诊断胸部.ppt

胸部检查CHESTPHYSICALEXAMINATION,华中科技大学附属协和医院呼吸科刘红菊,概述胸部体检内容(content)胸骨（sternum）胸廓（chest）肋骨（rib）脊柱（vertebra）胸壁（chestwall）乳房（breast）肺与胸膜（lungandpleura）心脏,chestphysicalexamination,体检注意事项：环境(environment)暴露部位体位(posture)顺序对称(symmetry),chestphysicalexamination,胸部体表标志(1),chestphysicalexamination,胸部体表标志(2),chestphysicalexamination,胸部体表标志(3),chestphysicalexamination,胸部体表标志(4),chestphysicalexamination,胸部体表标志(5),chestphysicalexamination,胸部体表标志(6),chestphysicalexamination,胸部体表标志(7),chestphysicalexamination,一、胸壁(chestwall)静脉：正常时不明显上下腔V受阻时充盈、曲张。皮下气肿（subcutaneousemphysema）捻发感（捻发音）胸壁压痛：是胸痛常见病因之一。注意胸骨叩压痛：白血病肋间隙：回缩：气道阻塞（三凹征之一）膨隆：胸水等,chestphysicalexamination,二、胸廓(thorax,chest)正常成人:前后径：横径1：1.5小儿、老人：前后径略小于或=横径,chestphysicalexamination,异常扁平胸（flatchest）肺TB桶状胸（barrelchest）COPD,chestphysicalexamination,BarrelChestAnteroposteriordiameterincreaseRatio1:1COPD,Pectuscarinatum(Pigeonchest)APdiametertransversediameter(前后径大于左右径、上下距离短)Prominentsternalprotrusion(胸骨下段前突)Ribsfallawayoneitherside(两侧肋骨凹陷),PectusexcavatumIndentationoflowersternumabovexiphoidprocess(剑突处显著内陷，形似漏斗),异常佝偻病胸（rachiticchest）：又称鸡胸（pigeonchest），佝偻病串珠（rachiticrosary）肋膈沟（Harrisonsgroove）漏斗胸（funnelchest）,chestphysicalexamination,畸型胸,异常,chestphysicalexamination,三、乳房(breast)主要方法：视诊对称、表观、乳头、皮肤回缩、注意腋窝和锁骨上窝触诊硬度弹性、压痛、包块,chestphysicalexamination,主要病变炎症红、肿、热、痛、硬结包块肿瘤恶性：粘连包块、桔皮样良性：活动、界清的包块,chestphysicalexamination,breastexamination,四、肺与胸膜(lung（R：P=1：4）新生儿：44次/min,chestphysicalexamination,inspectionofLung&pleura,2、呼吸频率(frequency)、幅度(amplitude)异常呼吸过速（tachypnea）24次/min(发热)呼吸过缓（bradypnea）12次/min(麻醉过量),chestphysicalexamination,inspectionofLung&pleura,2、呼吸频率(frequency)、幅度(amplitude)异常浅快：呼吸肌麻痹深快：剧烈运动深慢：Kussmauls呼吸,chestphysicalexamination,inspectionofLung&pleura,AWSE,3、呼吸节律(rhythm)：正常均匀异常潮式呼吸（Cheyne-Stokes）：周期30sec2min暂停5sec30min,chestphysicalexamination,inspectionofLung&pleura,3、呼吸节律(rhythm)：正常均匀异常间停呼吸（Biots呼吸）：中枢病变，比上更重。抑制性呼吸：疼痛时叹息样呼吸（sighing）：神经衰弱等,chestphysicalexamination,inspectionofLung&pleura,（二）palpation:1胸廓扩张度（thoracicexpansion）手法深呼吸对比单侧减弱：胸水、肺不张等。双侧减弱：肺气肿,chestphysicalexamination,(Thoracicexpansion)即呼吸时的胸廓动度ThehandsmovementshouldbesymmetryLocalizedpulmonarydiseasemaycauseonesideofthechesttomovelessthantheotherside.前胸拇指指向剑突，手掌置于前侧胸壁。后胸两手平置。