I腹部检查A课件

physicalexamination

腹部检查(1)

AbdominalExamination

landmarksandregions

体表标志和分区

inspection视诊

palpation触诊1LandmarksandRegions体表标志与分区

abdominallandmarks

腹部体表标志

abdominalregions

腹部分区2SurfaceLandmarksonInterior

体表标志(前面)xiphoidprocessofsternum剑突anterosuperioriliacspine髂前上棘superiormarginofospubis耻骨联合costalmargin肋弓下缘midline腹中线umbilicus脐pubicligament腹股沟韧带3TheFourAbdominalQuadrants

腹部四分区twoimaginaryperpendicularlines二条水平和垂直交叉线fourquadrants:

分四区

rightupper右上腹部

leftupper左上腹部

rightlower右下腹部

leftlower左下腹部5TheNineAbdominalAreas

腹部九分区Epigastric上腹部Umbilicalregion脐部Supra-pubicregion下腹部Righthypochondrium

右上腹部Lefthypochondrium

左上腹部Rightflankregion右腰部Leftflankregion左腰部Rightinguinal右下腹部Leftinguinal左下腹部6InspectionofAbdomen

腹部视诊

abdominal

contourandmovement

腹部外形和运动

abdominalwallinspection

腹壁视诊7NoticeProceeding

注意事项Patientindorsalposition

取仰卧位Exposurewholeabdomen

暴露全腹Doctorstandinrightside

立于右侧Observefromabovetobelow自上而下观察8Distension

腹部膨隆Abdominalwalldisorders腹壁改变Tumor:appearedclearlyinforce肿物:腹部用力时肿物明显Incrassation:hilumdepressedsuchasobesity增厚:脐部凹陷如肥胖Abdominalcavityincrease腹腔增大Fulldistension:normalpregnancyandabnormal全腹膨隆:正常妊娠和异常Localdistension局部膨隆Measuresurroundofabdomen测量腹围Aroundtheabdomenthroughhilumbysoftruler仰卧位用软尺绕脐一周10Contour:ProtuberantAbdomen

全腹膨隆Ascites:frogshapeofabdomen,accompaniedhilumhernia.腹水:蛙状腹常伴脐疝

causes:hepatocirrhosis,seriousheartfailure,pericarditis,renaldiseasesyndrome,peritoneumcancer.

病因:

肝硬化严重心衰缩窄性心包炎肾病综合征腹膜癌Gasesdistentionoftheintestines:sphericityofabdomen肠胀气:球形腹causes:ileus,intestinalparalysis.

病因:肠梗阻肠麻痹Organomegaly:enormousovarycystandteratoma.肿瘤:巨大卵巢囊肿畸胎瘤12LocalDistensionandDisorders

局部膨隆与疾病(1)Righthypochondrium:hepatomegaly,cholecystfluidaccumulation,colontumorunderliver右上腹部:肝肿大胆囊积液结肠肝曲肿瘤Epigastric:leftlobeofliverenlarged,gastriccancer,gastricdilation;inflammation,tumorandcystofpancreas上腹部:肝左叶肿大胃癌胃扩张胰腺炎症肿瘤囊肿Lefthypochondrium:spleenintumesce,giganticcolon,colontumorunderspleen左上腹部:脾肿大巨结肠结肠脾曲肿瘤Sideflankregion:kidneyintumesce,hydronephrosis,vastnessadrenalglandtumor侧腹部:肾肿大肾盂积水巨大肾上腺肿瘤14LocalDistensionandDisorders

局部膨隆与疾病(2)Umbilicalregion:hilumhernia,inflammationmass脐部:脐疝炎性包块Rightinguinal:ileo-colictuberculosisandtumor,crohndisease,appendixabscess右下腹部:回盲部结核肿瘤克隆病阑尾脓肿Leftinguinal:descendingorsigmoidcolontumororfeces左下腹部:降结肠或乙状结肠肿瘤粪块Supra-pubicregion:pregnancy,myomaofuterus,bladderenlarged,ovarytumor下腹部:妊娠子宫肌瘤膀胱胀大卵巢肿瘤15Contour:DepressionAbdomen

