诊断学腹部检查(英文)

1、Abdominal Examination Question : What do you think is the better or more appropriate sequence of abdominal examination compared with that in other areas? And why? Normal sequence: inspection, palpation, percussion, and auscultation Abdominal examination: inspection, auscultation, percussion, and pal

2、pationconvenient to perform the auscultation after the auscultation of the heart.avoid the negative impacts of palpations on auscultation of bowel sounds （ alteration of peristalsis） Anatomic Landmarks xiphoid (ensiform) process(剑状突起) of sternum(胸骨) costal margin肋弓缘 umbilicus脐 anterior superior ilia

3、c spine髂前上棘 inguinal ligament 腹股沟韧带 superior margin of os pubis耻骨上缘 anterior midline/midabdominal line 腹中线 lateral border of rectus muscles 腹直肌外缘 symphysis pubis (耻骨联合)Commonly used methods of subdividing the abdomen Zones of abdomen Four quadrants Nine sectionsThe anterior surface of the abdomen is

4、 divided into four quadrants by two intersecting linesone extending vertically from the xiphoid, through the umbilicus, to the symphysis pubis the other extending horizontally across the abdomen at the level of the umbilicus. Right lower quadrantLeft upper quadrantRight upper quadrantLeft lower quad

5、rantTwo imaginary, parallel, horizontal linesacross the lowest border of the costal margin across the anterior superior iliac spineTwo imaginary, parallel, vertical lines across the middle point of linking line formed by left anterior superior iliac and midabdominal line across the middle point of l

6、inking line formed by right anterior superior iliac and midabdominal lineLeft hypochondrial region 左季肋部Left lumber region 左腰部 Left iliac region 左髂部Right hypochondrial region右季肋部Right lumber region 右腰部Right iliac region 右髂部Epigastric region 上腹部Umbilical region 脐部Hypogastric region下腹部Question : What a

7、re the distinct benefits and disadvantages in Four-quadrant and Nine-section methods? Four-quadrant simple, practical, rough, imprecise (tenderness of epigastric regin)Nine-section elaborates more clearly and more exactly inconvenient limited scope of left or right hypochondrial region, left or righ

8、t iliac regionInspectionGeneral preparationurinate completely: bladder is emptyrelax abdominal muscles: lie on back with a pillow under head and knees bent expose abdomen completely: from xiphoid process to pubisbreasts should be covered: femaleInspection major contents abdominal contour respiratory

9、 movementsabdominal veinsgastral or intestinal pattern(胃型或肠型)peristalsis(蠕动波)abdominal rash, hernia(疝), striae(纹), etc.InspectionAbdominal Contourwhether the abdomen is symmetrical whether it is bulged or retractedwhether it is indicative of ascites or enclosed mass(包块)Normal abdominal flatness(腹部平坦

10、) abdominal fullness(腹部饱满) abdominal lowness(腹部低平) Abdominal flatness abdomen at the same level or lower as between costal margin and symphysis pubis ask the patient to sit, the lower part of umbilicus can become more or less protruded or bulged abdominal fullness very fat or a child, the abdomen is

11、 a little bit roundThe level of the abdomen higher than that of the surface between costal margin and symphysis pubisabdominal lowness very thin or slender, the level of the abdomen lower than that of the surface between costal margin and symphysis pubis ( little subcutaneous fat) abdominal flatness

12、, fullness, and lowness (normal cases) abdomen obviously protruded or bulged, or exceedingly retracted or depressed (abnormal and usually pathologic) Pathologic conditionsabdominal protuberance (bulge) 腹部膨隆I. Overall/generalized abdominal protuberance/bulge 全腹膨隆 several pathologic factors besides ov

13、erly obesity or physiologic pregnancy i. Peritoneal fluid a large amount of free fluid within the abdomen (ascites) abdominal wall can be lax in supine position fluid can deposit at both lateral sides (the contour just like a frog belly) lies on one side or sits the lower part of abdominal wall will

14、 be bulged ( movement of free fluid) commonly found in ascites complicated by portal hypertension (liver cirrhosis) in long-term ascites, the appearance of the umbilicus is protruded or everted (umbilical hernia) (obesity) the umbilicus is usually deeply inverted Apical belly尖腹 peritonitis or invasi

15、on of cancer cells (abdominal muscle: tense, usu. with the apical shape) a large amount of air accumulating in the cavity of stomach. globular shape ( two sides of lumber region is not obviously protrudent.) ask the patient to move or change the position the shape of abdomen remains globular commonl

16、y found in intestinal obstruction or enteroparalysis(肠麻痹) Peritoneal air 腹腔积气 Pneumoperitoneum气腹 air accumulating in the abdominal cavity commonly found in perforation of gastrointestinal diseases or artificial pneumoperitoneum meant to treat Huge abdominal enclosed mass 腹内巨大包块 usually found in full

