Abdominal Examination(腹部檢查)完整版

AbdominalExamination

Introduction

Question1:

Whatdoyouthinkisthebetterormoreappropriatesequenceofabdominalexaminationcomparedwiththatinotherareas?Andwhy?Normalsequence:inspection,palpation,percussion,andauscultationAbdominalexamination:inspection,auscultation,percussion,andpalpationIt’sconvenienttoperformtheauscultationofabdomenaftertheauscultationoftheheart.Toavoidthenegativeimpactsofaseriesofpalpationsonauscultationofbowelsoundsduetothealterationofperistalsis.Question2:CanwesaythatabdominalexaminationwillbeoutmodedandsupersededbecauseofremarkableadvancesinsupplementaryexaminationmethodssuchasX-ray,ultrasound,endoscopy,isotope,angiography,CT,MRI,etc.?DefinitelyNot.Becausetheabdominalexaminationisafundamentalmethodofdetectingabnormalsignsofabdomen.Palpationisthemostdifficultstepof

abdominalexamination,requiringmorepractice.AnatomicLandmarks—

xiphoid(ensiform)process(劍狀突起)ofsternum(胸骨)

—

costalmargin肋弓緣

—

umbilicus臍

—

anteriorsuperioriliacspine髂前上棘

—

inguinalligament

腹股溝韌帶

—

superiormarginofospubis恥骨上緣

—

anteriormidline/midabdominalline前中線/腹中線

—

lateralborderofrectusmuscles

腹直肌外緣

—

symphysispubis(恥骨聯(lián)合)

腹股溝韌帶inguinalligamentcostalmargin恥骨上緣superiormarginofospubisAnteriorsuperioriliacspinexiphoidprocessLateralborderofrectusmuscleumbilicus腹中線

midabdominallineCommonlyusedmethodsofsubdividingtheabdomen

Zonesofabdomen

腹部分區(qū)Fourquadrants

Ninesectionsrightlowerquadrantrightupperquadrantleftupperquadrantleftlowerquadrant√

Theanteriorsurfaceoftheabdomenisdividedintofourquadrantsbytwointersectinglines,oneextendingverticallyfromthexiphoid,throughtheumbilicus,tothesymphysispubis(恥骨聯(lián)合)andtheotherextendinghorizontallyacrosstheabdomenattheleveloftheumbilicus.√

ThisdividestheabdomenintotheRUQ(rightupperquadrant),RLQ(rightlowerquadrant),LUQ(leftupperquadrant),andLLQ(leftlowerquadrant.

√Thecontentoftheabdomenunderlyingeachofthefourquadrantsshouldbeknownasfollows:

Rightupperquadrant

Liver

Gallbladder膽囊

Duodenum十二指腸

Caputpancreas胰頭

Rightkidney右腎

Hepaticflexureofcolon結(jié)腸肝曲Leftupperquadrant

Stomach

Spleen脾

Leftkidney左腎

Caudapancreas胰尾

Splenicflexureofcolon結(jié)腸睥曲Rightlowerquadrant

Cecum盲腸

Appendix闌尾

Rightovaryanduterinetube右側(cè)卵巢及輸卵管

Rightureter右輸尿管

Leftlowerquadrant

Sigmoidcolon乙狀結(jié)腸

Leftovaryanduterinetube左側(cè)卵巢及輸卵管

Leftureter左輸尿管

epigastricregionumbilicalregionhypogastricregionrighthypochondriallefthypochondrialrightlumberregionrightiliacregionleftlumberregionleftiliacregionTwoimaginary,parallel,horizontallines

√acrossthelowestborderofthecostalmargin

√acrosstheanteriorsuperioriliacspineTwoimaginary,parallel,verticallines√acrossthemiddleoflinkinglineformedbyleftanteriorsuperioriliacandmidabdominalline√acrossthemiddleoflinkinglineformedbyrightanteriorsuperioriliacandmidabdominalline

Lefthypochondrialregion左上腹部；左季肋部

Spleen;stomach;splenicflexureofcolon;caudapancreas;leftkidney;leftadrenalgland(左腎上腺)