腹部凹陷Regionaldepression:surgicalscar局部凹陷:腹部手术瘢痕收缩General:scaphoidabdomen

全腹凹陷:舟状腹Cachexia:latedurationofchronicdepletedisease,malignanttumor,nervousanorexia

恶病质:慢性消耗性疾病晚期恶性肿瘤神经性厌食Earlyacutediffuseperitonitis:abdominalmusclespasmodiccontraction

早期急性弥漫性腹膜炎:腹肌痉挛性收缩16NormalRespiratoryMovement

正常呼吸运动MaleandChildren:Abdominalrespiratorymovement男性及小儿:以腹式呼吸为主Female:Chestrespiratorymovement女性:以胸式呼吸为主17AbnormalRespiratoryMovements

异常呼吸运动Decreased:inflammationalpain,volumeexpansion呼吸减弱:炎性疼痛腹腔容积增加disorders:acuteperitonitis,enteroparalysis,ascites,mass疾病:急性腹膜炎肠麻痹腹水肿物Increased:chestandlungdiseases呼吸增强:胸肺疾病disorders:ribfracture,Pleuraleffusion

疾病:肋骨骨折胸腔积液18GastricForm&PeristalticWave

胃型和蠕动波Gastricforminepigastricregion

上腹壁显出胃饱满隆起轮廓GastricPeristalticwaveinepigastricregion

上腹壁可见胃蠕动增强起伏的蠕动波型Positivewave:wavemovedfromlefttoright

正蠕动波:自左肋缘下向右推进的蠕动波Athwartwave:fromrighttoleftbyvomiting

逆蠕动波:自右向左的蠕动波见于剧烈呕吐时Cause:pyloricobstruction,feeblewallofabdomen提示:幽门梗阻腹壁薄弱20Intestinal

Form&PeristalticWave

肠型和蠕动波Intestineforminumbilicalandsupra-pubicregion

肠段饱满隆起在脐周或下腹壁显出轮廓Intestineperistalticwaveinabdominalwall

腹壁可见肠蠕动增强的起伏蠕动波型Cause:mechanicalileusaccompaniedsharpbowelsound提示:机械性肠梗阻伴高调肠鸣或金属音Smallintestinalobstruction:theformandwaveinumbilicalregion

小肠梗阻:脐周肠管呈多梯形蠕动波在脐周方向不一Colonobstruction:theformandwaveinborder

结肠梗阻:肠型和蠕动波出现在腹部周边21AbdominalWallInspection

腹壁视诊Inspecttheskin皮肤改变Color:redness,pallor,jaundice,eruption,&pyoderma颜色:发红苍白黄染水肿皮疹脓皮症

Striae裂纹Scar瘢痕Abdominalvaricosity腹壁静脉曲张23SkinSigns

皮肤征象SubcutaneoushemorrhageGrey-turner’ssignCullen’ssignPigmentationAddison’sdiseaseStriaeCushing’ssyndromePregnancyRapidweightgain皮下出血Grey-turner’s征Cullen’s征色素沉着阿迪森病裂纹库兴综合征妊娠纹快速肥胖纹24SubcutaneousHemorrhageSign

皮下出血征象Cullen’ssign:abluishdiscolorationoftheumbilicusresultingfromhemoperitoneumofanycause.Cullen征:脐周或下腹皮肤发蓝腹腔出血时血液渗到皮下Cullen’ssign26SkinPigmentation

皮肤色素沉着Addison’sdisease:pigmentationinskinWrinklebyadrenalglandfunctiondecrease.阿迪森病:皮肤皱折处色素沉着肾上腺皮质功能减退27SkinStriae

皮肤裂纹Silverstriae:stretchmarksconsistentwithweightgain

白纹:

肥胖腹壁真皮裂开Purplestriae:Hypercortisolism紫纹:皮质醇增多症Striaegravidarum: paleblueorpink

妊娠纹:淡兰色或粉红色产后为白色Purplestriae28DirectionoftheBloodflow

血流方向检查Usetwofingersonappearedvein 用两手指并拢压在静脉上Twofingerspressanddispart 两手指加压分开Loosensuperiorfinger松开上端手指Fastershowbloodflowdownwards 充盈快示血流向下Repeataboveaction重复以上动作Looseninferiorfinger松开下端手指Fastershowbloodflowupwards 充盈快示血流向上30PortalHypertension

门静脉高压Varicosityfromumbilicusradiatingsurround,likethejellyfish’shead.脐部一簇曲张静脉向四周放射如水母头状31ObstructionofVenaCava

腔静脉阻塞Varicosityontheflanks曲张静脉在侧腹部Obstructionofsuperiorvenacava:bloodstreamtodownwards.上腔静脉回流受阻血流方向向下Obstructionofinferiorvenacava:bloodstreamtoupwards.下腔静脉回流受阻血流方向向上32PalpationofAbdomen

腹部触诊

abdominalwall

腹壁触诊

organsintheabdomen

脏器触诊

masses

肿块触诊

fluidthrillandfluctuation

液体触诊33PalpationTechnique

触诊手法Thepatientissupineandrelaxduringpalpation.平卧低枕位腹部放松Fromfleettodeep由浅及深Alwaysbegininanareaofwherethatisfarthestfromthelocationofpain.先健后患Fromleftlowerinsequenceofathwarthourhand逆时针触摸34WallPalpationContent

腹壁触诊Abdominalmuscletone

腹壁肌肉紧张度Tenderness

压痛Reboundtenderness

反跳痛35AbdominalMuscleTone

腹壁肌肉紧张度Normal:soft正常:柔软Generalizedincreased:diffuseperitonealinflammationandcontentincrease全腹增加:弥漫腹膜炎症腹腔内容物增加RegionallyIncreased:Guardingiscontractionthemusclesoverlyinganinflamedviscusandperitoneum,maderigidity.局部增加:肌卫局限性腹膜炎Decrease:myastheniagravis,oldpeopleormultipara全腹减低:重症肌无力老年人或多产妇36GeneralizedIncreased

全腹紧张度增加Generalizedor“board-like”rigidity:acutediffuseperitonitis板状腹:全腹增加似板状急性弥漫性腹膜炎Doughkneadingsensation:chronictubercularperitonitis揉面感:慢性结核性腹膜炎37RegionallyIncreased

局部紧张度增加Regionalperitonealinflammationcausedbyneighboringorgan脏器炎症波及邻近腹膜Rightiliacregion:appendcitis,perforationofgastrointestinaltract右下腹:阑尾炎胃肠穿孔righthypochondrialregion:cholecystitis右上腹:胆囊炎lefthypochondrialregion:acutepancreatitis左上腹:急性胰腺炎38AbdominalWallTenderness

腹壁压痛Tendernessisthepainfeelingsinpressurebyhandreflectingunderlyingorgandisorders.

腹壁加压出现痛感提示腹内脏器病变Inflammation,congestion,tumor,rupture,andtorsionofintra-abdominalorgan

腹腔脏器炎症充血肿瘤破裂扭转Diseasesinthethorax

胸部病变牵涉Diseasesinthepelviccavity

盆腔疾病39ReboundTenderness(Blumbergsign)

反跳痛Examinationmethod:pressdeeplyandslowly,letslipsuddenly.

检查方法:逐渐深压腹壁突然松开Positivefinding:painprickupinloose.

阳性:

松开时疼痛加剧Clinicalmeanings:inflammationintheparietalperitoneum.

