诊断学英文课件：The Physical Examination of Abdomen （3）

1、,The Physical Examination of Abdomen （3）,Palpation -the most important method in examination of abdomen.,The preparation of patient: A)urination.B) the patient should be in supine position, low-pillow, patients arms keep relax at the two sides of the body, flex his thighs and knees, relax his abdomi

2、nal muscles.C) abdominal respiration.,According to different parts and organs of examination,the patient can be in right/left lateral decubitus position such as the examination of spleen/liverstanding position such as the examination of kidney.elbow-knee position tumor or ascites,Special positions,T

3、he preparation of doctor A)keep the hands warm, cut your nails.B)the doctor stands at the right side of patient, using your palmar instead of fingersC)examining gently and lightly from superficial to deep, and from healthy part to lesion area.D) observe the reaction and expression of patient.,The se

4、quence of palpation usually the sequence of palpation is contraclock direction: left lower left lumber left upper epigastric right upper right lumber right lower hypogastric umbilical.,The palpating methods1、light palpation 1cm(wall lesion)2、deep palpation 2cm(organ problem) (1)deep press palpation

5、(2)deep slipping palpation (3)bimanual palpation (4)ballottement (5)hook technique,The contents of palpation 1.abdominal wall tensity 2.tenderness and rebound tenderness 3.abdominal organs4.abdominal masses 5.fluid thrill 6.succussion splash,1.abdominal wall tensity (1). Increased tensity of general

6、ized abdominal muscles A)ascites or pneumoperitoneum.B)acute diffuse peritonitis caused by gastrointestinal perforation. board-like rigidity,C)Dough kneading sensation TB/chronic inflammatory peritonitis carcinomatous peritonitis,(2)Increased tensity of located abdominal muscles,organ inflammation r

7、ight upper abdomen acute cholecystitis left upper abdomenacute pancreatitis right lower abdomen acute appendicitis/gastric perforation,Inflammationincreased tensity,(3)Decreased tensity of abdominal wall decrease : chronic consumptive diseasetapping ascites elder multiparadisappear:myasthenia gravis

8、 spinal cord trauma,2.Tenderness and rebound tenderness,From the lesion of the wall or the cavity Inflammation Congestion Tumor Rupture Torsion Irritation of abdominal wall The part of tenderness is usually the location of lesion.,tenderness location,McBurney point（麦氏点）Rovsing sign（罗夫辛征）iliopsoas si

9、gn（腰大肌征）,appendicitis or cecitis,Rebound tenderness (located & diffused),Peritoneal irritation sign: tenderness Rebound tenderness muscle tonus,Peritonitis triad,3.Palpation of the organs 1). palpation of the liver,palpation with one hand bimanual palpation hook method ballottement,(1) palpation wit

10、h one hand -Used usually,Key points: Closed finger hand(Index finger front radial side) Finger placed Parallel to the costal margin Following the breath Along right midclavicular line and anterior midline Beginning: 2-3cm below hepatic dullness(or the Anterior superior iliac spine plane) Measure the

11、 distance to costal margin and xiphoid (cm),(2)bimanual palpationwhen it is difficult to palpate, this method may be used,(3)hook method used for thin patient or children(both hands),(4)ballottement(floating and sinking palpation) used for massive ascites,When you palpate the liver you should pay sp

12、ecial attention to the following items (1) size (2) consistency (3) contour margin (4) tenderness (5) pulsation (6) friction sensation (7) hepatojugulor reflux (8) liver thrill,(1). The size of livernormal sizenot palpable or palpable within 1 cm below the costal margin 3 cm below the xiphoid proces

13、sprolapse of liver,hepatomegaly diffuse hepatitis fatty liver early cirrhosis of liver hepatic congestion Budd-Chiari syndrome leukemia parasites diseaselocated enlargement of liver hepatic cyst hepatic abscess tumor,shrinking of liver acute liver necrosis cirrhosis of liver,(2)Consistency the consi

14、stency of liver is divided into 3 degrees hard as like frontalis - - cirrhosis carcinoma tough as like nose - acute hepatitis , fatty liver soft as like lips - normal liver,fluctuation,(3) Contour and margin normal liver: the surface is smooth and margin is regular,abnormal blunt nodular bulge lobul