17、-term pregnancy, huge ovarian cyst(卵巢囊肿), teratoma, etc. For any generalized abdominal bulge, circumference of abdomen should be measured in centimeters at the level of the umbilicus with a soft tape measure during normal abdominal breathing. Local abdominal bulge局部膨隆 enlarged viscera, tumor, inflam

18、matory enclosed mass, gastrointestinal flatulence(肠胃胀气), hernia, etc. Abdominal concavity/ retraction 腹部凹陷(In supine position) the abdomen at the level much lower than that between costal margin and symphysis pubis abdominal concavity/retraction. two kinds of retraction: overall abdominal retraction

19、 and local abdominal retraction. The former one: of greater significanceI. Overall abdominal concavity/retraction 全腹凹陷 usually found in patients severely emaciated or seriously dehydrated Scaphoid abdomen 舟状腹 the contour of abdomen: just like a boat (anterior abdomen almost approximating to spinal c

20、olumn + arch of rib, iliac crest (髂嵴) + symphysis pubis all apparent) commonly seen in cachexia(恶病质) Local abdominal retraction 局部凹陷 contraction of scar after operation and less common Abdominal WallCullen sign - A bluish discoloration of the umbilicus (occasionally seen after major intraperitoneal

21、hemorrhage)Grey-Turner sign- A similar discoloration of the flanks, (in the absence of trauma) seen following the extravasation of blood from intra-abdominal organs into extraperitoneal sites, as in hemorrhagic pancreatitisabdominal veins Normally, abdominal veins do not appear unless the patient is

22、 thinner or is light-complexioned, or abdominal inner pressure is elevated, ascites, huge abdominal tumor, pregnancy, etc. Prominence of distended abdominal veins(called abdominal wall varicosis(腹壁静脉曲张) : increased collateral circulation obstruction in the portal venous system (portal hypertension)

23、or the obstruction in the superior or inferior vena cava. obvious portal hypertension dilated veins appear to radiate outward from the umbilicus, like the head of medusa(水母) caput medusae(海蛇神头)normal direction of flow in abdominal vessels: away from the umbilicus the upper abdominal veins carry bloo

24、d upward to the superior vena cava; the lower abdominal veins drain downward to the inferior vena cava 胸壁静脉（chest wall vein） 腋静脉(axillary vein)上腔静脉大隐静脉(great saphenous vein)下腔静脉正常情况：脐上向上，脐下向下 If a vein is engorged, the direction of flow can be demonstrated by a simple maneuver.maneuver: placing the

25、index fingers side by side over the vein, pressing laterally, separating the fingers one by one, and observing the time it takes the veins to refill from each direction; The flow of venous blood is in the direction that fills faster. Usually the rate of filling is obviously faster in one direction t

26、han in the other, indicating the direction of flow in that portion of the collateral venous system. In portal hypertension normal flow direction is maintained. In contrast, obstruction of the vena cava alters the flow direction in these veins. 门静脉阻塞: 脐为中心,放射状（胚胎时）脐静脉（出生后闭塞）圆韧带（门脉高压时再通） 脐静脉（经脐孔） 腹壁浅静

27、脉 流向四方 In obstruction of the superior vena cava, the flow direction in the upper abdominal venous collaterals is reversed or downward. In inferior vena cava obstruction the direction is reversed in the lower abdominal veins, and they will drain upward. 上腔静脉阻塞: 脐上向下 下腔静脉阻塞: 脐下向上gastric or intestinal

28、pattern and peristalsis 正常人：一般看不到胃肠型和蠕动波，仅见于经产妇与极度消瘦腹壁松软者。 胃肠道梗阻:出现蠕动波（梗阻近端的胃、肠段饱满而隆起，可显出各自轮廓，称胃型或肠型）幽门梗阻：上腹部逆蠕动。小肠梗阻：不规则隆起，此起彼伏。结肠梗阻：全腹膨隆、宽大肠型。gastral or intestinal pattern(胃型或肠型) and peristalsis(蠕动波)In lean individuals, even in the absence of disease, motility of the stomach and intestines may be

29、reflected in the abdominal wall. When strong contractions are visible through an abdominal wall of average thickness, the possibility of bowel obstruction should be investigated.Reverse peristalsis indicates pyloric stenosis, duodenal stenosis, or malrotation of the bowel. Auscultation of Abdomen bo

30、wel sound Normal 正常：4-5次/分 Active 活跃：10次/分 Hyperactive 亢进：次数多、调高 Decreased 减弱：少于1次/分 Disappeared 消失：3-5分Bowel sounds 肠鸣音Auscultate bowel sounds with diaphragmatic head of stethoscope for at least one minute. If there are no bowel sounds, listen until you hear them or for at least 3-5 minutes. Normal

