胸部檢查專業(yè)知識(shí)培訓(xùn)

physicalexamination

肺部檢驗(yàn)(2)

PulmonaryExaminationpulmonaryauscultation

肺部聽(tīng)診signsinpulmonarydisease

肺部常見(jiàn)疾病體征AuscultationoftheLung

肺部聽(tīng)診

breathsound呼吸音

rales

啰音

vocalresonance語(yǔ)音共振pleuralfrictionrub胸膜摩擦音PrinciplesofSoundTransmission

聲音旳傳導(dǎo)Distance

傳導(dǎo)距離Numberofinterfaces

界面旳數(shù)量Thenatureofthetransmittingmedium

傳導(dǎo)介質(zhì)旳性質(zhì)Themoredensethemedium,thebetterthetransmission

傳導(dǎo)介質(zhì)密度越高傳導(dǎo)性能越好BreathSounds

呼吸音AirflowtremorInspiratoryphase:AscendingbranchExpiratoryphase:DescendingbranchHearingduration:LengthofthelineLoudness:ThicknessofthelinePitch:Angle氣流產(chǎn)生震動(dòng)吸氣相:升支呼氣相:降支聲音時(shí)間:線條長(zhǎng)短音響強(qiáng)弱:線條粗細(xì)音調(diào)高下:夾角大小ClassifyofBreathSound

呼吸音分類Normalandabnormal

正常和異常呼吸音Bronchialbreathsounds

支氣管呼吸音Vesicularbreathsounds肺泡呼吸音Bronchovesicularbreathsounds

支氣管肺泡呼吸音NormalBronchialBreathSounds

正常支氣管呼吸音Theyareharsherandofhigherpitchthanvesicularsounds.Itisanexpiratorysound.Inexpirationphase,it’srelativelylouder,higherpitchedandlastslonger.Bestheardatlaryngeal,suprasternalfossa,C6-7,andT1-2.氣流經(jīng)聲門氣道產(chǎn)生震動(dòng)“哈”旳聲音呼氣時(shí)聲門窄聲音響吸氣相長(zhǎng)強(qiáng)高呼氣相更長(zhǎng)更強(qiáng)更高聽(tīng)診部位喉部胸骨上窩頸椎6,7和胸椎1,2Normal

VesicularBreathSounds

正常肺泡呼吸音Lowpitched,fine,andheardwellattheperipheryofthelung.Itisaninspiratorysound.Ininspirationphase,it’srelativelylouder,higherpitchedandlastslonger氣流進(jìn)出肺泡產(chǎn)生振動(dòng)“夫”旳聲音吸氣時(shí)肺緊張聲音響吸氣相長(zhǎng)強(qiáng)高呼氣相短弱低聽(tīng)診部位:肺部區(qū)域乳房肩胛腋窩下部最清楚NormalBronchovesicularBreathSounds

正常支氣管肺泡呼吸音AmixtureofthetwoelementsThetwophasesarequitesimilarinintensity,duration,andpitch.BestheardanteriorlyovertheupperendofthesternumandjustbesideitatthelevelofLouis’sangle,andposteriorlyovertheinterscapularspacesatthelevelofthethirdandfourththoracicvertebrae,eitherorbothapices.支氣管和肺泡呼吸音重疊吸氣似肺泡呼吸音但較高較響亮呼氣似支氣管呼吸音但稍弱稍低聽(tīng)診部位胸骨角兩側(cè)肺尖前后肩胛間區(qū)AbnormalBreathSounds

異常呼吸音Abnormalitiesinvesicularbreathsoundarea,including:

在肺組織區(qū)域出現(xiàn)異常呼吸音Exaggeratedvesicularbreathinganddiminishedvesicularbreathing

異常肺泡呼吸音Abnormalbronchialbreathsounds

異常支氣管呼吸音Abnormalbronchovesicularbreathsounds

異常支氣管肺泡呼吸音AbnormalVesicularBreathSounds

異常肺泡呼吸音(1)Diminishedvesicularbreathsounds:reducedairinflowintothealveoli;decreasedvelocityofairflowintothelung;obstructionofbreathsoundconduction.肺泡呼吸音減弱:氣流量降低流速減慢傳導(dǎo)障礙Exaggeratedvesicularbreathsounds,unilateral:compensatorybreathsounds;bilateral:enhancedrespiratorymovementandventilatoryfunction.肺泡呼吸音增強(qiáng)單側(cè):代償原因雙側(cè):全身原因AbnormalVesicularBreathSounds

異常肺泡呼吸音(2)Prolongedbreathsounds:thelowerrespiratorytractspasm,ornarrowing;diminishedelasticityofthelungtissue.