15、ated,(4) tenderness normal liver: no tenderness Cause: inflammation or liver capsule stretched light: hepatitis ,congestion severe: hepatic abscess,(5) Pulsation normal liver: no pulsation conductive pulsation: aneurysm expansive pulsation:tricuspid incompetence,(6) friction sensation perihepatitis

16、(7) liver thrill: echinococcosis,(8) hepatojugulor reflux sign,(8) hepatojugulor reflux sign Key points: 1.Avoid Valsalva manoeuvre(deep breath,then hold that),because it will decrease the returned blood volume. 2. Palm presses the liver zone for 10s. 3.Open the mouth,and breathe calmly. 4.Observe t

17、he jugular vein.,Right heart failure,pericardial effusion,2). Palpation of spleen the position of the patient supine right lateral decubitus palpating methods palpation with single hand bimanual palpation ballottement,Key points: Vertical to the costal margin Usually from the umbilicus plane Followi

18、ng the movement of breath,Supine position -bimanual palpation,right lateral decubitus position bimanual palpation,Splenometry I line (A-B line) midclavicular line most usually used II line (A-C line) the longest line III line (D-F line)“+” cross anterior median line“-” doesnt cross,Splenomegaly degr

19、eemild:2 cm acute or chronic hepatitis, typhoid fevermoderate: 2 cm umbilicus horizon cirrhosis of liver chronic hemolytic jaundice severe:heavily below umbilicus or across the middle linechronic granulocytic leukemia myelofibrosis,Some organs may be misapprehend the spleen (1) enlargement of left k

20、idney lower extreme - blunt edge (2)enlargement of left lobe of liver no notch (3) splenic flexure of colon : irregular shape(4)cyst of pancreatic tail no movement following breath,3).Palpation of the gallbladder,Observe the enlargement and tenderness,Murphys sign acute cholecystitis Courvoisiers si

21、gn pancreatic carcinoma,4). Palpation of kidney,4). Palpation of kidney bimanual palpation to palpate right kidney,bimanual palpation to palpate left kidney,normal: not palpable palpable: (1) nephroptosis 肾下垂 1/2kindey palpable smooth surface middle hard, tenderness (-) (2)wandering kidney (3) enlar

22、gement of kidney hydronephrosis pyonephrosis tumor Polycystic Kidney,Tenderness points,hypochondrium point,Tenderness points kidney urinary tube point (1) upper ureter point (2) middle ureter point ureteritis ureterolithiasis (3) costovertebral(4) costolumber pyelonephritis kidney TB pyelolithiasis,

23、Costovertebral point,Costolumber point,5). Palpation of bladder,Normal: empty not palpable distended: palpable round fluid-filled smooth disappear after urination seen in urethremphraxis, myelopathy, unconsciousness, after anesthesia, retention of urine,6). Palpation of pancrease,6). Palpation of pa

24、ncrease,Normal: not palpable epigastric tenderness: acute pancreatitis epigastric cystic mass, under the liver, no movement, smooth, no tenderness pancreatic pseudocyst,4. Palpation of masses,Normal structure pathologic mass,the masses of abdomen may be caused by,enlarged organ ectopic organ cyst ca

25、rcinoma inflammatory tissues enlarged lymph nodes,(1)Normal structure of abdomen,1. rectus abdominis(vest line) 2. tendinea inscriptio 3. lower pole of the right kidney 4. cecum 5. lumber vertebral body 6. filling bladder 7. ventral aorta 8. transverse colon 9. sigmoid colon 10.sacral promontory 11.

26、 pregnant uterus 12.xiphoid process,12,(1)Normal structure of abdomen,A:aorta B:bladder C:cecum D:descending/sigmoid colon E:ensiform process,(2).Abnormal mass of abdomen when you palpate the mass of abdomen you should describe the location size contour consistency tenderness mobility pulsation,The

27、location of mass The mass usually originates from nearby organ. If the location of mass is variable, the mass may originate from omentum, mesentery, or with pedicle.,big masses without intestinal obstruction, the mass originate from mesentery peritoneum omentum postperitoneum,The size of mass The ma

28、ss should be measured with a ruler to see how big it is, but sometimes the measurement is difficult, such as deep masses, small masses. so you can estimate the size of mass, comparing with something like peanut, bean, egg, fist, babys head and so on.,Big masses usually indicate cyst such as ovarian

