消化系统诊断学PPT的word版 腹部检查 中英文对照版

消化系统诊断学部分的PPT整理：
使用说明：
1、略去了PPT中的图片，但是文字部分全部保留。

顺序同PPT。

2、橙色与红色标注的文字基本与PPT上一致，具体到个别字句会有出入。

3、中文系本人参照大绿书手工翻译，个别地方在内容上稍作了补充，仅供参考。

Abdominal Examination:
1.Sequence：inspection, auscultation, percussion, and palpation
望、听、叩、触
原因：（1）convenient to perform the auscultation after the auscultation of the heart.
便于在心脏听诊后进行腹部听诊
（2）avoid the negative impacts of palpations on auscultation of bowel sounds （←alteration of peristalsis）避免触诊对听肠鸣音的影响（改变了肠蠕动）
2、Anatomic Landmarks：解剖标志
（1）xiphoid (ensiform) process(剑状突起) of sternum(胸骨)
（2）costal margin肋弓缘
（3）umbilicus脐
（4）anterior superior iliac spine髂前上棘
（5）inguinal ligament 腹股沟韧带
（6）superior margin of os pubis耻骨上缘
（7）anterior midline/midabdominal line 腹中线
（8）lateral border of rectus muscles 腹直肌外缘
（9）symphysis pubis (耻骨联合)
3、Zones of abdomen：4 quadrants , 9 sections
The anterior surface of the abdomen is divided into four quadrants by two intersecting lines
前腹面经两条相交线分为四个区
(1) one extending vertically from the xiphoid, through the umbilicus, to the symphysis pubis
一条由剑突垂直向下经过脐，到达耻骨联合
(2) the other extending horizontally across the abdomen at the level of the umbilicus.
另一条在脐处水平横贯腹部
所以分为了4个区：
Right upper quadrant 右上腹部
Left upper quadrant 左上腹部
Right lower quadrant 右下腹部
Left lower quadrant 左下腹部
Two imaginary, parallel, horizontal lines 两条互相平行的假想水平线
（1）across the lowest border of the costal margin 经过两侧肋弓下缘的连线
（2）across the anterior superior iliac spine 经过两侧髂前上棘的连线
Two imaginary, parallel, vertical lines 两条互相平行的假想垂直线
（1）across the middle point of linking line formed by left anterior superior iliac and
midabdominal line 经过左髂前上棘至腹中线连线的中点
（2）across the middle point of linking line formed by right anterior superior iliac and midabdominal line 经过右髂前上棘至腹中线连线的中点
所以分为了9 sections：
Right hypochondrial region右季肋部
Left hypochondrial region 左季肋部
Right lumber region 右腰部
Left lumber region 左腰部
Right iliac region 右髂部
Left iliac region 左髂部
Epigastric region 上腹部
Umbilical region 脐部
Hypogastric region下腹部
4. Question : What are the distinct benefits and disadvantages in Four-quadrant and Nine-section methods? 四区法和九区法的明显优缺点？
Four-quadrant :
(1) simple, practical 简单实用
(2) rough, imprecise 粗糙不精确
(tenderness of epigastric region) （上腹部压痛）
Nine-section
(1) elaborates more clearly and more exactly 更清晰精确
(2) inconvenient 不方便
(3) limited scope of left or right hypochondrial region, left or right iliac region
左、右季肋部，左、右髂部范围局限
5. Inspection: General preparation 望诊的一般准备
（1）urinate completely: bladder is empty 膀胱排空
（2）relax abdominal muscles: lie on back with a pillow under head and knees bent 放松腹部肌肉：低枕仰卧位，双腿屈曲
（3）expose abdomen completely: from xiphoid process to pubis 充分暴露腹部：上至剑突，下至耻骨联合
（4）breasts should be covered: female 遮盖乳房：女性
6. Inspection: major contents望诊的主要内容
abdominal contour 腹部外形
respiratory movements 呼吸运动
abdominal veins 腹壁静脉
gastral or intestinal pattern(胃型或肠型)
peristalsis(蠕动波)
abdominal rash（皮疹）, hernia(疝), striae(纹), etc.
7. Inspection: Abdominal Contour 视诊
