消化肾脏泌尿腹部理学检查ppt课件(1)

Physical Examination of the Abdomen and Male Genital OrganThe Abdomen Extends from xiphoid process to the symphysis pubis Rectus abdominis Internal and external obliques Linea alba Inguinal ligament Contains vital organs Major Abdominal OrgansQuadrants of the abdomen Segments of the abdomenmid-clavicular linesubcostal planeanterior superior iliac spineLocalization of Visceral PainExamination of the Abdomen Good light and adequate exposure (xiphoid process to symphysis pubis, groin visible) Relaxed patient Patient supine, arms at side, knees slightly flexed Empty bladderExamination of the Abdomen Ask patient to point to any area of pain Examine non-painful side first “Visualize” underlying anatomy Watch patients face for signs of discomfort during the examinationPhysical Examination Sequence:- Inspection- Auscultation- Percussion - PalpationInspection of the Abdomen Skin: color, ecchymosis, rashes, lesions, striae, scars, dilated veins Contours: flat, roundedscaphoid, protuberant Symmetry: distention local bulgesInspection of the Abdomen Umbilicus: location displacement inflammation Musculature: masses hernia separation Surface motion: peristalsispulsationsAuscultation of the Abdomen Bowel sounds warmed diaphragm all quadrants frequency and character clicks and gurgles, borborygma normoactive: 5-34 per minute 5 continuous minutes to establish absenceAuscultation of the Abdomen Vascular sounds- Bruits warmed bellover aorta, renal, iliac, and femoral arteriesover liver (HCC or acute alcoholic hepatitis)- Venous humswarmed bellover epigastric and periumbilical area (increased collateral circulation between portal and systemic venous systems Friction rubsover liver and spleen (perihepatitis or perisplenitis) Percussion of the Abdomen To detect fluid, air, and fluid-filled or solid masses Stomach and intestines tympany (lower pitched for stomach left lower anterior rib cage and left epigastric area) Organs and solid masses: dullness Percuss all quadrants for distribution of tympany and dullness: tympany predominatesPercussion: Liver Liver span- right middle clavicular line- from tympany to dullness, then from resonance to dullness- 6-12 cm Percussion: Spleen- posterior to left MALsmall area of dullness from 6th to 10th ribs- lowest ICS (9th) in left AAL: Traubs spaceremains tympanic before and after deep breath by patient Percussion: kidney CV angle pain infection or musculo-skeletal causesPalpation Stand at patients side, usually right, with patient in supine position Bending patients knees may help relax muscles Proceed in a systematic manner Palpation of the Abdomen Light palpation- all 4 quadrants- 1 cm deep- identify muscular resistance, superficial massesPalpation of the Abdomen Deep palpation- all 4 quadrants- up to 4 cm deep- delineates organs and detects deeper masses Deep Palpation Characterize masses by: location size shape consistency tenderness pulsation mobility movement with respiration superficial versus intra-abdominal Palpation: Liver place left hand behind patient, parallel to and supporting the right 11th and 12th ribs, place right hand on patients right abdomen ask patient to take a deep breath Feel for the lower border at right costal margin If felt, should be smooth, firm, even and nontender Feel for nodules, tenderness and irregularity Palpation: Liver Hooking 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 breathPalpation: Gallbladder below liver margin at lateral border of the rectus abdominis muscle usually impalpable Murphys sign Courvoisiers law Palpation: Spleen with 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 spleen patient on his right side and his legs flexed at hips and knees Palpation: Kidney for right kidney: left hand behind and support patients right loin, right hand below right costal margin, press both hands firmly together firm, smooth and nontender left kidney usually impalpable Enlargement hydronephrosis, cyst or tumorPalpation: Aorta slightly left of the midline midway between xiphisternum and umbilicus felt in thin patient Additional Procedures in Abdominal Assessment Ascites assessment Rebound tenderness Ili