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1、1,第四节 胸部评估,2,1胸部的体表标志 熟悉胸部常用体表标志，包括骨骼标志、自然陷窝、人工划线和分区。胸壁、胸廓和乳房 了解异常胸壁、胸廓的临床特征，熟悉其发生原因。肺和胸膜 （1）视诊：要求了解呼吸运动的类型、各类呼吸困难的特征、呼吸频率和深度改变及意义。（2）触诊：熟悉肺部触诊内容。掌握肺部触诊的检查方法，胸廓扩张度改变和触觉语颤异常的临床意义。,3,（3）叩诊：了解直接和间接叩诊法的检查方法与应用、影响叩诊音的因素。熟悉胸部叩诊音的分类，肺下界移动度的叩诊方法。掌握肺部叩诊音和肺下界移动度改变的临床意义。（4）听诊：了解胸膜摩擦音的听诊特点和临床意义。熟悉正常呼吸音的种类、特点及分布
2、。啰音的发生机制、分类和听诊特点，语音共振的检查法及临床意义。掌握病理性呼吸音听诊的特点和临床意义。干、湿啰音产生的临床意义。,4,骨性标志包括：胸骨角、腹上角、胸骨剑突、肋骨、肋间隙、肩胛骨、肋脊角。自然陷窝 ：锁骨上窝、锁骨下窝、 人工划线包括；前正中线、左、右锁骨中线、腋前线、腋中线、腋后线、后正中线、肩胛线。,5,胸部体格检查纲要A.视诊1.检查者应面对病人站立，观察胸廓外形和对称性;2.观察呼吸形态；B.触诊3.触诊腋下淋巴结;4.触诊胸壁有无压痛；5.触诊乳房；6.在前胸检查呼吸动度：7.在后胸检查呼吸动度；8.触诊胸膜摩擦感；9.检查触觉语颤；,6,C叩诊10叩诊锁骨上窝，11叩
3、诊后胸部；12叩诊肺下界(肩胛下线)；13. 肩胛下线叩诊肺下界移动度：14叩诊前、侧胸部；D听诊15听诊锁骨上窝；16听诊前、侧胸部；17听诊后胸部；18检查有无胸膜摩擦音；19检查听觉语音。,7,AReview1Review skeleta1 1andmarks2topographic description of location for any positive physical findings：normal or abnormalBMethods3 Examiner should stand facing the patient and observe the shape and
4、symmetry of the chest.4 Measure respiratory rate5 palpate trachea and ev1uate position of the trachea6 palpate for tenderness,8,7.Breasts8.Evaluate posterior chest excursion9.EvaIuate Anterior Chest excursion10.Palpate for pleural friction rubs11.Check for tactile fremitus12.Percuss supraclavicutar
5、fosiae13.Percuss the posterior chest14.Percuss the lower margin of the lungs15.Percuss to detect diaPhragmatic movement at scapular lines16.Percuss the anterior and lateral chest,9,Mention of Conduction,Exposure/warmth/lighting /easy air Inspection, palpation, percussion, auscultationAnterior-latera
6、l-posterior Top- baseComparison: top to base/ left to right,10,Bone landmark,suprasternal notch(胸骨上切迹)clavicle（锁骨）Manubrium sterni(胸骨柄)Sternal angle(胸骨角) Louis anglesuprabdominal angle(腹上角)xiphoid process(剑突)Ribs & interspacesscapula(肩胛骨)spinous process(棘突)costolspinal angle(肋脊角),11,Natural fossa &
7、anatomic region,Axillary fossa Supraclavicular fossaSuprasternal fossaInfraclavicular fossaSuprascapular regionInfrascapular regionInterscapular region,12,Vertical lines,Anterior middle line(前正中线）Mid-clavicular lines（锁骨中线）Spinal line（后正中线） axillary lines (anterior,middle, posterior) （腋前、中、后线）Scapula
8、r lines（肩胛线）,13,14,The boundary of lung & pleura,Lung apexUpper boundary of the lungOuter boundaryInner boundaryLower boundary:,Midclavicular line 6th interspace Midaxillary line 8th interspaceInferior line 10th interspace,15,Chest wall,Vein : Blood flow directionSubcutaneius emphysema(皮下气肿)Tenderne
9、ssInterspace,16,触诊胸壁有无静脉显露、和皮下气肿和胸壁压痛皮下气肿检查方法1.用手按压时，有一种柔软带弹性的振动感似用手握雪一样的感觉，即握雪感；2，用听诊器边加压边听诊可以听到多个微小的“喳喳”音类似捻发音胸部压痛可见于（1）肋间压痛，为肋间神经炎，（2）肋软骨局部压痛，可伴有肿胀，为肋骨软骨炎；（3）胸骨压痛及叩击痛。为白血病的表现之一（4）胸壁局部压痛多见于胸壁软组织炎症脓肿，肋骨骨折；（5）肌肉压痛，见于肌炎、流行性肌痛等；,二、胸壁、胸廓与乳房,17,检查者面对病人站立，观察胸廓外形和对称性，估计病人胸廓前后径与左右径之比(正常为l:1. 5)。注意胸廓外形的变化。乳
10、房,18,Chest framwork,Normal A-P/T diameter: 1/1.5Flat chestBarrel chestRachitic chest Rachitic rosary（肋骨串珠） Funnel chest（漏斗胸）Unilateral deformationLocal bulge of chest wallThoracic deformity caused by deformed spine,19,A视诊 观察呼吸运动（1）呼吸运动类型（2）呼吸困难 （复习）（3）呼吸频率（4）呼吸节律,20,Inspection,Breathing movement: Di
