普外科常用体格检查专家讲座

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验法肛管直肠检验法腹部查体普外科常用体格检查专家讲座第1页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觉淋巴结肿大时应注意：

部位、大小、数目、硬度、压痛、活动度、有没有粘连，局部皮肤有没有红肿、瘢痕、窦道等普外科常用体格检查专家讲座第2页耳前淋巴结

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夹角附近触诊次序普外科常用体格检查专家讲座第3页12345678普外科常用体格检查专家讲座第4页普外科常用体格检查专家讲座第5页附：颈淋巴结分区普外科常用体格检查专家讲座第6页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”提醒甲亢，弥漫性甲状腺肿伴功效亢进可有收缩期动脉杂音肿大分度Ⅰ度：不能看出肿大但能触及Ⅱ度：能看到能触及，但在胸锁乳突肌以内Ⅲ度：超出胸锁乳突肌外侧缘普外科常用体格检查专家讲座第7页普外科常用体格检查专家讲座第8页乳腺查体两个体位：端坐位、仰卧位Inspectionofthebreastisthefirststepinphysicalexaminationandshouldbecarriedoutwiththepatientsitting,armsathersidesandthenoverhead.Palpationofthebreastformassesorotherchangesshouldbeperformedwiththepatientbothseatedandsupinewiththearmabducted.

——CURRENTMedicalDiagnosisandTreatment最好采取端坐和仰卧位检验，两侧乳房充分暴露，以利对比。

——人卫五年制《外科学》第8版普外科常用体格检查专家讲座第9页双侧对称：形状、大小、乳头水平不足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（长久/短期内），乳头乳晕糜烂视诊触诊（扪诊）Palpationwith

arotarymotionoftheexaminer’sfingersaswellas

ahorizontalstrippingmotionhasbeenrecommended.——CURRENTMedicalDiagnosisandTreatment标准

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，后患侧普外科常用体格检查专家讲座第10页发觉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，使胸肌担心，肿物活动是否受限乳头溢液：轻挤乳头，如有溢液，挤压乳晕四面，查出自哪一乳管普外科常用体格检查专家讲座第11页腋窝淋巴结体位：端坐位（直立位）腋窝境界普外科常用体格检查专家讲座第12页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普外科常用体格检查专家讲座第13页分组名称查体位置沿血管走行中央淋巴结群（中央群）腋窝内侧壁近肋骨及前锯肌处腋窝底胸肌淋巴结群（胸肌群，前群）前锯肌表面，胸小肌下缘胸外侧血管肩胛下淋巴结群（肩胛下群，后群）腋窝后皱襞深部肩胛下血管外侧淋巴结群（外侧群）腋窝外侧壁腋静脉远侧腋尖淋巴结群（尖群，锁骨下LN，内侧群）锁骨下肌下内，胸小肌上缘及内侧，锁胸筋膜深面腋静脉近侧锁骨上淋巴结

不属于腋窝淋巴结，但要求腋窝查体时触诊另外：胸肌间淋巴结（rotter淋巴结）属于腋窝淋巴结，但腋窝触诊时并未提及胸大肌、胸小肌之间血管周围脂肪内胸肩锋血管肌支触诊次序及传统解剖学分组普外科常用体格检查专家讲座第14页胸廓内淋巴结尖（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)普外科常用体格检查专家讲座第15页附：腋窝淋巴结分级普外科常用体格检查专家讲座第16页Rotter淋巴结属于几级淋巴结？人卫八年制《外科学》第2版：RotterLN属于Ⅰ级淋巴结人卫五年制《外科学》第8版：RotterLN属于Ⅱ级淋巴结部分医生依据实际解剖经验以及预后情况认为：RotterLN可归为Ⅲ级淋巴结普外科常用体格检查专家讲座第17页Whatmaybesignificantisthatthesenodesprovideaseparatepathwaytothesubclavicularnodesattheapexoftheaxilla,bypassingthemainaxillarylymphnodegroups.

——SaulKay.EVALUATIONOFROTTER’SLYMPHNODESINRADICAL MASTECTOMYSPECIMENSASAGUIDETOPROGNOSIS.Cancer.1965.11Rotter淋巴结临床意义术中标准：常规腋窝清扫时需要清扫Rotter淋巴结普外科常用体格检查专家讲座第18页EXAMINATIONOFANINGUINALHERNIA“Pleaseexaminethispatient’sgroin”Dongloves,introduceyourselfandexplainyourintention,thenexposethepatientSTANDpatientup,examinebothsides-MrXisa___whoappearsuncomfortableatrest.-Inoticeagroin/inguinoscrotallump.Squatdownandexamine!-Inspectasperalump:(ifunabletosee,askthepatient)1.Islumpaboveorbelowtheinguinalligament?Anyscrotallump?2.Estimatethedimensionsofthelump3.Anyskinchanges?Previousscars(lookhard)?4.Anylumpontheotherside?5.Abdominaldistension/visibleabdomass?-Sir,couldyouturnheadandcough?LookforVisiblecoughimpulse(seeninlargeinguinoscrotalhernias)-Sir,isthereanypainoverthegroinarea?Iamgoingtofeelthelump.Palpate:1.Cangetabovethelump?2.Canfeeltestis?3.Lump:consistency(soft,fluctuant),size,temperature,anytenderness?4.Sir,couldyouturnheadandcoughagain?FeelforPalpablecoughimpulse(bilaterally?)-Sir,couldyoureducethelumpforme?oReducible:Thepointofreductionis“aboveandmedialtothepubictubercle”(superficialring)oIncarcerated:Thepatientisunabletoreducethelump.腹股沟疝查体法《AndreSurgerynotesedittedbyChinYee(ed2b,)》普外科常用体格检查专家讲座第19页Laythepatientsupine.(supposingyou’restandingonpatient’sLEFT)-Reducetheherniaifpatienthasnotdoneso.-LocatetheDeepinguinalring:[viceversaforrightside]oLefthanddefinepatient’spubictubercle:fromumbilicusdownpubicsymp.totheleft1stbonyprominenceoRighthanddefinetheASIS(AnteriorSuperiorIliacSpine)oLefthandtothemidpointofinguinalligament2cmabove-Keeppressureondeepring,askpatienttositup&supporthispelvis,thenswingoverthebedandstandWithpatientstanding:-Sir,couldyouturnheadandcough?oifremainsreduced–indirecthernia,oifnot,directhernia.(pooraccuracy)-Removepressure&watchmovementofhernia:slideobliquely(indirect)orprojectforward(direct)-Percuss&ascultateforbowelsoundsExamineothersideOffer:1)Abdoexam:scars,masses,ascites,ARU,constipation,IO2)DREforBPH,impactedstools3)RespiratoryexamforCOPD4)Askpatientforhistoryofheavylifting

Differentialdiagnosis:-Femoralhernia-InguinalLN-Hydroceleofthecord(boys),orcanalofNuck(girls)-Saphenousvarix:[bluish-tinge,disappearsonlyingsupine,alsohaspositivecoughim