消化肾脏泌尿腹部理学检查

PhysicalExaminationof

theAbdomenand

MaleGenitalOrganTheAbdomenExtendsfromxiphoidprocesstothesymphysispubis01Rectusabdominis02Internalandexternalobliques03Lineaalba04Inguinalligament05Containsvitalorgans06MajorAbdominalOrgansQuadrantsoftheabdomenSegmentsoftheabdomenmid-clavicularlinesubcostalplaneanteriorsuperioriliacspineLocalizationofVisceralPainGoodlightandadequateexposure(xiphoidprocesstosymphysispubis,groinvisible)RelaxedpatientPatientsupine,armsatside,kneesslightlyflexed123Emptybladder4ExaminationoftheAbdomenAskpatienttopointtoanyareaofpain01Examinenon-painfulsidefirst02“Visualize”underlyinganatomy03Watchpatient’sfaceforsignsofdiscomfortduringtheexamination04ExaminationoftheAbdomenSequence:-Inspection-Auscultation-Percussion-PalpationPhysicalExaminationInspectionoftheAbdomencolor,ecchymosis,rashes,lesions,striae,scars,dilatedveinsSkin:flat,roundedscaphoid,protuberantContours:distentionlocalbulgesSymmetry:InspectionoftheAbdomenUmbilicus:locationdisplacementinflammationMusculature:massesherniaseparationSurfacemotion:peristalsispulsationsAuscultationoftheAbdomenBowelsoundswarmeddiaphragmallquadrantsfrequencyandcharacterclicksandgurgles,borborygmanormoactive:5-34perminute5continuousminutestoestablishabsenceAuscultationoftheAbdomenVascularsounds --Bruits warmedbell overaorta,renal,iliac,andfemoralarteries overliver(HCCoracutealcoholichepatitis) --Venoushums warmedbell overepigastricandperiumbilicalarea(increased collateralcirculationbetweenportalandsystemic venoussystemsFrictionrubs overliverandspleen(perihepatitisorperisplenitis)PercussionoftheAbdomenTodetectfluid,air,andfluid-filledorsolidmassesStomachandintestinestympany(lowerpitchedforstomach–leftloweranteriorribcageandleftepigastricarea)Organsandsolidmasses:dullnessPercussallquadrantsfordistributionoftympanyanddullness:tympanypredominatesPercussion:LiverLiverspan --rightmiddleclavicular line --fromtympanyto dullness,thenfrom resonancetodullness --6-12cmPercussion:Spleen01-posteriortoleftMAL02smallareaofdullness03from6thto10thribs04-lowestICS(9th)inleft05AAL:Traub’sspace06remainstympanic07beforeandafterdeep08breathbypatientPercussion:kidneyCVanglepaininfectionormusculo-skeletalcausesPalpationStandatpatient’sside,usuallyright,withpatientinsupinepositionBendingpatient’skneesmayhelprelaxmusclesProceedinasystematicmannerPalpationoftheAbdomenLightpalpation01-all4quadrants02-1cmdeep03-identifymuscular04resistance,superficial05masses06PalpationoftheAbdomenDeeppalpation-all4quadrants-upto4cmdeepanddetectsdeepermasses-delineatesorgansCharacterizemassesby:1location2size3shape4consistency5tenderness6pulsation7mobility8movementwithrespiration9superficialversusintra-abdominal10DeepPalpationPalpation:Liverplacelefthandbehindpatient,paralleltoandsupportingtheright11thand12thribs,placerighthandonpatient’srightabdomenFeelforthelowerborderatrightcostalmarginaskpatienttotakeadeepbreathIffelt,shouldbesmooth,firm,evenandnontenderFeelfornodules,tendernessandirregularityPalpation:Liver01Hookingtechnique:02-standtorightof03patient’schest,place04bothhands,sideby05side,ontheright06abdomenbelowthe07costalmargin08-askpatienttotakea09deepbreathPalpation:GallbladderbelowlivermarginatlateralborderoftherectusabdominismuscleMurphy’ssignusuallyimpalpableCourvoisier’slawPalpation:Spleenwithlefthandreachoverandaroundpatienttosupportandpressforwardhislowerleftribcage,withrighthandbelowleftcostalmarginandpressintowardspleenpatientonhisrightsideandhislegsflexedathipsandkneesPalpation:Kidneyforrightkidney:lefthandbehindandsupportpatient’srightloin,righthandbelowrightcostalmargin,pressbothhandsfirmlytogetherleftkidneyusuallyimpalpablefirm,smoothandnontenderEnlargementhydronephrosis,cystortumor1234Palpation:Aortaslightlyleftofthemidline01midwaybetweenxiphisternumandumbilicus02feltinthinpatient03AdditionalProceduresinAbdominalAssessmentMcBurney’spointAscitesassessment01Reboundtenderness02Iliopsoasmuscletest03Obturatormuscletest04Rovsing’ssign05Ballottement06FluidwavePuddlesignNoneofthemarespecificorcompletelyreliableShiftingdullnessAscitesAssessmentShiftingdullnessFluidwavePuddlesignReboundTendernesstodetermineperitonealirritationperformedatendofexaminationpressdeeplyandremovefingersquicklysharp,stabbingpain

Iliopsoasmuscletest -inappendicitis -experiencelowerquadrantpain -patientattemptstoflexhipwhileexaminerapplies pressuretolowerthigh Obturatormuscletest -inappendicitisor pelvicabscess -experiencepaininthe hypogastricarea -patientflexesrightleg athipandknee,examinerrotatestheleglaterallyandmediallyRovsing’ssignIfpalpationofthelowerleftquadrantofaperson'sabdomenresultsinmorepainintherightlowerquadrant,thepatientissaidtohaveapositiveRovsing'ssignandmayhaveappendicitisPhysicalexamination-PenisInspection1.Theskin2.Theprepuceorforeskin3.Theglans-ulcer,scar,nodule

orsignofinflammation4.Theurethralmeatus-size,

location,dischargePalpation-tendernessorinduration,sizeandcontour!Usegloves!Remembertoreplacethe

retractedforeskin

PhysicalExamination-

ScrotumanditscontentsInspection1.Skin-nodules,inflammation,ulcers2.Scrotalcontour–swelling,lumpsorveinsPalpation1.Testes:size,shape,consistency,tenderness,nodules2.Epididymis3.Spermaticcordandvasdeferens:nodulesorswellingTransilluminationPhysicalExamination-HerniaInspectionbulgesininguinalandfemoralareasPalpationIndirect,direct,femoralhernia,reducible,incarcerated,strangulatedPhysicalExamination–rectalexaminationInspectionbulging,hairyskinordiscolorationorscarinsacralarealumps,ulcers,inflammation,warts,fissures,rashesorexcoriationinperianalareas.PalpationPerianalsensation,bulbocavernousreflexThetonicityoftherectalsphincterProstate-size,shape,consistency,nodules,induration,asymmetry,tendernessSeminalvesiclesPeritonealcavity-rectalshelf,tendernessPatientStandingAndBentOverTheExaminingTableKnee-chestpositionProstateexamination()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?0102(一)整體評估()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，是否有檢