31、 bowel sounds are a glue-glue-like sound occurring either separately or together, approximately 4-5 times per minute. Pay attention to their frequency, pitch, and intensity. High-pitched (gurgling) sounds with increased frequency are regarded as hyperactivety.Lack of bowel sounds indicates little or

32、 no peristalsis.Bowel sounds 肠鸣音absence of any sound extremely weak + infrequent sounds heard after several minutes: immobile bowel of peritonitis or paralytic ileus (肠梗阻) sounds with a characteristic loud, rushing, high-pitched tinkling quality: in mechanical intestinal obstruction ( distention of

33、the bowel + peristaltic activity proximal to the site of the obstruction)PercussionGeneral percussionAll four quadrants of the abdomen are evaluated by percussion. Light percussion is preferable: produces a clearer tone.Tympany(鼓音) : the most common percussion sound in the abdomen gas collection; ap

34、preciated over the stomach, small intestine, and colon PercussionPercussion of the liverPercussion of the upper border of liver(肝上界) : along the right midclavicular line(右锁骨中线), right midaxillary line(右腋中线), and right scapular line(右肩胛线). The level of the shift from resonance downward into dullness

35、is defined as the upper border of liver. At this level, the liver is covered by lung and the border is also called the relative dullness border of liver(肝相对浊音界).Percussion of the liverThen percussing downward 1-2 intercostal space, the level of the shift from dullness into flatness(实音) is identified

36、 as the absolute dullness border of liver(肝绝对浊音界), without lung covering, and also called the lower border of lung(肺下界). Normally the the upper border of liver is located at the 5th intercostal space along the right midclavicular line, the 7th intercostal space along the right midaxillary line, and

37、the 10th intercostal space along the right scapular line.Percussion of the liverPercussion of the lower border of liver(肝下界) : along the right midclavicular line or anterior midline. The level of the shift from tympany upward into dullness is defined as the lower border of liver.Percussion of liver

38、span (肝上下径)with the patient breathing normally Percussion through the right midclavicular line from resonance over the lung field downward to dullness and from tympany over abdomen upward to dullnessMeasure from upper to lower border of dullness for liver span. It is normally about 9-11 cm in the mi

39、dclavicular line.Percussion of the Liver正常肝脏上界位置:右锁中线第5肋间。肝浊音界扩大:肝癌、肝脓肿等。肝浊音界缩小:暴发性肝炎、肝硬化等。肝浊音界下移:肺气肿、张力性气胸等。肝区叩痛:肝炎、肝脓肿等。肝浊音界消失：消化道穿孔等。Traube semilunar space胃泡鼓音区(9.56cm): 上界：膈肌及肺下缘 下界：肋弓 左界：脾脏 右界：肝左缘 Percussion of the Spleen 正常脾浊音界:左腋中线911肋间,长47cm 前方不超过腋前线 脾浊音区增大:脾肿大 脾浊音区缩小:气胸、胃扩张、肠胀气等。 Normally s

40、plenic dullness percussed between the 9th and the 11th intercostal space along left midaxillary line the scope 4-7cm without passing over left anterior axillary lineThis should be done when splenic enlargement is suspected.percussion of the spleen腋前线presence or absence of free fluid in the abdominal

41、 cavity (ascites)detected by several maneuvers (1) shifting dullness, (2) fluid wave (3) elbow-knee position( puddle test) lie on his back, percuss the abdomen at the umbilicus level from the midabdomen toward left sidetympany at midabdomen (the underlying bowel)dullness at the bilateral flanks (the

42、 accumulation of ascites) When the patient with ascites lies on his back, the fluid will migrate into the flanks, producing dullness laterally. Percussion - shifting dullnessShifting dullnessfind the point where percussion sound of tympany changes into dullness, should hold your pleximeter at that p

43、oint,simultaneously, ask the patient to turn on his right side and then continues to percuss the same point again.Shifting dullness If the sound changes from dullness to tympany, it means that the dullness has been shifted to a more dependent position. This implies that ascites is present. Shifting

44、dullnesspercuss the abdomen toward the right side. find the point where percussion sound changes, and hold your pleximeter at that point, simultaneously, ask the patient to turn on his left side and then continue to percuss the same point again to confirm the shift of dullness. Shifting dullnessA vo

45、lume of free fluid in the peritoneal cavity greater than 1000ml can be detected with this method. amount too little, shifting dullness not be found, ask the patient to take elbow-knee position (puddle test examination in terms of percussion) Elbow-knee position- puddle testElbow-knee positionThe pur

46、pose of elbow-knee position - let the patients umbilicus at the lowest levelpercuss from flanks toward the umbilicusElbow-knee positionIf percussion sound could change from tympany to dullness, it indicates ascites. Elbow-knee positiondetect as little as 120 mL of fluidmany feeble patients cannot co

