Name: X X X birthplace: Inner Mongolia Autonomous Region
Gender: Male Occupation: Worker
Age: 30 years old, date of admission: February 2009-14, 10: 30am.
Nationality: Han nationality Date of record: February 2009-14, 1 1: 40am.
Marriage: Married history: the patient himself.
Chief complaint: metastatic right lower abdominal pain for more than 3 days.
Current medical history: The patient suddenly developed abdominal pain with unknown cause and inducement three days ago, showing persistent dull pain, with umbilical as the focus, no obvious paroxysmal aggravation, low back radiation, mild nausea, vomiting, fever, chills, headache, dizziness, chest tightness, breath holding, abdominal distension, frequent urination, urgency, dysuria and diarrhea. After anti-inflammatory and symptomatic treatment in the outpatient department, the symptoms were not obviously relieved, and the pain gradually shifted to the right lower abdomen. Later, I went to our hospital for treatment. After examination, the outpatient service was diagnosed as "appendicitis" and was admitted to hospital for surgical treatment. Since the onset, the patient has been conscious, poor diet and rest, no obvious abnormality in urination and defecation, and no obvious change in weight.
Past history: past health, denying the history of hepatitis and tuberculosis and close contact, denying the history of heart disease, no history of major trauma and surgery, and no history of blood transfusion. Deny the history of drug and food allergy. No long-term medication history, local vaccination history.
Personal history: born and raised in the country of origin, lived here for work reasons three years ago, but denied the life history of the epidemic area and had no contact history with poisons. No history of major mental trauma. Deny bad habits. Married at the age of 25, the lover is in good health.
Family history: denying the family history of genetic diseases and infectious diseases.
To physically block an opposing player, as in ice hockey or lacrosse.
T 36.6℃ P80 times/min R20 times/min BP 1 10/70mmHg.
The patient, a young man, is generally in good condition, with moderate nutrition, normal development, clear mind, acceptable spirit, painful appearance, positive posture and physical cooperation. There is no yellow stain on the skin and mucous membrane of the whole body, no abnormal swelling of superficial lymph nodes, no deformity of skull and facial features, no edema of eyelids, no congestion of conjunctiva, transparent cornea, round pupils on both sides, light sensitivity and accommodation reflex. There is no abnormal secretion in ears, nose and mouth. There is no cyanosis in the lips, no bleeding in the gums, no ulcer in the buccal mucosa, no congestion in the pharynx and no swelling in the tonsils. The neck is soft, the trachea is centered, the thyroid gland is not big, the chest is symmetrical without deformity, the bilateral respiratory activity is symmetrical, the lungs squeak, the bilateral respiratory sounds are clear, and no obvious dry and wet rales are found. There is no protrusion in the precordial area, the apical beat is located at the fifth intercostal position of the left clavicle midline, the heart boundary is not large, the heart rate is 80 beats/min, and there is no abnormal noise in each valve area. Abdominal examination showed the operation. No abnormality was found in the examination of anus, rectum and external genitalia. There is no deformity in the spine and limbs, and the activity is good. Corneal reflex, abdominal wall reflex and testicular reflex are normal, biceps brachii, triceps brachii, knee tendon and achilles tendon reflex are normal, and Pap's sign and meningeal irritation sign are negative.
Operation situation: the abdomen is flat, no intestinal type and peristalsis waves are found, the abdominal muscles of the right lower abdomen are slightly tense, and the right lower abdomen is tender, with Macbeth's point as the focus, with mild rebound pain, negative Murphy's sign, no obvious swelling of the liver and spleen, no tapping pain of the liver and kidney, no voiced sound and slightly weak bowel sounds.
accessory examination
Time project results
Outpatient service is not checked.
Preliminary diagnosis:
1, acute suppurative appendicitis
2. Localized peritonitis
The first course of disease was recorded at 14 and 10:50 in the morning of February 2009.
Case characteristics:
1. Patient Bi Jianjun, male, 30 years old, had metastatic right lower abdominal pain for more than 3 days.
2. Physical examination: T 36.6℃ P80 times/min R20 times/min BP1170mmhg, flat abdomen, no intestinal type and peristalsis waves, slight tension in the right lower abdominal muscles, tenderness in the right lower abdomen, slight rebound pain with emphasis on Macbeth's point, negative Murphy's sign, and no swelling of the liver and spleen.
3. Auxiliary examination: the clinic did not check.
Preliminary diagnosis:
1, acute suppurative appendicitis
2. Localized peritonitis
Diagnostic basis:
1. Patient Bi Jianjun, male, 30 years old, had metastatic right lower abdominal pain for more than 3 days.
2. Physical examination: the abdomen is flat, no intestinal type and peristalsis waves are found, the abdominal muscles in the right lower abdomen are slightly tense, and the right lower abdomen is tender, with Maxwell's point as the focus, mild rebound pain, negative Murphy's sign, no swelling of the liver and spleen, less than other masses, negative percussion pain in the liver and kidney area, no moving dullness and slightly weak bowel sounds.
Differential diagnosis:
1. Stomach perforation: I have a history of upper abdominal pain for many years or have taken too many hormones and non-steroidal anti-inflammatory drugs recently. The onset is seasonal, the tenderness and rebound pain of the whole abdomen are obvious, and there is free gas under the diaphragm during peritoneal dialysis. This patient can be ruled out at present.
2. Right ureteral calculi: The pain in the right lower abdomen is paroxysmal colic, which often occurs after exercise or changing body position. There may be similar episodes before, and there is little water in peacetime. B-ultrasound is helpful for identification. We can't rule out this patient for the time being.
Preliminary diagnosis and treatment plan:
1. Routine surgical care, Grade II care, no diet.
2. Improve all kinds of examination and adjuvant therapy.
3. Emergency surgical treatment.