腹部检查 (2).ppt

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　　physical examination腹部检查 (2)Abdominal Examination

　　palpate mass 腹部包块触诊 percussion and auscultation 腹部叩诊和听诊 signs of common diseases 腹部常见疾病征象

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　　Abdominal Masses腹部包块

　　Physical mass In abdominal wall In abdominal cavity Pathological mass swelling of organ Inflammatory masses Tumor

　　生理包块 腹壁包块 腹腔包块 病理包块 脏器肿大 炎性包块 肿瘤

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　　Physical Masses生理性包块

　　Abdominal wall: venter musculi or tendinous intersections of musculus rectus abdominis 腹壁: 腹直肌肌腹及腱划 Abdominal cavity: lumbar centrum, sacral promontory, abdominal aorta, inferior pole of right kidney, transverse colon, sigmoid colon, cecum 腹腔: 腰椎体 骶骨岬 腹主动脉 右肾下极 横结肠 乙状结肠 盲肠

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　　Pathological Masses病理性包块

　　Shifting or swelling of parenchymatous organ 实质性脏器肿大 Distension of hollow viscus 扩大的空腔脏器 Inflammatory masses (abscess or adhesion) 炎性包块(脓肿或粘连) Tumor or cyst 肿瘤与囊肿 Lymphadenectasis 淋巴结肿大

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　　Characteristics of Palpation 触诊要点

　　Location: relation to organs Size: diameter in long, wide and thick Contour: shape, margin and surface Texture: soft, firm and hard Tenderness: inflammation, liver swelling Pulsation: dilative and conductive Movability: shift by respiration or hand

　　部位: 所在部位与该处脏器多相关连 大小: 纵长 横宽 深厚 可用实物比喻 轮廓: 形状 边缘 表面 质地: 柔软 中等硬度 质硬 压痛: 炎症 肝肿大 搏动: 膨胀性和传导性 移动度: 随呼吸移动 用手推动

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　　Fluid Thrill液波震颤

　　Technique: move flank wall by hand 检查方法: 用手推动一侧腹壁 Positive: the other hand feels liquid wave 阳性征象: 对侧手掌感到液体波动 Meaning: large volume of ascites, usually >3000ml 临床意义: 大量腹水在3~4升以上

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　　Percussion of Abdomen 腹部叩诊

　　organs in the abdomen 脏器叩诊 fluid in the abdomen 腹水叩诊

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　　Organs Percussion脏器叩诊

　　Percussion notes: indirect percussion 叩诊音: 间接叩诊 Tympany: hollow viscus as Traube’s area, intestine 鼓音: 空腔脏器 胃泡鼓音区 肠腔 Dullness or flatness: parenchyma viscus as liver or spleen, enlarged bladder or uterus 叩音或实音: 肝脏和脾脏实质脏器 增大的膀胱或子宫 Knock pain: indirect knock impress inflammation 叩击痛: 间接叩击 提示炎症 Organs: liver, gallbladder, kidney 脏器: 肝脏 胆囊 肾脏

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　　Abnormal Area of Tympany鼓音范围异常

　　Enlarged area: intestinal obstruction, perforation of gastrointerstinal tract 范围增大: 胃肠高度胀气 胃肠穿孔 Reduced area: swelling of parenchymatous organ, tumor, ascites 范围缩小: 肝脾等脏器极度肿大 腹腔肿瘤 大量腹水

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　　Traube’s Area胃泡鼓音界

　　Location: left hypochondrium 位置: 左季肋部 Upper border: left lung, diaphragm 上界: 左肺下缘 膈 Lower border: Rib 下界: 肋弓 Right border: liver 右界: 肝脏 Left border: spleen 左界: 脾脏

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　　Traube’s Area Abnormal胃泡鼓音范围异常

　　Pathology: content variation of stomach and compression of neighbor organ 机制: 胃内含气量变化 邻近器官扩大压迫 Enlarged: gastric dilatation, pylorus obstruction 扩大: 见于胃扩张 幽门梗阻 Reduced: swellings of liver or spleen, left pleural effusion, pericardial effusion 缩小: 见于肝脾肿大 左侧胸腔积液 心包积液

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　　Dullness Area of Liver肝脏浊音界

