呼吸循环系统体格检查.doc

physical examination心脏检查(1)Cardiac Examinationn inspection 视诊n palpation 触诊n percussion 叩诊n auscultation 听诊一.The projection of the heart at the anterior chest wall.二.The auscultatory area of cardial valves and the direction of the blood flow through the various valves1. The mitral valve area: The blood flow pass from the posterasuperior to the anterainferior left -the auculatory area is at apex area.三、Precordium: n 1.The superior border is below the left third intercostal spacen 2. The right border is at the midsternum linen 3.The left border is at the left midclavicular linen 4.The inferior border is above the diaphragmThe heart examinationInspection of the Heart 心脏视诊The focal point of inspection include:n precordium shapen 心前区外形n normal apical impulsen 正常心尖搏动n abnormal apical impulsen 异常心尖搏动n precordial abnormal impulsen 心前区异常搏动Precordium Shape心前区外形Precordial bulge 心前区隆起n Features: bony bulge 特点:骨骼突起 n Clinical importance: Congenital heart disease with right ventricular enlargement 提示:先天性心脏病右室大Precordial fullness 心前区饱满n Features: intercostal region fullness 特点:肋间软组织外突n Clinical importance: mass of pericardial effusion 提示:大量心包积液Normal Apical Impulse正常心尖搏动n 一、Inspectionn In most persons ,one can see,synchronous with cardic systolic,an outward movement of a small portion of the left chest wall caused by the beat of the cardic apex.This is the cardic or apex impulse.n It should be studied with the patient upright and lying in various position since in many instances the impalse may be fairly diffuseNormal Apical Impulse正常心尖搏动n Location: the 5th intercastal space 0.51.0 cm inside the left midclavicular line. n Range: 22.5cmn Direction: outward when ventricular systole begins and it coincide with the left cardic border n 位置: 第5肋间左锁骨中线 内0.51cmn 范围: 22.5cmn 方向: 收缩时向外搏动n 意义: 提示心尖位置 代表收缩期 提示心脏大小与心 脏的左缘一致Abnormal Apical Impulse异常心尖搏动 (1)Abnormal location 位置改变n Physical: posture, pregnancy, etc. 生理因素:体位 妊娠n Heart diseases 心脏病变 L.V and B.V enlargement: inferior left 左室或双室扩大:左下移位 R.V enlargement: left 右室扩大:向左移位n Chest and abdominal diseases 肺部或腹部疾病Abnormal Apical Impulse异常心尖搏动 (1)n When a large amount of fluid or air is present in the right plural civity will shift the heart toward the left; if a large amount of air or fluid in the left plural cavity ,will displace the heart toward the right.n Retraction of lungs: in severe unilateral plural pulmonary fibrosis or obstraction atlectasis ,the inpulse moves toward the affected side.n Pronounced distention of the abdomin as by gas fluid or large tumor,pushes the impulse upward and left. Abnormal Apical Impulse异常心尖搏动 (2)Abnormal range or intensity 范围强度异常n Increased intensity: LV hypertrophy, hyperthyroidism, fever, anemia, etc. 搏动增强: 左室肥厚 甲亢 发热 贫血n Decreased: myocardial diseases, pericardial effusion, pleural effusion of left thorax or left-side pneumothorax, emphysema. 搏动减弱: 心肌病变 心包积液 肺气肿 左胸腔积液或气胸Abnormal direction 方向改变n Inward impulse: adhesive pericarditis. 