whether the abdomen is symmetrical 腹部是否对称
whether it is bulged or retracted 是否膨隆或凹陷
whether it is indicative of ascites or enclosed mass(包块) 是否提示有腹水或包块Normal :
(1) abdominal flatness(腹部平坦) :
√ abdomen at the same level or lower as between costal margin and symp hysis pubis
前腹面处于肋弓缘与耻骨联合平面，或略微凹陷
√ ask the patient to sit, the lower part of umbilicus can become more or less protruded or bulged
要求病人坐位，脐以下部位可稍膨出
(2) abdominal fullness(腹部饱满) :
√ very fat or a child, the abdomen is a little bit round 肥胖者或小儿（尤其餐后）腹部外形饱满或膨隆
√The level of the abdomen higher than that of the surface between costal margin and symphysis pubis 前腹面超过肋弓缘至耻骨联合平面
(3) abdominal lowness(腹部低平):
√ very thin or slender, the level of the abdomen lower than that of the surface between costal margin and symphysis pubis (← little subcutaneous fat)
消瘦者前腹面低于肋弓缘至耻骨联合平面（由皮下脂肪少导致）
abdominal flatness, fullness, and lowness (normal cases)
√ abdomen obviously protruded or bulged, or exceedingly retracted or depressed
(abnormal and usually pathologic) 腹部明显膨隆或过分凹陷（异常，通常为病理）
8. Pathologic conditions 病理情况: abdominal protuberance (bulge) 腹部膨隆
I. Overall/generalized abdominal protuberance/bulge 全腹膨隆
√ ← several pathologic factors besides overly obesity or physiologic pregnancy
除了肥胖、妊娠等生理状况外，还有多种病理因素
i. Peritoneal fluid 腹腔积液
a large amount of free fluid within the abdomen (ascites 腹水) → abdominal wall can be lax in supine position仰卧位时腹壁松弛→ fluid can deposit at both lateral sides (the contour just like a frog belly) 液体下沉于腹腔两侧（外形如蛙腹）
√ lies on one side or sits 侧卧或坐位→ the lower part of abdominal wall will be bulged ( ← movement of free fluid) 腹下部膨出（由腹腔积液移动引起）
√ commonly found in ascites complicated by portal hypertension (liver cirrhosis) 见于肝硬化门脉高压症→in long-term ascites, the appearance of the umbilicus is protruded or everted (umbilical hernia) 在长期腹水中，脐外形凸出或外翻（脐疝）
√ (obesity) the umbilicus is usually deeply inverted（肥胖）脐通常下凹
Apical belly尖腹
← peritonitis腹膜炎or invasion of cancer cells癌细胞侵袭(abdominal muscle: tense, usu. with the apical shape) （腹肌：紧张，通常呈尖凸形）
Peritoneal air 腹内积气
√ ← a large amount of air accumulating in the cavity of stomach. 胃腔内大量积气
√ globular shape ( two sides of lumber region is not obviously protrudent.) 球形，两侧腰部膨出不明显
√ ask the patient to move or change the position → the shape of abdomen remains globular
要求病人移动或改变体位，腹部仍然呈球形
√ commonly found in intestinal obstruction肠梗阻or enteroparalysis(肠麻痹)
Pneumoperitoneum气腹
√ ← air accumulating in the abdominal cavity 腹腔内大量积气
√ commonly found in perforation of gastrointestinal diseases or artificial pneumoperitoneum meant to treat 常见于胃肠穿孔，或者治疗性人工气腹
Huge abdominal enclosed mass 腹内巨大包块
usually found in full-term pregnancy足月妊娠, huge ovarian cyst(卵巢囊肿), teratoma畸胎瘤, etc.
For any generalized abdominal bulge, circumference of abdomen should be measured in centimeters at the level of the umbilicus with a soft tape measure during normal abdominal breathing.
对于所有的全副膨隆情况，应该以厘米为单位，测量腹围。