Leftlumberregion左側(cè)腹部；左腰部

Descendingcolon(降結(jié)腸);jejunum(空腸)orileum(回腸);leftkidney

Leftiliacregion左下腹部；左髂部

Sigmoidcolon;femaleleftovaryanduterinetube;maleleftvaricosity(精索)andlymphnode

Righthypochondrialregion右上腹部；右季肋部

Rightlobeofliver(肝右葉);gallbladder;hepaticflexureofcolon;rightkidney;rightadrenalgland

Rightlumberregion右側(cè)腹部；右腰部

Ascendingcolon;jejunum(空腸);rightkidney

Rightiliacregion右下腹部；右髂部

Cecum(盲腸);appendix;lowerpartofileum(回腸);lymphnode;femalerightovaryanduterinetube;malerightvaricosity

Epigastricregion上腹部

Stomach;leftlobeofliver;duodenum(十二指腸);caputpancreasandbodyofpancreas;transversecolon;aortaabdominalis(腹主動脈);omentummajus/thegreateromentum(大網(wǎng)膜)

Umbilicalregion中腹部；臍部

Lowerpartofduodenum;jejunum;ileum;ptosis(下垂)partofthestomachortransversecolon;ureter(輸尿管);aortaabdominalis;mesentery(腸系膜)andlymphnodes;omentummajus

Hypogastricregion下腹部

Ileum;sigmoidcolon;ureter;fullbladder;pregnantuterus(子宮)

Question3:WhatarethedistinctbenefitsanddisadvantagesinFour-quadrantandNine-sectionmethods?Four-quadrant

√simple,practical,

√rough,imprecise

(tendernessofepigastric

regin)

Nine-section

√

elaboratesmoreclearlyandmoreexactly

√

inconvenient

√

limitedscopeofleftorrighthypochondrialregion,leftorrightiliacregion

Inspectionnotes

position(supine)

scopeofexposure(adequate,xiphoidprocess--symphysispubis,otherscovered

)

sequence

angle(side,tangent)Beforeanyphysicalexaminationiscarriedon,youshoulddoseveralgeneralpreparationsasfollows:

1.

Toaskthepatienttourinatecompletelytobesurethatthebladderisempty.

2.

Patientshouldbelyingonhisbackwithapillowunderhisheadandhiskneesbenttorelaxhisabdominalmuscles.

Besurethearmsareoneitherside,notbehindhishead.Alittleconversationorrepeatingofthepatient’shistorymighthelptorelaxthepatient.

3.

Toexposeabdomencompletelyfromthebreaststopubis.

Forfemalepatients,breastsshouldbecoveredwithasheet.

Themajorcontentsofinspectionabdominalcontourrespiratorymovementsabdominalveinsgastralorintestinalpattern(胃型或腸型)peristalsis(蠕動波)abdominalrash,hernia(疝),striae(紋),etc.Payattentionto

√

whethertheabdomenissymmetrical

√

whetheritisbulgedorretracted

√

whetheritisindicativeofascitesorenclosedmass(包塊)

Normal

√abdominalflatness(腹部平坦)

√

abdominalfullness(腹部飽滿)

√

abdominallowness(腹部低平)

Abdominalflatness

√theabdomenisatthesamelevelorlowerasbetweencostalmarginandsymphysispubis.

√Ifyouaskthepatienttosit,thelowerpartofumbilicuscanbecomemoreorlessprotrudedorbulged.abdominalfullnessIfheorsheisveryfatorisachild,theabdomenisalittlebitround.Theleveloftheabdomenishigherthanthatofthesurfacebetweencostalmarginandsymphysispubis.abdominallownessIfapatientisverythinorslender,theleveloftheabdomenislowerthanthatofthesurfacebetweencostalmarginandsymphysispubis,asaresultoflittlesubcutaneousfat.√Abdominalflatness,abdominalfullness,andabdominallownessareallnormalcases.

√

Iftheabdomenisobviouslyorextremelyprotrudedorbulged,oritisconspicuouslyorexceedinglyretractedordepressed,thatphenomenonisabnormalandusuallyindicatespathological.

someimportantpathologicalconditions

Abdominalprotuberance/bulge腹部膨隆

I.

Overall/generalizedabdominalprotuberance/bulge全腹膨隆

√Overallabdominalbulgecanbecausedbyseveralpathologicalfactorsbesidesoverlyobesityorphysiologicalpregnancy.

i.

