普外科常用体格检查ppt课件

.,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）,Palpationwitharotarymotionoftheexaminersfingersaswellasahorizontalstrippingmotionhasbeenrecommended.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,.,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：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,.,Whatmaybesignificantisthatthesenodesprovideaseparatepathwaytothesubclavicularnodesattheapexoftheaxilla,bypassingthemainaxillarylymphnodegroups.SaulKay.EVALUATIONOFROTTERSLYMPHNODESINRADICALMASTECTOMYSPECIMENSASAGUIDETOPROGNOSIS.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,.,EXAMINATIONOFANINGUINALHERNIA“Pleaseexaminethispatientsgroin”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),.,Laythepatientsupine.(supposingyourestandingonpatientsLEFT)-Reducetheherniaifpatienthasnotdoneso.-LocatetheDeepinguinalring:viceversaforrightsideoLefthanddefinepatientspubictubercle:fromumbilicusdownpubicsymp.totheleft1stbonyprominenceoRighthanddefinetheASIS(AnteriorSuperiorIliacSpine)oLefthandtothemidpointofinguinalligament2cmabove-Keeppressureondeepring,askpatienttositup&supporthispelvis,thenswingoverthebedandstandWithpatientstanding:-Sir,couldyouturnheadandcough?oifremainsreducedindirecthernia,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,.,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）,