11、aphragmatic vs costal respirationRespiratory rate:- Tachypnea-Bradypnea-Change of the breath depths,21,Inspection(2),Rhythm of the breath -Tidal breathing-Ataxic breathing-Inhibitory breathing-Sighing respiration,22,NormalBradypneaTachypneaKusmols breath Sighing respirationTidal breathAtaxic breathI
12、nhibitory breath,23,Palpation,Thoracic expansionVocal fremitus(触觉语颤)Pleural friction fremitus(胸膜摩擦感)Confirm the inspection,24,B.触诊检查呼吸扩张度正常两侧胸廓大致相等。检查触觉语颤为被检查者发音时，声波的振动沿气管、支气管及肺泡传到胸壁引起共鸣的振动，用手可触及。其强弱取决于支气管是否通畅，胸壁传导是否良好。声波的传播：声波在三种不同介质中的传播时其传导力固体最强，其次为液体气体最弱。坚硬均质的固体强于疏松非均质的固体发自声门的声波通过气管，支气管内的气体与管壁组织，
13、传导至小支气管、肺泡胸膜及胸壁，触诊时可感及震颤；,25,注意事项：检查时应注意以下四点：（1）病人发音要低沉，音调不能过高，在检查过程中发者的强度和音调要始终一致（2）要从上到下，先前胸后背部循序进行（3）注意左右对称部位对比检查；（4）两手贴胸压力要轻而均等；触诊胸膜摩擦感,26,C叩诊叩诊的方法叩诊音的分类清音：正常肺部的叩诊音。 过清音：见于肺气肿。 浊音：见于肺部含气减少或有炎症浸润时。 鼓音：正常可在左胸下侧叩得。 实音：见于大量胸腔积液叩诊的位置叩诊肺前界叩诊肺下界(肩胛下线)；肩胛下线叩诊肺下界移动度：,27,(三)percussion,1.叩诊方法 direct percus
14、sion indirect percussion:the palmar surfaceof the left distal phalanx of the middle finger serves as the pleximeter and is firmly placed on the chest wall in an interspace;parallel to the ribs.,28,3.胸部叩诊音的分类,The normal percussion note varies with the thick-ness of the chest wall and the force applie
15、d by the examiner. 1 The clear, long, low-pitched sound elicited over the normal lung is termed resonance.,29,2 Dullness occurs when the air content of the under-lying tissue is decreased and its solidity is increased.The sound is short, high-pitched, soft, and thudding,and lacks the vibratory quali
16、ty of a resonant sound.It is heard normally over the heart and is accompanied by an increased sense of resistance in the pleximeter finger.,30,3 Flatness is absolute dullness. When no air is present in the underlying tissue the sound is very short,feeble, and high-pitched; flatness is found over the
17、 muscle of the arm or thigh.4 Hyperresonance refers to a more vibrant, lower-pitched, louder, and longer sound heard normally over the lungs during maximum inspiration.,31,5 Tympany is difficult to describe but implies that the sound is moderately loud and fairly well sustained, with a musical quali
18、ty in which a specific pitch is often noted. It is normally heard in the left upper quadrant of the abdomen over the air filled stomach or over any hollow viscus. The pitch of tympany is variable, but it is usually high-pitched, clear, hollow, and drumlike.,Percussion notes and their characteristics
19、,33,Influencing factors for percussion,34,肺下界移动范围,检查时先于平静呼吸时在肩胛下角线上叩出肺下界，划一标记，然后分别在被评估者深吸气与深呼气后，屏住呼吸，再在同一线上自上而下叩出肺下界并作标记。最高点与最低点之间的距离即肺下界移动范围。,35,36,37,38,39,40,41,听诊,听诊的方法正常呼吸音：肺泡呼吸音，支气管呼吸音，支气管肺泡呼吸音病理性的呼吸音1.病理性肺泡呼吸音：(1)增强：生理性，病理性,42,听诊,病理性的呼吸音1.病理性肺泡呼吸音：(2)减弱或消失：呼吸音传导障碍，进入肺泡内的空气量减少，肺组织弹性减弱，呼吸运动受限，吸
20、气受限，呼吸中枢功能障碍，空气流通障碍,43,听诊,病理性的呼吸音1.病理性肺泡呼吸音：(3)呼气延长(4)断续性呼吸音(5)呼吸音粗糙2.病理性支气管呼吸音：肺组织实变，大空腔，压迫性肺不张3.病理性支气管肺泡呼吸音：,44,听诊,罗音： Rale 附加音，有干湿罗音1.湿罗音: Moist Rale(1)产生机理：气流通过有稀薄分泌物的支气管，气流通过有液体的空洞(2)种类：小；中；大水泡音和捻发音,45,听诊,1.湿罗音(3)特征：出现于吸气时，吸气末更明显；中小水泡音同时存在；部位较恒定；咳嗽以后减轻或消失(4)临床意义：广泛；肺底；局限湿罗音的不同意义,46,听诊,2.干罗音 Rhonchi(1)产生机理：空气通过狭窄的支气管腔，气流发生湍流形成(2)种类：高调和低调干罗音(3)特征：吸气和呼气都能听到，呼气时更清楚；部位和强度易变,47,听诊,2.干罗音(4)临床意义：干罗音遍布全肺野：弥漫性支气管炎，支气管哮喘，心源性哮喘局部固定的干罗音：局部炎症，肿瘤，疤痕引起支气管腔狭窄,48,听诊,语音共振产生机理和检查方法及临床意义与触觉语颤相同胸膜摩擦音特点；发生部位；临床意义,49,