G心脏检查B.ppt

Normal Heart Sounds正常心音正常心音n n origination of heart soundsorigination of heart sounds 心音产生机制心音产生机制心音产生机制心音产生机制n n differences between Sdifferences between S1 1&S&S2 2 第第第第一一心音和第心音和第心音和第心音和第二二心音的区分心音的区分心音的区分心音的区分Origination of Heart Sounds心音产生心音产生Systole Systole 收缩收缩收缩收缩 Diastole Diastole 舒张舒张舒张舒张Occurring of Heart Sounds心音起源心音起源n nS S1 1:caused by the closure of the mitral and tricuspid:caused by the closure of the mitral and tricuspid valves at the beginning of ventricular systolevalves at the beginning of ventricular systole 二尖瓣和三尖瓣关闭振动二尖瓣和三尖瓣关闭振动二尖瓣和三尖瓣关闭振动二尖瓣和三尖瓣关闭振动n nS S2 2:caused by the closure of the pulmonary and aortic:caused by the closure of the pulmonary and aortic valves at the end of ventricular systolevalves at the end of ventricular systole 主动脉瓣和肺动脉瓣关闭振动主动脉瓣和肺动脉瓣关闭振动主动脉瓣和肺动脉瓣关闭振动主动脉瓣和肺动脉瓣关闭振动n nS S3 3:caused by blood filling ventricle immediately after:caused by blood filling ventricle immediately after opening of the AV valves opening of the AV valves 舒张早期心室壁振动舒张早期心室壁振动舒张早期心室壁振动舒张早期心室壁振动n nS S4 4:caused by the systole of the atrium:caused by the systole of the atrium 舒张晚期心房收缩振动舒张晚期心房收缩振动舒张晚期心房收缩振动舒张晚期心房收缩振动Differences Between S1&S2第一心音和第二心音的区分第一心音和第二心音的区分S S1 1 第一心音第一心音第一心音第一心音S S2 2 第二心音第二心音第二心音第二心音Pitch Pitch 音调音调音调音调Low Low 低低低低High High 高高高高Intensity Intensity 强度强度强度强度High High 强强强强Low Low 弱弱弱弱Quality Quality 音质音质音质音质Blunter Blunter 低钝低钝低钝低钝Brisker Brisker 清脆清脆清脆清脆Duration Duration 持续时间持续时间持续时间持续时间 Long Long 长长长长Short Short 短短短短Interval Interval 两者间隔两者间隔两者间隔两者间隔S S1 1-S-S2 2 长长长长 S S2 2-S-S1 1 短短Apical impulse Apical impulse 心尖搏动心尖搏动心尖搏动心尖搏动Concomitant Concomitant 一致一致一致一致Post Post 之后之后之后之后Best site Best site 最响部位最响部位最响部位最响部位Apex Apex 心尖心尖心尖心尖Base Base 心底心底心底心底Abnormal Heart Sounds心音异常心音异常n n changes of intensity:changes of intensity:强度改变强度改变强度改变强度改变:increase increase 心音增强心音增强心音增强心音增强 decrease decrease 心音减弱心音减弱心音减弱心音减弱n n changes of quality:changes of quality:性质改变性质改变性质改变性质改变:pendulum rhythm pendulum rhythm 钟摆律钟摆律钟摆律钟摆律 fetal heart rhythm fetal heart rhythm 胎心律胎心律胎心律胎心律Influence Factor of Sound Intensity强度影响因素强度影响因素Sound production Sound production 心音产生心音产生心音产生心音产生n napex part:valve elasticity,place,movement apex part:valve elasticity,place,movement degree,raising speed of pressure combined with degree,raising speed of pressure combined with ventricle filling degree and contracting forceventricle filling degree and contracting force 心尖部心尖部心尖部心尖部(S S1 1)瓣膜弹性瓣膜弹性瓣膜弹性瓣膜弹性 位置位置位置位置 活动度活动度活动度活动度 