I腹部检查APPT课件.ppt

physicalexamination腹部检查(1)AbdominalExamination,landmarksandregions体表标志和分区inspection视诊palpation触诊,1,LandmarksandRegions体表标志与分区,abdominallandmarks腹部体表标志abdominalregions腹部分区,2,SurfaceLandmarksonInterior体表标志(前面),xiphoidprocessofsternum剑突,anterosuperioriliacspine髂前上棘,superiormarginofospubis耻骨联合,costalmargin肋弓下缘,midline腹中线,umbilicus脐,pubicligament腹股沟韧带,3,SurfaceLandmarksonPosterior体表标志(后面),Costovertebralangle肋脊角Vertebrocostalpoint肋脊点Costolumbarpoint肋腰点Spinousprocess脊柱棘突,4,TheFourAbdominalQuadrants腹部四分区,twoimaginaryperpendicularlines二条水平和垂直交叉线fourquadrants:分四区rightupper右上腹部leftupper左上腹部rightlower右下腹部leftlower左下腹部,5,TheNineAbdominalAreas腹部九分区,Epigastric上腹部Umbilicalregion脐部Supra-pubicregion下腹部Righthypochondrium右上腹部Lefthypochondrium左上腹部Rightflankregion右腰部Leftflankregion左腰部Rightinguinal右下腹部Leftinguinal左下腹部,6,InspectionofAbdomen腹部视诊,abdominalcontourandmovement腹部外形和运动abdominalwallinspection腹壁视诊,7,NoticeProceeding注意事项,Patientindorsalposition取仰卧位Exposurewholeabdomen暴露全腹Doctorstandinrightside立于右侧Observefromabovetobelow自上而下观察,8,AbdominalContour腹部外形,Normal:flattoroundedAbnormal:abdominaldistentionabdominaldepression,正常:平坦低平或饱满异常:腹部膨隆腹部凹陷,Flat平坦,Scaphoid舟状,Rounded饱满,Protuberant膨隆,9,Distension腹部膨隆,Abdominalwalldisorders腹壁改变Tumor:appearedclearlyinforce肿物:腹部用力时肿物明显Incrassation:hilumdepressedsuchasobesity增厚:脐部凹陷如肥胖Abdominalcavityincrease腹腔增大Fulldistension:normalpregnancyandabnormal全腹膨隆:正常妊娠和异常Localdistension局部膨隆Measuresurroundofabdomen测量腹围Aroundtheabdomenthroughhilumbysoftruler仰卧位用软尺绕脐一周,10,CommonCausesofDistension常见膨隆原因,Fat肥胖Fluid腹水Feces粪块Fetus妊娠Flatus胃肠胀气Fibroids子宫平滑肌瘤Fataltumor恶性肿瘤.Remember:5F,Protrudedumbilicus,ascites,ovariancyst,11,Contour:ProtuberantAbdomen全腹膨隆,Ascites:frogshapeofabdomen,accompaniedhilumhernia.腹水:蛙状腹常伴脐疝causes:hepatocirrhosis,seriousheartfailure,pericarditis,renaldiseasesyndrome,peirtoneumcancer.病因:肝硬化严重心衰缩窄性心包炎肾病综合征腹膜癌Gasesdistentionoftheintestines:sphericityofabdomen肠胀气:球形腹causes:ileus,intestinalparalysis.病因:肠梗阻肠麻痹Organomegaly:enormousovarycystandteratoma.肿瘤:巨大卵巢囊肿畸胎瘤,12,LocalDistension局部膨隆,Weaknessofabdominalwall:hernia腹壁薄弱:疝types:exomphalocele,femoraloringuinalhernia类型:脐疝股疝腹股沟疝Ventro-cavityoccupation:organdisorders腹腔占位:脏器病变diseases:organomegaly,tumor,inflammationmass,gastrointestinalpneumotamatosisect.