醫(yī)學(xué)專題-J腹部檢查B

physicalexamination

腹部(fùbù)檢查(2)

AbdominalExaminationpalpatemass

腹部(fùbù)包塊觸診percussionandauscultation

腹部叩診和聽診signsofcommondiseases

腹部常見疾病征象第一頁，共五十二頁。編輯課件AbdominalMasses

腹部(fùbù)包塊PhysicalmassInabdominalwallInabdominalcavityPathologicalmassswellingoforganInflammatorymassesTumor生理(shēnglǐ)包塊腹壁包塊腹腔包塊病理包塊臟器腫大炎性包塊腫瘤第二頁，共五十二頁。編輯課件PhysicalMasses

生理性包塊Abdominalwall:ventermusculiortendinousintersectionsofmusculusrectusabdominis腹壁:腹直肌肌腹及腱劃Abdominalcavity:lumbarcentrum,sacralpromontory,abdominalaorta,inferiorpoleofrightkidney,transversecolon,sigmoidcolon,cecum腹腔:腰椎體骶骨岬腹主動脈(dòngmài)右腎下極橫結(jié)腸乙狀結(jié)腸盲腸第三頁，共五十二頁。編輯課件PathologicalMasses

病理性包塊Shiftingorswellingofparenchymatousorgan實質(zhì)性臟器腫大Distensionofhollowviscus擴大的空腔臟器Inflammatorymasses(abscessoradhesion)炎性包塊(膿腫或粘連(zhānlián))Tumororcyst腫瘤與囊腫Lymphadenectasis淋巴結(jié)腫大第四頁，共五十二頁。編輯課件CharacteristicsofPalpation

觸診(chùzhěn)要點Location:relationtoorgansSize:diameterinlong,wideandthickContour:shape,marginandsurfaceTexture:soft,firmandhardTenderness:inflammation,liverswellingPulsation:dilativeandconductiveMovability:shiftbyrespirationorhand部位:所在部位與該處臟器多相關(guān)連大小:縱長橫寬深厚可用實物比喻輪廓:形狀邊緣表面質(zhì)地:柔軟中等硬度質(zhì)硬壓痛:炎癥肝腫大搏動:膨脹性和傳導(dǎo)性移動度:隨呼吸(hūxī)移動用手推動第五頁，共五十二頁。編輯課件FluidThrill

液波震顫(zhènchàn)Technique:moveflankwallbyhand

檢查方法:用手推動一側(cè)腹壁Positive:theotherhandfeelsliquidwave

陽性征象:對側(cè)手掌感到液體波動Meaning:large

volumeofascites,usually>3000ml臨床意義:大量腹水(fùshuǐ)在3~4升以上第六頁，共五十二頁。編輯課件PercussionofAbdomen

腹部(fùbù)叩診

organsintheabdomen

臟器叩診(kòuzhěn)fluidintheabdomen

腹水叩診第七頁，共五十二頁。編輯課件OrgansPercussion

臟器(zānɡqì)叩診Percussionnotes:indirectpercussion叩診音:間接叩診Tympany:hollowviscusasTraube’sarea,intestine鼓音:空腔臟器胃泡鼓音區(qū)腸腔Dullnessorflatness:parenchymaviscusasliverorspleen,enlargedbladderoruterus叩音或?qū)嵰?肝臟(gānzàng)和脾臟實質(zhì)臟器增大的膀胱或子宮Knockpain:indirectknockimpressinflammation

叩擊痛:間接叩擊提示炎癥Organs:liver,gallbladder,kidney臟器:肝臟膽囊腎臟第八頁，共五十二頁。編輯課件AbnormalAreaofTympany

鼓音范圍(fànwéi)異常Enlargedarea:intestinalobstruction,perforationofgastrointerstinaltract范圍增大:胃腸高度脹氣胃腸穿孔Reducedarea:swellingofparenchymatousorgan,tumor,ascites范圍縮小:肝脾等臟器極度(jídù)腫大腹腔腫瘤大量腹水第九頁，共五十二頁。編輯課件Traube’sArea

