體格檢查-血管課件

ChapterVThoraxD.Heartandbloodvessels

BloodVessel

byDr.Zhuo-renLu1.Inspection(1)Venousbloodpressurel

Whenthevenouspressureiselevated,anengorgedexternaljugularveincanbeseenabovetheloweronethirdofthedistancebetweensuperclavicleandtheangleofthejawwithpatientsittingerect,andabovethelowertwothirdofthedistancebetweensuperclavicleandtheangleofthejawatsupineposition.l

Itoftenindicatestheelevatedpressureintherightatriumandisanimportantsignofcongestiveheartfailure,pericardialconstriction,andpericardialeffusion.(2)ThevisiblepulsationintheneckveinsItindicatesthe

regurgitationoftricuspidvalveandthevisiblepulsationofcarotidarteryoccursinaorticregurgitation.Thelevelofvisiblepulsationintheneckveinsdescendsonnormalinspirationandrisesonexpiration.Thepulsationofjugularveinlooksdiffuse,butthepointofcarotidarterypulseislimited.Itrequiresmuchgreaterpressuretoeliminatethecarotidarterypulsewithadistinctpulsefeeling.

(3)Hepatojugularreflux

Compressionoftherightupperabdominalquadrantfor30to45secondswillresultinmoreprominentdistensionofexternaljugularvein.l

Itusuallyisanimportantsignofrightventricularfailureorpericardialeffusionorconstriction,becausebloodisbeingtransmittedfromthelivertothesuperiorvenacavewithoutreturningbacktorightatriummore.Itisusuallyusedtodistinguishhepotohemia

from

hepatitis,hepotoma,hepatocirrhosis.(4)Capillarypulsation

Checkcapillarypulsation

bypressingonnailsorlipswithaclearglassandlookingatthechangeofcolorfrompinktowhite.Capillarypulsationoccursinaorticregurgitationandotherabnormalitiesassociatedwithwidepulsepressure.2.Palpation(1)Examinerplacefingersovertheradialarteryandcanfeelthestrongarterypulsating.Itisstillaboundingpulsewhenelevatingthepatient’sarmoverhishead.Itiscalledaswater-hammerpulseandoftenoccursinaorticregurgitationandotherabnormalitiesassociatedwithwidepulsepressure.(2)Pulsusparadoxus(paradoxicalpulse)isanimportantsignofcardiactamponadewithtensepericardialeffusionandlessfrequentlywithchronicconstrictivepericarditis.Thetermreferstoweakeningofthepulseduringdeepinspiration.

4.Arterialbloodpressure(1)Measurebloodpressure(Bp)onrightarm.l

ThepointinwhichBpistobemeasuredshouldbeattheleveloftheheart.l

Placecuffincorrectlocation23cmabovetheelbowjointandmakeonefingeradmittedunderthecuff.l

Themercurycolumnonthemanometershouldbeproperlycalibratedwiththepointerat“0〞beforethecuffisinflated.l

Thestethoscopeisplacedfirmlyoverthebrachialartery.l

Theexaminerinflatedthecuffslowlybutsteadilyuntilthebrachialarterypulsedisappearsand20

30mmHghigher.Deflatethecuffslowlyattherateofabout2mmHg/min.l

Thenumberwheretheexaminerhearsthe

firstpulseisthesystolicpressure.Thenumberwherethepulsesounddisappearsisthediastolicpressure.Ifthedifferencebetweenweakeningofthesoundanditsdisappearanceis20mmHgorgreater,thesetwonumbers

shouldberecorded.l

Oneminutelater,thesameproceduremaybefollowedforasecondmeasurementofBp.Thelowestpressureisrecordedasthepatient’sBp.(2)UnderthenormalcircumstancesthereislittleornosignificantdifferenceinBp(5

10mmHg)inthetwoupperextremities.Thesystemicpressureisslightlyhigher,

20

40mmHg

inthelowerextremitiesbyplacingthecuffaroundthelowerthirdofthethighandthestethoscopeoverthepoplitealarterythanintheupper.ItisimportanttomearsurBpinthelowextremitieswhenthefemoralandpoplitealpulsesareeitherweakorabsentandinordertoruleoutcoarctationoftheaorta.Definitionsandclassificationofbloodpressurelevels(mmHg)byWHO/ISH1999CategorySystolicDiastolicOptimal<120<80Normal<130<85Highnormal130-13985-89Grade1hypertension(mild)140-15990-99Subgroup:borderline140-14990-94Grade2hypertension(moderate)160-179100-109Grade3hypertension(severe)

180

110Isolatedsystolichypertension

140<90subgroup:borderline140-149<90l

SomeseriouscausesoflowBpincludeacutemyocardialinfarction,hemorrhage,andshock.l

Increasedpulsepressurehappensfrequentlyinhyperthyroidism,aorticvalveregurgitation,etc.l

Inelderlypersonsthemos