负性心尖搏动: 心包粘连Precordial Abnormal Impulse心前区异常搏动n 2nd ICS, LSB: pulmonary hypertension, youth 胸骨左缘第二肋间: 肺动脉高压 青年人n 2nd ICS, RSB: aneurysm of ascending aorta 胸骨右缘第二肋间: 升主动脉瘤n 3rd, 4th ICS, LSB: R.V hypertrophy 胸骨左缘3, 4肋间: 右心室肥大n xiphoid process: R.V hypertrophy, abdominal aneurysm 剑突下: 右心室肥大 腹主动脉瘤Palpation of the Heart心脏触诊Palpation of the heart has three purposesn 1.Confirm the observation made during inspectionn 2.To detect the pulsatial movment that are not visiblen 3.To reveal the thrill or friction rubs in the presence of specific cardic diseaseApical Impulse心尖搏动n Clinical significance: signifying the start of the systolic phase 临床意义: 指示收缩期的开始n Location and range: same as in inspection 位置和范围: 与心尖搏动视诊相同n Increased (heave): forceful and sustained 增强: 搏动持续有力 lifting apical impulse 抬举性心脏搏动n Decreased: cannot palp. clearly 减弱: 不能清楚触到Abnormal of Apical Impulse心尖搏动异常n Increased causes: left ventricular pressure overload and consequent hypertrophy 增强原因: 左室内压升高和肥厚n Clinical significance: left ventricular hypertrophy 临床意义: 左心室肥大n Decreased causes: decreased contractibility of the myocardium 减弱原因: 心肌收缩力减弱n Clinical significance: heart failure, pericardial effusion, myocarditis 临床意义: 心力衰竭 心包积液 心肌炎Thrill震颤n Mechanism: formation of bloodflow vortices caused by valve stenosis or abnormal pathway. 产生机制: 血流旋涡引起低频较强震动 由瓣膜狭窄和异常通道引起n Types: systole, diastole, continuous 分型: 收缩期震颤 舒张期震颤 持续震颤n Clinical significance: reliable signs of organic heart diseases 临床意义: 器质性心脏病的征象Thrill in Systole收缩期震颤n 2nd ICS, LSB: pulmonic stenosis 胸骨左缘第二肋间: 肺动脉瓣狭窄n 2nd ICS, RSB: aortic stenosis 胸骨右缘第二肋间: 主动脉瓣狭窄n 3rd, 4th ICS, LSB: interventricular septal defect 胸骨左缘3, 4肋间: 室间隔缺损Thrill in Diastole and Continuous舒张期和持续性震颤n Diastolic thrill on apex: mitral stenosis 心尖部舒张期震颤: 二尖瓣狭窄n Continuous thrill on 2nd ICS, LSB: Patent ductus arteriosus 胸骨左缘第二肋间连续性震颤: 动脉导管未闭Pericardial Friction Fremitus心包摩擦感n Mechanism: inflammation or irritation of the pericardium 机制: 心包表面粗糙n Typical site: 4th ICS, LSB 部位: 胸骨左缘第四肋间n Feeling: friction like leather rubbing 感觉: 如皮革相互摩擦n Features: it is best palpated with the person sitting up and leaning forward, and with the breath held in expiration coincide with heart impulse 特点: 坐位前倾呼气末明显 与心跳一致 闭气时不消失n Clinical significance: pericarditis 意义: 提示心包炎Percussion of the Heart心脏叩诊n percussion of the heart border 心界叩诊n abnormal dullness heart border 心界异常Percussion Technique叩诊方法n Force: light percussion for the relative dullness border. 力量: 轻叩叩出相对浊音界n Position: supine: parallel the middle finger to intercostal; sitting: plumb the middle finger. 体位: 仰卧位: 板指与肋间平行 坐位: 板指与肋间垂直n Steps: from left to right, lower to upper, outward to inward 顺序: 先左后右 自下而上 由外向内n Left border: 23cm from the apical impulse 心左界: 心尖搏动外 23cm 开始n Right border: ICS next to the upper border of the liver 心右界: 肝上界上一肋间开始n Measure: the distance from dullness border to anterior midline 测量: 浊音界距前正中线的垂直距离Normal Relative Dullness Border of the Heart正常心浊音界Distance between dullness border and anterior midline心脏之相对浊音界距前正中线的距离Abnormal Dullness Heart Border心界叩诊异常 (1)heart variation 心脏改变n L.V enlargement: boot-shaped heart 左室扩大: 靴形心n L.A enlargement: pear-shaped heart 左房扩大: 梨形心n B.V enlargement: general enlarged heart 双室扩大: 普大心n R.V enlargement: conginetial and pulmonal heart disease 右室扩大: 先心 肺心n Pericardial effusion: flask-shaped heart 心包积液: 烧瓶心Abnormal Dullness Heart Border心界叩诊异常 (2)chest and lung diseases 胸肺疾病n Pleural effusion or lung consolidation: dullness border undetectable 胸腔积液或肺实变: 叩不出n Emphysema: “shrinked” dullness border 肺气肿: 心浊音界缩小abdominal disorders 腹部疾病n Diaphragm elevation: acrossing heart 膈升高: 横位心Boot-shaped Heart靴形心n Mechanism: L.V enlargementn Features: the left border extends to the inferior left, waist of the heart is deepened.widened of the aorta.n Causes: aortic insufficiency, hypertensive heart diseasen 机制: 左室扩大n 特点: 心左界向左下扩大 心腰加深 主动脉增宽n 病因: 主动脉瓣关闭不全 高血压心脏病Pear-shaped Heart梨形心n Mechanism: L.A enlargement and distension of pulmonary arteryn Features: dullness heart border in the 2nd, 3rd ICS on the LSB extends outside, waist of the heart bulges outn Causes: mitral stenosisn 机制: 左房扩大 肺动脉扩大n 特点: 胸骨左缘2, 3肋间 心浊音界向外扩大 心腰饱满或膨出n 病因: 二尖瓣狭窄General Enlarged Heart普大心n Mechanism: both left and right ventricle are enlargedn Features: the dullness border extends to both sides, the left border extends to inferior leftn Causes: cardiomyopathy, myocarditis, whole heart failuren 机制: 左右心室扩大n 特点: 心浊音界向双侧扩大 左界向下扩大n 病因 扩张型心肌病 克山病 重症心肌炎 全心衰竭Flask-shaped Heart烧瓶心n Mechanism: pericardial effusionn Features: n Sitting position: triangular dullness bordern Supine: widened dullness border of the base机制: 心包积液特点:n 坐位时 心浊音界呈三角形n 仰卧位 心底部浊音区增宽n 随体位心界改变Auscultation of the Heart心脏听诊n valve auscultation section 瓣膜听诊区n content of auscultation 听诊内容Valve Auscultation Section瓣膜听诊区n Mitral valve: in the apex area 二尖瓣听诊区: 心尖搏动最强点n Pulmonic valve: in the 2nd ICS, LSB 肺动脉瓣听诊区: 胸骨左缘第二肋间n Aortic valve: in the 2nd ICS, RSB 主动脉瓣听诊区: 胸骨右缘第二肋间n The 2nd of aortic valve: in the 3rd ICS, LSB 第二听诊区: 胸骨左缘第三肋间n Tricuspid valve: in the inferior sternum 三尖瓣听诊区: 胸骨左缘4, 5肋间Auscultation Order听诊顺序n Mitral valve 二尖瓣n The 2nd of aortic valve 主动脉瓣第二听诊区n Pulmonic valve 肺动脉瓣n Aortic valve 主动脉瓣n Tricuspid valve 三尖瓣Content of Heart Auscultation心脏听诊内容n Heart rate: 60100/min normally 心率: 正常60100次/分n Cardiac rhythm: regular or arrhythmia 心律: 规整 心律失常n Heart sounds: normal, abnormal 心音: 正常心音 异常心音n Heart murmurs 心脏杂音Arrhythmia心律失常n Sinus arrhythmia: quick in inspiration and slow in expiration 窦性心律不齐: 吸快呼慢n Premature beat: appear ahead and intermission behind 期前收缩: 提前出现 后有间歇n Atrial fibrillation: arrhythmia absolutely, heart sound intensity differing and pulse deficit 心房颤动: 心律绝对不整 心音强度弱不等 心率大于脉率(脉搏短绌)physical examination心脏检查(3)Cardiac Examinationn cardiac murmurs 心脏杂音n vascular examination 血管检查n heart disease 心脏疾病Heart murmurHeart murmurn Many murmur are indicative of valvular or other important defect ,yet others are unimportant and do not necessarily imply the presence of a heart lesion, conversely, severe heart disease often exsists in the absence of murmur.Auscultation of Murmurs心脏杂音听诊n mechanisms 产生机制n characterization 听诊要点n clinical meaning 临床意义Mechanisms杂音产生机制turbulent flowvorticesmurmur湍流旋涡杂音n Enhanced bloodflow velocity 血流加速n Stenosis or insufficiency of valves 瓣膜狭窄或关闭不全n Abnormal pathway (shunt) 异常通道(分流)n Floating materials in circulation 心腔内漂浮物n Stenosis or dilation of blood vessels 血管腔扩大或狭窄n Diminished viscosity 血液粘度降低turbulent flowvorticesmurmur湍流旋涡杂音n The normal blood flow is a streamline flow,while it become tuberlunt flow and be formed a vortices,the vortices produce viberation and make a noice called murmur. 