1、1,胸部检查,（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、叩诊、听诊检查方法，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
2、上下纵隔交界及相当于第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）,锁骨中线（midclavicular line
3、）（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张,上腔静脉阻
4、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）前后径与横径比值 1：1.5,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 Rachitic chest：佝偻病。漏斗胸（furn
5、nel 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,20,胸廓形态,23,Thoracic deformity,Barrel chest,Kyphosis,24,肺和胸膜视诊（Inspection）,Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult Three depressions sig
6、n 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, intension Deep and slow Severe metabolic acidosi
7、s (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, thoracic trauma 叹气样呼吸（Sighing breathing） Depression
8、, 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),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
9、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
10、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
11、；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 (tactil fremitus) Pleural friction fremitus
12、 Cellulose exudation in pleura due to pleurisy Holding breathing disappeared Tuberculous pleurisy, uremia, pulmo embolism,38,叩诊（Percussion）,39,1. 叩诊方法,间接叩诊（indirect percussion) 检查者一手的中指第1和第2指节作为叩诊板，置于欲叩诊的部位上 另一手的中指指端作为叩诊锤，以垂直方向叩击于板指上 直接叩诊（direct percussion） 顺序 Up to down, anterior to posterior,40,2.
13、 影响叩诊音的因素,Thickness of thoracic wall Calcification of costal cartilage Hydrothorax Containing gas in alveoli Alveolar tension Alveolar elasticity,41,3. 叩诊音分类,清音（Resonance） Normal 过清音（Hyperresonance） Emphysema 鼓音（Tympany） Cavity , pneumothorax 浊音（Dullness） Hydrothorax, atelectasis 实音（Flatness） Massiv
14、e Hydrothorax, massive atelectasis,叩诊音的类型和特点,42,43,4. 正常叩诊音,Lungs sound in percussion Resonance Slight dullness in some areas (upper, right, back) due to thickness of muscles and skeletons,44,4. 正常叩诊音,肺界的叩诊 肺上界（Apex of lungs） Kronig峡: 宽度5cm 变狭: TB, fibrosis 变宽: emphysema 肺前界（Anterior border） 相当于心脏的绝
15、对浊音界 肺下界（Lower border） 6th, 8th, 10th intercostal space in midclavicular line, midaxillary line, scapular line, respectively 降低: 肺气肿，腹腔内脏下垂 上升: 肺不张, 腹内压升高,45,4. 正常叩诊音,肺下界的移动范围,Decreased: emphysema, atelactasis, fibrosis, pulmo. edema, pneumonia Detected impossibly: pleura adhesion, massive hydrothor
16、ax, pneumothorax, diaphragmatic paralysis,46,5. 异常叩诊音,正常肺脏的清音区范围内，出现浊音、实音、过清音或鼓音 不能发现叩诊音改变的病变 The depth of the lesion 5 cm The diameter of the lesion 3 cm Mild hydrothorax,47,5. 异常叩诊音,浊音或实音 Decreased containing gases in alveoli Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis,4
17、8,5. 异常叩诊音,浊音或实音 No gases in alveoli Tumor Pulmo. Hydatid (肺包虫) Pneumocystis (肺囊虫) Non-liquefied lung abscess Others Hydrothorax Pleural thickness,49,5. 异常叩诊音,过清音 Emphysema 鼓音 Pneumothorax Large cavity (TB, lung abscess, lung cyst) Amphorophony (空瓮音)-有金属性回响 空洞巨大，位置表浅且腔壁光滑 张力性气胸,50,5. 异常叩诊音,Tympaniti