呼吸音延長(zhǎng):下呼吸道痙攣或狹窄肺組織彈性減退Intermittentandroughness:airflowasymmetryandnotsmooth.斷續(xù)和粗糙:氣流不均勻或不暢AbnormalBronchialBreathSounds

異常支氣管呼吸音Bronchialbreathsoundsappearsintheareawherethevesicularbreathsoundsdominate.肺泡呼吸音區(qū)出現(xiàn)支氣管呼吸音Named“tubularbreathsound”

又稱管狀呼吸音Mechanism:airwayopenbutlungtissuewithinfiltrationorlargecavity.

機(jī)制:氣道通暢肺組織密度增長(zhǎng)肺內(nèi)有空腔Causes:consolidationofthelung,largecavityinsidethelung,compressiveatelectasis.原因:肺內(nèi)炎癥實(shí)變壓迫性肺不張肺內(nèi)大空洞AbnormalBronchovesicularBreathSounds

異常支氣管肺泡呼吸音Bronchovesicularbreathsoundsappearsintheareawherethevesicularbreathsoundsdominate.肺泡呼吸音區(qū)出現(xiàn)支氣管肺泡呼吸音Mechanism:airwayopenwithbothnormallungtissueandconsolidation.機(jī)制:氣道通暢肺實(shí)變與正常肺并存Seeninbronchialpneumonia,tuberculosisofthelung,initialstagesoflobarpneumonia,compressedareaupperinpleuraleffusion.原因:支氣管肺炎肺結(jié)核大葉肺炎早期胸腔積液上方肺膨脹不全區(qū)域Rales

啰音rhonchiwheezestridorcracklesormoistralesonorityandnonsonoritycoarse,middleandfinecrepitus干啰音哮鳴音喘鳴音濕啰音響亮性非響亮粗中細(xì)捻發(fā)音Rhonchi

干啰音Rhonchiarelongcontinuousadventitioussounds,generatedbyairwaynarrowing.由氣道狹窄產(chǎn)生連續(xù)時(shí)間較長(zhǎng)旳附加音Inflammation-inducedmucosalcongestionandedematogetherwithexudate炎癥引起旳黏膜充血水腫伴分泌物增多Spasmodiccontractionofbronchialsmoothmuscle支氣管平滑肌痙攣性收縮Intralumenaltumororforeignbodyobstruction管腔內(nèi)腫瘤或異物堵塞Narrowingoflumencausedbycompression管壁受壓管腔狹窄NoticeofRhonchi

聽(tīng)診注意事項(xiàng)Distributing:generalizedorlocalized分布:彌漫散在或局限Phase:duringinspirationorexpiration時(shí)相:吸氣相或呼氣相Pitch:high-pitchedordeep-toned

音調(diào):高調(diào)和低調(diào)

pitchrelatedtodiameterofairway

音調(diào)高下與氣道管徑有關(guān)ClassifyofRhonchi

干啰音分類Generalrhonchi一般干啰音producedby

thicksecretioninbronchus

由支氣管粘稠分泌物所致Wheezes哮鳴音producedbybronchialsmoothmusclespasm

由支氣管平滑肌痙攣所致Stridor喘鳴音producedbylargeairwaynarrowing

由大氣道阻塞所致CompareswithGeneralRhonchiandWheeze

一般干啰音和哮鳴音旳比較Heardbothtwophases

吸氣呼氣均可聽(tīng)到High-pitchedordeep-toned

音調(diào)可高可低Distributingoddsanddispel

散在分布不均Aftercoughing:numberandpartvolatility

咳嗽后數(shù)量和部位易變Onlyinexpiration

在呼氣相High-pitched

音調(diào)高Permeateorlocalization

彌漫或局限固定Aftercoughinginvariability

咳嗽后不變thicksecretionmusclespasmSpecialtyofStridor

喘鳴音旳特點(diǎn)Loudaudibleinthroatandtrachea在喉和氣管附近聽(tīng)到Hearingininspiratoryphase

吸氣相明顯Usuallyaccompanyinspiratorydyspnea常伴有吸氣費(fèi)力Usuallyaccompanysignof“threedepressionssign”

常伴有“三凹”征ClinicalSignificance

臨床意義Changeableandfugitive,varyingtones:exudateinrespiratorytract:bronchitisDiffusewheeze:narrowingofsmallairways:asthmaLocalizedfixedwheezes:airwaynarrowing:tumororendobronchialtuberculosisStridor:largeairwayobstruction:laryngealspasm,foreignbody,tumor易變多音調(diào)干啰音粘稠分泌物:支氣管炎癥彌漫哮鳴音細(xì)支氣管縮窄:哮喘局限固定哮鳴音細(xì)支氣管狹窄:腫瘤結(jié)核喘鳴音大氣道阻塞:喉痙攣異物腫瘤ClinicalSignificance

