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1、Examination of the HeartJin Yu-huaDept.of Geriatrics,Examination of the Heart,Landmarks and topographic anatomy,Certain basic landmarks midsternal line(前正中线)midclavicular lines(锁骨中线)anterior,middle,and posterior axillary lines(腋前、中、后线),suprasternal notch（胸骨上窝）identification of various ribs and inter
2、costal space precordium（心前区）,Inspection,蹲下，双眼与被检查者胸廓平齐；双眼视线与心前区呈切线方向。,心前区局部隆起提示儿童期先心、风心和心肌炎后心肌病导致心脏增大；鸡胸和漏斗胸畸形伴有心前区隆起，常合并先心病；大量心包积液，心前区外观显得饱满；凹陷胸见于马方综合征及部分二脱。,心前区隆起与凹陷,apical impulse（心尖搏动）,心脏收缩时，左心室前壁在收缩早期撞击心前区胸壁，使相应部位肋间组织向外搏动。坐位时正常心尖搏动一般位于第五肋间左锁骨中线内处，距正中线约7-9cm，搏动范围直径约2-2.5cm。,体型：超力型、无力型；年龄：婴儿、儿童；体
3、位：卧位、右侧卧位、左侧卧位；呼吸：深吸气、深呼吸；妊娠,影响心尖搏动位置的生理因素,心脏疾病：左心室增大、右心室增大、全心增大、右位心；胸部疾病：一侧胸腔积液(pleural effusion)或气胸(pneumothorax)、一侧肺不张(atelectasis)或胸膜粘连(pleural-adhesion)、胸廓或脊柱畸形；腹部疾病：大腹水、腹腔内巨大肿瘤。,影响心尖搏动位置的病理因素,In mitral disease the impulse is displaced laterally.,In aortic disease the impulse is displaced both
4、laterally and downward.,Effect of massive right pleural effusion or pneumothorax,Effect of massive right atelectasis,生理条件下的变化：体型、肋间宽度；儿童；剧烈活动、情绪激动。,心尖搏动强度及范围的变化,病理条件下的变化：左心室肥大；心肌病变；心室腔扩大；心包积液；负性心尖搏动；甲亢、发热、严重贫血。,心尖搏动强度及范围的变化,Abnormal pulsations in the other areas:,胸骨左缘第二肋间：肺动脉高压或扩张；胸骨右缘第二肋间及胸骨上窝搏动：升主
5、动脉瘤及主动脉弓瘤；胸骨左缘第三、四肋间：右心室肥大或瘦弱者；剑突下搏动：右心室搏动或腹主动脉搏动。,Palpation,触诊能准确判断心尖搏动或其他搏动的位置、强弱和范围；心脏搏动的速率及节律变化；判断心脏收缩期的开始。,Method of Palpation,Thrill examination by palm,Apical impulse examination by finger,Apical impulse(心尖搏动),location duration amplitude intensity frequency regularity,Sustained sensation(抬举性搏
6、动):LVH Forceful,sustained,through systole with great amplitude more than 2cm diameter,Precordial lift or heavy:RVHDecrease amplitude:myocarditisMassive pericardial effusion:impulse cannot be palpable,剑突下搏动鉴别,检查者手指平放剑突下，指端指向剑突，向上后方施压，如搏动冲击指尖，且深吸气时增强，提示右心室肥大；搏动冲击手指指腹，且深吸气时减弱，提示腹主动脉搏动或腹主动脉瘤。,Thrill,血流经
7、口径较狭窄的部位，或循异常的方向流动而产生漩涡，使心壁或血管壁振动，传至胸壁而被触及。震颤的临床意义。,Any thrill should be described as to its location,its time in cardiac cycle,and its mode of extension or transmission.,Restricted or narrowed orifice thrill according blood velocityIntensity degree of narrowing to gradient between two chambers,dura
8、tion location disease systole second right ICS AS second left ICS PS third fourth left ICS VSD diastole apical area MScontinuous 2nd left ICS PDA,Pericardial friction rub,心包膜炎症渗出，脏层和壁层间的摩擦引起振动；与胸膜摩擦感的鉴别；胸骨左缘第四肋间处较易触及；收缩期较易触及、坐位前倾及呼气末更明显。,Percussion,叩诊可确定心界，判定心脏和大血管的大小、形状及其在胸廓内的位置。Relative cardiac du
