù)。
Patients presenting with abdominal pain and free intra-abodominal gas seen on radiograph warrant operation with limited exceptions.
如果患者有腹痛并且X光片上有腹腔內(nèi)氣體，絕大部分病人需要手術(shù)。
Observation with serial examinations may be appropriate for a patient with free gas after a colonoscopy.
結(jié)腸鏡檢查后出現(xiàn)自由氣體的病人需要觀察并做一系列的檢查。
Intra-abdominal gas can persist for a day or two following celiotomy.
剖腹術(shù)后腹腔內(nèi)氣體還可以遺留一至二天。
Imaging tests can reveal signs of vascular occlusion requiring operation.
放射學(xué)檢查可以提示需要手術(shù)的血管阻塞疾病。
After careful examination and evaluation, diagnostic uncertainty can remain. Some patients may have equivocal physical findings.
詳細(xì)的檢查和評估之后，診斷未明確的可以繼續(xù)觀察。一些病人可能表現(xiàn)出模棱兩可的體征。
When this occurs and the diagnosis is unclear and the patients wellness is unclear, it may be advisable to defer operation and to re-examine the patient carefully after several hours.
如果有上述情況，診斷不明確，病人癥狀無好轉(zhuǎn)，建議延期手術(shù)，數(shù)小時(shí)后再次詳細(xì)檢查。This is best done in a short-stay unit in the hospital, in a special unit in the emergency department, or if necessary, by regular hospital admission.
最好能在醫(yī)院短期留觀或者在急診室觀察，如果有必要可以入院觀察。
In a period of hours, vague pain with minimal physical findings may proceed to definite localized pain with tenderness, guarding, and rebound tenderness; if that occurs, operation should follow
如果在數(shù)小時(shí)內(nèi)，沒有明顯體征的腹脹轉(zhuǎn)化為明確的局限性腹痛，肌衛(wèi)和反跳痛，則手術(shù)指證明顯。
After several hours , the patient’s symptoms and signs may also resolve.
也有可能，數(shù)小時(shí)后病人的癥狀和體征消失。
When that happens, the patient can be dismissed, although the patient should have a follow-up appointment scheduled within a day or so to permit re-examination to be certain that an important diagnosis was not missed.
如果是這種情況，病人可以出院，雖然仍需短期的隨訪和重新檢查，以免遺漏重要的診斷。
Certain patients are difficult to evaluate because of special characteristics.
有些病人由于特殊性很難評估。
For example, patients who are neurologically impaired as result of stroke or a spinal cord injury may be difficult to evaluate.
如由于中風(fēng)或脊髓損傷導(dǎo)致的神經(jīng)系統(tǒng)功能不全的病人。
Patients who are under the influence of drugs or alcohol may require special or subsequent examination.
受藥物（毒品)或酒精影響的病人需要進(jìn)行特殊或者后續(xù)進(jìn)一步檢查。
Patients who take steroids or are otherwise immunosuppressed deserve special mention because steroids and immunosuppression mask the intensity of abdominal pain and the physical findings of severe, life-threatening intra-abdominal disease.
服用類固醇或免疫抑制劑的病人需要特別注意，因?yàn)轭惞檀己兔庖咭种苿┠苎谏w腹痛的程度及嚴(yán)重致命的腹腔疾病。
Patients in this category who have persistent, unequivocal abdominal pain and even minimal findings should be considered for surgical operation.
unequivocal明確的，不模棱兩可的
此類病人如果有持續(xù)性，明確的腹痛，甚至輕微的腹痛也應(yīng)該手術(shù)。
Some patients with clear findings of the acute abdomen may be treated without surgical operation
有些病人即使有明確的急腹癥也可以不需要手術(shù)。
For example, patients with perforated duodenal ulcer who seek attention late in the course of their disease after they have been sick for several days may be treated best by careful supportive care including nasogastric suction, intravenous fluids, and pain relief.
如十二指腸潰瘍穿孔病人，病人已有多天，而發(fā)作也很遲，最好進(jìn)行支持性治療，如胃腸減壓，靜脈輸液和止痛。
Certain patients with empyema積膿 of the gallbladder, especially those with other serious concomitant伴隨的 illnesses, can be treated by percutaneous drainage of the infected gallbladder and careful supportive care rather than with cholecystectomy.
對于膽囊積膿患者，尤其是伴有其他嚴(yán)重疾病，寧可選擇經(jīng)皮引流和支持療法，而不進(jìn)行膽囊切除術(shù)。
Chapter 47. APPROACH TO THE PATIENT WITH PAIN
Believe the patient's complaint of pain. Despite decades of effort, there is no neurophysiologic or chemical test that can measure pain in individual patients. Objective observations of grimacing, limping, and tachycardia may be useful in assessing the patient, but these signs are often absent in patients with chronic pain caused by large structural lesions. The clinician can acknowledge the patient's report of pain before understanding its cause. Acceptance of the patient's reality of pain does not obligate the physician to provide strong opioids or other particular types of treatments.
相信病人的投訴的痛苦。盡管幾十年的努力,沒有神經(jīng)生理或化學(xué)檢測方法能夠測量個(gè)別病人疼痛。目的觀察扮鬼臉,跛行,和心動(dòng)過速可能是有效的,但這些評估病人癥狀患者通常是慢性疼痛缺席造成大的構(gòu)造病變。臨床醫(yī)生可以認(rèn)可疼痛病人的報(bào)告前了解其原因。接受病人的現(xiàn)實(shí)痛苦并不意味醫(yī)生提供有力的阿片類藥物或其他特定類型的治療。
Evaluate the response to previous and current analgesic therapies. Record the dose and duration of each previous treatment. Optimal doses of the best medication for a particular syndrome often produce gratifying results in patients who failed a brief trial with lower doses.
評價(jià)前和電流響應(yīng)鎮(zhèn)痛治療。記錄劑量和持續(xù)一個(gè)以前的治療。最佳劑量的最好的藥物為一個(gè)特定的綜合征常發(fā)生失敗的病人可喜結(jié)果簡短審訊與較低的劑量。
