《心臟體檢》.ppt

1,Department of Diagnostics 1st Affiliated Hospital Chen Ming,Physical examination of heart,2,Equipment（器材）：Stethoscope（聽診器）； Position（體位）：Supine （臥位）or seated（坐位）a patient；standing to the right side of the patient （an examiner）； Environment（環(huán)境）：Quiet （安靜）； Exposure（暴露）：Strip to waist（腰部）； Lightening（光線）：Good；left side； tangent（切線）； Knowledge of anatomy（解剖知識）：thorough（全面） Considerate and gentle。,Physical examination of heart (心臟檢查) Preparation,3,Midsternal line（胸骨中線） or Anterior midline （前正中線） Midclavicular lines（鎖骨中線） Anterior, middle,and posterior axillary lines （腋前、中、后線） Sternal angle （胸骨角）- connected with 2th costal cartilage （與第二肋軟骨相連） Intercostal space （肋間隙）,Physical examination of heart (心臟檢查)landmarks of topographic anatomy（解剖標志）,4,Inspection (望診),Palpation (觸診),Percussion (叩診),Auscultation (聽診),心 臟 檢 查,Physical examination of heart (心臟檢查),5,Tangent lightening（切線方向光線）； Same height as thorax (與胸廓同高）。,Inspection（望診）-gist（要點）,6,Precordial prominence（心前區(qū)隆起）： Right ventricular hypertrophy at puberty（兒童發(fā)育完成前右心室肥大） Congenital heart disease (先天性心臟病) Rheumatic heart disease (風濕性心臟病) Massive pericardial effusion in the adult （成人大量心包積液）。,Inspection（望診）- Deformity of thoraxes（胸廓畸形）,7,Inspection（望診）- Apical impulse（心尖搏動）,Definition（定義）：Heart contracts（心臟收縮） impacts corresponding site of front chest（心尖向前沖擊前胸壁相應(yīng)位置) apical impulse (心尖搏動)。,8,Inspection（望診）,Normal apical impulse（正常心尖搏動）： Location-The 5th intercostal space（第五肋間）, 0.5 1.0 cm medial to left midclavicular line （左鎖骨中線內(nèi)側(cè) 0.5 1.0 cm ）； Diameter- 2.0 2.5 cm。,Inspection（望診）- Apical impulse（心尖搏動）,9,Physiological factors（生理性因素）： Left lateral position （左側(cè)臥位）- extend to the left（向左移）for 2.0 3.0 cm. Right lateral position（右側(cè)臥位）- extend to the right（向右移）for 1.0 2.5 cm.,Inspection（望診）- Displacement of apical impulse（心尖搏動移位）,10,Pathological factors（病理性因素）： Heart itself（心臟本身） Enlargement of left ventricle（左 心室增大）-extend to left and downwards（左下移位）；,Inspection（望診）- Displacement of apical impulse（心尖搏動移位）,11,Pathological factors（病理性因素）： Heart itself（心臟本身） Enlargement of right ventricle（右 心室增大）-extend to left but not downwards（向左不向下移位）； Enlargement of both ventricles（左 右室均增大）-extend to both left and right.,Inspection（望診）- Displacement of apical impulse（心尖搏動移位）,12,Pathological factors（病理性因素）： Displacement of mediastinum（縱隔移 位） Pleural adhesion （胸膜粘連）， pulmonary atelectasis of one side （肺 不張- displacement of apical impulse toward the diseased side（移向 患側(cè)）； Pleural effusion（胸腔積液）， pneumothorax of one side（氣胸）- displacement of apical impulse toward the opposite side（移向健側(cè)）.,Inspection（望診）- Displacement of apical impulse（心尖搏動移位）,13,Pathological factors（病理性因素）： Displacement of diaphragm（橫隔移位） Massive ascites （大量腹水），huge tumor of abdominal cavity （腹腔巨大 腫瘤）-displacement of apical impulse to left （移向左側(cè)）； Severe emphysema（肺氣腫）- displacement of apical impulse inward and downward（移向內(nèi)下）。