　　Method: percussion along the lines of right midclavicular, midaxillary and scapular line 方法: 沿右锁骨中线 右腋中线 右肩胛线叩诊 Superior border: relative dullness margin between liver and lung, it’s from resonance to dullness, correspond to top of liver., 肝上界:由肺区向下叩出肝与肺清音变浊音的 相对浊音界 相当于被肺遮盖的肝顶部 Inferior border: from abdomen tympany up to liver dullness margin 肝下界: 由腹部向上叩 鼓音变浊音

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　　Percussion of Superior and Inferior border肝上下浊音界叩诊

　　Superior border: intercostal space of 5th in right midclavicular, 7th in midaxillary and 10th in scapular line 肝上界: 右锁骨中线第 5 肋间 右腋中线第 7 肋间 右肩胛线第10肋间 Inferior border: costal margin in right midclavicular line 10th rib level in right midaxillary line 肝下界: 右锁骨中线右季肋下缘 右腋中线相当于第10肋骨水平

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　　Area of Liver肝界范围

　　Superior border: 1~2 inter-costal spaces higher than inferior lung border 肝上界: 肺下界的上1~2肋间 Inferior border: 1~2 cm higher than detected by palpation 肝下界: 较触及的肝界高1~2厘米 Liver span in right midclavicular line: 9~11 cm 肝上下径(右锁骨中线): 肝上下界间的距离约 9~11厘米

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　　Abnormal Findings肝浊音界异常

　　Enlarged: hepatic congestion, hepatitis, liver abscess, liver carcinoma 增大: 肝淤血 肝炎 肝脓肿 肝癌 Diminished: liver cirrhosis or necrosis 缩小: 肝硬化 肝坏死 Disappeared: perforation of gastrointestinal tract, abdominal surgery 消失: 代之以鼓音 胃肠穿孔 腹部手术后 Upward shifting: fibrosis or atelectasis of right lung, large volume of air or gas in the gastrointestinal tract 上移: 右肺纤维化 右肺不张 胃肠胀气 downward shifting: emphysema, right side pleural effusion, hepatoptosia 下移: 肺气肿 右胸腔积液 肝下垂

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　　Dullness Area of Spleen脾脏浊音界

　　Normal space 正常状况 Location: 9th~11th ICS alongside left midaxillary line 位置: 左腋中线9~11肋间 Diameter: superio-inferior 4~7 cm the anterior border not exceed anterior axillary line 范围: 上下径4~7厘米 前界不超过腋前线 Abnormal findings 叩诊异常 Enlarged: splenomegaly 范围增大: 脾肿大 Diminished: too much gas in surrounding organs 范围缩小: 胃扩张或肠胀气

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　　Dullness Area of Bladder or Uterus 膀胱或子宫浊音区

　　Bladder dullness area: physical signs in retention of urine, a smooth, firm, and regular swelling arising out of the pelvis which one cannot “get below” and which is dull to percussion. 膀胱浊音区: 判断膀胱膨胀程度 耻骨上方圆形浊音区 排尿或导尿后消失 Uterus dullness area: estimate enlarged uterus superior margin of pubis, not disappear after micturation or urethral catheterization 子宫浊音区: 判断子宫增大程度 耻骨上方浊音区 排尿或导尿后不消失

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　　Percussion of Ascites腹水叩诊

　　Shifting dullness: 移动性浊音 free fluid causes air-containing gut to float up to the most superior position 液体流动使含气脏器位于最高位置 volume of ascites usually exceeds 1000ml if detectable 腹水量在1000ml以上 Puddle sign: 水坑征 free fluid in the most inferior position in elbow-knee posture 肘膝位腹水位于最低位 a way to detect small amounts of fluid 用于发现少量腹水

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　　Shifting Dullness due to Ascites移动性浊音

　　Dullness area in both side of abdomen with dorsal position 平卧位时浊音区位于腹部的两侧 Dullness area moves to inferior when moved position 变换体位浊音区移至下方 Dullness movement follows position moved 浊音部位随体位变动而变动

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　　Puddle Sign due to Ascites水坑征

　　In elbow-knee posture 肘膝位 Percussion dullness in umbilical region 脐部叩诊呈浊音 Dullness disappear when position moved 变换体位浊音区消失

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　　Common Diseases腹水的常见病因

　　Hepatocirrhosis 肝硬化 Tuberculous peritonitis 结核性腹膜炎 Cardiac dysfunction 心功能不全 Nephropathy syndrome 肾病综合征 Primary or metastasis tumor in abdominal cavity 腹腔内肿瘤或其他部位肿瘤腹腔转移

