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1、心脏体检心脏体检 Equipment（器材器材）：）：Stethoscope（听诊器听诊器）；）；Position（体位体位）：）：Supine（卧位卧位）or seated（坐位坐位）a patient；standing to the right side of the patient （an examiner）；）；Environment（环境环境）：）：Quiet（安静安静）；）；Exposure（暴露暴露）：）：Strip to waist（腰部腰部）；）；Lightening（光线光线）：）：Good；left side；tangent（切线切线）；）；Knowledge of an
2、atomy（解剖知识解剖知识）：）：thorough（全面全面）Considerate and gentle。Physical examination of heart(心心脏脏检检查查)Preparation2 Physiological factors（生理性因素）：（生理性因素）：Left lateral position（左侧卧位）（左侧卧位）-extend to the left（向左移）（向左移）for 2.0 3.0 cm.Right lateral position（右侧卧位）（右侧卧位）-extend to the right（向右移）（向右移）for 1.0 2.5 cm.
3、Inspection（望望诊诊）-Displacement of apical impulse（心心尖尖搏搏动动移移位位）9Pathological factors（病理性因素）：（病理性因素）：Heart itself（心脏本身）（心脏本身）Enlargement of left ventricle（左（左 心室增大）心室增大）-extend to left and downwards（左下移位）；（左下移位）；Inspection（望望诊诊）-Displacement of apical impulse（心心尖尖搏搏动动移移位位）10 Pathological factors（病理性因素）
4、：（病理性因素）：Heart itself（心脏本身）（心脏本身）Enlargement of right ventricle（右（右 心室增大）心室增大）-extend to left but not downwards（向左不向下移位）；（向左不向下移位）；Enlargement of both ventricles（左（左 右室均增大）右室均增大）-extend to both left and right.Inspection（望望诊诊）-Displacement of apical impulse（心心尖尖搏搏动动移移位位）11 Pathological factors（病理性因素）
5、：（病理性因素）：Displacement of mediastinum（纵隔移（纵隔移 位）位）Pleural adhesion（胸膜粘连），（胸膜粘连），pulmonary atelectasis of one side（肺（肺 不张不张-displacement of apical impulse toward the diseased side（移向（移向 患侧）；患侧）；Pleural effusion（胸腔积液），（胸腔积液），pneumothorax of one side（气胸）（气胸）-displacement of apical impulse toward the opp
6、osite side（移向健侧）（移向健侧）.Inspection（望望诊诊）-Displacement of apical impulse（心心尖尖搏搏动动移移位位）12 Pathological factors（病理性因素）：（病理性因素）：Displacement of diaphragm（横隔移位）（横隔移位）Massive ascites（大量腹水），（大量腹水），huge tumor of abdominal cavity（腹腔巨大（腹腔巨大 肿瘤）肿瘤）-displacement of apical impulse to left（移向左侧）；（移向左侧）；Severe emph
7、ysema（肺气肿）（肺气肿）-displacement of apical impulse inward and downward（移向内下）。（移向内下）。Inspection（望望诊诊）-Displacement of apical impulse（心心尖尖搏搏动动移移位位）13 Physiological factors（生理性因素）：（生理性因素）：Thick chest wall（胸壁肥厚）（胸壁肥厚）-weak and narrow（减弱、缩小）；（减弱、缩小）；Thin chest wall（胸壁薄）（胸壁薄）-strong and wide（增强、较大）。（增强、较大）。In
8、spection（望望诊诊）-Changes of intensity and range in apical impulse(心心尖尖搏搏动动强强度度与与范范围围的的改改变变）14 Pathological factors（病理性因素）：（病理性因素）：Increase in intensity of apical impulse（心尖搏动增强）（心尖搏动增强）-fever（发热），（发热），anemia（贫血），（贫血），hyperthyroidism（甲状腺（甲状腺机能亢进）；机能亢进）；Decrease in intensity of apical impulse（心尖搏动减弱）（心尖
9、搏动减弱）-dilated cardiomyopathy（扩张型心肌病）（扩张型心肌病），acute myocardial infarction（急性心肌梗死），（急性心肌梗死），pericardial effusion（心包积液），（心包积液），emphysema（肺气肿）。（肺气肿）。Inspection（望望诊诊）-Changes of intensity and range in apical impulse(心心尖尖搏搏动动强强度度与与范范围围的的改改变变）15 Inspection（望望诊诊）-Inward impulse （负负性性心心尖尖搏搏动动）Definition（定义）：
