1、Physical Examination of the ChestThorax and Lung Inspection视诊 Palpation触诊 Percussion叩诊 Auscultation听诊Physical examination of the chest Bony chest skeletonSurface markersanatomy of the chest wallanatomy of the chest wallSurface markersThoracic LandmarksThoracic LandmarksThoracic Landmarksposteriorant
2、eriorThoracic LandmarksThoracic LandmarksRight oblique fissureHorizontal fissureDeformities or asymmetry Abnormal retraction of the lower interspaces during inspiration Local impairment in respiratory movementSkin: Color:pigmentation、jaundice、Vessels:Instercostal space and chest wall Deformalty Brea
3、thing patternInspection of thoraxExamination of chest Chest wall: Thorax:deformatity Lung and pleura:movement,frequency,rhythm BreastChest wall Veins Crepitation: subcutaneous emphysema Tenderness Intercostal spaceObstruction of superior vena cava上腔静脉阻塞上腔静脉阻塞Spider nevi 蜘蛛痣 Normal chest wall :前后径比:前
4、后径比1:1.5 flat chest:thin slender Barrel chest桶状胸桶状胸:COPD Kyphosis脊柱后凸脊柱后凸: vertibrate abnormalities Pectus excavatum漏斗胸漏斗胸:congenital Pectus carinatum鸡胸鸡胸:佝偻病佝偻病VitD deficiencyChest wall -inspectionThorax桶状胸 脊柱后凸 漏斗胸 前胸壁凸起畸形(鸡胸)Physical examination of the lung and pleuraInspection-lung Respiratory m
5、ovement Respiratory frequency Tachypnea Bradypnea Respiratory depth: Rapid shallow breathing Rapid deep breathing Respiratory rhythm tidal breathing(Cheyne-Stokes) Biots Sigh breathingPattrens of respirationBiots respirationKussmauls respirationCheyne-Stokes(tidal) respirationTachypneaBradypneaHyper
6、ventilationSighing respirationratedepthrhythmTachypnea: fever/pain/anemia/hyperthyroidism/cardiac failureBradypnea: over-dose of anesthetics/narcotics/increased intracranial pressureKussmaul respiration: acidosisCheyne-Stroke respiration: CNS disease as encephalitis/cerebral hemorrhage/brain abscess
7、,tumor,injury, vascular spasm,embolismBiots respiration: brain damage/drug induced suppression/increased intracranial pressureSighing respiration: neuroticPattrens of respiration Symmetry of chest excursion(chest expansion) Tactile fremitus Pleural friction rib触诊Palpation 胸廓扩张度不对称胸廓扩张度不对称Unsymmetry
8、of chest excursion(chest expansion) : Lung diseases:lung atelectasis, lung tumor,chronic cavitation pulmonary TB, pulmonary fibrosis, pulmonary bullae Pleural diseases: pleurisy, pleural effusion, pneumothorax, pleural thickening and pleural tumor Rib disease: frictured rib, TB, tumor, rib arthritis
