消化肾脏泌尿腹部理学检查.ppt

PhysicalExaminationoftheAbdomenandMaleGenitalOrgan TheAbdomen ExtendsfromxiphoidprocesstothesymphysispubisRectusabdominisInternalandexternalobliquesLineaalbaInguinalligamentContainsvitalorgans MajorAbdominalOrgans Quadrantsoftheabdomen Segmentsoftheabdomen mid clavicularline subcostalplane anteriorsuperioriliacspine LocalizationofVisceralPain ExaminationoftheAbdomen Goodlightandadequateexposure xiphoidprocesstosymphysispubis groinvisible RelaxedpatientPatientsupine armsatside kneesslightlyflexedEmptybladder ExaminationoftheAbdomen AskpatienttopointtoanyareaofpainExaminenon painfulsidefirst Visualize underlyinganatomyWatchpatient sfaceforsignsofdiscomfortduringtheexamination PhysicalExamination Sequence Inspection Auscultation Percussion Palpation InspectionoftheAbdomen Skin color ecchymosis rashes lesions striae scars dilatedveinsContours flat roundedscaphoid protuberantSymmetry distentionlocalbulges InspectionoftheAbdomen Umbilicus locationdisplacementinflammationMusculature massesherniaseparationSurfacemotion peristalsispulsations AuscultationoftheAbdomen Bowelsoundswarmeddiaphragmallquadrantsfrequencyandcharacterclicksandgurgles borborygmanormoactive 5 34perminute5continuousminutestoestablishabsence AuscultationoftheAbdomen Vascularsounds Bruitswarmedbelloveraorta renal iliac andfemoralarteriesoverliver HCCoracutealcoholichepatitis Venoushumswarmedbelloverepigastricandperiumbilicalarea increasedcollateralcirculationbetweenportalandsystemicvenoussystemsFrictionrubsoverliverandspleen perihepatitisorperisplenitis PercussionoftheAbdomen Todetectfluid air andfluid filledorsolidmassesStomachandintestinestympany lowerpitchedforstomach leftloweranteriorribcageandleftepigastricarea Organsandsolidmasses dullnessPercussallquadrantsfordistributionoftympanyanddullness tympanypredominates Percussion Liver Liverspan rightmiddleclavicularline fromtympanytodullness thenfromresonancetodullness 6 12cm Percussion Spleen posteriortoleftMALsmallareaofdullnessfrom6thto10thribs lowestICS 9th inleftAAL Traub sspaceremainstympanicbeforeandafterdeepbreathbypatient Percussion kidney CVanglepaininfectionormusculo skeletalcauses Palpation Standatpatient sside usuallyright withpatientinsupinepositionBendingpatient skneesmayhelprelaxmusclesProceedinasystematicmanner PalpationoftheAbdomen Lightpalpation all4quadrants 1cmdeep identifymuscularresistance superficialmasses PalpationoftheAbdomen Deeppalpation all4quadrants upto4cmdeep delineatesorgansanddetectsdeepermasses DeepPalpation Characterizemassesby location size shape consistency tenderness pulsation mobility movementwithrespiration superficialversusintra abdominal Palpation Liver placelefthandbehindpatient paralleltoandsupportingtheright11thand12thribs placerighthandonpatient srightabdomenaskpatienttotakeadeepbreathFeelforthelowerborderatrightcostalmarginIffelt shouldbesmooth firm evenandnontenderFeelfornodules tendernessandirregularity Palpation Liver Hookingtechnique standtorightofpatient schest placebothhands sidebyside ontherightabdomenbelowthecostalmargin askpatienttotakeadeepbreath Palpation Gallbladder belowlivermarginatlateralborderoftherectusabdominismuscleusuallyimpalpableMurphy ssignCourvoisier slaw Palpation Spleen withlefthandreachoverandaroundpatienttosupportandpressforwardhislowerleftribcage withrighthandbelowleftcostalmarginandpressintowardspleenpatientonhisrightsideandhislegsflexedathipsandknees Palpation Kidney forrightkidney lefthandbehindandsupportpatient srightloin righthandbelowrightcostalmargin pressbothhandsfirmlytogetherfirm smoothandnontenderleftkidneyusuallyimpalpableEnlargementhydronephrosis cystortumor Palpation Aorta slightlyleftofthemidlinemidwaybetweenxiphisternumandumbilicusfeltinthinpatient AdditionalProceduresinAbdominalAssessment AscitesassessmentReboundtendernessIliopsoasmuscletestObturatormuscletestRovsing ssignBallottement McBurney spoint AscitesAssessment ShiftingdullnessFluidwavePuddlesignNoneofthemarespecificorcompletelyreliable Shiftingdullness Fluidwave Puddlesign ReboundTenderness todetermineperitonealirritationperformedatendofexaminationpressdeeplyandremovefingersquicklysharp stabbingpain Iliopsoasmuscletest inappendicitis experiencelowerquadrantpain patientattemptstoflexhipwhileexaminerappliespressuretolowerthigh Obturatormuscletest inappendicitisorpelvicabscess experiencepaininthehypogastricarea patientflexesrightlegathipandknee examinerrotatestheleglaterallyandmedially Rovsing ssign Ifpalpationofthelowerleftquadrantofaperson sabdomenresultsinmorepainintherightlowerquadrant thepatientissaidtohaveapositiveRovsing ssignandmayhaveappendicitis Physicalexamination Penis Inspection1 Theskin2 Theprepuceorforeskin3 Theglans ulcer scar noduleorsignofinflammation4 Theurethralmeatus size location dischargePalpation tendernessorinduration sizeandcontour Usegloves Remembertoreplacetheretractedforeskin PhysicalExamination Scrotumanditscontents Inspection1 Skin nodules inflammation ulcers2 Scrotalcontour swelling lumpsorveinsPalpation1 Testes size shape consistency tenderness nodules2 Epididymis3 Spermaticcordandvasdeferens nodulesorswellingTransillumination PhysicalExamination Hernia InspectionbulgesininguinalandfemoralareasPalpationIndirect direct femoralhernia reducible incarcerated strangulated PhysicalExamination rectalexamination Inspectionbulging hairyskinordiscolorationorscarinsacralarealumps ulcers inflammation warts fissures rashesorexcoriationinperianalareas PalpationPerianalsensation bulbocavernousreflexThetonicityoftherectalsphincterProstate size shape consistency nodules induration asymmetry tendernessSeminalvesiclesPeritonealcavity rectalshelf tenderness PatientStandingAndBentOverTheExaminingTable Knee chestposition Prostateexamination 一 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 二 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的姿勢 表情及外觀 3 注意學生做視診時 是