胃泡鼓音界Location:lefthypochondrium

位置:左季肋部

Upperborder:leftlung,diaphragm

上界:左肺下緣膈

Lowerborder:Rib下界:肋弓Rightborder:liver右界:肝臟(gānzàng)Leftborder:spleen左界:脾臟第十頁，共五十二頁。編輯課件Traube’sArea

Abnormal

胃泡鼓音范圍(fànwéi)異常Pathology:contentvariationofstomachandcompressionofneighbororgan機制:胃內(nèi)含氣量變化鄰近器官(qìguān)擴大壓迫Enlarged:gastricdilatation,pylorusobstruction擴大:見于胃擴張幽門梗阻Reduced:swellingsofliverorspleen,leftpleuraleffusion,pericardialeffusion縮小:見于肝脾腫大左側(cè)胸腔積液心包積液第十一頁，共五十二頁。編輯課件DullnessAreaofLiver

肝臟(gānzàng)濁音界Method:percussionalongthelinesofrightmidclavicular,midaxillaryandscapularline方法:沿右鎖骨中線右腋中線右肩胛(jiānjiǎ)線叩診Superiorborder:relativedullnessmarginbetweenliverandlung,it’sfromresonancetodullness,correspondtotopofliver.,肝上界:由肺區(qū)向下叩出肝與肺清音變濁音的相對濁音界相當于被肺遮蓋的肝頂部Inferiorborder:fromabdomentympanyuptoliverdullnessmargin肝下界:由腹部向上叩鼓音變濁音第十二頁，共五十二頁。編輯課件Percussionof

SuperiorandInferiorborder

肝上下(shàngxià)濁音界叩診Superiorborder:intercostalspaceof5thinrightmidclavicular,7thinmidaxillaryand10thinscapularline

肝上界:右鎖骨中線第5肋間右腋中線第7肋間右肩胛(jiānjiǎ)線第10肋間Inferiorborder:costalmargininrightmidclavicularline10thriblevelinrightmidaxillaryline肝下界:右鎖骨中線右季肋下緣右腋中線相當于第10肋骨水平第十三頁，共五十二頁。編輯課件AreaofLiver

肝界范圍(fànwéi)Superiorborder:1~2inter-costalspaceshigherthaninferiorlungborder

肝上界:肺下界的上1~2肋間Inferiorborder:1~2cmhigherthandetectedbypalpation

肝下界:

較觸及的肝界高1~2厘米Liverspaninrightmidclavicularline:9~11cm肝上下徑(右鎖骨中線(zhōngxiàn)):肝上下界間的距離約9~11厘米第十四頁，共五十二頁。編輯課件AbnormalFindings

肝濁音(zhuóyīn)界異常Enlarged:hepaticcongestion,hepatitis,liverabscess,livercarcinoma增大:肝淤血肝炎肝膿腫肝癌(ɡānái)Diminished:livercirrhosisornecrosis縮小:肝硬化肝壞死Disappeared:perforationofgastrointestinaltract,abdominalsurgery消失:代之以鼓音胃腸穿孔腹部手術(shù)后Upwardshifting:fibrosisoratelectasisofrightlung,largevolumeofairorgasinthegastrointestinaltract上移:右肺纖維化右肺不張胃腸脹氣downwardshifting:emphysema,rightsidepleuraleffusion,hepatoptosia

下移:肺氣腫右胸腔積液肝下垂第十五頁，共五十二頁。編輯課件DullnessAreaofSpleen

脾臟(pízàng)濁音界Normalspace正常狀況Location:9th~11thICSalongsideleftmidaxillaryline

位置:左腋中線9~11肋間Diameter:superio-inferior4~7cmtheanteriorbordernotexceedanterioraxillaryline

范圍:上下徑4~7厘米(límǐ)前界不超過腋前線Abnormalfindings叩診異常Enlarged:splenomegaly

范圍增大:脾腫大Diminished:toomuchgasinsurroundingorgans

范圍縮小:胃擴張或腸脹氣第十六頁，共五十二頁。編輯課件DullnessAreaofBladder

orUterus

膀胱(pángguāng)或子宮濁音區(qū)Bladderdullnessarea:physicalsignsinretentionofurine,asmooth,firm,andregularswellingarisingoutofthepelviswhichonecannot“getbelow”andwhichisdulltopercussion.膀胱濁音區(qū):判斷膀胱膨脹程度(chéngdù)恥骨上方圓形濁音區(qū)排尿或?qū)蚝笙terusdullnessarea:estimateenlargeduterussuperiormarginofpubis,notdisappearaftermicturationorurethralcatheterization子宮濁音區(qū):判斷子宮增大程度恥骨上方濁音區(qū)排尿或?qū)蚝蟛幌У谑唔摚参迨?。編輯課件PercussionofAscites