9、 Thoracic cage disease Disease of diaphragm: unilateral paralysis Symmetry of chest excursion(chest expansion)- 为受检查者发出声音,声波沿气管、为受检查者发出声音,声波沿气管、支气管及肺泡传到胸壁所引起的震动,支气管及肺泡传到胸壁所引起的震动,由检查者的手触及,故称触觉语颤由检查者的手触及,故称触觉语颤tactile fremitus 方法:方法: 检查者以两手掌或两手掌尺侧缘轻轻检查者以两手掌或两手掌尺侧缘轻轻平放于受检者两侧的对称部位,令病平放于受检者两侧的对称部位,令病人反复说
10、人反复说1-2-3,或发长声,或发长声“依依”,此,此时手掌的震动感为语颤。时手掌的震动感为语颤。语音震颤Vocal fremitusLocation for tactile fremitusCauses of Changes in Tactile FremitusSubpleural cavity, lung infarction胸膜炎时,胸膜表面变粗糙,呼吸时两层胸膜相互摩擦,可触胸膜炎时,胸膜表面变粗糙,呼吸时两层胸膜相互摩擦,可触及到摩擦感,似皮革相互摩擦的感觉。及到摩擦感,似皮革相互摩擦的感觉。前胸下前部或腋中线第前胸下前部或腋中线第5、6肋间最明显。肋间最明显。Significan
11、cePleuritis:TB/suppurative, tumor of the pleura, severe dehydration, secondary pleural involvement: pneumonia/lung abscess/pulmonary embolismUremia胸膜摩擦感pleural friction fremitus Resonance轻音轻音 Hyperresonance过清音过清音 Tympany鼓音鼓音 Dullness浊音浊音 Flatness实音实音Percussion of the lung 叩诊Lung border Upper border
12、of the lung Anterior border Lower border: MCL/MAL/SL: 6/8/10 intercostal line Limits of lung movements: 68cm肺上界 自斜方肌前缘中央部开始叩诊为清音,逐渐叩向外侧,当有清音变为浊音时,即为肺上界的外侧终点,然后再由上述中央部叩向内侧,直至清音变为浊音时,即为肺上界的内侧终点。 该清音界的宽度为46cm,称为Krong峡意义意义 变浊或清音缩小:肺结变浊或清音缩小:肺结 核、肺纤维化核、肺纤维化 变清或增宽:肺气肿变清或增宽:肺气肿 正常相当于心浊音界 右肺前界相当于胸骨线位置 左肺前界相
13、当于胸骨旁线第46肋间隙的位置 肺前界浊音区扩大: Cardiomegaly,pericardial effusion, aortic aneurysm,enlargement of hilar lymph node enlargement肺前界 正常平静呼吸时在锁骨中线、腋中线和肩胛线的第6、8、10肋间隙 降低:pulmonary emphesema/lung bullae/abdominal visceroptosis(内脏下垂) 上升:lung atelectasis/pleural effusion/abdominal extension/hepatospleenomegaly 肺下
14、界 68cm肺下界移动度(diaphragmatic excursion)(3 3)肺下界移动度减弱:)肺下界移动度减弱:4cm 下,右上下,右上 左上左上清 音resonance特点特点: : 叩诊音较短,高调而不响亮叩诊音较短,高调而不响亮病因:病因:1. 1. 肺组织含气量减少的病变肺组织含气量减少的病变-肺肺 炎、结核、肺梗塞、肺广泛纤维炎、结核、肺梗塞、肺广泛纤维 化、肺不张等化、肺不张等 2. 2. 肺内不含气的占位病变:肿瘤、肺内不含气的占位病变:肿瘤、 肺脓肿肺脓肿 3. 3. 胸壁的病变胸壁的病变- -水肿、肿瘤等水肿、肿瘤等浊 音dullness 浊音的极端表现浊音的极端表
15、现 胸腔积液胸腔积液实 音flatness 空气封闭于空腔中空气封闭于空腔中 音调较清音为高,强度中等而响亮音调较清音为高,强度中等而响亮 病因:病因: 气胸气胸 靠近胸壁的大空洞,直径靠近胸壁的大空洞,直径3-4cm3-4cm,如空洞性肺结核、肺脓肿如空洞性肺结核、肺脓肿鼓 音typanny 较清音音调为低,有较深的回响,声较清音音调为低,有较深的回响,声 音相对音相对 较强,极易听见,持久性良好较强,极易听见,持久性良好 近似叩空盒子的声响近似叩空盒子的声响 见于肺气肿见于肺气肿过 清 音hyperresonance1.dullnessorflatness(1)decreasedair:p
16、neumonia,atelectasis,lunginfarct、TB(2)Noair:neoplasm,abscess,effusion,pleuralthichening(3)Pleura:effusion、thickening2.typany:pneumothorax,largecavity3.hyperresonnance:COPDAbnormal percussion 次序:由肺尖开始,自上而下,由胸前到胸侧(由腋窝上下),最后检查背部,两侧比较 部位: 前胸:锁骨上窝/锁骨中线上/中/下,腋前线上/下,腋中线上/下,左右两侧,16个部位 背部:腋后线上/下,肩胛区上/下,肩胛下区内
