消化腎臟泌尿腹部理學(xué)檢查

PhysicalExaminationof

theAbdomenand

MaleGenitalOrgan第1頁TheAbdomenExtendsfromxiphoidprocesstothesymphysispubisRectusabdominisInternalandexternalobliquesLineaalbaInguinalligamentContainsvitalorgans第2頁MajorAbdominalOrgans第3頁QuadrantsoftheabdomenSegmentsoftheabdomenmid-clavicularlinesubcostalplaneanteriorsuperioriliacspine第4頁LocalizationofVisceralPain第5頁ExaminationoftheAbdomenGoodlightandadequateexposure(xiphoidprocesstosymphysispubis,groinvisible)RelaxedpatientPatientsupine,armsatside,kneesslightlyflexedEmptybladder第6頁ExaminationoftheAbdomenAskpatienttopointtoanyareaofpainExaminenon-painfulsidefirst“Visualize”underlyinganatomyWatchpatient’sfaceforsignsofdiscomfortduringtheexamination第7頁P(yáng)hysicalExaminationSequence: --Inspection --Auscultation --Percussion --Palpation第8頁InspectionoftheAbdomenSkin: color,ecchymosis,rashes,lesions,striae,scars,dilatedveinsContours: flat,rounded scaphoid,protuberantSymmetry: distention localbulges第9頁InspectionoftheAbdomenUmbilicus: location displacement inflammationMusculature: masses hernia separationSurfacemotion: peristalsis pulsations第10頁AuscultationoftheAbdomenBowelsoundswarmeddiaphragmallquadrantsfrequencyandcharacterclicksandgurgles,borborygmanormoactive:5-34perminute5continuousminutestoestablishabsence第11頁AuscultationoftheAbdomenVascularsounds --Bruits

warmedbell overaorta,renal,iliac,andfemoralarteries overliver(HCCoracutealcoholichepatitis) --Venoushums warmedbell overepigastricandperiumbilicalarea(increased collateralcirculationbetweenportalandsystemic venoussystemsFrictionrubs overliverandspleen(perihepatitisorperisplenitis)第12頁第13頁P(yáng)ercussionoftheAbdomenTodetectfluid,air,andfluid-filledorsolidmassesStomachandintestinestympany(lowerpitchedforstomach–leftloweranteriorribcageandleftepigastricarea)Organsandsolidmasses:dullnessPercussallquadrantsfordistributionoftympanyanddullness:tympanypredominates第14頁P(yáng)ercussion:LiverLiverspan --rightmiddleclavicular line --fromtympanyto dullness,thenfrom resonancetodullness --6-12cm

第15頁P(yáng)ercussion:Spleen--posteriortoleftMAL smallareaofdullness from6thto10thribs--lowestICS(9th)inleft AAL:Traub’sspace remainstympanic beforeandafterdeep breathbypatient第16頁P(yáng)ercussion:kidneyCVanglepaininfectionormusculo-skeletalcauses第17頁P(yáng)alpationStandatpatient’sside,usuallyright,withpatientinsupinepositionBendingpatient’skneesmayhelprelaxmusclesProceedinasystematicmanner第18頁P(yáng)alpationoftheAbdomenLightpalpation --all4quadrants --1cmdeep --identifymuscular resistance,superficial masses第19頁P(yáng)alpationoftheAbdomenDeeppalpation --all4quadrants --upto4cmdeep --delineatesorgans anddetectsdeeper masses第20頁DeepPalpationCharacterizemassesby:

location

size shapeconsistency

tenderness

pulsation

mobility movementwithrespiration

superficialversusintra-abdominal第21頁P(yáng)alpation:Liverplacelefthandbehindpatient,paralleltoandsupportingtheright11thand12thribs,placerighthandonpatient’srightabdomenaskpatienttotakeadeepbreathFeelforthelowerborderatrightcostalmarginIffelt,shouldbesmooth,firm,evenandnontenderFeelfornodules,tendernessandirregularity第22頁P(yáng)alpation:LiverHookingtechnique: --standtorightof patient’schest,place bothhands,sideby side,ontheright abdomenbelowthe costalmargin --askpatienttotakea deepbreath第23頁P(yáng)alpation:GallbladderbelowlivermarginatlateralborderoftherectusabdominismuscleusuallyimpalpableMurphy’ssign

