H心脏检查C.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Auscultation of Murmurs,心脏杂音听诊,mechanisms,产生机制,characterization,听诊要点,clinical meaning,临床意义,Mechanisms,杂音产生机制,turbulent flowvorticesmurmur,湍流,旋涡,杂音,Stenosis or insufficiency of valves,瓣膜狭窄或关闭不全,Abnormal pathway(shunt),异常通道(分流),Floating materials in circulation,心腔内漂浮物,Stenosis or dilation of blood vessels,血管腔扩大或狭窄,Enhanced bloodflow velocity,血流加速,Diminished viscosity,血液粘度降低,Organic&Relative,器质性与相对性,Organic:valve disease,器质性:瓣膜本身病变,stenosis,狭窄,insufficiency,关闭不全,Relative:,pathway wide,相对性:通道扩大,stenosis,狭窄,insufficiency,关闭不全,Duration,杂音时期,Systolic,murmur(SM),Holosystolic,Early,Midsystolic,Late,Diastolic,murmur(DM),Holodiastolic,Early,Middiastolic,Late(presystolic),Continuous,收缩期杂音,全收缩期,收缩早期,收缩中期,收缩晚期,舒张期杂音,全舒张期,舒张早期,舒张中期,舒张晚期,连续性杂音,Distinguish Duration,时期的区分,systolic murmur,收缩期杂音,appear,between S,1,and S,2,same as,apical impulse,在第一心音与第二心音之间出现 与心尖搏动一致,diastolic murmur,舒张期杂音,appear,between S,2,and S,1,nonsame,as,apical impulse,在第 2 心音与第 1 心音之间出现 与心尖搏动不一致,Both Phase and Continues Murmur,双期杂音与连续性杂音,Both phase murmur,双期杂音,Cause:mitral stenosis and insufficiency,疾病:二狭二闭,Heart murmur appears in systole and diastole respectively.,收缩舒张期分别出现杂音,Auscultation:,Quality different and S,2,still,特点:杂音性质可不同,不遮盖第二心音,Continues murmur,连续性杂音,Cause:,Patent ductus arteriosus,疾病:动脉导管未闭,Starts in systole,continues without interruption through S,2,into diastole.,跨越收缩期和舒张期,Auscultation:,Quality same and S,2,disappear.,特点:杂音性质相同,遮盖第二心音,Pitch and Quality,杂音性质,Pitch,:,depends on pressure and rate of blood flow,音调:与血流的压力和流速相关,high,medium and low,高调 中等 低调,Quality:depends on degree of valve compromise,force of contractions and blood volume,音色:与瓣膜状况 收缩力和血容量相关,Harsh or raspy,粗糙或刺耳,Machine-like vibratory,机器样,Musical,乐音样,Blowing,吹风样,Rumbling,隆隆样,signing sound,叹气样(泼水样),Warble sound,鸟鸣样(鸥鸣 鸽鸣 雁鸣),Intensity,杂音强度,Influencing factors:,影响因素,Degree of change between calibers of the passages through which the blood is flowing,通道口的大小,Degree of pressure differential between the passages,通道两端的压力差,Speed of the blood flow,血流速度,Thickness of the tissues between the heart and the surface of the chest,传导距离,Intensity of Systolic Murmur,收缩期杂音强度,Grade:barely audible in quiet room,1,级:仔细听方可听到,Grade:quiet but clearly audible,2,级:容易听到但不响亮,Grade:moderately loud,3,级:较响亮,Grade:loud,associated with thrill,4,级:粗糙且响亮 伴传导震颤,Grade:very loud,thrill easily palpable,5,级:震耳,Grade:very loud,audible with stethoscope not in contact with chest,thrill palpable and visible,6,级:离开胸壁亦可闻及,Configuration or Shape,杂音形态,Types of intensity variety,杂音强度变化类型,Crescendo:,increasing intensity,递增型:强度逐渐增加,Decrescendo:decreasing intensity,递减型:强度逐渐减小,Crescendo-d,ecrescendo:,递增递减型:强度先增加后减小,Continuous:,连续型:收缩期增强到舒张期减弱,Plateau:same intensity,一贯型:强度大体保持一致,Transmission or Radiation,杂音传导,The greatest factor influencing radiation is intensity,随距离增加响度减弱性质不变,Radiation direction can be influenced by:origin of the murmur,direction of flow of turbulent stream,传导方向:与病变部位及血流方向相关,Mitral insufficiency:transmit to left oxter and scapular,二尖瓣关闭不全:向左腋下肩胛下传导,Aortic stenosis:transmit to right cervix,主动脉瓣狭窄:向右侧颈部传导,Aortic insufficiency:transmit to,apical area,主动脉瓣关闭不全:向心尖部传导,Mitral stenosis:no transmission,二尖瓣狭窄:不传导,Effect Murmurs of Factor,影响杂音强度因素,Exercise:murmurs which are inaudible or just barely heard with the patient