《心脏体检》PPT课件

1,Department of Diagnostics 1st Affiliated Hospital Chen Ming,Physical examination of heart,2,Equipment（器材）：Stethoscope（听诊器）； Position（体位）：Supine （卧位）or seated（坐位）a patient；standing to the right side of the patient （an examiner）； Environment（环境）：Quiet （安静）； Exposure（暴露）：Strip to waist（腰部）； Lightening（光线）：Good；left side； tangent（切线）； Knowledge of anatomy（解剖知识）：thorough（全面） Considerate and gentle。,Physical examination of heart (心脏检查) Preparation,3,Midsternal line（胸骨中线） or Anterior midline （前正中线） Midclavicular lines（锁骨中线） Anterior, middle,and posterior axillary lines （腋前、中、后线） Sternal angle （胸骨角）- connected with 2th costal cartilage （与第二肋软骨相连） Intercostal space （肋间隙）,Physical examination of heart (心脏检查)landmarks of topographic anatomy（解剖标志）,4,Inspection (望诊),Palpation (触诊),Percussion (叩诊),Auscultation (听诊),心 脏 检 查,Physical examination of heart (心脏检查),5,Tangent lightening（切线方向光线）； Same height as thorax (与胸廓同高）。,Inspection（望诊）-gist（要点）,6,Precordial prominence（心前区隆起）： Right ventricular hypertrophy at puberty（儿童发育完成前右心室肥大） Congenital heart disease (先天性心脏病) Rheumatic heart disease (风湿性心脏病) Massive pericardial effusion in the adult （成人大量心包积液）。,Inspection（望诊）- Deformity of thoraxes（胸廓畸形）,7,Inspection（望诊）- Apical impulse（心尖搏动）,Definition（定义）：Heart contracts（心脏收缩） impacts corresponding site of front chest（心尖向前冲击前胸壁相应位置) apical impulse (心尖搏动)。,8,Inspection（望诊）,Normal apical impulse（正常心尖搏动）： Location-The 5th intercostal space（第五肋间）, 0.5 1.0 cm medial to left midclavicular line （左锁骨中线内侧 0.5 1.0 cm ）； Diameter- 2.0 2.5 cm。,Inspection（望诊）- Apical impulse（心尖搏动）,9,Physiological factors（生理性因素）： Left lateral position （左侧卧位）- extend to the left（向左移）for 2.0 3.0 cm. Right lateral position（右侧卧位）- extend to the right（向右移）for 1.0 2.5 cm.,Inspection（望诊）- Displacement of apical impulse（心尖搏动移位）,10,Pathological factors（病理性因素）： Heart itself（心脏本身） Enlargement of left ventricle（左 心室增大）-extend to left and downwards（左下移位）；,Inspection（望诊）- Displacement of apical impulse（心尖搏动移位）,11,Pathological factors（病理性因素）： Heart itself（心脏本身） 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（望诊）- Displacement of apical impulse（心尖搏动移位）,12,Pathological factors（病理性因素）： Displacement of mediastinum（纵隔移 位） Pleural adhesion （胸膜粘连）， pulmonary atelectasis of one side （肺 不张- displacement of apical impulse toward the diseased side（移向 患侧）； Pleural effusion（胸腔积液）， pneumothorax of one side（气胸）- displacement of apical impulse toward the opposite side（移向健侧）.,Inspection（望诊）- Displacement of apical impulse（心尖搏动移位）,13,Pathological factors（病理性因素）： Displacement of diaphragm（横隔移位） Massive ascites （大量腹水），huge tumor of abdominal cavity （腹腔巨大 肿瘤）-displacement of apical impulse to left （移向左侧）； Severe emphysema（肺气肿）- displacement of apical impulse inward and downward（移向内下）。,Inspection（望诊）- Displacement of apical impulse（心尖搏动移位）,14,Physiological factors（生理性因素）： Thick chest wall（胸壁肥厚）- weak and narrow（减弱、缩小）； Thin chest wall（胸壁薄）- strong and wide（增强、较大）。