腹水(fùshuǐ)叩診Shiftingdullness:移動性濁音freefluidcausesair-containingguttofloatuptothemostsuperiorposition

液體流動使含氣臟器位于(wèiyú)最高位置volumeofascitesusuallyexceeds1000mlifdetectable

腹水量在1000ml以上Puddlesign:水坑征freefluidinthemostinferiorpositioninelbow-kneeposture肘膝位腹水位于最低位awaytodetectsmallamountsoffluid

用于發(fā)現(xiàn)少量腹水第十八頁，共五十二頁。編輯課件ShiftingDullnessduetoAscites

移動性濁音(zhuóyīn)Dullnessareainbothsideofabdomenwithdorsalposition平臥位時濁音區(qū)位于腹部的兩側(cè)Dullnessareamovestoinferiorwhenmovedposition變換(biànhuàn)體位濁音區(qū)移至下方Dullnessmovementfollowspositionmoved濁音部位隨體位變動而變動第十九頁，共五十二頁。編輯課件PuddleSignduetoAscites

水坑(shuǐkēnɡ)征Inelbow-kneeposture肘膝位Percussiondullnessinumbilicalregion臍部叩診呈濁音(zhuóyīn)Dullnessdisappearwhenpositionmoved變換體位濁音區(qū)消失第二十頁，共五十二頁。編輯課件CommonDiseases

腹水(fùshuǐ)的常見病因Hepatocirrhosis肝硬化Tuberculousperitonitis結(jié)核性腹膜炎Cardiacdysfunction心功能不全Nephropathysyndrome腎病綜合征Primaryormetastasistumor

inabdominalcavity腹腔內(nèi)腫瘤或其他部位(bùwèi)腫瘤腹腔轉(zhuǎn)移第二十一頁，共五十二頁。編輯課件CompareAscitesandOvarianCyst

腹水(fùshuǐ)和卵巢囊腫的鑒別Signs征象Ascites腹水Ovariancyst卵巢囊腫

Dorsalposition仰臥位

Umbilicus臍Percussionsound叩診音

Shiftingdullness移動性濁音Rulerpressingtest尺壓試驗

Sidedistension側(cè)腹膨隆Extrude突出Middletympanysidedullness中部鼓音兩側(cè)濁音Positive陽性Nojumpiness無跳動

Middledistension中腹膨隆Flat平坦Middledullnesssidetympany中部濁音兩側(cè)鼓音Negative陰性Rhythmjumpiness有節(jié)奏跳動第二十二頁，共五十二頁。編輯課件Differenceofdullnesssitesbetweenovariancyst

and

ascites

卵巢囊腫和腹水(fùshuǐ)濁音區(qū)的不同tympanytympanydullnessdullness第二十三頁，共五十二頁。編輯課件PercussionPaininLiverArea

肝區(qū)叩擊(kòujī)痛Technique:putleftpalminliverarea,righthandwithboxingknocktheleftbackofhandwithmiddleforce.方法:將左手掌平放于肝區(qū)右手握拳用中等強度(qiángdù)力量向左手背叩擊Normal:nopainsfeelinginliverarea.正常:肝區(qū)無叩擊痛Abnormal:

theknockpaininliverareaindicateshepatitisandliverabscess叩擊痛陽性:見于肝炎肝膿腫第二十四頁，共五十二頁。編輯課件PercussionPaininGallbladderArea

膽囊(dǎnnáng)區(qū)叩擊痛Technique:knockthesurfaceofgallbladderareawithmiddleforce.方法:叩擊膽囊部位(bùwèi)表面Normal:noknockpain正常:膽囊無叩擊痛Positive:cholecystitis陽性:提示膽囊炎第二十五頁，共五十二頁。編輯課件PercussionPaininKidneyArea

腎區(qū)叩擊(kòujī)痛Technique:sitorsidelie,方法:坐位或側(cè)臥位putleftpalmincostovertebralangle

area,righthandwithboxingknocktheleftbackofhandwithmiddleforce.

