资源描述
PhysicalExaminationoftheAbdomenandMaleGenitalOrgan,TheAbdomen,ExtendsfromxiphoidprocesstothesymphysispubisRectusabdominisInternalandexternalobliquesLineaalbaInguinalligamentContainsvitalorgans,MajorAbdominalOrgans,Quadrantsoftheabdomen,Segmentsoftheabdomen,mid-clavicularline,subcostalplane,anteriorsuperioriliacspine,LocalizationofVisceralPain,ExaminationoftheAbdomen,Goodlightandadequateexposure(xiphoidprocesstosymphysispubis,groinvisible)RelaxedpatientPatientsupine,armsatside,kneesslightlyflexedEmptybladder,ExaminationoftheAbdomen,AskpatienttopointtoanyareaofpainExaminenon-painfulsidefirst“Visualize”underlyinganatomyWatchpatientsfaceforsignsofdiscomfortduringtheexamination,PhysicalExamination,Sequence:-Inspection-Auscultation-Percussion-Palpation,InspectionoftheAbdomen,Skin:color,ecchymosis,rashes,lesions,striae,scars,dilatedveinsContours:flat,roundedscaphoid,protuberantSymmetry:distentionlocalbulges,InspectionoftheAbdomen,Umbilicus:locationdisplacementinflammationMusculature:massesherniaseparationSurfacemotion:peristalsispulsations,AuscultationoftheAbdomen,Bowelsoundswarmeddiaphragmallquadrantsfrequencyandcharacterclicksandgurgles,borborygmanormoactive:5-34perminute5continuousminutestoestablishabsence,AuscultationoftheAbdomen,Vascularsounds-Bruitswarmedbelloveraorta,renal,iliac,andfemoralarteriesoverliver(HCCoracutealcoholichepatitis)-Venoushumswarmedbelloverepigastricandperiumbilicalarea(increasedcollateralcirculationbetweenportalandsystemicvenoussystemsFrictionrubsoverliverandspleen(perihepatitisorperisplenitis),PercussionoftheAbdomen,Todetectfluid,air,andfluid-filledorsolidmassesStomachandintestinestympany(lowerpitchedforstomachleftloweranteriorribcageandleftepigastricarea)Organsandsolidmasses:dullnessPercussallquadrantsfordistributionoftympanyanddullness:tympanypredominates,Percussion:Liver,Liverspan-rightmiddleclavicularline-fromtympanytodullness,thenfromresonancetodullness-6-12cm,Percussion:Spleen,-posteriortoleftMALsmallareaofdullnessfrom6thto10thribs-lowestICS(9th)inleftAAL:Traubsspaceremainstympanicbeforeandafterdeepbreathbypatient,Percussion:kidney,CVanglepaininfectionormusculo-skeletalcauses,Palpation,Standatpatientsside,usuallyright,withpatientinsupinepositionBendingpatientskneesmayhelprelaxmusclesProceedinasystematicmanner,PalpationoftheAbdomen,Lightpalpation-all4quadrants-1cmdeep-identifymuscularresistance,superficialmasses,PalpationoftheAbdomen,Deeppalpation-all4quadrants-upto4cmdeep-delineatesorgansanddetectsdeepermasses,DeepPalpation,Characterizemassesby:locationsizeshapeconsistencytendernesspulsationmobilitymovementwithrespirationsuperficialversusintra-abdominal,Palpation:Liver,placelefthandbehindpatient,paralleltoandsupportingtheright11thand12thribs,placerighthandonpatientsrightabdomenaskpatienttotakeadeepbreathFeelforthelowerborderatrightcostalmarginIffelt,shouldbesmooth,firm,evenandnontenderFeelfornodules,tendernessandirregularity,Palpation:Liver,Hookingtechnique:-standtorightofpatientschest,placebothhands,sidebyside,ontherightabdomenbelowthecostalmargin-askpatienttotakeadeepbreath,Palpation:Gallbladder,belowlivermarginatlateralborderoftherectusabdominismuscleusuallyimpalpableMurphyssignCourvoisierslaw,Palpation:Spleen,withlefthandreachoverandaroundpatienttosupportandpressforwardhislowerleftribcage,withrighthandbelowleftcostalmarginandpressintowardspleenpatientonhisrightsideandhislegsflexedathipsandknees,Palpation:Kidney,forrightkidney:lefthandbehindandsupportpatientsrightloin,righthandbelowrightcostalmargin,pressbothhandsfirmlytogetherfirm,smoothandnontenderleftkidneyusuallyimpalpableEnlargementhydronephrosis,cystortumor,Palpation:Aorta,slightlyleftofthemidlinemidwaybetweenxiphisternumandumbilicusfeltinthinpatient,AdditionalProceduresinAbdominalAssessment,AscitesassessmentReboundtendernessIliopsoasmuscletestObturatormuscletestRovsingssignBallottement,McBurneyspoint,AscitesAssessment,ShiftingdullnessFluidwavePuddlesignNoneofthemarespecificorcompletelyreliable,Shiftingdullness,Fluidwave,Puddlesign,ReboundTenderness,todetermineperitonealirritationperformedatendofexaminationpressdeeplyandremovefingersquicklysharp,stabbingpain,Iliopsoasmuscletest-inappendicitis-experiencelowerquadrantpain-patientattemptstoflexhipwhileexaminerappliespressuretolowerthigh,Obturatormuscletest-inappendicitisorpelvicabscess-experiencepaininthehypogastricarea-patientflexesrightlegathipandknee,examinerrotatestheleglaterallyandmedially,Rovsingssign,Ifpalpationofthelowerleftquadrantofapersonsabdomenresultsinmorepainintherightlowerquadrant,thepatientissaidtohaveapositiveRovsingssignandmayhaveappendicitis,Physicalexamination-Penis,Inspection1.Theskin2.Theprepuceorforeskin3.Theglans-ulcer,scar,noduleorsignofinflammation4.Theurethralmeatus-size,location,dischargePalpation-tendernessorinduration,sizeandcontour!Usegloves!Remembertoreplacetheretractedforeskin,PhysicalExamination-Scrotumanditscontents,Inspection1.Skin-nodules,inflammation,ulcers2.Scrotalcontourswelling,lumpsorveinsPalpation1.Testes:size,shape,consistency,tenderness,nodules2.Epididymis3.Spermaticcordandvasdeferens:nodulesorswellingTransillumination,PhysicalExamination-Hernia,InspectionbulgesininguinalandfemoralareasPalpationIndirect,direct,femoralhernia,reducible,incarcerated,strangulated,PhysicalExaminationrectalexamination,Inspectionbulging,hairyskinordiscolorationorscarinsacralarealumps,ulcers,inflammation,warts,fissures,rashesorexcoriationinperianalareas.PalpationPerianalsensation,bulbocavernousreflexThetonicityoftherectalsphincterProstate-size,shape,consistency,nodules,induration,asymmetry,tendernessSeminalvesiclesPeritonealcavity-rectalshelf,tenderness,PatientStandingAndBentOverTheExaminingTable,Knee-chestposition,Prostateexamination,(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的姿勢、表情及外觀?()3.注意學生做視診時，是否有檢查腹部的外形(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?,(三)聽診評估,()1.注意學生做聽診時，是否有用手溫熱之聽診器diaphragm面聽腸音?(正常腸蠕動約為每分鐘5-35次)()2.注意學生做聽診時，是否有用手溫熱之聽診器bell面聽主動脈、腎動脈，髂動脈及股動脈有無bruit?()3.注意學生做聽診時，是否有聽肝臟及脾臟之磨擦音(frictionrub)?,(四)扣診評估,()1.注意學生做扣診時，是否依正確方向(RUQLUQLLQRLQ)在四象限敲出鈍音及鼓音?()2.注意學生做扣診時，是否能敲出liverspan的大小?(正常6-12cm大小,rightMCL)()3.注意學生做扣診時，是否能敲出spleenspan的大小?()4.注意學生做扣診時，是否有做後腰部CVangle之knockingtenderness？,(五)觸診評估,()1.注意學生做觸診前，是否先讓病患雙腳微屈?()2.注意學生做觸診時，是否先用單手有系統地做淺層觸診(1cm以內)?()3.注意學生做觸診時，是否再用雙手有系統地做深層(4cm左右)觸診?()4.注意學生做觸診時，是否以雙手(左手在病患背側,右手在病患腹側)，對肝臟及脾臟作觸診?()5.注意學生做觸診時，是否以雙手(左手在病患腹側,右手在病患背側)，對腎臟作觸診?,(六)肛門及生殖器評估,()1.注意學生做肛診理學檢查前，有無向患者說明檢查的原因及目的？()2.注意學生做肛診理學檢查時，是否讓患者擺出正確的受檢查姿勢？()3.注意學生做完肛診檢查後，是否能畫出正確的攝護腺圖形？,
展开阅读全文