,Inspection（望诊）-Changes of intensity and range in apical impulse(心尖搏动强度与范围的改变）,15,Pathological factors（病理性因素）： Increase in intensity of apical impulse（心尖搏动增强）- fever（发热），anemia （贫血）， hyperthyroidism（甲状腺机能亢进）； Decrease in intensity of apical impulse（心尖搏动减弱）-dilated cardiomyopathy（扩张型心肌病） ，acute myocardial infarction（急性心肌梗死），pericardial effusion（心包积液）， emphysema（肺气肿）。,Inspection（望诊）-Changes of intensity and range in apical impulse(心尖搏动强度与范围的改变）,16,Inspection（望诊）- Inward impulse （负性心尖搏动）,Definition（定义）：invagination（内陷） of apical impulse when contracting。 Significance（意义）：adhesive pericarditis（粘连性心包积液）。,17,Inspection（望诊）- precordial impulse（心前区搏动）,Impulse at 3th 4th left intercostal space just lateral to sternum (胸骨左 缘3 4肋间） : right ventricular hypertrophy（右室肥 大）; Impulse at xiphoid process（剑突下搏 动）: right ventricular hypertrophy; beating of abdominal aorta（腹主动脉搏 动）.,18,Impulse at base of heart（心底部搏动）： 2nd left intercostal space just lateral to sternum (胸骨左缘2肋间）: dilation of pulmonary artery； pulmonary hypertension. 2nd right intercostal space just lateral to sternum (胸骨右缘2肋间）: dilation of ascending aorta（升主动 脉扩张）。,Inspection（望诊）- precordial impulse（心前区搏动）,19,Inspection（望诊）-contents （内容）,Deformity of thoraxes （胸廓畸形） Apical impulse （心尖搏动） Precordial impulse （心前区搏动）,20,Palpation（触诊） Importance of palpation（触诊意义）,To confirm the observations made during inspection （进一步证实望诊所见）； To detect invisible pulsatile movements （发现望诊看不见的搏动）； To reveal thrill and pericardial friction rubs（发现震颤和心包摩擦感）。,21,Palpation（触诊）-method （方法）,Right palm first （先用右手手掌）- detecting thrills（检查震颤）； Fingertips then（后用指尖）- detecting pulsations（检查搏动）。,22,Definition（定义）：Slow and forceful beat in apex（心尖区徐缓、有力的搏动），lift finger tip （可使手指尖端抬起）。 Significance（意义）：Sign of left ventri- cular hypertrophy（左室肥大的体征）。,Palpation（触诊）- heaving apex impulse (抬举样心尖搏动）,23,Palpation（触诊）-thrills （震颤）,Definition（定义）： Tiny vibrations felt by palm（手掌感觉到的一种细小震动感），somewhat similar to the sensations on the throat of a purring cat，therefore also called purring （与在猫喉部摸到的呼吸震颤类似，故亦称猫喘）。 Mechanism：The same as cardiac murmurs（同杂音）。,24,Significance（意义）： Signs of organic heart diseases（器质性心脏病的体征）； always Thrill - cardiac murmur， not always Cardiac murmur - thrill； Usually - congenital heart disease（先天性心脏病）、valvular stenosis（瓣 膜狭窄），seldom valvular regurgi- tation（关闭不全）。,Palpation（触诊）-thrills （震颤）,25,Palpation（触诊）-thrills （震颤）,Clinical importance of thrills at apex （心前区震颤的临床意义） Location（部位） Phase（时相） Disease 2nd right intercostal systole（收缩期） aortic space just lateral to stenosis sternum (胸骨右缘2肋间） （主动脉瓣狭窄） 2nd left intercostal systole（收缩期） pulmonary space just lateral to stenosis sternum (胸骨左缘2肋间） （肺动脉瓣狭窄） 3th-4th left intercostal systole（收缩期） ventricular space just lateral to septal defect sternum (胸骨左缘3-4肋间） （室间隔缺损） 2nd left intercostal continuous（连续性） patent ductus space just lateral to arteriosus sternum (胸骨左缘2肋间） （动脉导管未闭） Apex（心尖区） diastole（舒张期） mitral stenosis （二尖瓣狭窄）,26,Palpation（触诊）-pericardial friction rubs（心包摩擦感）,Definition（定义） Acute pericarditis（急性心包炎） Fibrin effuses from pericardium（心包膜纤维素渗出） Roughness of peri- cardium（心包粗糙） Visceral and parietal pericardial surfaces rub against each other when heart beats （心脏搏动时脏层与壁层心包摩擦） Pericardial friction rubs（心包摩擦感）。