普外科常用体格检查-课件

普外科常用体格检查1普外科常用体格检查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”，大家应该也有点累了，稍作休息大家有疑问的，可以询问和交流9大家应该也有点累了，稍作休息大家有疑问的，可以询问和交流91010乳腺查体两个体位：端坐位、仰卧位Inspectionofthebreastisthefirststepinphysicalexaminationandshouldbecarriedoutwiththepatientsitting,armsathersidesandthenoverhead.Palpationofthebreastformassesorotherchangesshouldbeperformedwiththepatientbothseatedandsupinewiththearmabducted.

——CURRENTMedicalDiagnosisandTreatment2015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11乳腺查体两个体位：端坐位、仰卧位Inspectionof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）Palpationwitharotarymotionoftheexaminer’sfingersaswellasahorizontalstrippingmotionhasbeenrecommended.——CURRENTMedicalDiagnosisandTreatment2015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12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13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14腋窝淋巴结体位：端坐位（直立位）腋窝境界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15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16触诊顺序及传统解剖学分组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（肩胛下）前群淋巴结（胸肌）胸肌间淋巴结(rotter)17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18附：腋窝淋巴结分级18Rotter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级淋巴结部分医生根据实际解剖经验以及预后情况认为：RotterLN可归为Ⅲ级淋巴结19Rotter淋巴结属于几级淋巴结？人卫八年制《外科学》第2版Whatmaybesignificantisthatthesenodesprovideaseparatepathwaytothesubclavicularnodesattheapexoftheaxilla,bypassingthemainaxillarylymphnodegroups.

——SaulKay.EVALUATIONOFROTTER’SLYMPHNODESINRADICAL MASTECTOMYSPECIMENSASAGUIDETOPROGNOSIS.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20WhatmaybesignificantisthaEXAMINATIONOFANINGUINALHERNIA“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,2012)》21EXAMINATIONOFANINGUINALHERLaythepatientsupine.(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,alsohaspositivecoughimpulse]-