,Inspection（望診）- Displacement of apical impulse（心尖搏動移位）,14,Physiological factors（生理性因素）： Thick chest wall（胸壁肥厚）- weak and narrow（減弱、縮?。?Thin chest wall（胸壁?。? strong and wide（增強、較大）。,Inspection（望診）-Changes of intensity and range in apical impulse(心尖搏動強度與范圍的改變）,15,Pathological factors（病理性因素）： Increase in intensity of apical impulse（心尖搏動增強）- fever（發(fā)熱），anemia （貧血）， hyperthyroidism（甲狀腺機能亢進）； Decrease in intensity of apical impulse（心尖搏動減弱）-dilated cardiomyopathy（擴張型心肌?。?，acute myocardial infarction（急性心肌梗死），pericardial effusion（心包積液）， emphysema（肺氣腫）。,Inspection（望診）-Changes of intensity and range in apical impulse(心尖搏動強度與范圍的改變）,16,Inspection（望診）- Inward impulse （負性心尖搏動）,Definition（定義）：invagination（內(nèi)陷） of apical impulse when contracting。 Significance（意義）：adhesive pericarditis（粘連性心包積液）。,17,Inspection（望診）- precordial impulse（心前區(qū)搏動）,Impulse at 3th 4th left intercostal space just lateral to sternum (胸骨左 緣3 4肋間） : right ventricular hypertrophy（右室肥 大）; Impulse at xiphoid process（劍突下搏 動）: right ventricular hypertrophy; beating of abdominal aorta（腹主動脈搏 動）.,18,Impulse at base of heart（心底部搏動）： 2nd left intercostal space just lateral to sternum (胸骨左緣2肋間）: dilation of pulmonary artery； pulmonary hypertension. 2nd right intercostal space just lateral to sternum (胸骨右緣2肋間）: dilation of ascending aorta（升主動 脈擴張）。,Inspection（望診）- precordial impulse（心前區(qū)搏動）,19,Inspection（望診）-contents （內(nèi)容）,Deformity of thoraxes （胸廓畸形） Apical impulse （心尖搏動） Precordial impulse （心前區(qū)搏動）,20,Palpation（觸診） Importance of palpation（觸診意義）,To confirm the observations made during inspection （進一步證實望診所見）； To detect invisible pulsatile movements （發(fā)現(xiàn)望診看不見的搏動）； To reveal thrill and pericardial friction rubs（發(fā)現(xiàn)震顫和心包摩擦感）。,21,Palpation（觸診）-method （方法）,Right palm first （先用右手手掌）- detecting thrills（檢查震顫）； Fingertips then（后用指尖）- detecting pulsations（檢查搏動）。,22,Definition（定義）：Slow and forceful beat in apex（心尖區(qū)徐緩、有力的搏動），lift finger tip （可使手指尖端抬起）。 Significance（意義）：Sign of left ventri- cular hypertrophy（左室肥大的體征）。,Palpation（觸診）- heaving apex impulse (抬舉樣心尖搏動）,23,Palpation（觸診）-thrills （震顫）,Definition（定義）： Tiny vibrations felt by palm（手掌感覺到的一種細小震動感），somewhat similar to the sensations on the throat of a purring cat，therefore also called purring （與在貓喉部摸到的呼吸震顫類似，故亦稱貓喘）。 Mechanism：The same as cardiac murmurs（同雜音）。,24,Significance（意義）： Signs of organic heart diseases（器質(zhì)性心臟病的體征）； always Thrill - cardiac murmur， not always Cardiac murmur - thrill； Usually - congenital heart disease（先天性心臟?。?、valvular stenosis（瓣 膜狹窄），seldom valvular regurgi- tation（關(guān)閉不全）。