心脏检查 physical examination of the heart
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心脏检查 physical examination of the heart. 周达新 中山医院心内科. 第五节 心脏检查. 物理检查的意义 检查的环境:坐位、卧位,右侧 检查的项目:视、触、叩、听. 视诊内容. 心尖搏动 心前区异常搏动. 胸廓畸形. 胸廓: 桶状胸、鸡胸、扁平胸等 心前区:(饱满或隆起) 先天性心脏病, 肺动脉瓣狭窄 风湿性心脏病(少见) 心包炎,(大量心包积液) - PowerPoint PPT PresentationTRANSCRIPT
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心脏检查physical examination of the heart
周达新中山医院心内科
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第五节 心脏检查• 物理检查的意义• 检查的环境:坐位、卧位,右侧• 检查的项目:视、触、叩、听
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视诊内容• 心尖搏动• 心前区异常搏动
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胸廓畸形• 胸廓: 桶状胸、鸡胸、扁平胸等• 心前区:(饱满或隆起)• 先天性心脏病,• 肺动脉瓣狭窄• 风湿性心脏病(少见)• 心包炎,(大量心包积液)• 胸骨右缘 II-III :主动脉(瓣)病变 Marfan’syndrome
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Apical impulse 心尖搏动• 产生机理心脏周围结构心脏收缩的方式 心脏收缩时产生搏动或凹陷 缩窄型心包炎
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Apical impulse 心尖搏动正常人心尖搏动
部位范围
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Apical impulse 心尖搏动• 心尖搏动移位(生理性)1 、横膈的影响2 、纵隔的位置3 、心脏增大4 、体位改变
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心尖搏动的强度、范围• 生理情况下: 范围变大、变小、不见 强度增强、减弱• 病理情况下:气胸,胸腔积液等 范围变大、变小 强度增强、减弱
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Inward impulse负性心尖搏动• 粘连性心包炎 , 与周围组织粘连,• 重度右心室肥大
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心前区异常搏动• L3-4 异常搏动• 剑突下异常搏动• 心底部异常搏动
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触诊• 方法,部位、力度• 触诊注意事项• 内容 心尖搏动 异常搏动 震颤( thrill ) 心包磨擦感
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部位 时相 常见病变
I I胸骨左缘 SM 肺动脉瓣狭窄,右室流出道狭窄I I胸骨左缘 DM 原发性肺动脉扩张I I胸骨左缘 DM+SM 动脉导管未闭I I胸骨右缘 SM 主动脉瓣狭窄,I I I - I V胸骨左缘 SM 室间隔缺损,肥厚性梗阻性心肌病
心尖部 SM 重度二尖瓣关闭不全心尖部 DM 二尖瓣狭窄
心前区震颤的意义
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心尖搏动• 心尖搏动, S1 、收缩 抬举性心尖搏动
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Thrill 震颤• 震颤发生部位• 震颤发生时相• 分析意义,(表格)
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心包摩擦感• 时相• 性质• 不同时期
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叩诊• 相对浊音界• 绝对浊音界
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叩诊方法、顺序• 医生• 患者• 一般的顺序• 因人而异
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心界的组成• 右界:上腔静脉、右心房• 左界:气管、主动脉结、肺动脉段、左心耳、左心室• 心腰部,心上界、心下界
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正常浊音界• 2-3 II 2-3 • 2-3 III 3.5-4.5• 3-4 IV 5-6• V 7-9
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浊音界改变及意义• 心脏移位:胸、腹部病变• 心脏本身的病变 左心室的肥大靴型心 右心室肥大 左、右心室肥大,普大型心 左心房合并右心室 梨型心 主动脉瘤样扩张
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心脏听诊• 意义• 听诊器的选择• 听诊的环境• 患者的体位
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听诊区域• 血液动力学情况• 二尖瓣听诊区• 主动脉瓣听诊区• 主动脉瓣第二听诊区• 肺动脉瓣听诊区• 三尖瓣听诊区• 听诊顺序
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听诊内容• 心率 heart rate • 心律 cardiac rhythm • 心音 heart sound • 杂音 cardiac murmurs • 额外心音 extra cardiac sound
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心率 heart rate
• 60-100次 / 分• 心动过缓• 心动过速
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心律 cardiac rhythm
• 窦性心律不齐 sinus arrhythmia • 期前收缩, premature beat• 早搏,二联律、三联律• 心房颤动 atrial fibrillation : 脉搏短绌 pulse deficit
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心音 heart sound
• 第一心音 first heart sound • 第二心音 second heart sound • 第三心音 third heart sound • 第四心音 fourth heart sound
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第一心音 first heart sound
• 组成成分• 持续时间 100ms• 与心尖搏动、颈动脉搏动同时• QRS 20-40ms• 低• 最响部位
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第二心音 second heart sound
• 组成成分• 持续时间 80msT 波后• 低• 最响部位
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第三心音 third heart sound
• 组成成分• 持续时间 : 40ms• 低• 最响部位
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第四心音 fourth heart sound
• 心房收缩,心壁产生震动• 一般听不到
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心音鉴别• S1 低调, S2 高调,最响的部位不一样• S1、 S2 的距离• S1 和心尖搏动、颈动脉搏动同时• 移行听诊
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心音改变及意义• 心音强度改变:第一、二心音• 心音性质改变• 心音分裂 splitting of heart sounds
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第一心音强度改变• S1 增强:二尖瓣狭窄,高热甲亢贫血• S1 减弱:二尖瓣关闭不全心肌炎心肌病• 心肌梗死心功能不全• S1 强弱不等 心房颤动,大炮音• •