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　　Compare Ascites and Ovarian Cyst腹水和卵巢囊肿的鉴别

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　　Difference of dullness sites between ovarian cyst and ascites 卵巢囊肿和腹水浊音区的不同

　　tympany

　　tympany

　　dullness

　　dullness

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　　Percussion Pain in Liver Area肝区叩击痛

　　Technique: put left palm in liver area, right hand with boxing knock the left back of hand with middle force. 方法: 将左手掌平放于肝区 右手握拳用中等强度力量向左手背叩击 Normal: no pains feeling in liver area. 正常: 肝区无叩击痛 Abnormal: the knock pain in liver area indicates hepatitis and liver abscess 叩击痛阳性: 见于肝炎 肝脓肿

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　　Percussion Pain in Gallbladder Area胆囊区叩击痛

　　Technique: knock the surface of gallbladder area with middle force. 方法: 叩击胆囊部位表面 Normal: no knock pain 正常: 胆囊无叩击痛 Positive: cholecystitis 阳性: 提示胆囊炎

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　　Percussion Pain in Kidney Area肾区叩击痛

　　Technique: sit or side lie, 方法: 坐位或侧卧位 put left palm in costovertebral angle area, right hand with boxing knock the left back of hand with middle force. 用左手掌平放肋脊角及邻近区域 右手握空拳以中等强度力量 向左手背扣击 Normal: no knock pain 正常: 肾区无扣击痛

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　　Costovertebral Angle Tenderness肾区叩击痛阳性

　　Nephritis 肾炎 Pyelonephritis 肾盂肾炎 Renal tuberculosis 肾结核 Calculus 肾结石 Perinephritis 肾周围炎

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　　Auscultation of Abdomen腹部听诊

　　bowel sounds 肠鸣音 vascular sounds 血管杂音 friction rub 摩擦音 scratch sound 搔弹音 splashing sound 振水音

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　　Bowel Sounds肠鸣音

　　Principle: peristaltic activity emits various gurgling and bubbling sounds as air and fluid interfaces change with contraction waves. borborygmus: loud prolonged gurgles. 定义: 肠蠕动肠管气液体流动产生咕噜或冒泡音 Normal: 4~5/min 正常: 每分钟 4~5 次 Abnormal: increased, decreased and absence. 异常: 活跃和亢进 减弱和消失

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　　Bowel Sounds Increased肠鸣音活跃和亢进

　　Increased: >10/min: hypermotile states such as acute gastroenteritis, blood in the small bowel 活跃: >10次/分(肠蠕动增强) 急性肠炎 胃肠道大出血 服泻药 饥饿 High-pitched tinkling:intestinal fluid and air under pressure, as in early obstruction 亢进: >10次/分(响亮高亢甚至金属音) 机械性肠梗阻

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　　Bowel Sounds Decreased肠鸣音减弱和消失

　　Decreased: postlaparotomy, electrolyte imbalance, senile constipation 减弱: 1次/3~5分 (肠蠕动减弱) 腹膜炎 低血钾 老年性便秘 Absence: acute peritonitis, paralytic ileusone must listen for at least a full 3 minutes before pronouncing that peristalsis has ceased 消失: 4分钟以上听不到(肠蠕动消失) 急性腹膜炎 麻痹性肠梗阻

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　　Vascular Sounds血管杂音

　　Principle: Turbulent flow in a dilated, constricted, or tortuous vessel. 机制: 血管扩张或狭窄产生湍流 Artery murmur: eject or draught in systolic with high pitch and strong sound. 动脉杂音: 收缩期喷射性或吹风样 音调高音响强 Venous murmur: continuous murmur with low pitch and ebb sound. 静脉杂音: 连续性嗡鸣 音调低 音响弱

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　　Common Cause血管杂音常见病因

　　Artery 动脉性 Epigastrium: abdominal aorta stricture or aneurism 上腹部: 腹主动脉狭窄或腹主动脉瘤 Umbilical or in the flanks: renal artery stricture 脐周或侧腹部: 肾动脉狭窄 Right hypochondrium: hepatic artery stricture usually compressed by pancreas or left liver cancer. 右季肋部: 肝动脉狭窄 常见于胰腺癌 肝左叶癌 Venous 静脉性 Recanalized umbilical vein: portal hypertension accompanied varicosity in abdominal wall 脐周: 门静脉高压腹壁静脉曲张