Courvoisier’slaw

第24頁P(yáng)alpation:Spleenwithlefthandreachoverandaroundpatienttosupportandpressforwardhislowerleftribcage,withrighthandbelowleftcostalmarginandpressintowardspleenpatientonhisrightsideandhislegsflexedathipsandknees第25頁P(yáng)alpation:Kidneyforrightkidney:lefthandbehindandsupportpatient’srightloin,righthandbelowrightcostalmargin,pressbothhandsfirmlytogetherfirm,smoothandnontenderleftkidneyusuallyimpalpableEnlargementhydronephrosis,cystortumor第26頁P(yáng)alpation:Aortaslightlyleftofthemidlinemidwaybetweenxiphisternumandumbilicusfeltinthinpatient第27頁AdditionalProceduresinAbdominalAssessmentAscitesassessmentReboundtendernessIliopsoasmuscletestObturatormuscletestRovsing’ssignBallottementMcBurney’spoint第28頁AscitesAssessmentShiftingdullnessFluidwavePuddlesignNoneofthemarespecificorcompletelyreliable第29頁

ShiftingdullnessFluidwavePuddlesign第30頁ReboundTendernesstodetermineperitonealirritationperformedatendofexaminationpressdeeplyandremovefingersquicklysharp,stabbingpain第31頁

Iliopsoasmuscletest -inappendicitis -experiencelowerquadrantpain -patientattemptstoflexhipwhileexaminerapplies pressuretolowerthigh Obturatormuscletest -inappendicitisor pelvicabscess -experiencepaininthe hypogastricarea -patientflexesrightleg athipandknee,examinerrotatestheleglaterallyandmedially第32頁Rovsing’ssignIfpalpationofthelowerleftquadrantofaperson'sabdomenresultsinmorepainintherightlowerquadrant,thepatientissaidtohaveapositiveRovsing'ssignandmayhaveappendicitis第33頁P(yáng)hysicalexamination-PenisInspection1.Theskin2.Theprepuceorforeskin3.Theglans-ulcer,scar,nodule

orsignofinflammation4.Theurethralmeatus-size,

location,dischargePalpation-tendernessorinduration,sizeandcontour!Usegloves!Remembertoreplacethe

retractedforeskin

第34頁P(yáng)hysicalExamination-

ScrotumanditscontentsInspection1.Skin-nodules,inflammation,ulcers2.Scrotalcontour–swelling,lumpsorveinsPalpation1.Testes:size,shape,consistency,tenderness,nodules2.Epididymis3.Spermaticcordandvasdeferens:nodulesorswellingTransillumination第35頁第36頁P(yáng)hysicalExamination-HerniaInspectionbulgesininguinalandfemoralareasPalpation

Indirect,direct,femoralhernia,reducible,incarcerated,strangulated第37頁P(yáng)hysicalExamination–

rectalexamination

Inspectionbulging,hairyskinordiscolorationorscarinsacralarealumps,ulcers,inflammation,warts,fissures,rashesorexcoriationinperianalareas.PalpationPerianalsensation,bulbocavernousreflexThetonicityoftherectalsphincterProstate-size,shape,consistency,nodules,induration,asymmetry,tendernessSeminalvesiclesPeritonealcavity-rectalshelf,tenderness第38頁P(yáng)atientStandingAndBentOverTheExaminingTable

Knee-chestposition第39頁P(yáng)rostateexamination第40頁(一)整體評(píng)估()1.注意學(xué)生在為病患進(jìn)行身體檢查時(shí)，與否有先自我介紹，態(tài)度溫和自然地先向病患解釋並使病患放鬆心情?()2.注意學(xué)生在為病患進(jìn)行身體檢查時(shí)，與否站在病患之右側(cè)位置?第41頁(二)視診評(píng)估()1.注意學(xué)生做視診時(shí)，除檢查前面腹部外，與否有檢查兩側(cè)腰部及後背部？()2.注意學(xué)生做視診時(shí)，與否有仔細(xì)注意看病患旳姿勢(shì)、表情及外觀?()3.注意學(xué)生做視診時(shí)，與否有檢查腹部旳外形(凹陷或平坦或膨脹)，肚臍突出或凹陷，有無手術(shù)痕跡，有無