消化肾脏泌尿腹部理学检查专家讲座.pptx

Physical Examination of the Abdomen and Male Genital Organ消化肾脏泌尿腹部理学检查第1页The AbdomenExtends from xiphoid process to the symphysis pubisRectus abdominisInternal and external obliques Linea albaInguinal ligamentContains vital organs 消化肾脏泌尿腹部理学检查第2页Major Abdominal Organs消化肾脏泌尿腹部理学检查第3页Quadrants of the abdomenSegments of the abdomenmid-clavicular linesubcostal planeanterior superior iliac spine消化肾脏泌尿腹部理学检查第4页Localization of Visceral Pain消化肾脏泌尿腹部理学检查第5页Examination of the AbdomenGood light and adequate exposure(xiphoid process to symphysis pubis,groin visible)Relaxed patientPatient supine,arms at side,knees slightly flexedEmpty bladder消化肾脏泌尿腹部理学检查第6页Examination of the AbdomenAsk patient to point to any area of painExamine non-painful side first“Visualize”underlying anatomyWatch patients face for signs of discomfort during the examination消化肾脏泌尿腹部理学检查第7页Physical ExaminationSequence:-Inspection-Auscultation-Percussion-Palpation消化肾脏泌尿腹部理学检查第8页Inspection of the AbdomenSkin:color,ecchymosis,rashes,lesions,striae,scars,dilated veinsContours:flat,roundedscaphoid,protuberantSymmetry:distention local bulges消化肾脏泌尿腹部理学检查第9页Inspection of the AbdomenUmbilicus:location displacement inflammationMusculature:masses hernia separationSurface motion:peristalsispulsations消化肾脏泌尿腹部理学检查第10页Auscultation of the AbdomenBowel soundswarmed diaphragmall quadrantsfrequency and characterclicks and gurgles,borborygmanormoactive:5-34 per minute5 continuous minutes to establish absence消化肾脏泌尿腹部理学检查第11页Auscultation of the AbdomenVascular sounds-Bruits warmed bell over aorta,renal,iliac,and femoral arteries over liver(HCC or acute alcoholic hepatitis)-Venous hums warmed bell over epigastric and periumbilical area(increased collateral circulation between portal and systemic venous systemsFriction rubs over liver and spleen(perihepatitis or perisplenitis)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Percussion of the AbdomenTo detect fluid,air,and fluid-filled or solid massesStomach and intestines tympany(lower pitched for stomach left lower anterior rib cage and left epigastric area)Organs and solid masses:dullnessPercuss all quadrants for distribution of tympany and dullness:tympany predominates消化肾脏泌尿腹部理学检查第14页Percussion:LiverLiver span-right middle clavicular line-from tympany to dullness,then from resonance to dullness-6-12 cm 消化肾脏泌尿腹部理学检查第15页Percussion:Spleen -posterior to left MAL small area of dullness from 6th to 10th ribs -lowest ICS(9th)in left AAL:Traubs space remains tympanic before and after deep breath by patient 消化肾脏泌尿腹部理学检查第16页Percussion:kidneyCV angle painCV angle pain infection or musculo-infection or musculo-skeletal causesskeletal causes消化肾脏泌尿腹部理学检查第17页PalpationStand at patients side,usually right,with patient in supine positionBending patients knees may help relax musclesProceed in a systematic manner 消化肾脏泌尿腹部理学检查第18页Palpation of the AbdomenLight palpation-all 4 quadrants-1 cm deep-identify muscular resistance,superficial masses消化肾脏泌尿腹部理学检查第19页Palpation of the AbdomenDeep palpation-all 4 quadrants-up to 4 cm deep-delineates organs and detects deeper masses 