压力上升速度压力上升速度压力上升速度压力上升速度(心室充盈度和收缩力心室充盈度和收缩力心室充盈度和收缩力心室充盈度和收缩力)n nbase part:valve disorders,pressure in arterybase part:valve disorders,pressure in artery 心底部心底部心底部心底部(S S2 2)瓣膜病变瓣膜病变瓣膜病变瓣膜病变 动脉内压力动脉内压力动脉内压力动脉内压力Sound conduction Sound conduction 心音传导心音传导心音传导心音传导n nconducting distance:pericardium,lung and chest conducting distance:pericardium,lung and chest wall thicknesswall thickness 传导距离传导距离传导距离传导距离:心包心包心包心包 肺脏肺脏肺脏肺脏 胸壁厚度胸壁厚度胸壁厚度胸壁厚度Changes of S1 Intensity第一心音第一心音强度改变强度改变Increase:Increase:增强增强增强增强n nmitral and/or tricuspid stenosis mitral and/or tricuspid stenosis 二尖瓣狭窄二尖瓣狭窄二尖瓣狭窄二尖瓣狭窄n nHyperdynamic circulatory states such as fever,anemia,Hyperdynamic circulatory states such as fever,anemia,hyperthyroidism.hyperthyroidism.血流加速如发热血流加速如发热血流加速如发热血流加速如发热 贫血贫血贫血贫血 甲亢甲亢甲亢甲亢n nShorting of the PR interval or complete heart block on Shorting of the PR interval or complete heart block on ECG.P-RECG.P-R间期缩短或间期缩短或间期缩短或间期缩短或完全房室传导阻滞完全房室传导阻滞完全房室传导阻滞完全房室传导阻滞Decrease:Decrease:减弱减弱减弱减弱n nMyocardial diseases.Myocardial diseases.心肌病心肌病心肌病心肌病n nMitral and/or tricuspid regurgitation.Mitral and/or tricuspid regurgitation.二尖瓣关闭不全二尖瓣关闭不全二尖瓣关闭不全二尖瓣关闭不全n nProlongation of PR interval.Prolongation of PR interval.P-RP-R间期延长间期延长间期延长间期延长n nAortic valves regurgitation.Aortic valves regurgitation.主动脉瓣关闭不全主动脉瓣关闭不全主动脉瓣关闭不全主动脉瓣关闭不全心房心房心房心房瓣膜瓣膜瓣膜瓣膜心室心室心室心室Changes of S2 Intensity第第二二心音心音强度改变强度改变n nS S2 2 has two elements,A has two elements,A2 2 and P and P2 2.第二心音分为主动脉瓣第二音和肺动脉瓣第二音第二心音分为主动脉瓣第二音和肺动脉瓣第二音第二心音分为主动脉瓣第二音和肺动脉瓣第二音第二心音分为主动脉瓣第二音和肺动脉瓣第二音n nA A2 2 increase:hypertension,aortosclerosis.increase:hypertension,aortosclerosis.主动脉瓣第二音增强主动脉瓣第二音增强主动脉瓣第二音增强主动脉瓣第二音增强:高血压高血压高血压高血压 主动脉硬化主动脉硬化主动脉硬化主动脉硬化n nP P2 2 increase:mitral sternosis or insufficiency,L.V failure,increase:mitral sternosis or insufficiency,L.V failure,and congenital heart diseases with left to right shunt.and congenital heart diseases with left to right shunt.肺动脉瓣第二音增强肺动脉瓣第二音增强肺动脉瓣第二音增强肺动脉瓣第二音增强:二尖瓣狭窄及关闭不全二尖瓣狭窄及关闭不全二尖瓣狭窄及关闭不全二尖瓣狭窄及关闭不全 左心功能不全左心功能不全左心功能不全左心功能不全 先天性心脏病左向右分流先天性心脏病左向右分流先天性心脏病左向右分流先天性心脏病左向右分流n nA A2 2 decrease:aortic stenosis or insufficiency decrease:aortic stenosis or insufficiency 主动脉瓣第二音减弱主动脉瓣第二音减弱主动脉瓣第二音减弱主动脉瓣第二音减弱:主动脉瓣狭窄及关闭不全主动脉瓣狭窄及关闭不全主动脉瓣狭窄及关闭不全主动脉瓣狭窄及关闭不全n nP P2 2 decrease:pulmonic stenosis or insufficiency decrease:pulmonic stenosis or insufficiency 肺动脉瓣第二音减弱肺动脉瓣第二音减弱肺动脉瓣第二音减弱肺动脉瓣第二音减弱:肺动脉瓣狭窄及关闭不全肺动脉瓣狭窄及关闭不全肺动脉瓣狭窄及关闭不全肺动脉瓣狭窄及关闭不全动脉动脉动脉动脉瓣膜瓣膜瓣膜瓣膜心室心室心室心室Changes of SChanges of S1 1 and S and S2 2 Intensity Simultaneously Intensity Simultaneously第一和第二心音强度同时改变第一和第二心音强度同时改变n nIncrease:blood velocity is increased,as in Increase:blood velocity is increased,as in anemia,fever,hyperthyroidism,anxiety,and anemia,fever,hyperthyroidism,anxiety,and during exercise.during exercise.