10、（定义）：invagination（内陷）（内陷）of apical impulse when contracting。Significance（意义）：（意义）：adhesive pericarditis（粘连性心包积液）。（粘连性心包积液）。16 Inspection（望望诊诊）-precordial impulse（心心前前区区搏搏动动）Impulse at 3th 4th left intercostal space just lateral to sternum(胸骨左胸骨左 缘缘3 4肋间）肋间）:right ventricular hypertrophy（右室肥（右室肥 大）大）
11、;Impulse at xiphoid process（剑突下搏（剑突下搏 动）动）:right ventricular hypertrophy;beating of abdominal aorta（腹主动脉搏（腹主动脉搏 动）动）.17 Impulse at base of heart（心底部搏动）：（心底部搏动）：2nd left intercostal space just lateral to sternum(胸骨左缘胸骨左缘2肋间）肋间）:dilation of pulmonary artery；pulmonary hypertension.2nd right intercostal
12、 space just lateral to sternum(胸骨右缘胸骨右缘2肋间）肋间）:dilation of ascending aorta（升主动（升主动 脉扩张）。脉扩张）。Inspection（望望诊诊）-precordial impulse（心心前前区区搏搏动动）18 Inspection（望望诊诊）-contents（内容）Deformity of thoraxes（胸廓畸形）（胸廓畸形）Apical impulse（心尖搏动）（心尖搏动）Precordial impulse（心前区搏动）（心前区搏动）19 Palpation（触触诊诊）Importance of palpa
13、tion（触触诊诊意意义义）To confirm the observations made during inspection（进一步证实望诊所见）；（进一步证实望诊所见）；To detect invisible pulsatile movements（发现望诊看不见的搏动）；（发现望诊看不见的搏动）；To reveal thrill and pericardial friction rubs（发现震颤和心包摩擦感）。（发现震颤和心包摩擦感）。20 Palpation（触触诊诊）-method（方方法法）Right palm first（先用右手手掌）（先用右手手掌）-detecting t
14、hrills（检查震颤）；（检查震颤）；Fingertips then（后用指尖）（后用指尖）-detecting pulsations（检查搏动）。（检查搏动）。21Definition（定义）：（定义）：Slow and forceful beat in apex（心尖区徐缓、有力的搏动），（心尖区徐缓、有力的搏动），lift finger tip（可使手指尖端抬起）。（可使手指尖端抬起）。Significance（意义）（意义）：Sign of left ventri-cular hypertrophy（左室肥大的体征）。（左室肥大的体征）。Palpation（触触诊诊）-heaving
15、 apex impulse (抬抬举举样样心心尖尖搏搏动动）22 Palpation（触触诊诊）-thrills （震震颤颤）Definition（定义）：（定义）：Tiny vibrations felt by palm（手掌感觉到的一种细小震动感），（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（与在猫喉部摸到的呼吸震颤类似，故亦称猫喘）。吸震颤类似，故亦称猫喘）。Mechanism：The sa
16、me as cardiac murmurs（同杂音）。（同杂音）。23 Significance（意义）：（意义）：Signs of organic heart diseases（器（器质性心脏病的体征）；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）、（先天性心脏病）、valvular stenosis（瓣（瓣 膜狭窄），膜狭窄），seldom valvular regurgi-tation（关闭不全）。（关闭不全）
17、。Palpation（触触诊诊）-thrills （震震颤颤）24 Palpation（触触诊诊）-thrills （震震颤颤）Clinical importance of thrills at apex （心前区震颤的临床意义）（心前区震颤的临床意义）Location Location（部位）（部位）Phase Phase（时相）（时相）Disease Disease 2nd right intercostal systole2nd right intercostal systole（收缩期）（收缩期）aortic aortic space just lateral to stenosiss
18、pace just lateral to stenosissternum(sternum(胸骨右缘胸骨右缘2 2肋间）肋间）（主动脉瓣狭窄）（主动脉瓣狭窄）2nd left intercostal systole 2nd left intercostal systole（收缩期）（收缩期）pulmonary pulmonary space just lateral to stenosisspace just lateral to stenosis sternum(sternum(胸骨左缘胸骨左缘2 2肋间）肋间）（肺动脉瓣狭窄）（肺动脉瓣狭窄）3th-4th left intercostal
19、systole3th-4th left intercostal systole（收缩期）（收缩期）ventricular ventricularspace just lateral to septal defectspace just lateral to septal defectsternum(sternum(胸骨左缘胸骨左缘3-43-4肋间）肋间）（室间隔缺损）（室间隔缺损）2nd left intercostal continuous2nd left intercostal continuous（连续性）（连续性）patent ductus patent ductusspace jus