消化肾脏泌尿腹部理学检查第20页Deep PalpationCharacterize masses by:location size shape consistency tenderness pulsation mobility movement with respiration superficial versus intra-abdominal 消化肾脏泌尿腹部理学检查第21页Palpation:Liverplace left hand behind patient,parallel to and supporting the right 11th and 12th ribs,place right hand on patients right abdomenask patient to take a deep breathFeel for the lower border at right costal margin If felt,should be smooth,firm,even and nontenderFeel for nodules,tenderness and irregularity 消化肾脏泌尿腹部理学检查第22页Palpation:LiverHooking technique:-stand to right of patients chest,place both hands,side by side,on the right abdomen below the costal margin-ask patient to take a deep breath消化肾脏泌尿腹部理学检查第23页Palpation:Gallbladderbelow liver margin at lateral border of the rectus abdominis muscle usually impalpable Murphys sign Courvoisiers law 消化肾脏泌尿腹部理学检查第24页Palpation:Spleenwith left hand reach over and around patient to support and press forward his lower left rib cage,with right hand below left costal margin and press in toward spleenpatient on his right side and his legs flexed at hips and knees 消化肾脏泌尿腹部理学检查第25页Palpation:Kidneyfor right kidney:left hand behind and support patients right loin,right hand below right costal margin,press both hands firmly togetherfirm,smooth and nontenderleft kidney usually impalpable EnlargementEnlargement hydronephrosis,cyst or tumorhydronephrosis,cyst or tumor消化肾脏泌尿腹部理学检查第26页Palpation:Aortaslightly left of the midline midway between xiphisternum and umbilicus felt in thin patient 消化肾脏泌尿腹部理学检查第27页Additional Procedures in Abdominal AssessmentAscites assessmentRebound tendernessIliopsoas muscle testObturator muscle testRovsings signBallottementMcBurneys point消化肾脏泌尿腹部理学检查第28页Ascites AssessmentShifting dullnessFluid wavePuddle signNone of them are specific or completely reliable消化肾脏泌尿腹部理学检查第29页 Shifting dullnessFluid wavePuddle sign消化肾脏泌尿腹部理学检查第30页Rebound Tendernessto determine peritoneal irritationperformed at end of examinationpress deeply and remove fingers quicklysharp,stabbing pain消化肾脏泌尿腹部理学检查第31页 Iliopsoas muscle test-in appendicitis-experience lower quadrant pain-patient attempts to flex hip while examiner applies pressure to lower thigh Obturator muscle test-in appendicitis or pelvic abscess-experience pain in the hypogastric area-patient flexes right leg at hip and knee,examiner rotates the leg laterally and medially 消化肾脏泌尿腹部理学检查第32页Rovsings signIf palpation of the lower left quadrant of a persons abdomen results in more pain in the right lower quadrant,the patient is said to have a positive Rovsings sign and may have appendicitis消化肾脏泌尿腹部理学检查第33页Physical examination-Penisenis InspectionInspection 1.The skin 1.The skin 2.The prepuce or foreskin 2.The prepuce or foreskin 3.The glans-ulcer,scar,nodule 3.The glans-ulcer,scar,nodule or sign of inflammation or sign of inflammation 4.The urethral meatus-size,4.The urethral meatus-size,location,discharge location,discharge Palpation-tenderness or induration,Palpation-tenderness or induration,size and contoursize and contour !Use gloves !Use gloves !Remember to replace the !Remember