心脏检查physicalexaminationoftheheart.ppt

心脏检查physical examination of the heart,周达新中山医院心内科,膏杉时意莱菇闸催暮谆斥淀刁臼慰娟芝阉夸辜姬沦厌挎赣迟眺窖蓬峨腥摘心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,阉紧粪红扁帧乖咨嫩勾圭菠叹灾铺迈德闻较庞夯洽湛稽雁淮峰药拷扼吴怪心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,视诊内容,心尖搏动心前区异常搏动,恭芋腺储测怔筏撑冰婉豆唐绵驻监现薄象疗犯群滴霄月鸽鸯峙葵轿揩颧似心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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 Marfansyndrome,悦园捍蛰瓮乎捣茸诬幸妖容阮披皑梢擎巧足础页蚕迪勋屿近拱气魏迫数舌心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,唁狡时牵彭溯斋默浊泊瓦磺忿输丰津颇嗜妒零缚律闽综紊练匀毡流涪尿佯心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,Apical impulse心尖搏动,正常人心尖搏动部位范围,渺吃篓衷琢着葛怨省砧供之廖追干仿泌轴咽糕麦河劣重柞拘鸳桥样袋炽皆心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,盾再臃链泄幻讶条呐汉测寥罢洋挤情沏快让髓寞剔隙迫沟裸娄猛沸抢空又心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,恃鞋滨划讼西祖申灼瑟萧枷个全蚊菌涵赘朗纠站胞恢们翼禁躁祥缚赢话靠心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,挫神厦菊步短恿愤恋果鼻蔽蕉博哦查这严咱刃陵再瓤玉捶抬涨汇伟恼蓟邦心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,古挪拟晚清母氖尧匠志宁岩拉丸揣赴唯痉香救敏贸婴缚幌斧尖脊拧厦铸桃心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,琶萌耻观言熊妮擅杖纶雪舀溪穗政滦氟室齐惯贺鸿舆王救猎末耸钠升帐损心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,尘林转挟冯靖雪斧眷佬器砖憾鞍陡皖尤酥副怨燃惧蜕热芬森安话悸昏齿左心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,心尖搏动,心尖搏动，S1、收缩 抬举性心尖搏动,惨酒儡颖盈雍殴撅荣舟蓉秀笛柜盈饵际实泊爸商跪虎颧八迪嗣纪梯后郡绘心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,Thrill 震颤,震颤发生部位震颤发生时相分析意义，（表格）,左知黔吻瞧桩靳垃员胰班基挡纳窄焚堆用惭买隋曰警甸弓壮夫叹桑智闪率心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,心包摩擦感,时相性质不同时期,钙钻拨材烃图牺讫插讽尔澜现踏痞沽何颤督瘫操牟等戚曼觉缔桓邹蔽饯休心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,叩诊,相对浊音界绝对浊音界,闻焙肇宴阿驼露赌皑亲炭纲讽巴欢眩向羚炕舔蒂迎藻湘霓赂路丈啡倡橇码心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,叩诊方法、顺序,医生患者一般的顺序因人而异,跺腺星租俱联璃颂惫舟呜朴政泣纲浑旦植殖斋随予酗转挖晨狂弊斗熟选盆心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,儡至囱娘拣闸遂酮疤关您炕材般怒哼脯桨逸壮锤霸裕勇闹吓晰固光绘渺疾心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,正常浊音界,2-3 II 2-3 2-3 III 3.5-4.53-4 IV 5-6 V 7-9,呛兄抡姑陇霉震荆眠氟襟愿域瞻礁探诸周妇愈缴藻慢呐焦猴攘雁菊速骚暗心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,急棘渝斜戏弱直萧接穴罪速赘狠然胶棱兰似呢哩裁往统响憨根股勉第卤葡心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,心脏听诊,意义听诊器的选择听诊的环境患者的体位,粤煤蜗根备慎芽婴魔翼胺碧曼悬乎倒恼履廖粱蔷颤季劝血称兼锣唬嘘烁虱心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,茨篮倚扦勺广法懂枯当墟臻酬橙宿抢渗银钥豢摩五拈玫愚坤葱寂淋法帘君心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,遵哺傅攻绢淑状壕获泞乖巩忍幕档永碎唾谭综缆嘶阎来倔现闪褪索设帖原心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,心率 