Peritonealfluid

Ifthereisalargeamountoffreefluidwithintheabdomen,i,e.ascites,abdominalwallcanbelaxinsupineposition,fluidcandepositatbothlateralsides,thecontourjustlikeafrogbelly.√Ifthepatientliesononesideorsits,thelowerpartofabdominalwallwillbebulged,asfromthemovementoffreefluid.

√

Thisiscommonlyfoundinascitescomplicatedbyportalhypertensionoflivercirrhosis.Atthatcase,esp.inlong-standingascites,theappearanceoftheumbilicusisprotrudedoreverted.

√

Inobesityandfat,theumbilicusisusuallydeeplyinverted.

Apicalbelly尖腹

Apicalbellyiscausedbyperitonitisorinfiltrationofcancers,andhenceabdominalmuscleistense,usu.withtheapicalshape.

Peritonealair腹腔積氣

√Peritonealairiscausedbyalargeamountofairaccumulatinginthecavityofstomach.√Thegeneralshapeofabdomenisglobularandtwosidesoflumberregionisnotobviouslyprotrudent.

√Ifyouaskthepatienttomoveorchangetheposition,theshapeofabdomenremainsglobular.

√Thisiscommonlyfoundinintestinalobstructionorenteroparalysis(腸麻痹).

Pneumoperitoneum氣腹

√

Pneumoperitoneumiscausedbyairaccumulatingintheabdominalcavity.

√Itiscommonlyfoundinperforationofgastrointestinaldiseasesorartificialpneumoperitoneummeanttotreat.

Hugeabdominalenclosedmass

腹內(nèi)巨大包塊

Hugeabdominalenclosedmassisusuallyfoundinfull-termpregnancy,hugeovariancyst(卵巢囊腫),teratoma,etc.

Foranygeneralizedabdominalbulge,circumferenceofabdomenshouldbemeasuredincentimetersattheleveloftheumbilicuswithasofttapemeasureduringnormalabdominalbreathing.

Localabdominalbulge局部膨隆

Localabdominalbulgeisusuallycausedbyenlargedviscera,tumor,inflammatoryenclosedmass,gastrointestinalflatulence(腸胃脹氣),hernia,etc.

Abdominalconcavity/retraction腹部凹陷

Insupineposition,iftheabdomenisatthelevelmuchlowerthanthatbetweencostalmarginandsymphysispubis,wecallitabdominalconcavity/retraction.Therearetwokindsofretraction,thatis,overallabdominalretractionandlocalabdominalretraction.Theformeroneisofgreatsignificance.

I.

Overallabdominalconcavity/retraction

全腹凹陷

Overallabdominalretractionisusuallyfoundinpatientsseverelyemaciatedorseriouslydehydrated.

Scaphoidabdomen舟狀腹

√Scaphoidabdomenissocalledbecausethecontourofabdomenisshapedlikeaboat,withtheanteriorabdomenalmostapproximatingtospinalcolumnandarchofrib,iliaccrest(髂嵴),aswellassymphysispubisallappearing.

√Thissigniscommonlyseenincachexia(惡病質(zhì)).

Localabdominalretraction

局部凹陷

Localabdominalretractioniscausedbythecontractionofscarafteroperationandislesscommon.

abdominalcontour

abdominalprotuberance(腹部膨隆)Overall/generalizedabdominalprotuberance/bulge:

ascites,frogbelly,apicalbellyperitonealair;pneumoperitoneum

abdominalenclosedmass

Local:局部包塊:炎性、腫瘤、粘連。注意包塊的部位、外形、移位、搏動。

腹部凹陷

(abdominalconcavity)

全腹凹陷:舟狀腹(scaphoidabdomen)，

見于惡液質(zhì)、糖尿病、甲亢、

Sheehan病等。

局部凹陷:疤痕收縮。

腹壁情況Rash皮疹:部位、形態(tài)、色彩、時間等。Pigment色素:Addison’sdisease;Cullensign;Grey-Turnersign。Abdominalstriae腹紋:白紋、妊娠紋、紫紋。Scar瘢痕:手術(shù)史的證實。Hernia疝:腹股溝斜、直疝；腹壁疝；臍疝。Umbilicus臍部：Bodyhairs體毛:男、女性差異。Groin腹股溝：包塊、結(jié)節(jié)、疤痕、異常搏動。

Cullensign

-----

Abluishdiscolorationoftheumbilicusoccasionallyisseenaftermajorintraperitonealhemorrhage.