待测者正常腹式呼吸时，用软尺经脐平面绕腹一周所得周长（脐周腹围）。

Ⅱ.Local abdominal bulge局部膨隆
← enlarged viscera脏器肿大, tumor, inflammatory enclosed mass炎症性肿块, gastrointestinal flatulence(肠胃胀气), hernia, etc.
9. Abdominal concavity/ retraction 腹部凹陷
(In supine position仰卧位) the abdomen at the level much lower than that between costal margin and symphysis pubis 前腹壁明显低于剑突至耻骨联合的水平面→ abdominal concavity/retraction.
two kinds of retraction: overall abdominal retraction全腹凹陷and local abdominal retraction局部凹陷（较为少见）.
The former one: of greater significance 全腹凹陷更具意义
I.Overall abdominal concavity/retraction 全腹凹陷
usually found in patients severely emaciated or seriously dehydrated
多见于消瘦和严重脱水者
Scaphoid abdomen 舟状腹
√ the contour of abdomen: just like a boat (anterior abdomen almost approximating to spinal column + arch of rib, iliac crest (髂嵴) + symphysis pubis all apparent)
腹部外形：舟状（前腹壁凹陷几乎贴近脊柱+肋弓，髂嵴+耻骨联合）
√ commonly seen in cachexia(恶病质)
Local abdominal retraction 局部凹陷
← contraction of scar after operation and less common手术后腹壁瘢痕收缩所致，较少见
10. Abdominal Wall
Rash皮疹:部位、形态、色彩、时间等。

Pigment色素:Addison’s disease（肾上腺皮质功能减退）; Cullen sign (A bluish discoloration of the umbilicus 脐部变蓝(occasionally seen after major intraperitoneal hemorrhage有时见于腹膜后大出血); Grey-Turner sign (A similar discoloration of the flanks左腰部皮肤呈蓝色, (in the absence of trauma) seen following the extravasation of blood from intra-abdominal organs into extraperitoneal sites见于血液自腹膜后间隙渗到腹侧壁皮下, as in hemorrhagic pancreatitis急性出血性胰腺炎)
Abdominal striae腹纹:白纹、妊娠纹、紫纹。

Scar 瘢痕:手术史的证实。

Hernia 疝:腹股沟斜、直疝；腹壁疝；脐疝。

Umbilicus 脐部：
Body hairs 体毛:男、女性差异。

Groin 腹股沟：包块、结节、疤痕、异常搏动。

11.abdominal veins: 腹壁静脉
Normally, abdominal veins do not appear unless the patient is thinner or is light-complexioned, or abdominal inner pressure is elevated,← ascites, huge abdominal tumor, pregnancy, etc.
正常情况下，腹壁静脉一般不显，除非患者消瘦，皮肤白皙，或腹内压升高（由腹水，腹腔巨大肿物，妊娠等所致）。

The presence of distended abdominal veins: impairment of circulation ← portal hypertension or obstruction of superior or inferior vena cava.
静脉曲张：循环障碍（门静脉高压，或上、下腔静脉回流受阻而有侧支循环形成）
√ Prominence of these vessels (called abdominal wall varicosis(腹壁静脉曲张) : increased collateral circulation增加了侧支循环← obstruction in the portal venous system or in the vena cava门静脉系统或腔静脉回流受阻.
√ obvious portal hypertension → dilated veins appear to radiate outward from the umbilicus于脐部可见一簇曲张静脉向四周放射, like the head of medusa像水母头caput medusae(海蛇神头)
normal direction of flow in abdominal vessels: away from the umbilicus —— the upper abdominal veins carry blood upward to the superior vena cava; the lower abdominal veins drain downward to the inferior vena cava
正常腹壁静脉血流方向：脐水平线以上的腹壁静脉血流自下向上至上腔静脉；脐水平线以下的腹壁静脉血流自上向下至下腔静脉。

正常情况：脐上向上，脐下向下
√If a vein is engorged, the direction of flow can be demonstrated by a simple maneuver.
当一条静脉充盈时，血流方向可借简单的指压法鉴别。

maneuver: 指压法（绿书P245下部）
√ placing the index fingers side by side over the vein, pressing laterally, separating the fingers one by one, and observing the time it takes the veins to refill from each direction;
√The flow of venous blood is in the direction that fills faster.
Usually the rate of filling is obviously faster in one direction than in the other, indicating the direction of flow in that portion of the collateral venous system. 通常其中一个方向的静脉充盈速度快于另一个方向，提示那一段侧支静脉系统的血流方向。

In portal hypertension normal flow direction is maintained. In contrast, obstruction of the vena cava alters the flow direction in these veins.
在门静脉高压的情况下，依旧为正常血流方向。