47、operate in the performance of this test (this method requires the patient to maintain such discomfortable position for several minutes) DifferentiationHuge ovarian cyst a large area of dullness at midabdomen tympany at laterals (bowels could be pushed to the bilateral flanks) The dullness of ovarian

48、 cyst could not shift. DifferentiationRuler pressing test to differentiate huge ovarian cyst from real ascites take the supine position, a hard ruler on the patients abdominal wall horizontally, presses the ruler downward with two hands DifferentiationIf huge ovarian cyst exists, the pulsation of ab

49、dominal aorta will conduct to the ruler via the cyst, leading to rhythmic pulsation of the hard ruler.If free fluid, not cyst, exists in the abdominal cavity, the pulsation of abdominal aorta could not conduct, so the hard ruler has no such rhythmic pulsation.Palpation principle of palpationa)relax

50、the patientb) palpate four quadrants superficially from LLQ counterclockwise c) palpate all areas counterclockwise and superficially from left lower quadrant screening for tenseness(紧张度), tenderness(压痛), masses, etc. d) Examination begins with gentle maneuvers and then palpation occurs more deeply.

51、e) Examiner uses the palms of his hands with fingers together and arm relaxed and forearm on a horizontal plane.f) The examiner presses with his fingers. principle of palpation Using the palmer surface of the fingers, examiner palpates in four quadrants to identify masses, tenderness, pulsations, et

52、c. The abdominal wall should be depressed more than 2 cm. When deep palpation is difficult, examiner may want to use left hand placed over right hand to help exert pressure. To palpate four quadrants deeply 浅部触诊(light palpation) 深部触诊(deep palpation) 深部滑行触诊(deep slipping palpation)： 腹腔包块、器官 双手触诊(bima

53、nual palpation)： 肝、脾、肾、腹腔肿物。 深压触诊 (deep press palpation): 确定腹腔压痛点与反跳痛 冲击（浮沉）触诊(ballottement): 适用于腹部大量积液时肝脾及腹腔包块难以触 及者。触诊基本方法触诊的注意点 对被检查者 1. 仰卧体位、曲膝、垫枕。 2. 腹部充分暴露。 对检查者 1.右侧站立；前臂与腹部表面同一水平 2.先左下逆时针；先正常后异常部位 3.边触诊边观察反应与表情，边谈话，减少患 者紧张 If a mass is suspected, determine its size, contour, mobility, tender

54、ness, smoothness, irregularity, the hardness or softness and listen with stethoscope for a bruit over the mass. If there is tenderness, determine the point of maximal tenderness and distribution.To check for rebound tenderness: palpate deeply at the point of tenderness, pause briefly, then remove th

55、e fingers quickly. Watch the patients face to see whether it hurts. check other areas in the same manner for comparison contents of palpationa)abdominal tenseness腹壁紧张度 In normal persons, abdominal wall is somewhat tense, but usually soft when palpated and easily depressed , and is called abdominal s

56、oftness(腹壁柔软). 腹壁紧张度适中，触之柔软，有一定阻力和弹性对触诊无明显抵抗感pathologic conditions an abnormal or of abdominal tenseness 1) of abdominal tenseness Abdominal tenseness , not accompanyed by muscle spasm, the abdominal contents, as gastrointestinal flatulence(肠胃胀气), artificial pneumoperitoneum(人工气腹), ascites, etc. Boa

57、rd-like rigidity 板状腹 If abdominal wall is palpated as obviously tense, even as rigid as a board, board-like rigidity is so called. 按压腹壁阻力较大，有明显的抵抗感 the spasm of abdominal muscle peritoneal irritation, as the perforation of the gastrointeatinal diseases or rupture of the viscera 急性弥漫性腹膜炎 Dough kneadi

58、ng sensation 揉面感；柔韧感 If abdominal wall is palpated as pliable and tough, and if it has resistance and is not easily depressed, then the examiner feels the sensation of dough kneading.全腹紧张度增加，触之尤如揉面团一样 Usually seen in tuberculosis peritonitis or cancerous peritonitis 慢性炎症对腹壁的刺激，腹膜增厚，肠管、肠系膜粘连 abdomina

59、l tenseness the decrease or disappearance of abdominal muscles tension(张力)；Usually found in chronic deeline(消耗性疾病) or drainage of large amount of ascitesSupplementary:Two types of pain may be elicited by palpation.1. Visceral(内脏的) an organic lesion or functional disturbance within an abdominal viscu

60、s e.g. seen in an obstructive lesion of the intestine (a buildup of pressure and distention of the gut) sveral characteristics: dull, poorly localized, and difficult for the patient to characterize2. Somatic(躯体的；体壁的) the distress noted in painful lesions of the skin sharp, bright, and well localized