Grey-Turnersign

-----Asimilardiscolorationoftheflanks,intheabsenceoftrauma,occasionallyisseenfollowingtheextravasationofbloodfromintra-abdominalorgansintoextraperitonealsites,asinhemorrhagicpancreatitis.

√

Inthenormalfemalethepubichairisroughlytriangularwiththebaseabovethesymphysis,whereasinthemaleitisintheshapeofadiamond,oftenwithhaircontinuingtotheumbilicus.√

Thedistributionandquantityofhairmaybealteredbychronicliverdiseaseandvariousendocrineabnormalities.

腹壁靜脈及其血流方向

上腔靜脈阻塞:向下下腔靜脈阻塞:向上門靜脈阻塞:臍為中心,放射狀,

水母頭(caputmedusae)。abdominalveins

Normally,abdominalveinsdonotappearunlessthepatientisthinnerorislight-complexioned,orabdominalinnerpressureiselevated,asfromascites,hugeabdominaltumor,pregnancy,etc.

√

Thepresenceofdistendedabdominalveinsindicatesimpairmentofcirculationcausedbyportalhypertensionorobstructionofsuperiororinferiorvenacava.

√Prominenceofthesevessels,calledabdominalwallvaricosis(腹壁靜脈曲張),indicates

increasedcollateralcirculationasaresultofobstructionintheportalvenoussystemorinthevenacava.

√

Withobviousportalhypertension,thedilatedveinsappeartoradiateoutwardfromtheumbilicus,liketheheadofmedusa(水母),sothesedistendedveinsarecalledcaputmedusae(海蛇神頭).

Remember:

√Itisknownthatthenormaldirectionofflowinabdominalvesselsisawayfromtheumbilicus,thatis,theupperabdominalveinscarrybloodupwardtothesuperiorvenacavaandthelowerabdominalveinsdraindownwardtotheinferiorvenacava.√

Ifaveinisengorged,thedirectionofflowcanbedemonstratedby

asimplemaneuver.

maneuver:

√placingtheindexfingerssidebysideoverthevein,pressinglaterally,separatingthefingersonebyone,andobservingthetimeittakestheveinstorefillfromeachdirection;

√Theflowofvenousbloodisinthedirectionthatfillsthefastest.RememberUsuallytherateoffillingisobviouslyfasterinonedirectionthanintheother,indicatingthedirectionofflowinthatportionofthecollateralvenoussystem.Inportalhypertensionnormalflowdirectionismaintained.Incontrast,obstructionofthevenacavaalterstheflowdirectionintheseveins.

Inobstructionofthesuperiorvenacava,theflowdirectionintheupperabdominalvenouscollateralsisreversedordownward.

Ininferiorvenacavaobstructionthedirectionisreversedinthelowerabdominalveins,andtheywilldrainupward.

呼吸運(yùn)動

正常表現(xiàn)：男性、小兒：腹式為主。女性：胸式為主。病理狀態(tài)：腹式受限—腹部炎癥、包塊、積液、膈肌麻痹。腹式增強(qiáng)—癔癥性呼吸、胸部疾病。

respiratorymovementsRespirationinafemaleismainlycostal,andlittlemovementoftheabdominalwalloccurs;Inmalesandchildren,thebreathingisquietwiththemajorrespiratorymovementbeingabdominal.Restrictionoftheabdominalphaseofrespiration,especiallyinthemalepatient,maybefoundindiseaseandinflammationbelowthediaphragm(particularlyperitonitis).Inseverecase,asinacuteperitonitisfromgastrointestinalperforationorphrenoplegia(膈癱瘓),i.e.,diaphragmparalysis,respirationentirelydisappears.

胃腸型和蠕動波

gastricorintestinalpatternandperistalsis

正常人：見于經(jīng)產(chǎn)婦與消瘦腹壁松軟者。幽門梗阻：上腹部逆蠕動。小腸梗阻：不規(guī)則隆起，此起彼伏。結(jié)腸梗阻：全腹膨隆、寬大腸型。gastralorintestinalpattern(胃型或腸型)andperistalsis(蠕動波)

Inleanindividuals,evenintheabsenceofdisease,motilityofthestomachandintestinesmaybereflectedintheabdominalwall.Whenstrongcontractionsarevisiblethroughanabdominalwallofaveragethickness,thepossibilityofbowelobstructionshouldbeinvestigated.Reverseperistalsisindicatespyloricstenosis,duodenalstenosis,ormalrotationofthebowel.

