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1、（1 1）掌握胸部常用的体表标志和人工划）掌握胸部常用的体表标志和人工划线，胸部的陷窝和分区；线，胸部的陷窝和分区；（2 2）掌握胸、肺部视诊、触诊检查方法，）掌握胸、肺部视诊、触诊检查方法，能获得较正确的结果；识别正常状态和异能获得较正确的结果；识别正常状态和异常体征；常体征；（3 3）熟悉肺部常见体征的临床意义。）熟悉肺部常见体征的临床意义。教学目的教学目的第1页/共70页胸部的体表标志胸部的体表标志骨骼标志骨骼标志自然陷窝自然陷窝一、天然标志一、天然标志二、人工划线或分区二、人工划线或分区第2页/共70页3骨骼标志（Skeletal landmarks）Sternal anglesubs
2、capular angle Intercostal spaceSpinous processxiphoid Costalspinal angleSuprasternal notchManubrium sterniscapula第3页/共70页骨骼标志（Skeletal landmarks）胸骨角：胸骨角：Louis Louis 角。两侧分别与左右第角。两侧分别与左右第2 2肋软骨连接，肋软骨连接，为为计数肋骨和肋间隙顺序的主要标志计数肋骨和肋间隙顺序的主要标志。胸骨角还标志。胸骨角还标志支气管分叉支气管分叉、心房上缘心房上缘和和上下纵隔交界上下纵隔交界及及相当于第相当于第5 5胸胸椎的水平椎的
3、水平腹上角：胸骨下角（腹上角：胸骨下角（infrasternal angle)infrasternal angle)，相当于，相当于横膈的穹窿部，正常约横膈的穹窿部，正常约70-11070-110肩胛下角：肩胛骨的最下端。直立位两上肢自然下垂肩胛下角：肩胛骨的最下端。直立位两上肢自然下垂时，作为时，作为第第7 7或第或第8 8肋骨水平的标志，肋骨水平的标志，或相当于或相当于第第8 8胸椎胸椎的水平，的水平，作为作为后胸部计数肋骨的标志后胸部计数肋骨的标志4第4页/共70页5人工划线和自然陷窝（Anterior imaginary lines and landmarks）epigastric a
4、ngle Infraclavicular fossaAnterior midlineSuprasternal fossaSupraclavicular fossaSternal lineParasternal lineMidclavicular line第5页/共70页6人工划线和自然陷窝（Lateral imaginary lines）Anterior axillary lineMidaxillary linePosterior axillary line第6页/共70页7人工划线和自然陷窝（Posterior imaginary lines and landmarks）Scapular l
5、inePosterior midlineInfrascapular regionInterscapular regionSuprascapular regionScapular region第7页/共70页人工划线和自然陷窝锁骨中线（锁骨中线（midclavicular linemidclavicular line）（左、右）为通过）（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骨中点向下的垂直线肩胛线（肩胛线（scapular linescapular line）（左、右）为双臂下垂时通）（左、右）为双臂下垂时通
6、过肩胛下角与后正中线平行的垂直线过肩胛下角与后正中线平行的垂直线8第8页/共70页9Anterior view of lobes第9页/共70页10Posterior view of lobes第10页/共70页11Right lateral view of lobes第11页/共70页12Left lateral view of lobes第12页/共70页 表表里里 上上下下 前前后后 视、触、叩、听顺序进行视、触、叩、听顺序进行 胸部检查顺序胸部检查顺序第13页/共70页视诊（视诊（inspection)皮肤皮肤胸壁静脉胸壁静脉肋间隙肋间隙胸廓形态胸廓形态呼吸运动呼吸运动乳房乳房第14页
7、/共70页胸壁皮肤胸壁皮肤颜色、肿胀颜色、肿胀第15页/共70页胸壁静脉胸壁静脉有无充盈或曲张有无充盈或曲张上腔静脉阻塞时，静脉血流方向自上而下上腔静脉阻塞时，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？如何判断胸壁静脉的血流方向？第16页/共70页p有无回缩或膨隆有无回缩或膨隆p吸气时肋间隙回缩提示呼吸道阻塞吸气时肋间隙回缩提示呼吸道阻塞p肋间隙膨隆见于大量胸腔积液、张力性气胸、严重肺气肿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患者用力呼气时p胸壁肿瘤、主动脉瘤、婴儿和儿童时期心脏明显肿大者，
8、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相应局部的肋间隙常膨出肋间隙肋间隙第17页/共70页胸廓形态胸廓形态患者体位：坐位或立位患者体位：坐位或立位裸露全部胸廓裸露全部胸廓平静呼吸平静呼吸前、后、左、右、两侧对比视诊前、后、左、右、两侧对比视诊（1 1）两侧对称性）两侧对称性（2 2）横径与前后径比值）横径与前后径比值 1 1：1.51.5第18页/共70页Barrel chestGibbus第19页/共70页胸廓形态Flat chestFlat chest：体型瘦长，慢性消耗性疾病：体型瘦长，慢性消耗性疾病Barrel chestBarrel chest：严重
9、肺气肿，老年或矮胖体型者：严重肺气肿，老年或矮胖体型者Rachitic chestRachitic chest：佝偻病。漏斗胸（：佝偻病。漏斗胸（furnnel furnnel chestchest）指胸骨剑突处显著内陷，形似漏斗。鸡胸）指胸骨剑突处显著内陷，形似漏斗。鸡胸（pigeon chestpigeon chest）指胸廓的前后径略长于左右径，上）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；平坦或下陷胸廓一侧变形：膨隆；平坦或下陷胸廓局部隆起胸廓局部隆起脊柱畸形脊柱畸形20第20页/共70
10、页胸廓形态胸廓形态第21页/共70页22Thoracic deformity Pectus excavatumBarrel chest Kyphosis第22页/共70页23肺和胸膜视诊（Inspection）1.Respiratory movementAbdominal breathing:male adult and child Thoracic breathing:female adultThree depressions signdyspnea第23页/共70页24肺和胸膜视诊（Inspection）2.Respiratory rate:16-18 f/minTachypnea:20