增强增强增强增强:血流加速如贫血血流加速如贫血血流加速如贫血血流加速如贫血 发热发热发热发热 甲亢甲亢甲亢甲亢 焦虑和运动焦虑和运动焦虑和运动焦虑和运动n nDecrease:blood velocity is decreased,as Decrease:blood velocity is decreased,as myocardial diseases,increased overlying myocardial diseases,increased overlying tissue,fat,or fluid obscure sounds.tissue,fat,or fluid obscure sounds.减弱减弱减弱减弱:血流缓慢如心肌病血流缓慢如心肌病血流缓慢如心肌病血流缓慢如心肌病 传导受阻如肺气肿传导受阻如肺气肿传导受阻如肺气肿传导受阻如肺气肿 心包积液心包积液心包积液心包积液 脂肪增厚脂肪增厚脂肪增厚脂肪增厚Changes of Quality 心音性质改变心音性质改变n nChanges of SChanges of S1 1 quality:S quality:S1 1 same as S same as S2 2 (blankness)(blankness)第一心音性质改变第一心音性质改变第一心音性质改变第一心音性质改变:第一心音与第二心音相同第一心音与第二心音相同第一心音与第二心音相同第一心音与第二心音相同(单调单调单调单调)n nDiastolic phase shorten:same as systolic(single rule)Diastolic phase shorten:same as systolic(single rule)舒张时限缩短舒张时限缩短舒张时限缩短舒张时限缩短:收缩期与舒张期时限相同收缩期与舒张期时限相同收缩期与舒张期时限相同收缩期与舒张期时限相同(单律单律单律单律)n nCharacteristic:pendular rhythm,embryocardiaCharacteristic:pendular rhythm,embryocardia 听诊特点听诊特点听诊特点听诊特点:钟摆律钟摆律钟摆律钟摆律 胎心律胎心律胎心律胎心律n nClinical meaning:myocardial damage severely,as Clinical meaning:myocardial damage severely,as acute myocardial infarction,severe myocarditis,.acute myocardial infarction,severe myocarditis,.提示提示提示提示:心肌严重受损如急性心肌梗塞心肌严重受损如急性心肌梗塞心肌严重受损如急性心肌梗塞心肌严重受损如急性心肌梗塞 重症心肌炎重症心肌炎重症心肌炎重症心肌炎Splitting of Heart Sounds心音分裂心音分裂n n first heart sound splitting first heart sound splitting 第一心音分裂第一心音分裂第一心音分裂第一心音分裂n n second heart sound splittingsecond heart sound splitting 第二心音分裂第二心音分裂第二心音分裂第二心音分裂Splitting of First Heart Sounds第一心音分裂第一心音分裂n nArea for auscultation:apical area.Area for auscultation:apical area.部位部位部位部位:心尖部心尖部心尖部心尖部 n nCommon diseases:right bundle Common diseases:right bundle branch block,pulmonary branch block,pulmonary hypertension,right heart failurehypertension,right heart failure 病因病因病因病因:右束支传导阻滞右束支传导阻滞右束支传导阻滞右束支传导阻滞 肺动脉高压肺动脉高压肺动脉高压肺动脉高压 右心功能不全右心功能不全右心功能不全右心功能不全Splitting of Second Heart Sounds第二心音分裂第二心音分裂n nAreas for auscultation:base of heartAreas for auscultation:base of heart 部位部位部位部位:心底部心底部心底部心底部n nMechanisms:asynchrony between closure Mechanisms:asynchrony between closure of the aortic and pulmonic valves.of the aortic and pulmonic valves.机制机制机制机制:主动脉瓣与肺动脉瓣关闭不同步主动脉瓣与肺动脉瓣关闭不同步主动脉瓣与肺动脉瓣关闭不同步主动脉瓣与肺动脉瓣关闭不同步n nVariations:wide splitting,fixed splitting,Variations:wide splitting,fixed splitting,reversed splitting.reversed splitting.