《肺部體檢》課件

1、1胸部檢查(1)（1）掌握胸部常用的體表標(biāo)志和人工劃線，胸部的陷窩和分區(qū)；（2）掌握胸、肺部視診、觸診檢查方法，能獲得較正確的結(jié)果；識(shí)別正常狀態(tài)和異常體征；（3）熟悉肺部常見(jiàn)體征的臨床意義。教學(xué)目的胸部的體表標(biāo)志骨骼標(biāo)志自然陷窩一、天然標(biāo)志二、人工劃線或分區(qū)4骨骼標(biāo)志（Skeletal landmarks）Sternal anglesubscapular angle Intercostal spaceSpinous processxiphoid Costalspinal angleSuprasternal notchManubrium sterniscapula骨骼標(biāo)志（Skeletal la

2、ndmarks）胸骨角：Louis 角。兩側(cè)分別與左右第2肋軟骨連接，為計(jì)數(shù)肋骨和肋間隙順序的主要標(biāo)志。胸骨角還標(biāo)志支氣管分叉、心房上緣和上下縱隔交界及相當(dāng)于第5胸椎的水平腹上角：胸骨下角（infrasternal angle)，相當(dāng)于橫膈的穹窿部，正常約70-110肩胛下角：肩胛骨的最下端。直立位兩上肢自然下垂時(shí)，作為第7或第8肋骨水平的標(biāo)志，或相當(dāng)于第8胸椎的水平，作為后胸部計(jì)數(shù)肋骨的標(biāo)志56人工劃線和自然陷窩（Anterior imaginary lines and landmarks）epigastric angle Infraclavicular fossaAnterior midl

3、ineSuprasternal fossaSupraclavicular fossaSternal lineParasternal lineMidclavicular line7人工劃線和自然陷窩（Lateral imaginary lines ）Anterior axillary lineMidaxillary linePosterior axillary line10Anterior view of lobes11Posterior view of lobes12Right lateral view of lobes胸壁皮膚顏色、腫脹胸壁靜脈有無(wú)充盈或曲張上腔靜脈阻塞時(shí)，靜脈血流方向自上而

4、下下腔靜脈阻塞時(shí)，靜脈血流方向自下而上如何判斷胸壁靜脈的血流方向？有無(wú)回縮或膨隆吸氣時(shí)肋間隙回縮提示呼吸道阻塞肋間隙膨隆見(jiàn)于大量胸腔積液、張力性氣胸、嚴(yán)重肺氣腫患者用力呼氣時(shí)胸壁腫瘤、主動(dòng)脈瘤、嬰兒和兒童時(shí)期心臟明顯腫大者，相應(yīng)局部的肋間隙常膨出肋間隙胸廓形態(tài)患者體位：坐位或立位裸露全部胸廓平靜呼吸前、后、左、右、兩側(cè)對(duì)比視診（1）兩側(cè)對(duì)稱(chēng)性（2）橫徑與前后徑比值 1：1.5胸廓形態(tài)Flat chest：體型瘦長(zhǎng)，慢性消耗性疾病Barrel chest：嚴(yán)重肺氣腫，老年或矮胖體型者Rachitic chest：佝僂病。漏斗胸（furnnel chest）指胸骨劍突處顯著內(nèi)陷，形似漏斗。雞胸（p

5、igeon chest）指胸廓的前后徑略長(zhǎng)于左右徑，上下距離較短，胸骨下端常前突，胸廓前側(cè)壁肋骨凹陷胸廓一側(cè)變形：膨?。黄教够蛳孪菪乩植柯∑鸺怪?1胸廓形態(tài)23Thoracic deformity Pectus excavatumBarrel chest Kyphosis24肺和胸膜視診（Inspection）Respiratory movementAbdominal breathing: male adult and child Thoracic breathing: female adultThree depressions signdyspnea25肺和胸膜視診（Inspectio

6、n）Respiratory rate: 16-18 f/minTachypnea: 20 f/minBradypnea: 500ml: breathlessness, chest depress52Signs (Moderate to massive effusion)TachypneaLimited movement of affected sideCostal interspaces of affected side are widerTrachea shifts to opposite sideDecreased vocal fremitus Dullness or flatness D

