心脏体格检查 (2)

1,DepartmentofDiagnostics1stAffiliatedHospitalChenMing,Physicalexaminationofheart,2,Equipment（器材）：Stethoscope（听诊器）；Position（体位）：Supine（卧位）orseated（坐位）apatient；standingtotherightsideofthepatient（anexaminer）；Environment（环境）：Quiet（安静）；Exposure（暴露）：Striptowaist（腰部）；Lightening（光线）：Good；leftside；tangent（切线）；Knowledgeofanatomy（解剖知识）：thorough（全面）Considerateandgentle。,Physicalexaminationofheart(心脏检查)Preparation,3,Midsternalline（胸骨中线）orAnteriormidline（前正中线）Midclavicularlines（锁骨中线）Anterior,middle,andposterioraxillarylines（腋前、中、后线）Sternalangle（胸骨角）-connectedwith2thcostalcartilage（与第二肋软骨相连）Intercostalspace（肋间隙）,Physicalexaminationofheart(心脏检查)landmarksoftopographicanatomy（解剖标志）,4,Inspection(望诊),Palpation(触诊),Percussion(叩诊),Auscultation(听诊),心脏检查,Physicalexaminationofheart(心脏检查),5,Tangentlightening（切线方向光线）；Sameheightasthorax(与胸廓同高）。,Inspection（望诊）-gist（要点）,6,Precordialprominence（心前区隆起）：Rightventricularhypertrophyatpuberty（儿童发育完成前右心室肥大）Congenitalheartdisease(先天性心脏病)Rheumaticheartdisease(风湿性心脏病)Massivepericardialeffusionintheadult（成人大量心包积液）。,Inspection（望诊）-Deformityofthoraxes（胸廓畸形）,7,Inspection（望诊）-Apicalimpulse（心尖搏动）,Definition（定义）：Heartcontracts（心脏收缩）impactscorrespondingsiteoffrontchest（心尖向前冲击前胸壁相应位置)apicalimpulse(心尖搏动)。,8,Inspection（望诊）,Normalapicalimpulse（正常心尖搏动）：Location-The5thintercostalspace（第五肋间）,0.51.0cmmedialtoleftmidclavicularline（左锁骨中线内侧0.51.0cm）；Diameter-2.02.5cm。,Inspection（望诊）-Apicalimpulse（心尖搏动）,9,Physiologicalfactors（生理性因素）：Leftlateralposition（左侧卧位）-extendtotheleft（向左移）for2.03.0cm.Rightlateralposition（右侧卧位）-extendtotheright（向右移）for1.02.5cm.,Inspection（望诊）-Displacementofapicalimpulse（心尖搏动移位）,10,Pathologicalfactors（病理性因素）：Heartitself（心脏本身）Enlargementofleftventricle（左心室增大）-extendtoleftanddownwards（左下移位）；,Inspection（望诊）-Displacementofapicalimpulse（心尖搏动移位）,11,Pathologicalfactors（病理性因素）：Heartitself（心脏本身）Enlargementofrightventricle（右心室增大）-extendtoleftbutnotdownwards（向左不向下移位）；Enlargementofbothventricles（左右室均增大）-extendtobothleftandright.,Inspection（望诊）-Displacementofapicalimpulse（心尖搏动移位）,12,Pathologicalfactors（病理性因素）：Displacementofmediastinum（纵隔移位）Pleuraladhesion（胸膜粘连），pulmonaryatelectasisofoneside（肺不张-displacementofapicalimpulsetowardthediseasedside（移向患侧）；Pleuraleffusion（胸腔积液），pneumothoraxofoneside（气胸）-displacementofapicalimpulsetowardtheoppositeside（移向健侧）.,Inspection（望诊）-Displacementofapicalimpulse（心尖搏动移位）,13,Pathologicalfactors（病理性因素）：Displacementofdiaphragm（横隔移位）Massiveascites（大量腹水），hugetumorofabdominalcavity（腹腔巨大肿瘤）-displacementofapicalimpulsetoleft（移向左侧）；Severeemphysema（肺气肿）-displacementofapicalimpulseinwardanddownward（移向内下）。