上腹部搏動由腹主動脈搏動傳導(dǎo)，可見于正常較瘦者。異常情況：1.腹主動脈瘤和肝血管瘤

2.右心室增大：二尖瓣狹窄或三尖瓣關(guān)閉不全

腹部聽診

腸鳴音(bowelsound,gurglingsound)

正常：4-5次/分活躍：10次/分亢進(jìn)：次數(shù)多、調(diào)高減弱：少于1次/分消失：3-5分Bowelsounds(borhorygmus)腸鳴音

Auscultatebowelsoundswithdiaphragmaticheadofstethoscopeforatleastoneminute.

Iftherearenobowelsounds,listenuntilyouhearthemorforatleast5minutes.Normalbowelsoundsareaglue-glue,glue-glue-likesoundoccurringeitherseparatelyortogether,approximately4-5timesperminute.Payattentiontothefrequency,pitch,andintensity.High-pitched(gurgling)soundswithincreasedfrequencyareregardedashyperactivety.Lackofbowelsoundsindicatelittleornoperistalsis.

Bowelsounds(borhorygmus)腸鳴音

Theabsenceofanysoundorextremelyweakandinfrequentsoundsheardafterseveralminutesofcontinuousauscultationordinarilyrepresenttheimmobilebowelofperitonitisorparalyticileus.Incontrast,increasedsoundswithacharacteristicloud,rushing,high-pitchedtinklingqualityoftenoccurinmechanicalintestinalobstructionandmaybeaccompaniedbywavesofpain.Thelatterfindingsarecausedbydistentionofthebowelandincreasedperistalticactivityproximaltothesiteoftheobstruction.

血管雜音(vesselmurmurs)

動脈性：中腹部或腹部一側(cè)、動脈瘤或主動脈狹窄、收縮期雜音。

靜脈性：臍周、門脈高壓、無收縮期與舒張期性質(zhì)。

Murmurs(雜音)orbruits

Murmursfromarteriesarecalledbruitsandaresimilartolow-pitchedheartmurmurs.Murmursfromveinssoundlikeahumandaremorecontinuous;theyarecalledvenousbruitsorvenoushum.

Tobeofsignificanceabruitmustbeheardconsistentlyintheareaifthepatientismovedintovariouspositions,anditmustbeheardwithextremelylightpressureonthediaphragmofthestethoscopeorwithbell-typeheadofstethoscope:

摩擦音(frictionrubs)脾梗塞、脾周圍炎、肝周圍炎、或膽囊炎累及腹膜。搔刮試驗(scratchtest)

確定肝臟邊緣；確定腹水。水坑試驗（puddletest)

確定腹水少至120ml

叩診

正常腹部叩診音

鼓音(tympany)為主;

實音僅見于肝脾(腫大)部位.PercussionGeneralpercussionAllfourquadrantsoftheabdomenareevaluatedbypercussion.Lightpercussionispreferable,sinceitproducesaclearertone.Tympany(鼓音)isthemostcommonpercussionsoundintheabdomenduetogascollection.Itisappreciatedoverthestomach,smallintestine,andcolon.PercussionoftheliverPercussionoftheupperborderofliver(肝上界)isexecutedalongtherightmidclavicularline(右鎖骨中線),rightmidaxillaryline(右腋中線),andrightscapularline(右肩胛線).Theleveloftheshiftfromresonancedownwardintodullnessisdefinedastheupperborderofliver.Atthislevel,theliveriscoveredbylungandhencetheborderisalsocalledtherelativedullnessborderofliver(肝相對濁音界).PercussionoftheliverThenpercussingdownward1-2intercostalspace,theleveloftheshiftfromdullnessintoflatness(實音)isidentifiedastheabsolutedullnessborderofliver(肝絕對濁音界),withoutlungcovering,andalsocalledthelowerborderoflung(肺下界).Normallythetheupperborderofliverlocatesatthe5th

intercostalspacealongtherightmidclavicularline,the7th

intercostalspacealongtherightmidaxillaryline,andthe10th

intercostalspacealongtherightscapularline.

PercussionoftheliverPercussionofthelowerborderofliver(肝下界)isexecutedalongtherightmidclavicularlineoranteriormidline.Theleveloftheshiftfromtympanyupwardintodullnessisdefinedasthelowerborderofliver.