类型类型类型类型:顺分裂顺分裂顺分裂顺分裂 固定分裂固定分裂固定分裂固定分裂 逆分裂逆分裂逆分裂逆分裂 Wide Splitting顺顺分裂分裂n nTypical at the end of inspirationTypical at the end of inspiration 吸气吸气吸气吸气末末末末分裂明显分裂明显分裂明显分裂明显n nPhysiologic splitting:deep inspirationPhysiologic splitting:deep inspiration 生理分裂生理分裂生理分裂生理分裂:吸气相回右心血量增加吸气相回右心血量增加吸气相回右心血量增加吸气相回右心血量增加n nGeneral splitting General splitting 通常分裂通常分裂通常分裂通常分裂n nDelayed PDelayed P2 2:pulmonary hypertension,mitral stenosis,:pulmonary hypertension,mitral stenosis,pulmonic stenosis,right bundle branch block.pulmonic stenosis,right bundle branch block.肺动脉瓣关闭延迟肺动脉瓣关闭延迟肺动脉瓣关闭延迟肺动脉瓣关闭延迟:肺动脉高压肺动脉高压肺动脉高压肺动脉高压 二尖瓣狭窄二尖瓣狭窄二尖瓣狭窄二尖瓣狭窄 肺动脉瓣狭窄肺动脉瓣狭窄肺动脉瓣狭窄肺动脉瓣狭窄 右束支阻滞右束支阻滞右束支阻滞右束支阻滞n nEarly AEarly A2 2:mitral insufficiency,IVSD:mitral insufficiency,IVSD 主动脉瓣关闭提前主动脉瓣关闭提前主动脉瓣关闭提前主动脉瓣关闭提前:二尖瓣关闭不全二尖瓣关闭不全二尖瓣关闭不全二尖瓣关闭不全 室间隔缺损室间隔缺损室间隔缺损室间隔缺损INPIRATION EXSPIRATION INPIRATION EXSPIRATION S S1 1 S S2 2 S S1 1 S S2 2 A A2 2 P P2 2 A A2 2P P2 2Fixed Splitting固定分裂固定分裂n nSplitting is unaffected by respirationSplitting is unaffected by respiration 分裂不受呼吸影响分裂不受呼吸影响分裂不受呼吸影响分裂不受呼吸影响n nMechanism:delayed closure of the pulmonic valve(output Mechanism:delayed closure of the pulmonic valve(output of the right ventricle is greater than that of the left)of the right ventricle is greater than that of the left)机制机制机制机制:肺动脉瓣关闭延迟肺动脉瓣关闭延迟肺动脉瓣关闭延迟肺动脉瓣关闭延迟n nBlood flow from left atrium to the right passing through Blood flow from left atrium to the right passing through septal defects amortized affection of respiration.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房间隔缺损处血液左向右分流缓冲呼吸影响房间隔缺损处血液左向右分流缓冲呼吸影响房间隔缺损处血液左向右分流缓冲呼吸影响n nCommon diseases:large atrial septal defects and right Common diseases:large atrial septal defects and right ventricular failure.ventricular failure.病因病因病因病因:大的房间隔缺损并右心功能不全大的房间隔缺损并右心功能不全大的房间隔缺损并右心功能不全大的房间隔缺损并右心功能不全INSPIRATION EXPIRATION INSPIRATION EXPIRATION S S1 1 S S2 2 S S1 1 S S2 2A A2 2P P2 2 A A2 2P P2 2Reversed Splitting逆分裂逆分裂n nTypical at the end of expirationTypical at the end of expiration 呼气末分裂明显呼气末分裂明显呼气末分裂明显呼气末分裂明显n nParadoxical Splitting:PParadoxical Splitting:P2 2 occurs firstly,followed by A occurs firstly,followed by A2 2 反常分裂反常分裂反常分裂反常分裂:肺动脉瓣第二音肺动脉瓣第二音肺动脉瓣第二音肺动脉瓣第二音 出现在主动脉瓣第二音之前出现在主动脉瓣第二音之前出现在主动脉瓣第二音之前出现在主动脉瓣第二音之前n nMechanism:closure of the aortic valve is delayedMechanism:closure of the aortic valve is delayed 机制机制机制机制:主动脉瓣关闭明显延迟主动脉瓣关闭明显延迟主动脉瓣关闭明显延迟主动脉瓣关闭明显延迟n nCommon diseases:Left bundle branch block,Aortic Common diseases:Left bundle branch block,Aortic stenosis.stenosis.