20、t lateral to arteriosusspace just lateral to arteriosussternum(sternum(胸骨左缘胸骨左缘2 2肋间）肋间）（动脉导管未闭）（动脉导管未闭）ApexApex（心尖区）（心尖区）diastole diastole（舒张期）（舒张期）mitral stenosis mitral stenosis （二尖瓣狭窄）（二尖瓣狭窄）25 Palpation（触触诊诊）-pericardial friction rubs（心心包包摩摩擦擦感感）Definition（定义）（定义）Acute pericarditis（急性心包炎急性心包炎）F
21、ibrin effuses from pericardium（心包（心包膜纤维素渗出）膜纤维素渗出）Roughness of peri-cardium（心包粗糙）（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）（心脏搏动时脏层与壁层心包摩擦）Pericardial friction rubs（心包摩擦感）。（心包摩擦感）。26 Palpation（触触诊诊）-pericardial friction rubs（心心包包摩摩擦擦感感）Fe
22、atures 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.27 Palpation（触触诊诊）-contents（内容）Apical impulse and heaving apex impulse（心尖搏动和抬举样心尖搏动）（
23、心尖搏动和抬举样心尖搏动）Thrills（震颤）（震颤）Pericardial friction rubs（心包摩擦感）（心包摩擦感）28 Percussion（叩叩诊诊）Aim（目的）：（目的）：To detect size of heart and its contour（确定心界大小及形态）。（确定心界大小及形态）。29Percussion（叩叩诊诊）Relative and absolute dullness of the heart30 Percussion-method of percussion （叩叩诊诊方方法法）Use mediate percussion（间接叩诊）；（间接
24、叩诊）；In recumbent position（仰卧体位）；（仰卧体位）；Place pleximeter parallel with intercostal space when patient is in recumbent position（当病人仰卧位，板（当病人仰卧位，板 指与肋间隙平行）；指与肋间隙平行）；31 Percussion-method of percussion （叩叩诊诊方方法法）Compare percussion note of each intercostal space from lateral aspect inwards，from lower part
25、 upwards （从外向内，从下向上逐一肋间隙比较叩诊（从外向内，从下向上逐一肋间隙比较叩诊 音）；音）；32 Heart and great vessels give absolute dullness on percussion（心脏和大血管叩诊为（心脏和大血管叩诊为绝对浊音），绝对浊音），and the parts of heart overlaid by lung give relative dullness on percussion（心脏被（心脏被肺遮盖部分叩诊为相肺遮盖部分叩诊为相对浊音）对浊音）which re-presents real size and shape of
26、heart(代表心脏的真实大小和形态代表心脏的真实大小和形态)。Percussion-method of percussion （叩叩诊诊方方法法）33 Percussion-method of percussion （叩叩诊诊方方法法）Percussion of the right margin of the heart(心右界的叩诊心右界的叩诊):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叩诊从肝浊音界上一肋间开始);Carry
27、 out upwards intercostal space by intercostal space,to the second intercostal space(由下往上由下往上,逐一肋间叩诊逐一肋间叩诊,直到第二肋间直到第二肋间).34 Left margin first and then right margin（先叩左界后叩右界）。（先叩左界后叩右界）。From lateral aspect inwards，from lower part upwards（从外向内，从下向上）。（从外向内，从下向上）。Percussion-sequence of percussion （叩叩诊诊顺顺
28、序序）35 Percussion（叩诊）Normal area of relative dullness （正常心脏相对浊音界）（正常心脏相对浊音界）RightRight（cmcm）Intercostal space Left Intercostal space Left（cmcm）2 2 3 2 3 2 3 32 2 3 3.5 3 3.5 4.5 4.53 3 4 5 4 5 6 6 7 7 9 9Distance from left midclavicular line to midsternal line is 8 10 cm（左锁骨中线距胸骨中线（左锁骨中线距胸骨中线8 10cm）。
29、）。Percussion（叩叩诊诊）-normal area of relative dullness（正正常常心心脏脏相相对对浊浊音音界界）8 10 cm36Percussion（叩叩诊诊）-composition of various parts of heart border（心心浊浊音音界界组组成成）Right border：superior venacave,ascending aorta,right atrium.Left border：aortic knob,pulmonary arterial trunk，left auricle，left ventricle.Inferior
30、 border：right ventricle，lesser part of leftventricle.37Percussion（叩叩诊诊）-changes in area of cardiac dullness（心心浊浊音音界界改改变变）Factors of heart itself（心脏本身因素）（心脏本身因素）Enlargement of left ventricle（左室（左室增大）增大）Cardiac dullness extends to left and downwards（心浊音界移向左下）（心浊音界移向左下）and is in the shape of a boot（呈靴形
31、）。（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（常见于主动脉瓣关闭不全和高血压性心脏病）压性心脏病）and is called“aortic”type（主动脉型）。（主动脉型）。38Percussion（叩叩诊诊）-changes in area of cardiac dullness（心心浊浊音音界界改改变变）Cardiac dullness extends to left and downwards（心浊音界移向左下）（心浊音界移向左下）and is in
32、 the shape of a boot（呈靴形）（呈靴形）-“aortic”type（主（主动脉型）。动脉型）。39Percussion（叩叩诊诊）-changes in area of cardiac dullness（心心浊浊音音界界改改变变）Factors of heart itself（心脏本身因素）（心脏本身因素）Enlargement of right ventricle（右室（右室增大）增大）-pulmonary heart disease（肺源（肺源性心脏病）性心脏病）Slight enlargement-no obvious change in area of relati
33、ve dullness（轻（轻度增大时心脏相对浊音界无明显改变）；度增大时心脏相对浊音界无明显改变）；Prominent enlargement relative dullness enlarged both to left and right but not downwards（显著增大时心脏相对（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）。浊音界向左右增大，但向左不向下增大）。40Percussion（叩叩诊诊）-changes in area of cardiac dullness（心心浊浊音音界界改改变变）Factors of heart itself（心脏本身因素）（心脏
34、本身因素）Enlargement of both ventricles（左（左 右室均增大）右室均增大）Enlargement of heart bilaterally （两侧增大）；（两侧增大）；Commonly seen in dilated cardiomyopathy（常见于扩张型心肌（常见于扩张型心肌 病）。病）。41 Factors of heart itself（心脏本身因素）（心脏本身因素）Pericardial effusion（心包积液）：（心包积液）：Enlargement of heart bilaterally（两侧（两侧增大）；增大）；Heart border ch
35、anges according to bodys position（心浊音界随体位改变而改变）（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）（坐位时呈三角形）and the outline of heart border 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（卧位时心浊音界增大尤其是心底部浊音界增宽）。音界增宽）。Percussion（叩叩诊诊）-changes
36、in area of cardiac dullness（心心浊浊音音界界改改变变）42Percussion（叩叩诊诊）-changes in area of cardiac dullness（心心浊浊音音界界改改变变）Factors of heart itself（心脏本身因素）（心脏本身因素）Enlargement of left atrium and pulmonary artery（左房增大及肺动脉段增（左房增大及肺动脉段增宽）宽）Makes concave part of left border of heart protruding outwards and cardiac dull
37、ness becomes pear shaped（心腰膨（心腰膨出，心浊音界呈梨形）；出，心浊音界呈梨形）；Commonly seen in mitral stenosis and is called“mitral”type（二尖瓣型）（二尖瓣型）。43Percussion（叩叩诊诊）-cchanges in area of cardiac dullness（心心浊浊音音界界改改变变）插插P145图图2-5-27Enlargement of left atrium and pulmonary artery（左房增大及肺动脉段增宽）（左房增大及肺动脉段增宽）makes concave part
38、of left border of heart protruding outwards and cardiac dullness becomes pear shaped（心腰（心腰膨出，心浊音界呈梨形）膨出，心浊音界呈梨形）-“mitral”type（二尖瓣型）。（二尖瓣型）。44Percussion（叩叩诊诊）-changes in area of cardiac dullness（心心浊浊音音界界改改变变）Extracardial factors（心脏以外因素）（心脏以外因素）Emphysema dullness of heart is narrowed or can not be per
39、cussed（肺（肺气肿时心浊音界缩小或不能叩出）。气肿时心浊音界缩小或不能叩出）。45Auscultation（听听诊诊）-auscultatory valve areas（心心脏脏瓣瓣膜膜听听诊诊区区）Definition（定义）：（定义）：When heart valves open and close，they make sounds which can be transmitted to body surface.The locations where examiners canhear the sounds most clearly and easily are called au
40、scultatory valve areas.(心脏各心脏各瓣膜开放与关闭时所产生的声音传导到体表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最易听清的部位称心脏瓣膜听诊区)。46Auscultation（听听诊诊）-auscultatory valve areas（心心脏脏瓣瓣膜膜听听诊诊区区）47Auscultation（听听诊诊）-auscultatory valve areas（心心脏脏瓣瓣膜膜听听诊诊区区）Locations of auscultatory valve areas (心脏瓣膜听诊区位置心脏瓣膜听诊区位置)Valves LocationsValv
