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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，局部皮肤有无红肿、瘢痕、窦道等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•触诊顺序12356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乳腺查体•两个体位：端坐位、仰卧位•Inspectionofthebreastisthefirststepinphysicalexaminationandshouldbecarriedoutwiththepatientsitting,armsathersidesandthenoverhead.•Palpationofthebreastformassesorotherchangesshouldbeperformedwiththepatientbothseatedandsupinewiththearmabducted.——CURRENTMedicalDiagnosisandTreatment2015•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•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•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胸尖峰动脉腋动脉腋悬韧带腋筋膜肩胛下动脉腋静脉肩胛下肌大圆肌背阔肌胸内侧神经分组名称查体位置沿血管走行中央淋巴结群（中央群）腋窝内侧壁近肋骨及前锯肌处腋窝底胸肌淋巴结群（胸肌群，前群）前锯肌表面，胸小肌下缘胸外侧血管肩胛下淋巴结群（肩胛下群，后群）腋窝后皱襞深部肩胛下血管外侧淋巴结群（外侧群）腋窝外侧壁腋静脉远侧腋尖淋巴结群（尖群，锁骨下LN，内侧群）锁骨下肌下内，胸小肌上缘及内侧，锁胸筋膜深面腋静脉近侧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胸肩锋血管肌支•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Ⅰ级淋巴结•人卫五年制《外科学》第8版：RotterLN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：RotterLN可归为Ⅲ级淋巴结•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)》Laythepatientsupine.(supposingyou’restandingonpatient’sLEFT)-Reducetheherniaifpatienthasnotdoneso.-LocatetheDeepinguinalring:[viceversaforrightside]oLefthanddefinepatient’spubictubercle:fromumbilicusdownpubicsymp.totheleft1stbonyprominenceoRighthanddefinetheASIS(AnteriorSuperiorIliacSpine)oLefthandtothemidpointofinguinalligament2cmabove-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