提示:炎症波及壁层腹膜40PeritonealIrritationSign

腹膜刺激征Threesignsameappear:TendernessReboundtendernessGuarding

三联征:压痛反跳痛腹肌紧张Clinicalmeaning:acuteperitonitis

提示:急性腹膜炎41PressurePainPoint

压痛点Tenderpointofgallbladder胆囊压痛点McBurney’spoint麦氏点又称阑尾压痛点42OthersofPressurePainPoint

其他常见压痛点①Gastritisandulcer

胃炎和溃疡②Duodenumulcer十二指肠溃疡③Pancreatitisandtumor胰腺炎或肿瘤⑥Smallintestinedisorders小肠疾病⑦Bladderoruterusillness膀胱或子宫病变⑧Inflammationortuberculosisincecum 回盲部炎症结核⑨Inflammationortumorinsigmoidflexure

乙状结肠炎症或肿瘤⑩Spleenorcolonillness

脾或结肠脾曲病变⑾Liverorcolonillness肝或结肠肝曲病变43NoRelationshiptotheLocation

压痛点不指示病变部位Earlyacuteappendcitis:paininuporumbilicusLowlobarpneumonia:tendernessinrighthypochondriumCholecystdisease:tendernessinrightloinPancreasinflammation:tendernessinleftloin急性阑尾炎早期上腹部或脐周压痛肺下叶炎症季肋部压痛胆囊病变右腰部压痛胰体胰尾部炎症左腰部压痛44OrgansPalpationintheAbdomen

腹部脏器触诊LiverpalpationSpleenpalpationGallbladderpalpationPancreaspalpationKidneypalpationIntestinepalpationBladderpalpation肝脏触诊脾脏触诊胆囊触诊胰腺触诊肾脏触诊肠管触诊膀胱触诊45NormalPalpableStructures

正常腹部可触及的结构Xyphoidprocess剑突Nomalliveredge正常肝脏边缘Rightkidney,lowerpole右肾下极Cecum/ascendingcolon盲肠和升结肠Uterus(gravid)子宫Pulsatileaorta腹主动脉Rectusmuscles,lateralborders腹直肌侧缘Sacralpromontory腰椎椎体Sigmoidcolon乙状结肠Fullbladder充盈膀胱46PalpationoftheLiver

肝脏触诊Method:palpateincostaledgeandxiphoidprocess方法:单手或双手触摸肋缘和剑突下Notice:twolegsflectionandabdominalrespiratory注意:双腿屈曲腹式呼吸Rightliver:palpatefromlevelofanteriorinferioriliacspineandouteredgeofrightrectusmuscleslateralbordersuptocostaledge右肝:自髂前上棘水平右腹直肌外缘开始自下而上触诊至肋缘Leftliver:palpatefromlevelofumbilicusuptoxiphoidprocess左肝:脐水平开始触至剑突47PalpationContents

触诊内容

Size,quality(soft,firm,hard)肝脏大小质地(软如口唇韧如鼻尖硬如前额)Surface:smooth,irregular,nodular表面:光滑不规则结节Margin:sharp,blunt

边缘:锐利变钝Tenderness压痛Hepatojugularreflux肝颈静脉回流征48NormalLiver

正常肝脏Commonlynonpalpable一般触不到Ifpalpable,inferiorborderonlyincostaledgelessthan1cm

xiphoidprocesslessthan3cm如触到肝脏右肋缘下<1cm

剑突下<3cmSoftquality,smoothsurface,

sharp

margin,notenderness

质地柔软表面光滑边缘锐利无压痛49LiverLocationandSize

肝脏位置和大小变化Hepatomegaly肝脏肿大

diffuseswell:hepatitis,hepaticcongestion

弥漫性肿大:肝炎肝淤血

localswell:hepaticabscess,cyst,tumor

局限性肿大:肝脓肿囊肿肿瘤Hepatoptosis肝脏下移

emphysema,rightpleuraleffusion肺气肿右侧胸腔积液50Tendernessofliver

肝脏压痛Tendernessofliver:madebylivercapsulainflammationorpullings

肝脏压痛:由肝包膜炎症及包膜受牵拉所致Gentlydiffuse:hepatitis,hepaticcongestion轻度弥漫性压痛:肝炎肝淤血Localacuity:washyabscessofliver局限剧烈压痛:较表浅的肝脓肿Patency:primaryhepaticcarcinoma明显压痛:原发性肝癌51HepatojugularReflux