,27,Palpation（触诊）-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（触诊）-contents（内容）,Apical impulse and heaving apex impulse （心尖搏动和抬举样心尖搏动） Thrills （震颤） Pericardial friction rubs （心包摩擦感）,29,Percussion（叩诊）,Aim（目的）： To detect size of heart and its contour（确定心界大小及形态）。,30,Percussion（叩诊）,Relative and absolute dullness of the heart,31,Percussion- method of percussion （叩诊方法）,Use mediate percussion（间接叩诊）； In recumbent position（仰卧体位）； Place pleximeter parallel with intercostal space when patient is in recumbent position （当病人仰卧位，板 指与肋间隙平行）；,32,Percussion- method of percussion （叩诊方法）,Compare percussion note of each intercostal space from lateral aspect inwards，from lower part upwards （从外向内，从下向上逐一肋间隙比较叩诊 音）；,33,Heart and great vessels give absolute dullness on percussion（心脏和大血管叩诊为绝对浊音），and the parts of heart overlaid by lung give relative dullness on percussion（心脏被 肺遮盖部分叩诊为相 对浊音）which re- presents real size and shape of heart (代表心脏的真实大小和形态) 。,Percussion- method of percussion （叩诊方法）,34,Percussion- method of percussion （叩诊方法）,Percussion of the right margin of the heart (心右界的叩诊): Begins from the intercostal space one interspace higher than the border of liver dullness (叩诊从肝浊音界上一肋间开始); Carry out upwards intercostal space by intercostal space , to the second intercostal space (由下往上,逐一肋间叩诊,直到第二肋间).,35,Left margin first and then right margin（先叩左界后叩右界）。 From lateral aspect inwards，from lower part upwards（从外向内，从下向上）。,Percussion- sequence of percussion （叩诊顺序）,36,Percussion（叩诊）,Normal area of relative dullness （正常心脏相对浊音界） 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（左锁骨中线距胸骨中线8 10cm）。,Percussion（叩诊）-normal area of relative dullness（正常心脏相对浊音界）,37,Percussion（叩诊）-composition of various parts of heart border（心浊音界组成）,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（叩诊）-changes in area of cardiac dullness（心浊音界改变）,Factors of heart itself（心脏本身因素） Enlargement of left ventricle（左室增大） Cardiac dullness extends to left and downwards（心浊音界移向左下）and is in the shape of a boot（呈靴形）。 Commonly seen in aortic regurgitation and hypertensive heart disease（常见于主动脉瓣关闭不全和高血压性心脏病）and is called “aortic” type（主动脉型）。,39,Percussion（叩诊）-changes in area of cardiac dullness（心浊音界改变）,Cardiac dullness extends to left and downwards（心浊音界移向左下）and is in the shape of a boot（呈靴形）-“aortic” type （主动脉型）。,40,Percussion（叩诊）-changes in area of cardiac dullness（心浊音界改变）,Factors of heart itself（心脏本身因素） Enlargement of right ventricle（右室增大）- pulmonary heart disease（肺源性心脏病） Slight enlargement - no obvious change in area of relative dullness（轻度增大时心脏相对浊音界无明显改变）； Prominent enlargement relative dullness enlarged both to left and right but not downwards（显著增大时心脏相对浊音界向左右增大，但向左不向下增大）。