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 尽管 虽然 )
尽管有这些困难，外科医生必须作出是否手术的选择。有一些外科手术的指征。
For example, definite signs of peritonitis such as tenderness, guarding, and rebound tenderness support the decision to operate. ( Peritonitis 腹膜炎)
比如说，特定的腹膜炎体征如腹痛，肌卫，反跳痛都支持手术的决定。
Likewise， severe or increasing localized abdominal tenderness should prompt an operation.
同样的，严重的或者逐渐加重的局限性腹痛也应马上手术。
Patients with abdominal pain and signs of sepsis that cannot be explained by any other finding should undergo operation.
无法解释的腹痛伴随脓毒症的病人应该进行手术。
Those patients suspected of having acute intestinal ischemia should be operated on after complete evalution.
对怀疑肠缺血的病人需进行充分评估后手术。
Certain radiogragphic findings confidently predict the need for operation.
某些诊断学的发现比较确切地提示了手术指证。
These finding include pneumoperitoneum and radiologic evidence of gastrointestinal perforation
这些发现包括气腹证或者胃肠穿孔的放射学证据。
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光片上有腹腔内气体，绝大部分病人需要手术。
Observation with serial examinations may be appropriate for a patient with free gas after a colonoscopy.
结肠镜检查后出现自由气体的病人需要观察并做一系列的检查。
Intra-abdominal gas can persist for a day or two following celiotomy.
剖腹术后腹腔内气体还可以遗留一至二天。
Imaging tests can reveal signs of vascular occlusion requiring operation.
放射学检查可以提示需要手术的血管阻塞疾病。
After careful examination and evaluation, diagnostic uncertainty can remain. Some patients may have equivocal physical findings.
详细的检查和评估之后，诊断未明确的可以继续观察。一些病人可能表现出模棱两可的体征。
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.
如果有上述情况，诊断不明确，病人症状无好转，建议延期手术，数小时后再次详细检查。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.
最好能在医院短期留观或者在急诊室观察，如果有必要可以入院观察。
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
如果在数小时内，没有明显体征的腹胀转化为明确的局限性腹痛，肌卫和反跳痛，则手术指证明显。
After several hours , the patient’s symptoms and signs may also resolve.
也有可能，数小时后病人的症状和体征消失。
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.
如果是这种情况，病人可以出院，虽然仍需短期的随访和重新检查，以免遗漏重要的诊断。
Certain patients are difficult to evaluate because of special characteristics.
有些病人由于特殊性很难评估。
For example, patients who are neurologically impaired as result of stroke or a spinal cord injury may be difficult to evaluate.
如由于中风或脊髓损伤导致的神经系统功能不全的病人。
Patients who are under the influence of drugs or alcohol may require special or subsequent examination.
受药物（毒品)或酒精影响的病人需要进行特殊或者后续进一步检查。
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.
服用类固醇或免疫抑制剂的病人需要特别注意，因为类固醇和免疫抑制剂能掩盖腹痛的程度及严重致命的腹腔疾病。
Patients in this category who have persistent, unequivocal abdominal pain and even minimal findings should be considered for surgical operation.
unequivocal明确的，不模棱两可的
此类病人如果有持续性，明确的腹痛，甚至轻微的腹痛也应该手术。
Some patients with clear findings of the acute abdomen may be treated without surgical operation
有些病人即使有明确的急腹症也可以不需要手术。
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.
如十二指肠溃疡穿孔病人，病人已有多天，而发作也很迟，最好进行支持性治疗，如胃肠减压，静脉输液和止痛。
Certain patients with empyema积脓 of the gallbladder, especially those with other serious concomitant伴随的 illnesses, can be treated by percutaneous drainage of the infected gallbladder and careful supportive care rather than with cholecystectomy.
对于胆囊积脓患者，尤其是伴有其他严重疾病，宁可选择经皮引流和支持疗法，而不进行胆囊切除术。
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.
相信病人的投诉的痛苦。尽管几十年的努力,没有神经生理或化学检测方法能够测量个别病人疼痛。目的观察扮鬼脸,跛行,和心动过速可能是有效的,但这些评估病人症状患者通常是慢性疼痛缺席造成大的构造病变。临床医生可以认可疼痛病人的报告前了解其原因。接受病人的现实痛苦并不意味医生提供有力的阿片类药物或其他特定类型的治疗。
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.
评价前和电流响应镇痛治疗。记录剂量和持续一个以前的治疗。最佳剂量的最好的药物为一个特定的综合征常发生失败的病人可喜结果简短审讯与较低的剂量。