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第二心音强度改变• S2 增强:主动脉瓣区,肺动脉瓣区• S2 减弱:低血压,主动脉肺动脉
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心音性质的改变• 单音律• 钟摆律 or 胎心律
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心音分裂 splitting of heart sounds
• 三尖瓣比二尖瓣晚 20-30ms• 肺动脉瓣 比主动脉瓣晚 30ms• 只有大于 40ms 时人耳可以分辨
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S1 分裂• CRBBB• 肺动脉高压
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S2 分裂• 生理性分裂 physiologic splitting • 通常分裂: general splitting • 固定性分裂 fixed splitting , ASD 反之?• 逆分裂 reversed splitting ( paradoxical
splitting )反常分裂,(病理性)
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额外心音 extra cardiac sound
• 奔马律 gallop rhythm • 开瓣音 opening snap • 心包扣击音 pericardial knock • 收缩期喷射音 systolic ejection sound • 喀啦音 click
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奔马律 1gallop rhythm
• 舒张早期奔马律( S3 ): protodiastolic gallop (右室、左室)• 发生在有严重疾病的基础上• 心率快• 特点• 舒张晚期奔马律 late diastolic gallop ( S4 )左心室舒张功能下降• 高血压,肥厚性 ( S1前 100ms )• 心肌病 主动脉狭窄
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奔马律 2
• 重叠奔马律 咚 - 嗒 - 嗒• 四音律 克 -伦 -嗒 -呐
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开瓣音 opening snap
• 二尖瓣开放扑击音• 响亮、短促扑击音• S2后 70ms 伴有 S1 增强• 意义
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心包扣击音 pericardial knock
• 心室舒张也是一个主动的过程• S2 后约 90-120ms• 心室舒张突然受阻• 肿瘤扑落音• S2后 80-120ms 低调,体位改变而改变 比开瓣音晚
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收缩期额外心音• 收缩早期喷射音 early systolic ejection
sound ( click) SS11 的形成的形成• 特点:高频爆裂音,高调、短促 S1 后 50-70ms• 机理:半月瓣开启时突然受限,振动• 主动脉瓣区喷射音• 高血压、主动脉瓣狭窄、主动脉扩张主动脉瘤• 二尖瓣脱垂综合征 (mid and late click)
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肺动脉收缩期喷射音• 先天性心脏病• 原发性肺动脉扩张• 特发性肺动脉高压• 轻度肺动脉瓣狭窄
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主动脉瓣收缩期喷射音• 1 、高血压病• 2 、主动脉瘤• 3 、主动脉瓣狭窄• 4 、主动脉缩窄• 5 、主动脉瓣关闭不全
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收缩中晚期喀啦音 mid and late systolic click
• 特点:喀啦,高调 短促• 二尖瓣脱垂综合征
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心脏杂音 cardiac murmurs
机理1 、血流加速 高热、甲亢、贫血、运动2 、瓣口或流出道狭窄,绝对和相对狭窄3 、关闭不全4 、异常通道5 、结构异常,双腔右心室等6 、血管扩张
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涡流的形成
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涡流的形成
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涡流的形成
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特性及听诊要点 1
1 、部位及传导方向2 、不同心动周期 收缩期 舒张期 连续性 双期杂音
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特性及听诊要点 2
3 、性质:隆隆样、机器样、叹气样、喷射样4 、强度、形态:5 、体位、呼吸、运动
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杂音的意义• 生理性杂音和病理性杂音区别• 生理性: III 以下、柔和、无震颤、收缩期• 病理性:心脏扩大?、粗糙、 III 以上• 功能性:瓣膜本身无病变,但可以是病但可以是病理性的理性的
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收缩期杂音 1systolic murmurs
二尖瓣区生理性:高热、贫血、甲亢 柔和、局限、不传导、 I-II ,短病理性:粗糙、高调、传导、 III 以上 可掩盖 S1
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收缩期杂音 2systolic murmurs
主动脉瓣生理性: I-II级、柔和、短、不传导病理性: III 以上、响亮粗糙、喷射样收缩中期 向颈部传导、递增递减型 主动脉瓣狭窄,两叶式主动脉瓣、流出道狭窄、膜性或肌性狭窄
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肺动脉瓣区• 生理性,• 病理性,肺动脉瓣扩张,右室流出道狭窄,肺动脉高压等
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收缩期杂音 3systolic murmurs
三尖瓣功能性:先天性心脏病,二尖瓣狭窄等病理性: 少见
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其他部位 4
L3-4、 L2-3• 功能性• 病理性
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舒张期杂音 1diastolic murmurs
二尖瓣• 功能性: Austin Flint 杂音• 器质性:中晚期、隆隆样、低调、局限 递增型、震颤
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舒张期杂音 2diastolic murmurs
主动脉瓣区递减型、叹气样、向心尖部传导
肺动脉瓣区少见,肺动脉扩张导致相对性关闭不全吹风样,柔和、局限
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连续性杂音 continuous murmurs
• L2-3 : PDA• L3-4 主动脉窦瘤破裂
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心包摩察音 pericardial friction sound
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心包摩察音 pericardial friction sound
• 心房收缩 - 心室收缩 - 心室舒张• 心室收缩 - 心室舒张• 心室收缩• 心包炎、心肌梗死、尿毒症晚期
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血管检查• 水冲脉 water hammer pulse :高动力循环状态 贫血、甲亢 动脉导管未闭、主动脉关闭不 全、• 奇脉 paradoxical pulse :心包积液
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周围血管体征• 枪击音 pisto shot sound • Duroziez双重杂音• 毛细血管搏动征 capillart pulsation • 重度贫血、甲亢、重度主动脉瓣关闭不全
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