9、llness(心相对浊音界)Absolute cardiac dullness(心绝对浊音界),Method of percussion for heart,Percussion with finger parallel to cardiac outlines,Percussion with finger at right angle to cardiac outline,叩诊顺序,先左后右由外向内自下而上,Heart borders,Right border of the heart formed by sup vena(上腔静脉),ascending aorta(升主动脉),right a
10、trium(右心房),Left border of the heart formed by aorta arch(主动脉弓),pulmonary arterial trunk(肺动脉段),left atria appendage(左心房),LV(左心室),Inferior border of the heart formed by RV(右心室),lesser extent LV,Normal heart dullness right(cm)ICS,MSL left(cm)2-3 2-3 3-4 5-6 7-9Normally from midsternal line to MCL is ab
11、out 8-10cm,Cardiac enlargement,左心室增大：心左界向左下扩大，心腰加深接近直角，使心脏浊音界呈靴形，或称“主动脉型”（aortic heart）。见于主动脉瓣关闭不全、高血压性心脏病等,The heart silhouette looks like a shoe,右心室增大：轻度增大仅绝对浊音界增大，显著增大时相对浊音界向两侧扩大，向左增大较显著。常见于肺源性心脏病等。,左心房增大：胸骨左缘第三肋间心浊音界向外，心腰部消失或膨出。二尖瓣狭窄时，左心房及肺动脉均扩大，心腰部饱满或膨出，心浊音界的外形成为梨形，或称“二尖瓣型”,The heart silhouette
12、 is like a pear,左右心室增大：心浊音界向两侧扩大，且左界向左下 扩大，呈普大型。常见于扩张型心肌病、重症心肌炎、全心衰竭。,Pericardial effusion,心包积液：心浊音界向两侧扩大，相对浊音界与绝对浊音界接近，坐位呈三角烧瓶形，仰卧位心浊音界发生改变。,The heart silhouette is like a flask,The heart silhouette is like a globe,心外因素,胸壁较厚或肺气肿时，心浊音界变小，重度肺气肿时可能叩不出心浊音界；心脏邻近存在可产生浊音的病变时，心脏本身的浊音区无法辨别；大量胸腔积液、积气：患侧心界叩不出
13、，健侧心浊音界外移；,心外因素,大量腹腔积液或腹腔巨大肿瘤：膈抬高，心脏呈横位，叩诊心界向左扩大；胃内含气量增多时，可影响心脏左界下部叩诊。深吸气、妊娠后期，膈抬高，心脏呈横位，叩诊心界向左扩大；,Review,Precordial bulge(心前区隆起)congenital heart disease rheumatic heart disease(before puberty)pericardical effusion(adult life),Normal apical impulse,The apex impulse is normally located in or about th
14、e fifth costal interspace inside the left midclavicular line when the patient is supine.The extent of impulse is about 22.5 cm.,Displacement of the apical impulse,Heart disease LVD displaced to lateral and inferior,Displacement of the apical impulse,RVD displaced to left and upward,Displacement of t
15、he apical impulse,Congenital dextrocardiac right CHF,myocarditis,myocardiopathy apical impulse decrease intensity,Displacement of the apical impulse,Massive pericardial effusion apical impulse disappear,Displacement of the apical impulse,Thoracic disease pneumothorax,pleural effusion shifted to heal
16、thy side,Displacement of the apical impulse,Pleural-adhesion,atelectasis shifted to disease sideEmphysema with RVH to inferior to subxiphoid,Whats the meaning of Apical ImpulseInward ImpulseBroadbent sign,Review,Method of palpationPrecordial pulsantion:LVH,RVH,myocarditis,massive pericardial effusio
17、nMechanism of thrillClinical significance of precordial thrill,复习,心界叩诊的顺序正常心浊音界的组成心脏浊音界改变及临床意义,重要名词,主动脉型心(靴形心)普大型心二尖瓣型心(梨形心)烧瓶形心球形心,单选题,正常成人心尖搏动位于A.第四肋间,左锁骨中线内侧0.10.5cmB.第五肋间,左锁骨中线内侧0.51.0cmC.第五肋间,右锁骨中线内侧0.51.0cmD.第四肋间,左锁骨中线内侧1.01.5cmE.第五肋间,右锁骨中线内侧2.02.5cm,正常成人心尖搏动范围以直径计算为A.1.01.5cmB.1.52.0cmC.2.02.