但是腔静脉回流受阻会改变这些静脉的血流方向。

门静脉阻塞: 脐为中心,放射状
In obstruction of the superior vena cava, the flow direction in the upper abdominal venous collaterals is reversed or downward.
In inferior vena cava obstruction the direction is reversed in the lower abdominal veins, and they will drain upward.
上腔静脉阻塞: 脐上向下
下腔静脉阻塞: 脐下向上
12. gastric or intestinal pattern and peristalsis:胃肠型和蠕动波
正常人：见于经产妇与消瘦腹壁松软者。

幽门梗阻：上腹部逆蠕动。

小肠梗阻：不规则隆起，此起彼伏。

结肠梗阻：全腹膨隆、宽大肠型。

13. gastral or intestinal pattern(胃型或肠型) and peristalsis(蠕动波)
In lean individuals, even in the absence of disease, motility of the stomach and intestines may be reflected in the abdominal wall. 在极度消瘦的个体上，即使没有疾病，腹壁也能看到胃肠运动。

When strong contractions are visible through an abdominal wall of average thickness, the possibility of bowel obstruction should be investigated. 当能在体型正常的个体的腹壁上看到强烈收缩，应检查是否为肠梗阻。

Reverse peristalsis indicates pyloric stenosis, duodenal stenosis, or malrotation of the bowel.逆蠕动波提示幽门狭窄，十二指肠狭窄，或者“肠旋转不良？”。

14.Auscultation of Abdomen 腹部听诊
bowel sound 肠鸣音
Normal 正常：4-5次/分
Active 活跃：10次/分
Hyperactive 亢进：次数多、调高
Decreased 减弱：少于1次/分
Disappeared 消失：3-5分
15. Bowel sounds 肠鸣音
(1) Auscultate bowel sounds with diaphragmatic head of stethoscope for at least one minute.用听诊器膜型体件听至少1分钟。

(2) If there are no bowel sounds, listen until you hear them or for at least 3-5 minutes. 如果没有
肠鸣音，继续听，直到听见肠鸣音，或者持续听诊3~5分钟。

(3) Normal bowel sounds are a glue-glue-like sound occurring either separately or together, approximately 4-5 times per minute. 正常的肠鸣音为断断续续的咕噜咕噜声，大约每分钟4~5次。

(4) Pay attention to their frequency, pitch, and intensity. High-pitched (gurgling) sounds with increased frequency are regarded as hyperactivety.注意肠鸣音的频率、音调、声响。

次数多且肠鸣音响亮、高亢，为肠鸣音亢进。

(5) Lack of bowel sounds indicates little or no peristalsis.未闻及肠鸣音，提示弱或无肠蠕动。

(6) absence of any sound ／extremely weak + infrequent sounds heard after several minutes: immobile bowel of peritonitis腹膜炎or paralytic ileus (肠梗阻)
(7 )↑ sounds with a characteristic loud, rushing, high-pitched tinkling quality响亮、高亢，甚至叮当声或金属调: in mechanical intestinal obstruction机械性肠梗阻(← distention of the bowel 肠腔扩大+ ↑ peristaltic activity proximal to the site of the obstruction肠蠕动亢进处接近梗阻部位)
16.Percussion 叩诊
General percussion
All four quadrants of the abdomen are evaluated by percussion. 应用于四个区。

Light percussion is preferable: produces a clearer tone. 轻触：产生更清楚的音。

Tympany(鼓音) : the most common percussion sound in the abdomen 腹部叩诊最常见的音← gas collection积气; appreciated（明显）over the stomach, small intestine, and colon
16.1 Percussion of the liver
Percussion of the upper border of liver(肝上界) : along the right midclavicular line(沿右锁骨中线), right midaxillary line(右腋中线), and right scapular line(右肩胛线).
The level of the shift from resonance downward into dullness is defined as the upper border of liver. At this level, the liver is covered by lung and the border is also called the relative dullness border of liver(肝相对浊音界).
当由清音转为浊音时，即为肝上界。

此处相当于被肺遮盖的肝顶部，故又称肝相对浊音界。

Then percussing downward 1-2 intercostal space, the level of the shift from dullness into flatness(实音) is identified as the absolute dullness border of liver(肝绝对浊音界), without lung covering, and also called the lower border of lung(肺下界).
再向下叩1~2肋间，则浊音变实音，此处肝脏不再被肺遮盖而贴近胸壁，称肝绝对浊音界，亦为肝下界。