29、cyst, hepatic cyst or polycystic kidney. Intestinal tumors usually accompany with intestinal obstruction. Masses with variable size indicate spasm of intestinal segment.,The contour of mass the boundary of masses is clear or not the surface is smooth or not the margin is sharp or blunt round and smo

30、oth mass indicate a cyst, Irregular, nodular, hard mass indicate malignant tumor A soft cystic mass in right hypochondrial region indicate distended gallbladder A mass with notch in left upper quadrant indicate spleen,The consistency of mass soft mass cyst, abscess middle hard inflammatory mass hard

31、 tumor the tenderness of mass severe tenderness inflammatory mass light tenderness tumor,The mobility of mass a mass moves with respiration it maybe from liver, spleen, stomach, kidney, gallbladder or transverse colon a mass can be moved with hand it may be from stomach, intestine or mesentery, A ma

32、ss can be moved easily and widely it may be from a tumor with a stalk wandering kidney wandering spleen A mass can not be moved it may be from postperitoneal or inflammatory mass,The pulsation of mass abdominal aneurysm or a mass next to the aorta enlargement of liver with pulsation tricuspid valve

33、incompetence,5. Fluid thrills with the patient in supine position, the examiners left hand is placed on the patient s right flank, an assistant (another person) places one hand on the middle of the abdomen to prevent the transmission of any wave through the tissues of the abdominal wall,The examiner

34、ss right hand then lightly taps the left flank of the patient, in the presence of a significant amount of ascites(above 3000-4000ml), a wave will be transmitted through the fluid to the examiners left hand as a sharp impulse.,6. Succussion splash,Succussion splashthis examining method can check for

35、gastric retention. If succussion splash is positive after meal 6-8 hours indicating pyloric obstruction or gastric dilatation.,点击添加文本,点击添加文本,点击添加文本,点击添加文本,Clinical cases,点击添加文本,点击添加文本,点击添加文本,点击添加文本,CASE 1,male，65yrs Chief complain :continuous epigastric pain for five years,nausea and vomiting for a

36、month. Present history：He felt repeated upper abdominal pain for five years.The position lied below the xiphoid process, dull pain.It often happened 1 hour after meals and the symptoms became obvious in winter and spring. 1 months ago he started nausea and vomiting stomach contents 1-2hours after me

37、als accompanied with abdominal distention. Vomiting had a bad smell.He put out black stool a week ago,2-3times/d.He felt weak and dizzy.There was no fever and he lost weight of 5kg.,点击添加文本,点击添加文本,点击添加文本,点击添加文本,Physical examination,Nutritional status, face:wasting and anemia Skin and mucosa:pale Supe

38、rficial lymph nodes: enlarged left subclavian lymph nodes, tenacious, no tenderness Conjunctiva and sclera：Conjunctiva pale, sclera slightly yellow Abdomen inspection: contour:subxiphoid left local protuberance ；gastric pattern. Abdomen palpation ： subxiphoid left tendernessmass:epigastric region(le

39、ft), d=5cm,irregular shape,hard、mild tenderness,no mobility Succussion splash,点击添加文本,点击添加文本,点击添加文本,点击添加文本,Primary diagnosis:,Gastric ulcer，canceration？ Pyloric obstruction Upper gastrointestinal hemorrhage,CASE 1,After he was accepted to the hospital,severe abdominal pain emerged with profuse sweati

40、ng.The pain got more severe when the position changed. Abdomen physical examination： inspection： abdominal respiratory movement decreased auscultation ：bowel sound disappeared palpation： tenderness,rebound tenderness,muscle tonus(+) percussion：tympany，liver dullness disappeared,点击添加文本,点击添加文本,点击添加文本,

41、点击添加文本,Diagnosis:GI tract perforation,点击添加文本,点击添加文本,点击添加文本,点击添加文本,CASE 2,male，65yrs Chief complaint:feeling weak for half a year,abdominal distention for a month. Present history： Six months ago the onset of fatigue and loss of appetite appeared, then the condition progressively aggravated. He did not get diagnosis and treatment. 1 months ago he felt abdominal distension, without nausea and vomiting.The stool could not be shaped, 3-4 times a day, with urine color yellow.The urine volume decreased, 24h urin