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ru2en: 22.1.6. Differential diagnosis
Because the differential diagnosis of a cost
time, it is advisable to carry it in a certain sequence:
1) The first rule similar to the clinical picture of other acute surgical
abdominal disease, requiring urgent
operations, 2) then - acute diseases of the stomach, requiring no
urgent surgery, and 3) finally rule out other non-surgical
disease, occurring under the guise of "acute abdomen". Naturally, the
this division is conditional, since the analysis of clinical
symptoms of different diseases is carried out simultaneously, and additional
methods of research produced in a specific sequence
- From simple to complex, trying to select the most informative.
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ru2en: 1. Acute illness requiring emergency surgery. N e p p a r a m and c Nye gastric ulcer and in e e n d a n and m and n e p t a n d guts of different
from the presence of acute appendicitis classic triad of symptoms (70 80%): a history of peptic ulcer disease, sudden dagger-like pain in epigastGeneral area, "doskoobraznoe" muscle tension of the abdominal wall.
In addition, when the perforation ulcers rarely vomiting, body temperature in
the first few hours are not increased. In addition, we can determine the free gas in
abdominal cavity as percussion (disappearance of liver dullness), so
and radiographically (bright band of gas under the dome of the diaphragm). It should be
mindful of the fact that he was in the abdominal cavity contents and inflammatory
exudate on the right down a side channel to the right
640
iliac fossa.

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ru2en: Accordingly, the epigastric pain of moving
in the lower right quadrant of the abdomen, which may resemble a typical
for appendicitis symptom of "moving pains" (Kocher-Volkovych). But
perforation at ulcer pain is spreading, but does not move from
epigastrium in the hypogastrium. With perforated ulcer pain, tenderness, safety
tension in the upper abdomen, symptoms of irritation of the peritoneum
epigastric saved, only increases the area of the abdominal wall,
where these symptoms can be determined. In patients with acute appendicitis
"Migration" of pain and tenderness in the right iliac region features
irritation of the peritoneum in the rest of the abdomen did not identify

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ru2en: Acute intestinal obstruction may resemble atypical
flowing acute appendicitis. Diagnostic errors can be avoided
if we consider that the pain of acute intestinal obstruction is accompanied by
repeated vomiting and not bringing relief to palpation
abdominal symptoms of irritation of the peritoneum can not be detected, and during the
radiological examination of the abdominal cavity in the loops of intestine
detect liquid levels ("Kloybera bowl"). In children, the cause
obstruction may be intussusception, its vices
development and congenital adhesions in the ileocecal angle.

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ru2en: For n and p y w e n n a d e b pipe p e m e n t n o C and a typical appearance
severe cramping abdominal pain, radiating to the shoulder girdle,
lower back, rectum. Precedes the onset of pain the next delay
menstruation. Abdominal pain accompanied by symptoms of internal
bleeding (general weakness, dizziness, fainting short).
On examination, pay attention to the pale skin and mucous
shell with a soft pulse. Patients prefer to sit as a
horizontal position of the blood irritates the diaphragmatic peritoneum,
that is manifested by pain in the shoulder girdle (a symptom of "Vanka-vstanka"). The hallmark
feature is the discrepancy between the intensity of pain
stomach and almost complete lack of muscle protection (stomach remains
soft!). For positive symptoms of irritation of the peritoneum in shelving
places the abdomen with a significant accumulation of blood in the abdomen can be
determine the percussion dullness. Vaginal examination helps
clarify the diagnosis reveal a bulging posterior fornix, the thickening
and softening of the cervix, soreness walls rectouterine
ugulubleniya. Pendulum displacement of the cervix are painful
(Symptom Promptov) uterus is usually enlarged, often referred to
dark brown discharge. In the analysis of blood - a picture normohromnoy anemia.
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ru2en: When torsion and rupture of large cysts and I h n and o in,
which occur as ectopic pregnancy, it is sometimes possible for bimanual
vaginal study palpated round, three-dimensional
formation with a dense surface.
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41-2375 641

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ru2en: 2. Acute diseases that do not require, as a rule, an emergency operation.
Acute cholecystitis is most often starts after a breach diet
with very severe epigastric pain, then localized in the right upper quadrant.
The initial stage of the attack is accompanied by the often repeated
vomiting of food and bile. Unlike podpechenochnogo appendicitis zone
maximum pain and tenderness corresponds to the projection of the bottom of the gall
the bladder. Here we show the muscle tension of the abdominal wall, the symptoms

irritation of the peritoneum, increased palpates the painful


gallbladder, as well as identify symptoms Ortner, Murphy, Musso.
With a high arrangement of the inflamed appendix area pain and maximum
41-2375 641
Noah is projected often painful lateral location of the projection of the gall
the bladder.