17、/外,左右两侧12部位听诊Auscultation of the lung Classification of Common Lung SoundsAdventitious SoundsAuscultation-normal breath sound Normal breathing sound: Tracheal breath sound Bronchial breath sound Bronchovesicular sound Vesicular sound 支气管呼吸音-bronchial breathing sound:呼吸气流在声门、气管、主支气管形成湍流发出声音 呼气较强,在喉部、
18、锁骨上窝、背部第6、7颈椎/1、2胸椎附近:呼吸气流在细支气管和肺泡内进出发出声音。 肺泡呼吸音-vesicular breathing sound:吸气交呼气长,除气管、支气管部位皆可听到 支气管肺泡呼吸音Bronchovesicular sound:两者兼有,胸骨两侧1、2肋间,肩胛骨第34 胸椎水平Normal breath sounds: 进入肺泡的空气流量减少或流速减慢进入肺泡的空气流量减少或流速减慢 1.1.传导异常:传导异常:pneumothoraxpneumothorax、pleural effusionpleural effusion、pleural thickeningpl
19、eural thickening 2.2.胸廓胸廓/ /肺扩张异常肺扩张异常:lung lung atelectasis,fricturedatelectasis,frictured rib,laterib,late pregnancy,massivepregnancy,massive ascitesascites and and gianggiang abdominal tumor abdominal tumor 3.3.通气动力异常通气动力异常:diaphragmatic diaphragmatic paralysis,CNSparalysis,CNS supression,anesthe
20、ticcsupression,anestheticc/narcotics /narcotics overdose,hypocalemia,fatigueoverdose,hypocalemia,fatigue or or paralysisiparalysisi of respiratory muscle of respiratory muscle 4.4.通气阻力增加通气阻力增加:central lung central lung cancer,lymphoma,airwaycancer,lymphoma,airway disease as disease as asthma,COPD,fo
21、reignasthma,COPD,foreign body bodyAbnormal breath soundAbnormal breath sound-decreased vesicular sound-decreased vesicular sound肺泡呼吸音增强肺泡呼吸音增强 生理状态:生理状态:PhysilogicalPhysilogical: baby : baby 、exerciseexercise 病理状态与代偿性:发热、新陈代谢亢进时,一侧肺病对侧代偿:病理状态与代偿性:发热、新陈代谢亢进时,一侧肺病对侧代偿:TBTB、肺炎、肿瘤等。、肺炎、肿瘤等。呼吸延长:呼吸延长:气道阻
22、力增加:慢支、哮喘气道阻力增加:慢支、哮喘断续性呼吸音:断续性呼吸音:粗糙呼吸音:粗糙呼吸音:粘膜水肿不光滑,气流不畅,呼吸音粗糙,支气管炎粘膜水肿不光滑,气流不畅,呼吸音粗糙,支气管炎/ /肺炎早期肺炎早期异常支气管呼吸音:异常支气管呼吸音:肺实变、肺大腔、压迫缩性肺不张肺实变、肺大腔、压迫缩性肺不张异常支气管肺泡呼吸音:异常支气管肺泡呼吸音:肺炎、肺炎、TBTB、积液压迫、积液压迫异常呼吸音异常呼吸音啰音(水泡音) crackles or rales正常情况下不存在啰音Adventitious Lung Sounds机制:机制: 吸气时气体通过呼吸道内的稀薄分泌物吸气时气体通过呼吸道内的稀
23、薄分泌物 时形成的水泡破裂而产生的声音时形成的水泡破裂而产生的声音 由于小支气管壁因分泌物粘着而陷闭,由于小支气管壁因分泌物粘着而陷闭, 当吸气时突然张开重新充气所产生的爆当吸气时突然张开重新充气所产生的爆 裂音裂音湿 啰 音moist rales 断续而短暂,一次即连续多个断续而短暂,一次即连续多个出现出现 吸气时或吸气终末时较为明显吸气时或吸气终末时较为明显 部位比较固定和局限部位比较固定和局限 大中小水泡音可同时存在大中小水泡音可同时存在 咳嗽或排痰后可减轻或消失咳嗽或排痰后可减轻或消失 湿 啰 音 的 特 点 湿罗音moist rale: 水泡音bubble sound,爆裂音crac