Normally the the upper border of liver is located at the 5th intercostal space along the right midclavicular line, the 7th intercostal space along the right midaxillary line, and the 10th intercostal space along the right scapular line.
正常情况下，在右锁骨中线上，肝上界在第五肋间；在右腋中线上，肝上界为第七肋间；在右肩胛线上，肝上界在第十肋间。

Percussion of the lower border of liver(肝下界) :along the right midclavicular line or anterior midline. The level of the shift from tympany upward into dullness is defined as the lower border of liver.
由腹部鼓音区沿右锁骨中线或前正中线向上叩，由鼓音转为浊音处即是肝下界。

（因
为人耳区分鼓音变浊音较为容易。

）
Percussion of liver span (肝上下径)
with the patient breathing normally 患者须正常呼吸
Percussion through the right midclavicular line from resonance over the lung field downward to dullness and from tympany over abdomen upward to dullness
叩诊须从肺部清音区沿右锁骨中线向下叩至浊音，从腹部鼓音区向上叩至浊音。

Measure from upper to lower border of dullness for liver span. It is normally about 9-11 cm in the midclavicular line.
匀称体型者的正常肝脏在右锁骨中线上，其上界在第5肋间，下界位于右季肋下缘，两者之间的距离为肝上下径，约9~11cm。

Percussion of the Liver:
正常肝脏上界位置:右锁中线第5肋间。

肝浊音界扩大:肝癌、肝脓肿等。

肝浊音界缩小:暴发性肝炎、肝硬化等。

肝浊音界下移:肺气肿、张力性气胸等。

肝区叩痛:肝炎、肝脓肿等。

肝浊音界消失：消化道穿孔等。

Traube semilunar space胃泡鼓音区(9.5 6cm):
上界：膈肌及肺下缘下界：肋弓
左界：脾脏右界：肝左缘
16.2 Percussion of the Spleen 脾脏叩诊
正常脾浊音界:左腋中线9~11肋间,长4~7cm 前方不超过腋前线
脾浊音区增大:脾肿大
脾浊音区缩小:气胸、胃扩张、肠胀气等。

Normally splenic dullness percussed between the 9th and the 11th intercostal space along left midaxillary line
正常时，在左腋中线第9~11肋之间叩到脾浊音。

√ the scope 4-7cm 长度约4~7cm
√ without passing over left anterior axillary line 前方不超过腋前线
This should be done when splenic enlargement is suspected.
当可察觉脾肿大时，才做脾脏叩诊。

17.presence or absence of free fluid in the abdominal cavity (ascites) 腹腔出现游离积液
detected by several maneuvers 能用多种指压法探查
(1) shifting dullness, 移动性浊音
(2) fluid wave 液波
(3) elbow-knee position( puddle test) 水坑试验
18. Percussion --- shifting dullness
lie on his back, percuss the abdomen at the umbilicus level from the midabdomen toward left side
患者仰卧位，自腹中部脐平面开始向患者左侧叩诊
tympany at midabdomen (the underlying bowel) 腹中部为鼓音（因为场馆内有气体而在液面浮起）
dullness at the bilateral flanks(the accumulation of ascites)When the patient with ascites lies on his back, the fluid will migrate into the flanks, producing dullness laterally. 两侧腹部呈浊音（因为腹水积聚在此）
find the point where percussion sound of tympany changes into dullness, should hold your pleximeter at that point,发现鼓音变浊音时，在声音转变处板指固定不动
simultaneously, ask the patient to turn on his right side and then continues to percuss the same point again. 与此同时，要求患者右侧卧位，在板指固定处再度叩诊
If the sound changes from dullness to tympany, it means that the dullness has been shifted to a more dependent position. This implies that ascites is present.如果闻及浊音又变为鼓音，说明浊音区因体位改变而移动了。

提示有腹水存在。

percuss the abdomen toward the right side. 同样方法向右侧叩诊。

find the point where percussion sound changes, and hold your pleximeter at that point, 发现鼓音变浊音时，在声音转变处板指固定不动
simultaneously, ask the patient to turn on his left side and then continue to percuss the same point again to confirm the shift of dullness. 与此同时，要求患者左侧卧位，在板指固定处再度叩诊
A volume of free fluid in the peritoneal cavity greater than 1000ml can be detected
with this method. 当腹腔内游离积液达1000ml以上时，即可用此法查出。

