腰椎间盘突出症鉴别诊断的思路与方法

疼痛是所有腰腿痛病例共同的临床症状,但疼痛的病因、病理、部位（范围或区域）、强度、性质、演变情况、影响因素与伴随症状等具有一定的特点与规律。这些差异既是特定疾病临床诊断的首要依据,也是鉴别诊断的重要线索。腰椎间盘突出症临床诊断的前提是一系列的排他诊断,掌握一些类症鉴别诊断的思路与方法,将有助于该病的诊断与鉴别。     

银屑病合并褐黄病性关节炎1例

<正>褐黄病性关节炎发病率低,临床报道较少,人们对他的认识不足,导致其与银屑病性关节炎、类风湿性关节炎及强直性脊柱炎的鉴别诊断难度加大。本例褐黄病性关节炎患者合并长期银屑病病史,并有长期雷公藤口服用药史,造成其与银屑病等其他疾病的鉴别难度增大,内源性及外源性病因不清,导致首诊发生偏差。现将病例资料及鉴别诊断报道如下。1病例回顾患者,男,64岁,因"双膝关节疼痛伴活动受限5年余"就诊。     

《临床症状鉴别诊断丛书》已出版

由刘德铭教授担任总主编的《临床症状鉴别诊断丛书》于09年7月在科学出版社出版，该套丛书根据最新的研究成果和理念编写，结合“诊断流程图”等手段，能迅速提高临床医师对内科疾病诊断的思维能力；各分册主编均为全国高等医学教育学会诊断学分会的临床专家，按照临床医师诊治病人的思维模式展开，系统地从症状、体征、各种实验室检查结果和影像学表现等来进行疾病诊断与鉴别诊断；通过对典型病例或疑难病例的简要分析，与读者一起分享编者在诊断此病例过程中的体会与经验或教训。     

急性颈椎间盘突出症的诊断与治疗

自ＣＴ、ＭＲＩ相继用于临床,对颈椎间盘突出症的诊断给以极大的帮助,本文仅就急性颈椎间盘突出症在诊断、分类、治疗及鉴别诊断方面进行探讨。典型病例例１男,４２岁,无明显诱因,突感颈肩部疼痛,相继出现右上肢放射痛,因疼痛剧烈急症入院。查体：颈部活动受限,右...     

尿常规在小儿急性阑尾炎鉴别诊断中的作用

急性阑尾炎仍然是小儿临床外科易被误诊的疾病。特别是小儿对疼痛描述不清，常常使医生难以判断，我们对1991年1月-2002年1月12例误诊病例进行分析，发现尿常规对这些病例鉴别诊断有非常重要的作用。     

布鲁氏菌性脊柱炎诊断和治疗研究进展

布鲁氏菌病是由布鲁氏杆菌感染引起的人畜共患传染病,典型临床表现为骨关节疼痛、全身乏力、高烧(波浪热)和出汗等。布鲁氏杆菌常常侵犯骨关节系统,尤其是脊柱,腰椎是最常受累的部位,造成布鲁氏菌性脊柱炎。由于患者的临床症状体征和影像学表现与其他脊柱疾病相似,因此容易误诊误治甚至造成不良后果。本文对布鲁氏菌性脊柱炎的流行病学、典型的临床症状体征、辅助检查、鉴别诊断和治疗方法等研究进展作一综述。     

IC/PBS和OAB的鉴别诊断

间质性膀胱炎/膀胱疼痛综合征(IC/PBS)与膀胱过度活动症(OAB)目前均缺乏特异性的诊断指标,而是基于临床症状和排除其他疾病做出诊断。两种疾病均有尿频、尿急等类似表现,使得临床上的鉴别存在困难。临床研究发现所有表现为尿频、尿急的患者均需要作两者的鉴别诊断,且难治性OAB患者中IC的发病率显著升高。本文综合病史、体检、排尿日记、尿动力学检查等方面讨论了IC/PBS与OAB的鉴别诊断流程,以提高临床医生的诊疗水平。     