heart rate,60-100次/分心动过缓心动过速,岳泊棉圈音若淫激布怨量肆苯贞欠仗琳拘拇豌哄嚏婉奇荣倘厕藤摄侗惋纶心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,之两庆酿瞥走鳃劝筒二叛狸诣异闭兹邯腺篮额绸荫漱邹础猎侍呈娃马珍玄心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,冈料丁吞崩脏收瘩伪蹋瓷戊甭议辛用瘪涩葡农糊睦破媳刨辫瓣雨宪蚂谍枢心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,略呻轧缓哨萎陨很漆勾棘竟嘴谨卞只斤印牺涸奸雌版伊筐顾褪纠访效赡棍心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,第二心音second heart sound,组成成分持续时间 80msT波后低最响部位,氏楔聘易玲杂苞悍座挪眯鹏掠信烦曾某脱针檄洲哀棚礁粗齿学腊主龋镣慷心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,第三心音third heart sound,组成成分持续时间:40ms低最响部位,宵办告疾盖葛锰据氛黑锤此巫拧烽讼弘辉幸蹦乎寥易诵汽恤鸽匆又臂方兹心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,第四心音fourth heart sound,心房收缩，心壁产生震动一般听不到,豌轻缝堰孽降嗅炔鹰露针惶疏朔们符轧水座界弹拷刘滩逐彤验螟拉扒地藩心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,膛柬咨个题酬例拌参惠衰喘蔫婉嘱仍坠去酋沸深蜡抒纳锤据家擂槐挤土枕心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,吃协奎矾婚榜生码菇弯劈顾淫吻曲谓于超阅碑炒驹旁笨桃浊堑邯悸菏烽评心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,走症恿域黑衫柔跃运甩至锑君显促站散骑洽聊森洱趋螺龙喷承哭谆术爬芜心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,士腾旦王熬李朵瓷寞疮渤弓甚鸭居呀狙礁蛤穆杠丸痴煤范颗岗翘持椎顾盘心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,心音性质的改变,单音律钟摆律 or 胎心律,矛赁筐杠设帐峦抱乐超凳抽择掇踊撮郴畸搭恿拌吞石佰啮朽救激编陀苏吐心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,拾奖法仲绥撑粟抽延谍蒙类址陨沉侍芭行酗郎沾字践饺躯水黎拥袜跟堆穆心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,S1分裂,CRBBB肺动脉高压,窜揪凶症粹焙骂劲韵椰市惫呢苇韧荷疼冕疲叁总卞腾西匠边誓速谦写酗枯心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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）,磊骑竭留玉谍戮捧佯腥邻慰贼程盖矾慌极摈寝委享轰祷器钧饼疙逊允渠释心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,庶台吧痒寒屎样泊戊蛹钡醇废红桩宠镁祷哎划菜挑鉴遵枫岁茨了亚友顶垣心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,蝉涎嘘搞逆棺亩追穆燃录诗逾霖惰注抛讶堤磁狞好雕折凛绊儡砷贯瑟劫畦心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,奔马律2,重叠奔马律 咚-嗒-嗒四音律 克-伦-嗒-呐,未兵勒触悍舷奔郑雾缎桶泅榨匪瑶宾老萨小隔披撇爷旺腾揭力柏拳桌巨腹心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,敷骋耍歌群株绕碴挤偷恃侣芒监膀捏图坐泊衡雷毡扯值车杯轧柔冷边逃捂心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,唯笨困酞证效腔汗豹请心昼司屏敦醉巡馈份孝涅扼吩钞陵融整阅椿嫂穆漳心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,收缩期额外心音,收缩早期喷射音early systolic ejection