肝颈静脉回流征Technique:presstheliverregionofsurfaceofhepatomegalyinducingmoredistendedofcervicalvein

检查方法:压迫肝区或增大肝脏的表面,颈静脉怒张更加明显称肝颈静脉回流征阳性Significance:hepaticcongestionbyrightheartfailure,pericardialeffusion,constrictivepericarditis临床意义:表明肝淤血右心功能不全心包积液缩窄性心包炎52PulsationofLiver

肝脏搏动Conductivepulsation:liverconductundersideabdominalaorticpulsation传导性搏动:肝传导了下面腹主动脉的搏动Dilativepulsation:tricuspidvalveinsufficiencymadehepaticblooddilativepulsation

扩张性搏动:三尖瓣关闭不全引起肝脏血管扩张性搏动53ComparewithCauseSigns

肝脏肿大及病变征象Sign征象Hepatitis肝炎Congestion肝淤血Cirrhosis肝硬化Carcinoma肝癌Size大小Quality质地Surface表面Margin边缘Tenderness压痛Hepatojugularreflux肝颈回流征

Enlarged增大Firm韧

Smooth光滑Abitround稍圆

Have有

Negative阴性Enlarged增大Firm韧Smooth光滑Blunt钝圆Have有

Positive阳性Uncertion早大晚小Hard硬Nodule小结节Sharp锐利No无Negative阴性

Enlarged增大Hard硬Nodus结节Irregular不整Have有Negative阴性54PalpationoftheSpleen

脾脏触诊Location:supineorstarboardposition

体位:平卧或右侧卧位Position:leftcostalmargin

部位:左肋缘下Technique:deepsleepingandbimanualpalpation手法:深部滑行触诊和双手触诊Direction:uprightwithcostaledge方向:与肋缘垂直Character:vestigeintheinneredge特征:内缘有切迹55PalpationContents

触诊内容Size:threelines大小:三条线Consistency:soft,firm,hard质地:软质韧硬Surface:smooth,nodular表面:光滑小结节Tenderness压痛Frictionrubs摩擦感56MeasureofEnlargedSpleen

肿大脾脏的测量Thefirstline:betweencostalmarginandlowedgeofspleeninleftmidclavicularline1线(甲乙线):左锁骨中线上肋缘至脾下缘Thesecondline:betweenthepointoftheleftmidclaviculcrosscostalmarginandthepointofspleenapoapsis.2线(甲丙线):左锁骨中线肋缘点至脾最远点Thethirdline:betweenrightsideofspleenandmidline,expresswithpositiveornegative3线(丁戊线):脾右缘至正中线以(＋)(－)表示57SpleenEnlargementDegrees

脾脏肿大分度Mildenlargement:<2cmundertherib轻度肿大:肋下<2cmModerateenlargement:notexceedthelevelofumbilicus中度肿大:不过脐Severeenlargement:exceedthelevelofumbilicusormidline高度肿大:过脐或中线12358SpleenEnlargementMeanings

脾脏肿大的意义Mildenlargement:typhoidfever,hepatitis,malaria,endocarditis,sepsis轻度肿大:伤寒肝炎疟疾心内膜炎败血症Moderateenlargement:hepatocirrhosis,aftermalaria,lymphoma,chroniclymphocyticleukemia,中度肿大:肝硬化疟疾后淋巴瘤慢性淋巴白血病Severeenlargement:chronicgranulocyticleukemia,chronicmalaria,medullafibrosis高度肿大:慢性粒细胞白血病慢性疟疾骨髓纤维化59PalpationoftheGallbladder

胆囊触诊Technique:sleepingpalpation方法:单手滑行触诊Normal:cannotpalpable正常:不能触及Swelling:smooth,ovalorpear-shapedmassemergingfrombelowtherightcostalmargin,movedbyrespiratory.肿大:右肋下腹直肌外缘触及梨形或卵圆形肿物可随呼吸上下运动60PalpableSigns