,41,Percussion（叩诊）-changes in area of cardiac dullness（心浊音界改变）,Factors of heart itself（心脏本身因素） Enlargement of both ventricles（左 右室均增大） Enlargement of heart bilaterally （两侧增大）； Commonly seen in dilated cardiomyopathy（常见于扩张型心肌 病）。,42,Factors of heart itself（心脏本身因素） Pericardial effusion（心包积液）： Enlargement of heart bilaterally（两侧增大）； Heart border changes according to bodys position（心浊音界随体位改变而改变）- it becomes triangular in erect position（坐位时呈三角形） and the outline of heart border can be enlarged， especially the widening of base of heart in recumbent position（卧位时心浊音界增大尤其是心底部浊音界增宽）。,Percussion（叩诊）-changes in area of cardiac dullness（心浊音界改变）,43,Percussion（叩诊）-changes in area of cardiac dullness（心浊音界改变）,Factors of heart itself（心脏本身因素） Enlargement of left atrium and pulmonary artery（左房增大及肺动脉段增宽） Makes concave part of left border of heart protruding outwards and cardiac dullness becomes pear shaped（心腰膨出，心浊音界呈梨形）； Commonly seen in mitral stenosis and is called “mitral” type （二尖瓣型）。,44,Percussion（叩诊）-cchanges in area of cardiac dullness（心浊音界改变）,插P145图2-5-27,Enlargement of left atrium and pulmonary artery（左房增大及肺动脉段增宽）makes concave part of left border of heart protruding outwards and cardiac dullness becomes pear shaped（心腰膨出，心浊音界呈梨形）-“mitral” type （二尖瓣型）。,45,Percussion（叩诊）-changes in area of cardiac dullness（心浊音界改变）,Extracardial factors（心脏以外因素） Emphysema dullness of heart is narrowed or can not be percussed（肺气肿时心浊音界缩小或不能叩出）。,46,Auscultation（听诊）-auscultatory valve areas（心脏瓣膜听诊区）,Definition（定义）： When heart valves open and close，they make sounds which can be transmitted to body surface. The locations where examiners canhear the sounds most clearly and easily are called auscultatory valve areas.(心脏各瓣膜开放与关闭时所产生的声音传导到体表最易听清的部位称心脏瓣膜听诊区)。,47,Auscultation（听诊）-auscultatory valve areas（心脏瓣膜听诊区）,48,Auscultation（听诊）-auscultatory valve areas（心脏瓣膜听诊区）,Locations of auscultatory valve areas (心脏瓣膜听诊区位置) Valves Locations Mitral valve area site where the strongest (二尖瓣区) heart beats are palpated. Or apex area(心尖区) (心尖搏动最强处) Pulmonary valve area left 2nd intercostal space (肺动脉瓣区) just lateral to sternum (胸骨左缘第2肋间) Aortic area right 2nd intercostal space (主动脉瓣区) just lateral to sternum (胸骨右缘第2肋间) Second aortic area left 3nd intercostal space (主动脉瓣第2听诊区) just lateral to sternum (胸骨左缘第3肋间) Tricuspid valve area junction of xiphoid process (三尖瓣区) and sternum(剑突与胸骨交界处),49,Auscultation（听诊）- auscultatory order (听诊顺序),Start from apex area（从心尖区开始）； Carry out auscultation clockwise and sequentially（逆时针方向依次听诊）：apex area，pulmonary valve area，aortic area，2nd aortic area， tricuspid valve area（心尖区，肺动脉瓣区，主动脉瓣区，主动脉瓣第2听诊区，三尖瓣区）。,50,Auscultation（听诊）-heart rate （心率）,Definition（定义） Number of heart beating per minute （每分钟心搏次数）。 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 (安静、清醒状态下60 100次/ 分）。 Abnormal heart rate（异常心率）： Faster than 100 beats/min- tachy- cardia (超过100次/分时为心动过速); Slower than 60 beats/min- brady- cardia (慢于60次/分时为心动过缓)。