臨床意義Localizedrhonchisuggestsobstructionofanyetiologye.g.,tumor,foreignbodyormucous.Mucoussecretionswilldisappearwithcoughing,sowouldtherhonchus.Expiratoryrhonchiimpliesobstructiontointrathoracicairways.DiffusedrhonchiwouldsuggestadiseasewithgeneralizedairwayobstructionlikeasthmaorCOPD.AsthmaticscanalsohaveinspiratoryrhonchiwhileitisuncommoninCOPD.Crackles

濕啰音Interruptedadventitioussounds

斷續(xù)旳附加音Makeanotationabouttiming,intensity,effectwithrespiration,position,coughingandcharacter.

注意出現(xiàn)部位時(shí)間強(qiáng)度呼吸和咳嗽旳影響MostCracklesinducedbyairflowthroughthefluidattheairwayandalveolus.

多數(shù)由氣流經(jīng)過(guò)氣道和肺泡內(nèi)旳液體引起thepopopenofthecollapsedfinebronchioleandalveoliformedcrepitus.

陷閉旳細(xì)支氣管和肺泡忽然張開(kāi)形成捻發(fā)音ClassificationofCrackles

濕啰音分類Coarsecrackles:exudateintrachea,bronchioleorcavity.

粗濕啰音:氣管主支氣管或空洞內(nèi)液體Mediumcrackles:exudateinbronchiole.

中濕啰音:支氣管內(nèi)液體Finecrackles:exudateinbronchioleoralveolus.

細(xì)濕啰音:細(xì)支氣管肺泡內(nèi)液體Crepitus:collapsedbronchioleoralveoliopen.

捻發(fā)音:陷閉旳細(xì)支氣管肺泡開(kāi)放CharactersoftheCrackles

聽(tīng)診特點(diǎn)DominateduringinspirationphaseorattheendofinspirationFixedsiteofauscultationTransientStablequalityMediumandfinecracklesmaycoexistcoarsecracklesmaydiminishordisappearaftercough.吸氣時(shí)或吸氣終末明顯部位較恒定時(shí)間較短暫性質(zhì)不易變中小水泡音可并存大水泡音咳嗽后可減輕或消失CharactersoftheCrackles

聽(tīng)診特點(diǎn)Whenthecracklesareheardattheendofinspirationandthebeginningofexpirationthefluidorsecretionsareprobablyinrespiratorybronchioles:mediumcrackles.Ifthecracklesareheardthroughoutitimpliesthesecretionsareinbronchi:coarsecrackles.ClinicalSignificance

臨床意義Localizedcrackles:regionaldiseasesBilateralcracklesinlowerfieldofthelungswithrhonchi:bronchitiswithlunginfectionCracklesinbilateralbasesofthelungs:pulmonarycongestioncausedbyheartfailureGeneralizedcoarsecracklesinbilaterallungfields:acutepulmonaryedema局部濕啰音:肺局部炎癥兩下肺散在干濕啰音:支氣管炎并感染兩肺底對(duì)稱性濕啰音:左心功能不全兩肺滿布濕啰音:急性肺水腫ClinicalSignificance

臨床意義coarsecrackles:exudateintrachea,bronchioleorcavity.maybeseeninbronchiectasis,pulmonaryedema,tuberculosisorlungabscess.mediumcrackles:exudateinbronchea(mediumsize).maybemetinbronchitis,bronchopeumonia.finecrackles:exudateinbronchiole.maybeseenin:bronchiolitis,bronchopneumonia,pulmonarycongestionorpulmonaryinfarction.crepitus:exudateinbronchioleoralveoli.Theymaybeseeninpulmonarycongestionorearlypneumonia.VocalResonance

語(yǔ)音共振Wavefromtractalongthelungandpleuraltothechestwall.

聲波振動(dòng)經(jīng)過(guò)氣道肺組織到胸壁Mechanism:sameastactilefremitusbutbyhearing.

機(jī)制:同觸覺(jué)語(yǔ)顫但為聽(tīng)診Decreased:bronchialobstructionandconductdistanceadd.減弱:支氣管阻塞或傳導(dǎo)距離增長(zhǎng)Increased:consolidationandlargecavityinsidethelung.