疾病:脏器肿大肿瘤炎性包块胃肠胀气等,13,LocalDistensionandDisorders局部膨隆与疾病(1),Righthypochondrium:hepatomegaly,cholecystfluidaccumulation,colontumorunderliver右上腹部:肝肿大胆囊积液结肠肝曲肿瘤Epigastric:leftlobeofliverenlarged,gastriccancer,gastricdilation;inflammation,tumorandcystofpancreas上腹部:肝左叶肿大胃癌胃扩张胰腺炎症肿瘤囊肿Lefthypochondrium:spleenintumesce,giganticcolon,colontumorunderspleen左上腹部:脾肿大巨结肠结肠脾曲肿瘤Sideflankregion:kidneyintumesce,hydronephrosis,vastnessadrenalglandtumor侧腹部:肾肿大肾盂积水巨大肾上腺肿瘤,14,LocalDistensionandDisorders局部膨隆与疾病(2),Umbilicalregion:hilumhernia,inflammationmass脐部:脐疝炎性包块Rightinguinal:ileo-colictuberculosisandtumor,crohndisease,appendixabscess右下腹部:回盲部结核肿瘤克隆病阑尾脓肿Leftinguinal:descendingorsigmoidcolontumororfeces左下腹部:降结肠或乙状结肠肿瘤粪块Supra-pubicregion:pregnancy,myomaofuterus,bladderenlarged,ovarytumor下腹部:妊娠子宫肌瘤膀胱胀大卵巢肿瘤,15,Contour:DepressionAbdomen腹部凹陷,Regionaldepression:surgicalscar局部凹陷:腹部手术瘢痕收缩General:scaphoidabdomen全腹凹陷:舟状腹Cachexia:latedurationofchronicdepletedisease,malignanttumor,nervousanorexia恶病质:慢性消耗性疾病晚期恶性肿瘤神经性厌食Earlyacutediffuseperitonitis:abdominalmusclespasmodiccontraction早期急性弥漫性腹膜炎:腹肌痉挛性收缩,16,NormalRespiratoryMovement正常呼吸运动,MaleandChildren:Abdominalrespiratorymovement男性及小儿:以腹式呼吸为主Female:Chestrespiratorymovement女性:以胸式呼吸为主,17,AbnormalRespiratoryMovements异常呼吸运动,Decreased:inflammationalpain,volumeexpansion呼吸减弱:炎性疼痛腹腔容积增加disorders:acuteperitonitis,enteroparalysis,ascites,mass疾病:急性腹膜炎肠麻痹腹水肿物Increased:chestandlungdiseases呼吸增强:胸肺疾病disorders:ribfracture,Pleuraleffusion疾病:肋骨骨折胸腔积液,18,GIForm&PeristalticWave胃肠型和蠕动波,Mechanism:weaknessofabdominalwallordilatationofstomachandintestine机制:腹壁薄弱或胃肠扩张Gastricandintestinalform:stomachandintestineshapesappearsinabdominalwall胃肠型:胃肠在腹壁上显出轮廓Peristalticwave:gastricandintestinalwavesappearsinabdominalwall蠕动波:腹壁可见起伏胃肠波型,19,GastricForm&PeristalticWave胃型和蠕动波,Gastricforminepigastricregion上腹壁显出胃饱满隆起轮廓GastricPeristalticwaveinepigastricregion上腹壁可见胃蠕动增强起伏的蠕动波型Positivewave:wavemovedfromlefttoright正蠕动波:自左肋缘下向右推进的蠕动波Athwartwave:fromrighttoleftbyvomiting逆蠕动波:自右向左的蠕动波见于剧烈呕吐时Cause:pyloricobstruction,feeblewallofabdomen提示:幽门梗阻腹壁薄弱,20,IntestinalForm&PeristalticWave肠型和蠕动波,Intestineforminumbilicalandsupra-pubicregion肠段饱满隆起在脐周或下腹壁显出轮廓Intestineperistalticwaveinabdominalwall腹壁可见肠蠕动增强的起伏蠕动波型Cause:mechanicalileusaccompaniedsharpbowelsound提示:机械性肠梗阻伴高调肠鸣或金属音Smallintestinalobstruction:theformandwaveinumbilicalregion小肠梗阻:脐周肠管呈多梯形蠕动波在脐周方向不一Colonobstruction:theformandwaveinborder结肠梗阻:肠型和蠕动波出现在腹部周边,21,Pulsation搏动,Markedpulsationoftheaortaoccurswithwidenedpulsepressureandwithaorticaneurysm明显搏动见于脉压增大腹主动脉瘤Youmayseethepulsationsfromtheaortabeneaththeskinintheepigastricarea,particularlyinthinpersonswithgoodmusclewallrelaxation搏动多见于上腹部消瘦和腹壁松弛时易出现,22,AbdominalWallInspection腹壁视诊,Inspecttheskin皮肤改变Color:redness,pallor,jaundice,eruption,&pyoderma颜色:发红苍白黄染水肿皮疹脓皮症Striae裂纹Scar瘢痕Abdominalvaricosity腹壁静脉曲张,23,SkinSigns皮肤征象,SubcutaneoushemorrhageGrey-turnerssignCullenssignPigmentationAddisonsdiseaseStriaeCushingssyndromePregnancyRapidweightgain,皮下出血Grey-turners征Cullens征色素沉着阿迪森病裂纹库兴综合征妊娠纹快速肥胖纹,24,SubcutaneousHemorrhageSign皮下出血征象,Grey-Turnerssign:massiveecchymosesoccurontheabdomenorontheflanksasaresultofhemorrhagicpancreatitisorstangulatedbowel.Grey-Turner征:左腰皮肤呈蓝色出血性胰腺炎血液渗到皮下Cullenssign:abluishdiscolorationoftheumbilicusresultingfromhemoperitoneumofanycause.Cullen征:脐周或下腹皮肤发蓝腹腔出血时血液渗到皮下,Cullenssign,25,SkinPigmentation皮肤色素沉着,Addisonsdisease:pigmentationinskinWrinklebyadrenalglandfunctiondecrease.阿迪森病:皮肤皱折处色素沉着肾上腺皮质功能减退,Addisonsdisease,26,SkinStriae皮肤裂纹,Silverstriae:stretchmarksconsistentwithweightgain白纹:肥胖腹壁真皮裂开Purplestriae:Hypercortisolism紫纹:皮质醇增多症Striaegravidarum:paleblueorpink妊娠纹:淡兰色或粉红色产后为白色,Purplestriae,27,VaricosityofAbdomen腹壁静脉曲张,Theveinappearanceaccompaniedcircuityinabdominalwall.腹壁静脉显露并伴迂曲Varicosityindicatedincreasedveinpressureandformationofsidecirculation.静脉压力增高侧支循环形成,28,DirectionoftheBloodflow血流方向检查,Usetwofingersonappearedvein用两手指并拢压在静脉上Twofingerspressanddispart两手指加压分开Loosensuperiorfinger松开上端手指Fastershowbloodflowdownwards充盈快示血流向下Repeataboveaction重复以上动作Looseninferiorfinger松开下端手指Fastershowbloodflowupwards充盈快示血流向上,29,PortalHypertension门静脉高压,Varicosityfromumbilicusradiatingsurround,likethejellyfishshead.脐部一簇曲张静脉向四周放射如水母头状,30,ObstructionofVenaCava腔静脉阻塞,Varicosityontheflanks曲张静脉在侧腹部Obstructionofsuperiorvenacava:bloodstreamtodownwards.上腔静脉回流受阻血流方向向下Obstructionofinferiorvenacava:bloodstreamtoupwards.下腔静脉回流受阻血流方向向上,31,PalpationofAbdomen腹部触诊,abdominalwall腹壁触诊organsintheabdomen脏器触诊masses肿块触诊fluidthrillandfluctuation液体触诊,32,PalpationTechnique触诊手法,Thepatientissupineandrelaxduringpalpation.平卧低枕位腹部放松Fromfleettodeep由浅及深Alwaysbegininanareaofwherethatisfarthestfromthelocationofpain.先健后患Fromleftlowerinsequenceofathwarthourhand逆时针触摸,33,WallPalpationContent腹壁触诊,Abdominalmuscletone腹壁肌肉紧张度Tenderness压痛Reboundtenderness反跳痛,34,AbdominalMuscleTone腹壁肌肉紧张度,Normal:soft正常:柔软Generalizedincreased:diffuseperitonealinflammationandcontentincrease全腹增加:弥漫腹膜炎症腹腔内容物增加RegionallyIncreased:Guardingiscontractionthemusclesoverlyinganinflamedviscusandperitoneum,maderigidity.