普外科常用體格檢查ppt課件

1、普外科常用體格檢查,北京積水潭醫(yī)院 普外科 劉亞奇,1,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 腹股溝疝檢查法 肛管直腸檢查法 腹部查體,2,頸部淋巴結(jié),觸診 示、中、環(huán)指并攏，指腹按壓滑動(dòng)觸診,發(fā)現(xiàn)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、有無(wú)粘連，局部皮膚有無(wú)紅腫、瘢痕、竇道等,3,觸診順序,4,1,2,3,4,5,6,7,8,5,6,附：頸淋巴結(jié)分區(qū),7,甲狀腺查體,8,9,10,視診,觸診（捫診）,Palpation with a rotary motion of the examiners fingers as well as a horizontal

2、stripping motion has been recommended. CURRENT Medical Diagnosis and Treatment 2015,原則 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),11,發(fā)現(xiàn)乳腺腫塊,12,腋窩淋巴結(jié),體位：端坐位（直立位）,腋窩境界,13,14,觸診順序及傳統(tǒng)解剖學(xué)分組,15,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?。?胸肌間淋巴結(jié)(rotter),16,附：腋窩淋巴結(jié)分級(jí),17,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：R

3、otter LN屬于級(jí)淋巴結(jié) 人衛(wèi)五年制外科學(xué)第8版：Rotter LN屬于級(jí)淋巴結(jié) 部分醫(yī)生根據(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(jí)淋巴結(jié),18,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

4、IN RADICAL MASTECTOMY SPECIMENS AS A GUIDE TO PROGNOSIS. Cancer. 1965.11,Rotter淋巴結(jié)的臨床意義,術(shù)中原則：常規(guī)腋窩清掃時(shí)需要清掃Rotter淋巴結(jié),19,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 bot

5、h 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 ski

6、n 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. Pa

7、lpate: 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

8、 “above and medial to the pubic 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, 2012),20,Lay the patient supine. (supposing youre standing on patients LEFT) - Reduce the hernia if patient has not done so. -

9、 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 pressur

10、e 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 (ind

11、irect) 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 h

12、ernia - 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,21,肛管直腸檢查法,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(kāi)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(rùn)滑液）,肛周指診: 肛管腫塊、壓痛、皮膚疣狀物、條索、外痔 測(cè)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(dòng)感、腫塊、硬結(jié)、狹窄，直腸粘膜完整性 直腸前壁距肛緣4-5cm：男性前列腺；女性子宮頸 必要時(shí)雙合診 出指后：指套血跡、黏液（有血跡而