1.Enhanced blood flow velocity血流加速n The normal blood flow is a blood streamline flow,while the blood flow velocity is enhanced,the streamline flow will be change to a tuberlant flowvortices(or eddies)and form the extra soundmurmur. Such as exercise,fever hyperthyroidism.2. Stenosis or insufficiency of valves 瓣膜狭窄或关闭不全n A pathologic process may stiffen、shorter or other wise deform the leaflet,so that complet closure dose not take place(insufficiency or regargitation)n Depanding on the valve involved,during ventricule systale, the blood flow backwards from contracting ventricule to the relaxing auliculemake a mitral regargitation or tricusped regargitation;during diastale,from the aortic or pulmonary backward to the relaxing ventricule,called aortic or pulmonary regargitation2. Stenosis or insufficiency of valves 瓣膜狭窄或关闭不全Such as:Systole murmur: mitral or tricuspid regargitation. aortic or pulmonary stenosis.Diastale murmur: mitral or tricuspid stenosis. aortic or pulmonary regargitation3. Abnormal pathway (shunt) 异常通道(分流)n While exist abnormal communication between heart chambers or vessels,blood flow through abnormal channel into another heart chamber or vessel will make the vortices and produce murmur. Such as: congenitally patent ductus arterious interventricule septal defect 4. Floating materials in circulation 心腔内漂浮物n In bacterial endocarditis, a murmur may be caused by the presence in blood stream of a large vegetation,one end of the tissue is attached to the ventricular wall or valve(leaflet) while the other floats free in the stream. such as: bacterial endocarditis rupture of the cordae5. Stenosis or dilation of blood vessels 血管腔扩大或狭窄n The blood flow through a normal or a stenosis orifice into a vessel whose caliber is wider than normal may produce vortices and make a murmur. such as: aneurysm of aorta stenosis of vessel6.Diminished the viscosity 血液粘度降低n While the viscosity of blood is diminished will enhanced the blood flow velocity and produce tuberlent blood flow make a murmur. Organic & Relative器质性与相对性n Organic: valve disease 器质性: 瓣膜本身病变 n Relative: pathway wide or narrow 相对性: 通道扩大 Characterization of Murmurs杂音听诊要点n Locationn Durationn Pitch and Qualityn Intensity and Timing n Transmission or radiationn Effect murmurs of factorn 杂音的部位n 杂音的时期n 杂音的性质n 杂音的强度n 杂音的传导n 影响杂音的因素Location杂音部位n Apical area: mitral valven Aortic area: aortic valven Pulmonic area: pulmonic valven Inferior sternum: tricuspid valven 3rd, 4th ICS, LSB: ventricular septal defectn 2nd, 3rd ICS, LSB: patent ductus arteriosus杂音出现和最响部位与 病变部位 血流方向 传导介质相关n 心尖部: 二尖瓣n 主动脉瓣听诊区: 主动脉瓣n 肺动脉瓣听诊区: 肺动脉瓣n 胸骨下端: 三尖瓣n 胸骨左缘 3. 4 肋间: 室间隔n 胸骨左缘 2. 