19. Elbow-knee position--- puddle test
amount too little, shifting dullness not be found, ask the patient to take elbow-knee position (puddle test examination in terms of percussion)
当腹水量少，用移动性浊音不能查出时，要求患者取肘膝位。

Elbow-knee position:
The purpose of elbow-knee position --- let the patient’s umbilicus at the lowest level
肘膝位——为了让患者脐部处于最低位
percuss from flanks toward the umbilicus 由侧腹部向脐部叩诊
If percussion sound could change from tympany to dullness, it indicates ascites.
如果叩诊音由鼓音转为浊音，则提示有腹水（水坑试验阳性）。

detect as little as 120 mL of fluid 当积液≥120ml时，可用此法查及。

many feeble patients cannot cooperate in the performance of this test (this method requires the patient to maintain such discomfortable position for several minutes)
许多虚弱患者无法配合水坑试验叩诊（此法要求患者保持十多分钟这种不舒服的姿势。

）
Differentiation:
Huge ovarian cyst 巨大卵巢囊肿
√ a large area of dullness at midabdomen 腹中部大面积浊音
√ tympany at laterals (bowels could be pushed to the bilateral flanks) 腹部两侧为鼓音（因为肠管被卵巢囊肿压挤至两侧腹部）
√ The dullness of ovarian cyst could not shift. 卵巢囊肿的浊音不呈移动性
Ruler pressing test 尺压试验
√ to differentiate huge ovarian cyst from real ascites 用于鉴别巨大卵巢囊肿和腹水
√ take the supine position, a hard ruler on the patient’s abdominal wall horizontally, presses the ruler downward with two hands. 患者仰卧位，用一硬尺横置于腹壁上，检查者两手将尺下压
If huge ovarian cyst exists, the pulsation of abdominal aorta will conduct to the ruler via the cyst, leading to rhythmic pulsation of the hard ruler.
如果存在巨大卵巢囊肿，则腹主动脉的节律性搏动可经囊肿传导到硬尺。

If free fluid, not cyst, exists in the abdominal cavity, the pulsation of abdominal aorta could not conduct, so the hard ruler has no such rhythmic pulsation.
如果腹腔内为游离积液，而非囊肿，则腹主动脉的节律性搏动无法被传导到硬尺。

20.Palpation 触诊
principle of palpation 触诊的原则
a) relax the patient 患者放松
b) palpate four quadrants superficially from LLQ counterclockwise 据四区法，由左下腹开始逆时针方向依次检查全腹各区表面。

c) palpate all areas counterclockwise and superficially from left lower quadrant screening for tenseness(紧张度), tenderness(压痛), masses, etc.
d) Examination begins with gentle maneuvers and then palpation occurs more deeply. 先以轻柔动作检查，再行深部触诊。

e) Examiner uses the palms of his hands with fingers together and arm relaxed and forearm on a horizontal plane. 检查者手臂放松，前臂应与腹部平面在同一水平，用整个手掌检查。

f) The examiner presses with his fingers. 用手指触压。

To palpate four quadrants deeply 深部触诊
√Using the palmer surface of the fingers, examiner palpates in four quadrants to identify masses, tenderness, pulsations, etc. 检查者用手指掌面在腹壁各象限检查，紧张度，搏动，有无肿块等。

√ The abdominal wall should be depressed more than 2 cm. 压力约为下压腹壁2cm以上。

√ When deep palpation is difficult, examiner may want to use left hand placed over right hand to help exert pressure. 当深部触诊困难时，检查者可将左手置于右手上帮助施加压力。

21. 触诊基本方法
浅部触诊(light palpation)
深部触诊(deep palpation)
深部滑行触诊(deep slipping palpation)：腹腔包块、器官
双手触诊(bimanual palpation)：肝、脾、肾、腹腔肿物。

深压触诊(deep press palpation):确定腹腔压痛点与反跳痛
冲击（浮沉）触诊(ballottement):适用于腹部大量积液时肝脾及腹腔包块难以触及者。