用左手掌平放肋脊角及鄰近區(qū)域右手握空拳以中等強度(qiángdù)力量向左手背扣擊Normal:noknockpain正常:腎區(qū)無扣擊痛第二十六頁，共五十二頁。編輯課件CostovertebralAngleTenderness

腎區(qū)叩擊(kòujī)痛陽性Nephritis腎炎(shènyán)Pyelonephritis腎盂腎炎Renaltuberculosis腎結(jié)核Calculus腎結(jié)石Perinephritis腎周圍炎第二十七頁，共五十二頁。編輯課件AuscultationofAbdomen

腹部(fùbù)聽診

bowelsounds腸鳴音

vascularsounds血管(xuèguǎn)雜音

frictionrub摩擦音scratchsound搔彈音

splashingsound振水音第二十八頁，共五十二頁。編輯課件BowelSounds

腸鳴音Principle:peristalticactivityemitsvariousgurglingandbubblingsoundsasairandfluidinterfaceschangewithcontractionwaves.borborygmus:loudprolongedgurgles.定義:腸蠕動腸管氣液體流動產(chǎn)生咕嚕或冒泡音Normal:4~5/min正常:每分鐘4~5

次Abnormal:increased,decreasedandabsence.

異常(yìcháng):活躍和亢進減弱和消失第二十九頁，共五十二頁。編輯課件BowelSoundsIncreased

腸鳴音活躍(huóyuè)和亢進Increased:>10/min:hypermotilestatessuchasacutegastroenteritis,bloodinthesmallbowel活躍:>10次/分(腸蠕動增強)急性腸炎胃腸道大出血服瀉藥(xièyào)饑餓High-pitchedtinkling:intestinalfluidandairunderpressure,asinearlyobstruction亢進:>10次/分(響亮高亢甚至金屬音)機械性腸梗阻第三十頁，共五十二頁。編輯課件BowelSoundsDecreased

腸鳴音減弱(jiǎnruò)和消失Decreased:postlaparotomy,electrolyteimbalance,senileconstipation減弱:1次/3~5分(腸蠕動減弱) 腹膜炎低血鉀老年性便秘(biànmì)

Absence:acuteperitonitis,paralyticileus

onemustlistenforatleastafull3minutesbeforepronouncingthatperistalsishasceased消失:4分鐘以上聽不到(腸蠕動消失)急性腹膜炎麻痹性腸梗阻第三十一頁，共五十二頁。編輯課件VascularSounds

血管(xuèguǎn)雜音Principle:Turbulentflowinadilated,constricted,ortortuousvessel.機制:血管擴張或狹窄產(chǎn)生湍流(tuānliú)Arterymurmur:ejectordraughtinsystolicwithhighpitchandstrongsound.動脈雜音:收縮期噴射性或吹風(fēng)樣音調(diào)高音響強Venousmurmur:continuousmurmurwithlowpitchandebbsound.靜脈雜音:連續(xù)性嗡鳴音調(diào)低音響弱第三十二頁，共五十二頁。編輯課件CommonCause

血管(xuèguǎn)雜音常見病因Artery動脈性Epigastrium:abdominalaortastrictureoraneurism上腹部:腹主動脈狹窄或腹主動脈瘤Umbilicalorintheflanks:renalarterystricture臍周或側(cè)腹部:腎動脈狹窄Righthypochondrium:hepaticarterystrictureusuallycompressedbypancreasorleftlivercancer.右季肋部:肝動脈狹窄常見于胰腺癌肝左葉癌Venous靜脈性Recanalizedumbilicalvein:portalhypertensionaccompaniedvaricosityinabdominalwall

臍周:門靜脈高壓(gāoyā)腹壁靜脈曲張第三十三頁，共五十二頁。編輯課件FrictionRub

摩擦音Principle:irritatedfibrin-ladenperitonealsurfacesgratewithmotion機制:腹膜表面(biǎomiàn)炎性滲出運動摩擦Meaning:seeninlocalizedperitonitis