to replace the retracted foreskin retracted foreskin 消化肾脏泌尿腹部理学检查第34页Physical Examination-S Scrotum and its contentscrotum and its contents InspectionInspection 1.Skin-nodules,inflammation,1.Skin-nodules,inflammation,ulcers ulcers 2.Scrotal contour 2.Scrotal contour swelling,swelling,lumps or veinslumps or veins PalpationPalpation 1.Testes:size,shape,consistency,1.Testes:size,shape,consistency,tenderness,nodules tenderness,nodules 2.Epididymis 2.Epididymis 3.Spermatic cord and vas 3.Spermatic cord and vas deferens:nodules or swelling deferens:nodules or swelling TransilluminationTransillumination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Physical Examination-HerniaInspectionInspection bulges in inguinal and bulges in inguinal and femoral areasfemoral areasPalpationPalpation Indirect,direct,femoral Indirect,direct,femoral hernia,reducible,hernia,reducible,incarcerated,strangulatedincarcerated,strangulated消化肾脏泌尿腹部理学检查第37页Physical Examination rectal examinationrectal examination Inspection Inspection bulging,hairy skin or discoloration or scar in sacral bulging,hairy skin or discoloration or scar in sacral areaarealumps,ulcers,inflammation,warts,fissures,lumps,ulcers,inflammation,warts,fissures,rashes or excoriation in perianal areas.rashes or excoriation in perianal areas.PalpationPalpation Perianal sensation,bulbocavernous reflex Perianal sensation,bulbocavernous reflex The tonicity of the rectal sphincter The tonicity of the rectal sphincter Prostate-size,shape,consistency,nodules,induration,Prostate-size,shape,consistency,nodules,induration,asymmetry,tendernessasymmetry,tenderness Seminal vesiclesSeminal vesicles Peritoneal cavity-rectal shelf,tendernessPeritoneal cavity-rectal shelf,tenderness消化肾脏泌尿腹部理学检查第38页Patient Standing And Bent Over The Examining Table Knee-chest position消化肾脏泌尿腹部理学检查第39页Prostate examination消化肾脏泌尿腹部理学检查第40页(一一)整體評估整體評估()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(二二)視診評估視診評估()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，有無腫塊，有無靜脈浮起或紫斑?消化肾脏泌尿腹部理学检查第42页(三三)聽診評估聽診評估()1.注意學生做聽診時，是否有用手溫熱之聽診器diaphragm面聽腸音?(正常腸蠕動約為每分鐘5-35次)()2.注意學生做聽診時，是否有用手溫熱之聽診器bell面聽主動脈、腎動脈，髂動脈及股動脈有無bruit?()3.注意學生做聽診時，是否有聽肝臟及脾臟之磨擦音(friction rub)?消化肾脏泌尿腹部理学检查第43页(四四)扣診評估扣診評估()1.()1.注意學生做扣診時，是否依正確方向注意學生做扣診時，是否依正確方向(RUQLUQLLQRLQ)(RUQLUQLLQRLQ)在四象限敲出鈍音及在四象限敲出鈍音及鼓音鼓音?()2.()2.注意學生做扣診時，是否能敲出注意學生做扣診時，是否能敲出liver liver spanspan大小大小?(?(正常正常6-12cm6-12cm大小大小,right MCL),right MCL)()3.()3.注意學生做扣診時，是否能敲出注意學生做扣診時，是否能敲出spleen spleen spanspan大小大小?()4.()4.注意學生做扣診時，是否有做後腰部注意學生做扣診時，是否有做後腰部CV CV angleangle之之knocking tendernessknocking tenderness？消化肾脏泌尿腹部理学检查第44页(五五)觸診評估觸診評估()1.()1.注意學生做觸診前，是否先讓病患雙腳微注意學生做觸診前，是否先讓病患雙腳微屈屈?()2.()2.注意學生做觸診時，是否先用單手有系統注意學生做觸診時，是否先用單手有系統地做淺層觸診地做淺層觸診(1cm(1cm以內以內)?)?()3.()3.注意學生做觸診時，是否再用雙手有系統注意學生做觸診時，是否再用雙手有系統地做深層地做深層(4cm(4cm左右左右)觸診觸診?()4.()4.注意學生做觸診時，是否以雙手注意學生做觸診時，是否以雙手(左手在左手在病患背側病患背側,右手在病患腹側右手在病患腹側)，對肝臟及脾臟作，對肝臟及脾臟作觸診觸診?()5.()5.注意學生做觸診時，是否以雙手注意學生做觸診時，是否以雙手(左手在左手在病患腹側病患腹側,右手在病患背側右手在病患背側)，對腎臟作觸診，對腎臟作觸診?消化肾脏泌尿腹部理学检查第45页(六六)肛門及生殖器評估肛門及生殖器評估()1.注意學生做肛診理學檢查前，有無向患者說明檢查原因及目标？()2.注意學生做肛診理學檢查時，是否讓患者擺出正確受檢查姿勢？()3.注意學生做完肛診檢查後，是否能畫出正確攝護腺圖形？消化肾脏泌尿腹部理学检查第46页