41、es LocationsMitral valve area site where the strongest Mitral valve area site where the strongest (二尖瓣区二尖瓣区)heart beats are palpated.)heart beats are palpated.Or apex area(Or apex area(心尖区心尖区)()(心尖搏动最强处心尖搏动最强处)Pulmonary valve area left 2nd intercostal spacePulmonary valve area left 2nd intercostal s
42、pace(肺动脉瓣区肺动脉瓣区)just lateral to sternum)just lateral to sternum (胸骨左缘第胸骨左缘第2 2肋间肋间)Aortic area right 2nd intercostal space Aortic area right 2nd intercostal space(主动脉瓣区主动脉瓣区)just lateral to sternum)just lateral to sternum (胸骨右缘第胸骨右缘第2 2肋间肋间)Second aortic area left 3nd intercostal space Second aortic
43、 area left 3nd intercostal space(主动脉瓣第主动脉瓣第2 2听诊区听诊区)just lateral to sternum)just lateral to sternum (胸骨左缘第胸骨左缘第3 3肋间肋间)Tricuspid valve area junction of xiphoid processTricuspid valve area junction of xiphoid process (三尖瓣区三尖瓣区)and sternum()and sternum(剑突与胸骨交界处剑突与胸骨交界处)48Auscultation（听听诊诊）-auscultato
44、ry order(听听诊诊顺顺序序)Start from apex area（从心尖区开始）；（从心尖区开始）；Carry out auscultation clockwise and sequentially（逆时针方向依次听诊）：（逆时针方向依次听诊）：apex area，pulmonary valve area，aortic area，2nd aortic area，tricuspid valve area（心尖区，肺动脉瓣区，主动脉（心尖区，肺动脉瓣区，主动脉瓣区，主动脉瓣第瓣区，主动脉瓣第2听诊区，三尖瓣区）。听诊区，三尖瓣区）。49Auscultation（听听诊诊）-heart
45、rate （心心率率）Definition（定义）（定义）Number of heart beating per minute （每分钟心搏次数）。（每分钟心搏次数）。Varies with age,sex，physical activity and emotional status.50 Normal range of heart rate for adults:In rest and conscious state,60 100 beats/min(安静、清醒状态下安静、清醒状态下60 100次次/分）。分）。Abnormal heart rate（异常心率）：（异常心率）：Faster
46、than 100 beats/min-tachy-cardia(超过超过100次次/分时为心动过速分时为心动过速);Slower than 60 beats/min-brady-cardia(慢于慢于60次次/分时为心动过缓分时为心动过缓)。Auscultation（听听诊诊）-heart rate （心心率率）51Auscultation（听听诊诊）-cardiac rhythm (心心律律)Definition（定义）：（定义）：Rhythm of heart beating(心脏跳动的节心脏跳动的节律律)。In normal condition,cardiac rhythm is sin
47、us and basically regular(正常情况正常情况下心律为窦性且节律基本整齐下心律为窦性且节律基本整齐)。52 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部分青年人可出现随呼吸改变的心律改变的心律,吸气时心率增快
48、吸气时心率增快,呼气时减慢呼气时减慢,称称窦性心律不齐窦性心律不齐)。Auscultation（听听诊诊）-cardiac rhythm (心心律律)53Auscultation（听听诊诊）-abnormal cardiac rhythm(异异常常心心律律)Premature beats（过早搏动）（过早搏动）In the background of regular heart-beats a heartbeat appears in advance abruptly,followed by a longer interval(在在规则心律基础上规则心律基础上,突然提前出现一次心跳突然提前出现
49、一次心跳,其后有其后有较长间隙较长间隙)。54 Premature beats（期前收缩或过早搏动）（期前收缩或过早搏动）Premature 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过早搏动规则出现称联律,一次窦性一次窦性搏动后出现一次过早搏动称二联律搏动后出现一次过早搏动称二联律,每二次窦性搏每二次窦性搏动后出现一
50、次过早搏动称三联律动后出现一次过早搏动称三联律,以此类推以此类推).Auscultation（听听诊诊）-abnormal cardiac rhythm(异异常常心心律律)55Auscultation（听听诊诊）-abnormal cardiac rhythm(异异常常心心律律)Atrial fibrillation(心房颤动心房颤动)“three inconsistencies”（“三不等三不等”）Cardiac rhythm is absolutely irregu-lar(心律绝对不齐心律绝对不齐);Intensity of first heart sound is not the sa