普外科常用体格检查ppt课件.pptx
普外科常用体格检查,北京积水潭医院 普外科 刘亚奇,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,颈部淋巴结,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,触诊顺序,1,2,3,4,5,6,7,8,附：颈淋巴结分区,甲状腺查体,视诊,触诊（扪诊）,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,发现乳腺肿块,腋窝淋巴结,体位：端坐位（直立位）,腋窝境界,触诊顺序及传统解剖学分组,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),附：腋窝淋巴结分级,Rotter淋巴结属于几级淋巴结？,人卫八年制外科学第2版：Rotter LN属于级淋巴结人卫五年制外科学第8版：Rotter LN属于级淋巴结部分医生根据实际解剖经验以及预后情况认为：Rotter LN可归为级淋巴结,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 SPECIMENS AS A GUIDE TO PROGNOSIS.Cancer.1965.11,Rotter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,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 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 changes?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.Palpate: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“above and medial to the pubic tubercle”(superficial ring)o Incarcerated:The patient is unable to reduce the lump.,腹股沟疝查体法,Andre Surgery notes editted by ChinYee(ed 2b,2012),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 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&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)-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 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,肛管直肠检查法,体位：左侧卧位、膝胸位、截石位、蹲位、弯腰前俯位视诊 双手拇指/示中环指，分开臀沟 红肿、血、脓、粪便、黏液、瘘口、外痔、疣状物、溃疡、肿块及脱垂直肠指诊（右手带手套润滑液）,肛周指诊:肛管肿块、压痛、皮肤疣状物、条索、外痔测试肛管括约肌松紧度：正常只能伸入一指，并紧缩感肛管直肠壁：触痛、波动感、肿块、硬结、狭窄，直肠粘膜完整性直肠前壁距肛缘4-5cm：男性前列腺；女性子宫颈必要时双合诊出指后：指套血迹、黏液（有血迹而未触及病变应行乙状结肠镜）,腹部查体,视诊 腹部外形、呼吸运动、腹壁静脉、胃肠型及蠕动波、皮疹、色素、腹纹、瘢痕、疝、脐、上腹部搏动听诊 肠鸣音、血管杂音叩诊 全腹叩诊、肝区（肝浊音界+叩痛）、胃泡鼓音区、脾脏（脾浊音界+叩痛）、移动性浊音触诊 腹壁紧张度、压痛及反跳痛、肾盂及输尿管点压痛、肝脏、脾脏、胆囊、腹部包块、液波震颤、振水音、腹壁反射、腹股沟淋巴结,完,