,Palpation（觸診）-thrills （震顫）,25,Palpation（觸診）-thrills （震顫）,Clinical importance of thrills at apex （心前區(qū)震顫的臨床意義） Location（部位） Phase（時相） Disease 2nd right intercostal systole（收縮期） aortic space just lateral to stenosis sternum (胸骨右緣2肋間） （主動脈瓣狹窄） 2nd left intercostal systole（收縮期） pulmonary space just lateral to stenosis sternum (胸骨左緣2肋間） （肺動脈瓣狹窄） 3th-4th left intercostal systole（收縮期） ventricular space just lateral to septal defect sternum (胸骨左緣3-4肋間） （室間隔缺損） 2nd left intercostal continuous（連續(xù)性） patent ductus space just lateral to arteriosus sternum (胸骨左緣2肋間） （動脈導管未閉） Apex（心尖區(qū)） diastole（舒張期） mitral stenosis （二尖瓣狹窄）,26,Palpation（觸診）-pericardial friction rubs（心包摩擦感）,Definition（定義） Acute pericarditis（急性心包炎） Fibrin effuses from pericardium（心包膜纖維素滲出） Roughness of peri- cardium（心包粗糙） Visceral and parietal pericardial surfaces rub against each other when heart beats （心臟搏動時臟層與壁層心包摩擦） Pericardial friction rubs（心包摩擦感）。,27,Palpation（觸診）-pericardial friction rubs（心包摩擦感）,Features to and fro grating sensation; both in systole and diastole; best sensed at apex or 3th 4th left intercostal space just lateral to sternum; clearer if patients lean against forward; disappear: pericardial effusion.,28,Palpation（觸診）-contents（內(nèi)容）,Apical impulse and heaving apex impulse （心尖搏動和抬舉樣心尖搏動） Thrills （震顫） Pericardial friction rubs （心包摩擦感）,29,Percussion（叩診）,Aim（目的）： To detect size of heart and its contour（確定心界大小及形態(tài)）。,30,Percussion（叩診）,Relative and absolute dullness of the heart,31,Percussion- method of percussion （叩診方法）,Use mediate percussion（間接叩診）； In recumbent position（仰臥體位）； Place pleximeter parallel with intercostal space when patient is in recumbent position （當病人仰臥位，板 指與肋間隙平行）；,32,Percussion- method of percussion （叩診方法）,Compare percussion note of each intercostal space from lateral aspect inwards，from lower part upwards （從外向內(nèi)，從下向上逐一肋間隙比較叩診 音）；,33,Heart and great vessels give absolute dullness on percussion（心臟和大血管叩診為絕對濁音），and the parts of heart overlaid by lung give relative dullness on percussion（心臟被 肺遮蓋部分叩診為相 對濁音）which re- presents real size and shape of heart (代表心臟的真實大小和形態(tài)) 。,Percussion- method of percussion （叩診方法）,34,Percussion- method of percussion （叩診方法）,Percussion of the right margin of the heart (心右界的叩診): Begins from the intercostal space one interspace higher than the border of liver dullness (叩診從肝濁音界上一肋間開始); Carry out upwards intercostal space by intercostal space , to the second intercostal space (由下往上,逐一肋間叩診,直到第二肋間).,35,Left margin first and then right margin（先叩左界后叩右界）。 From lateral aspect inwards，from lower part upwards（從外向內(nèi)，從下向上）。,Percussion- sequence of percussion （叩診順序）,36,Percussion（叩診）,Normal area of relative dullness （正常心臟相對濁音界） Right（cm） Intercostal space Left（cm） 2 3 2 3 2 3 3.5 4.5 3 4 5 6 7 9 Distance from left midclavicular line to midsternal line is 8 10 cm（左鎖骨中線距胸骨中線8 10cm）。,Percussion（叩診）-normal area of relative dullness（正常心臟相對濁音界）,37,Percussion（叩診）-composition of various parts of heart border（心濁音界組成）,Right border ： superior vena cave, ascending aorta, right atrium.,Left border ： aortic knob, pulmonary arterial trunk， left auricle， left ventricle.,Inferior border： right ventricle， lesser part of left ventricle.,38,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,Factors of heart itself（心臟本身因素） Enlargement of left ventricle（左室增大） Cardiac dullness extends to left and downwards（心濁音界移向左下）and is in the shape of a boot（呈靴形）。 