1、第四節 胸部評估1胸部的體表標志 熟悉胸部常用體表標志，包括骨骼標志、自然陷窩、人工劃線和分區。胸壁、胸廓和乳房 了解異常胸壁、胸廓的臨床特征，熟悉其發生原因。肺和胸膜 1視診：要求了解呼吸運動的類型、各類呼吸困難的特征、呼吸頻率和深度改變及意義。2觸診：熟悉肺部觸診內容。掌握肺部觸診的檢查方法，胸廓擴張度改變和觸覺語顫異常的臨床意義。3叩診：了解直接和間接叩診法的檢查方法與應用、影響叩診音的因素。熟悉胸部叩診音的分類，肺下界移動度的叩診方法。掌握肺部叩診音和肺下界移動度改變的臨床意義。4聽診：了解胸膜摩擦音的聽診特點和臨床意義。熟悉正常呼吸音的種類、特點及分布。啰音的發生機制、分類和聽診特點

2、，語音共振的檢查法及臨床意義。掌握病理性呼吸音聽診的特點和臨床意義。干、濕啰音產生的臨床意義。 骨性標志包括：胸骨角、腹上角、胸骨劍突、肋骨、肋間隙、肩胛骨、肋脊角。自然陷窩 ：鎖骨上窩、鎖骨下窩、 人工劃線包括；前正中線、左、右鎖骨中線、腋前線、腋中線、腋后線、后正中線、肩胛線。胸部體格檢查綱要A.視診1.檢查者應面對病人站立，觀察胸廓外形和對稱性;2.觀察呼吸形態；B.觸診3.觸診腋下淋巴結;4.觸診胸壁有無壓痛；5.觸診乳房；6.在前胸檢查呼吸動度：7.在后胸檢查呼吸動度；8.觸診胸膜摩擦感；9.檢查觸覺語顫；C叩診10叩診鎖骨上窩，11叩診后胸部；12叩診肺下界(肩胛下線)；13. 肩

3、胛下線叩診肺下界移動度：14叩診前、側胸部；D聽診15聽診鎖骨上窩；16聽診前、側胸部；17聽診后胸部；18檢查有無胸膜摩擦音；19檢查聽覺語音。AReview1Review skeleta1 1andmarks2topographic description of location for any positive physical findings：normal or abnormalBMethods3 Examiner should stand facing the patient and observe the shape and symmetry of the chest.4 Mea

4、sure respiratory rate5 palpate trachea and ev1uate position of the trachea6 palpate for tenderness7.Breasts8.Evaluate posterior chest excursion9.EvaIuate Anterior Chest excursion10.Palpate for pleural friction rubs11.Check for tactile fremitus12.Percuss supraclavicutar fosiae13.Percuss the posterior

5、 chest14.Percuss the lower margin of the lungs15.Percuss to detect diaPhragmatic movement at scapular lines16.Percuss the anterior and lateral chestMention of ConductionExposure/warmth/lighting /easy air Inspection, palpation, percussion, auscultationAnterior-lateral-posterior Top- baseComparison: t

6、op to base/ left to rightBone landmarksuprasternal notch(胸骨上切跡)clavicle鎖骨Manubrium sterni(胸骨柄)Sternal angle(胸骨角) Louis anglesuprabdominal angle(腹上角)xiphoid process(劍突)Ribs & interspacesscapula(肩胛骨)spinous process(棘突)costolspinal angle(肋脊角)Natural fossa & anatomic regionAxillary fossa Supraclavicular

7、 fossaSuprasternal fossaInfraclavicular fossaSuprascapular regionInfrascapular regionInterscapular regionVertical linesAnterior middle line(前正中線Mid-clavicular lines鎖骨中線Spinal line后正中線 axillary lines (anterior,middle, posterior) 腋前、中、后線Scapular lines肩胛線The boundary of lung & pleuraLung apexUpper boun

8、dary of the lungOuter boundaryInner boundaryLower boundary: Midclavicular line 6th interspace Midaxillary line 8th interspaceInferior line 10th interspaceChest wallVein : Blood flow directionSubcutaneius emphysema(皮下氣腫)TendernessInterspace觸診胸壁有無靜脈顯露、和皮下氣腫和胸壁壓痛皮下氣腫檢查方法1.用手按壓時，有一種柔軟帶彈性的振動感似用手握雪一樣的感覺，即

9、握雪感；2，用聽診器邊加壓邊聽診可以聽到多個微小的“喳喳音類似捻發音胸部壓痛可見于1肋間壓痛，為肋間神經炎，2肋軟骨局部壓痛，可伴有腫脹，為肋骨軟骨炎；3胸骨壓痛及叩擊痛。為白血病的表現之一4胸壁局部壓痛多見于胸壁軟組織炎癥膿腫，肋骨骨折；5肌肉壓痛，見于肌炎、流行性肌痛等；二、胸壁、胸廓與乳房檢查者面對病人站立，觀察胸廓外形和對稱性，估計病人胸廓前后徑與左右徑之比(正常為l:1. 5)。注意胸廓外形的變化。乳房Chest framworkNormal A-P/T diameter: 1/1.5Flat chestBarrel chestRachitic chest Rachitic rosa

10、ry肋骨串珠 Funnel chest漏斗胸Unilateral deformationLocal bulge of chest wallThoracic deformity caused by deformed spine A視診 觀察呼吸運動1呼吸運動類型2呼吸困難 復習3呼吸頻率4呼吸節律InspectionBreathing movement: Diaphragmatic vs costal respirationRespiratory rate:- Tachypnea-Bradypnea-Change of the breath depthsInspection(2)Rhythm o

11、f the breath -Tidal breathing-Ataxic breathing-Inhibitory breathing-Sighing respirationNormalBradypneaTachypneaKusmols breath Sighing respirationTidal breathAtaxic breathInhibitory breathPalpationThoracic expansionVocal fremitus(觸覺語顫)Pleural friction fremitus(胸膜摩擦感)Confirm the inspectionB.觸診檢查呼吸擴張度正

12、常兩側胸廓大致相等。檢查觸覺語顫為被檢查者發音時，聲波的振動沿氣管、支氣管及肺泡傳到胸壁引起共鳴的振動，用手可觸及。其強弱取決于支氣管是否通暢，胸壁傳導是否良好。聲波的傳播：聲波在三種不同介質中的傳播時其傳導力固體最強，其次為液體氣體最弱。堅硬均質的固體強于疏松非均質的固體發自聲門的聲波通過氣管，支氣管內的氣體與管壁組織，傳導至小支氣管、肺泡胸膜及胸壁，觸診時可感及震顫； 本卷須知：檢查時應注意以下四點：1病人發音要消沉，音調不能過高，在檢查過程中發者的強度和音調要始終一致2要從上到下，先前胸后背部循序進行3注意左右對稱部位比照檢查；4兩手貼胸壓力要輕而均等；觸診胸膜摩擦感C叩診叩診的方法叩診

13、音的分類清音：正常肺部的叩診音。 過清音：見于肺氣腫。 濁音：見于肺部含氣減少或有炎癥浸潤時。 鼓音：正常可在左胸下側叩得。 實音：見于大量胸腔積液叩診的位置叩診肺前界叩診肺下界(肩胛下線)；肩胛下線叩診肺下界移動度：(三)percussion1.叩診方法 direct percussion indirect percussion:the palmar surfaceof the left distal phalanx of the middle finger serves as the pleximeter and is firmly placed on the chest wall in

14、an interspace;parallel to the ribs. 3.胸部叩診音的分類 The normal percussion note varies with the thick-ness of the chest wall and the force applied by the examiner. 1 The clear, long, low-pitched sound elicited over the normal lung is termed resonance. 2 Dullness occurs when the air content of the under-ly

15、ing tissue is decreased and its solidity is increased.The sound is short, high-pitched, soft, and thudding,and lacks the vibratory quality of a resonant sound.It is heard normally over the heart and is accompanied by an increased sense of resistance in the pleximeter finger. 3 Flatness is absolute d

16、ullness. When no air is present in the underlying tissue the sound is very short,feeble, and high-pitched; flatness is found over the muscle of the arm or thigh.4 Hyperresonance refers to a more vibrant, lower-pitched, louder, and longer sound heard normally over the lungs during maximum inspiration

17、. 5 Tympany is difficult to describe but implies that the sound is moderately loud and fairly well sustained, with a musical quality in which a specific pitch is often noted. It is normally heard in the left upper quadrant of the abdomen over the air filled stomach or over any hollow viscus. The pit

18、ch of tympany is variable, but it is usually high-pitched, clear, hollow, and drumlike. Percussion notes and their characteristicsInfluencing factors for percussion肺下界移動范圍 檢查時先于平靜呼吸時在肩胛下角線上叩出肺下界，劃一標記，然后分別在被評估者深吸氣與深呼氣后，屏住呼吸，再在同一線上自上而下叩出肺下界并作標記。最高點與最低點之間的距離即肺下界移動范圍。聽診聽診的方法正常呼吸音：肺泡呼吸音，支氣管呼吸音，支氣管肺泡呼吸音病理性的呼吸音1.病理性肺泡呼吸音：(1)增強：生理性，病理性聽診病理性的呼吸音1.病理性肺泡呼吸音：(2)減弱或消失：呼吸音傳導障礙，進入肺泡內的空氣量減少，肺組織彈性減弱，呼吸運動受限，吸氣受限，呼吸中樞功能障礙，空氣流通障礙聽診病理性的呼吸音1.病理性肺泡呼吸音：(3)呼氣延長(4)斷續性呼吸音(5)呼吸音粗糙2.病理性支氣管呼吸音：肺組織實變，大空腔，壓迫性肺不張3.病理性支氣管肺泡呼吸音：聽診羅音： Rale 附加音，有干濕羅音1.濕羅音: Moist Rale(1)產生機理：氣流通過有稀薄分泌物的支氣管，氣流通過有液體的