普外科常用体格检查PPT课件.ppt

普外科常用体格检查 北京积水潭医院普外科刘亚奇 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 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 3 触诊顺序 4 1 2 3 4 5 6 7 8 5 6 附 颈淋巴结分区 7 甲状腺查体 8 9 10 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 11 发现乳腺肿块 12 腋窝淋巴结 体位 端坐位 直立位 腋窝境界 13 14 触诊顺序及传统解剖学分组 15 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 16 附 腋窝淋巴结分级 17 Rotter淋巴结属于几级淋巴结 人卫八年制 外科学 第2版 RotterLN属于 级淋巴结人卫五年制 外科学 第8版 RotterLN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 RotterLN可归为 级淋巴结 18 Whatmaybesignificantisthatthesenodesprovideaseparatepathwaytothesubclavicularnodesattheapexoftheaxilla bypassingthemainaxillarylymphnodegroups SaulKay EVALUATIONOFROTTER SLYMPHNODESINRADICALMASTECTOMYSPECIMENSASAGUIDETOPROGNOSIS 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 19 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 腹股沟疝查体法 AndreSurgerynotesedittedbyChinYee ed2b 2012 20 Laythepatientsupine supposingyou restandingonpatient sLEFT Reducetheherniaifpatienthasnotdoneso LocatetheDeepinguinalring viceversaforrightside oLefthanddefinepatient spubictubercle fromumbilicusdown pubicsymp totheleft 1stbonyprominenceoRighthanddefinetheASIS AnteriorSuperiorIliacSpine oLefthandtothemidpointofinguinalligament 2cmabove 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 AskpatientforhistoryofheavyliftingDifferentialdiagnosis Femoralhernia InguinalLN Hydroceleofthecord boys orcanalofNuck girls Saphenousvarix bluish tinge disappearsonlyingsupine alsohaspositivecoughimpulse Undescendedtestes Lipomaofthecord 21 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 22