消化肾脏泌尿腹部理学检查专家讲座

PhysicalExaminationof

theAbdomenand

MaleGenitalOrgan消化肾脏泌尿腹部理学检查第1页TheAbdomenExtendsfromxiphoidprocesstothesymphysispubisRectusabdominisInternalandexternalobliquesLineaalbaInguinalligamentContainsvitalorgans消化肾脏泌尿腹部理学检查第2页MajorAbdominalOrgans消化肾脏泌尿腹部理学检查第3页QuadrantsoftheabdomenSegmentsoftheabdomenmid-clavicularlinesubcostalplaneanteriorsuperioriliacspine消化肾脏泌尿腹部理学检查第4页LocalizationofVisceralPain消化肾脏泌尿腹部理学检查第5页ExaminationoftheAbdomenGoodlightandadequateexposure(xiphoidprocesstosymphysispubis,groinvisible)RelaxedpatientPatientsupine,armsatside,kneesslightlyflexedEmptybladder消化肾脏泌尿腹部理学检查第6页ExaminationoftheAbdomenAskpatienttopointtoanyareaofpainExaminenon-painfulsidefirst“Visualize”underlyinganatomyWatchpatient’sfaceforsignsofdiscomfortduringtheexamination消化肾脏泌尿腹部理学检查第7页PhysicalExaminationSequence: --Inspection --Auscultation --Percussion --Palpation消化肾脏泌尿腹部理学检查第8页InspectionoftheAbdomenSkin: color,ecchymosis,rashes,lesions,striae,scars,dilatedveinsContours: flat,rounded scaphoid,protuberantSymmetry: distention localbulges消化肾脏泌尿腹部理学检查第9页InspectionoftheAbdomenUmbilicus: location displacement inflammationMusculature: masses hernia separationSurfacemotion: peristalsis pulsations消化肾脏泌尿腹部理学检查第10页AuscultationoftheAbdomenBowelsoundswarmeddiaphragmallquadrantsfrequencyandcharacterclicksandgurgles,borborygmanormoactive:5-34perminute5continuousminutestoestablishabsence消化肾脏泌尿腹部理学检查第11页AuscultationoftheAbdomenVascularsounds --Bruits

warmedbell overaorta,renal,iliac,andfemoralarteries overliver(HCCoracutealcoholichepatitis) --Venoushums warmedbell overepigastricandperiumbilicalarea(increased collateralcirculationbetweenportalandsystemic venoussystemsFrictionrubs overliverandspleen(perihepatitisorperisplenitis)消化肾脏泌尿腹部理学检查第12页消化肾脏泌尿腹部理学检查第13页PercussionoftheAbdomenTodetectfluid,air,andfluid-filledorsolidmassesStomachandintestinestympany(lowerpitchedforstomach–leftloweranteriorribcageandleftepigastricarea)Organsandsolidmasses:dullnessPercussallquadrantsfordistributionoftympanyanddullness:tympanypredominates消化肾脏泌尿腹部理学检查第14页Percussion:LiverLiverspan --rightmiddleclavicular line --fromtympanyto dullness,thenfrom resonancetodullness --6-12cm

消化肾脏泌尿腹部理学检查第15页Percussion:Spleen--posteriortoleftMAL smallareaofdullness from6thto10thribs--lowestICS(9th)inleft AAL:Traub’sspace remainstympanic beforeandafterdeep breathbypatient消化肾脏泌尿腹部理学检查第16页Percussion:kidneyCVanglepaininfectionormusculo-skeletalcauses消化肾脏泌尿腹部理学检查第17页PalpationStandatpatient’sside,usuallyright,withpatientinsupinepositionBendingpatient’skneesmayhelprelaxmusclesProceedinasystematicmanner消化肾脏泌尿腹部理学检查第18页PalpationoftheAbdomenLightpalpation --all4quadrants --1cmdeep --identifymuscular resistance,superficial masses消化肾脏泌尿腹部理学检查第19页PalpationoftheAbdomenDeeppalpation --all4quadrants --upto4cmdeep --delineatesorgans anddetectsdeeper masses消化肾脏泌尿腹部理学检查第20页DeepPalpationCharacterizemassesby:

location

size shapeconsistency

tenderness

pulsation

mobility movementwithrespiration

superficialversusintra-abdominal消化肾脏泌尿腹部理学检查第21页Palpation:Liverplacelefthandbehindpatient,paralleltoandsupportingtheright11thand12thribs,placerighthandonpatient’srightabdomenaskpatienttotakeadeepbreathFeelforthelowerborderatrightcostalmarginIffelt,shouldbesmooth,firm,evenandnontenderFeelfornodules,tendernessandirregularity消化肾脏泌尿腹部理学检查第22页Palpation:LiverHookingtechnique: --standtorightof patient’schest,place bothhands,sideby side,ontheright abdomenbelowthe costalmargin --askpatienttotakea deepbreath消化肾脏泌尿腹部理学检查第23页Palpation:GallbladderbelowlivermarginatlateralborderoftherectusabdominismuscleusuallyimpalpableMurphy’ssign

