普外科常用体格检查课件

普外科常用体格检查北京积水潭医院普外科1 普外科常用体格检查北京积水潭医院 普外科 1目录甲状腺及颈部淋巴结查体乳腺及腋窝淋巴结查体腹股沟疝检查法肛管直肠检查法腹部查体2目录甲状腺及颈部淋巴结查体2颈部淋巴结视诊局部征象：皮肤隆起、颜色、皮疹、瘢痕、瘘管全身状态触诊示、中、环指并拢，指腹按压滑动触诊发现淋巴结肿大时应注意：部位、大小、数目、硬度、压痛、活动度、有无粘连，局部皮肤有无红肿、瘢痕、窦道等3颈部淋巴结视诊局部征象：皮肤隆起、颜色、皮疹、瘢痕、瘘管触诊耳前淋巴结耳屏前方耳后淋巴结（乳突淋巴结）耳后乳突表面，胸锁乳突肌止点处枕淋巴结枕部皮下，斜方肌起点与胸锁乳突肌止点之间颌下淋巴结颌下腺附近，下颌角与颏部中间部位颏下淋巴结颏下三角内，下颌舌骨肌表面，两侧下颌骨前端中点后方颈前淋巴结胸锁乳突肌表面及下颌角处颈后淋巴结斜方肌前缘锁骨上淋巴结锁骨与胸锁乳突肌所形成的夹角附近触诊顺序4耳前淋巴结 耳屏前方触诊顺序412345678512345678566附：颈淋巴结分区7附：颈淋巴结分区7甲状腺查体视诊大小及对称性触诊峡部：“前拇指，后示指”，胸骨上切迹起向上，配合吞咽侧叶：“前拇指，后示、中指”，“推气管，触对侧”听诊钟型听件低调连续性静脉“嗡鸣”提示甲亢，弥漫性甲状腺肿伴功能亢进可有收缩期动脉杂音肿大分度度：不能看出肿大但能触及度：能看到能触及，但在胸锁乳突肌以内度：超过胸锁乳突肌外侧缘8甲状腺查体视诊 大小及对称性峡部：“前拇指，后示指”，99乳腺查体两个体位：端坐位、仰卧位Inspection of the breast is the first step in physical examination and should be carried out with the patient sitting,arms at her sides and then overhead.Palpation of the breast for masses or other changes should be performed with the patient both seated and supine with the arm abducted.CURRENT Medical Diagnosis and Treatment 2015最好采用端坐和仰卧位检查，两侧乳房充分暴露，以利对比。人卫五年制外科学第8版10乳腺查体两个体位：端坐位、仰卧位Inspection of 双侧对称：形状、大小、乳头水平局限性隆起或凹陷皮肤红肿、橘皮样改变、酒窝征浅表静脉扩张乳头：内陷（长期/短期内），乳头乳晕糜烂视诊触诊（扪诊）Palpation with a rotary motion of the examiners fingers as well as a horizontal stripping motion has been recommended.CURRENT Medical Diagnosis and Treatment 2015原则手指掌面、不要捏（不用指尖）外上（腋尾部）、外下、内下、内上及中央区先健侧，后患侧11双侧对称：形状、大小、乳头水平局限性隆起或凹陷皮肤红肿、橘皮发现乳腺肿块大小硬度表面光滑程度边界活动度皮肤粘连：轻捻起肿物表面皮肤与深部组织关系：嘱双手叉腰，使胸肌紧张，肿物活动是否受限乳头溢液：轻挤乳头，如有溢液，挤压乳晕四周，查出自哪一乳管12发现乳腺肿块大小硬度表面光滑程度边界活动度皮肤粘连：轻捻起肿腋窝淋巴结体位：端坐位（直立位）腋窝境界13腋窝淋巴结体位：端坐位（直立位）腋窝境界13锁骨下肌胸外侧神经锁胸筋膜胸大肌头静脉胸小肌胸尖峰动脉腋动脉腋悬韧带腋筋膜肩胛下动脉腋静脉肩胛下肌大圆肌背阔肌胸内侧神经14锁骨下肌胸外侧神经锁胸筋膜胸大肌头静脉胸小肌胸尖峰动脉腋动脉触诊顺序及传统解剖学分组15触诊顺序及传统解剖学分组15胸廓内淋巴结尖（顶）淋巴结中央淋巴结外侧群淋巴结后群淋巴结（肩胛下）前群淋巴结（胸肌）胸肌间淋巴结(rotter)16胸廓内淋巴结尖（顶）淋巴结中央淋巴结外侧群淋巴结后群淋巴结（附：腋窝淋巴结分级17附：腋窝淋巴结分级17Rotter淋巴结属于几级淋巴结？人卫八年制外科学第2版：RotterLN属于级淋巴结人卫五年制外科学第8版：RotterLN属于级淋巴结部分医生根据实际解剖经验以及预后情况认为：RotterLN可归为级淋巴结18Rotter淋巴结属于几级淋巴结？人卫八年制外科学第2版What may be significant is that these nodes provide a separate pathway to the subclavicular nodes at the apex of the axilla,bypassing the main axillary lymph node groups.Saul Kay.EVALUATION OF ROTTERS LYMPH NODES IN RADICAL MASTECTOMY SPECIMENS AS A GUIDE TO PROGNOSIS.Cancer.1965.11Rotter淋巴结的临床意义术中原则：常规腋窝清扫时需要清扫Rotter淋巴结19What may be significant is thaEXAMINATION OF AN INGUINAL HERNIA“Please examine this patients groin”Don gloves,introduce yourself and explain your intention,then expose the patient STAND patient up,examine both sides-Mr X is a _ who appears uncomfortable at rest.-I notice a groin/inguinoscrotal lump.Squat down and examine!