,Auscultation（听诊）-heart rate （心率）,52,Auscultation（听诊）-cardiac rhythm (心律),Definition（定义）： Rhythm of heart beating (心脏跳动的节律)。 In normal condition, cardiac rhythm is sinus and basically regular (正常情况下心律为窦性且节律基本整齐)。,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. (部分青年人可出现随呼吸改变的心律, 吸气时心率增快, 呼气时减慢, 称窦性心律不齐)。,Auscultation（听诊）-cardiac rhythm (心律),54,Auscultation（听诊）- abnormal cardiac rhythm(异常心律),Premature beats（过早搏动） In the background of regular heart-beats a heartbeat appears in advance abruptly, followed by a longer interval (在规则心律基础上, 突然提前出现一次心跳, 其后有较长间隙)。,55,Premature beats（期前收缩或过早搏动） 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. (过早搏动规则出现称联律,一次窦性搏动后出现一次过早搏动称二联律,每二次窦性搏动后出现一次过早搏动称三联律,以此类推).,Auscultation（听诊）- abnormal cardiac rhythm(异常心律),56,Auscultation（听诊）- abnormal cardiac rhythm(异常心律),Atrial fibrillation (心房颤动) “three inconsistencies” （ “三不等” ） Cardiac rhythm is absolutely irregu- lar (心律绝对不齐); Intensity of first heart sound is not the same (第一心音强弱不等); Pulse rate is less than heart rate pulse deficit (脉搏次数小于心率脉搏 短绌）。,57,Auscultation（听诊）- heart sounds （心音）,There are 4 heart sounds in a cardiac cycle （在一个心动周期中有4个心音）。 According to the sequence ，they are named as S1，S2，S3 and S4（根据先后 秩序，依次命名为第一、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关闭而产生）。 Mitral valve closure precedes tricuspid valve closure (二尖瓣关闭早于三尖瓣关闭）, but on auscultation S1 can only be heard as one sound（但听诊时仅为一个声音）。,Auscultation（听诊）- the first heart sounds（第一心音）,59,Auscultation（听诊）- the first heart sounds（第一心音）,S1 indicates the beginning of the ventricular contraction（ S1代表心室收缩的开始）。,60,Auscultation（听诊）- the first heart sound（第一心音）,Characteristic of S1 on auscultation： Lower key （音调低钝）； Stronger intensity（强度较响）； Dull tone (性质较钝)； Longer period（历时较长）； Same time as apical impulse（与心 尖搏动同时出现）； Loudest at apex（在心尖部最响）。,61,Auscultation（听诊）- second heart sound（第二心音）,S2 indicates the onset of ventricular relaxation (S2 提示心室舒张开始)。 S2 is mainly composed of the closures of aortic valve and pulmonary valve (S2主要由第二组成成分由主动脉瓣和肺动脉瓣关闭组成)。,62,The aortic valve closure precedes pulmonary valves (主动脉瓣关闭较肺动脉瓣稍早). A2 and P2 refer to closure of aortic and pulmonary valves, respectively (A2和P2分别代表S2的主动脉瓣关闭成分和肺动脉瓣关闭成分). But on auscultation ，S2 can only be heard as one sound（但听诊时仅为一个声音）。,Auscultation（听诊）- second heart sound（第二心音）,63,Auscultation（听诊）- second heart sound（第二心音）,A2 is most clearly audible over aortic area and P2 over pulmonary valve area(A2在主动脉瓣膜听诊区听诊最清楚，P2在肺动脉瓣膜听诊区听诊最清楚）。Generally speaking P2 A2 in juvenile, P2 A2 in adults and P2 A2 in old people.,64,Auscultation（听诊）- second heart sound（第二心音）,Characteristic of S2 on auscultation： Higher key （音调较高）； Weaker than S1 in intensity （强度较S1 弱）； Clear tone (性质较清脆)； Shorter period（历时较短）； Later than apical impulse（在心尖搏动之 后）； Loudest at heart base（在心底部最响）。,65,Auscultation（听诊）- third heart sound（第三心音）,At early diastole of ventricle（在心室舒张 早期）。 