3 肋间: 动脉导管Duration杂音时期Systolic murmur (SM)n Holosystolicn Earlyn Midsystolicn LateDiastolic murmur (DM)n Holodiastolicn Earlyn Middiastolicn Late (presystolic)Continuous收缩期杂音n 全收缩期n 收缩早期n 收缩中期n 收缩晚期舒张期杂音n 全舒张期n 舒张早期n 舒张中期n 舒张晚期连续性杂音Systolic murmur (SM)This is the murmur which coincide with the first sound (totally or partially making it,or occurs in any part of the period between the first and second soud) and can be divided four kinds.n Holosystolicn Earlyn Midsystolicn LateDiastolic murmur (DM)This murmur occure at the time of the second sound partially or totally making it or follow second sound, occuring between it and next sound,and also can be divided four kinds.n Holodiastolicn Earlyn Middiastolicn Late (presystolic)ContinuousStart in systole,continuous without interrupture through S2 in all or part of diastale,dose not necessarilly persistent through out entre cardic cycle. Distinguish Duration时期的区分n systolic murmur 收缩期杂音 appear between S1 and S2, same as apical impulse 在第一心音与第二心音之间出现 与心尖搏动一致n diastolic murmur 舒张期杂音 appear between S2 and S1, nonsame as apical impulse 在第 2 心音与第 1 心音之间出现 与心尖搏动不一致Both Phase and Continues Murmur双期杂音与连续性杂音Both phase murmur 双期杂音n Cause: mitral stenosis and insufficiency 疾病: 二狭二闭n Heart murmur appears in systole and diastole respectively. 收缩舒张期分别出现杂音n Auscultation: Quality different and S2 still 特点: 杂音性质可不同 不遮盖第二心音Continues murmur 连续性杂音n Cause: Patent ductus arteriosus 疾病: 动脉导管未闭n Starts in systole, continues without interruption through S2 into diastole. 跨越收缩期和舒张期n Auscultation: Quality same and S2 disappear. 特点: 杂音性质相同 遮盖第二心音Pitch and Quality杂音性质Pitch: depends on pressure and rate of blood flow 音调: 与血流的压力和流速相关n high, medium and low 高调 中等 低调Quality: depends on degree of valve compromise, force of contractions and blood volume 音色: 与瓣膜状况 收缩力和血容量相关n Harsh or soft 粗糙或柔和n Blowing 吹风样n Rumbling 隆隆样n sighing sound 叹气样(泼水样)n Machine-like vibratory 机器样n Musical 乐音样n Warble sound 鸟鸣样(鸥鸣 鸽鸣 雁鸣)Intensity杂音强度Influencing factors: 影响因素n Degree of change between calibers of the passages through which the blood is flowing 通道口的大小n Degree of pressure differential between the passages 通道两端的压力差n Speed of the blood flow 血流速度n Thickness of the tissues between the heart and the surface of the chest 传导距离Intensity of Systolic Murmur收缩期杂音强度n Grade: barely audible in quiet room 1 级: 仔细听方可听到n Grade: quiet but clearly audible 2 级: 容易听到但不响亮n Grade: moderately loud 3 级: 较响亮n Grade: loud, associated with thrill 4 级: 粗糙且响亮 伴传导震颤n Grade: very loud, thrill palpable easily 5 级: 震耳n Grade: very loud, audible with stethoscope not in contact with chest, thrill palpable easily 6 级: 离开胸壁亦可闻及Configuration or Shape杂音形态Types of intensity variety 杂音强度变化类型n Crescendo: increasing intensity 递增型: 强度逐渐增加n Decrescendo: decreasing intensity 递减型: 强度逐渐减小n Crescendo-decrescendo: 递增递减型: 强度先增加后减小n Continuous: 连续型: 收缩期增强到舒张期减弱n Plateau: same intensity 一贯型: 强度大体保持一致Transmission or Radiation杂音传导n The greatest factor influencing radiation is intensity 随距离增加响度减弱性质不变n Radiation direction can be influenced by: origin of the murmur, direction of flow of turbulent stream 传导方向: 与病变部位及血流方向相关n Mitral insufficiency: transmit to left oxter and scapular 二尖瓣关闭不全: 向左腋下肩胛下传导n Aortic stenosis: transmit to right cervix 主动脉瓣狭窄: 向右侧颈部传导n Aortic insufficiency: transmit to apical area 主动脉瓣关闭不全: 向心尖部传导n Mitral stenosis: no transmission 二尖瓣狭窄: 不传导Effect Murmurs of Factor影响杂音强度因素n Exercise: murmurs which ar