7、ecreased or disappeared vesicular breath sound Decreased or disappeared vocal resonance Pleural friction rub Abnormal bronchial breath sound in upper area of the fluid53Pneumothorax 54Symptoms Sudden chest pain DyspneaForced sitting positionUnaffected side lyingDry coughTension pneumothoraxProgressi

8、ve dyspneaSevere sweatTyckycardiaTension, agitatedCyanosisRespiratory failure55Signs 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（1

9、）胸骨角 (sternal angle)-Louis角的確定及意義？（2）肩胛下角的確定及意義？（3）鎖骨中線的確定及意義？57常見(jiàn)異常呼吸類(lèi)型的病因和特點(diǎn)類(lèi)型特點(diǎn)病因呼吸停止呼吸消失心臟停搏Biots呼吸規(guī)則呼吸后出現(xiàn)長(zhǎng)周期呼吸停止又開(kāi)始呼吸顱內(nèi)壓增高，藥物引起呼吸抑制，大腦損害Cheyne-Stokes呼吸不規(guī)則呼吸呈周期性，呼吸頻率和深度逐漸增加和逐漸減少以至呼吸暫停交替出現(xiàn)藥物引起的呼吸抑制，充血性心力衰竭，大腦損傷Kussmaul呼吸呼吸深快代謝性酸中毒58肺與胸膜常見(jiàn)疾病的體征疾病胸廓呼吸動(dòng)度氣管位置語(yǔ)音震顫叩診音響呼吸音羅音語(yǔ)音共振大葉性肺炎對(duì)稱(chēng)患側(cè)減弱居中患側(cè)增強(qiáng)肺氣腫桶狀雙側(cè)

10、減弱居中雙側(cè)減弱哮喘對(duì)稱(chēng)雙側(cè)減弱居中雙側(cè)減弱肺水腫對(duì)稱(chēng)雙側(cè)減弱居中正?；驕p弱肺不張患側(cè)平坦患側(cè)減弱移向患側(cè)減弱或消失胸腔積液患側(cè)飽滿患側(cè)減弱移向健側(cè)減弱或消失氣胸患側(cè)飽滿患側(cè)減弱或消失移向健側(cè)減弱或消失病例書(shū)寫(xiě)格式視診：胸壁靜脈無(wú)曲張，肋間隙無(wú)狹窄或飽滿，胸廓兩側(cè)對(duì)稱(chēng)，無(wú)畸形，呼吸運(yùn)動(dòng)兩側(cè)對(duì)稱(chēng)，胸式呼吸為主，呼吸頻率18次/分，節(jié)律規(guī)整。觸診：胸壁無(wú)壓痛，無(wú)皮下捻發(fā)感，胸廓擴(kuò)張度兩側(cè)對(duì)稱(chēng)，語(yǔ)音震顫兩側(cè)強(qiáng)度一致，無(wú)胸膜摩擦感。Large left Hemithorax can be seen in all of the following except: 1.Left pleural effus

11、ion 2.Left Pneumothorax 3.Kyphoscoliosis 4.Agenesis of right lung QuestionsSmaller 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 Which statement is correct in counting the Respira

12、tory rate: 1.BP, Pulse and Respiratory rate should be taken 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

13、counting his respiratory rate Bradypnea is seen in all of the following except: 1.Brain Tumor 2.Myxedema （粘液水腫）3.Morphine overdose 4.Congestive heart failure Slow deep breathing is: 1.Kussmals breathing 2.Biots respiration 3.Cheyne stokes breathing 4.Sighs 5.Sleep apnea In Congestive Heart failure f

14、ollowing can occur except: 1.Increased Respiratory rate 2.Cheyne stokes breathing 3.Platypnea 4.Orthopnea 5.Labored breathing 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

15、 with splinting 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 mass Patient has consolidation of right lower lobe. You would expect:1.No change in chest expansion2.Decreased expansion of ri