病因病因病因病因:左束支传导阻滞左束支传导阻滞左束支传导阻滞左束支传导阻滞 主动脉瓣狭窄主动脉瓣狭窄主动脉瓣狭窄主动脉瓣狭窄INPIRATION EXSPIRATIONINPIRATION EXSPIRATION S S1 1 S S2 2 S S1 1 S S2 2P P2 2A A2 2 P P2 2 A A2 2Extra Heart Sounds额外心音额外心音n n systolic extra heart sounds systolic extra heart sounds 收缩期额外心音收缩期额外心音收缩期额外心音收缩期额外心音n n diastolic extra heart soundsdiastolic extra heart sounds 舒张期额外心音舒张期额外心音舒张期额外心音舒张期额外心音Extra Heart Sounds额外心音额外心音SystolicSystolicn nEarly systole:ejection soundsEarly systole:ejection soundsn nMid-/Late systole:clickMid-/Late systole:clickDiastolicDiastolicn nEarly diastole:opening snap,Early diastole:opening snap,pericardial knock pericardial knock n nMid-diastole:third heart soundMid-diastole:third heart soundn nLate diastole:fourth heart soundLate diastole:fourth heart soundn ngallop rhythmgallop rhythm收缩收缩收缩收缩n n早期喷射音早期喷射音早期喷射音早期喷射音n n中晚期喀喇音中晚期喀喇音中晚期喀喇音中晚期喀喇音舒张舒张舒张舒张n n早期开瓣音早期开瓣音早期开瓣音早期开瓣音 心包叩击音心包叩击音心包叩击音心包叩击音n n中期第三心音中期第三心音中期第三心音中期第三心音n n晚期第四心音晚期第四心音晚期第四心音晚期第四心音n n奔马律奔马律奔马律奔马律Early Systole Ejection Sounds收缩早期喷射音收缩早期喷射音n nSounds from opening of the semilunar valvesSounds from opening of the semilunar valves 半月瓣开放产生的声音半月瓣开放产生的声音半月瓣开放产生的声音半月瓣开放产生的声音n nMechanism:blood flow passing through stenosic valves Mechanism:blood flow passing through stenosic valves made vibration of blood vessel wall and valvesmade vibration of blood vessel wall and valves 机制机制机制机制:瓣膜狭窄时血流引起血管壁和瓣膜振动瓣膜狭窄时血流引起血管壁和瓣膜振动瓣膜狭窄时血流引起血管壁和瓣膜振动瓣膜狭窄时血流引起血管壁和瓣膜振动n nArea for auscultation:base of the heartArea for auscultation:base of the heart 听诊部位听诊部位听诊部位听诊部位:心底部心底部心底部心底部n nCharacter:short and high pitched,with a click qualityCharacter:short and high pitched,with a click quality 特点特点特点特点:高调清脆短促高调清脆短促高调清脆短促高调清脆短促n nClinical significance:aortic stenosis,pulmonic stenosisClinical significance:aortic stenosis,pulmonic stenosis 提示提示提示提示:主动脉瓣狭窄主动脉瓣狭窄主动脉瓣狭窄主动脉瓣狭窄 肺动脉瓣狭窄肺动脉瓣狭窄肺动脉瓣狭窄肺动脉瓣狭窄Midsystolic Click收缩中期喀喇音收缩中期喀喇音n nDuring ballooning creates the clickDuring ballooning creates the click 瓣叶翻入心房后出现的声音瓣叶翻入心房后出现的声音瓣叶翻入心房后出现的声音瓣叶翻入心房后出现的声音n nMechanism:the sudden tensing of the valve leaflets Mechanism:the sudden tensing of the valve leaflets and the chordiae tendinae made the vibrationand the chordiae tendinae made the vibration 机制机制机制机制:瓣叶和腱索突然拉紧产生振动瓣叶和腱索突然拉紧产生振动瓣叶和腱索突然拉紧产生振动瓣叶和腱索突然拉紧产生振动n nArea for auscultation:the apexArea for auscultation:the apex 听诊部位听诊部位听诊部位听诊部位:心尖部心尖部心尖部心尖部n nCharacter:short and high pitched,with a click qualityCharacter:short and high pitched,with a click quality 