,Inspection（望诊）-Displacementofapicalimpulse（心尖搏动移位）,14,Physiologicalfactors（生理性因素）：Thickchestwall（胸壁肥厚）-weakandnarrow（减弱、缩小）；Thinchestwall（胸壁薄）-strongandwide（增强、较大）。,Inspection（望诊）-Changesofintensityandrangeinapicalimpulse(心尖搏动强度与范围的改变）,15,Pathologicalfactors（病理性因素）：Increaseinintensityofapicalimpulse（心尖搏动增强）-fever（发热），anemia（贫血），hyperthyroidism（甲状腺机能亢进）；Decreaseinintensityofapicalimpulse（心尖搏动减弱）-dilatedcardiomyopathy（扩张型心肌病），acutemyocardialinfarction（急性心肌梗死），pericardialeffusion（心包积液），emphysema（肺气肿）。,Inspection（望诊）-Changesofintensityandrangeinapicalimpulse(心尖搏动强度与范围的改变）,16,Inspection（望诊）-Inwardimpulse（负性心尖搏动）,Definition（定义）：invagination（内陷）ofapicalimpulsewhencontracting。Significance（意义）：adhesivepericarditis（粘连性心包积液）。,17,Inspection（望诊）-precordialimpulse（心前区搏动）,Impulseat3th4thleftintercostalspacejustlateraltosternum(胸骨左缘34肋间）:rightventricularhypertrophy（右室肥大）;Impulseatxiphoidprocess（剑突下搏动）:rightventricularhypertrophy;beatingofabdominalaorta（腹主动脉搏动）.,18,Impulseatbaseofheart（心底部搏动）：2ndleftintercostalspacejustlateraltosternum(胸骨左缘2肋间）:dilationofpulmonaryartery；pulmonaryhypertension.2ndrightintercostalspacejustlateraltosternum(胸骨右缘2肋间）:dilationofascendingaorta（升主动脉扩张）。,Inspection（望诊）-precordialimpulse（心前区搏动）,19,Inspection（望诊）-contents（内容）,Deformityofthoraxes（胸廓畸形）Apicalimpulse（心尖搏动）Precordialimpulse（心前区搏动）,20,Palpation（触诊）Importanceofpalpation（触诊意义）,Toconfirmtheobservationsmadeduringinspection（进一步证实望诊所见）；Todetectinvisiblepulsatilemovements（发现望诊看不见的搏动）；Torevealthrillandpericardialfrictionrubs（发现震颤和心包摩擦感）。,21,Palpation（触诊）-method（方法）,Rightpalmfirst（先用右手手掌）-detectingthrills（检查震颤）；Fingertipsthen（后用指尖）-detectingpulsations（检查搏动）。,22,Definition（定义）：Slowandforcefulbeatinapex（心尖区徐缓、有力的搏动），liftfingertip（可使手指尖端抬起）。Significance（意义）：Signofleftventri-cularhypertrophy（左室肥大的体征）。,Palpation（触诊）-heavingapeximpulse(抬举样心尖搏动）,23,Palpation（触诊）-thrills（震颤）,Definition（定义）：Tinyvibrationsfeltbypalm（手掌感觉到的一种细小震动感），somewhatsimilartothesensationsonthethroatofapurringcat，thereforealsocalledpurring（与在猫喉部摸到的呼吸震颤类似，故亦称猫喘）。Mechanism：Thesameascardiacmurmurs（同杂音）。,24,Significance（意义）：Signsoforganicheartdiseases（器质性心脏病的体征）；alwaysThrill-cardiacmurmur，notalwaysCardiacmurmur-thrill；Usually-congenitalheartdisease（先天性心脏病）、valvularstenosis（瓣膜狭窄），seldomvalvularregurgi-tation（关闭不全）。