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ru2en: Epigastric phase of acute appendicitis can be taken on a t r d s
n a n a p e a r and r, if it is particularly bright and is accompanied by a pressing
pain in the epigastrium, nausea and profuse vomiting. In this case,
clarify whether there is a characteristic of pancreatic pain in the irradiation
back, girdle patient the type of "wrap" or "poluobrucha." Usually
at the same time, there are marked tachycardia at normal temperature
the body. The abdomen is soft, just painful in the epigastrium. Pay
attention to the discrepancy between the severity of the condition and moderate muscle
protection only in the upper abdomen. In addition, the exhibit
characteristic symptoms of pancreatitis Kerth, Mayo-Robson, the Resurrection
(No pulsation of the abdominal aorta). Ultrasonography and CT are
changes characteristic of pancreatitis in pancreas size
and density.

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ru2en: In patients with acute and a n e k with m and m on the attack often coincides with the beginning
menstruation or termination, hypothermia, physical overexertion.
Pain, in contrast to the pelvic appendicitis immediately begins
abdomen and radiating to the back, groin, accompanied by
profuse muco-purulent discharge from the vagina. Vaginal
study palpates sharply painful right sided tuboovarian infiltration, determine the positive symptom Promptov
(80% of patients). Body temperature at adnexitis, usually above 38 C

but leukocytosis and stab shift expressed moderately (except


cases of gonorrheal salpingoophoritis).
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ru2en: Acute mesenteric limfoadenit a springfall season, most often develops in people younger than 20 years, is characterized by
attack of pain in the right iliac region with the spread of
on parumbilical. After the pain comes high body temperature.
When abdominal palpation reveals tenderness at the root of the mesentery of the projection
the small intestine (along the line connecting the right peredneverhnyuyu
arista with the left upper quadrant). Muscle tension is absent, the symptoms
irritation of the peritoneum were negative. The disease is characterized by
monotony, the severity of intoxication (hyperthermia,
tachycardia, leukocytosis with left shift), the gradual regression of symptoms
against the background of anti-inflammatory therapy.
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ru2en: Non-surgical disease, occurring under the guise of "acute abdomen".
Atypical form of appendicitis should be differentiated from P and C
t of p o n n e and renal colic. It begins with a sharp (not dull)
pain in the right half of the lumbar region, may be accompanied by
vomiting, frequent urging to urinate. The pain may shift to
right iliac region, radiate to the thigh, groin, genital
authorities. In this case there is not intense, typical of appendicitis, the local
abdominal pain or symptoms of irritation of the peritoneum.
Body temperature is normal. In the urine analysis show a considerable
of fresh red blood cells. Ultrasonography (emergency or urgent Urography) can be visualized in the pelvis concretions or ureter
against the background of the cups and pelvic kidney.

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ru2en: N c e d a a a n n e n d y l and I p H and I form an acute yersiniosis different
increase in temperature to 38-39 "C. The fever is accompanied by severe
intoxication (fever, heavy sweating, headache, myalgia)
nausea, vomiting, loose stools, abdominal pain without clear lo642
localization. Then the pain is concentrated in the right iliac region,
here there is severe local pain: symptoms of irritation
peritoneum expressed mild. The blood found neutrophilic
leukocytosis (up to 15 109 / L) and a significant increase in erythrocyte sedimentation rate.

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ru2en: For nehenhandnapp a and p, and in patients developing an intense
cramping abdominal pain, local or generalized. To her
join nausea, vomiting, delayed stool, fever, tachycardia,
hypertension, urinary retention. But it is not expressed
symptoms of irritation of the peritoneum, local tenderness on palpation
the stomach is negligible. For porphyria characterized by staining of urine
dark red color, especially if it is exposed to the source
light for some time.
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ru2en: Example of a well with tons of p o n d n and basal pleurisy and n m n e a o n and I, especially
younger children, may lead to errors in diagnosis.
To avoid them, you must pay attention to the characteristic cyanosis
nasolabial triangle, cough, shortness of breath expressed, the weakening
breath and wheeze over the affected department of the lung, as well as friction noise
pleura.

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ru2en: The cause of diagnostic errors may be abdominal
syndrome of diabetes and a b d e t e. In the differential diagnosis
important history. The complaints is dominated by lust, the total

weakness, polyuria. Abdominal pain has no specific localization. In


state precoma patients appears tachypnea, hypotension, lethargy,
drowsiness, acetone smell from mouth. Pathogenetic treatment relieves pain
in the abdomen.
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ru2en: In hemorrhagic vasculitis (disease-Shanley
on - Henoch) cramping abdominal pain, without a specific location.
Despite the intense pain abdominal wall remains soft,
well accessible to palpation. Body temperature is usually normal. At
mild form of the disease there is no leukocytosis, severe - it can reach
30 109 / L, and erythrocyte sedimentation rate increased to 80 mm / h. This disease is especially
petechial rash characteristic of the lower extremities and buttocks.
Myocardial infarction (usually the back wall of the left
ventricular) may occur epigastric pain, but stress
abdominal wall muscles, as a rule, no, no, and symptoms
irritation of the peritoneum.

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