,2、语音(触觉）震颤vocal（tactile)fremitus发音传导手感手法、对称、交叉对比正常传导环节对音感影响发音、支气管密度、胸壁,chestphysicalexamination,palpationofLung&pleura,语音震颤(Vocalfremitus,Tactilefremitus)Techniquetwo:Usepalmarsurfaceofbothhandsandplacesagainstthepatientschestwall，Askthepatientsay“yi”.Speechcreatesvibrationsthatcanbefeltonthechestwall.,语音震颤的强弱主要取决于气管、支气管是否通畅，胸壁传导是否良好而定。最强区：肩胛间区及左右胸骨旁第1、2肋间隙；最弱区：肺底,增强：空洞、实变、压迫性膨胀不全减弱：传导途径中任一环节受阻,chestphysicalexamination,palpationofLung&pleura,3胸膜摩擦感（pleuralfrictionfremitus）双相下前侧部明显皮革摩擦的感觉：急性胸膜炎,chestphysicalexamination,palpationofLung&pleura,（三）percussion:方法：直接（immediate）间接（mediate）基本音清、鼓、浊、实正常叩诊区与肺界,chestphysicalexamination,叩诊的方法:直接叩诊:中指掌侧或手指并拢以指尖对胸壁进行直接叩击被检查部位，借拍击的反响和指下的振动感判断病变情况。适用于面积大的病变：胸膜肥厚，大量胸、腹水,Placetheleftmiddlefingeragainsttheinterspace（欲叩诊部位）.,IndirectPercussion,正常叩诊区与肺界(1),chestphysicalexamination,percussionofLung&pleura,正常叩诊区与肺界(2),chestphysicalexamination,percussionofLung&pleura,正常叩诊区与肺界(3),percussionofLung&pleura,chestphysicalexamination,正常叩诊区与肺界(4),chestphysicalexamination,percussionofLung&pleura,异常叩诊音：实音(flatness)过清音(hyperresonance)(胸水)(肺气肿)清音resonance浊音(dullness)鼓音(tympany)(大叶肺炎)(气胸)浊鼓音(肺水肿),chestphysicalexamination,percussionofLung&pleura,胸部异常叩诊音：正常清音区范围出现了浊音、实音、过清音或鼓音。其具体类型取决于病变的性质范围的大小及部位的深浅。距胸部皮肤4cm以上、直径小于3cm的病变，不易发现叩诊音的变化。,异常叩诊音举例：,percussionofLung&pleura,chestphysicalexamination,（四）Auscultation1、正常呼吸音,chestphysicalexamination,2、异常呼吸音：异常肺泡呼吸音减弱或消失：阻塞等增强：缺氧、酸中毒等呼气音延长：哮喘等断续：局部炎症粗糙：炎症,chestphysicalexamination,auscultationoflung&pleura,异常支气管呼吸音正常肺泡呼吸音的部位听到支气管呼吸音：实变、空腔、膨胀不全,chestphysicalexamination,auscultationoflung&pleura,异常支气管肺泡呼吸音正常肺泡呼吸音部位听到混合呼吸音：病因与上类似，但掺杂正常组织,chestphysicalexamination,auscultationoflung&pleura,3、罗音（rales）干罗音（rhonchi）机制：狭窄、部分阻塞：炎症、痉挛、肿瘤、异物,auscultationoflung&pleura,chestphysicalexamination,特点：持续时间长，一次一个，呼气相更显，易变，双侧多见。分类：鼾音（sonorus）：低调哨笛音（sibilant）：高调局限：内膜TB、肿瘤广泛：哮喘,auscultationoflung&pleura,chestphysicalexamination,湿罗音（moistrales）,水泡音（bubblesound）机制：气过水声特点：断续而短暂、一次多个、咳嗽后可消失、多在吸气相(末)、恒定。,chestphysicalexamination,auscultationoflung&pleura,分类：大中小捻发音,chestphysicalexamination,auscultationoflung&pleura,意义：炎症、肺水肿等,auscultationoflung&pleura,chestphysicalexamination,捻发音发生机制,4、语音共振（vocalresonance）机理与意义：语音震颤异常支气管呼吸音同时出现语音共振支气管语音（bronchophony）胸语音(pectoriloquy)羊鸣音(egophony)耳语音(