局部增加:肌卫局限性腹膜炎Decrease:myastheniagravis,oldpeopleormultipara全腹减低:重症肌无力老年人或经产妇,35,GeneralizedIncreased全腹紧张度增加,Generalizedor“board-like”rigidity:acutediffuseperitonitis板状腹:全腹增加似板状急性弥漫性腹膜炎Doughkneadingsensation:chronictubercularperitonitis揉面感:慢性结核性腹膜炎,36,RegionallyIncreased局部紧张度增加,Regionalperitonealinflammationcausedbyneighboringorgan脏器炎症波及邻近腹膜Rightiliacregion:appendcitis,perforationofgastrointestinaltract右下腹:阑尾炎胃肠穿孔righthypochondrialregion:cholecystitis右上腹:胆囊炎lefthypochondrialregion:acutepancreatitis左上腹:急性胰腺炎,37,AbdominalWallTenderness腹壁压痛,Tendernessisthepainfeelingsinpressurebyhandreflectingunderlyingorgandisorders.腹壁加压出现痛感提示腹内脏器病变Inflammation,congestion,tumor,rupture,andtorsionofintra-abdominalorgan腹腔脏器炎症充血肿瘤破裂扭转Diseasesinthethorax胸部病变牵涉Diseasesinthepelviccavity盆腔疾病,38,ReboundTenderness(Blumbergsign)反跳痛,Examinationmethod:pressdeeplyandslowly,letslipsuddenly.检查方法:逐渐深压腹壁突然松开Positivefinding:painprickupinloose.阳性:松开时疼痛加剧Clinicalmeanings:inflammationintheparietalperitoneum.提示:炎症波及壁层腹膜,39,PeritonealIrritationSign腹膜刺激征,Threesignsameappear:TendernessReboundtendernessGuarding三联征:压痛反跳痛腹肌紧张Clinicalmeaning:acuteperitonitis提示:急性腹膜炎,40,PressurePainPoint压痛点,Tenderpointofgallbladder胆囊压痛点McBurneyspoint麦氏点又称阑尾压痛点,41,OthersofPressurePainPoint其他常见压痛点,Gastritisandulcer胃炎和溃疡Duodenumulcer十二指肠溃疡Pancreatitisandtumor胰腺炎或肿瘤Smallintestinedisorders小肠疾病Bladderoruterusillness膀胱或子宫病变Inflammationortuberculosisincecum回盲部炎症结核Inflammationortumorinsigmoidflexure乙状结肠炎症或肿瘤Spleenorcolonillness脾或结肠脾曲病变Liverorcolonillness肝或结肠肝曲病变,42,NoRelationshiptotheLocation压痛点不指示病变部位,Earlyacuteappendcitis:paininuporumbilicusLowlobarpneumonia:tendernessinrighthypochondriumCholecystdisease:tendernessinrightloinPancreasinflammation:tendernessinleftloin,急性阑尾炎早期上腹部或脐周压痛肺下叶炎症季肋部压痛胆囊病变右肩胛下区压痛胰体胰尾部炎症左腰部压痛,43,OrgansPalpationintheAbdomen腹部脏器触诊,LiverpalpationSpleenpalpationGallbladderpalpationPancreaspalpationKidneypalpationIntestinepalpationBladderpalpation,肝脏触诊脾脏触诊胆囊触诊胰腺触诊肾脏触诊肠管触诊膀胱触诊,44,NormalPalpableStructures正常腹部可触及的结构,Xyphoidprocess剑突Nomalliveredge正常肝脏边缘Rightkidney,lowerpole右肾下极Cecum/ascendingcolon盲肠和升结肠Uterus(gravid)子宫,Pulsatileaorta腹主动脉Rectusmuscles,lateralborders腹直肌侧缘Sacralpromontory腰椎椎体Sigmoidcolon乙状结肠Fullbladder充盈膀胱,45,PalpationoftheLiver肝脏触诊,Method:palpateincostaledgeandxiphoidprocess方法:单手或双手触摸肋缘和剑突下Notice:twolegsflectionandabdominalrespiratory注意:双腿屈曲腹式呼吸Rightliver:palpatefromlevelofanteriorinferioriliacspineandouteredgeofrightrectusmuscleslateralbordersuptocostaledge右肝:自髂前上棘水平右腹直肌外缘开始自下而上触诊至肋缘Leftliver:palpatefromlevelofumbilicusuptoxiphoidprocess