at rest may be more clearly heard after physical exertion.,运动影响:运动后使杂音增强,Respiration:full expiration made left cardiac murmur,d,eep inspiration made right cardiac murmur,.,呼吸影响:用力呼气使左心杂音增强,深吸气使右心杂音增强,Position:influence the location of the heart and the returned blood volume,体位改变:使心脏位置和回心血量相应改变,Classification of Murmurs,杂音的分类,Functional murmurs,功能性杂音,Physiologic:velocity of blood flow,生理性:血流加速,Relative:enlargement of the orifice,usually reversible,相对性:有腔隙或瓣环的扩大 有可逆性,Organic murmurs,器质性杂音,Organic damage,有器质性损害,Most of the diastolic and continues murmurs are organic,舒张期及连续性杂音绝大多数为器质性杂音,Functional and Organic Murmurs,收缩期杂音的鉴别,Functional,功能性,Organic,器质性,Age,年龄,Young,儿童青少年,Unlimited,不定,Location,部位,Pulmonic/apical,肺动脉瓣或心尖部,Any area,各部位,Character,性质,Soft,smooth,柔和,Coarse,high pitch,粗糙高调,Duration,时间,Short,短,Long(whole systole),长（全收缩期）,Intensity,强度,or=3/6,Thrill,震颤,no,无,Yes,有,Transmission,传导,Localized,局限,extensive,传导,Location and Duration to Diagnose,杂音部位时期对诊断的提示,systolic,收缩期,insufficiency stenosis,关闭不全 狭窄,mitral valve,二尖瓣,aortic valve,主动脉瓣,tricuspid valve,三尖瓣,pulmonic valve,肺动脉瓣,stenosis insufficiency,狭窄 关闭不全,Graham-Steell,diastolic Austin-Flint,舒张期,Systolic murmur in left sternum intercostal 34:,ventricular septal defect,胸骨左缘,3 4,肋间收缩期杂音:室间隔缺损,Continuous,machine-like in,left sternum,intercostal,2:,patent ductus arteriosus,胸骨左缘第,2,肋间连续型杂音:动脉导管末闭,Systolic Murmurs at the Apex,心尖部收缩期杂音,Quality:blowing,性质:吹风样,Physiologic,生理性,Pathologic:,病理性:,Insufficiency of mitral valve,二尖瓣关闭不全,Transmission of a systolic murmur arising elsewhere(aortic stenosis),主动脉瓣狭窄传导,Diastolic Murmurs at the Apex,心尖部舒张期杂音,Quality:rumbling,性质:隆隆样,Pathologic:,病理性,Structural stenosis of mitral valve,器质性二尖瓣狭窄,Relative stenosis of mitral valve,相对性二尖瓣狭窄,Austin-Flint,murmur,主动脉瓣关闭不全所致,Systolic Murmurs in the Pulmonic Area,肺动脉瓣区收缩期杂音,Quality:blowing,性质:吹风样,Physiologic:common,生理性,:,常见,Pathologic:,病理性:,Stenosis of pulmonic valve,肺动脉瓣狭窄,Transmission(from aortic area),主动脉瓣区传导,Diastolic Murmurs in the Pulmonic Area,肺动脉瓣区舒张期杂音,Quality:blowing,性质:吹风样,Pathologic:,病理性:,Insufficiency of pulmonic valve,肺动脉瓣关闭不全,Graham-Steell murmur,二尖瓣狭窄所致,Systolic Murmurs in the Aortic Area,主动脉瓣区收缩期杂音,Quality:blowing,性质:吹风样,Pathologic:,病理性:,Stenosis of aortic valve,主动脉瓣狭窄,Aneurysm of aorta,主动脉夹层瘤,Transmission of a murmur originating elsewhere,其他区杂音传导,Diastolic Murmurs in the Aortic Area,主动脉瓣区舒张期杂音,Quality:sighing sound,性质:叹气样,Pathologic:,病理性:,insufficiency of aortic valve,主动脉瓣关闭不全,Relative insufficiency of aortic valve,主动脉瓣相对性关闭不全,Transmission,传导,Murmurs in the Tricuspid Area,三尖瓣区杂音,Systolic murmurs:,Relative or organic insufficiency of tricuspid valve,收缩期杂音:,相对性或器质性,三尖瓣关闭不全,Diastolic murmurs:,Stenosis of tricuspid valve,舒张期杂音,:,三尖瓣狭窄,Murmurs in Left Edge of Sternum,胸骨左缘,杂音,Systolic,blowing in intercostal 3,4:,induced by ventricular septal defect,34,肋间收缩期吹风样,室间隔缺损,Continuous,machine-like in intercostal 2:induced by,patent ductus arteriosus,第2肋间连续性机器样,动脉导管未闭,Pericardial Friction Rubs,心包摩擦音,Pathogenesis:Irritated visceral and parietal pericardial surfaces grate against each other,意义:心包膜表面粗糙,Best heard site:LSB,3rd,4th ICS,部位:胸骨左缘第3,4肋间,Characteristics:occur at the same time with heartbeats and have no relation with respiration,特点,:,与心跳相一致 与呼吸无关,Clinical significance:pericarditis,提示:心包炎,Vascular Examination,血管检查,pulse examination,脉搏检查,blood vessel