颈椎病与周围神经卡压的肌电图鉴别

颈椎病性神经根受损患者均有不同程度的上肢疼痛 ,感觉过敏、感觉麻木、肌肉萎缩、肌力减退等 ,而这些症状与体征亦可发生于各种周围神经卡压综合征。对某些病例 ,从神经病学和影像学的角度很难进行鉴别诊断 ,神经肌电图检查对各种神经卡压综合征有良好的定位作用 ,有助于同颈椎病进行鉴别诊断。1　临床资料1.1　一般资料　 2 0 0 2年以来我院对 10例被临床诊断为颈椎病及 8例疑为神经卡压征和其他疾病进行神经肌电图检查。1.2　方法　采用丹麦 Dantec Keypoint神经肌电图仪 ,对所有病例进行神经肌电图检查 ,对拟诊为颈椎病患者 ,EMG检查…     

非寄生虫性肝脏囊性疾病的诊断与治疗

随着影像学技术的飞速发展,非寄生虫性肝脏囊性疾病的临床诊断取得了巨大的进步,但对于某些疾病的鉴别诊断仍显不足.单纯多发肝囊肿与多囊肝病的鉴别诊断需结合家族遗传史、囊肿数目、是否合并多囊肾、有无分隔及B超检查特点;单纯单发肝囊肿与肝内胆管囊腺瘤的鉴别需结合影像学特点及活组织病理学检查结果.在治疗上,腹腔镜技术已广泛应用于肝脏囊性疾病的治疗,但并不能完全取代开腹手术,具体选择仍需依据患者的特点采取个体化、多样性的治疗手段.     

《头颈影像学病例精粹》已出版

<正>《头颈影像学病例精粹》包含了164个病例,均系作者在临床工作中积累的临床和影像资料完整的病例,包括传统的神经放射学、耳鼻喉疾病、颅底及颅神经的病变,此外还包括口腔颌面外科的疾病。本书针对性强、涉及面广,目的是帮助影像科医师及临床医师掌握头颈部疾病的诊断思维方法,开阔分析和鉴别诊断的思路,从而提高对头颈部疾病的诊断分析能力。本书对广大中青年医师会有很好的启迪作用!     

The predictive value of five clinical signs in the evaluation of meniscal pathology

One hundred sixty-one consecutive patients with knee pain of at least 1 year's duration were studied on a prospective basis to determine the predictive value of five common clinical tests for the diagnosis of meniscal tears. Each patient had a preoperative examination that evaluated the presence or absence of joint line tenderness, pain on forced flexion, the presence of a positive McMurray test, positive Apley grind and distraction tests, and the presence of a block to extension. The results of these tests were then compared to arthroscopic findings. This study indicates that no one test is predictive for the diagnosis of a meniscal tear; a combination of tests should be used. The presence of anterior cruciate ligament pathology will render these tests less effective for diagnosis of meniscal pathology. Chondromalacia patella is negatively correlated with the presence of joint line tenderness and pain on forced flexion.     

Use of radioisotope bone scans in children with obscure foot pain

Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with foot pain have shown that bone scans are valuable diagnostic tools, especially in instances in which clinical evaluation and conventional radiography have failed to provide a clear answer. To our knowledge, no similar investigation has ever been conducted in the pediatric population. The objective of this study was to determine the utility of bone scans as a diagnostic tool for children with foot pain of unclear etiology. Our secondary objective was to determine whether obtaining a bone scan, in fact, alters the treatment plan of such patients. Chart review was done, documenting the prebone scan versus post bone scan diagnosis and treatment plans. We found that bone scans were diagnostically useful in 38 of 49 [77.6%, 66-87, 90% confidence interval (CI)] cases, helping to establish new diagnoses in 31 of 49 (63%, 51-75, 90% CI) cases, and directing the treatment of children with clinically unclear foot pain in 31 of 49 (63%, 51-75, 90% CI) cases. We conclude that children between the age of 2 and 11 years who present with unilateral or bilateral foot pain of unclear clinical etiology, with a normal or inconclusive radiograph and physical examination, and who had no previous magnetic resonance imaging and/or computed tomography scan, may benefit from the use of a bone scan to guide diagnosis and treatment.     