Commonly seen in aortic regurgitation and hypertensive heart disease（常見于主動脈瓣關(guān)閉不全和高血壓性心臟?。゛nd is called “aortic” type（主動脈型）。,39,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,Cardiac dullness extends to left and downwards（心濁音界移向左下）and is in the shape of a boot（呈靴形）-“aortic” type （主動脈型）。,40,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,Factors of heart itself（心臟本身因素） Enlargement of right ventricle（右室增大）- pulmonary heart disease（肺源性心臟?。?Slight enlargement - no obvious change in area of relative dullness（輕度增大時心臟相對濁音界無明顯改變）； Prominent enlargement relative dullness enlarged both to left and right but not downwards（顯著增大時心臟相對濁音界向左右增大，但向左不向下增大）。,41,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,Factors of heart itself（心臟本身因素） Enlargement of both ventricles（左 右室均增大） Enlargement of heart bilaterally （兩側(cè)增大）； Commonly seen in dilated cardiomyopathy（常見于擴張型心肌 ?。?。,42,Factors of heart itself（心臟本身因素） Pericardial effusion（心包積液）： Enlargement of heart bilaterally（兩側(cè)增大）； Heart border changes according to bodys position（心濁音界隨體位改變而改變）- it becomes triangular in erect position（坐位時呈三角形） and the outline of heart border can be enlarged， especially the widening of base of heart in recumbent position（臥位時心濁音界增大尤其是心底部濁音界增寬）。,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,43,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,Factors of heart itself（心臟本身因素） Enlargement of left atrium and pulmonary artery（左房增大及肺動脈段增寬） Makes concave part of left border of heart protruding outwards and cardiac dullness becomes pear shaped（心腰膨出，心濁音界呈梨形）； Commonly seen in mitral stenosis and is called “mitral” type （二尖瓣型）。,44,Percussion（叩診）-cchanges in area of cardiac dullness（心濁音界改變）,插P145圖2-5-27,Enlargement of left atrium and pulmonary artery（左房增大及肺動脈段增寬）makes concave part of left border of heart protruding outwards and cardiac dullness becomes pear shaped（心腰膨出，心濁音界呈梨形）-“mitral” type （二尖瓣型）。,45,Percussion（叩診）-changes in area of cardiac dullness（心濁音界改變）,Extracardial factors（心臟以外因素） Emphysema dullness of heart is narrowed or can not be percussed（肺氣腫時心濁音界縮小或不能叩出）。,46,Auscultation（聽診）-auscultatory valve areas（心臟瓣膜聽診區(qū)）,Definition（定義）： When heart valves open and close，they make sounds which can be transmitted to body surface. The locations where examiners can hear the sounds most clearly and easily are called auscultatory valve areas.(心臟各瓣膜開放與關(guān)閉時所產(chǎn)生的聲音傳導到體表最易聽清的部位稱心臟瓣膜聽診區(qū))。