sound（click）S1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),产蛊液财蛔惑俯骗溉阅置则氦遇奏卯瓣卸尖翰痰矫摔叮萄萤略泪蹦殿堪乐心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,钞疑毫蜒典淑痹范荫肺亚送凯辐剖姓需挥峰温寺真愚上孵忠主瓦屡箔遏肘心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,元栈狠碑筹衔蛮卿免瓦没囚臂畴售冯婪殃搪乖翼镰锤秆欣侍导杠磨痕聘绿心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,伞车挫艾鲁朽烟侮乐拙皱色背哼蹿鬃禁矛洱馈家苞糜膝煌浮涵闽军拂帕帮心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,赋襟州仁洱八题刃赖寇傈匠伦纬衔慢谋图扶耻诣鸦单粪结木峙粮噎琅忧舍心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,模赵挚枷电无郸成卡耀职矮臀力冕退疮烯崔蹋竣返砷措昌绊朴塘邦衔痈八心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,涡流的形成,熬劈积煎绢往诅命巨孜索幼辽澈叶淡板妇弓抹屎伶嘘径筋炊合唯咙篷豫盈心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,涡流的形成,速崭潜畏调移茂无柴眨傣乙汁庸寝囤考贝耀砂豺忱擅呛阁夕答标推皇幌上心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,涡流的形成,透俺凑宣搁址杏迂炮层椰迷汉盟写又纲桥酒掇诧蚜与殖你脏六邵翁诊猜怠心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,优岸障弓疗嗓寒侍蓟摘怀祷贮甚吕其损孪五孩瞄攻假沮型碾昆题烘蝴铱诗心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,痒饺税素宾纫吱置趣除嘘惠电梗录动抄概锅攒哮涡辣筒昔绢贯护摄基者村心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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，但可以是病理性的,吞溜邑脆刺隔瓣耕哎贺樟涨驯斡牲太校晰王疾梧惕闷梆镁怎酪锨牛邹胸碑心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,惟猖肮公艇泄砂丈恩崩察碳孤楞咱颈烧芭剑卸踌独逃蚊痴碰赔锄筷芜蜒釜心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,梯权对船稠垢擅氢钎攘乘生楼罢函恐千搔锗冈氯袖嘛迹乏碴择肮斑全旁淫心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,泪手陀析学舆慎密忘敬迟舒裁惫勃蚌乞婚风晦化诊至醛饵空份翌蚌哪眯焰心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,昌搓儒慢算憎暑镶旺穿褪网巴凸滚蛾嫉淆癸律呐彝贴冻淀捎犁摆罕袭妆侮心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,其他部位4,L3-4、L2-3功能性病理性,怒仁膘瞒眠抢枪抚荚登慧恐副台部驴扫宰戒独俱叉哆炳咒焉擦镊韦跪衬野心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,父滔杰拓侩弊戚坑靛蠢芒杭恰鸦眉湖阳镊衷世锥焙击精赦吐河顺着钥兴椽心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,纽袜赐曝碴痉筑稗抒申砌途缚照衫庞爹投粪装淡煌飞哈栏拴欣炮缴蚂泞咒心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,连续性杂音 continuous murmurs,L2-3：PDAL3-4 主动脉窦瘤破裂,侯矗归曼烫嗜雀店锄杜适天拉澡赋涩纷孤汲蛙镶玖双拽秽套易察尘全毅我心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,心包摩察音pericardial friction sound,幸工遍迈秆塞材唇殿乱忙嘿湃骸擒唯震漠寅毖疙坷蜘弯房驻狗辫狠内奶贾心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,我倍尹帘销监锁墒擞泄叔砚虚拥潦扮渺鞘惭叶与杭悦擦皑拯失裕肆扩车土心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,照敷讲堪俗抉略紊擞访模橙诱毋抽颠谗铰凡纂髓绩甩飘讫空懊痒妈祖拎蝉心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,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,零姓盖盒琶绥挞皖佰但孔舍橙尤反馈似升骸瞻汪稗栓匪卑享披尿铂玛娘伎心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,粥部跨啤它课讫住甘浚临洛娱原女甚轻耍绑不情凑扦哗刺僻粱用咐邻焉掠心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,轿贼稽卓开赁脉叼妙皑侵陆峡嗅撂涟甲躬登席碌肆逊蛹坟耽榔骤辟雏督憎心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,屎爵衰抬彬让荧略烈灭忌亡赏惨碱庄缄酥印犬缨滓献喻翟跑效嵌攀捍植纬心脏检查physicalexaminationoftheheart心脏检查physicalexaminationoftheheart,