胆囊触诊征象Tenderness:painfeelingingallbladderpointwheninspiration胆囊触痛征:吸气时胆囊点触痛Murphy’ssign:tendernessstopsinspirationusuallybyacutecholecystitis莫非氏征:胆囊触痛致吸气中止提示急性胆囊炎Courvoisier’ssign:gallbladderswellingaccompaniedjaundicebutnotenderness,usuallybycarcinomaofheadofpancreas.库瓦济埃征:胆囊肿大无触痛伴黄疸提示胰头癌61Murphy’sSign

莫非氏征

Technique:Holdyourfingersundertheliverborder.手指放于肝脏下缘Positivesign:Asthedescendingliverpushestheinflamedgallbladderontotheexamininghand,thepersonfeelssharppainandabruptlystopsinspirationmidway.

阳性:吸气时肝脏和胆囊下移手指触及炎性胆囊时被检者因剧痛中止吸气62MechanismsofDistensionoftheGallbladder

胆囊肿大的机制NormalgallbladderNotpalpableMucoceleofG.BStoneinneckNon-dilatedductsPalpabledistendedgallbladderCarcinomaofheadofpancreasDilatedductsDilatedG.BLiverdiffuselydistended63Corvoisier’sLaw

库瓦济埃征Whenthegallbladderispalpablethejaundiceisunlikelytobeduetostones.Thegallbladderwall,inthepresenceofgallstones,wouldbefibroticandnon-distensible.

胆囊结石时胆囊壁常有纤维化不易扩大胆囊肿大伴黄疸多与胆囊结石无关Obstructivejaundicewithoutapalpablegall-bladderdoesnotnecessarilyimplythatthejaundiceisduetostones.Astoneintheneckofthegall-bladdermaycauseadistendedmucoceleofthegall-bladder.

阻塞性黄疸不伴胆囊肿大不一定提示结石所致黄疸胆囊颈结石可引起胆囊黏液充盈扩大64PathologicalFindings

异常征象Gallbladderswellingaccompaniedwith

胆囊肿大伴有Tenderness:inflammation触痛:胆囊炎Jaundice:biliaryobstruction

黄疸:胆管阻塞Hardness:stone,carcinoma实性感:结石癌肿Murphy’ssign:inflammation

莫非氏征:急性炎症65PalpationofthePancreas

胰腺触诊Technique:sleepingpalpation

检查方法:滑行触诊Normal:nopalpable

正常:不能触及Enlarged:levelzostermassinepigastricorlefthypochondrium

胰腺肿大:上腹中部或左上腹横行带状肿块66DiseaseoftheEnlargedPancreas

肿大胰腺常见疾病TendernessandAbdominalmuscletoneincrease:acutepancreatitis压痛及腹肌紧张:急性胰腺炎Blueskininflanks:hemorrhageandnecrosisofpancreas腰部皮肤发蓝:胰腺出血坏死Rigidityandfixation:chronicpancreatitis

质硬固定:慢性胰腺炎Rigidityandnode:pancreascarcinoma

质硬凸凹不平:胰腺癌smoothcysticandnotenderness:pancreaticpseudocyst囊性表面光滑无压痛:胰腺假性囊肿67PalpationoftheKidney

肾脏触诊Method:bimanualpalpation

触诊方法:双手触诊法Specialsign:smooth,circlebody

特征:光滑钝圆形物Normal:nonpalpable

正常:触不到

Palpablekidneymaysuggestabnormal

触及肾脏提示异常68MeaningofPalpableKidney

触及肾脏的意义Down-shiftingofthekidney:nephroptosia,floatingkidney肾脏移位:肾下垂游走肾Kidneyenlargement:hydronephrosis,polycystickidney,tumor肾脏肿大:肾盂积水多囊肾肾肿瘤69RenalSwellings

肾脏肿大Unilateral单侧Bilateral双侧

Hydronephrosis肾盂积水Pyonephrosis化脓性肾病Cysts肾囊肿Abscess肾脓肿Tumor肾肿瘤

Polycysticdiseases多囊肾Hydronephroses肾盂积水70PressurePaininthePoint

压痛点Vertebrocostalandcostolumbarpoint