Fast filling flow from left atrium to ventricle tension and vibration of ventricular wall, chordae tendineae and papillary muscles S3 .,66,Auscultation（听诊）- third heart sound（第三心音）,Characteristic of S3 on auscultation： Soft and low key （轻而音调低）； Sounds like the echo of S2(似为S2的回 音）； Shorter period（历时较短）； Limited at apex or its inner upper side （局限在心尖部或期内上方）； Clearly heard in expiration and at lateral position (仰卧位或呼气时较清楚)；,67,Auscultation（听诊）- third heart sound（第三心音）,Characteristic of S3 on auscultation： At the end of ventricular diastole (出现 在心室舒张期）； Usually heard only in some children and young people （正常情况只有在部分 儿童和青少年中才听到)。 Usually heard in pathological conditions (通常在病理情况下听到）。,68,Auscultation（听诊）- differentiation of heart sounds（心音的鉴别）,Differentiation between S1 and S2(第一、 二心音的鉴别） S1（第一心音） S2（第二心音） Cardiac cycle onset of ventri onset of ventri （心动周期） cular systole cular diastole Key（音调） lower（低调） higher（高调） Duration（时限） longer（长） shorter（短） Best heard area apex（心尖区） base（心底部） （听诊最好部位） Interval（间距） S1-S2 S2-S1 Synchronization yes（是） no（不是） with apical impulse （与心尖搏动同步）,69,Auscultation（听诊）- accentuated S1 （第一心音增强）,Common in mitral stenosis (常见于二尖瓣狭窄）： Mitral stenosis (二尖瓣狭窄） less filling of left ventricle （左室充盈减少） lower position of mitral valve leaflets（二尖瓣叶位置较 低） faster pressure increase and shorter contraction for left ventricle(左室压力上升速度加速和收缩时间缩短） large vibrations in the movement of mitral valve leaflets (二尖瓣叶活动幅度大） louder S1 (响亮S1）。,心脏舒张时,心脏收缩时,70,Auscultation（听诊）- accentuated S1 （第一心音增强）,Intense contractility of ventricle such as exercise, fever, hyperthyroidism (心肌 收缩力增强如运动，发热和甲状腺功能亢进) and tachycardia (心动过速)。,71,Auscultation（听诊）- weakened S1 （第一心音减弱）,Common in mitral insufficiency (常见于 二尖瓣关闭不全)； Aortic insufficiency (主动脉瓣关闭不全) ， prolonged P-R interval (P-R间期延长）； In myocarditis (心肌炎）、myocardial infarction (心肌梗死)、cardiomyopathy (心肌病)、heart failure (心力衰竭)；,72,Auscultation（听诊）- unequal S1 （第一心音强度不等）,Common in atrial fibrillation (常见于心 房颤动）； Completely atrial ventricular block (完 全性房室传导阻滞）- cannon sound （大炮音）.,73,Auscultation（听诊）- Changes of S2 in intensity（第二心音强度改变）,Changes of pressure of systemic circulation or pulmonary circulation and of semi-lunar valves are the main causes resulting in change of S2. (体循 环或肺循环阻力的大小和半月瓣改变是影响 S2的主要原因）。,74,Auscultation（听诊）- accentuated S2 （第二心音增强）,Increased systemic pressure or blood flow（体循环压力或血流增加） strong closure of aortic valves（主动脉瓣关闭有力) larger vibrations in the movement of aortic valve leaflets (主动脉瓣活动幅度增 大） A2。,75,Auscultation（听诊）- accentuated S2 （第二心音增强）,A2is common in hypertension and atherosclerosis ( A2常见于高血压和 动脉粥样硬化）。,76,Auscultation（听诊）- accentuated S2 （第二心音增强）,Increased pulmonary pressure or blood flow（肺循环压力或血流增加） strong closure of pulmonary valves（肺动脉瓣关 闭增强) larger vibrations in the movement of pulmonary valve leaflets (肺动脉瓣活动幅度增大） P2。,77,P2 is common in pulmonary heart disease and congenital heart diseases with shunt from left to right such as atrial septal defect (ASD), ventricular septal defect (VSD) and p