G心脏检查B课件

1、hysical examination心脏检查 (2)Auscultation of Heart Sounds心音听诊 normal heart sounds abnormal heart sounds splitting of heart sounds extra heart sounds正常心音异常心音心音分裂额外心音Normal Heart Sounds正常心音 origination of heart sounds 心音产生机制 differences between S1 & S2 第一心音和第二心音的区分Origination of Heart Sounds心音产生Systole

2、收缩 Diastole 舒张Occurring of Heart Sounds心音起源S1: caused by the closure of the mitral and tricuspid valves at the beginning of ventricular systole 二尖瓣和三尖瓣关闭振动S2: caused by the closure of the pulmonary and aortic valves at the end of ventricular systole 主动脉瓣和肺动脉瓣关闭振动S3: caused by blood filling ventricle

3、 immediately after opening of the AV valves 舒张早期心室壁振动S4: caused by the systole of the atrium 舒张晚期心房收缩振动First Heart Sound, S1 第一心音Signaling the beginning of systole. 提示收缩期开始It has characters of low pitch, long duration. 音调低 时间长 “咚” It can be heard best in the apex area. 在心尖部听诊最清楚Differences Between S

4、1 & S2第一心音和第二心音的区分S1 第一心音S2 第二心音Pitch 音调Low 低High 高Intensity 强度High 强Low 弱Quality 音质Blunter 低钝Brisker 清脆Duration 持续时间 Long 长Short 短Interval 两者间隔S1-S2 长 S2-S1 短Apical impulse 心尖搏动Concomitant 一致Post 之后Best site 最响部位Apex 心尖Base 心底Abnormal Heart Sounds心音异常 changes of intensity: 强度改变: increase 心音增强 decre

5、ase 心音减弱 changes of quality: 性质改变: pendulum rhythm 钟摆律 fetal heart rhythm 胎心律Changes of S1 Intensity第一心音强度改变Increase: 增强mitral and/or tricuspid stenosis 二尖瓣狭窄Hyperdynamic circulatory states such as fever, anemia, hyperthyroidism. 血流加速如发热 贫血 甲亢Shorting of the PR interval or complete heart block on EC

6、G. P-R间期缩短或完全房室传导阻滞Decrease: 减弱Myocardial diseases. 心肌病Mitral and/or tricuspid regurgitation. 二尖瓣关闭不全Prolongation of PR interval. P-R间期延长Aortic valves regurgitation. 主动脉瓣关闭不全心房瓣膜心室Changes of S2 Intensity第二心音强度改变S2 has two elements, A2 and P2. 第二心音分为主动脉瓣第二音和肺动脉瓣第二音A2 increase: hypertension, aortoscle

7、rosis. 主动脉瓣第二音增强: 高血压 主动脉硬化P2 increase: mitral sternosis or insufficiency, L.V failure, and congenital heart diseases with left to right shunt. 肺动脉瓣第二音增强: 二尖瓣狭窄及关闭不全 左心功能不全 先天性心脏病左向右分流A2 decrease: aortic stenosis or insufficiency 主动脉瓣第二音减弱: 主动脉瓣狭窄及关闭不全P2 decrease: pulmonic stenosis or insufficiency

8、肺动脉瓣第二音减弱: 肺动脉瓣狭窄及关闭不全动脉瓣膜心室Changes of S1 and S2 Intensity Simultaneously第一和第二心音强度同时改变Increase: blood velocity is increased, as in anemia, fever, hyperthyroidism, anxiety, and during exercise.增强: 血流加速如贫血 发热 甲亢 焦虑和运动Decrease: blood velocity is decreased, as myocardial diseases, increased overlying ti

9、ssue, fat, or fluid obscure sounds. 减弱: 血流缓慢如心肌病 传导受阻如肺气肿 心包积液 脂肪增厚Splitting of Heart Sounds心音分裂 first heart sound splitting 第一心音分裂 second heart sound splitting 第二心音分裂Splitting of First Heart Sounds第一心音分裂Area for auscultation: apical area. 部位: 心尖部 Common diseases: right bundle branch block, pulmonar

10、y hypertension, right heart failure 病因: 右束支传导阻滞 肺动脉高压 右心功能不全Wide Splitting顺分裂Typical at the end of inspiration 吸气末分裂明显Physiologic splitting: deep inspiration 生理分裂: 吸气相回右心血量增加General splitting 通常分裂Delayed P2: pulmonary hypertension, mitral stenosis, pulmonic stenosis, right bundle branch block. 肺动脉瓣关