24、kle 分类:响亮湿罗音/非响亮湿罗音 粗湿罗音coarse rale:大水泡音:气管/支气管/空洞,吸气早起bronchiectasis/severe pulmonary edema/sputum retention due to coma 中湿罗音medium rales: 中水泡音中等大小支气管,吸气中期,bronchitis/lobar pneumonia 细湿罗音fine rales: 小水泡音-小气管,吸气后期,bronchiolitis/lobar pneumonia/pulmonary congestion or embolism 捻发音crepitus: alveolitis
25、/interstitial lung disease(pulmonary fibrosis) 固定性湿罗音:bronchiectasis/pulmonary fibrosis啰音Ralesadventitious soundClassification of crackle粗湿啰音,大水泡音Coarse crackle: trachea,main bronchus, cavity,_bronchiectasis, TB, pulmonary edema,abscess/ sputum in 中湿啰音/中水泡音medium carckle: mediun-size bronchus_bronch
26、itis,bronchopneumonia细湿啰音、小水泡音fine crackle: bronchiole_bronchilitis, bronchopneumonia,lung congestion/infarctionVelcro 啰音:interstitial lung disease捻发音creptus:bronchiolitis,alveolitis,congestion固定性湿啰音fixed crackle机制机制: : 气管、支气管或细支气管狭窄或部分阻塞,气管、支气管或细支气管狭窄或部分阻塞,气流通过时,产生湍流或粘稠分泌物振动产生的气流通过时,产生湍流或粘稠分泌物振动产生的
27、。干啰音(哮鸣音) 持续时间较长持续时间较长 带乐音的呼吸附加音,音调较高带乐音的呼吸附加音,音调较高 吸气及呼气均可闻及,尤以呼气时明显吸气及呼气均可闻及,尤以呼气时明显 强度、性质、部位不固定,易变性强度、性质、部位不固定,易变性干 啰 音 特 点哨笛音哨笛音sibilant sibilant rhonchirhonchi 鼾音鼾音(Sonorous (Sonorous rhonichirhonichi) ) 音调音调 高高 低低性质性质 乐音性乐音性 鼾鼾 声声部位部位 较小的支气管较小的支气管 气管或主支气管气管或主支气管 或细支气管或细支气管干 啰 音 的 分 类Diseases r
28、elated Result from airway obstruction Mucosal edema Neoplasm Bronchospasm TB foreign body compressionAuscultationvocal resonance Bronchophony支气管语音 Perctoriloquy胸语音 Egophony羊语音 Whispered耳语银 Bronchial asthma Bronchitis Chronic obstructive pulmonary disease Neoplasm TB双侧性双侧性: :1.1. 慢性支气管炎慢性支气管炎2.2. 支气管
29、哮喘支气管哮喘3.3. 心源性哮喘心源性哮喘 局限性局限性: :1.1. 支气管内膜结核支气管内膜结核 2.2. 肿瘤肿瘤 临 床 意 义 与胸膜摩擦感相同。用听诊器听及。似一手掩与胸膜摩擦感相同。用听诊器听及。似一手掩 耳另一只手指在其手背上摩擦时所听到的声音。耳另一只手指在其手背上摩擦时所听到的声音。 特点:特点: 1.1.性质粗糙,似两手背或两张皮革互相摩擦的声音。性质粗糙,似两手背或两张皮革互相摩擦的声音。 2.2.呼吸两相均可听到,深吸气明显,屏气时消失。呼吸两相均可听到,深吸气明显,屏气时消失。 3.3.最常听到的部位是前下侧胸壁。最常听到的部位是前下侧胸壁。 4.4.变化快,短期
30、内出现短期内消失。变化快,短期内出现短期内消失。 5.5.常伴有胸痛。常伴有胸痛。胸膜摩擦音pleural friction rub 见于急性纤维素性胸膜炎,结核性胸见于急性纤维素性胸膜炎,结核性胸膜炎早期,大叶肺炎累及胸膜,尿毒症,膜炎早期,大叶肺炎累及胸膜,尿毒症,胸膜肿瘤,严重脱水胸膜高度干燥。胸膜肿瘤,严重脱水胸膜高度干燥。临 床 意 义Technique for determining the position of the trachea.Tracheal deviationPhysical examination of the chest Inspection: deformat
31、ion of the chest,respiration Palpation: respiratory movement, tactile fremitus Percussion: resonance, hyperresonance,typanny dullness, flatness Auscultation: Breathing sound: bronchial sound, bronchovesicular,vesicular Adventitious sound: Moist rales; dry rales( wheeze)Classic Physical Findings in Some Common Pulmonary Disorders