22.触诊的注意点:
对被检查者——
1. 仰卧体位、曲膝、垫枕。

2. 腹部充分暴露。

对检查者——
1.右侧站立；前臂与腹部表面同一水平
2.先左下逆时针；先正常后异常部位
3.边触诊边观察反应与表情，边谈话，减少患者紧张
√ If a mass is suspected, determine its size, contour, mobility, tenderness, smoothness, irregularity, the hardness or softness and listen with stethoscope for a bruit over the mass.
如果触诊到肿块，再确定它的大小、形态、活动度、压痛、光滑度、不规则度？、软硬，并且用听诊器听肿块上有无杂音。

√ If there is tenderness, determine the point of maximal tenderness and distribution.
如果有压痛，确定最剧烈的压痛点，以及压痛范围。

To check for rebound tenderness: 检查反跳痛
palpate deeply at the point of tenderness, pause briefly, then remove the fingers quickly. Watch the patient’s face to see whether it hurts.
深触压痛点，在此处稍停片刻，使压痛感觉趋于稳定，然后迅速将手抬起。

观察患者表情（痛苦表情或呻吟），看他是否感觉到了腹痛骤然加重。

check other areas in the same manner for comparison 用同样的方法检查其它部位做比较。

23. contents of palpation 触诊内容
a) abdominal tenseness腹壁紧张度
In normal persons, abdominal wall is somewhat tense, but usually soft when palpated and easily depressed , and is called abdominal softness(腹壁柔软).
在正常个体中，腹壁有一定张力，但是一般触之柔软，较易压陷，称腹壁柔软。

pathologic conditions → an abnormal ↑ or ↓ of abdominal tenseness
↑ of abdominal tenseness腹壁紧张度增加
√ Abdominal tenseness ↑, not accompanyed by muscle spasm无肌痉挛, ← t he ↑ abdominal content腹腔内容物增加, as gastrointestinal flatulence(肠胃胀气), artificial pneumoperitoneum(人工气腹), ascites, etc.
Board-like rigidity板状腹
√ If abdominal wall is palpated as obviously tense, even as rigid as a board, board-like rigidity is so called. 如果腹壁明显紧张，甚至强直，硬如木板，称板状腹。

√ ← the spasm of abdominal muscle由腹肌痉挛引起← peritoneal irritation, as the perforation of the gastrointeatinal diseases or rupture of the viscera 由腹膜刺激所致，比如急性胃肠穿孔或脏器破裂
Dough kneading sensation揉面感；柔韧感
√ If abdominal wall is palpated as pliable and tough, and if it has resistance and is not easily depressed, then the examiner feels the sensation of dough kneading.
腹壁柔韧且具抵抗力，不易压陷，检查者感到有揉面感。

√ Usually seen in tuberculosis peritonitis or cancerous peritonitis常见于结核性腹膜炎，或癌性腹膜炎。

↓ abdominal tenseness腹壁紧张度减低
← the decrease or disappearance of abdominal muscle’s tension(肌张力降低或消失)；Usually found in chronic deeline(消耗性疾病) or drainage of large amount of ascites （大量放腹水）
Supplementary: 补充
Two types of pain may be elicited by palpation.两种触诊可引发的疼痛。

(1)Visceral(内脏的)
√ ← an organic lesion or functional disturbance within an abdominal viscus腹腔内脏器的器质性损伤或功能障碍
√ e.g. seen in an obstruc tive lesion of the intestine (a buildup of pressure and distention of the gut) 例如，肠梗阻性损害（肠内压力升高膨胀）
√ s everal characteristics: dull, poorly localized, and difficult for the patient to characterize 特点：钝痛，定位不清，描述困难
(2). Somatic(躯体的；体壁的)
√ ≈ the distress no ted in painful lesions of the skin
√ sharp, bright, and well localized剧烈，明了，定位明确
√ not caused primarily by involvement of the viscera 内脏不是引起疼痛的主要原因
√ indicates involvement of one of the somatic structures, such as the parietal peritoneum or the abdominal wall itself 提示了与疼痛相关的体壁结构，例如壁层腹膜或者腹壁本身。

√ an inflammatory process originating in a viscus will produce visceral pain that may extend to involve the peritoneum. 内脏的炎性反应会产生影响到腹膜的内脏疼痛。

√ Inflammation of the peritoneum → somatic pain.
√ best illustrated by appendicitis(阑尾炎) : the pain is at first poorly localized, dull, ill defined, and primarily midline (when it is entirely visceral in origin). →as the inflammation spreads to the peritoneum, the pain becomes sharp, bright, and well localized in the right lower quadrant over the involved region.
e.g.阑尾炎：疼痛起初为钝痛，定位不清，难定义，主要在正中线上（当完全是内脏性原因引起时）→当炎症刺激传至腹膜，疼痛变得剧烈，明了，定位明确，在右下腹（麦氏点）。