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　　Friction Rub摩擦音

　　Principle: irritated fibrin-laden peritoneal surfaces grate with motion 机制: 腹膜表面炎性渗出运动摩擦 Meaning: seen in localized peritonitis 提示: 局限性腹膜炎 Technique: heard at correspond area in deep respiratory 方法: 深呼吸时在相应部位听到 Clinical cause: spleen infarction, spleen and liver circumference inflammation, cholecystitis 病因: 脾梗塞 脾周围炎 肝周围炎 胆囊炎

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　　Scratch Sound搔弹音

　　Mechanism: sound wave conductive diversity in differ medium made noise alteration. Aids in static border definition 机制: 声波在不同介质中传导的差异致声响改变 有助于确定实质脏器或液体边界 Technique: put the stethoscope in central and the hand scratch to it, when sound suddenly increased indicate the border. 方法: 听诊器置于中央 手边搔弹边向听诊器移动 声响突然增强为其边界 Meaning: confirm inferior border of the liver and ascites (<120ml) 意义: 确定肝脏下界和小量腹水范围

　　scratch test

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　　Splashing Sound振水音

　　Mechanism: caused by increased air and fluid in the stomach, splash sound produce when air and fluid succussed. 机制: 胃内气体和液体增加 气体与液体受冲击振动产生声音 Technique: heard splash sound from stethoscope in epigastric and when the hand moving stomach 方法: 听诊器置于上腹部 用手推动上腹部可听到振水声 Meaning: when limosis appeared clew pyloric obstruction, gastric dilatation or large hiatus hernia 意义: 空腹时出现提示幽门梗阻 胃扩张 食管裂孔疝

　　succussion test

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　　Common Disease of Abdomen腹部常见疾病

　　conditions causing liver changes 肝脏改变常见原因 ascites 腹水征 peritonitis 腹膜炎 acute gastric or duodenal perforation 急性胃十二指肠穿孔

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　　Conditions Causing Liver Changes肝脏改变常见原因

　　Primary hepatic carcinoma and metastases 原发性肝癌或转移癌 Right heart failure 右心功能不全 Overinflated lungs 肺气肿 Diffuse infiltration 弥漫性肝肿大 Cirrhosis of liver 肝硬化

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　　Primary hepatic carcinoma and metastases原发性肝癌和转移癌

　　Tenderness in epigastrium and wasting 上腹部压痛和消瘦 Large hard irregular liver easily palpable per abdomen 上腹部可触及大而硬的肝脏 High right diaphragm with dullness to percussion and diminished breath sounds over lower chest 右膈抬高 右下肺呼吸音减低 Clinical signs may stimulate pleural effusion at right base posterior 晚期可伴有右肺底胸腔积液

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　　Right Heart Failure右心功能不全

　　Tender enlarged liver 肝脏增大压痛 Right diaphragm not necessarily elevated 右膈不一定抬高 Distended cervical vein and hepatojuglar reflux positive 颈静脉怒张 肝颈静脉回流征阳性 Other signs of right heart failure such as pendulous edema 低垂部位水肿等其它右心功能不全征象 Systolic pulsation of liver if tricuspid incompetence present 三尖瓣关闭不全时有肝脏收缩期搏动

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　　Emphysema肺气肿

　　Liver edge soft and palpable per abdomen 肋缘下触及质软的肝下缘 Chest hyper-resonant with levels of liver 肝上界水平叩呈过清音 Dullness depressed 肝相对浊音区浊音减弱 Accompanied barrel chest 伴有桶状胸

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　　Diffuse Infiltration of the Liver弥漫性肝浸润

　　Generalized firm regular enlarged liver 肝脏肿大变硬形态正常 Spleen may also be palpable 脾脏可同时触及 Caused by amyloid or sarcoidosis 可由淀粉样变或肉芽肿疾病引起 Biliary duct disorders may accompany enlarged gallbladder and jaundice 胆道病变可伴有胆囊增大和黄疸

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　　Cirrhosis of Liver肝硬化

　　Small liver to percussion but a hard edge may be palpable under the xiphoid 剑突下触及边钝质硬缩小的肝脏 Spleen palpable 脾脏肋缘下可触及 Varicosity and ascites 脐周静脉曲张和腹水征 palmar erythema, spider angioma and Gynaecomastia 肝掌 蜘蛛痣 男性乳房发育 Gastrointestinal haemorrhage 消化道出血

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　　Physical Examination Point肝硬化失代偿期检体要点

