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1、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）； Lightenin
2、g（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）
3、- 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 heigh
4、t 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,I
5、nspection（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
6、 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,P
7、athological 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
8、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 t
9、oward 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 tumo
10、r 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
11、 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）-di
12、lated 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。 S
13、ignificance（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
14、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 impu
15、lse（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 thri
16、ll 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 ve
17、ntri- 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：
18、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）
19、,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
20、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,Palpatio
21、n（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,Palpatio
22、n（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 i
23、mpulse 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
24、（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
25、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,Percu
26、ssion- 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,
27、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
28、 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 ： ao
29、rtic 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 d
30、ownwards（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
31、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
32、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）； C
33、ommonly 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
34、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 art
35、ery（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
36、 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
37、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 can hear the sounds most clearly and easily are called
38、 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 be
39、ats 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 sternu
40、m (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 v
41、alve 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6
42、0 100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,
43、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
44、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） P
45、remature 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
46、 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）,Th
47、ere 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