普外科常用體格檢查專(zhuān)家講座

目錄甲狀腺及頸部淋巴結(jié)查體乳腺及腋窩淋巴結(jié)查體腹股溝疝檢驗(yàn)法肛管直腸檢驗(yàn)法腹部查體普外科常用體格檢查專(zhuān)家講座第1頁(yè)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(dòng)觸診發(fā)覺(jué)淋巴結(jié)腫大時(shí)應(yīng)注意：

部位、大小、數(shù)目、硬度、壓痛、活動(dòng)度、有沒(méi)有粘連，局部皮膚有沒(méi)有紅腫、瘢痕、竇道等普外科常用體格檢查專(zhuān)家講座第2頁(yè)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(diǎn)處枕淋巴結(jié)

枕部皮下，斜方肌起點(diǎn)與胸鎖乳突肌止點(diǎn)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(diǎn)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)斜方肌前緣鎖骨上淋巴結(jié)鎖骨與胸鎖乳突肌所形成夾角附近觸診次序普外科常用體格檢查專(zhuān)家講座第3頁(yè)12345678普外科常用體格檢查專(zhuān)家講座第4頁(yè)普外科常用體格檢查專(zhuān)家講座第5頁(yè)附：頸淋巴結(jié)分區(qū)普外科常用體格檢查專(zhuān)家講座第6頁(yè)甲狀腺查體視診大小及對(duì)稱(chēng)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(duì)側(cè)”聽(tīng)診鐘型聽(tīng)件低調(diào)連續(xù)性靜脈“嗡鳴”提醒甲亢，彌漫性甲狀腺腫伴功效亢進(jìn)可有收縮期動(dòng)脈雜音腫大分度Ⅰ度：不能看出腫大但能觸及Ⅱ度：能看到能觸及，但在胸鎖乳突肌以?xún)?nèi)Ⅲ度：超出胸鎖乳突肌外側(cè)緣普外科常用體格檢查專(zhuān)家講座第7頁(yè)普外科常用體格檢查專(zhuān)家講座第8頁(yè)乳腺查體兩個(gè)體位：端坐位、仰臥位Inspectionofthebreastisthefirststepinphysicalexaminationandshouldbecarriedoutwiththepatientsitting,armsathersidesandthenoverhead.Palpationofthebreastformassesorotherchangesshouldbeperformedwiththepatientbothseatedandsupinewiththearmabducted.

——CURRENTMedicalDiagnosisandTreatment最好采取端坐和仰臥位檢驗(yàn)，兩側(cè)乳房充分暴露，以利對(duì)比。

——人衛(wèi)五年制《外科學(xué)》第8版普外科常用體格檢查專(zhuān)家講座第9頁(yè)雙側(cè)對(duì)稱(chēng)：形狀、大小、乳頭水平不足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(zhǎng)久/短期內(nèi)），乳頭乳暈糜爛視診觸診（捫診）Palpationwith

arotarymotionoftheexaminer’sfingersaswellas

ahorizontalstrippingmotionhasbeenrecommended.——CURRENTMedicalDiagnosisandTreatment標(biāo)準(zhǔn)

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?yún)^(qū)

先健側(cè)，后患側(cè)普外科常用體格檢查專(zhuān)家講座第10頁(yè)發(fā)覺(jué)乳腺腫塊大小硬度表面光滑程度邊界活動(dòng)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，使胸肌擔(dān)心，腫物活動(dòng)是否受限乳頭溢液：輕擠乳頭，如有溢液，擠壓乳暈四面，查出自哪一乳管普外科常用體格檢查專(zhuān)家講座第11頁(yè)腋窩淋巴結(jié)體位：端坐位（直立位）腋窩境界普外科常用體格檢查專(zhuān)家講座第12頁(yè)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(dòng)脈腋動(dòng)脈腋懸韌帶腋筋膜肩胛下動(dòng)脈腋靜脈肩胛下肌大圓肌背闊肌胸內(nèi)側(cè)神經(jīng)普外科常用體格檢查專(zhuān)家講座第13頁(yè)分組名稱(chēng)查體位置沿血管走行中央淋巴結(jié)群（中央群）腋窩內(nèi)側(cè)壁近肋骨及前鋸肌處腋窩底胸肌淋巴結(jié)群（胸肌群，前群）前鋸肌表面，胸小肌下緣胸外側(cè)血管肩胛下淋巴結(jié)群（肩胛下群，后群）腋窩后皺襞深部肩胛下血管外側(cè)淋巴結(jié)群（外側(cè)群）腋窩外側(cè)壁腋靜脈遠(yuǎn)側(cè)腋尖淋巴結(jié)群（尖群，鎖骨下LN，內(nèi)側(cè)群）鎖骨下肌下內(nèi)，胸小肌上緣及內(nèi)側(cè)，鎖胸筋膜深面腋靜脈近側(cè)鎖骨上淋巴結(jié)

不屬于腋窩淋巴結(jié)，但要求腋窩查體時(shí)觸診另外：胸肌間淋巴結(jié)（rotter淋巴結(jié)）屬于腋窩淋巴結(jié)，但腋窩觸診時(shí)并未提及胸大肌、胸小肌之間血管周?chē)緝?nèi)胸肩鋒血管肌支觸診次序及傳統(tǒng)解剖學(xué)分組普外科常用體格檢查專(zhuān)家講座第14頁(yè)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)普外科常用體格檢查專(zhuān)家講座第15頁(yè)附：腋窩淋巴結(jié)分級(jí)普外科常用體格檢查專(zhuān)家講座第16頁(yè)Rotter淋巴結(jié)屬于幾級(jí)淋巴結(jié)？人衛(wèi)八年制《外科學(xué)》第2版：RotterLN屬于Ⅰ級(jí)淋巴結(jié)人衛(wèi)五年制《外科學(xué)》第8版：RotterLN屬于Ⅱ級(jí)淋巴結(jié)部分醫(yī)生依據(jù)實(shí)際解剖經(jīng)驗(yàn)以及預(yù)后情況認(rèn)為：RotterLN可歸為Ⅲ級(jí)淋巴結(jié)普外科常用體格檢查專(zhuān)家講座第17頁(yè)Whatmaybesignificantisthatthesenodesprovideaseparatepathwaytothesubclavicularnodesattheapexoftheaxilla,bypassingthemainaxillarylymphnodegroups.

——SaulKay.EVALUATIONOFROTTER’SLYMPHNODESINRADICAL MASTECTOMYSPECIMENSASAGUIDETOPROGNOSIS.Cancer.1965.11Rotter淋巴結(jié)臨床意義術(shù)中標(biāo)準(zhǔn)：常規(guī)腋窩清掃時(shí)需要清掃Rotter淋巴結(jié)普外科常用體格檢查專(zhuān)家講座第18頁(yè)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.腹股溝疝查體法《AndreSurgerynotesedittedbyChinYee(ed2b,)》普外科常用體格檢查專(zhuān)家講座第19頁(yè)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