,Palpation（触诊）-thrills（震颤）,25,Palpation（触诊）-thrills（震颤）,Clinicalimportanceofthrillsatapex（心前区震颤的临床意义）Location（部位）Phase（时相）Disease2ndrightintercostalsystole（收缩期）aorticspacejustlateraltostenosissternum(胸骨右缘2肋间）（主动脉瓣狭窄）2ndleftintercostalsystole（收缩期）pulmonaryspacejustlateraltostenosissternum(胸骨左缘2肋间）（肺动脉瓣狭窄）3th-4thleftintercostalsystole（收缩期）ventricularspacejustlateraltoseptaldefectsternum(胸骨左缘3-4肋间）（室间隔缺损）2ndleftintercostalcontinuous（连续性）patentductusspacejustlateraltoarteriosussternum(胸骨左缘2肋间）（动脉导管未闭）Apex（心尖区）diastole（舒张期）mitralstenosis（二尖瓣狭窄）,26,Palpation（触诊）-pericardialfrictionrubs（心包摩擦感）,Definition（定义）Acutepericarditis（急性心包炎）Fibrineffusesfrompericardium（心包膜纤维素渗出）Roughnessofperi-cardium（心包粗糙）Visceralandparietalpericardialsurfacesrubagainsteachotherwhenheartbeats（心脏搏动时脏层与壁层心包摩擦）Pericardialfrictionrubs（心包摩擦感）。,27,Palpation（触诊）-pericardialfrictionrubs（心包摩擦感）,Featurestoandfrogratingsensation;bothinsystoleanddiastole;bestsensedatapexor3th4thleftintercostalspacejustlateraltosternum;clearerifpatientsleanagainstforward;disappear:pericardialeffusion.,28,Palpation（触诊）-contents（内容）,Apicalimpulseandheavingapeximpulse（心尖搏动和抬举样心尖搏动）Thrills（震颤）Pericardialfrictionrubs（心包摩擦感）,29,Percussion（叩诊）,Aim（目的）：Todetectsizeofheartanditscontour（确定心界大小及形态）。,30,Percussion（叩诊）,Relativeandabsolutedullnessoftheheart,31,Percussion-methodofpercussion（叩诊方法）,Usemediatepercussion（间接叩诊）；Inrecumbentposition（仰卧体位）；Placepleximeterparallelwithintercostalspacewhenpatientisinrecumbentposition（当病人仰卧位，板指与肋间隙平行）；,32,Percussion-methodofpercussion（叩诊方法）,Comparepercussionnoteofeachintercostalspacefromlateralaspectinwards，fromlowerpartupwards（从外向内，从下向上逐一肋间隙比较叩诊音）；,33,Heartandgreatvesselsgiveabsolutedullnessonpercussion（心脏和大血管叩诊为绝对浊音），andthepartsofheartoverlaidbylunggiverelativedullnessonpercussion（心脏被肺遮盖部分叩诊为相对浊音）whichre-presentsrealsizeandshapeofheart(代表心脏的真实大小和形态)。,Percussion-methodofpercussion（叩诊方法）,34,Percussion-methodofpercussion（叩诊方法）,Percussionoftherightmarginoftheheart(心右界的叩诊):Beginsfromtheintercostalspaceoneinterspacehigherthantheborderofliverdullness(叩诊从肝浊音界上一肋间开始);Carryoutupwardsintercostalspacebyintercostalspace,tothesecondintercostalspace(由下往上,逐一肋间叩诊,直到第二肋间).,35,Leftmarginfirstandthenrightmargin（先叩左界后叩右界）。Fromlateralaspectinwards，fromlowerpartupwards（从外向内，从下向上）。,Percussion-sequenceofpercussion（叩诊顺序）,36,Percussion（叩诊）,Normalareaofrelativedullness（正常心脏相对浊音界）Right（cm）IntercostalspaceLeft（cm）2323233.54.5345679Distancefromleftmidclavicularlinetomidsternallineis810cm（左锁骨中线距胸骨中线810cm）。