物理診斷學(xué)：胸部檢查

1胸部檢查（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、叩診、聽診檢查方法，能獲得較正確的結(jié)果；識別正常狀態(tài)和異常體征；（3）熟悉肺部常見體征的臨床意義。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（Skeletallandmarks）Sternalanglesubscapularangle

IntercostalspaceSpinousprocessxiphoidCostalspinalangleSuprasternalnotchManubriumsterniscapula骨骼標(biāo)志（Skeletallandmarks）胸骨角：Louis角。兩側(cè)分別與左右第2肋軟骨連接，為計數(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（infrasternalangle)，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，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，作為后胸部計數(shù)肋骨的標(biāo)志56人工劃線和自然陷窩（Anteriorimaginarylinesandlandmarks）epigastricangle

InfraclavicularfossaAnteriormidlineSuprasternalfossaSupraclavicularfossaSternallineParasternallineMidclavicularline7人工劃線和自然陷窩（Lateralimaginarylines）AnterioraxillarylineMidaxillarylinePosterioraxillaryline8人工劃線和自然陷窩（Posteriorimaginarylinesandlandmarks）ScapularlinePosteriormidlineInfrascapularregionInterscapularregionSuprascapularregionScapularregion人工劃線和自然陷窩鎖骨中線（midclavicularline）（左、右）為通過鎖骨的肩峰端與胸骨端兩者中點的垂直線，即通過鎖骨中點向下的垂直線肩胛線（scapularline）（左、右）為雙臂下垂時通過肩胛下角與后正中線平行的垂直線910Anteriorviewoflobes11Posteriorviewoflobes12Rightlateralviewoflobes13Leftlateralviewoflobes

表—里上—下前—后視、觸、叩、聽順序進行胸部檢查順序視診（inspection)皮膚胸壁靜脈肋間隙胸廓形態(tài)呼吸運動乳房胸壁皮膚——顏色、腫脹……胸壁靜脈——有無充盈或曲張上腔靜脈阻塞時，靜脈血流方向自上而下下腔靜脈阻塞時，靜脈血流方向自下而上如何判斷胸壁靜脈的血流方向？有無回縮或膨隆吸氣時肋間隙回縮提示呼吸道阻塞肋間隙膨隆見于大量胸腔積液、張力性氣胸、嚴(yán)重肺氣腫患者用力呼氣時胸壁腫瘤、主動脈瘤、嬰兒和兒童時期心臟明顯腫大者，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)對比視診（1）兩側(cè)對稱性（2）前后徑與橫徑比值1：1.5胸廓形態(tài)Flatchest：體型瘦長，慢性消耗性疾病Barrelchest：嚴(yán)重肺氣腫，老年或矮胖體型者Rachiticchest：佝僂病。漏斗胸（furnnelchest）指胸骨劍突處顯著內(nèi)陷，形似漏斗。雞胸（pigeonchest）指胸廓的前后徑略長于左右徑，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：膨隆；平坦或下陷胸廓局部隆起脊柱畸形20胸廓形態(tài)23ThoracicdeformityBarrelchest

Kyphosis24肺和胸膜視診（Inspection）RespiratorymovementAbdominalbreathing:maleadultandchildThoracicbreathing:femaleadultThreedepressionssigndyspnea25肺和胸膜視診（Inspection）Respiratoryrate:16-18f/minTachypnea:>20f/minBradypnea:<12f/min26肺和胸膜視診（Inspection）Shallowandfastrespiratorymuscularparalysis,elevatedintraabdominalpressure,pneumonia,pleurisyDeepandfastAgitation,intension

DeepandslowSeveremetabolicacidosis(Kussmaul’sbreathing)27肺和胸膜視診（Inspection）Respiratoryrhythm