Percussionof

liverspan(肝上下徑)Percussionofliverspanshouldbedonewiththepatientbreathingnormally.Percussionshouldoccurthroughtherightmidclavicularlinefromresonanceoverthelungfielddownwardtodullnessandfromtympanyoverabdomenupwardtodullness.Measurefromuppertolowerborderofdullnessforliverspan.Itisnormallyabout9-11cminthemidclavicularline.肝臟叩診正常肝臟上界位置:右鎖中線第5肋間。肝濁音界擴(kuò)大:肝癌、肝膿腫等。肝濁音界縮小:暴發(fā)性肝炎、肝硬化等。肝濁音界下移:肺氣腫、張力性氣胸等。肝區(qū)叩痛:肝炎、肝膿腫等。肝濁音界消失：消化道穿孔等。Dullnessextendingintothenormallytympaniticrightupperquadrantindicateshepaticenlargement,amassadjacenttotheliver,ordownwarddisplacementoftheliver.Theremaybeanabsenceofliverdullnessfollowingperforationofahollowviscus,whichallowsfreeairtoentertheabdominalcavity.Thisindicationofanintra-abdominalcatastrophemustbecorrelatedwiththeclinicalsituation,sinceonoccasioninterpositionofthehepaticflexureofthecolonbetweenthediaphragmandtheliver(間位結(jié)腸[結(jié)腸位于肝與橫膈之間])willproducethesamefindingwithnoclinicalconsequences.

胃泡鼓音區(qū)與脾臟叩診Traubetympanicarea(9.56cm):

上界：膈肌及肺下緣下界：肋弓左界：脾臟右界：肝左緣

正常脾濁音界:左腋中線9~11肋間,長

4~7cm

脾濁音區(qū)增大:脾腫大脾濁音區(qū)縮小:氣胸、胃擴(kuò)張、腸脹氣等。Percussionofthespleen

Topercussforsplenicdullness

√Thisshouldbedonewhensplenicenlargementissuspected.

√

Normallysplenicdullnesscanbepercussedbetween9intercostalspaceto11intercostalspacealongleftmidaxillaryline,thescopethatis4-7cm,withoutpassingoverleftanterioraxillaryline.

presenceorabsenceoffreefluidintheabdominalcavity(ascites)Thismaybedetectedbyseveralmaneuvers(1)shiftingdullness,(2)fluidwave,and(3)elbow-kneeposition.

移動性濁音(shiftingdullness)

檢查體位與方法:

側(cè)臥位:>1000ml;

肘膝位(elbow-kneeposition):200-500ml以上。

注意點(diǎn)：腸道梗阻,積液過多;

腹腔巨大腫瘤(如卵巢):

體位改變(shiftingdullness)；

尺壓試驗(rulerpressingtest)。Percussionforshiftingdullness(移動性濁音)

Theexaminershouldfirsttellthepatienttolieonhisback(inthesupineposition).,tympanyatmidabdomencouldbefoundbecauseoftheunderlyingbowel.Atthesametime,dullnessatthebilateralflankscouldbefoundduringpercussionduetotheaccumulationofascites.Thereasonisthatwhenthepatientwithascitesliesonhisback,thefluidwillmigrateintotheflanks,producingdullnesslaterally.

Percussionforshiftingdullness(移動性濁音)

Whendullnessisfoundintheflanks,Thelineofdemarcationbetweenthedullnessandtympanyismarked.Theexaminerpercussesthepatient’sabdomenattheumbilicuslevelfromthemidabdomentowardthepatient’sleftside.Iftheexaminerfindsthepointwherepercussionsoundoftympanychangesintodullness,theexaminershouldholdhispleximeteronthatpoint,simultaneously,askthepatienttoturnonhisrightsideandthencontinuetopercussthesamepointagain.Ifthesoundchangesfromdullnesstotympany,itmeansthatthedullnesshasbeenshiftedtoamoredependentposition.Thisimpliesthatascitesispresent.

Percussionforshiftingdullness(移動性濁音)

Similarly,theexaminerpercussesthepatient’sabdomentowardthepatient’srightside.Iftheexaminerfindsthepointwherepercussionsoundoftympanychangesintodullness,theexaminershouldholdhispleximeteronthatpoint,simultaneously,askthepatienttoturnonhisleftsideandthencontinuetopercussthesamepointagaintoconfirmtheshiftofdullness.

