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1、,一、血 管 检 查Examination of the Vessels,Examination Methods,InspectionPalpation Percussion Auscultation,Examination of the Peripheral Vessels,IncludingPulseArterial Blood PressureVascular MurmurPeripheral Vessel Sign,一、脉搏(Pulse),部位浅表动脉：桡动脉(Radial)颈动脉(Carotid)方法(Palpation)食指、中指、环指指腹平放、双侧内容脉率、脉律、紧张度动脉壁弹性
2、、强弱、波形变化,（一）脉率(Pulse Rate),正常：成人：60100 bpm婴幼儿：130 bpm异常：短绌脉(Pulse Deficit)：房颤增快：发热、甲亢减慢：药物、病窦(Sick Sinus Syndrome),hl:Detect in the upper and lower extremities,（二）脉律(Pulse Rhythm),生理：吸：呼：窦性心律不齐(Sinus Arrhythmia)病理：绝对不齐：房颤联脉：二联脉 三联脉 脱落脉(Dropped Pulse)：房室传导阻滞(AVB),（三）紧张度与动脉壁状态,紧张度(Tensity)血压（收缩压）影响动脉壁
3、状态(Arterial Wall Status)动脉硬化(arteriosclerosis)（索条迂曲、结节状）,hl:Peripheral pulse are palpated,their symmetry and the elasticity of the underlying arterial wall are noted.,（四）强弱(Strength),影响心排血量(CO)、脉压(PP)、外周血管阻力(PVR)分类(Classification)洪脉(Bounding Pulse)：高热、甲亢、主动脉瓣关闭不全细脉(microsphygmia)：主动脉瓣狭窄、心力衰竭、休克,（五）波
4、形(Undulate Form),1、正常2、水冲脉3、交替脉4、奇脉5、无脉,hl:Seven typical and common wave forms,1、正常(Normal Wave),升支（扣击波 Ascending branch）左室收缩早期主动脉壁波峰（潮波 Spike）左室收缩中晚期、部分血流逆反 主动脉壁降支（重搏波 Descending branch）左室舒张期主动脉瓣关闭 血流持续流向外周外周折回近端后又向前主动脉壁弹性回缩见于：明显动脉硬化，重博波不明显,2、水冲脉(Water Hammer Pulse),特点：骤起骤落，如潮水涨落方法：紧握患者手腕掌面，将其前壁臂高举
5、过头感知水冲的脉搏意义：主动脉瓣关闭不全、甲亢、严重贫血、动脉导管未闭,hl:In disorders with rapid runoff of arterial blood,pulse will have a rapid upstroke and then collapse.,3、交替脉(Pulsus Alternans),特点：节律正常、强弱交替 意义：左室收缩强弱交替 高血压性心脏病、急性心肌梗死、主动脉瓣关闭 不全、左心室衰竭。,4、奇脉(Paradoxical Pulse),机 制：正常：吸气 回心血量 systolic BP decrease up to 10 mmHg CO不变
6、脉搏不变肺血容量 异常：吸气回心血量 drop of SBP is greater than normal CO 脉搏或消失 肺血容量 收缩压：吸气呼气 10mmHg以上（吸停脉）,4、奇脉(Paradoxical Pulse),意义：缩窄性心包炎(Constrictive Pericarditis)心包填塞(Pericardial Temponade),hl:In disorders that restrict normal right ventricular compliance.,5、无脉(Pulseless),特点：脉搏消失意义：多发大动脉炎(Polyarteritis)（大动脉闭塞
7、Arterial occlusion）严重休克,hl:Weak or absent leg pulses,二、血压 Blood Pressure,动脉血压或体循环血压,（一）测量方法(Method of Measurement),直接法：主动脉监护测压系统 危重、疑难。间接法（袖带加压法,cuff-pressing）：用汞柱式血压计(Sphygmomanometer)易受周围动脉舒缩变化影响(Radial,brachial,femoral artery),操 作 规 程,1、禁烟半小时、安静休息510分钟、仰或坐位。2、右上肢裸露伸直、轻外展、肘部与心脏同一水平。3、气袖均匀紧贴皮肤缠于上臂、
8、其下缘在肘窝以上2.5cm、气袖中央位于肱动脉表面。4、听诊器胸件置于搏动上、向袖带内充气、边充气边听诊。,听 诊 要 点,1、边充边听2、动脉搏动消失，再升高30cmHg后，缓慢放气（2-6mmHg/s）3、平视汞柱表面,气 袖 宽 度,标准：1213cm,包裹80%上臂手臂粗大或测大腿：增宽20cm手臂太细或儿童：78cm,hl:BP are measured in both arms and legs.BP cuff width must be 20%of the diameter of the limb.,Korotkoff 5期法,第一期：第一声、收缩压第二期：声音逐渐增强第三期：柔
9、和吹风杂音第四期：音调突然变低顿第五期：声音消失、舒张压,hl:First sound as the mercury column falls is the systolic pressure and the last is the diastolic pressure.,脉压=收缩压舒张压,平均动脉压=舒张压+1/3脉压,（二）血压标准（mmHg）2010中国高血压防治指南,类别 收缩压 舒张压正常血压 120 80正常高值 120139 8089一级高血压（轻度mild）140159 9099二级高血压（中度moderate）160179 100109三级高血压（重度severe）180