18、c dullness (浊鼓音) 肺泡壁松弛，肺泡含气量减少 Atelectasis Congestive or resolution stage of pneumonia Pulmo. edema,51,5. 异常叩诊音,Special areas on percussion in moderate hydrothorax,52,听诊（Auscultation）,53,听诊顺序,54,听诊,Normal breath sound Abnormal breath sound Adventitious sound（crackles, rales） Vocal resonance (语音共振) P
19、leural friction rub,55,1. 正常呼吸音,气管呼吸音 支气管呼吸音 正常人喉部、胸骨上窝、背部第6、7颈椎及第1、2胸椎附近 支气管肺泡呼吸音 正常人胸骨两侧第1、2肋间隙，肩胛间区第3、4胸椎水平以及肺尖前后部 肺泡呼吸音 大部分肺野,4种正常呼吸音特征比较,56,57,2. 异常呼吸音,Abnormal vesicular breath sound Abnormal bronchial breath sound Abnormal bronchovesicular breath sound,58,异常肺泡呼吸音(1),减弱或消失 胸廓活动受限 呼吸肌疾病 支气管阻塞 压
20、迫性肺膨胀不全 Hydrothorax or pneumothorax 腹部疾病 增强 呼吸运动及通气功能增强 Exercise, fever, anemia, metabolic acidosis, compensation (single lung),59,异常肺泡呼吸音 (2),呼气音延长 _ 下呼吸道部分阻塞、痉挛或狭窄 / 肺组织弹性减退 Bronchitis Asthma emphysema,60,异常肺泡呼吸音(3),断续性呼吸音（齿轮呼吸音Cogwheel breath sound） TB Pneumonia 粗糙性呼吸音 _ 支气管粘膜轻度水肿或炎症浸润造成不光 滑或狭窄 b
21、ronchitis Early stage of pneumonia,61,异常支气管呼吸音,在正常肺泡呼吸音部位听到支气管呼吸音，为异常的支气管呼吸音，或称管样呼吸音 Consolidation: lobar pneumonia (consolidation stage) Large cavity: TB, lung abscess Compressed atelectasis: hydrothorax,62,异常支气管肺泡呼吸音,在正常肺泡呼吸音区域内听到支气管肺泡呼吸音 The lesion is relatively smaller, deeper or mixed with norm
22、al lung tissue. bronchopneumonia TB Early stage of lobar pneumonia Upper area of hydrothorax,63,3. 啰音,moist Crackles Rhonchi (wheezes),64,湿啰音,Mechanism 吸气时气体通过呼吸道内的分泌物形成水泡破裂所产生的声音或由于小支气管壁因分泌物粘着而陷闭，吸气时突然张开重新充气所产生的爆裂音,65,湿啰音的特点,Adventitious sound Intermittent Appeared in phase of inspiration or early
23、expiration Constant in site Unchanged in character Medium and fine crackles exist meantime Less or disappeared after cough sometimes,66,湿啰音分类(1),According to intensity of the sound 响亮性 moist crackles-啰音响亮，实变或空洞，见于肺炎、肺脓肿或空洞型肺结核 非响亮性 moist crackles-声音较低，病变周围有较多的正常肺泡组织,67,湿啰音分类(2),按呼吸道腔径大小和腔内渗出物的多寡 Coa
24、rse: trachea, main bronchi, or cavity Bronchiectasis, pulmo. edema, TB, lung abscess, coma (wheezy phlegm, 痰鸣) Medium: bronchi bronchitis, bronchopneumonia,68,Classification of moist crackles(3),Fine: bronchioli 细支气管炎、支气管肺炎、肺淤血和肺梗死 Velcro 啰音: Interstitial lung disease Crepitus: 细支气管炎和肺泡炎症或充血，如肺淤血、肺炎
25、早期和肺泡炎等。正常老年人或长期卧床患者肺底可听及,69,湿啰音部位,Local: local lesion Pneumonia TB Bronchiectasis Both bases Pulmo. congestion Bronchopneumonia, Full fields Acute pulmo. Edema Severe bronchopneumonia,70,干啰音（Rhonchi，wheezes）,Mechanism 由于气管、支气管或细支气管狭窄或部分阻塞，空气吸入或呼出时发生湍流所产生的声音 Causes Congestion Secretion Spasma Tumor
26、Foreign subject Compression (lymph node, mediastinal tumor),71,干啰音的特点,附加音 音调较高 持续时间较长，吸气及呼气时均可听及，以呼气时明显 强度和性质易改变，部位易变换 喘鸣 (appeared in main bronchi),72,干啰音的分类,Sibilant (哨笛音，高调) Bonchioli, smaller bronchi Sonorous (鼾音，低调) Trachea, main bronchi,73,干啰音的部位,Both fields Asthma Chronic bronchitis Acute lef
27、t heart failure (cardiac asthma) Local site Tumor Endobronchial TB,74,语音共振（Vocal resonance）,Increased sound transmission due to changed density of lung tissue Bronchophony (支气管语音） Consolidation Pectoriloqny (胸语音) Massive consolidation Egophony (羊鸣音) Upper area of hydrothorax Whispered (耳语音) Consolid
