消化肾脏泌尿腹部理学检查

消化肾脏泌尿腹部理学检查TheAbdomenExtendsfromxiphoidprocesstothesymphysispubisRectusabdominisInternalandexternalobliquesLineaalbaInguinalligamentContainsvitalorgansMajorAbdominalOrgansQuadrantsoftheabdomenSegmentsoftheabdomenmid-clavicularlinesubcostalplaneanteriorsuperioriliacspineLocalizationofVisceralPainExaminationoftheAbdomenGoodlightandadequateexposure(xiphoidprocesstosymphysispubis,groinvisible)RelaxedpatientPatientsupine,armsatside,kneesslightlyflexedEmptybladderExaminationoftheAbdomenAskpatienttopointtoanyareaofpainExaminenon-painfulsidefirst“Visualize”underlyinganatomyWatchpatient’sfaceforsignsofdiscomfortduringtheexaminationPhysicalExaminationSequence: --Inspection --Auscultation --Percussion --PalpationInspectionoftheAbdomenSkin: color,ecchymosis,rashes,lesions,striae,scars,dilatedveinsContours: flat,rounded scaphoid,protuberantSymmetry: distention localbulgesInspectionoftheAbdomenUmbilicus: location displacement inflammationMusculature: masses hernia separationSurfacemotion: peristalsis pulsationsAuscultationoftheAbdomenBowelsoundswarmeddiaphragmallquadrantsfrequencyandcharacterclicksandgurgles,borborygmanormoactive:5-34perminute5continuousminutestoestablishabsenceAuscultationoftheAbdomenVascularsounds --Bruits

warmedbell overaorta,renal,iliac,andfemoralarteries overliver(HCCoracutealcoholichepatitis) --Venoushums warmedbell overepigastricandperiumbilicalarea(increased collateralcirculationbetweenportalandsystemic venoussystemsFrictionrubs overliverandspleen(perihepatitisorperisplenitis)PercussionoftheAbdomenPercussion:LiverLiverspan --rightmiddleclavicular line --fromtympanyto dullness,thenfrom resonancetodullness --6-12cm

Percussion:Spleen--posteriortoleftMAL smallareaofdullness from6thto10thribs--lowestICS(9th)inleft AAL:Traub’sspace remainstympanic beforeandafterdeep breathbypatientPercussion:kidneyCVanglepaininfectionormusculo-skeletalcausesPalpationStandatpatient’sside,usuallyright,withpatientinsupinepositionBendingpatient’skneesmayhelprelaxmusclesProceedinasystematicmannerPalpationoftheAbdomenLightpalpation --all4quadrants --1cmdeep --identifymuscular resistance,superficial massesPalpationoftheAbdomenDeeppalpation --all4quadrants --upto4cmdeep --delineatesorgans anddetectsdeeper massesDeepPalpationCharacterizemassesby:

location

size

shape

consistency

tenderness

pulsation

mobility

movementwithrespiration

superficialversusintra-abdominalPalpation:Liverplacelefthandbehindpatient,paralleltoandsupportingtheright11thand12thribs,placerighthandonpatient’srightabdomenaskpatienttotakeadeepbreathFeelforthelowerborderatrightcostalmarginIffelt,shouldbesmooth,firm,evenandnontenderFeelfornodules,tendernessandirregularityPalpation:LiverHookingtechnique: --standtorightof patient’schest,place bothhands,sideby side,ontheright abdomenbelowthe costalmargin --askpatienttotakea deepbreathPalpation:GallbladderbelowlivermarginatlateralborderoftherectusabdominismuscleusuallyimpalpableMurphy’ssign

Courvoisier’slaw

Palpation:Spleenwithlefthandreachoverandaroundpatienttosupportandpressforwardhislowerleftribcage,withrighthandbelowleftcostalmarginandpressintowardspleenpatientonhisrightsideandhislegsflexedathipsandkneesPalpation:Kidneyforrightkidney:lefthandbehindandsupportpatient’srightloin,righthandbelowrightcostalmargin,pressbothhandsfirmlytogetherfirm,smoothandnontenderleftkidneyusuallyimpalpableEnlargementhydronephrosis,cystortumorPalpation:AortaslightlyleftofthemidlinemidwaybetweenxiphisternumandumbilicusfeltinthinpatientAdditionalProceduresinAbdominalAssessmentMcBurney’spointAscitesAssessmentShiftingdullnessFluidwavePuddlesignNoneofthemarespecificorcompletelyreliable

ShiftingdullnessFluidwavePuddlesignReboundTendernesstodetermineperitonealirritationperformedatendofexaminationpressdeeplyandremovefingersquicklysharp,stabbingpain

Rovsing’ssignIfpalpationofthelowerleftquadrantofaperson'sabdomenresultsinmorepainintherightlowerquadrant,thepatientissaidtohaveapositiveRovsing'ssignandmayhaveappendicitisPhysicalexamination-PenisInspection1.Theskin2.Theprepuceorforeskin3.Theglans-ulcer,scar,nodule

orsignofinflammation4.Theurethralmeatus-size,

location,dischargePalpation-tendernessorinduration,sizeandcontour!Usegloves!Remembertoreplacethe

retractedforeskin

PhysicalExamination-

ScrotumanditscontentsPhysicalExamination-HerniaInspectionbulgesininguinalandfemoralareasPalpation

Indirect,direct,femoralhernia,reducible,incarcerated,strangulatedPhysicalExamination–

rectalexamination

Inspectionbulging,hairyskinordiscolorationorscarinsacralarealumps,ulcers,inflammation,warts,fissures,rashesorexcoriationinperianalareas.PalpationPerianalsensation,bulbocavernousreflexThetonicityoftherectalsphincterProstate-size,shape,consistency,nodules,induration,asymmetry,tendernessSeminalvesiclesPeritonealcavity-rectalshelf,tendernessPatientStandingAndBentOverTheExaminingTable

Knee-chestpositionProstateexamination(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旳姿勢、表情及外觀?()3.注意學生做視診時，是否有檢查腹部旳外形(凹陷或平坦或膨脹)，肚臍突出或凹陷，有無手術痕跡，有無腫塊，有無靜脈浮起或紫斑