10、110单纯收缩期高血压 140 90,（三）血压变化的临床意义,高血压(Hypertension),1、诊断(Diagnosis)：至少三次非同日SBP140/90mmHg或DBP 90mmHg如仅SBP140mmHg-收缩期高血压,hl:1.Upper limit of normal is 140/90mmHg,at least 2BP determination should be made on 3 separate days before labeling a patient hypertensive.2.Much lower in infants and children.3.BP
11、equals flow(CO)times resistance,so whatever the causes are,they must lead to increase total peripheral resistance(TPR)by inducing vasoconstriction or to increase cardiac output(CO).,高血压(Hypertension),2、分类(Classification)：原发高血压(Primary/Essential)继发高血压（症状性高血压Secondary）:5%3、意义：高危因素：动脉粥样硬化、冠心病重要原因：心力衰竭,
12、hl:Secondary is associated with bilateral parenchymal disease or potentially curable disorders as pheochromocytoma,Cushings syndrome,primary aldosteronism,renal vascular disease,coarction of the aorta.,低血压(Hypotension),1、诊断：凡血压低于90/6050mmHg2、意义：休克、心肌炎急性心脏压塞偶见血压偏低体质（一贯低血压）,hl:If the postural hypotens
13、ion is suspected,BP is measured with patient supine,seated and standing.,双上肢压差,正常：5-10mmHg异常：10mmHg 多发性大动脉炎 先天性动脉畸形,hl:Normal person may have up to 10 mmHg difference between right and left arm.,上下肢血压异常,正常：下肢血压 上肢 2040mmHg异常：下肢血压上肢 主动脉缩窄，胸腹主动脉型大动脉炎,hl:1.Leg pressure is usually 20-40 mmHg higher than
14、 arm pressure.2.If hypertension is found,a careful examination should be carried out to exclude the coarction of the aorta(weak or absent pulses,lower pressure in the legs compared to the arms.There may be bruit in the back and upper pericordium),（四）动态血压监测 ABPM Ambulatory Blood Pressure Monitoring,适
15、用：白大衣、隐匿、难治、阵发设定：白昼：6am10pm，15分钟测量一次晚间：10pm6am，30分钟测量一次,hl:Sporadic higher levels in patients who have resting for 5min suggest an unusual lability of BP that may be precede sustained hypertension.Office BP is often higher than that obtained at home by ABPM.“Office”or“White coat”hypertension refers
16、to BP that is consistently elevated in the office but otherwise normal.,（四）动态血压监测 ABPM Ambulatory Blood Pressure Monitoring,标 准：24小时平均血压130/80mmHg；白昼平均血压 135/85mmHg；高峰：8am10am；4pm6pm夜间平均血压 120/70mmH正常昼夜节律：夜间血压较白昼下降10%-20%,三、血管杂音及周围血管征(Vascular Murmur and Peripheral Vascular Sign),颈静脉(Jugular Vein)：颈
17、静脉快速流入上腔静脉(superior vena cava)营营声、颈根部近锁骨处低调、连续、柔和、坐立手指压迫颈静脉杂音消失 鉴别：甲亢、先心腹壁静脉：肝硬化门高压引起腹壁静脉曲张连续、营营声脐周或上腹部,（一）静脉杂音(Venous Bruit),hl:Careful examination of neck vein is important.It acts as an open venous conduit to the right atrium(except in case of superior vena cava obstruction).,（二）动脉杂音(Arterial Bru
18、it),部位：周围动脉、肺动脉、冠状动脉意义：甲 亢 甲状腺侧叶 连续性多发大动脉炎 狭窄部位 收缩期肾动脉狭窄 上腹部或腰背部 收缩期肺部动静脉瘘 胸部相应部位 连续性外周动静脉瘘 病变相应部位 连续性冠状动静脉瘘 心前区表浅部位 连续性或双期,（三）周围血管征(Peripheral Vascular Sign),1、枪击音 Pistol Shot Sound 外周较大动脉；股动脉(Femoral artery)短促、与心跳一致、射枪音主动脉瓣关闭不全、甲亢、严重贫血2、Duroziez双重音加压股动脉 双重音：收缩期、舒张期、吹风主动脉瓣关闭不全,hl:Bruit may be heaved that may be a manifestation of an obstructive process.,（三）周围血管征(Peripheral Vascular Sign),3、毛细血管搏动征 Capillary Pulsation 方法：手指轻压病人指甲末端或玻片轻压病人口唇粘膜 局部变白；当心脏收缩时 局部变红 特点：心动周期局部变红、白交替 意义：重度主动脉瓣关闭不全周围血管征阳性：水冲脉、枪击音、Duroziez双重音、毛细血管搏动征,