左肝:脐水平开始触至剑突,46,PalpationContents触诊内容,Size,quality(soft,firm,hard)肝脏大小质地(软如口唇韧如鼻尖硬如前额)Surface:smooth,irregular,nodular表面:光滑不规则结节Margin:sharp,blunt边缘:锐利变钝Tenderness压痛Hepatojugularreflux肝颈静脉回流征,47,NormalLiver正常肝脏,Commonlynonpalpable一般触不到Ifpalpable,inferiorborderonlyincostaledgelessthan1cmxiphoidprocesslessthan3cm如触到肝脏右肋缘下1cm剑突下3cmSoftquality,smoothsurface,sharpmargin,notenderness质地柔软表面光滑边缘锐利无压痛,48,LiverLocationandSize肝脏位置和大小变化,Hepatomegaly肝脏肿大diffuseswell:hepatitis,hepaticcongestion弥漫性肿大:肝炎肝淤血localswell:hepaticabscess,cyst,tumor局限性肿大:肝脓肿囊肿肿瘤Hepatoptosis肝脏下移emphysema,rightpleuraleffusion肺气肿右侧胸腔积液,49,Tendernessofliver肝脏压痛,Tendernessofliver:madebylivercapsulainflammationorpullings肝脏压痛:由肝包膜炎症及包膜受牵拉所致Gentlydiffuse:hepatitis,hepaticcongestion轻度弥漫性压痛:肝炎肝淤血Localacuity:washyabscessofliver局限剧烈压痛:较表浅的肝脓肿Patency:primaryhepaticcarcinoma明显压痛:原发性肝癌,50,HepatojugularReflux肝颈静脉回流征,Technique:presstheliverregionofsurfaceofhepatomegalyinducingmoredistendedofcervicalvein检查方法:压迫肝区或增大肝脏的表面颈静脉怒张更加明显称肝颈静脉回流征阳性Significance:hepaticcongestionbyrightheartfailure,pericardialeffusion,constrictivepericarditis临床意义:表明肝淤血右心功能不全心包积液缩窄性心包炎,51,PulsationofLiver肝脏搏动,Conductivepulsation:liverconductundersideabdominalaorticpulsation传导性搏动:肝传导了下面腹主动脉的搏动Dilativepulsation:tricuspidvalveinsufficiencymadehepaticblooddilativepulsation扩张性搏动:三尖瓣关闭不全引起肝脏血管扩张性搏动,52,ComparewithCauseSigns肝脏肿大及病变征象,53,PalpationoftheSpleen脾脏触诊,Location:supineorstarboardposition体位:平卧或右侧卧位Position:leftcostalmargin部位:左肋缘下Technique:deepsleepingandbimanualpalpation手法:深部滑行触诊和双手触诊Direction:uprightwithcostaledge方向:与肋缘垂直Character:vestigeintheinneredge特征:内缘有切迹,54,PalpationContents触诊内容,Size:threelines大小:三条线Consistency:soft,firm,hard质地:软质韧硬Surface:smooth,nodular表面:光滑小结节Tenderness压痛Frictionrubs摩擦感,55,MeasureofEnlargedSpleen肿大脾脏的测量,Thefirstline:betweencostalmarginandlowedgeofspleeninleftmidclavicularline1线(甲乙线):左锁骨中线上肋缘至脾下缘Thesecondline:betweenthepointoftheleftmidclaviculcrosscostalmarginandthepointofspleenapoapsis.2线(甲丙线):左锁骨中线肋缘点至脾最远点Thethirdline:betweenrightsideofspleenandmidline,expresswithpositiveornegative3线(丁戊线):脾右缘至正中线以()()表示,56,SpleenEnlargementDegrees脾脏肿大分度,Mildenlargement:2cmundertherib轻度肿大:肋下2cmModerateenlargement:notexceedthelevelofumbilicus中度肿大:不过脐Severeenlargement:exceedthelevelofumbilicusormidline高度肿大:过脐或中线,1,2,3,57,SpleenEnlargementMeanings脾脏肿大的意义,Mildenlargement:typhoidfever,hepatitis,malaria,endocarditis,sepsis轻度肿大:伤寒肝炎疟疾心内膜炎败血症Moderateenlargement:hepatocirrhosis,aftermalaria,lymphoma,chroniclymphocyticleukemia,中度肿大:肝硬化疟疾后遗症淋巴瘤慢性淋巴白血病Severeenlargement:chronicgranulocyticleukemia,chronicmalaria,medullafibrosis高度肿大:慢性粒细胞白血病慢性疟疾骨髓纤维化,58,PalpationoftheGallbladder胆囊触诊,Technique:sleepingpalpation方法:单手滑行触诊Normal:cannotpalpable正常:不能触及Swelling:smooth,ovalorpear-shapedmassemergingfrombelowtherightcostalmargin,movedbyrespiratory.