增強(qiáng):肺泡充斥液體或肺內(nèi)有空洞MethodofExamination

檢驗(yàn)措施

Patienttosay"99""1,2,3"or"E"

病人發(fā)音Listenallaroundthechestandcomparebothside.

雙側(cè)對(duì)比胸部聽(tīng)診

Vocalresonanceincreasedwhenhearingclearlyinpatientwhisper.

病人耳語(yǔ)可清楚聽(tīng)到為增強(qiáng)Intensitydecreasedwhenhearingnotclearlyinpatientsayingnormalvoice.

病人一般說(shuō)話聽(tīng)不清時(shí)為減弱

ClinicalSignificance

臨床意義Increasedvocalresonanceincludedbronchophony,pectoriloquy,andaddedwhispering:seeninloberpneumonia,cavitydisease.語(yǔ)音增強(qiáng)涉及支氣管語(yǔ)音胸語(yǔ)音和耳語(yǔ)音增強(qiáng):見(jiàn)于大葉性肺炎空洞病變Egophonyisaspecialincreasedvocalresonancewithqualitativevariation:seenincompressedlungtissuewithpleuraleffusion.羊鳴音是語(yǔ)音增強(qiáng)伴聲音變化:見(jiàn)于胸腔積液上方肺受壓區(qū)域Decreasedvocalresonance:seeninemphysema,obstructiveatelectasis,mass,pleuraleffusion,pneumothorax,edemaofchestwall,obesity.

語(yǔ)音減弱:見(jiàn)于肺氣腫阻塞性肺不張肺腫塊胸腔積液氣胸胸壁水腫肥胖IncreasedVocalResonance

語(yǔ)音共振增強(qiáng)Bronchophony:spokenvoicechangestobemoreconcentrated,nearerthelistener’sear,andthewordsaremoreclearlyheard.Seeninsolidificationorcompressionoflungtissue

支氣管語(yǔ)音:肺實(shí)變Pectoriloquy:theintensityofthespokenvoiceisincreased,seeninsolidificationoflungtissue

胸語(yǔ)音:大面積肺實(shí)變PleuralFrictionRub

胸膜摩擦音Mechanism:Therawsurfacesofpleuragrateandmayproduceanaudiblesoundresemblingcreakingleather.機(jī)制:胸膜表面粗糙產(chǎn)生似皮革摩擦?xí)A聲音Features:scratching,gratingrelatedtorespiration,bestheardattheendofinspirationphase,onlowerlungnearthemidaxillaryline.

特點(diǎn):吸氣末腋中線肺下部明顯Disappearwhenstopbreathing,maindifferencetopericardialfrictionsound.

閉氣時(shí)消失:與心包摩擦音區(qū)別Clinicalsignificance:inflammationofpleura.

臨床意義:胸膜炎癥PleuralRub

胸膜摩擦Normalparietalandvisceralpleuraglidesmoothlyduringrespiration.

正常胸膜表面光滑呼吸時(shí)無(wú)摩擦音Ifthepleuraisroughenedduetoanyreason,ascratching,gratingsound,relatedtorespirationisheard.

胸膜表面粗糙可聞及與呼吸有關(guān)旳摩擦音Youcanhearthesoundbycompressingharderwiththestethoscopeandmakingthepatienttakedeepbreaths.

聽(tīng)診器在胸壁上加壓和深呼吸更易聞及Itislocalizedandcanbepalpable.

局部存在并可觸及摩擦感CommonLungDiseaseSign

肺部常見(jiàn)疾病體征

emphysema肺氣腫

atelectasis肺不張

pneumonia肺炎實(shí)變

pneumothorax氣胸

pleuraleffusion胸腔積液Emphysema

肺氣腫Pathology:airtrappinginthelung

Inspection:barrelchestPalpation:decreaseddynamiceventsofrespirationandtactilefremitusPercussion:hyperresonce;Down-shiftingoftheinferiorborderofthelungAuscultation:decreasedbreathsoundsandvocalresonance機(jī)制雙肺含氣增多視診桶狀胸觸診呼吸動(dòng)度減弱語(yǔ)顫減弱叩診過(guò)清音肺下界下移聽(tīng)診呼吸音減弱語(yǔ)音共振減弱Atelectasis

肺不張Pathology:theairwayisobstructedandthelungholdsnoairInspection:theaffectedchestwallisflattenedPalpation:decreaseddynamiceventsofrespirationandtactilefremitus;ThetracheaisshiftedtotheaffectedsidePercussion:dullnessorflatnessAuscultation:breathsoundsandvocalresonancedisappear.機(jī)制氣道阻塞肺不含氣視診患側(cè)胸廓凹陷觸診患側(cè)呼吸動(dòng)度減弱