提示:局限性腹膜炎Technique:heardatcorrespondareaindeeprespiratory

方法:深呼吸時在相應(yīng)部位聽到Clinicalcause:spleeninfarction,spleenandlivercircumferenceinflammation,cholecystitis

病因:脾梗塞脾周圍炎肝周圍炎膽囊炎第三十四頁，共五十二頁。編輯課件ScratchSound

搔彈音Mechanism:soundwaveconductivediversityindiffermediummadenoisealteration.Aidsinstaticborderdefinition機制:聲波在不同介質(zhì)中傳導(dǎo)的差異致聲響改變有助于確定實質(zhì)臟器或液體邊界Technique:putthestethoscopeincentralandthehandscratchtoit,whensoundsuddenlyincreasedindicatetheborder.方法:聽診器置于中央手邊搔彈邊向聽診器移動聲響突然增強為其邊界Meaning:confirminferiorborderoftheliverandascites(<120ml)意義:確定肝臟下界和小量腹水(fùshuǐ)范圍scratchtest第三十五頁，共五十二頁。編輯課件SplashingSound

振水音Mechanism:causedbyincreasedairandfluidinthestomach,splashsoundproducewhenairandfluidsuccussed.

機制:胃內(nèi)氣體和液體增加氣體與液體受沖擊振動產(chǎn)生聲音(shēngyīn)Technique:heardsplashsoundfromstethoscopeinepigastricandwhenthehandmovingstomach方法:聽診器置于上腹部

用手推動上腹部可聽到振水聲Meaning:whenlimosisappearedclewpyloricobstruction,gastricdilatationorlargehiatushernia意義:

空腹時出現(xiàn)提示幽門梗阻

胃擴張食管裂孔疝succussiontest第三十六頁，共五十二頁。編輯課件CommonDiseaseofAbdomen

腹部(fùbù)常見疾病

conditionscausingliverchanges

肝臟改變常見原因(yuányīn)

ascites腹水征

peritonitis腹膜炎

acutegastricorduodenal

perforation急性胃十二指腸穿孔第三十七頁，共五十二頁。編輯課件ConditionsCausingLiverChanges

肝臟改變(gǎibiàn)常見原因Primaryhepaticcarcinomaandmetastases原發(fā)性肝癌(ɡānái)或轉(zhuǎn)移癌Rightheartfailure

右心功能不全Overinflatedlungs肺氣腫Diffuseinfiltration彌漫性肝腫大Cirrhosisofliver

肝硬化第三十八頁，共五十二頁。編輯課件Primaryhepaticcarcinomaandmetastases

原發(fā)性肝癌(ɡānái)和轉(zhuǎn)移癌Tendernessinepigastriumandwasting

上腹部壓痛和消瘦Largehardirregularlivereasilypalpableperabdomen

上腹部可觸及大而硬的肝臟Highrightdiaphragmwithdullnesstopercussionanddiminishedbreathsoundsoverlowerchest

右膈抬高右下肺呼吸音減低(jiǎndī)Clinicalsignsmaystimulatepleuraleffusionatrightbaseposterior

晚期可伴有右肺底胸腔積液第三十九頁，共五十二頁。編輯課件RightHeartFailure

右心功能不全Tenderenlargedliver

肝臟增大壓痛Rightdiaphragmnotnecessarilyelevated

右膈不一定抬高Distendedcervicalveinandhepatojuglarrefluxpositive

頸靜脈怒張肝頸靜脈回流征陽性(yángxìng)Othersignsofrightheartfailuresuchaspendulousedema

低垂部位水腫等其它右心功能不全征象Systolicpulsationofliveriftricuspidincompetencepresent

三尖瓣關(guān)閉不全時有肝臟收縮期搏動第四十頁，共五十二頁。編輯課件Emphysema

肺氣腫

Liveredgesoftandpalpableperabdomen

肋緣下觸及質(zhì)軟的肝下緣Chesthyper-resonantwithlevelsofliver

肝上界水平(shuǐpíng)叩呈過清音Dullnessdepressed

肝相對濁音區(qū)濁音減弱Accompaniedbarrelchest

伴有桶狀胸第四十一頁，共五十二頁。編輯課件DiffuseInfiltrationoftheLiver

彌漫性肝浸潤(jìnrùn)Generalizedfirmregularenlargedliver

肝臟腫大變硬形態(tài)正常Spleenmayalsobepalpable

脾臟可同時觸及Causedbyamyloidorsarcoidosis

可由淀粉樣變或肉芽腫疾病(jíbìng)引起B(yǎng)iliaryductdisordersmayaccompanyenlargedgallbladderandjaundice