,47,Auscultation（聽診）-auscultatory valve areas（心臟瓣膜聽診區(qū)）,48,Auscultation（聽診）-auscultatory valve areas（心臟瓣膜聽診區(qū)）,Locations of auscultatory valve areas (心臟瓣膜聽診區(qū)位置) Valves Locations Mitral valve area site where the strongest (二尖瓣區(qū)) heart beats are palpated. Or apex area(心尖區(qū)) (心尖搏動最強處) Pulmonary valve area left 2nd intercostal space (肺動脈瓣區(qū)) just lateral to sternum (胸骨左緣第2肋間) Aortic area right 2nd intercostal space (主動脈瓣區(qū)) just lateral to sternum (胸骨右緣第2肋間) Second aortic area left 3nd intercostal space (主動脈瓣第2聽診區(qū)) just lateral to sternum (胸骨左緣第3肋間) Tricuspid valve area junction of xiphoid process (三尖瓣區(qū)) and sternum(劍突與胸骨交界處),49,Auscultation（聽診）- auscultatory order (聽診順序),Start from apex area（從心尖區(qū)開始）； Carry out auscultation clockwise and sequentially（逆時針方向依次聽診）：apex area，pulmonary valve area，aortic area，2nd aortic area， tricuspid valve area（心尖區(qū)，肺動脈瓣區(qū)，主動脈瓣區(qū)，主動脈瓣第2聽診區(qū)，三尖瓣區(qū)）。,50,Auscultation（聽診）-heart rate （心率）,Definition（定義） Number of heart beating per minute （每分鐘心搏次數(shù)）。 Varies with age, sex， physical activity and emotional status.,51,Normal range of heart rate for adults: In rest and conscious state, 60 100 beats/min (安靜、清醒狀態(tài)下60 100次/ 分）。 Abnormal heart rate（異常心率）： Faster than 100 beats/min- tachy- cardia (超過100次/分時為心動過速); Slower than 60 beats/min- brady- cardia (慢于60次/分時為心動過緩)。,Auscultation（聽診）-heart rate （心率）,52,Auscultation（聽診）-cardiac rhythm (心律),Definition（定義）： Rhythm of heart beating (心臟跳動的節(jié)律)。 In normal condition, cardiac rhythm is sinus and basically regular (正常情況下心律為竇性且節(jié)律基本整齊)。,53,Some young people may have irregular cardiac rhythms due to respiration, that is, in inspiration heart rate becomes faster，and in expiration heart rate becomes slower. It is called sinus arrhythmia. (部分青年人可出現(xiàn)隨呼吸改變的心律, 吸氣時心率增快, 呼氣時減慢, 稱竇性心律不齊)。,Auscultation（聽診）-cardiac rhythm (心律),54,Auscultation（聽診）- abnormal cardiac rhythm(異常心律),Premature beats（過早搏動） In the background of regular heart-beats a heartbeat appears in advance abruptly, followed by a longer interval (在規(guī)則心律基礎(chǔ)上, 突然提前出現(xiàn)一次心跳, 其后有較長間隙)。,55,Premature beats（期前收縮或過早搏動） Premature beats appear regularly. A sinus beat is followed by a premature beat bigeminy; every 2 sinus beats are followed by a premature beattrigeminy, and so on. (過早搏動規(guī)則出現(xiàn)稱聯(lián)律,一次竇性搏動后出現(xiàn)一次過早搏動稱二聯(lián)律,每二次竇性搏動后出現(xiàn)一次過早搏動稱三聯(lián)律,以此類推).,Auscultation（聽診）- abnormal cardiac rhythm(異常心律),56,Auscultation（聽診）- abnormal cardiac rhythm(異常心律),Atrial fibrillation (心房顫動) “three inconsistencies” （ “三不等” ） Cardiac rhythm is absolutely irregu- lar (心律絕對不齊); Intensity of first heart sound is not the same (第一心音強弱不等); Pulse rate is less than heart rate pulse deficit (脈搏次數(shù)小于心率脈搏 短絀）。,57,Auscultation（聽診）- heart sounds （心音）,There are 4 heart sounds in a cardiac cycle （在一個心動周期中有4個心音）。 According to the sequence ，they are named as S1，S2，S3 and S4（根據(jù)先后 秩序，依次命名為第一、二、三和四心音）。 S1 and S2 can be heard with ease in normal subjects. In some young people S3 can be heard. However，S4 is almost inaudible and only heard in pathological state.,58,S1 is mainly caused by the closures of mitral valve and tricuspid valve （S1主要由二尖瓣和三尖瓣的關(guān)閉而產(chǎn)生）。 Mitral valve closure precedes tricuspid valve closure (二尖瓣關(guān)閉早于三尖瓣關(guān)閉）, but on auscultation S1 can only be heard as one sound（但聽診時僅為一個聲音）。