特点特点特点特点:高调清脆短促高调清脆短促高调清脆短促高调清脆短促n nClinical significance:mitral valve prolapseClinical significance:mitral valve prolapse 提示提示提示提示:二尖瓣脱垂二尖瓣脱垂二尖瓣脱垂二尖瓣脱垂Opening Snap开瓣音开瓣音n nMechanism:the deformed mitral valve opens with a noiseMechanism:the deformed mitral valve opens with a noise 机制机制机制机制:开放的二尖瓣突然振动开放的二尖瓣突然振动开放的二尖瓣突然振动开放的二尖瓣突然振动n nCharacter:sharp and high pitched,with a snapping qualityCharacter:sharp and high pitched,with a snapping quality 特点特点特点特点:高调清脆短促高调清脆短促高调清脆短促高调清脆短促n nAreas for auscultation:the third or fourth left interspace at Areas for auscultation:the third or fourth left interspace at the sternal border,less well at the apexthe sternal border,less well at the apex 听诊部位听诊部位听诊部位听诊部位:胸骨左缘胸骨左缘胸骨左缘胸骨左缘3,43,43,43,4肋间肋间肋间肋间 以及心尖部以及心尖部以及心尖部以及心尖部n nClinical significance:mitral stenosis(the elasticity of the Clinical significance:mitral stenosis(the elasticity of the valve may be fine)valve may be fine)提示提示提示提示:二尖瓣狭窄二尖瓣狭窄二尖瓣狭窄二尖瓣狭窄(瓣膜弹性尚好瓣膜弹性尚好瓣膜弹性尚好瓣膜弹性尚好)Pericardial Knock心包叩击音心包叩击音n nMechanism:pericardial incrassation and Mechanism:pericardial incrassation and conglutination,ventricle sudden stop in diastolic conglutination,ventricle sudden stop in diastolic made wall vibrancy.made wall vibrancy.机制机制机制机制:心包增厚粘连心包增厚粘连心包增厚粘连心包增厚粘连 心室舒张骤停心室舒张骤停心室舒张骤停心室舒张骤停 室壁产生振动室壁产生振动室壁产生振动室壁产生振动n nCharacter:short and loweringCharacter:short and lowering 特点特点特点特点:低沉短促低沉短促低沉短促低沉短促n nArea for auscultation:in the apexArea for auscultation:in the apex 听诊部位听诊部位听诊部位听诊部位:心尖部心尖部心尖部心尖部n nClinical significance:pericarditis,Clinical significance:pericarditis,pericardial pericardial incrassation and conglutinationincrassation and conglutination 提示提示提示提示:缩窄性心包炎缩窄性心包炎缩窄性心包炎缩窄性心包炎 心包增厚粘连心包增厚粘连心包增厚粘连心包增厚粘连Gallop奔马律奔马律Mechanism:decreased compliance of the ventricle Mechanism:decreased compliance of the ventricle caused by severe myocardial damagecaused by severe myocardial damage 机制机制机制机制:心肌严重受损致室壁顺应性差心肌严重受损致室壁顺应性差心肌严重受损致室壁顺应性差心肌严重受损致室壁顺应性差Classification:Classification:分类分类分类分类n nProtodiastolic gallop(Ventricular gallop,SProtodiastolic gallop(Ventricular gallop,S3 3 gallop)gallop)舒张早期奔马律舒张早期奔马律舒张早期奔马律舒张早期奔马律(室性奔马律室性奔马律室性奔马律室性奔马律 第三心音奔马律第三心音奔马律第三心音奔马律第三心音奔马律)n nLate diastolic gallop(atrial gallop,SLate diastolic gallop(atrial gallop,S4 4 gallop)gallop)舒张晚期奔马律舒张晚期奔马律舒张晚期奔马律舒张晚期奔马律(房性奔马律房性奔马律房性奔马律房性奔马律 第四心音奔马律第四心音奔马律第四心音奔马律第四心音奔马律)n nQuadruple rhythm and summation soundQuadruple rhythm and summation sound 四音律和重叠奔马律四音律和重叠奔马律四音律和重叠奔马律四音律和重叠奔马律Protodiastolic gallop舒张早期奔马律舒张早期奔马律n nMechan