《肺部体检》课件

1、1胸部检查(1)（1）掌握胸部常用的体表标志和人工划线，胸部的陷窝和分区；（2）掌握胸、肺部视诊、触诊检查方法，能获得较正确的结果；识别正常状态和异常体征；（3）熟悉肺部常见体征的临床意义。教学目的胸部的体表标志骨骼标志自然陷窝一、天然标志二、人工划线或分区4骨骼标志（Skeletal landmarks）Sternal anglesubscapular angle Intercostal spaceSpinous processxiphoid Costalspinal angleSuprasternal notchManubrium sterniscapula骨骼标志（Skeletal la

2、ndmarks）胸骨角：Louis 角。两侧分别与左右第2肋软骨连接，为计数肋骨和肋间隙顺序的主要标志。胸骨角还标志支气管分叉、心房上缘和上下纵隔交界及相当于第5胸椎的水平腹上角：胸骨下角（infrasternal angle)，相当于横膈的穹窿部，正常约70-110肩胛下角：肩胛骨的最下端。直立位两上肢自然下垂时，作为第7或第8肋骨水平的标志，或相当于第8胸椎的水平，作为后胸部计数肋骨的标志56人工划线和自然陷窝（Anterior imaginary lines and landmarks）epigastric angle Infraclavicular fossaAnterior midl

3、ineSuprasternal fossaSupraclavicular fossaSternal lineParasternal lineMidclavicular line7人工划线和自然陷窝（Lateral imaginary lines ）Anterior axillary lineMidaxillary linePosterior axillary line10Anterior view of lobes11Posterior view of lobes12Right lateral view of lobes胸壁皮肤颜色、肿胀胸壁静脉有无充盈或曲张上腔静脉阻塞时，静脉血流方向自上而

4、下下腔静脉阻塞时，静脉血流方向自下而上如何判断胸壁静脉的血流方向？有无回缩或膨隆吸气时肋间隙回缩提示呼吸道阻塞肋间隙膨隆见于大量胸腔积液、张力性气胸、严重肺气肿患者用力呼气时胸壁肿瘤、主动脉瘤、婴儿和儿童时期心脏明显肿大者，相应局部的肋间隙常膨出肋间隙胸廓形态患者体位：坐位或立位裸露全部胸廓平静呼吸前、后、左、右、两侧对比视诊（1）两侧对称性（2）横径与前后径比值 1：1.5胸廓形态Flat chest：体型瘦长，慢性消耗性疾病Barrel chest：严重肺气肿，老年或矮胖体型者Rachitic chest：佝偻病。漏斗胸（furnnel chest）指胸骨剑突处显著内陷，形似漏斗。鸡胸（p

5、igeon chest）指胸廓的前后径略长于左右径，上下距离较短，胸骨下端常前突，胸廓前侧壁肋骨凹陷胸廓一侧变形：膨隆；平坦或下陷胸廓局部隆起脊柱畸形21胸廓形态23Thoracic deformity Pectus excavatumBarrel chest Kyphosis24肺和胸膜视诊（Inspection）Respiratory movementAbdominal breathing: male adult and child Thoracic breathing: female adultThree depressions signdyspnea25肺和胸膜视诊（Inspectio

6、n）Respiratory rate: 16-18 f/minTachypnea: 20 f/minBradypnea: 500ml: breathlessness, chest depress52Signs (Moderate to massive effusion)TachypneaLimited movement of affected sideCostal interspaces of affected side are widerTrachea shifts to opposite sideDecreased vocal fremitus Dullness or flatness D

7、ecreased or disappeared vesicular breath sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of the fluid53Pneumothorax 54Symptoms Sudden chest pain DyspneaForced sitting positionUnaffected side lyingDry coughTension pneumothoraxProgressi

8、ve dyspneaSevere sweatTyckycardiaTension, agitatedCyanosisRespiratory failure55Signs Costal interspaces in affected side are widerLimited movement of affected side Decreased or disappeared vocal fremitus Trachea and heart shift to opposite sideTympanyVesicular breath sound decreased or disappeared（1

9、）胸骨角 (sternal angle)-Louis角的确定及意义？（2）肩胛下角的确定及意义？（3）锁骨中线的确定及意义？57常见异常呼吸类型的病因和特点类型特点病因呼吸停止呼吸消失心脏停搏Biots呼吸规则呼吸后出现长周期呼吸停止又开始呼吸颅内压增高，药物引起呼吸抑制，大脑损害Cheyne-Stokes呼吸不规则呼吸呈周期性，呼吸频率和深度逐渐增加和逐渐减少以至呼吸暂停交替出现药物引起的呼吸抑制，充血性心力衰竭，大脑损伤Kussmaul呼吸呼吸深快代谢性酸中毒58肺与胸膜常见疾病的体征疾病胸廓呼吸动度气管位置语音震颤叩诊音响呼吸音罗音语音共振大叶性肺炎对称患侧减弱居中患侧增强肺气肿桶状双侧

10、减弱居中双侧减弱哮喘对称双侧减弱居中双侧减弱肺水肿对称双侧减弱居中正常或减弱肺不张患侧平坦患侧减弱移向患侧减弱或消失胸腔积液患侧饱满患侧减弱移向健侧减弱或消失气胸患侧饱满患侧减弱或消失移向健侧减弱或消失病例书写格式视诊：胸壁静脉无曲张，肋间隙无狭窄或饱满，胸廓两侧对称，无畸形，呼吸运动两侧对称，胸式呼吸为主，呼吸频率18次/分，节律规整。触诊：胸壁无压痛，无皮下捻发感，胸廓扩张度两侧对称，语音震颤两侧强度一致，无胸膜摩擦感。Large left Hemithorax can be seen in all of the following except: 1.Left pleural effus

11、ion 2.Left Pneumothorax 3.Kyphoscoliosis 4.Agenesis of right lung QuestionsSmaller left Hemithorax can be seen in all of the following except: 1.Consolidation of left lower lobe2.Atelectasis of left lung3.Left Pleural fibrosis4.Agenesis of left lung Which statement is correct in counting the Respira

12、tory rate: 1.BP, Pulse and Respiratory rate should be taken first 2.Tell the patient that you are going to count his respiraory rate before counting 3.Count it aduring examination of Respiratory system steps 4.After patient is in a relaxed state count it without the patient being aware that you are

13、counting his respiratory rate Bradypnea is seen in all of the following except: 1.Brain Tumor 2.Myxedema （粘液水肿）3.Morphine overdose 4.Congestive heart failure Slow deep breathing is: 1.Kussmals breathing 2.Biots respiration 3.Cheyne stokes breathing 4.Sighs 5.Sleep apnea In Congestive Heart failure f

14、ollowing can occur except: 1.Increased Respiratory rate 2.Cheyne stokes breathing 3.Platypnea 4.Orthopnea 5.Labored breathing Possible causes of unilateral diminution or delay in chest expansion include all of the following except: 1.Pleural effusion 2.Asthma 3.Pulmonary consolidation 4.Pleural pain

15、 with splinting Assessment of chest expansion with deep inspiration helps identify the side of abnormality. Patient has decreased chest expansion on the left. Which is the most likely condition the patient may have: 1.Emphysema/COPD 2.Bronchial asthma 3.Right pleural fibrosis 4.Left pneumothorax 5.Right lung mass Patient has consolidation of right lower lobe. You would expect:1.No change in chest expansion2.Decreased expansion of ri