,Auscultation（聽診）- the first heart sounds（第一心音）,59,Auscultation（聽診）- the first heart sounds（第一心音）,S1 indicates the beginning of the ventricular contraction（ S1代表心室收縮的開始）。,60,Auscultation（聽診）- the first heart sound（第一心音）,Characteristic of S1 on auscultation： Lower key （音調(diào)低鈍）； Stronger intensity（強度較響）； Dull tone (性質(zhì)較鈍)； Longer period（歷時較長）； Same time as apical impulse（與心 尖搏動同時出現(xiàn)）； Loudest at apex（在心尖部最響）。,61,Auscultation（聽診）- second heart sound（第二心音）,S2 indicates the onset of ventricular relaxation (S2 提示心室舒張開始)。 S2 is mainly composed of the closures of aortic valve and pulmonary valve (S2主要由第二組成成分由主動脈瓣和肺動脈瓣關(guān)閉組成)。,62,The aortic valve closure precedes pulmonary valves (主動脈瓣關(guān)閉較肺動脈瓣稍早). A2 and P2 refer to closure of aortic and pulmonary valves, respectively (A2和P2分別代表S2的主動脈瓣關(guān)閉成分和肺動脈瓣關(guān)閉成分). But on auscultation ，S2 can only be heard as one sound（但聽診時僅為一個聲音）。,Auscultation（聽診）- second heart sound（第二心音）,63,Auscultation（聽診）- second heart sound（第二心音）,A2 is most clearly audible over aortic area and P2 over pulmonary valve area(A2在主動脈瓣膜聽診區(qū)聽診最清楚，P2在肺動脈瓣膜聽診區(qū)聽診最清楚）。Generally speaking P2 A2 in juvenile, P2 A2 in adults and P2 A2 in old people.,64,Auscultation（聽診）- second heart sound（第二心音）,Characteristic of S2 on auscultation： Higher key （音調(diào)較高）； Weaker than S1 in intensity （強度較S1 弱）； Clear tone (性質(zhì)較清脆)； Shorter period（歷時較短）； Later than apical impulse（在心尖搏動之 后）； Loudest at heart base（在心底部最響）。,65,Auscultation（聽診）- third heart sound（第三心音）,At early diastole of ventricle（在心室舒張 早期）。 Fast filling flow from left atrium to ventricle tension and vibration of ventricular wall, chordae tendineae and papillary muscles S3 .,66,Auscultation（聽診）- third heart sound（第三心音）,Characteristic of S3 on auscultation： Soft and low key （輕而音調(diào)低）； Sounds like the echo of S2(似為S2的回 音）； Shorter period（歷時較短）； Limited at apex or its inner upper side （局限在心尖部或期內(nèi)上方）； Clearly heard in expiration and at lateral position (仰臥位或呼氣時較清楚)；,67,Auscultation（聽診）- third heart sound（第三心音）,Characteristic of S3 on auscultation： At the end of ventricular diastole (出現(xiàn) 在心室舒張期）； Usually heard only in some children and young people （正常情況只有在部分 兒童和青少年中才聽到)。 Usually heard in pathological conditions (通常在病理情況下聽到）。,68,Auscultation（聽診）- differentiation of heart sounds（心音的鑒別）,Differentiation between S1 and S2(第一、 二心音的鑒別） S1（第一心音） S2（第二心音） Cardiac cycle onset of ventri onset of ventri （心動周期） cular systole cular diastole Key（音調(diào)） lower（低調(diào)） higher（高調(diào)） Duration（時限） longer（長） shorter（短） Best heard area apex（心尖區(qū)） base（心底部） （聽診最好部位） Interval（間距） S1-S2 S2-S1 Synchronization yes（是） no（不是） with apical impulse （與心尖搏動同步）,69,Auscultation（聽診）- accentuated S1 （第一心音增強）,Common in mitral stenosis (常見于二尖瓣狹窄）： Mitral stenosis (二尖瓣狹窄） less filling of left ventricle （左室充盈減少） lower position of mitral valve leaflets（二尖瓣葉位置較 低） faster pressure incr