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1、1,胸部检查(1),（1）掌握胸部常用的体表标志和人工划线，胸部的陷窝和分区； （2）掌握胸、肺部视诊、触诊检查方法，能获得较正确的结果；识别正常状态和异常体征； （3）熟悉肺部常见体征的临床意义。,教学目的,胸部的体表标志,骨骼标志 自然陷窝,一、天然标志,二、人工划线或分区,4,骨骼标志（Skeletal landmarks）,Suprasternal notch,Manubrium sterni,scapula,骨骼标志（Skeletal landmarks）,胸骨角：Louis 角。两侧分别与左右第2肋软骨连接，为计数肋骨和肋间隙顺序的主要标志。胸骨角还标志支气管分叉、心房上缘和上下纵
2、隔交界及相当于第5胸椎的水平 腹上角：胸骨下角（infrasternal angle)，相当于横膈的穹窿部，正常约70-110 肩胛下角：肩胛骨的最下端。直立位两上肢自然下垂时，作为第7或第8肋骨水平的标志，或相当于第8胸椎的水平，作为后胸部计数肋骨的标志,5,6,人工划线和自然陷窝（Anterior imaginary lines and landmarks）,7,人工划线和自然陷窝（Lateral imaginary lines ）,8,人工划线和自然陷窝（Posterior imaginary lines and landmarks）,人工划线和自然陷窝,锁骨中线（midclavicul
3、ar line）（左、右）为通过锁骨的肩峰端与胸骨端两者中点的垂直线，即通过锁骨中点向下的垂直线 肩胛线（scapular line）（左、右）为双臂下垂时通过肩胛下角与后正中线平行的垂直线,9,10,Anterior view of lobes,11,Posterior view of lobes,12,Right lateral view of lobes,13,Left lateral view of lobes,表里 上下 前后 视、触、叩、听顺序进行,胸部检查顺序,视诊（inspection),皮肤 胸壁静脉 肋间隙 胸廓形态 呼吸运动 乳房,胸壁皮肤颜色、肿胀,胸壁静脉有无充盈或曲
4、张,上腔静脉阻塞时，静脉血流方向自上而下 下腔静脉阻塞时，静脉血流方向自下而上 如何判断胸壁静脉的血流方向？,有无回缩或膨隆 吸气时肋间隙回缩提示呼吸道阻塞 肋间隙膨隆见于大量胸腔积液、张力性气胸、严重肺气肿患者用力呼气时 胸壁肿瘤、主动脉瘤、婴儿和儿童时期心脏明显肿大者，相应局部的肋间隙常膨出,肋间隙,胸廓形态,患者体位：坐位或立位 裸露全部胸廓 平静呼吸 前、后、左、右、两侧对比视诊 （1）两侧对称性 （2）横径与前后径比值 1：1.5,Barrel chest,Gibbus,胸廓形态,Flat chest：体型瘦长，慢性消耗性疾病 Barrel chest：严重肺气肿，老年或矮胖体型者
5、Rachitic chest：佝偻病。漏斗胸（furnnel chest）指胸骨剑突处显著内陷，形似漏斗。鸡胸（pigeon chest）指胸廓的前后径略长于左右径，上下距离较短，胸骨下端常前突，胸廓前侧壁肋骨凹陷 胸廓一侧变形：膨隆；平坦或下陷 胸廓局部隆起 脊柱畸形,21,胸廓形态,23,Thoracic deformity,Pectus excavatum,Barrel chest,Kyphosis,24,肺和胸膜视诊（Inspection）,Respiratory movement Abdominal breathing: male adult and child Thoracic b
6、reathing: female adult Three depressions sign dyspnea,25,肺和胸膜视诊（Inspection）,Respiratory rate: 16-18 f/min Tachypnea: 20 f/min Bradypnea: 12 f/min,26,肺和胸膜视诊（Inspection）,Shallow and fast respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy Deep and fast Agitation, inte
7、nsion Deep and slow Severe metabolic acidosis (Kussmauls breathing),27,肺和胸膜视诊（Inspection）,Respiratory rhythm 潮式呼吸（Cheyne-Stokes breathing） 间停呼吸（Biots breathing） _Decreased excitability of respiratory center 抑制性呼吸（Inhibited breathing ） Sudden cessation of breathing due to chest pain Pleurisy, thoraci
8、c trauma 叹气样呼吸（Sighing breathing） Depression, intension,呼吸方式胸式、腹式 呼吸频率 呼吸深度 呼吸节律 吸气时相和呼气时相的时间变化 两侧呼吸运动的一致性,呼吸运动,触诊（palpation）,胸壁压痛（tenderness) 胸廓扩张度（thoracic expansion) 语音震颤（vocal fremitus）触觉震颤（tactile fremitus) 胸膜摩擦感（pleural friction fremitus）,皮下气肿(subcutaneous emphysema),胸廓扩张度（thoracic expansion),
9、检查部位：胸廓前下部及背部 手法：前胸双拇指分别沿肋缘指向剑突，拇指尖在前正中线两侧对称部位，指间留一块松弛的皮褶，指间距约2cm，手掌和其余伸展的手指置于前侧胸 背部（同前） 观察内容：嘱受检者做深呼吸，观察拇指随胸廓扩张而分离的距离，测定两侧呼吸运动是否一致,胸廓扩张度（thoracic expansion),临床意义：一侧胸廓扩张受限见于大量胸腔积液、气胸、胸膜增厚和肺不张等,31,语音震颤（vocal fremitus）-触觉震颤（tactile fremitus),体位：前胸部仰卧位或坐位 背部坐位 检查顺序：前胸部-背部 手法：检查者双手半握拳，将尺侧缘轻轻放在病人胸壁两侧的对称部