Courvoisier’slaw

消化肾脏泌尿腹部理学检查第24页Palpation:Spleenwithlefthandreachoverandaroundpatienttosupportandpressforwardhislowerleftribcage,withrighthandbelowleftcostalmarginandpressintowardspleenpatientonhisrightsideandhislegsflexedathipsandknees消化肾脏泌尿腹部理学检查第25页Palpation:Kidneyforrightkidney:lefthandbehindandsupportpatient’srightloin,righthandbelowrightcostalmargin,pressbothhandsfirmlytogetherfirm,smoothandnontenderleftkidneyusuallyimpalpableEnlargementhydronephrosis,cystortumor消化肾脏泌尿腹部理学检查第26页Palpation:Aortaslightlyleftofthemidlinemidwaybetweenxiphisternumandumbilicusfeltinthinpatient消化肾脏泌尿腹部理学检查第27页AdditionalProceduresinAbdominalAssessmentAscitesassessmentReboundtendernessIliopsoasmuscletestObturatormuscletestRovsing’ssignBallottementMcBurney’spoint消化肾脏泌尿腹部理学检查第28页AscitesAssessmentShiftingdullnessFluidwavePuddlesignNoneofthemarespecificorcompletelyreliable消化肾脏泌尿腹部理学检查第29页

ShiftingdullnessFluidwavePuddlesign消化肾脏泌尿腹部理学检查第30页ReboundTendernesstodetermineperitonealirritationperformedatendofexaminationpressdeeplyandremovefingersquicklysharp,stabbingpain消化肾脏泌尿腹部理学检查第31页

Iliopsoasmuscletest -inappendicitis -experiencelowerquadrantpain -patientattemptstoflexhipwhileexaminerapplies pressuretolowerthigh Obturatormuscletest -inappendicitisor pelvicabscess -experiencepaininthe hypogastricarea -patientflexesrightleg athipandknee,examinerrotatestheleglaterallyandmedially消化肾脏泌尿腹部理学检查第32页Rovsing’ssignIfpalpationofthelowerleftquadrantofaperson'sabdomenresultsinmorepainintherightlowerquadrant,thepatientissaidtohaveapositiveRovsing'ssignandmayhaveappendicitis消化肾脏泌尿腹部理学检查第33页Physicalexamination-PenisInspection1.Theskin2.Theprepuceorforeskin3.Theglans-ulcer,scar,nodule

orsignofinflammation4.Theurethralmeatus-size,

location,dischargePalpation-tendernessorinduration,sizeandcontour!Usegloves!Remembertoreplacethe

retractedforeskin

消化肾脏泌尿腹部理学检查第34页PhysicalExamination-

ScrotumanditscontentsInspection1.Skin-nodules,inflammation,ulcers2.Scrotalcontour–swelling,lumpsorveinsPalpation1.Testes:size,shape,consistency,tenderness,nodules2.Epididymis3.Spermaticcordandvasdeferens:nodulesorswellingTransillumination消化肾脏泌尿腹部理学检查第35页消化肾脏泌尿腹部理学检查第36页PhysicalExamination-HerniaInspectionbulgesininguinalandfemoralareasPalpation

Indirect,direct,femoralhernia,reducible,incarcerated,strangulated消化肾脏泌尿腹部理学检查第37页PhysicalExamination–

rectalexamination

Inspectionbulging,hairyskinordiscolorationorscarinsacralarealumps,ulcers,inflammation,warts,fissures,rashesorexcoriationinperianalareas.PalpationPerianalsensation,bulbocavernousreflexThetonicityoftherectalsphincterProstate-size,shape,consistency,nodules,induration,asymmetry,tendernessSeminalvesiclesPeritonealcavity-rectalshelf,tenderness消化肾脏泌尿腹部理学检查第38页PatientStandingAndBentOverTheExaminingTable

Knee-chestposition消化肾脏泌尿腹部理学检查第39页Prostateexamination消化肾脏泌尿腹部理学检查第40页(一)整體評估()1.注意學生在為病患進行身體檢查時，是否有先自我介紹，態度溫和自然地先向病患解釋並使病患放鬆心情?()2.注意學生在為病患進行身體檢查時，是否站在病患之右側位置?消化肾脏泌尿腹部理学检查第41页(二)視診評估()1.注意學生做視診時，除檢查前面腹部外，是否有檢查兩側腰部及後背部？()2.注意學生做視診時，是否有仔細注意看病患姿勢、表情及外觀?()3.注意學生做視診時，是否有檢查腹部外形(凹陷或平坦或膨脹)，肚臍突出或凹陷，有無手術痕跡，有無腫