,Percussion（叩诊）-normalareaofrelativedullness（正常心脏相对浊音界）,37,Percussion（叩诊）-compositionofvariouspartsofheartborder（心浊音界组成）,Rightborder：superiorvenacave,ascendingaorta,rightatrium.,Leftborder：aorticknob,pulmonaryarterialtrunk，leftauricle，leftventricle.,Inferiorborder：rightventricle，lesserpartofleftventricle.,38,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,Factorsofheartitself（心脏本身因素）Enlargementofleftventricle（左室增大）Cardiacdullnessextendstoleftanddownwards（心浊音界移向左下）andisintheshapeofaboot（呈靴形）。Commonlyseeninaorticregurgitationandhypertensiveheartdisease（常见于主动脉瓣关闭不全和高血压性心脏病）andiscalled“aortic”type（主动脉型）。,39,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,Cardiacdullnessextendstoleftanddownwards（心浊音界移向左下）andisintheshapeofaboot（呈靴形）-“aortic”type（主动脉型）。,40,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,Factorsofheartitself（心脏本身因素）Enlargementofrightventricle（右室增大）-pulmonaryheartdisease（肺源性心脏病）Slightenlargement-noobviouschangeinareaofrelativedullness（轻度增大时心脏相对浊音界无明显改变）；Prominentenlargementrelativedullnessenlargedbothtoleftandrightbutnotdownwards（显著增大时心脏相对浊音界向左右增大，但向左不向下增大）。,41,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,Factorsofheartitself（心脏本身因素）Enlargementofbothventricles（左右室均增大）Enlargementofheartbilaterally（两侧增大）；Commonlyseenindilatedcardiomyopathy（常见于扩张型心肌病）。,42,Factorsofheartitself（心脏本身因素）Pericardialeffusion（心包积液）：Enlargementofheartbilaterally（两侧增大）；Heartborderchangesaccordingtobodysposition（心浊音界随体位改变而改变）-itbecomestriangularinerectposition（坐位时呈三角形）andtheoutlineofheartbordercanbeenlarged，especiallythewideningofbaseofheartinrecumbentposition（卧位时心浊音界增大尤其是心底部浊音界增宽）。,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,43,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,Factorsofheartitself（心脏本身因素）Enlargementofleftatriumandpulmonaryartery（左房增大及肺动脉段增宽）Makesconcavepartofleftborderofheartprotrudingoutwardsandcardiacdullnessbecomespearshaped（心腰膨出，心浊音界呈梨形）；Commonlyseeninmitralstenosisandiscalled“mitral”type（二尖瓣型）。,44,Percussion（叩诊）-cchangesinareaofcardiacdullness（心浊音界改变）,插P145图2-5-27,Enlargementofleftatriumandpulmonaryartery（左房增大及肺动脉段增宽）makesconcavepartofleftborderofheartprotrudingoutwardsandcardiacdullnessbecomespearshaped（心腰膨出，心浊音界呈梨形）-“mitral”type（二尖瓣型）。,45,Percussion（叩诊）-changesinareaofcardiacdullness（心浊音界改变）,Extracardialfactors（心脏以外因素）Emphysemadullnessofheartisnarrowedorcannotbepercussed（肺气肿时心浊音界缩小或不能叩出）。,46,Auscultation（听诊）-auscultatoryvalveareas（心脏瓣膜听诊区）,Definition（定义）：Whenheartvalvesopenandclose，theymakesoundswhichcanbetransmittedtobodysurface.Thelocationswhereexaminerscanhearthesoundsmostclearlyandeasilyarecalledauscultatoryvalveareas.(心脏各瓣膜开放与关闭时所产生的声音传导到体表最易听清的部位称心脏瓣膜听诊区)。