Orthopaedic basis for occupationally related arm and neck pain

A prospective clinical study of 204 individuals with occupationally related upper limb or neck pain was initiated to determine the major symptom patterns, the physical findings, and changes in laboratory tests that are exhibited by these subjects. On the basis of this information it was possible to determine the proportion that was suffering from a recognizable, pathologically discrete, musculoskeletal disorder. The study shows that in the majority (58%) of these people, a discrete musculoskeletal disorder exists. The most common diagnoses were peripheral nerve entrapments (19%) and arthropathies (16%). In 42% a discrete diagnosis was not made and the nature of the disorder, in these, is discussed.     

Periappendicitis: is it a clinical entity?

The aim of this study was to identify clinical parameters that may help distinguish periappendicitis from the more common clinical entity of acute appendicitis. Serosal inflammation of the appendix without mucosal involvement constitutes the condition known as periappendicitis. In most situations this is a sequel of extra-appendicular sepsis and is likely to benefit from treatment targeted to the underlying pathology. But the majority of these cases are initially treated for acute appendicitis as clinical distinction between the two conditions is difficult. In this study some commonly used clinical yardsticks have been analyzed with respect to their value in this subtle diagnosis. We reviewed 231 successive cases clinically diagnosed as acute appendicitis; of these 18 had histologically demonstrated periappendicitis. Eight parameters were studied: age, gender, temperature, white blood cell count, location and duration of pain, associated symptoms, and peritoneal signs. Significant statistical differences were found between the two groups with regard to pain location, pain duration, and the presence of peritoneal signs. It may be possible to suspect periappendicitis preoperatively with meticulous clinical assessment. This may be of value in avoiding missed nonappendicular pathologies.     

Acute pyelonephritis: analysis of 52 cases

Acute pyelonephritis (APN) is a frequent disease, but diagnostic approach, evolution into abscesses, and indication to hospitalization are still open problems. We have made a retrospective analysis of APN cases observed in our hospital. We identified 58 patients (pt) and selected 52 of these who presented fever and loin pain at the onset (31 were hospitalized in Nephrology and 21 in other units). Urine culture was positive in 11/48 cases (22.9%), blood cultures in 3/26 cases (11.5%) (Escherichia coli). Renal sonography was normal in 20/48 cases (41.6%) and suggestive for APN in 23/48 cases (47.9%). CT with contrast medium was normal in 9/28 cases (32.1%) and positive in 19/28 cases (67.8%), with evidence of unique or multiple hypodense areas; abscesses were found in 8 patients (28.5%). No statistically significant differences were found between patients with positive or negative CT as regards fever, leukocytosis, ESR, CRP, CRP at 20 days, urinary leukocytes, urine culture, duration of symptoms before hospitalization. Moreover no differences were found between patients with and without abscesses. CT was performed more frequently among patients hospitalized in Nephrology than among patients hospitalized in other services (24/31-77.4%-vs. 4/21-19%-, p = 0.05). NMR was abnormal in 6/9 cases. A radiographic documentation of APN was obtained in 61.53% of patients with clinical diagnosis of APN. Of these, only 18.7% had positive urine culture. In conclusion, our data suggest that demonstration of urine infection is not necessary for APN diagnosis, when clinical and/or radiologic diagnosis of APN has been made. Evolution into abscesses is frequent and not easily susceptible on clinical ground; for this reason we think it is advisable to perform CT or NMR systematically. Differences in clinical behavior between different units suggest the need for diagnostic guidelines.     

