～腹部の身体診察法～
Inspection
The Skin
Note scars, striae, dilated veins, rashes and lesions, the umbilicus, the contour of the abdomen, peristalsis, and pulsations.
Auscultation
Bowel sounds
- Increased =>diarrhea,early intestinal obstruction
- Decreased, absent =>adynamic ileus,peritonitis.
Bruits
Listen for bruits over the aorta, the iliac arteries, and the femoral arteries.
Venous Hum
soft humming noise with both systolic and diastolic components. It indicates increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis.
Friction Rubs
rare. They are grating sounds with respiratory variation.
They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct.
Percussion & Palpation
Percussion of the liver
Measure the vertical span of liver dullness in the right midclavicular line.
Palpation of the liver
Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below.
Percussion of the spleen
Percuss the left lower anterior chest wall between lung resonance above and the costal margin, an area termed Traube's space. As you percuss along the routes suggested by the arrows in the following figures, note the lateral extent of tympany.
Assessing percussion tenderness of the kidneys
Pressure from your fingertips may be enough to elicit tenderness, but if not, use fist percussion. Place the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your fist.
Assessing the aorta
Press firmly deep in the upper abdomen, slightly to the left of the midline, and identify the aortic pulsations, Assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta.
Important sign and findings!!
Murphy’s sign @Acute Cholecystitis
Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Ask the patient to take a deep breath. Watch the patient’s breathing and note the degree of tenderness.
Ascites
1.Ascitic fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness).
2.Test for a fluid wave
Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. This pressure helps to stop the transmission of a wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. Unfortunately, this sign is often negative until ascites is obvious, and it is sometimes positive in people without ascites.
☆Appendicitis
1.Rebound tenderness
Rebound tenderness suggests peritoneal inflammation, if appendicitis. If other signs are typically positive, you can save the patient unnecessary pain by omitting this test.
2.Rovsing’s sign and referred rebound tenderness
Press deeply and evenly in the left lower quadrant. Then quickly withdraw your fingers. Pain in the right lower quadrant during left-sided pressure suggests appendicitis (a positive Rovsing’s sign). So does right lower quadrant pain on quick withdrawal (referred rebound tenderness).
3.Psoas sign
Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. Increased abdominal pain on either maneuver constitutes a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed
4.Obturator sign
Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Right hypogastric pain constitutes a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix.
最終更新：2010年05月20日 20:26