11、f/minBradypnea:500ml:breathlessness,chest depress第50页/共70页51Signs (Moderate to massive effusion)TachypneaLimited movement of affected sideCostal interspaces of affected side are widerTrachea shifts to opposite sideDecreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breat
12、h sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of the fluid第51页/共70页52Pneumothorax 第52页/共70页53Symptoms Sudden chest pain DyspneaForced sitting positionUnaffected side lyingDry coughTension pneumothoraxProgressive dyspneaSevere swea
13、tTyckycardiaTension,agitatedCyanosisRespiratory failure第53页/共70页54Signs Costal interspaces in affected side are widerLimited movement of affected side Decreased or disappeared vocal fremitus Trachea and heart shift to opposite sideTympanyVesicular breath sound decreased or disappeared第54页/共70页（1 1）胸
14、胸骨骨角角 (sternal sternal angle)-Louisangle)-Louis角的确定及意义？角的确定及意义？（2 2）肩胛下角的确定及意义？）肩胛下角的确定及意义？（3 3）锁骨中线的确定及意义？）锁骨中线的确定及意义？第55页/共70页56常见异常呼吸类型的病因和特点常见异常呼吸类型的病因和特点类型特点病因呼吸停止呼吸消失心脏停搏Biots呼吸规则呼吸后出现长周期呼吸停止又开始呼吸颅内压增高，药物引起呼吸抑制，大脑损害Cheyne-Stokes呼吸不规则呼吸呈周期性，呼吸频率和深度逐渐增加和逐渐减少以至呼吸暂停交替出现药物引起的呼吸抑制，充血性心力衰竭，大脑损伤Kussma
15、ul呼吸呼吸深快代谢性酸中毒第56页/共70页57肺与胸膜常见疾病的体征肺与胸膜常见疾病的体征疾病胸廓呼吸动度气管位置语音震颤叩诊音响呼吸音罗音语音共振大叶性肺炎对称患侧减弱居中患侧增强肺气肿桶状双侧减弱居中双侧减弱哮喘对称双侧减弱居中双侧减弱肺水肿对称双侧减弱居中正常或减弱肺不张患侧平坦患侧减弱移向患侧减弱或消失胸腔积液患侧饱满患侧减弱移向健侧减弱或消失气胸患侧饱满患侧减弱或消失移向健侧减弱或消失第57页/共70页病例书写格式病例书写格式视诊：胸壁静脉无曲张，肋间隙无狭窄或饱满，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，胸廓两侧对称，无畸形，呼吸运动两
16、侧对称，胸式呼吸为主，呼吸频率胸式呼吸为主，呼吸频率1818次次/分，节律规整。分，节律规整。触诊：胸壁无压痛，无皮下捻发感，胸廓扩张触诊：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，无胸膜度两侧对称，语音震颤两侧强度一致，无胸膜摩擦感。摩擦感。第58页/共70页Large left Hemithorax can be seen in all of the following except:1.Left pleural effusion 2.Left Pneumothorax 3.Kyphoscoliosis 4.Agenesis of right lung Quest
17、ions第59页/共70页Smaller left Hemithorax can be seen in all of the following except:1.Consolidation of left lower lobe2.Atelectasis of left lung3.Left Pleural fibrosis4.Agenesis of left lung 第60页/共70页Which statement is correct in counting the Respiratory rate:1.BP,Pulse and Respiratory rate should be ta
18、ken 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 respiratory rate 第61页/共70页Bradypnea is seen
19、 in all of the following except:1.Brain Tumor 2.Myxedema（粘液水肿）（粘液水肿）3.Morphine overdose 4.Congestive heart failure 第62页/共70页Slow deep breathing is:1.Kussmals breathing 2.Biots respiration 3.Cheyne stokes breathing 4.Sighs 5.Sleep apnea 第63页/共70页In Congestive Heart failure following can occur except:
20、1.Increased Respiratory rate 2.Cheyne stokes breathing 3.Platypnea 4.Orthopnea 5.Labored breathing 第64页/共70页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 第65
21、页/共70页Assessment 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 mas
22、s 第66页/共70页Patient has consolidation of right lower lobe.You would expect:1.No change in chest expansion2.Decreased expansion of right hemithorax3.Decreased expansion of left hemithorax4.Increased expansion of left hemithorax第67页/共70页Tactile fremitis is decreased in all of the following conditions except:1.Pleural effusion 2.Pleural fibrosis 3.Pneumothorax 4.Lobar pneumonia 第68页/共70页再 见69第69页/共70页70感谢您的观看！第70页/共70页