A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica

Summary The diagnostic power or clinical parameters in the diagnosis of lumbar disc herniation in patients with monoradicular pain was evaluated in a prospective study with a 100% verification of the diagnosis.Eighty patients with monoradicular pain corresponding to the fifth lumbar or the first sacral nerve root were included. Pre-operatively a number of clinical parameters were recorded and compared to the intra-operative finding of a disc herniation. The parameters were analysed by receiver operating characteristic (ROC) curves. Results from the available literature were analysed by ROC curves for comparison.In 76% of the cases a disc herniation was discovered. The level of the disc herniation was correctly predicted in 93% of these cases by the location of the pain alone or supplemented by neurological signs. Apart from radicularly distributed pain, all parameters in the present study and in the literature had no or low diagnostic accuracy.Thus, in patients with monoradicular sciatica further clinical parameters do not add to the diagnosis of lumbar disc herniation.     

Emergency hospitalization for acute, non-accidental abdominal pain. Prospective data of a surgical university clinic

During a 19-month period 549 patients (278 women, 271 men) suffering from abdominal pain unrelated to trauma (mean age 48.2 years) entered the emergency room of the Department of Surgery of the University Hospital Zürich. 43% presented during business hours, whereas 57% were admitted during nighttime and/or weekends. Clinical examination, abdominal roentgenograms (upright and supine) as well as sonography were the most commonly used diagnostic tools. 40% suffered from abdominal pain of unknown cause. The most common diagnosis on admission was appendicitis. Only half of these cases really proved to be an appendicitis. In 36% the diagnosis on admission corresponds both to the initial diagnosis made by a member of staff during his first visit, as well as to the final diagnosis. The initial diagnosis agrees in 57% with the final diagnosis. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostics are less important than the clinical evaluation. The decision between operative or nonoperative treatment was mainly based on clinical findings.     

家族性腺瘤性息肉病的手术治疗:附45例报告

目的　总结家族性腺瘤性息肉病 (FAP)的临床诊治经验和教训。方法　回顾性分析手术治疗 45例FAP的临床病例资料。行全大肠切除回肠造瘘术 2 5例 ,次全结肠切除 直肠息肉电灼术15例 ,结肠全切除、直肠黏膜剥除、回肠经直肠肌鞘脱出及回肠肛管吻合术 5例。结果　患者首诊平均年龄 3 3 .5岁 ,3 5例有家族史。便血、腹泻、腹痛是常见临床表现。息肉数量均在 10 0个以上。术前漏误诊 10例 (2 2 .2 % )。癌变者 2 8例 (62 .2 % ) ,未癌变者 10例 (2 2 .2 % ) ,不典型增生 7例 (15 .6% )。癌变组与未癌变组间年龄相差有显著意义 (P <0 .0 5 )。 40例获定期复查随访。无癌变者存活 2～ 2 0a ;肝转移是癌变者死亡的主要原因 ,其存活时间 2 .5～ 4.5a。结论　FAP缺乏特征性临床表现 ,容易漏诊误诊 ;根据患者具体情况 ,早期手术治疗是防止FAP癌变的关键。     

Preoperative diagnosis of intramedullary spinal schwannomas

Intramedullary spinal schwannomas are rare benign spinal cord tumors and are easily misdiagnosed because of the imaging characteristics shared with intramedullary glioma. Correct preoperative definitive diagnosis is essential for treatment and prognosis. To improve the preoperative diagnostic strategy, clinical and imaging data of seven patients with intramedullary spinal schwannoma (6 men, mean age 44 years, mean duration of illness 4.2 years) treated in our department between 2003 and 2010 were collected and retrospectively evaluated. The cervical cord was affected in five patients, followed by the thoracic cord in two. All seven cases were misdiagnosed as intramedullary glioma based on the imaging characteristics. Comparison of the clinical features of these 7 patients with those of patients with intramedullary tumors (173 ependymomas and 70 astrocytomas) admitted during the same period revealed significant differences in somatic pain and root pain as the initial symptoms between intramedullary spinal schwannomas and ependymomas (p = 0.005) and between intramedullary spinal schwannomas and astrocytomas (p = 0.019), but not between ependymomas and astrocytomas (p = 0.175). Root or somatic pain as an initial symptom is important for the preoperative diagnosis of intramedullary spinal schwannoma, especially if the imaging characteristics are not entirely specific.