Avolumeoffreefluidintheperitonealcavitygreaterthan1000mlcanbedetectedwiththismethod.

Iftheamountistoolittle,shiftingdullnesscouldnotbefound,theexaminercouldaskthepatienttotakeelbow-kneeposition,lettingtheumbilicusatthelowestlevel,andthenpercussesthepatientfromflankstowardtheumbilicus.Ifpercussionsoundcouldchangefromtympanytodullness,itindicatesascites.

HugeovarycystHugeovarycystmayalsocausealargeareaofdullness,butatmidabdomenwithtympanyatlaterals,becausebowelscouldbepushedtothebilateralflanks.Thedullnessofovarycystcouldnotshift.

HugeovarycystRulerpressingtestcouldbeusedtodifferentiatehugeovarycystfromrealascites.Thepatientshouldtakethesupineposition,andtheexaminerputsahardruleronthepatient’sabdominalwallhorizontallyandthenpressestherulerdownwardwithtwohands.Ifhugeovarycystexists,thepulsationofabdominalaortawillconducttotherulerviathecyst,leadingtorhythmicpulsationofthehardruler.Iffreefluidnotcystexistsintheabdominalcavity,thepulsationofabdominalaortacouldnotconduct,sothehardrulerhasnosuchrhythmicpulsation.

膀胱叩診：

確定膀胱內(nèi)是否有尿，必要時導(dǎo)尿證實。肋脊角叩診：

肋脊角叩痛:腎盂腎炎、腎結(jié)石、腎結(jié)核、腎周圍炎等。Palpation

Thisprocedureisusuallythemostimportantandoftenthemostdifficulttoperformaccurately.

theprincipleofpalpation

a)

Torelaxthepatient

√Duringpalpationthepatientshouldcontinuetoliesupinewitharmsrelaxedonthechestoratthesides.

√Theexaminershouldmakecertainthathishandsarewarm.

√Heshouldassurethepatientthathewillmakeaneffortnottocausediscomfortandfollowupthisassurancebyavoidingattheoutsetanareaalreadydescribedaspainful.

√Ifthepatientexhibitsticklishness,theexaminershoulddisregarditandtrytocontinue.

√Ifthisprovesunsuccessful,itisusefultohavethepatientplacehisownhandonhisabdomen,sincethisnevertickles.

√

Theexaminermaytentativelyexertpressureontheabdomenthroughthepatient’sownhand,andgraduallyincreasethepressure,whileassuringthepatientthattheexaminationwillcausenodiscomfort.

√Whenthepatienthasrelaxed,theexamineragainplaceshisownhandontheabdomenandallowsthepatienttomaintaincontactwithhishand.Thisusuallycompletestherelaxationoftheticklishpatient,andtheexaminationproceedsasusual.

√

Theexaminationbeginswithgentleexplorationoftheabdominalwallandwithnoeffortmadetopalpatedeeply.

√Thepatientmaybefurtherrelaxedbyinstructinghimtobreatheslowlyanddeeply.

√Aswithinspection,theinitialstepin

palpationmaybefacilitatedbydistractingconversationorquestionsregardingthehistory.

√Ifthepatientremainstenseoriftheabdominalwallisverymuscular,betterresultsmaybeobtainedbyhavingthepatientflexthethighsandknees.

√Itshouldbeemphasizedagainthatduringthepreliminarystagesmusclerelaxationisthegoal.Atthistimenoattemptshouldbemadeeithertoelicitdiscomfortortopalpateforamassorenlargedviscus.

b)

Topalpatefourquadrants

superficiallyfromLLQcounterclockwise

√

Topalpateallareasoftheabdomencounterclockwiseandsuperficiallyfromleftlowerquadrantscreeningfortenseness(緊張度),tenderness(壓痛),masses,etc.

√Examinationbeginswithgentlemaneuversandthenpalpationoccursmoredeeply.√Examinerusesthepalmsofhishandswithfingerstogetherandarmrelaxedandforearmonahorizontalplane.

√Theexaminerpresseswithhisfingers.

c)

Topalpatefourquadrantsdeeply

√Usingthepalmersurfaceofthefingers,examinerpalpatesinfourquadrantstoidentifymasses,tenderness,pulsations,etc.√