　　Liver change: size reduced, hard quality, sharp margin 肝脏改变: 肝脏缩小 质硬边锐 表面细颗粒状 Liver function damage 肝功能受损 skin: gloom face, pigmentation, petechia, jaundice 皮肤: 面色灰暗 色素沉着 出血点淤斑 黄疸 blood vessel: capillary dilatation, spider angioma 血管: 面颈上胸部毛细血管扩张 蜘蛛痣 肝掌 breast: gynecomastia in the male 乳房: 男性乳房发育 Portal hypertension induced side branch circulation: splenomegaly, varicosity of abdomen, ascites sign 门脉高压侧枝循环形成: 脾脏肿大 腹壁静脉曲张 腹水征

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　　Signs of Hepatic Cirrhosis肝硬化征象

　　Mental state Jaundice Fetor Hepatomegaly and gallbladder Flapping tremor (asterixis) Asscites Gastrointestinal haemorrhage Bruising Oedema

　　Spider naevi Gynaecomastia Splenomegaly Needle marks Umbilical hernia Superficial abdominal veins Palmar erythema Dupuytren’s contracture Finger clubbing and leukonychia Testicular atrophy sparse body hair Haemorrhoids

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　　Ascites Sign腹水征

　　Inspection: frog shape of abdomen in dorsal position, hypogastrium region distension with hilum hernia in stand. 视诊: 仰卧位蛙状腹 直立位下腹膨隆脐突出 Palpation: fluid thrill (ascites large than 3000 ml) 触诊: 液波震颤 (腹水量>3000ml) Percussion: shifting dullness (ascites large than 1000 ml), puddle sign (small amounts of fluid) 叩诊: 移动性浊音 (腹水量>1000ml) 水坑征 (少量腹水) Auscultation: umbilicus scratch sound in elbow-knee posture (ascites >120ml) 听诊: 脐部搔弹音 (腹水量>120ml)

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　　Acute Perforated Gastric or Duodenal Ulcer急性胃十二指肠穿孔

　　Suddenly epigastric pain, forced supine position and twin lower limbs flection 突发上腹痛 强迫仰卧位 双下肢屈曲 Acute peritonitis signs, tenderness and rebound pain in epigastrium or round umbilicus quarter 急性腹膜炎征象 压痛反跳痛位于上腹部和脐周 Hepatic dullness region decrease or disappear 肝浊音区缩小消失 shifting dullness in abdomen 腹部移动性浊音

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　　Physical Examination Point 急性胃肠穿孔检体要点

　　Gas in abdominal cavity: dullness area of liver disappear 腹腔气体: 肝浊音区缩小消失 Liquid in abdomen: shifting dullness 腹腔液体: 腹部移动性浊音 Inflammation in abdomen: acute peritonitis sign, serious in epigastric and umbilical region. 腹部炎症反应: 急性弥漫性腹膜炎征象 压痛反跳痛位于上腹部和脐周 forepart: acute ache face, compulsive supine position, lower limbs flection 早期: 急性痛苦面容 冷汗 强迫仰卧位 双下肢屈曲 anaphase: high fever, pulse frequency 后期: 高热 失水 精神萎靡 面色灰白 眼球凹陷 脉搏频数

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　　Acute Peritonitis Signs急性腹膜炎征象

　　Inspection: general depression in abdomen, decreased or disappeared abdominal respiration 视诊: 腹部凹陷 腹部呼吸运动减弱消失 Palpation: tenderness, rebound tenderness, rigid abdominal wall 触诊: 压痛和反跳痛 腹壁呈板状硬 Percussion: shifting dullness 叩诊: 可有移动性浊音 Auscultation: decreased or absence of bowel sounds 听诊: 肠鸣音减弱消失

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　　Intestinal Obstruction肠梗阻

　　Symptom: abdominal pain, vomiting, no defecate and anus exhaust 症状: 腹痛 呕吐 无排便和肛门排气 Inspection: full distension, intestine form and peristaltic wave 视诊: 腹部膨隆 肠型 可见肠蠕动波 Palpation: rigid abdominal wall, tenderness and rebound pain 触诊: 腹肌紧张 压痛及反跳痛 Percussion: tympany region increased 叩诊: 鼓音范围增大 Auscultation: mechanical ileus accompanied sharp bowel sound and decreased or absence of bowel sounds in paralysis ileus 听诊: 机械性肠梗阻肠鸣音亢进 麻痹性肠梗阻肠鸣音减弱或消失