潮式呼吸（Cheyne-Stokes’breathing）間停呼吸（Biot’sbreathing）_____Decreasedexcitabilityofrespiratorycenter抑制性呼吸（Inhibitedbreathing）SuddencessationofbreathingduetochestpainPleurisy,thoracictrauma嘆氣樣呼吸（Sighingbreathing）Depression,intension

呼吸方式——胸式、腹式呼吸頻率呼吸深度呼吸節(jié)律吸氣時相和呼氣時相的時間變化兩側(cè)呼吸運動的一致性呼吸運動觸診（palpation）胸壁壓痛（tenderness)胸廓擴張度（thoracicexpansion)語音震顫（vocalfremitus）——觸覺震顫（tactilefremitus)胸膜摩擦感（pleuralfrictionfremitus）皮下氣腫(subcutaneousemphysema)胸廓擴張度（thoracicexpansion)檢查部位：胸廓前下部及背部手法：前胸——雙拇指分別沿肋緣指向劍突，拇指尖在前正中線兩側(cè)對稱部位，指間留一塊松弛的皮褶，指間距約2cm，手掌和其余伸展的手指置于前側(cè)胸背部（同前）觀察內(nèi)容：囑受檢者做深呼吸，觀察拇指隨胸廓擴張而分離的距離，測定兩側(cè)呼吸運動是否一致胸廓擴張度（thoracicexpansion)

臨床意義：一側(cè)胸廓擴張受限見于大量胸腔積液、氣胸、胸膜增厚和肺不張等31語音震顫（vocalfremitus）-觸覺震顫（tactilefremitus)體位：前胸部——仰臥位或坐位背部——坐位檢查順序：前胸部-背部手法：檢查者雙手半握拳，將尺側(cè)緣輕輕放在病人胸壁兩側(cè)的對稱部位，令病人用低音調(diào)拉長聲發(fā)出“一……”的聲音，由上向下，左右交叉進行對比觀察內(nèi)容：比較雙手掌震動感語音震顫（vocalfremitus）-觸覺震顫（tactilefremitus)檢查部位（前6后8）語音震顫（vocalfremitus）-觸覺震顫（tactilefremitus)檢查部位（前6后8）語音震顫（vocalfremitus）-觸覺震顫（tactilefremitus)

影響語音震顫強度的因素：發(fā)音的強弱、音調(diào)的高低、胸壁的厚薄、支氣管至胸壁距離的差異語音震顫減弱或消失見于：肺泡內(nèi)含氣量過多，如肺氣腫；支氣管阻塞，如阻塞性肺不張；大量胸腔積液或氣胸；胸膜高度增厚粘連；胸壁皮下氣腫語音震顫增強見于：肺泡內(nèi)炎癥浸潤，如大葉性肺炎實變期、大片肺梗死等；接近胸膜的肺內(nèi)巨大空腔，如空洞性肺結(jié)核、肺膿腫等35胸膜摩擦感（pleuralfrictionfremitus）檢查部位:前胸前下側(cè)部或腋中線第5、6肋間方法:受檢者取仰臥位，令受檢者做深呼吸，檢查者用手掌輕貼病人胸壁觀察內(nèi)容:感覺有無兩層胸膜相互摩擦的感覺37肺和胸膜觸診（Palpation）

ThoracicexpansionMassivehydrothorax,pneumonia,pleuralthickening,atelectasisVocalfremitus(tactilfremitus)

PleuralfrictionfremitusCelluloseexudationinpleuraduetopleurisyHoldingbreathingdisappearedTuberculouspleurisy,uremia,pulmoembolism

38叩診（Percussion）391.叩診方法間接叩診（indirectpercussion)檢查者一手的中指第1和第2指節(jié)作為叩診板，置于欲叩診的部位上另一手的中指指端作為叩診錘，以垂直方向叩擊于板指上

直接叩診（directpercussion）順序Uptodown,anteriortoposterior402.影響叩診音的因素ThicknessofthoracicwallCalcificationofcostalcartilageHydrothoraxContaininggasinalveoliAlveolartensionAlveolarelasticity