-Inspect as per a lump:(if unable to see,ask the patient)1.Is lump above or below the inguinal ligament?Any scrotal lump?2.Estimate the dimensions of the lump 3.Any skin changes?Previous scars(look hard)?4.Any lump on the other side?5.Abdominal distension/visible abdo mass?-Sir,could you turn head and cough?Look for Visible cough impulse(seen in large inguinoscrotal hernias)-Sir,is there any pain over the groin area?I am going to feel the lump.Palpate:1.Can get above the lump?2.Can feel testis?3.Lump:consistency(soft,fluctuant),size,temperature,any tenderness?4.Sir,could you turn head and cough again?Feel for Palpable cough impulse(bilaterally?)-Sir,could you reduce the lump for me?o Reducible:The point of reduction is“above and medial to the pubic tubercle”(superficial ring)o Incarcerated:The patient is unable to reduce the lump.腹股沟疝查体法Andre Surgery notes editted by ChinYee(ed 2b,2012)20EXAMINATION OF AN INGUINAL HERLay the patient supine.(supposing youre standing on patients LEFT)-Reduce the hernia if patient has not done so.-Locate the Deep inguinal ring:vice versa for right side o Left hand define patients pubic tubercle:from umbilicus down pubic symp.to the left 1st bony prominence o Right hand define the ASIS(Anterior Superior Iliac Spine)o Left hand to the midpoint of inguinal ligament 2cm above-Keep pressure on deep ring,ask patient to sit up&support his pelvis,then swing over the bed and stand With patient standing:-Sir,could you turn head and cough?o if remains reduced indirect hernia,o if not,direct hernia.(poor accuracy)-Remove pressure&watch movement of hernia:slide obliquely(indirect)or project forward(direct)-Percuss&ascultate for bowel sounds Examine other side Offer:1)Abdo exam:scars,masses,ascites,ARU,constipation,IO 2)DRE for BPH,impacted stools 3)Respiratory exam for COPD 4)Ask patient for history of heavy lifting Differential diagnosis:-Femoral hernia-Inguinal LN-Hydrocele of the cord(boys),or canal of Nuck(girls)-Saphenous varix:bluish-tinge,disappears on lying supine,also has positive cough impulse-Undescended testes-Lipoma of the cord 21Lay the patient supine.(suppo肛管直肠检查法体位：左侧卧位、膝胸位、截石位、蹲位、弯腰前俯位视诊双手拇指/示中环指，分开臀沟红肿、血、脓、粪便、黏液、瘘口、外痔、疣状物、溃疡、肿块及脱垂直肠指诊（右手带手套润滑液）肛周指诊:肛管肿块、压痛、皮肤疣状物、条索、外痔测试肛管括约肌松紧度：正常只能伸入一指，并紧缩感肛管直肠壁：触痛、波动感、肿块、硬结、狭窄，直肠粘膜完整性直肠前壁距肛缘4-5cm：男性前列腺；女性子宫颈必要时双合诊出指后：指套血迹、黏液（有血迹而未触及病变应行乙状结肠镜）22肛管直肠检查法体位：左侧卧位、膝胸位、截石位、蹲位、弯腰前俯腹部查体视诊腹部外形、呼吸运动、腹壁静脉、胃肠型及蠕动波、皮疹、色素、腹纹、瘢痕、疝、脐、上腹部搏动听诊肠鸣音、血管杂音叩诊全腹叩诊、肝区（肝浊音界+叩痛）、胃泡鼓音区、脾脏（脾浊音界+叩痛）、移动性浊音触诊腹壁紧张度、压痛及反跳痛、肾盂及输尿管点压痛、肝脏、脾脏、胆囊、腹部包块、液波震颤、振水音、腹壁反射、腹股沟淋巴结23腹部查体视诊23完24完24