课件：熟悉胸部叩诊音的分类.ppt

第四节 胸部评估,1胸部的体表标志 熟悉胸部常用体表标志，包括骨骼标志、自然陷窝、人工划线和分区。 胸壁、胸廓和乳房 了解异常胸壁、胸廓的临床特征，熟悉其发生原因。 肺和胸膜 （1）视诊：要求了解呼吸运动的类型、各类呼吸困难的特征、呼吸频率和深度改变及意义。 （2）触诊：熟悉肺部触诊内容。掌握肺部触诊的检查方法，胸廓扩张度改变和触觉语颤异常的临床意义。,（3）叩诊：了解直接和间接叩诊法的检查方法与应用、影响叩诊音的因素。熟悉胸部叩诊音的分类，肺下界移动度的叩诊方法。掌握肺部叩诊音和肺下界移动度改变的临床意义。 （4）听诊：了解胸膜摩擦音的听诊特点和临床意义。熟悉正常呼吸音的种类、特点及分布。啰音的发生机制、分类和听诊特点，语音共振的检查法及临床意义。掌握病理性呼吸音听诊的特点和临床意义。干、湿啰音产生的临床意义。,骨性标志包括：胸骨角、腹上角、胸骨剑突、肋骨、肋间隙、肩胛骨、肋脊角。 自然陷窝 ：锁骨上窝、锁骨下窝、 人工划线包括；前正中线、左、右锁骨中线、腋前线、腋中线、腋后线、后正中线、肩胛线。,胸部体格检查纲要 A.视诊 1.检查者应面对病人站立，观察胸廓外形和对称性; 2.观察呼吸形态； B.触诊 3.触诊腋下淋巴结; 4.触诊胸壁有无压痛； 5.触诊乳房； 6.在前胸检查呼吸动度： 7.在后胸检查呼吸动度； 8.触诊胸膜摩擦感； 9.检查触觉语颤；,C叩诊 10叩诊锁骨上窝， 11叩诊后胸部； 12叩诊肺下界(肩胛下线)； 13. 肩胛下线叩诊肺下界移动度： 14叩诊前、侧胸部； D听诊 15听诊锁骨上窝； 16听诊前、侧胸部； 17听诊后胸部； 18检查有无胸膜摩擦音； 19检查听觉语音。,AReview 1Review skeleta1 1andmarks 2topographic description of location for any positive physical findings：normal or abnormal BMethods 3 Examiner should stand facing the patient and observe the shape and symmetry of the chest. 4 Measure respiratory rate 5 palpate trachea and ev1uate position of the trachea 6 palpate for tenderness,7.Breasts 8.Evaluate posterior chest excursion 9.EvaIuate Anterior Chest excursion 10.Palpate for pleural friction rubs 11.Check for tactile fremitus 12.Percuss supraclavicutar fosiae 13.Percuss the posterior chest 14.Percuss the lower margin of the lungs 15.Percuss to detect diaPhragmatic movement at scapular lines 16.Percuss the anterior and lateral chest,Mention of Conduction,Exposure/warmth/lighting /easy air Inspection, palpation, percussion, auscultation Anterior-lateral-posterior Top- base Comparison: top to base/ left to right,Bone landmark,suprasternal notch(胸骨上切迹) clavicle（锁骨） Manubrium sterni(胸骨柄) Sternal angle(胸骨角) Louis angle suprabdominal angle(腹上角) xiphoid process(剑突) Ribs & interspaces scapula(肩胛骨) spinous process(棘突) costolspinal angle(肋脊角),Natural fossa & anatomic region,Axillary fossa Supraclavicular fossa Suprasternal fossa Infraclavicular fossa Suprascapular region Infrascapular region Interscapular region,Vertical lines,Anterior middle line(前正中线） Mid-clavicular lines（锁骨中线） Spinal line（后正中线） axillary lines (anterior,middle, posterior) （腋前、中、后线） Scapular lines（肩胛线）,The boundary of lung & pleura,Lung apex Upper boundary of the lung Outer boundary Inner boundary Lower boundary:,Midclavicular line 6th interspace Midaxillary line 8th interspace Inferior line 10th interspace,Chest wall,Vein : Blood flow direction Subcutaneius emphysema(皮下气肿) Tenderness Interspace,触诊胸壁有无静脉显露、和皮下气肿和胸壁压痛 皮下气肿检查方法 1.用手按压时，有一种柔软带弹性的振动感似用手握雪一样的感觉，即握雪感； 2，用听诊器边加压边听诊可以听到多个微小的“喳喳”音类似捻发音 胸部压痛可见于（1）肋间压痛，为肋间神经炎，（2）肋软骨局部压痛，可伴有肿胀，为肋骨软骨炎；（3）胸骨压痛及叩击痛。为白血病的表现之一（4）胸壁局部压痛多见于胸壁软组织炎症脓肿，肋骨骨折；（5）肌肉压痛，见于肌炎、流行性肌痛等；,二、胸壁、胸廓与乳房,检查者面对病人站立，观察胸廓外形和对称性，估计病人胸廓前后径与左右径之比 (正常为l:1. 5)。注意胸廓外形的变化。 