11、闭延迟: 肺动脉高压 二尖瓣狭窄 肺动脉瓣狭窄 右束支阻滞Early A2: mitral insufficiency, IVSD 主动脉瓣关闭提前: 二尖瓣关闭不全 室间隔缺损INPIRATION EXSPIRATION S1 S2 S1 S2 A2 P2 A2P2Fixed Splitting固定分裂Splitting is unaffected by respiration 分裂不受呼吸影响Mechanism: delayed closure of the pulmonic valve (output of the right ventricle is greater than that

12、 of the left) 机制: 肺动脉瓣关闭延迟Blood flow from left atrium to the right passing through septal defects amortized affection of respiration. 房间隔缺损处血液左向右分流缓冲呼吸影响Common diseases: large atrial septal defects and right ventricular failure. 病因: 大的房间隔缺损并右心功能不全INSPIRATION EXPIRATION S1 S2 S1 S2A2P2 A2P2Reversed S

13、plitting逆分裂Typical at the end of expiration 呼气末分裂明显Paradoxical Splitting: P2 occurs firstly, followed by A2 反常分裂: 肺动脉瓣第二音 出现在主动脉瓣第二音之前Mechanism: closure of the aortic valve is delayed 机制: 主动脉瓣关闭明显延迟Common diseases: Left bundle branch block, Aortic stenosis. 病因: 左束支传导阻滞 主动脉瓣狭窄INPIRATION EXSPIRATION S

14、1 S2 S1 S2P2A2 P2 A2Extra Heart Sounds额外心音 systolic extra heart sounds 收缩期额外心音 diastolic extra heart sounds 舒张期额外心音Extra Heart Sounds额外心音SystolicEarly systole: ejection soundsMid-/Late systole: clickDiastolicEarly diastole: opening snap, pericardial knock Mid-diastole: third heart soundLate diastole

15、: fourth heart soundgallop rhythm收缩早期喷射音中晚期喀喇音舒张早期开瓣音 心包叩击音中期第三心音晚期第四心音奔马律Early Systole Ejection Sounds收缩早期喷射音Sounds from opening of the semilunar valves 半月瓣开放产生的声音Mechanism: blood flow passing through stenosic valves made vibration of blood vessel wall and valves 机制: 瓣膜狭窄时血流引起血管壁和瓣膜振动Area for auscu

16、ltation: base of the heart 听诊部位: 心底部Character: short and high pitched, with a click quality 特点: 高调清脆短促Clinical significance: aortic stenosis, pulmonic stenosis 提示: 主动脉瓣狭窄 肺动脉瓣狭窄Opening Snap开瓣音Mechanism: the deformed mitral valve opens with a noise 机制: 开放的二尖瓣突然振动Character: sharp and high pitched, wit

17、h a snapping quality 特点: 高调清脆短促Areas for auscultation: the third or fourth left interspace at the sternal border, less well at the apex 听诊部位: 胸骨左缘3, 4肋间 以及心尖部Clinical significance: mitral stenosis (the elasticity of the valve may be fine) 提示: 二尖瓣狭窄 (瓣膜弹性尚好)Pericardial Knock心包叩击音Mechanism: pericardia

18、l incrassation and conglutination, ventricle sudden stop in diastolic made wall vibrancy. 机制: 心包增厚粘连 心室舒张骤停 室壁产生振动Character: short and lowering 特点: 低沉短促Area for auscultation: in the apex 听诊部位: 心尖部Clinical significance: pericarditis, pericardial incrassation and conglutination 提示: 缩窄性心包炎 心包增厚粘连Protod

19、iastolic gallop舒张早期奔马律Mechanism: pathological S3 机制: 病理性第三心音Origin: left ventricle, right ventricle 起源: 左室和右室Character: tone lower, intension feeble 音调较低 强度较弱Area for auscultation: left ventricle in the apex and loud in expiratory end, right ventricle in sternum lower edge left side and loud in insp

20、iratory end. 左室: 心尖部最清楚 呼气末明显 右室: 胸骨下端左缘 吸气末明显Clinical significance: heart failure 提示: 心力衰竭 Physical S3 & Pathological S3生理性与病理性第三心音的区分Normal S3生理性第三心音Pathological S3病理性第三心音Individual人群Healthy under age 健康未成年Severe heart disease严重心脏病HR 心率100/minPosture体位影响 when sit or stand 坐起或站立消失No effect无影响S2-S3 interval心音间隔Short短Long长Intensity强度Loud 强Louder 更强Late Diastolic Gallop舒张晚期奔马律Mechanism: pathological S4 机制: 病理性第四心音Area for auscultation: