Chapter 1 CHEST PAIN

Size: px

Start display at page:

Download "Chapter 1 CHEST PAIN"

握似时
7 years ago
Views:

1 Chapter 3 The Physical Examination of Respiratory System BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 1

2 Teaching Requirements A. To master 1. The Procedure of palpation,percussion and auscultation 2. The mechanism of inspection,palpation,percussion and auscultation 3. The clinical significance of increased vocal fremitus B. To be familiar with None C. To be acquainted with The clinical significance of vibratory palpation of the pleura Thinking Cap 1. What are the causes of diminished local excursion of the thorax? 2. What is the difference between obstructive atelectasis and compression atelectasis? 3. Which kind of cavity transmits vibrations better than normal lung tissue? BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 2

3 Part Ⅰ Superficial Thoracic Anatomy Anatomic Landmarks of Chest Wall: 1. The Angle of Louis: A landmark for counting ribs anteriorly because the second ribs abuts the junction that forms the angle. 2. The Inferior Scapular Angle: The inferior angle of the scapula is usually at the eighth interspace ; this allows one to identify the eighth rib posteriorly to count ribs in the back. Imaginary Lines of The Chest Wall: Midsternal line Midclavicular line Anterior axillary line Midaxillary line Posterior axillary line Midspinal line Scapula line Part Ⅱ Examination Inspection 1. Respiratory Rate: The respiratory rate should be counted unobtrusively, such as pretending to count the pulse, because many persons tend to breathe faster when their attention is directed to their breathing. 1) Normal Respiratory Rate:16-20 cycles/min 2) Tachypnea (more than 24 cycles/min) Occurs with fear, fever, cardiac insufficiency, pain, pulmonary embolism, acute respiratory distress from infections, pleurisy, anemia, and hyperthyroidism. 3) Bradypnea (less than 12 cycles/min) Occurs with uremia, structural intracranial lesions (especially conditions with increased intracranial pressure), and CNS-depressant drugs (benzodiazepines, alcohol) 2. Respiratory Pattern Table 1 Patterns of abnormal breathing Pattern Characteristic Cause Apnea Absence of breathing Cardiac arrest Biot s Irregular breathing with long periods of apnea Cheyne-Stokes Irregular breathing with intermittent periods of increased and decreased rates and depths of breaths alternating with Increased intracranial pressure Drug-induced respiratory depression Brain damage Drug-induced respiratory depression Congestive heart failure Brain damage BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 3

4 periods of apnea Kussmaul s Fast and deep Metabolic acidosis Palpation 1. Testing Excursion of the Anterior Middle Thorax 1) Procedure: With your fingers high in each axilla and your thumbs abducted, place the palms on the anterior chest. Move the hands medially, dragging skin to provide slack. Until the thumb tips meet in the middle at the level of the sixth ribs. Have the patient inspire deeply letting your hands follow the chest movements. The thumbs should move apart. 2) Clinical Significance: Diminished Local Excursion of the Thorax: This points to a lesion in the underlying wall, pleura, or lung. Causes include pain, fibrosis, Pneumotorax, or consolidation. 2. Vibratory Palpation of the Lungs 1) Procedure: Test for vocal fremitus by applying the palmar bases of the fingers of one hand to the interspaces. Alternatively, the ulnar side of the hand and fifth finger may be used. Ask the patient to repeat the test words one ( yi),or one-two-three, using the same pitch and intensity of voice each time. With the same hand, compare symmetrical parts of the chest sequentially, such as the left infraclavicular fossa, then the right; left fourth interspace, then right. 2) Clinical Significance: Increased Descreased Pneumonia Unilateral Pneumothorax Pleural effusion Bronchial obstruction Atelectasis(incomplete expansion of lung tissue) Bilateral Chronic obstructive lung disease Chest wall thickening(muscle,fat) A. Vocal Fremitus Diminished or Absent: The interposition of filters obstructs transmission of vibration through the chest wall, such as thickened pleura, pleural effusion, pneumothorax or loss of lung parenchyma. B. Vocal Fremitus Increased: Consolidated tissue in pneumonia or inflammation around a lung abscess, when in contact with a bronchus or cavity in the lung, transmits bronchotracheal air vibrations with greater efficiency than do the air-filled pulmonary alveoli. 3. Vibratory Palpation of the Pleura 1) Procedure: The same method with the vibratory palpation of the lung, just the doctors palms should be placed on the sixth interspace of the Midaxillary line, and need t ask the patient to repeat any word. 2) Clinical Significance: The tactile sensation is like two pieces of leather being rubbed together, which BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 4

5 suggests the inflammation of the pleura. Percussion 1. In-direct Percussion: 1) Procedure: Place the distal two phalanges of the middle finger of the left hand firmly against the chest wall in the inter costal spaces parallel to the ribs. Strike the distal interphalangeal joint with a quick, sharp stroke with the tip of the middle finger of the right hand, one or two rapid staccato blows in succession. Hold the forearm stationary and make the striking motion with the wrist. Note both sound elicited and the sense of resistance and vibration underneath the finger. Percuss from side to side, comparing symmetrical areas of the chest. The Sound: Resonance: over the normal lung Dullness: over the heart Flatness: over the muscle of the arm or thigh Hyperresonance: over the lungs during maximum inspiration Tympany: over the airfilled stomach or over any hollow viscus 2) Clinical Significance: i. Dullness Replacing Resonance in the Upper Lung: This finding suggests neoplasm, atelectasis or consolidation of the Lung. ii. Dullness Replacing Resonance in the Lower Lung: To the causes in the upper lung must be added pleural effusion, pleural thickening, and elevation of the diaphragm. iii. Flatness Replacing Resonance or Dullness: Almost invariably, flatness in the thorax results from massive pleural effusion. iv. Hyperresonance Replacing Resonance or Dullness: When lung resonance is replaced by hyperresonance and the area of hepatic and cardiac dullness is encroached upon, either pulmonary emphysema or pneumothorax are suggested. v. Tympany Replacing Resonance: This occurs almost exclusively with a large pneumothorax. 2. Percussion Map of the Thorax: The entire lung surface is normally resonant. At the apices, a band of resonance, known as the Krönig isthmus, runs over the shoulders like shoulder straps. Hepatic dullness ranges downward from the right sixth rib to merge into hepatic flatness. The Traube semilunar space of tympany extends downward from the left sixth ribs; it is variable in extent, depending upon the amount of gas in the stomach. Posteriorly, the dullness below the lung bases begins at about the tenth ribs. 3. Percussion the excursion of the Posterior Lung Bases Mark the level of the lung bases by percussing the patient s chest while the patient inspiring deeply and holding his breath. And then have the patient expire deeply and hold her breath while you percuss the level after descent. Normally, the base should move downward 6~8cm. Auscultation BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 5

6 Procedure: Instruct the patient to breathe, with his mouth open, a little deeper and faster than normal; demonstrate it to him yourself. Notice especially the character of the breath sounds and the presence of abnormal sounds. Compare each area examined with the symmetric area of the opposite thorax and with other adjacent pulmonary zones. If any abnormality is noted, go over the front and back again while the patient whispers test words, such as one-two-three or yi, to determine the absence or the presence of whispered pectoriloquy. Test similarly with the spoken voice for bronchophony. Listen for friction rubs, bone crepitus, and other special sounds. 1. Breath sounds 1) Normal Breath sounds Characteristics of Breath sounds Characteristic Bronchial Bronchovesicular Vesicular Intensity Loud Moderate Soft Pitch High Moderate Low I:E ratio* 1:3 1:1 3:1 Description Tubular Rustling but tubular Gentle rustling Normal locations Manubrium Over mainstem bronchi Most of peripheral lung * Ratio of duration of inspiration to expiration i. Bronchial breath sounds are loud and high pitched and sound like air rushing through a tube. The expiratory component is louder and longer than the inspiratory component. These sounds are normally heard when one listens over the manubrium. A definite pause is heard between the two phases. ii. Bronchovesicular breath sounds are a mixture of bronchial and vesicular sounds. The inspiratory and expiratory components are equal in length. They are normally heard only in the first and second interspaces anteriorly and between the scapulae posteriorly.this is the area overlying the carina and main-stem bronchi. iii. Vesicular breath sounds are the soft, low- pitched sounds heard over most of the lung fields. The inspiratory component is much longer than the expiratory component, which is also much softer and frequently inaudible. 2) Abnormal Breath sounds i. Asthmatic or Obstructive Breathing: Like bronchial breathing, inspiration is short and expiration prolonged, but there is no confusing the two.in asthma, the expiratory phase is several times longer than in bronchial breathing, and pitch is much higher. The listener is aware that expiration is active, not passive, and may require significant effort. Frequently, but not always, asthmatic breathing is accompanied by wheezes audible without the stethoscope. Emphysema produces a similar pattern of breath sounds, but wheezing is absent and the intensity of sound is diminished. ii. Amphoric Breathing: This sound is produced by a large empty superficial pneumothorax. The Latin word for jug is amphora. Amphoric breath sounds have the quality generated by blowing air over the mouth of a bottle. When BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 6

7 the pitch is relatively low and the sound hollow, it is called cavernous breathing, with the same pathologic significance. iii. Metamorphosing Breathing: The breath sounds suddenly change in intensity in different parts of the cycle. This is usually caused by movement of a loose bronchial plug. 2. Adventitious sounds Sounds Mechanism Causes Crackle Excess airway secretions Bronchitis, respiratory infections, pulmonary edema, fibrosis, congestive heart failure Wheeze Rapid airflow through obstructed airway Asthma, bronchitis, pulmonary edema, obstruction by tumor or foreign body congestive heart failure Rhonchus Transient airway plugging Bronchitis 1) Crackles(Rales):Crackles result from the opening and closing of alveoli and small airways during respiration. In pulmonary edema, fine rales may be produced by air bubbling through fluid in the distal small airways. Inspiratory crackles (fine rales) resemble the sound of several hairs being rubbed together between thumb and forefinger. 2) Wheezes (Musical Rales): Wheezes arises from turbulent air flow and the vibrations of the walls of the small airways in which there is partial obstruction to airflow. Wheezes are heard predominantly during expiration. They occur when airways are narrowed by bronchospasm, edema, collapse, neoplasm, or foreign body. 3) Rhonchus: Rhonchi occur as low-pitched gurgling sounds when there is liquid within the larger airways from inflammatory secretions or drowning and in agonal states. They clear or change significantly after an effective cough. 3. Voice sounds In the normal lungs, whispered words are faint and their syllables are not distinct, except over the main bronchi. Increases in loudness and distinctness have clinical significance, indicating consolidation, atelectasis, or fibrosis, which improve transmission or vibrations. 4. Pleural Friction Rub Pleural friction rubs occur when inflamed, unlubricated surfaces of pleurae rub together during respiration. They are characterized as the creaking of new leather. Listen at the spot where the patient feels pleuritic pain. Rubs may be ephemeral and disappear after several respiratory cycles. BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 7

8 胸部体格检查第一部分 : 胸壁体表标志骨骼标志 1. 胸骨角 : 前胸定位肋骨的标识, 第二肋软骨与之相连 2. 肩胛下角 : 后胸定位肋骨的标识, 肩胛下角通常位于第八肋间隙水平胸部体表标志线前正中线锁骨中线腋前线腋中线腋后线后正中线肩胛线第二部分体格检查视诊 1. 呼吸频率计算呼吸频率需在患者不自知的情况下进行, 如假装在数脉搏, 因多数人注意力集中到自己的呼吸次数时会不自觉加快呼吸 1) 正常呼吸频率 :16-20 次 / 分 2) 呼吸过速 :( 大于 24 次 / 分 ) 见于紧张发热心功能不全疼痛肺栓塞感染后急性呼吸功能受损胸膜炎贫血及甲状腺功能亢进 3) 呼吸频率过缓 :( 小于 12 次 / 分 ) 见于尿毒症颅脑损伤 ( 尤见于颅内压增高 ), 及服用过量中枢抑制药物 ( 苯二氮酒精 ) 2. 呼吸节律异常呼吸节律节律特征病因呼吸暂停呼吸停止心脏骤停比奥呼吸夹杂长时间呼吸停顿颅内压增高药物导致的呼吸抑制脑损伤陈 - 施呼吸呼吸快慢深浅交替, 并有呼吸停顿药物导致的呼吸抑制充血性心衰脑损伤库斯莫尔深而大代谢性酸中毒 BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 8

9 触诊 1. 呼吸动度 ( 前胸正中 ) 1) 方法 : 将双手掌对称放在前胸, 使两拇指相近, 余手指斜上位于腋窝下轻轻移动两掌并带动掌下皮肤直至两拇指在正中线第六肋水平相及令患者深吸气, 同时检查者手掌随胸廓运动外展, 此时两拇指分开 2) 临床意义 : 局部动度减弱 : 提示局部胸壁胸膜及肺组织病变, 病因可能为疼痛肺纤维化气胸肺实变 2. 触觉语颤 1) 方法 : 触觉语颤可用小鱼际及小指放在肋间隙感知令患者重复说一或一 - 二 - 三, 需保持发声的音调及响弱一致检查者需用同一手掌在胸壁对称部位依次比较, 如先左锁骨上窝, 再右侧, 先左第四肋间隙, 再右侧 2) 临床意义增强减弱肺炎单侧气胸胸膜渗出支气管堵塞肺不张 ( 肺组织不能完全张开 ) 双侧慢性阻塞性肺病胸壁增厚 ( 肌肉, 脂肪 ) A. 触觉语颤减弱或消失 : 提示诸如胸膜增厚胸膜渗出气胸或肺组织缺失等情况使震动在胸壁的传导减弱 B. 触觉语颤增强 : 肺炎实变肺脓肿其周围炎症浸润同时与支气管相连肺内空洞, 皆通过气道传导震动, 故比正常时在肺泡内传导增强 3. 胸膜摩擦感 1) 方法 : 同检查触觉语颤, 此时患者不需重复发声, 检查者只需将手掌置于腋中线第六肋间隙感知即可 2) 临床意义 : 如感到掌下似皮革间摩擦之感, 提示胸膜炎症改变叩诊 1. 间接叩诊 1) 方法 : 将左中指远端两节指骨紧贴胸壁平行置于肋间隙中, 右中指连续快速敲击左中指远端指关节需运用腕关节之力, 保持前臂不动注意叩出的声音及指下的震动阻力感叩诊需两侧对称比较进行叩诊音 : 清音 : 正常肺组织浊音 : 心脏实音 : 手臂或腿骨的肌肉过清音 : 肺最大程度吸气时鼓音 : 胃泡充气及空腔脏器 BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 9

10 2) 临床意义 vi. 上肺浊音替代清音 : 提示肿瘤肺不张及肺实变 vii. 下肺浊音替代清音 : 除上肺浊音情况所提示病变外, 还需考虑胸膜渗出胸膜增厚横隔抬高 viii. 实音替代清音浊音 : 提示大块胸膜渗出 ix. 过清音取代清音或浊音 : 如过清音取代肺清音且肝浊音界心浊音界缩小, 提示肺气肿或气胸 x. 鼓音取代清音 : 基本只在大范围气胸时发生 2. 肺部定界叩诊 : 肺尖处, 可叩出一清音带, 称为 Krönig 峡, 其在两肩上类似肩带肝浊音界起自右第六肋止于肝实音界特劳比半月鼓音区起自左第六肋, 其宽度随胃内含气量不同而变化在后胸部, 肺底下的浊音区起于第十肋 3. 肺下界移动度令患者深吸气屏住后叩出肺下界并标记, 再令患者深呼气屏住后叩出肺下界并标记通常, 肺下界移动度应为 6-8cm 听诊方法 : 令患者张口呼吸, 指导其呼吸稍加快加深, 并亲自示范注意呼吸音的特点及异常呼吸音的出现每一区域的呼吸音需与相邻区域及对侧对应区域比较, 如听到异常音, 回到出现异常音的起始部分, 嘱患者低声重复或 1 以发现胸语音同样方法亦可发现支气管音还需听诊摩擦音骨捻轧音及其他特殊声响等 1. 呼吸音 1) 正常呼吸音呼吸音特点特点支气管支气管肺泡肺泡强弱响亮中等柔和声调高调中等低调吸呼比 1:3 1:1 3:1 性状管状沙沙状兼管状柔和的沙沙声位置胸骨柄主支气管大部分外周肺野 iv. 支气管音响亮且高调, 类似空气快速经过管道的声音, 其呼气相较吸气相高调且持久支气管呼吸音常可在胸骨柄上方听到呼气吸气之间有停顿 v. 支气管肺泡呼吸音是支气管呼吸音及肺泡呼吸音的混合, 其呼吸两相时限相等, 只可在前胸第一二肋间及肩胛间区听到上述区域为气管隆突及主支气管的上方 vi. 肺泡呼吸音为低调柔和的呼吸音, 可在大部分肺野听到其吸气相远长于呼气相, 且更柔和更易听到 2) 异常呼吸音支气管哮喘或阻塞样呼吸音 : 类似支气管呼吸音, 吸气相短, 呼气相长, 但两者不难鉴别在支气管哮喘中, 其呼气相几倍长于支气管音的呼气成分, 且音调更高检查者可注意到其呼气非主动运动而为被动运动且非常费力有时甚至不用听诊器就可听到伴哮鸣音的阻塞样呼吸音肺气肿也可有类似呼吸音, 但音调多降低且不伴哮鸣音 BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 10

11 2. 啰音啰音机制病因湿啰音过度的气道分泌物支气管炎, 呼吸道感染, 肺水肿, 肺纤维化, 充血性心衰哮鸣音气流快速通过阻塞的气道哮喘, 支气管炎, 肺水肿, 异物或肿瘤阻塞, 充血性心衰鼾音暂时的气道阻塞支气管炎 4) 湿啰音 : 湿啰音由吸气时小气道及肺泡的开合产生在肺水肿时, 细湿啰音可能为终末气道内气体通过液体变为气泡破裂之声捻发音类似拇指示指捻动头发的声音 5) 哮鸣音 : 哮鸣音见于气流猛烈且小气道因部分阻塞而使管腔震动时哮鸣音在呼气时更响, 发生在引起气道狭窄的疾病如 : 支气管痉挛肺水肿肺塌陷肿瘤异物等 6) 鼾音 : 鼾音为低调的咯咯声, 为大气道内有液体的声音, 见于大气道炎性分泌物溺水及临终状态在有效的咳嗽后, 鼾音可明显减弱或消失 3. 听觉语音在正常肺组织, 除主支气管外, 听觉语音十分微弱且音节含糊故如听觉语音增强且易于分辨则提示如下可增强传导的疾病 : 肺实变肺不张肺纤维化 4. 胸膜摩擦音当胸膜被炎症浸润, 或两胸膜间无润滑液, 则在吸气时可听到胸膜摩擦感此感觉被描述为新皮革的吱吱声在患者感觉胸膜疼痛的点听取此音胸膜摩擦音可能较短暂, 呼吸后可消失 BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 11

12 Glossary inspection: 视诊 palpation: 触诊 percussion: 叩诊 auscultation: 听诊 The Angle of Louis: 胸骨角 abut: 邻接, 毗邻 scapular: 肩的, 肩胛的 Midsternal line: 前正中线 clavicular: 锁骨的 axillary: 腋窝的 unobtrusively: 不唐突的 tachypnea: 呼吸急促 embolism: 栓子 pleurisy: 胸膜炎 anemia: 贫血 hyperthyroidism: 甲亢 bradypnea: 呼吸减慢 uremia: 尿毒症 CNS:Central nervous system 中枢神经系统 depressant: 有镇静作用的 benzodiazepine: 苯二氮 intracranial: 头颅内的, 颅骨内的 congestive heart failure: 充血性心衰 metabolic acidosis: 代谢性酸中毒 abduct: 外展 pleura: 胸膜 fibrosis: 纤维化 pneumothorax: 气胸 ulnar: 尺骨 infraclavicular fossa: 锁骨下窝 interspace: 肋间隙 abscess: 脓肿 tactile fremitus: 触觉语颤 atelectasis: 先天性肺不张 phalanx: 指骨 resonance: 清音 dullness: 浊音 flatness: 实音 hyperresonance: 过清音 tympany: 鼓音 neoplasm: 肿瘤 diaphragm: 横隔膜 BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 12

13 pulmonary emphysema: 肺气肿 apices: apex 的复数, 顶点 Traube semilunar space: 特劳比氏半月区, 左前胸下部之鼓音区, 与胃内含气有关 tracheal: 气管的 pectoriloquy: 胸语音 bronchophony: 支气管声 ( 利用听诊器置于健康支气管所能听到的声音 ) bone crepitus: 骨捻轧音 ( 两骨折断端摩擦之音 ) bronchial: 支气管的 bronchovesicular: 支气管肺泡的 vesicular: 肺泡的 extrathoracic trachea: 胸廓外气管 manubrium: 胸骨柄 mainstem bronchi: 主支气管 carina: 气管隆突 amphoric: 空瓮 metamorphose: 变质 plug: 栓, 堵塞物 crackle: 湿啰音 wheeze: 哮鸣音 bronchospasm: 支气管痉挛 collapse: 气道萎陷 rhonchus: 鼾音 agonal: ( 尤指临死时 ) 痛苦的 asthma: 哮喘 consolidation: 实变 unlubricated: 无润滑的 ephemeral: 短暂的 BILINGUAL TEACHING MATERIALS OF DIAGNOSTICS 13

Microsoft PowerPoint - 980907 張竣期- 胸腔理學檢查.ppt

Microsoft PowerPoint - 980907 張竣期- 胸腔理學檢查.ppt 胸腔理學檢查胸腔內科張竣期醫師 98 年 9 月 7 日大綱 (A) 視診 (Inspection) (B) 觸診 (Palpation) (C) 叩診 (Percussion) (D) 聽診 (Auscultation) 1 (A) 視診 (1) 呼吸窘迫 (2) 呼吸次數 (3) 呼吸型態 (4) 胸廓外型 (5) 杵狀指 (1)