√ After a painful area is located, the examiner should determine whether the pain is constant under the pressure of the examing hand or if it is transient, tending to disappear even though pressure is continued over the area.
确定疼痛部位之后，检查者需查明在检查者手的施压下，疼痛是持续存在的，还是暂时性的，即使对该区持续施压，疼痛也往往会消失。

√ Pain caused by inflammation usually remains unchanged or increases as pressure is applied 【拒按】. 由炎症反应引起的疼痛在受触压时，通常持续存在，或者变剧烈。

√ Visceral pain as the result of distention or contraction of a viscus tends to become less severe while pressure is maintained 【喜按】.由内脏扩张或收缩所引起的内脏性疼痛在受触压时，往往会变轻。

√ When pain has been elicited, the examiner should test the phenom enon of rebound tenderness. 当触诊腹部出现压痛后，检查者需检查反跳痛。

√ found only when the peritoneum(壁层腹膜) overlying a diseased viscus becomes inflamed
只有当壁层腹膜被它所覆盖的病变内脏累及时，才能查到躯体性疼痛。

√ Although it may be produced in different ways, the most common is to press firmly over a region distant from the tender area and then suddenly release the pressure. The patient will feel a sharp stab of pain in the area of disease if true rebound tenderness is present.
尽管反跳痛可通过多种方法检查，但是最常见的还是触压远离压痛处的部位，然后突然抬起手撤去力。

如果的确存在反跳痛，那么患者在病变处会感到一下剧烈的刺痛。

√ pressure applied in the right lower quadrant and then suddenly released will cause a marked increase in pain over an area of diverticulitis(憩室炎) in the left quadrant
当左半区有憩室炎时，对右下腹施压并且马上撤去压力会引起病变区疼痛显著增加。

√ Rebound tenderness may also be elicited by ha ving pressure over the tender area and having the patient cough or strain.
反跳痛也可由对压痛区施压，并且导致患者咳嗽或肌肉拉伸所引起。

√ At times, if the area involved is small, rebound tenderness may be elicited only over the most tender area of the abdomen.
有时受累部位比较小，反跳痛可能仅可在腹部压痛最明显处查及。

24.Tenderness and rebound tenderness
压痛(tenderness)+无反跳痛：腹内脏器炎症尚未累及壁层腹膜
压痛+反跳痛(rebound tenderness)：反跳痛--- 腹膜壁层已受炎症累及征象
腹膜刺激征（peritoneal irritation sign):压痛+反跳痛+腹肌紧张（“腹膜炎三联征”）；反跳痛可在远离受试部位发生（提示局部或弥漫性腹膜炎）
25.Palpation of Viscera----- liver 肝脏触诊
To palpate liver at midclavicular锁骨中线and midsternal lines 正中线
肝脏触诊手法的注意点:
四指并拢,食指前端桡侧（非指尖）接触肝脏。

右锁中线、前正中线为描述部位。

腹直肌外缘稍外。

密切配合呼吸运动,吸气时手指上抬速度落后于腹壁抬起，呼气时手指下压提前于腹壁下陷（“上抬慢，下压快”）。

大量腹水——冲击触诊。

不要误判(腹直肌腱划、右肾下极、横结肠)。

√ right hand held parallel to the lower border of the costal margin
右手与肋缘大致平行地放在右侧腹部
√ In the midclavicular starting at the anterior superior iliac crest, press down firmly and ask patient to inhale deeply
在右锁骨中线与髂前上棘交点处触压，并且要求患者深吸气。

√ allows the liver to move down to meet your fingertips
（吸气是为了）让肝脏能向下与检查者的指尖相触。

√ If you feel nothing, press up a few centimeters toward the rib cage and repeat the maneuver. Do this continuously until you feel the liver or reach the costal margin.
如果未触及，则将触压点向肋弓方向移动几厘米，重复之前的动作，直至能触及肝脏或到达肋缘。

√ Normally the liver is not p alpable, but sometimes the examiner may feel the edge of the normal liver at or slightly below the right costal margin.。