,47,Auscultation（听诊）-auscultatoryvalveareas（心脏瓣膜听诊区）,48,Auscultation（听诊）-auscultatoryvalveareas（心脏瓣膜听诊区）,Locationsofauscultatoryvalveareas(心脏瓣膜听诊区位置)ValvesLocationsMitralvalveareasitewherethestrongest(二尖瓣区)heartbeatsarepalpated.Orapexarea(心尖区)(心尖搏动最强处)Pulmonaryvalvearealeft2ndintercostalspace(肺动脉瓣区)justlateraltosternum(胸骨左缘第2肋间)Aorticarearight2ndintercostalspace(主动脉瓣区)justlateraltosternum(胸骨右缘第2肋间)Secondaorticarealeft3ndintercostalspace(主动脉瓣第2听诊区)justlateraltosternum(胸骨左缘第3肋间)Tricuspidvalveareajunctionofxiphoidprocess(三尖瓣区)andsternum(剑突与胸骨交界处),49,Auscultation（听诊）-auscultatoryorder(听诊顺序),Startfromapexarea（从心尖区开始）；Carryoutauscultationclockwiseandsequentially（逆时针方向依次听诊）：apexarea，pulmonaryvalvearea，aorticarea，2ndaorticarea，tricuspidvalvearea（心尖区，肺动脉瓣区，主动脉瓣区，主动脉瓣第2听诊区，三尖瓣区）。,50,Auscultation（听诊）-heartrate（心率）,Definition（定义）Numberofheartbeatingperminute（每分钟心搏次数）。Varieswithage,sex，physicalactivityandemotionalstatus.,51,Normalrangeofheartrateforadults:Inrestandconsciousstate,60100beats/min(安静、清醒状态下60100次/分）。Abnormalheartrate（异常心率）：Fasterthan100beats/min-tachy-cardia(超过100次/分时为心动过速);Slowerthan60beats/min-brady-cardia(慢于60次/分时为心动过缓)。,Auscultation（听诊）-heartrate（心率）,52,Auscultation（听诊）-cardiacrhythm(心律),Definition（定义）：Rhythmofheartbeating(心脏跳动的节律)。Innormalcondition,cardiacrhythmissinusandbasicallyregular(正常情况下心律为窦性且节律基本整齐)。,53,Someyoungpeoplemayhaveirregularcardiacrhythmsduetorespiration,thatis,ininspirationheartratebecomesfaster，andinexpirationheartratebecomesslower.Itiscalledsinusarrhythmia.(部分青年人可出现随呼吸改变的心律,吸气时心率增快,呼气时减慢,称窦性心律不齐)。,Auscultation（听诊）-cardiacrhythm(心律),54,Auscultation（听诊）-abnormalcardiacrhythm(异常心律),Prematurebeats（过早搏动）Inthebackgroundofregularheart-beatsaheartbeatappearsinadvanceabruptly,followedbyalongerinterval(在规则心律基础上,突然提前出现一次心跳,其后有较长间隙)。,55,Prematurebeats（期前收缩或过早搏动）Prematurebeatsappearregularly.Asinusbeatisfollowedbyaprematurebeatbigeminy;every2sinusbeatsarefollowedbyaprematurebeattrigeminy,andsoon.(过早搏动规则出现称联律,一次窦性搏动后出现一次过早搏动称二联律,每二次窦性搏动后出现一次过早搏动称三联律,以此类推).,Auscultation（听诊）-abnormalcardiacrhythm(异常心律),56,Auscultation（听诊）-abnormalcardiacrhythm(异常心律),Atrialfibrillation(心房颤动)“threeinconsistencies”（“三不等”）Cardiacrhythmisabsolutelyirregu-lar(心律绝对不齐);Intensityoffirstheartsoundisnotthesame(第一心音强弱不等);Pulserateislessthanheartratepulsedeficit(脉搏次数小于心率脉搏短绌）。,57,Auscultation（听诊）-heartsounds（心音）,Thereare4heartsoundsinacardiaccycle（在一个心动周期中有4个心音）。Accordingtothesequence，theyarenamedasS1，S2，S3andS4（根据先后秩序，依次命名为第一、二、三和四心音）。S1andS2canbeheardwitheaseinnormalsubjects.InsomeyoungpeopleS3canbeheard.However，S4isalmostinaudibleandonlyheardinpathologicalstate.,58,S1ismainlycausedbytheclosuresofmitralvalveandtricuspidvalve（S1主要由二尖瓣和三尖瓣的关闭而产生）。