10、位，令病人用低音调拉长声发出“一”的声音，由上向下，左右交叉进行对比 观察内容：比较双手掌震动感,语音震颤（vocal fremitus）-触觉震颤（tactile fremitus),检查部位（前6后8）,语音震颤（vocal fremitus）-触觉震颤（tactile fremitus),检查部位（前6后8）,语音震颤（vocal fremitus）-触觉震颤（tactile fremitus),影响语音震颤强度的因素：发音的强弱、音调的高低、胸壁的厚薄、支气管至胸壁距离的差异 语音震颤减弱或消失见于：肺泡内含气量过多，如肺气肿；支气管阻塞，如阻塞性肺不张；大量胸腔积液或气胸；胸膜高度增
11、厚粘连；胸壁皮下气肿 语音震颤增强见于：肺泡内炎症浸润，如大叶性肺炎实变期、大片肺梗死等；接近胸膜的肺内巨大空腔，如空洞性肺结核、肺脓肿等,35,胸膜摩擦感（pleural friction fremitus）,检查部位:前胸前下侧部或腋中线第5、6肋间 方法:受检者取仰卧位，令受检者做深呼吸，检查者用手掌轻贴病人胸壁 观察内容:感觉有无两层胸膜相互摩擦的感觉,37,肺和胸膜触诊（Palpation）,Thoracic expansion Massive hydrothorax, pneumonia, pleural thickening, atelectasis Vocal fremitus
12、 (tactil fremitus) Pleural friction fremitus Cellulose exudation in pleura due to pleurisy Holding breathing disappeared Tuberculous pleurisy, uremia, pulmo embolism,38,Main symptoms and signs in common respiratory diseases,39,Labor pneumonia,40,Symptoms,Chill Continued fever: 39-40C Chest pain Tach
13、ypnea Cough Rusty sputum,41,Signs (1),General signs Acute facial features, blushing (颜面潮红) Nares flaring (dyspnea) Cyanosis Tachycardia Simple herpes around lips,42,Signs (2),Congestion stage Decreased movement of respiration in affected area Increased vocal fremitus Dullness Crepitus,43,Signs (3),C
14、onsolidation stage Obviously increased vocal fremitus (resonance) Dullness or flatness Abnormal bronchial breath sound (tubular breath sound) Pleural friction rub Resolution Moist crackles,44,Chronic bronchitis with emphysema,45,Symptoms,Chronic productive cough White mucous sputum or pus sputum (in
15、fection) Usually exacerbation in winter Morning cough To last more than 3 months Exertional dyspnea Breathlessness (dyspnea) Chest depress,46,Signs,Barrel chest Movement of respiration Vocal fremitus Hyperresonance The lower border of lungs downward Shifting range of bottom of lung Cardiac dullness
16、area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode),47,Bronchial asthma,48,Symptom,Expiratory dyspnea with wheezing,49,Signs,Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitu
17、s Hyperresonance Rhonchi in full fields of lungs,50,Hydrothorax (pleural effusion),51,Symptoms,Dry cough Chest pain Disappeared with growing of pleural effusion Reappeared with the fluid decreasing Affected side lying Dyspnea, orthopnea, palpitation The symptoms of underlying disease, 300ml: no obvi
18、ous symptoms 500ml: breathlessness, chest depress,52,Signs (Moderate to massive effusion),Tachypnea Limited movement of affected side Costal interspaces of affected side are wider Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath
19、sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of the fluid,53,Pneumothorax,54,Symptoms,Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough Tension pneumothorax Progressive dyspnea Severe sweat Tyckycard
20、ia Tension, agitated Cyanosis Respiratory failure,55,Signs,Costal interspaces in affected side are wider Limited movement of affected side Decreased or disappeared vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or disappeared,（1）胸骨角 (sternal angle)-L
21、ouis角的确定及意义？ （2）肩胛下角的确定及意义？ （3）锁骨中线的确定及意义？,57,常见异常呼吸类型的病因和特点,58,肺与胸膜常见疾病的体征,病例书写格式,视诊：胸壁静脉无曲张，肋间隙无狭窄或饱满，胸廓两侧对称，无畸形，呼吸运动两侧对称，胸式呼吸为主，呼吸频率18次/分，节律规整。 触诊：胸壁无压痛，无皮下捻发感，胸廓扩张度两侧对称，语音震颤两侧强度一致，无胸膜摩擦感。,Large left Hemithorax can be seen in all of the following except: 1.Left pleural effusion 2.Left Pneumothora
22、x 3.Kyphoscoliosis 4.Agenesis of right lung,Questions,Smaller left Hemithorax can be seen in all of the following except: 1.Consolidation of left lower lobe 2.Atelectasis of left lung 3.Left Pleural fibrosis 4.Agenesis of left lung,Which statement is correct in counting the Respiratory rate: 1.BP, P
23、ulse and Respiratory rate should be taken first 2.Tell the patient that you are going to count his respiraory rate before counting 3.Count it aduring examination of Respiratory system steps 4.After patient is in a relaxed state count it without the patient being aware that you are counting his respi
24、ratory rate,Bradypnea is seen in all of the following except: 1.Brain Tumor 2.Myxedema （粘液水肿） 3.Morphine overdose 4.Congestive heart failure,Slow deep breathing is: 1.Kussmals breathing 2.Biots respiration 3.Cheyne stokes breathing 4.Sighs 5.Sleep apnea,In Congestive Heart failure following can occu
25、r except: 1.Increased Respiratory rate 2.Cheyne stokes breathing 3.Platypnea 4.Orthopnea 5.Labored breathing,Possible causes of unilateral diminution or delay in chest expansion include all of the following except: 1.Pleural effusion 2.Asthma 3.Pulmonary consolidation 4.Pleural pain with splinting,A
26、ssessment of chest expansion with deep inspiration helps identify the side of abnormality. Patient has decreased chest expansion on the left. Which is the most likely condition the patient may have: 1.Emphysema/COPD 2.Bronchial asthma 3.Right pleural fibrosis 4.Left pneumothorax 5.Right lung mass,Pa
27、tient has consolidation of right lower lobe. You would expect: 1.No change in chest expansion 2.Decreased expansion of right hemithorax 3.Decreased expansion of left hemithorax 4.Increased expansion of left hemithorax,Tactile fremitis is decreased in all of the following conditions except: 1.Pleural effusion 2.Pleural fibrosis 3.Pneumothorax 4.Lobar pneumonia,再 见,70,