普外科常用体格检查

乳腺查体
• 两个体位：端坐位、仰卧位
• Inspection of the breast is the first step in physical examination and should be carried out with the patient sitting, arms at her sides and then overhead.
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
Palpation with a rotary motion of the examiner’s fingers as well as a horizontal stripping motion has been recommended.
——CURRENT Medical Diagnosis and Treatment 2015
胸肩锋血管 肌支
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Ⅰ级淋巴结 • 人卫五年制《外科学》第8版：Rotter LN属于Ⅱ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Ⅲ级淋巴结
• 最好采用端坐和仰卧位检查，两侧乳房充分暴露，以利对比。 ——人卫五年制《外科学》第8版
• 视诊
双侧对称：形状、大小、乳头水平 局限性隆起或凹陷 皮肤红肿、橘皮样改变、酒窝征 浅表静脉扩张 乳头：内陷（长期/短期内），乳头乳晕糜烂
• 触诊（扪诊）
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
《Andre Surgery notes editted by ChinYee (ed 2b, 2012)》
EXAMINATION OF AN INGUINAL HERNIA “Please examine this patient’s 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.
• 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 2015
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.
• Rotter淋巴结的临床意义
• 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.
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
• 视诊 局部征象：皮肤隆起、颜色、皮疹、瘢痕、瘘管 全身状态
• 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
——Saul Kay. EVALUATION OF ROTTER’S LYMPH NODES IN RADICAL MASTECTOMY SPECIMENS AS A GUIDE TO PROGNOSIS. Cancer. 1965.11
• 术中原则：常规腋窝清扫时需要清扫Rotter淋巴结
腹股沟疝查体法
红肿、瘢痕、窦道等
• 触诊顺序
耳前淋巴结 耳屏前方 耳后淋巴结（乳突淋巴结） 耳后乳突表面，胸锁乳突肌止点处 枕淋巴结 枕部皮下，斜方肌起点与胸锁乳突肌止点之间 颌下淋巴结 颌下腺附近，下颌角与颏部中间部位 颏下淋巴结 颏下三角内，下颌舌骨肌表面，两侧下颌骨前端中点后方 颈前淋巴结 胸锁乳突肌表面及下颌角处 颈后淋巴结 斜方肌前缘 锁骨上淋巴结 锁骨与胸锁乳突肌所形成的夹角附近
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
Lay the patient supine. (supposing you’re standing on patient’s LEFT) - Reduce the hernia if patient has not done so. - Locate the Deep inguinal ring: [vice versa for right side] o Left hand define patient’s 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
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 • 源自文库要时双合诊 • 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）
1
3
2
5 6
附：颈淋巴结分区
甲状腺查体
• 视诊 大小及对称性 • 触诊
峡部：“前拇指，后示指”，胸骨上切迹起向上，配合吞咽
侧叶：“前拇指，后示、中指”，“推气管，触对侧”
• 听诊 钟型听件 低调连续性静脉“嗡鸣”提示甲亢，弥漫性甲状腺肿伴功能亢进 可有收缩期动脉杂音
• 肿大分度 Ⅰ度：不能看出肿大但能触及 Ⅱ度：能看到能触及，但在胸锁乳突肌以内 Ⅲ度：超过胸锁乳突肌外侧缘
腋窝外侧壁
腋尖淋巴结群（尖群，锁骨下LN， 锁骨下肌下内，胸小肌上缘及
内侧群）
内侧，锁胸筋膜深面
锁骨上淋巴结 不属于腋窝淋巴结，但要求腋窝查体时触诊
另外：
胸肌间淋巴结（rotter淋巴结） 属于腋窝淋巴结，但腋窝触诊时并未 提及
胸大肌、胸小肌之间血管周围 脂肪内
沿血管走行 腋窝底 胸外侧血管 肩胛下血管 腋静脉远侧 腋静脉近侧
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.
• 发现乳腺肿块
大小 硬度 表面光滑程度 边界 活动度 皮肤粘连：轻捻起肿物表面皮肤 与深部组织关系： 嘱双手叉腰， 使胸肌紧张，肿物活动是否受限 乳头溢液：轻挤乳头，如有溢液， 挤压乳晕四周，查出自哪一乳管
腋窝淋巴结 • 体位：端坐位（直立位）
• 腋窝境界
锁骨下肌
胸外侧神经
锁胸筋膜 胸大肌 头静脉 胸小肌
腋悬韧带
腋筋膜
背阔肌
胸尖峰动脉 腋动脉
肩胛下动脉
腋静脉 肩胛下肌 胸内侧 神经 大圆肌
• 触诊顺序及传统解剖学分组
分组名称
查体位置
中央淋巴结群（中央群）
腋窝内侧壁近肋骨及前锯肌处
胸肌淋巴结群（胸肌群，前群）
前锯肌表面，胸小肌下缘
肩胛下淋巴结群（肩胛下群，后群） 腋窝后皱襞深部
外侧淋巴结群（外侧群）