普外科常用體格檢查課件

1、 普外科常用體格檢查1目錄甲狀腺及頸部淋巴結(jié)查體乳腺及腋窩淋巴結(jié)查體腹股溝疝檢查法肛管直腸檢查法腹部查體2頸部淋巴結(jié)視診局部征象：皮膚隆起、顏色、皮疹、瘢痕、瘺管全身狀態(tài)觸診 示、中、環(huán)指并攏，指腹按壓滑動觸診發(fā)現(xiàn)淋巴結(jié)腫大時應(yīng)注意： 部位、大小、數(shù)目、硬度、壓痛、活動度、有無粘連，局部皮膚有無紅腫、瘢痕、竇道等3耳前淋巴結(jié) 耳屏前方耳后淋巴結(jié)（乳突淋巴結(jié)） 耳后乳突表面，胸鎖乳突肌止點處枕淋巴結(jié) 枕部皮下，斜方肌起點與胸鎖乳突肌止點之間頜下淋巴結(jié) 頜下腺附近，下頜角與頦部中間部位頦下淋巴結(jié) 頦下三角內(nèi)，下頜舌骨肌表面，兩側(cè)下頜骨前端中點后方頸前淋巴結(jié) 胸鎖乳突肌表面及下頜角處頸后淋巴結(jié) 斜方

2、肌前緣鎖骨上淋巴結(jié) 鎖骨與胸鎖乳突肌所形成的夾角附近觸診順序41234567856附：頸淋巴結(jié)分區(qū)7甲狀腺查體視診 大小及對稱性觸診峽部：“前拇指，后示指”，胸骨上切跡起向上，配合吞咽側(cè)葉：“前拇指，后示、中指”，“推氣管，觸對側(cè)”聽診 鐘型聽件低調(diào)連續(xù)性靜脈“嗡鳴”提示甲亢，彌漫性甲狀腺腫伴功能亢進(jìn)可有收縮期動脈雜音腫大分度度：不能看出腫大但能觸及度：能看到能觸及，但在胸鎖乳突肌以內(nèi)度：超過胸鎖乳突肌外側(cè)緣8大家應(yīng)該也有點累了，稍作休息大家有疑問的，可以詢問和交流910乳腺查體兩個體位：端坐位、仰臥位Inspection of the breast is the first step in

3、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最好采用端坐和仰臥位檢查

4、，兩側(cè)乳房充分暴露，以利對比。 人衛(wèi)五年制外科學(xué)第8版11雙側(cè)對稱：形狀、大小、乳頭水平局限性隆起或凹陷皮膚紅腫、橘皮樣改變、酒窩征淺表靜脈擴(kuò)張乳頭：內(nèi)陷（長期/短期內(nèi)），乳頭乳暈糜爛視診觸診（捫診）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原則 手指掌面、不要捏（不用指尖） 外上（腋尾部）、外下、內(nèi)下、內(nèi)上及中央

5、區(qū) 先健側(cè)，后患側(cè)12發(fā)現(xiàn)乳腺腫塊大小硬度表面光滑程度邊界活動度皮膚粘連：輕捻起腫物表面皮膚與深部組織關(guān)系： 囑雙手叉腰，使胸肌緊張，腫物活動是否受限乳頭溢液：輕擠乳頭，如有溢液，擠壓乳暈四周，查出自哪一乳管13腋窩淋巴結(jié)體位：端坐位（直立位）腋窩境界14鎖骨下肌胸外側(cè)神經(jīng)鎖胸筋膜胸大肌頭靜脈胸小肌胸尖峰動脈腋動脈腋懸韌帶腋筋膜肩胛下動脈腋靜脈肩胛下肌大圓肌背闊肌胸內(nèi)側(cè)神經(jīng)15觸診順序及傳統(tǒng)解剖學(xué)分組16胸廓內(nèi)淋巴結(jié)尖（頂）淋巴結(jié)中央淋巴結(jié)外側(cè)群淋巴結(jié)后群淋巴結(jié)（肩胛下）前群淋巴結(jié)（胸?。┬丶￠g淋巴結(jié)(rotter)17附：腋窩淋巴結(jié)分級18Rotter淋巴結(jié)屬于幾級淋巴結(jié)？人衛(wèi)八年制外科學(xué)第

6、2版：Rotter LN屬于級淋巴結(jié)人衛(wèi)五年制外科學(xué)第8版：Rotter LN屬于級淋巴結(jié)部分醫(yī)生根據(jù)實際解剖經(jīng)驗以及預(yù)后情況認(rèn)為：Rotter LN可歸為級淋巴結(jié)19What 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

7、IN RADICAL MASTECTOMY SPECIMENS AS A GUIDE TO PROGNOSIS. Cancer. 1965.11Rotter淋巴結(jié)的臨床意義術(shù)中原則：常規(guī)腋窩清掃時需要清掃Rotter淋巴結(jié)20EXAMINATION 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 si

8、des - 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 ch

9、anges? 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. Palpat

10、e: 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 “ab

11、ove and medial to the pubic tubercle” (superficial ring) o Incarcerated: The patient is unable to reduce the lump. 腹股溝疝查體法Andre Surgery notes editted by ChinYee (ed 2b, 2012)21Lay the patient supine. (supposing youre standing on patients LEFT) - Reduce the hernia if patient has not done so. - Locate

12、 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 dee

13、p 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) o

14、r 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 -

15、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 22肛管直腸檢查法體位：左側(cè)臥位、膝胸位、截石位、蹲位、彎腰前俯位視診 雙手拇指/示中環(huán)指，分開臀溝 紅腫、血、膿、糞便、黏液、瘺口、外痔、疣狀物、潰瘍、腫塊及脫垂直腸指診（右手帶手套潤滑液）肛周指診: 肛管腫塊、壓痛、皮膚疣狀物、條索、外痔測試肛管括約肌松緊度：正常只能伸入一指，并緊縮感肛管直腸壁：觸痛、波動感、腫塊、硬結(jié)