What is the difference between light and deep abdominal palpation?

Light palpation is superficial, pressing to approximately 1 cm depth to identify superficial organs, masses, and abdominal wall crepitus. Deep palpation applies firm pressure to examine internal organs like the liver, kidneys, spleen, and stomach, and can detect organomegaly and aortic aneurysm. Both techniques are essential for comprehensive abdominal assessment.

How should you position and prepare a patient before performing abdominal palpation?

Position the patient supine with proper draping to maintain modesty. Explain the procedure and obtain consent. Ask the patient to identify painful areas and examine those last to minimize guarding. Encourage abdominal relaxation by having the patient bend their knees and breathe with their abdomen. These measures reduce voluntary muscle resistance and improve exam accuracy.

What technique should you use when examining the liver during abdominal palpation?

Place your right hand lateral to the rectus muscle below the liver's percussed border, fingers oriented cephalad. Ask the patient to take a deep breath; the liver descends and its edge meets your fingertips. Continue moving upward to feel the edge, typically a few centimeters below the right costal margin. Note the edge's texture and regularity as you palpate.

How do you detect an enlarged spleen during palpation?

A normal spleen is rarely palpable, but an enlarged spleen displaces downward below the rib cage and medially across the abdomen. Starting in the left lower quadrant, move your fingers slightly upward with each inspiration and expiration, pressing downward and toward the patient's head. If not felt initially, repeat with the patient lying on their right side.

What is the two-hand palpation technique and when should it be used?

In two-hand palpation, place your non-dominant hand on top of your dominant hand. Keep the lower hand relaxed and press with the upper hand's fingers on the distal phalangeal joints of the lower hand. This technique is useful in obese patients or when voluntary muscle resistance is present, allowing one hand to produce pressure while the other feels the underlying structures.

How do you perform kidney palpation to detect enlargement?

Position your left hand at the costophrenic angle and palpate with your right hand pressing forward, attempting to capture the kidney between your hands. Ask the patient to take a deep breath and feel for the kidney on inspiration. If felt, ask the patient to exhale and hold their breath to feel the kidney return to its expiratory position. Repeat on the left side.

What information does abdominal palpation provide during patient assessment?

Abdominal palpation identifies areas of tenderness, organomegaly, and tumors, providing valuable information about problem localization and severity. It integrates findings from history and other abdominal exam components to guide subsequent diagnostic steps. For skilled examiners, palpation assesses both large superficial organs and smaller deeper structures, though patient anatomy may affect examination difficulty.

腹部检查 III：触诊

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1. 轻柔触诊

轻触诊有助于确定压痛区域以及因腹壁僵硬（不自主的肌肉痉挛）或保护性收缩（腹壁肌肉的自主性收缩）引起的腹壁抵抗。此外，还可用于识别浅表器官或肿块，或更少见的腹壁捻发音（由皮下组织内的气体或液体引起）。

确保患者体位正确，并向其解释检查过程。
请患者指出疼痛或压痛区域，并最后检查该区域（以避免因紧张导致的全腹肌紧张）。轻柔地检查疼痛区域，不要试图重新诱发疼痛。
为促进腹部放松，可让患者调整体位或屈膝卧位。也可指导患者进行腹式呼吸，同时将手上下移动，趁腹壁在吸气/呼气周期中运动时进行触诊。这些措施通常可减轻自主性腹肌紧张。
使用惯用手，保持手指并拢，用指腹（手指的平坦面）以轻柔的环形动作按压约1 cm深度。
按顺时针方向依次检查所有腹部区域。移动至不同部位时应稍抬起手，避免突然的戳刺动作。
若患者怕痒，可先让患者将手置于检查者的手下方，片刻后将检查者的手滑入患者手下方进行触诊。
触诊时注意观察患者面部，有无不适或疼痛表现。
注意腹壁是否存在不规则隆起、浅表器官或肿块，以及捻发音（触诊时皮下组织内气体或液体产生的捻发样感觉）。

