普外科常用體格檢查

1、 普外科慣用體格檢驗(yàn)北京積水潭醫(yī)院 普外科 劉亞奇第1頁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)法腹部查體第2頁頸部淋巴結(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)覺淋巴結(jié)腫大時應(yīng)注意： 部位、大小、數(shù)目、硬度、壓痛、活動度、有沒有粘連，局部皮膚有沒有紅腫、瘢痕、竇道等第3頁耳前淋巴結(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

2、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第4頁12345678第5頁第6頁附：頸淋巴結(jié)分區(qū)第7頁甲狀腺查體視診 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”提醒甲亢，彌漫性甲狀腺腫伴功效亢進(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：超出胸鎖乳突肌外側(cè)緣第8頁第9頁乳腺查體兩個體位：端坐位、仰臥位Inspection of the breast is the first step

3、 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 最好采取端坐和仰臥位檢驗(yàn)

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版第10頁雙側(cè)對稱：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（長久/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 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

5、健側(cè)，后患側(cè)第11頁發(fā)覺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，使胸肌擔(dān)心，腫物活動是否受限乳頭溢液：輕擠乳頭，如有溢液，擠壓乳暈四面，查出自哪一乳管第12頁腋窩淋巴結(jié)體位：端坐位（直立位）腋窩境界第13頁鎖骨下肌胸外側(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)第14頁分組名稱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

6、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)，但腋窩觸診時并未提及胸大肌、胸小肌之間血管周圍脂肪內(nèi)胸肩鋒血管肌支觸診次序及傳統(tǒng)解剖學(xué)分組第15頁胸廓內(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)第16頁附：腋窩淋巴結(jié)分級第17頁Rotter淋巴結(jié)屬于幾級淋巴結(jié)？人衛(wèi)八年制外科學(xué)第2版：Rotter LN屬于級淋巴結(jié)人衛(wèi)五年制外科學(xué)第8版：

7、Rotter LN屬于級淋巴結(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：Rotter LN可歸為級淋巴結(jié)第18頁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 SPECIM

8、ENS AS A GUIDE TO PROGNOSIS. Cancer. 1965.11Rotter淋巴結(jié)臨床意義術(shù)中標(biāo)準(zhǔn)：常規(guī)腋窩清掃時需要清掃Rotter淋巴結(jié)第19頁EXAMINATION 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 appea

9、rs 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

10、 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 lum

11、p? 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

12、 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, )第20頁Lay the patient supine. (supposing youre standing on patients LEFT) - Reduce the hernia if patient has not done so. - Locate the Deep inguinal ring: vice

13、 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

14、 & 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) -

15、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 th

16、e 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 第21頁肛管直腸檢驗(yàn)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、