乳房,Chest framwork,Normal A-P/T diameter: 1/1.5 Flat chest Barrel chest Rachitic chest Rachitic rosary（肋骨串珠） Funnel chest（漏斗胸） Unilateral deformation Local bulge of chest wall Thoracic deformity caused by deformed spine,A视诊 观察呼吸运动 （1）呼吸运动类型 （2）呼吸困难 （复习） （3）呼吸频率 （4）呼吸节律,Inspection,Breathing movement: Diaphragmatic vs costal respiration Respiratory rate: - Tachypnea -Bradypnea -Change of the breath depths,Inspection(2),Rhythm of the breath -Tidal breathing -Ataxic breathing -Inhibitory breathing -Sighing respiration,Normal Bradypnea Tachypnea Kusmols breath Sighing respiration Tidal breath Ataxic breath Inhibitory breath,Palpation,Thoracic expansion Vocal fremitus(触觉语颤) Pleural friction fremitus(胸膜摩擦感) Confirm the inspection,B.触诊 检查呼吸扩张度正常两侧胸廓大致相等。 检查触觉语颤为被检查者发音时，声波的振动沿气管、支气管及肺泡传到胸壁引起共鸣的振动，用手可触及。其强弱取决于支气管是否通畅，胸壁传导是否良好。 声波的传播：声波在三种不同介质中的传播时其传导力固体最强，其次为液体气体最弱。坚硬均质的固体强于疏松非均质的固体发自声门的声波通过气管，支气管内的气体与管壁组织，传导至小支气管、肺泡胸膜及胸壁，触诊时可感及震颤；,2019/8/30,25,可编辑,注意事项：检查时应注意以下四点： （1）病人发音要低沉，音调不能过 高，在检查过程中发者的强度和音调要始终一致 （2）要从上到下，先前胸后背部循序进行 （3）注意左右对称部位对比检查； （4）两手贴胸压力要轻而均等； 触诊胸膜摩擦感,C叩诊 叩诊的方法 叩诊音的分类 清音：正常肺部的叩诊音。 过清音：见于肺气肿。 浊音：见于肺部含气减少或有炎症浸润时。 鼓音：正常可在左胸下侧叩得。 实音：见于大量胸腔积液 叩诊的位置 叩诊肺前界 叩诊肺下界(肩胛下线)； 肩胛下线叩诊肺下界移动度：,(三)percussion,1.叩诊方法 direct percussion indirect percussion:the palmar surface of the left distal phalanx of the middle finger serves as the pleximeter and is firmly placed on the chest wall in an interspace;parallel to the ribs.,3.胸部叩诊音的分类,The normal percussion note varies with the thick-ness of the chest wall and the force applied by the examiner. 1 The clear, long, low-pitched sound elicited over the normal lung is termed resonance.,2 Dullness occurs when the air content of the under-lying tissue is decreased and its solidity is increased.The sound is short, high-pitched, soft, and thudding,and lacks the vibratory quality of a resonant sound.It is heard normally over the heart and is accompanied by an increased sense of resistance in the pleximeter finger.,3 Flatness is absolute dullness. When no air is present in the underlying tissue the sound is very short,feeble, and high-pitched; flatness is found over the muscle of the arm or thigh. 4 Hyperresonance refers to a more vibrant, lower-pitched, louder, and longer sound heard normally over the lungs during maximum inspiration.,5 Tympany is difficult to describe but implies that the sound is moderately loud and fairly well sustained, with a musical quality in which a specific pitch is often noted. It is normally heard in the left upper quadrant of the abdomen over the air filled stomach or over any hollow viscus. The pitch of tympany is variable, but it is usually high-pitched, clear, hollow, and drumlike.,Percussion notes and their characteristics,Influencing factors for percussion,肺下界移动范围,检查时先于平静呼吸时在肩胛下角线上叩出肺下界，划一标记，然后分别在被评估者深吸气与深呼气后，屏住呼吸，再在同一线上自上而下叩出肺下界并作标记。最高点与最低点之间的距离即肺下界移动范围。,听诊,听诊的方法 正常呼吸音：肺泡呼吸音，支气管呼吸音，支气管肺泡呼吸