413.叩診音分類清音（Resonance）Normal過清音（Hyperresonance）Emphysema鼓音（Tympany）Cavity,pneumothorax濁音（Dullness）Hydrothorax,atelectasis實音（Flatness）MassiveHydrothorax,massiveatelectasis叩診音的類型和特點類型強度音調(diào)時限性質(zhì)清音響亮低長空響過清音極響亮極低較長回響鼓音響亮高中等鼓響樣濁音中等中-高中等重?fù)袈晿訉嵰羧醺叨虡O鈍42434.正常叩診音Lung’ssoundinpercussionResonanceSlightdullnessinsomeareas(upper,right,back)duetothicknessofmusclesandskeletons444.正常叩診音肺界的叩診肺上界（Apexoflungs）Kronig峽:寬度5cm變狹:TB,fibrosis變寬:emphysema肺前界（Anteriorborder）相當(dāng)于心臟的絕對濁音界肺下界（Lowerborder）6th,8th,10thintercostalspaceinmidclavicularline,midaxillaryline,scapularline,respectively降低:肺氣腫，腹腔內(nèi)臟下垂上升:肺不張,腹內(nèi)壓升高454.正常叩診音肺下界的移動范圍Decreased:emphysema,atelactasis,fibrosis,pulmo.edema,pneumoniaDetectedimpossibly:pleuraadhesion,massivehydrothorax,pneumothorax,diaphragmaticparalysisShiftingrangeofbottomoflung

6-8cmAlongthescapularlineTopercussbottomoflung,markingToaskthepat.toinspiredeeplyandholdTopercussbottomoflung,markingToaskthepat.toexpiredeeplyandholdTopercussbottomoflung,markingTomeasurethedist.betweenupperandlowerlines465.異常叩診音正常肺臟的清音區(qū)范圍內(nèi)，出現(xiàn)濁音、實音、過清音或鼓音不能發(fā)現(xiàn)叩診音改變的病變Thedepthofthelesion>5cmThediameterofthelesion3cmMildhydrothorax475.異常叩診音濁音或?qū)嵰鬌ecreasedcontaininggasesinalveoliPneumoniaAtelectasis?TBPulmo.embolismPulmo.edemaPulmo.fibrosis485.異常叩診音濁音或?qū)嵰鬘ogasesinalveoliTumorPulmo.Hydatid(肺包蟲)Pneumocystis(肺囊蟲)Non-liquefiedlungabscessOthersHydrothoraxPleuralthickness495.異常叩診音過清音Emphysema鼓音PneumothoraxLargecavity(TB,lungabscess,lungcyst)Amphorophony(空甕音)-有金屬性回響空洞巨大，位置表淺且腔壁光滑張力性氣胸

505.異常叩診音Tympaniticdullness(濁鼓音)肺泡壁松弛，肺泡含氣量減少AtelectasisCongestiveorresolutionstageofpneumoniaPulmo.edema515.異常叩診音SpecialareasonpercussioninmoderatehydrothoraxDamoiseau’scurveGarland’strianglearea(tympaniticdullness)Grocco’strianglearea(dullness)52聽診（Auscultation）

53聽診順序

54聽診NormalbreathsoundAbnormalbreathsoundAdventitioussound（crackles,rales）Vocalresonance(語音共振)Pleuralfrictionrub551.正常呼吸音氣管呼吸音支氣管呼吸音正常人喉部、胸骨上窩、背部第6、7頸椎及第1、2胸椎附近支氣管肺泡呼吸音正常人胸骨兩側(cè)第1、2肋間隙，肩胛間區(qū)第3、4胸椎水平以及肺尖前后部肺泡呼吸音大部分肺野BronchovesicularBronchialBronchialBronchovesicular4種正常呼吸音特征比較特征氣管呼吸音支氣管呼吸音支氣管肺泡呼吸音肺泡呼吸音強度極響亮響亮中等柔和音調(diào)極高高中等低吸:呼1:11:31:13:1性質(zhì)粗糙管樣沙沙聲，但管樣輕柔的沙沙聲正常聽診區(qū)域胸外氣管胸骨柄主支氣管大部分肺野56572.異常呼吸音AbnormalvesicularbreathsoundAbnormalbronchialbreathsoundAbnormalbronchovesicularbreathsound58異常肺泡呼吸音(1)減弱或消失胸廓活動受限呼吸肌疾病支氣管阻塞壓迫性肺膨脹不全Hydrothoraxorpneumothorax腹部疾病