Mitralvalveclosureprecedestricuspidvalveclosure(二尖瓣关闭早于三尖瓣关闭）,butonauscultationS1canonlybeheardasonesound（但听诊时仅为一个声音）。,Auscultation（听诊）-thefirstheartsounds（第一心音）,59,Auscultation（听诊）-thefirstheartsounds（第一心音）,S1indicatesthebeginningoftheventricularcontraction（S1代表心室收缩的开始）。,60,Auscultation（听诊）-thefirstheartsound（第一心音）,CharacteristicofS1onauscultation：Lowerkey（音调低钝）；Strongerintensity（强度较响）；Dulltone(性质较钝)；Longerperiod（历时较长）；Sametimeasapicalimpulse（与心尖搏动同时出现）；Loudestatapex（在心尖部最响）。,61,Auscultation（听诊）-secondheartsound（第二心音）,S2indicatestheonsetofventricularrelaxation(S2提示心室舒张开始)。S2ismainlycomposedoftheclosuresofaorticvalveandpulmonaryvalve(S2主要由第二组成成分由主动脉瓣和肺动脉瓣关闭组成)。,62,Theaorticvalveclosureprecedespulmonaryvalves(主动脉瓣关闭较肺动脉瓣稍早).A2andP2refertoclosureofaorticandpulmonaryvalves,respectively(A2和P2分别代表S2的主动脉瓣关闭成分和肺动脉瓣关闭成分).Butonauscultation，S2canonlybeheardasonesound（但听诊时仅为一个声音）。,Auscultation（听诊）-secondheartsound（第二心音）,63,Auscultation（听诊）-secondheartsound（第二心音）,A2ismostclearlyaudibleoveraorticareaandP2overpulmonaryvalvearea(A2在主动脉瓣膜听诊区听诊最清楚，P2在肺动脉瓣膜听诊区听诊最清楚）。GenerallyspeakingP2A2injuvenile,P2A2inadultsandP2A2inoldpeople.,64,Auscultation（听诊）-secondheartsound（第二心音）,CharacteristicofS2onauscultation：Higherkey（音调较高）；WeakerthanS1inintensity（强度较S1弱）；Cleartone(性质较清脆)；Shorterperiod（历时较短）；Laterthanapicalimpulse（在心尖搏动之后）；Loudestatheartbase（在心底部最响）。,65,Auscultation（听诊）-thirdheartsound（第三心音）,Atearlydiastoleofventricle（在心室舒张早期）。Fastfillingflowfromleftatriumtoventricletensionandvibrationofventricularwall,chordaetendineaeandpapillarymusclesS3.,66,Auscultation（听诊）-thirdheartsound（第三心音）,CharacteristicofS3onauscultation：Softandlowkey（轻而音调低）；SoundsliketheechoofS2(似为S2的回音）；Shorterperiod（历时较短）；Limitedatapexoritsinnerupperside（局限在心尖部或期内上方）；Clearlyheardinexpirationandatlateralposition(仰卧位或呼气时较清楚)；,67,Auscultation（听诊）-thirdheartsound（第三心音）,CharacteristicofS3onauscultation：Attheendofventriculardiastole(出现在心室舒张期）；Usuallyheardonlyinsomechildrenandyoungpeople（正常情况只有在部分儿童和青少年中才听到)。Usuallyheardinpathologicalconditions(通常在病理情况下听到）。,68,Auscultation（听诊）-differentiationofheartsounds（心音的鉴别）,DifferentiationbetweenS1andS2(第一、二心音的鉴别）S1（第一心音）S2（第二心音）Cardiaccycleonsetofventrionsetofventri（心动周期）cularsystoleculardiastoleKey（音调）lower（低调）higher（高调）Duration（时限）longer（长）shorter（短）Bestheardareaapex（心尖区）base（心底部）（听诊最好部位）Interval（间距）S1-S2S2-S1Synchronizationyes（是）no（不是）withapicalimpulse（与心尖搏动同步）,69,Auscultation（听诊）-accentuatedS1（第一心音增强）,Commoninmitralstenosis(常见于二尖瓣狭窄）：Mitralstenosis(二尖瓣狭窄）lessfillingofleftventricle（左室充盈减少）lowerpositionofmitralvalveleaflets（二尖瓣叶位置较低）fasterpressureincreaseandshortercontractionforleftventricle(左室压力上升速度加速和收缩时间缩短）largevibrationsinthemovementofmitralvalveleaflets(二尖瓣叶活动幅度大）louderS1(响亮S1）。