腹部检查 I：视诊与听诊

Key surface landmarks include the costal margins, xiphoid process, rectus abdominal muscle, linea alba, umbilicus, iliac crest, inguinal ligament, and symphysis pubis. The abdominal exam extends from the xiphoid and costal margins superiorly to the symphysis pubis inferiorly. Knowing these landmarks is essential for accurately documenting patient complaints and physical findings.

The abdomen is subdivided into four quadrants by two imaginary lines intersecting at the umbilicus: right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant. A more detailed topography divides it into nine regions: right and left hypochondriac, right and left lumbar, right and left iliac, plus epigastric, umbilical, and hypogastric regions. Understanding organ location within each region aids clinical interpretation.

Inspect the skin for rashes, ecchymoses, jaundice, dilated veins, striae, lesions, bruises, and scars. Examine abdominal shape—flat, protuberant, or scaphoid—and check for symmetry. Look for visible hernias, masses, pulsations, or peristalsis. Purplish discoloration around the umbilicus indicates subcutaneous intraperitoneal bleeding, suggesting acute hemorrhagic pancreatitis. Asymmetry and overall bulging warrant further investigation.

Use the diaphragm of a pre-warmed stethoscope to listen over each of the four abdominal quadrants for 30-40 seconds. Normal gurgling sounds occur at 5-34 per minute. If bowel sounds are absent in an asymptomatic patient, listen for at least three full minutes before confirming absence. In symptomatic patients, absent sounds suggest paralytic ileus, while hyperactive, high-pitched sounds may indicate early bowel obstruction.

Listen at seven locations: above the right renal artery, the aorta, the left renal artery, the common iliac arteries, and the femoral arteries for at least five seconds each. Listen for bruits, which are audible vascular swishing sounds caused by turbulent flow. Their presence indicates stenosis in renal, iliac, or femoral arteries, or suggests abdominal aortic aneurysm. This assessment is crucial for detecting vascular pathology.

Request the patient to lie supine at a 30-45 degree angle with knees slightly flexed and arms at their sides. Ensure the bladder is empty and the patient is comfortable. Expose the abdomen from above the xiphoid to the suprapubic region while maintaining modesty. Provide adequate lighting, minimize noise, wash your hands, warm them and the stethoscope, and explain each step to the patient as you proceed.

Friction rubs are rare findings detected by listening over the liver and spleen during auscultation. Their presence suggests inflammation of the peritoneal surface of the organ from infection, tumor, or infarct. Recognizing this abnormal finding is important for identifying serious pathology. After completing inspection and auscultation, the exam continues with acute abdominal pain assessment.