增強呼吸運動及通氣功能增強Exercise,fever,anemia,metabolicacidosis,compensation(singlelung)59異常肺泡呼吸音

(2)呼氣音延長___下呼吸道部分阻塞、痙攣或狹窄/

肺組織彈性減退

BronchitisAsthmaemphysema60異常肺泡呼吸音(3)斷續(xù)性呼吸音（齒輪呼吸音Cogwheelbreathsound）TBPneumonia粗糙性呼吸音____支氣管粘膜輕度水腫或炎癥浸潤造成不光滑或狹窄

bronchitisEarlystageofpneumonia61異常支氣管呼吸音在正常肺泡呼吸音部位聽到支氣管呼吸音，為異常的支氣管呼吸音，或稱管樣呼吸音

Consolidation:lobarpneumonia(consolidationstage)Largecavity:TB,lungabscessCompressedatelectasis:hydrothorax62異常支氣管肺泡呼吸音在正常肺泡呼吸音區(qū)域內(nèi)聽到支氣管肺泡呼吸音Thelesionisrelativelysmaller,deeperormixedwithnormallungtissue.bronchopneumoniaTBEarlystageoflobarpneumoniaUpperareaofhydrothorax

633.啰音moistCracklesRhonchi(wheezes)64濕啰音

Mechanism

吸氣時氣體通過呼吸道內(nèi)的分泌物形成水泡破裂所產(chǎn)生的聲音或由于小支氣管壁因分泌物粘著而陷閉，吸氣時突然張開重新充氣所產(chǎn)生的爆裂音65濕啰音的特點AdventitioussoundIntermittentAppearedinphaseofinspirationorearlyexpirationConstantinsiteUnchangedincharacterMediumandfinecracklesexistmeantimeLessordisappearedaftercoughsometimes66濕啰音分類(1)Accordingtointensityofthesound響亮性moistcrackles-啰音響亮，實變或空洞，見于肺炎、肺膿腫或空洞型肺結(jié)核非響亮性moistcrackles-聲音較低，病變周圍有較多的正常肺泡組織67濕啰音分類(2)按呼吸道腔徑大小和腔內(nèi)滲出物的多寡Coarse:trachea,mainbronchi,orcavityBronchiectasis,pulmo.edema,TB,lungabscess,coma(wheezyphlegm,痰鳴)Medium:bronchibronchitis,bronchopneumonia68Classificationofmoistcrackles(3)Fine:bronchioli細(xì)支氣管炎、支氣管肺炎、肺淤血和肺梗死Velcro啰音:InterstitiallungdiseaseCrepitus:

細(xì)支氣管炎和肺泡炎癥或充血，如肺淤血、肺炎早期和肺泡炎等。正常老年人或長期臥床患者肺底可聽及69濕啰音部位Local:locallesionPneumoniaTBBronchiectasisBothbasesPulmo.congestionBronchopneumonia,Fullfields

Acutepulmo.EdemaSeverebronchopneumonia70干啰音（Rhonchi，wheezes）Mechanism

由于氣管、支氣管或細(xì)支氣管狹窄或部分阻塞，空氣吸入或呼出時發(fā)生湍流所產(chǎn)生的聲音CausesCongestionSecretionSpasmaTumorForeignsubjectCompression(lymphnode,mediastinaltumor)