18、5cmD.2.53.0cmE.以上都不是,心尖搏动的论述,错误的是A.搏动范围以直径计算为1.01.5cmB.可位于第五肋间左锁骨中线内0.5cmC.可位于第四肋间D.可位于第六肋间E.体位、体型对心尖搏动位置有影响,心尖搏动移位的论述,错误的是A.肥胖体型者,心尖搏动可上移至第四肋间B.瘦长体型者,心尖搏动可下移至第六肋间C.左心室增大时心尖搏动向左下移位D.右心室增大时心尖搏动向右移位E.一侧胸膜粘连、增厚、心尖搏动向患侧移位,心前区搏动错误的是A.胸骨左缘第34肋间搏动可见于右心室肥大B.剑突下搏动可见于右心室肥大,亦可见于腹主动脉瘤C.胸骨左缘第2肋间收缩期搏动可见于肺动脉高压D.胸骨
19、右缘第2肋间收缩期搏动可见于主动脉弓动脉瘤E.以上都不是,单选题,震颤的论述,错误的是A.在心尖区触及收缩期震颤可见于二狭B.临床上凡触及震颤均可认为心脏有器质性病变C.触诊有震颤的部位多数可听到杂音D.在胸骨右缘第2肋间触及收缩期震颤可见于主狭E.在胸骨左缘第2肋间触及收缩期震颤可见于肺动脉瓣狭窄,心包摩擦感的论述,错误的是A.为心脏收缩时脏层与壁层心包相互摩擦而产生B.随渗液的增多,心包脏层与壁层分离时摩擦感消失C.多在心前区或胸骨左缘第3、4肋间触及D.以收缩期、前倾体位更为明显E.以吸气末更为清楚,标准配伍型题,A.胸骨左缘第二肋间收缩期震颤B.胸骨左缘34肋间收缩期震颤C.胸骨左缘第
20、二肋间连续性震颤D.心尖区舒张期震颤E.胸骨右缘第二肋间收缩期震颤主动脉瓣狭窄?肺动脉瓣狭窄?动脉导管未闭?二尖瓣狭窄?,单选题,心浊音界改变的论述,正确的是A.一侧大量胸水积液可使心界移向患侧B.一侧大量气胸可使心界移向患侧C.肺气肿时心界变大D.一侧肺不张可使心界移向患侧E.以上均不是,心脏叩诊浊音界向左下扩大、心腰加深，见于A.二尖瓣狭窄B.高血压性心脏病C.三尖瓣狭窄D.心肌病E.克山病,心脏叩诊左心房和肺动脉段增大,使心腰部饱满或膨出可见于A.主动脉瓣关闭不全B.二尖瓣狭窄C.二尖瓣关闭不全D.心包积液E.房间隔缺损,心包积液的特征为A.心浊音界向左下增大B.心浊音界向右增大C.梨形心D.心界向两侧扩大,同时浊音界可随体位而改变E.以上均不是,标准配伍型题,A.靴形心B.胸骨右缘第1,2肋间浊音界增宽C.普大型心D.梨形心E.三角形烧瓶样心扩张性心肌病?二尖瓣狭窄?高血压性心脏病?心包积液?,