肿大:右肋下腹直肌外缘触及梨形或卵圆形肿物可随呼吸上下运动,59,PalpableSigns胆囊触诊征象,Tenderness:painfeelingingallbladderpointwheninspiration胆囊触痛征:吸气时胆囊点触痛Murphyssign:tendernessstopsinspirationusuallybyacutecholecystitis莫非氏征:胆囊触痛致吸气中止提示急性胆囊炎Courvoisierssign:gallbladderswellingaccompaniedjaundicebutnotenderness,usuallybycarcinomaofheadofpancreas.库瓦西耶征:胆囊肿大无触痛伴黄疸提示胰头癌,60,MurphysSign莫非氏征,Technique:Holdyourfingersundertheliverborder.手指放于肝脏下缘Positivesign:Asthedescendingliverpushestheinflamedgallbladderontotheexamininghand,thepersonfeelssharppainandabruptlystopsinspirationmidway.阳性:吸气时肝脏和胆囊下移手指触及炎性胆囊时被检者因剧痛中止吸气,61,MechanismsofDistensionoftheGallbladder胆囊肿大的机制,NormalgallbladderNotpalpable,MucoceleofG.BStoneinneckNon-dilatedductsPalpabledistendedgallbladder,CarcinomaofheadofpancreasDilatedductsDilatedG.BLiverdiffuselydistended,62,Whenthegallbladderispalpablethejaundiceisunlikelytobeduetostones.Thegallbladderwall,inthepresenceofgallstones,wouldbefibroticandnon-distensible.胆囊结石时胆囊壁常有纤维化不易扩大胆囊肿大伴黄疸多与胆囊结石无关Obstructivejaundicewithoutapalpablegall-bladderdoesnotnecessarilyimplythatthejaundiceisduetostones.Astoneintheneckofthegall-bladdermaycauseadistendedmucoceleofthegall-bladder.阻塞性黄疸不伴胆囊肿大不一定提示结石所致黄疸胆囊颈结石可引起胆囊黏液充盈扩大,63,PathologicalFindings异常征象,Gallbladderswellingaccompaniedwith胆囊肿大伴有Tenderness:inflammation触痛:胆囊炎Jaundice:biliaryobstruction黄疸:胆管阻塞Hardness:stone,carcinoma实性感:结石癌肿Murphyssign:inflammation莫非氏征:急性炎症,64,PalpationofthePancreas胰腺触诊,Technique:sleepingpalpation检查方法:滑行触诊Normal:nopalpable正常:不能触及Enlarged:levelzostermassinepigastricorlefthypochondrium胰腺肿大:上腹中部或左上腹横行带状肿块,65,DiseaseoftheEnlargedPancreas肿大胰腺常见疾病,TendernessandAbdominalmuscletoneincrease:acutepancreatitis压痛及腹肌紧张:急性胰腺炎Blueskininflanks:hemorrhageandnecrosisofpancreas腰部皮肤发蓝:胰腺出血坏死Rigidityandfixation:chronicpancreatitis质硬固定:慢性胰腺炎Rigidityandnode:pancreascarcinoma质硬凸凹不平:胰腺癌smoothcysticandnotenderness:pancreaticpseudocyst囊性表面光滑无压痛:胰腺假性囊肿,66,PalpationoftheKidney肾脏触诊,Method:bimanualpalpation触诊方法:双手触诊法Specialsign:smooth,circlebody特征:光滑钝圆形物Normal:nonpalpable正常:触不到Palpablekidneymaysuggestabnormal触及肾脏提示异常,67,MeaningofPalpableKidney触及肾脏的意义,Down-shiftin