examination,血管杂音,Peripheral Arteries Blood Vessels,周围动脉血管,carotid artery,颈动脉,brachial artery,肱动脉,radial artery,桡动脉,femoral artery,股动脉,popliteal artery,腘,动脉,posterial tibial artery,胫后动脉,dorsalis pedis artery,足背动脉,Characteristics of Palpation,触诊特点,Pulse rate,脉率,(,是否与心率一致,),Pulse rhythm,脉律,(,节律是否整齐,),Contour(wave form),强度,(,增强,洪脉 减弱,细脉,),Amplitude(strength),紧张度,(,血管张力与弹性,),Symmetry,对称性,Obstructions to blood flow,方法:手指指腹,Arterial Pulse Abnormalities,脉搏异常,Infrequent pulse,迟脉,Alternating pulse,交替脉,Water-hammer pulse,水冲脉,Dicrotic pulse,重搏脉,Pulsus paradoxus,奇脉,Alternating Pulse,交替脉,characterized by alternation of a pulsation of small amplitude with the pulsation of large amplitude while the rhythm is normal.,脉搏强弱交替出现,Seen in left ventricular failure(more significant if pulse slow),提示左心功能不全,Water-hammer Pulse,水冲脉,Owning a greater amplitude than the normal pulse,a rapid rise to a narrow summit,and a sudden descent.,脉搏起伏大时间短,Seen in aortic regurgitation,patent ductus arteriosus.,提示主动脉瓣关闭不全 动脉导管未闭,Pulsus Paradoxus,奇脉,Characterized by an exaggerated decrease(10 mmHg)in the amplitude of pulsation during inspiration and increased amplitude during expiration.,吸气时脉搏明显减弱,Seen in premature cardiac contraction,tracheobronchial obstruction,bronchial asthma,emphysema,pericardial effusion,constrictive pericarditis.,提示心脏受压如肺过度充气 心包积液 缩窄性心包炎,Bruits and Hums,异常声音及征象,Hyperthyroidism:a soft,pulsatile,whooshing,blowing sound in the thyroid gland area,甲状腺机能亢进:甲状腺区血管柔和吹风样杂音,Polyarteritis:large artery systolic murmur,多发性大动脉炎:大动脉血管收缩期杂音,Renal artery stenosis:systolic murmur in upper abdomen and back,肾动脉狭窄:上腹及腰背部收缩期杂音,Aortic insufficiency:pistol shot sound,Duroziez double murmur,capillary pulsation.,脉压增大:,枪击音 杜氏双重杂音,毛细血管搏动征(甲床红白交替),Peripheral Vascular Sign,周围血管征,Vascular sign:,征象,Water-hammer Pulse,水冲脉,Carotid artery,impulse,颈动脉搏动,Nodding spasm,点头运动,Capillary pulsation,毛细血管搏动征,Pistol shot sound,枪击音,Duroziez double murmur,杜氏双重杂音,Clinical meaning:aortic insufficiency,hypertension,Hyperthyroidism,提示:主动脉瓣关闭不全 高血压 甲状腺机能亢进,Heart Disease,心脏疾病,mitral,stenosis,二尖瓣狭窄,aortic insufficiency,主动脉瓣关闭不全,Mitral Stenosis,二尖瓣狭窄,(1),L.A enlargement,Pulmonary artery dilation,R.V enlargement,左房增大肺动脉扩张右室增大,Inspection:Mitral face(malar flush),apical impulse,left,视诊:二尖瓣面容 心尖搏动向左移位,Palpation:diastolic thrill at the apex area,触诊:心尖部舒张期震颤,Percussion:,pear-shaped heart,叩诊:梨型心,Mitral Stenosis Auscultation,二尖瓣狭窄,(2),Apex area:,心尖部,Heart sounds:,Accentuation of,S,1,第一心音亢进,Extra sound:opening snaps,开瓣音,Murmurs:mid-or late-diastolic rumbling in quality,decrescendo-crescendo,usually localized,heard more clearly with the patient recumbent or on his left side or after moderate exercise.,舒张中晚期隆隆样杂音,Pulmonic area:,肺动脉瓣区,Heart sounds:Accentuation and splitting of,S,2,第二心音亢进分裂,Murmur:Graham-steell,G-S,杂音,Aortic Insufficiency,主动脉瓣关闭不全,(1),Inspection:Apical impulse,to left inferior,视诊:心尖搏动向左下移位,carotid artery,impulse,颈动脉搏动,Palpation:lifting apical impulse,触诊:抬举性心尖搏动,water-hammer pulse,水冲脉,Percussion:boot-shaped heart,叩诊:靴型心,Aortic Insufficiency,Auscultation,主动脉瓣关闭不全听诊,(2),Aortic area:,主动脉瓣区,Heart sounds:,S,2,第二心音减弱,Murmur:early diastolic,high pitch,blowing,radiating to the apex,舒张期递减型叹气样杂音,Apex area:,心尖部,Heart sounds:S,1,第一心音减弱,Murmurs:,Austin-Flint,A-F,杂音,next presentation,预告下次内容,abdominal examination,腹部检查,inspection and palpation,视诊和触诊,