28、ation,Increased density of lung tissue: Consolidation vs Atelectasis,75,胸膜摩擦音（Pleural friction rub）,胸膜面由于炎症、纤维素渗出变粗糙 听诊部位 inferolateral thoracic wall (maximal shifting area of lung) 屏气时消失 呼吸及心脏搏动时均可听到: mediastinal pleurisy 病因 Tuberculous pleurisy Pulmo. embolism Uremia Pleural mesothelioma,76,Main s
29、ymptoms and signs in common respiratory diseases,77,Labor pneumonia,78,Symptoms,Chill Continued fever: 39-40C Chest pain Tachypnea Cough Rusty sputum,79,Signs (1),General signs Acute facial features, blushing (颜面潮红) Nares flaring (dyspnea) Cyanosis Tachycardia Simple herpes around lips,80,Signs (2),
30、Congestion stage Decreased movement of respiration in affected area Increased vocal fremitus Dullness Crepitus,81,Signs (3),Consolidation stage Obviously increased vocal fremitus (resonance) Dullness or flatness Abnormal bronchial breath sound (tubular breath sound) Pleural friction rub Resolution M
31、oist crackles,82,Chronic Obstructive Pulmonary Disease (Chronic bronchitis with emphysema),83,Symptoms,Chronic productive cough White mucous sputum or pus sputum (infection) Usually exacerbation in winter Morning cough To last more than 3 months Exertional dyspnea Breathlessness (dyspnea) Chest depr
32、ess,84,Signs,Barrel chest Movement of respiration Vocal fremitus Hyperresonance The lower border of lungs downward Shifting range of bottom of lung Cardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode),85,Bronchial asthma,86,Symptom
33、,Expiratory dyspnea with wheezing,87,Signs,Expiratory dyspnea with wheezing Orthopnea Cyanosis Severe sweat Decreased movement of respiration Decreased vocal fremitus Hyperresonance Rhonchi in full fields of lungs,88,Hydrothorax (pleural effusion),89,Symptoms,Dry cough Chest pain Disappeared with gr
34、owing of pleural effusion Reappeared with the fluid decreasing Affected side lying Dyspnea, orthopnea, palpitation The symptoms of underlying disease, 300ml: no obvious symptoms 500ml: breathlessness, chest depress,90,Signs (Moderate to massive effusion),Tachypnea Limited movement of affected side C
35、ostal interspaces of affected side are wider Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of the fluid,91,Pneum
36、othorax,92,Symptoms,Sudden chest pain Dyspnea Forced sitting position Unaffected side lying Dry cough Tension pneumothorax Progressive dyspnea Severe sweat Tyckycardia Tension, agitated Cyanosis Respiratory failure,93,Signs,Costal interspaces in affected side are wider Limited movement of affected s
37、ide Decreased or disappeared vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or disappeared,94,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。,96,叩诊：呈清音，肺下界在右侧锁骨中线、腋中线、肩胛线
38、上分别是第6、第8和第10肋间隙，在左侧腋中线、肩胛线上分别是第8和第10肋间隙，移动度约6cm。 听诊：双肺呼吸音清，无病理性呼吸音，未闻及干、湿性啰音和胸膜摩擦音，两侧语音共振无明显差别。,病例书写格式,当两上肢自然下垂时，肩胛下角一般位于,A. 第5肋间水平 B第6肋间水平 C第7肋间水平 D第9肋间水平 E第10肋间水平,严重肺气肿患者的胸廓形态为,A扁平胸 B桶状胸 C串珠胸 D漏斗胸 E鸡胸,下列哪种疾病触诊时语颤增强,A肺气肿 B肺实变 C气胸 D阻塞性肺不张 E胸壁皮下气肿,下列哪处肺下界移动范围最大,A腋前线及腋中线 B腋中线及腋后线 C锁骨中线及腋中线 D肩胛下角线及腋后线 E胸骨旁线及肩胛下角线,异常支气管呼吸音见于,A大叶性肺炎实变期 B肺内大空腔 C压迫性肺不张 D阻塞性肺不张 E胸膜高度增厚粘连,谢 谢！,102,