71干啰音的特點

附加音音調(diào)較高持續(xù)時間較長，吸氣及呼氣時均可聽及，以呼氣時明顯強度和性質(zhì)易改變，部位易變換

喘鳴

(appearedinmainbronchi)72干啰音的分類Sibilant(哨笛音，高調(diào))Bonchioli,smallerbronchiSonorous(鼾音，低調(diào))Trachea,mainbronchi73干啰音的部位

BothfieldsAsthmaChronicbronchitisAcuteleftheartfailure(cardiacasthma)LocalsiteTumorEndobronchialTB74語音共振（Vocalresonance）

Increasedsoundtransmissionduetochangeddensityoflungtissue

Bronchophony(支氣管語音）ConsolidationPectoriloqny(胸語音)MassiveconsolidationEgophony(羊鳴音)UpperareaofhydrothoraxWhispered(耳語音)ConsolidationIncreaseddensityoflungtissue:ConsolidationvsAtelectasis75胸膜摩擦音（Pleuralfrictionrub）胸膜面由于炎癥、纖維素滲出變粗糙

聽診部位inferolateralthoracicwall(maximalshiftingareaoflung)屏氣時消失呼吸及心臟搏動時均可聽到:mediastinalpleurisy病因

TuberculouspleurisyPulmo.embolismUremiaPleuralmesothelioma76Mainsymptomsandsignsincommonrespiratorydiseases77Laborpneumonia78SymptomsChillContinuedfever:39-40oCChestpainTachypneaCoughRustysputum79Signs(1)GeneralsignsAcutefacialfeatures,blushing(顏面潮紅)Naresflaring(dyspnea)CyanosisTachycardiaSimpleherpesaroundlips80Signs(2)Congestionstage

DecreasedmovementofrespirationinaffectedareaIncreasedvocalfremitusDullnessCrepitus81Signs(3)ConsolidationstageObviouslyincreasedvocalfremitus(resonance)DullnessorflatnessAbnormalbronchialbreathsound(tubularbreathsound)PleuralfrictionrubResolutionMoistcrackles82ChronicObstructivePulmonaryDisease(Chronicbronchitiswithemphysema)83SymptomsChronicproductivecoughWhitemucoussputumorpussputum(infection)UsuallyexacerbationinwinterMorningcoughTolastmorethan3months

ExertionaldyspneaBreathlessness(dyspnea)Chestdepress84Signs

BarrelchestMovementofrespirationVocalfremitus

HyperresonanceThelowerborderoflungsdownwardShiftingrangeofbottomoflungCardiacdullnessarea

Decreasedvesicularbreathsound

ProlongedexpirationMoistcracklesand/orrhonchi(acuteepisode)85Bronchialasthma86SymptomExpiratorydyspneawithwheezing87SignsExpiratorydyspneawithwheezingOrthopneaCyanosisSeveresweatDecreasedmovementofrespirationDecreasedvocalfremitusHyperresonanceRhonchiinfullfieldsoflungs88Hydrothorax

(pleuraleffusion)89SymptomsDrycoughChestpainDisappearedwithgrowingofpleuraleffusionReappearedwiththefluiddecreasing

AffectedsidelyingDyspnea,orthopnea,palpitationThesymptomsofunderlyingdisease300ml:noobvioussymptoms>500ml:breathlessness,chestdepress90Signs(Moderatetomassiveeffusion)TachypneaLimitedmovementofaffectedsideCostalinterspacesofaffectedsidearewiderTracheashiftstooppositesideDecreasedvocalfremitusDullnessorflatnessDecreasedordisappearedvesicularbreathsoundDecreasedordisappearedvocalresonancePleuralfrictionrubAbnormalbronchialbreathsoundinupperareaofthefluid91Pneumothorax92SymptomsSuddenchestpainDyspneaForcedsit