膽道病變可伴有膽囊增大和黃疸第四十二頁，共五十二頁。編輯課件CirrhosisofLiver

肝硬化Smalllivertopercussionbutahardedgemaybepalpableunderthexiphoid

劍突下觸及邊鈍質(zhì)硬縮小的肝臟Spleenpalpable

脾臟肋緣下可觸及Varicosityandascites臍周靜脈曲張(jìngmài-qūzhāng)和腹水征palmarerythema,spiderangiomaandGynaecomastia

肝掌蜘蛛痣男性乳房發(fā)育Gastrointestinalhaemorrhage消化道出血第四十三頁，共五十二頁。編輯課件PhysicalExaminationPoint

肝硬化失代償(dàichánɡ)期檢體要點Liverchange:sizereduced,hardquality,sharpmargin肝臟改變:肝臟縮小質(zhì)硬邊銳表面細顆粒狀Liverfunctiondamage肝功能受損

skin:gloomface,pigmentation,petechia,jaundice皮膚:面色灰暗色素沉著出血點淤斑黃疸

bloodvessel:capillarydilatation,spiderangioma血管:面頸上胸部毛細血管擴張蜘蛛痣肝掌

breast:gynecomastiainthemale乳房:男性乳房發(fā)育Portalhypertensioninducedsidebranchcirculation:splenomegaly,varicosityofabdomen,ascitessign

門脈高壓側(cè)枝循環(huán)(xúnhuán)形成:脾臟腫大腹壁靜脈曲張腹水征第四十四頁，共五十二頁。編輯課件SignsofHepaticCirrhosis

肝硬化征象(zhēngxiàng)MentalstateJaundiceFetorHepatomegalyandgallbladderFlappingtremor(asterixis)AsscitesGastrointestinalhaemorrhageBruisingOedemaSpidernaeviGynaecomastiaSplenomegalyNeedlemarksUmbilicalherniaSuperficialabdominalveinsPalmarerythemaDupuytren’scontractureFingerclubbingandleukonychiaTesticularatrophysparsebodyhairHaemorrhoids第四十五頁，共五十二頁。編輯課件AscitesSign

腹水(fùshuǐ)征Inspection:frogshapeofabdomenindorsalposition,hypogastriumregiondistensionwithhilumherniainstand.視診:仰臥位蛙狀腹直立位下腹膨隆臍突出Palpation:fluidthrill(asciteslargethan3000ml)觸診:液波震顫(腹水量(shuǐliànɡ)>3000ml)Percussion:shiftingdullness(asciteslargethan1000ml),puddlesign(smallamountsoffluid)叩診:移動性濁音(腹水量>1000ml)水坑征(少量腹水)Auscultation:umbilicusscratchsound

inelbow-kneeposture(ascites>120ml)聽診:臍部搔彈音(腹水量>120ml)第四十六頁，共五十二頁。編輯課件AcutePerforatedGastricorDuodenalUlcer

急性胃十二指腸(shíèrzhǐcháng)穿孔Suddenlyepigastricpain,forcedsupinepositionandtwinlowerlimbsflection

突發(fā)上腹痛

強迫仰臥位雙下肢屈曲(qūqǔ)Acuteperitonitissigns,tendernessandreboundpaininepigastriumorroundumbilicusquarter

急性腹膜炎征象

壓痛反跳痛位于上腹部和臍周Hepaticdullnessregiondecreaseordisappear

肝濁音區(qū)縮小消失

shiftingdullnessinabdomen

腹部移動性濁音第四十七頁，共五十二頁。編輯課件PhysicalExamina