,心脏舒张时,心脏收缩时,70,Auscultation（听诊）-accentuatedS1（第一心音增强）,Intensecontractilityofventriclesuchasexercise,fever,hyperthyroidism(心肌收缩力增强如运动，发热和甲状腺功能亢进)andtachycardia(心动过速)。,71,Auscultation（听诊）-weakenedS1（第一心音减弱）,Commoninmitralinsufficiency(常见于二尖瓣关闭不全)；Aorticinsufficiency(主动脉瓣关闭不全)，prolongedP-Rinterval(P-R间期延长）；Inmyocarditis(心肌炎）、myocardialinfarction(心肌梗死)、cardiomyopathy(心肌病)、heartfailure(心力衰竭)；,72,Auscultation（听诊）-unequalS1（第一心音强度不等）,Commoninatrialfibrillation(常见于心房颤动）；Completelyatrialventricularblock(完全性房室传导阻滞）-cannonsound（大炮音）.,73,Auscultation（听诊）-ChangesofS2inintensity（第二心音强度改变）,Changesofpressureofsystemiccirculationorpulmonarycirculationandofsemi-lunarvalvesarethemaincausesresultinginchangeofS2.(体循环或肺循环阻力的大小和半月瓣改变是影响S2的主要原因）。,74,Auscultation（听诊）-accentuatedS2（第二心音增强）,Increasedsystemicpressureorbloodflow（体循环压力或血流增加）strongclosureofaorticvalves（主动脉瓣关闭有力)largervibrationsinthemovementofaorticvalveleaflets(主动脉瓣活动幅度增大）A2。,75,Auscultation（听诊）-accentuatedS2（第二心音增强）,A2iscommoninhypertensionandatherosclerosis(A2常见于高血压和动脉粥样硬化）。,76,Auscultation（听诊）-accentuatedS2（第二心音增强）,Increasedpulmonarypressureorbloodflow（肺循环压力或血流增加）strongclosureofpulmonaryvalves（肺动脉瓣关闭增强)largervibrationsinthemovementofpulmonaryvalveleaflets(肺动脉瓣活动幅度增大）P2。,77,P2iscommoninpulmonaryheartdiseaseandcongenitalheartdiseaseswithshuntfromlefttorightsuchasatrialseptaldefect(ASD),ventricularseptaldefect(VSD)andpatentductusarteriosus(PDA)(常见于肺源性心脏病和左向右分流的先天性心脏病）。,Auscultation（听诊）-accentuatedS2（第二心音增强）,78,Auscultation（听诊）-weakenedS2（第二心音减弱）,Decreasedsystemicpressureorbloodflow（体循环压力或血流减小）weakclosureofaorticvalves（主动脉瓣关闭减弱)smallervibrationsinthemovementofaorticvalveleaflets(主动脉瓣活动幅度减小）A2。A2iscommoninhypotensionandaorticstenosis(常见于低血压和主动脉瓣狭窄）。,79,Auscultation（听诊）-weakenedS2（第二心音减弱）,Decreasedpulmonarypressureorbloodflow（肺循环压力或血流减小）weakclosureofpulmonaryvalves（肺动脉瓣关闭无力)smallervibrationsinthemovementofpulmonaryvalveleaflets(肺动脉瓣活动幅度减小）P2。P2iscommoninhypotensionandpulmonarystenosis(常见于低血压和肺动脉瓣狭窄）。,80,Auscultation（听诊）-Splittingofheartsounds(心音分裂）,Inphysiologicalcondition:Theonsetofleftventricularcontractionprecedesthatofrightventricularcontraction(左室收缩早于右室).Mitralvalveclosureprecedestricu-spidvalveclosurefor0.020.03s(二尖瓣关闭较三尖瓣早0.020.03秒).,81,Inphysiologic