2. 深部触诊

浅部触诊可提供有关潜在压痛点、浅层结构及腹壁的信息，而深部触诊则可用于检查内脏器官，并明确腹腔内肿块的位置。此外，深部触诊还可发现其他压痛区域。

从与疼痛部位相对的象限开始。操作过程中持续观察患者面部，注意是否有疼痛或不适的表现。
将手掌平放于腹壁，施加稳固的向下和纵向压力。保持手指在皮肤上相对固定，采用滚动动作进行触诊。
对于肥胖患者或存在自主性腹肌紧张的患者，采用双手触诊法。
1. 将非优势手放在优势手之上。
2. 保持下方的手放松，用上方手的手指按压在下方手远端指间关节处。这样，一只手施加压力，另一只手用于感知。
依次触诊四个腹部象限。可触及的腹部器官包括肝脏、盲肠、乙状结肠，有时还包括横结肠和胃。肿大的肾脏、胆囊、脾脏以及主动脉肿块也可能被触及。（图1）

3. 肝脏触诊

在吸气时，肝脏下缘可在右侧肋骨下方约3 cm处触及。肝脏触诊可采用单手或双手法，对于肥胖患者，所谓的"钩指"技术也可能有所帮助。

单手肝脏触诊
1. 将右手置于患者腹壁，位于腹直肌外侧，低于叩诊所确定的肝浊音界水平。
2. 手指朝向患者头部或略斜向中线方向，用力向上（朝向患者头部）按压。
3. 嘱患者深吸气。吸气时肝脏下移，其边缘可触及触诊手指的指尖。
4. 继续触诊，将手逐渐移向肋缘，直至触及肝缘（通常位于右侧肋缘下数厘米处）。注意肝缘的质地和规则性。触诊时轻度压痛属正常现象。
5. 当手指触及肝缘时，在患者持续深吸气的同时，略微减轻腹壁压力。此动作可使检查者感知肝脏前表面滑过指腹的感觉。注意记录肝脏表面的质地，如有无结节、颗粒感等。（图2）
双手肝脏触诊
1. 将左手置于患者背部，平第十一至第十二肋处，轻柔向上推压，使肝脏上抬至更易触及的位置。
2. 嘱患者深吸气，并按上述方法用右手进行触诊。
"钩指"触诊法
当常规触诊方法无法触及肝脏时，此技术可能有所帮助。
1. 站在患者右侧，面向患者足部。
2. 将弯曲的手指置于肋缘边缘上方。
3. 嘱患者深吸气，同时尝试在向下和向上（朝向患者头部）按压的过程中感知肝缘。

4. 脾脏触诊

正常大小的脾脏通常无法触及。偶尔可在左侧肋缘处触及脾脏的尖端。当脾脏显著肿大时，会推挤胃部，并向下延伸至肋缘下方，向腹部内侧扩大，甚至可在右下腹象限触及（图3）。

嘱患者深吸气，然后在呼气时尝试触诊脾脏的下缘。
从右下腹开始，每次呼吸周期后将手指略向上移动。
触诊时向下并向患者头部方向按压，然后放松，动作与触诊肝脏下缘相同。
若未触及脾脏，让患者侧卧于右侧，重复检查。
部分检查者采用双手触诊法，即用右手进行触诊，同时将左手置于患者左侧肋骨后方，向上推压肋骨及软组织。

5. 肾脏触诊

肾脏为腹膜后器官，在健康成人中通常无法触及。有时可通过双手触诊评估肿大的肾脏 "投票遴选" 技术（源自法语单词） 叩诊时的震颤感，意味着 "翻动"）。检查者一只手置于腹直肌外侧的上腹部象限，另一只手放在肋膈角处并向上推压（使肾脏更接近腹前壁）（图4）。该操作在深吸气时进行，此时肾脏下移，可触及肾脏的下极。